Digital postprocessing analysis of prostatic perfusion in neutered dogs.

B-mode ultrasound is routinely performed to evaluate the prostate gland in neutered dogs, although, the detection of malignancies may be challenging. Contrast-enhanced ultrasound (CEUS) has shown to be useful for the assessment of prostatic perfusion in normal and diseased dogs, although the interpretation of contrast ultrasonographic features may still be subjective. A quantitative tool for evaluating prostatic perfusion might improve the reliability of the results in terms of early detection of prostate neoplasia in neutered dogs. The present study aimed to evaluate the applicability of a postprocessing analysis tool to CEUS of the prostate in healthy neutered dogs, to provide quantitative measurements, and to study the influence of individual characteristics on prostatic regression. Twenty-three neutered dogs underwent a B-mode and CEUS examination of the prostate to acquire data about prostatic morphology and microcirculation. The prostate was imaged using a 5-7.5 MHz linear transducer and contrast was administered intravenously. Videoclips were analyzed by using Qontrast software and a postprocessing digital analysis tool (ImageJ) to measure perfusion peak intensity, time to peak, and vascularization ratio at the moment of the peak, which were then related to body weight, age, and time elapsed since orchiectomy. Correlation tests revealed higher vascularization in younger compared with older dogs (P < .05) and in smaller compared with larger dogs (P < .05). Time elapsed since orchiectomy (P > .05) did not affect prostatic perfusion. Contrast-enhanced ultrasound and the postprocessing analysis tool ImageJ allowed analysis of vascular perfusion in all dogs and have the potential to improve the diagnostic possibilities for andrological examination.

Effect of Maca aqueous extract addition to a freezing extender for canine semen.

This study investigated the effect of the addition of Lepidium meyenii (Maca) to the freezing extender on the post-thaw quality of dog semen. Ten canine ejaculates were frozen following a two-step protocol using a tris-glucose-citrate egg yolk extender with or without the addition of 10 µl/mL of aqueous extract of Maca (Maca and ctrl groups, respectively). Prior to (fresh semen) and after freezing (T0) sperm motility, kinetic parameters, viability and mitochondrial membrane potential (MMP), as well as the levels of malondialdehyde (MDA) were evaluated. In addition, sperm motility, kinetic parameters, viability and MMP were examined up to 2 h of incubation of 37 °C after thawing (T1 and T2) to evaluate thermo-resistance. The addition of Maca reduced MDA concentration at T0 (p < 0.05) and increased total motility, the percentage of sperm with medium velocity and WOB at T1. Progressive motility decreased (p < 0.05) at T1 in the ctrl group, whereas it was not affected in Maca group at any time point. In addition, the percentage of hyperactivated spermatozoa remained constant at T1 in the ctrl, while in the Maca group an increase (p < 0.05) of this parameter was recorded. Although no differences were found for MMP between groups at any time points, a decrease of viable sperm with low MMP was observed in ctrl group between T0 and T1 and in Maca group between T1 and T2. The addition of Maca prior freezing reduced the extent of lipid peroxidation and activated canine sperm motility and hyperactivation after thawing.

Effect of crocin supplementation in the extender on the quality of chilled canine semen.

The aim of the study was to evaluate the effects of crocin on canine sperm quality parameters during prolonged storage at 4 °C. Ejaculates from 10 dogs were diluted in a TRIS- egg yolk extender supplemented with 0 (control group), 0.5, 1, and 2 mM crocin and stored at 4 °C. Sperm membrane functional integrity, motility, and kinetics were assessed after 3 h, 24 h, 4 days and 7 days of storage. Based on the results, the more efficient concentration of crocin (0.5 mM) was chosen to evaluate sperm intracellular ROS levels, lipid peroxidation, and DNA fragmentation vs. the control. Semen with the addition of 0.5 mM crocin with respect to the control exhibited: i) increased (P < 0.05) sperm membrane functionality at 4 and 7 days of storage; ii) higher (P < 0.05) average path (VAP), straight-line velocities (VSL), and beat cross frequency (BCF) at 4 d of storage at 4 °C; iii) decreased (P < 0.05) intracellular ROS levels after 3 and 24 h storage. No differences in lipid peroxidation and DNA fragmentation were recorded between the control and C0.5 groups at any time point. Lipid peroxidation did not increase over time, while DNA fragmentation increased (P < 0.05) in both groups after 4 days of storage. The results demonstrated that the enrichment of extender with crocin improves to a certain extent canine semen quality, particularly after 4 days of storage at 4 °C.

Blood Coagulation and Beyond: Position Paper from the Fourth Maastricht Consensus Conference on Thrombosis.

The Fourth Maastricht Consensus Conference on Thrombosis included the following themes. Theme 1: The "coagulome" as a critical driver of cardiovascular disease. Blood coagulation proteins also play divergent roles in biology and pathophysiology, related to specific organs, including brain, heart, bone marrow, and kidney. Four investigators shared their views on these organ-specific topics. Theme 2: Novel mechanisms of thrombosis. Mechanisms linking factor XII to fibrin, including their structural and physical properties, contribute to thrombosis, which is also affected by variation in microbiome status. Virus infection-associated coagulopathies perturb the hemostatic balance resulting in thrombosis and/or bleeding. Theme 3: How to limit bleeding risks: insights from translational studies. This theme included state-of-the-art methodology for exploring the contribution of genetic determinants of a bleeding diathesis; determination of polymorphisms in genes that control the rate of metabolism by the liver of P2Y12 inhibitors, to improve safety of antithrombotic therapy. Novel reversal agents for direct oral anticoagulants are discussed. Theme 4: Hemostasis in extracorporeal systems: the value and limitations of ex vivo models. Perfusion flow chamber and nanotechnology developments are developed for studying bleeding and thrombosis tendencies. Vascularized organoids are utilized for disease modeling and drug development studies. Strategies for tackling extracorporeal membrane oxygenation-associated coagulopathy are discussed. Theme 5: Clinical dilemmas in thrombosis and antithrombotic management. Plenary presentations addressed controversial areas, i.e., thrombophilia testing, thrombosis risk assessment in hemophilia, novel antiplatelet strategies, and clinically tested factor XI(a) inhibitors, both possibly with reduced bleeding risk. Finally, COVID-19-associated coagulopathy is revisited.

Ovarian contrast-enhanced ultrasonography and Doppler fluxometry in bitches during the postovulatory estrus and corpora lutea formation.

The aim of the present study was to evaluate the vascularization features of canine ovaries during the follicular phase and the formation of the corpora lutea by using Doppler ultrasonography and Contrast-Enhanced Ultrasound (CEUS). Eight healthy bitches were enrolled in the study and were evaluated at five different timepoints (T1 - T5) of the estrous cycle established by vaginal cytology and serum progesterone concentration. Ultrasonographic examinations were performed by a single operator using the ACUSON S2000/SIEMENS machine equipped with a linear multifrequency transducer (9.0 MHz). Color-coded Doppler evaluation of the ovarian parenchyma was performed to investigate the aspects of the signal detection throughout the different timepoints. Pulsed-wave Doppler of the intraovarian arteries was performed to evaluate spectral waveform and doppler velocimetric parameters of Systolic Peak Velocity (SPV cm/s), End Diastolic Velocity (EDV cm/s), Resistivity Index (RI) and Pulsatility Index (PI). CEUS evaluation of the ovaries was performed using a vascular contrast agent (SonoVue®, Bracco, Sao Paulo, Brazil) and the CADENCE™ Contrast Pulse Sequencing (CPS, Siemens) software, in order to perform both qualitative and quantitative analysis. Perfusion parameters of pixel number, peak intensity (PPI in %), time to peak intensity (TTP in s), mean transit time (MTT in s) and area under the curve (AUC in %). Colour-coded Doppler evaluation demonstrated an increase in signal detection as cycle progressed, with blood flow initially detected with few coloured pixels and mainly at the ventral surface of the ovaries. Further on, the number of coloured pixels increased and spreading to the central region, resulting in a circular-like pattern around the corpora hemorrhagica. The spectral waveform was consistent at all timepoints. SPV (cm/s) and EDV (cm/s) presented a numeric trend and a slight statistical difference at all timepoints, whereas no difference was found for RI and PI. CEUS evaluation demonstrated an increase in pixel intensity across all the timepoints. Quantitative CEUS analysis revealed a statistical difference in PPI (%), MTT (s) and AUC (%) at T5. CEUS evaluation of the ovaries was feasible and demonstrated a marked increase in perfusion parameters in the late postovulatory period, demonstrating its applicability in the assessment of canine corpora lutea development.

The Bidirectional Link Between RNA Cleavage and Polyadenylation and Genome Stability: Recent Insights From a Systematic Screen.

The integrity of the genome is governed by multiple processes to ensure optimal survival and to prevent the inheritance of deleterious traits. While significant progress has been made to characterize components involved in the DNA Damage Response (DDR), little is known about the interplay between RNA processing and the maintenance of genome stability. Here, we describe the emerging picture of an intricate bidirectional coupling between RNA processing and genome integrity in an integrative manner. By employing insights from a recent large-scale RNAi screening involving the depletion of more than 170 components that direct (alternative) polyadenylation, we provide evidence of bidirectional crosstalk between co-transcriptional RNA 3'end processing and the DDR in a manner that optimizes genomic integrity. We provide instructive examples illustrating the wiring between the two processes and show how perturbations at one end are either compensated by buffering mechanisms at the other end, or even propel the initial insult and thereby become disease-eliciting as evidenced by various disorders.

High-definition ultrasonography in the evaluation of the reproductive tract of bitches during the follicular phase of the estrous cycle.

The aim was to sonographically evaluate the reproductive tract of bitches during the follicular phase of the estrous cycle using High Density (HD) ultrasonic techniques. Females (n = 8) were evaluated at five different times throughout the follicular phase, as determined by vaginal cytology and blood progesterone concentrations. Ultrasonic exams were performed using the ACUSON S2000/SIEMENS device utilizing a multifrequency HD transducer (5.5-18 MHz). Videos of the ovaries were obtained and recordings were evaluated using a DICOM viewer software for counting and measuring the ovarian structures, which were assigned to groups based on diameter in mm: G1: ≤ 1; G2: from 1.01 to 3.5; G3 from 3.51 to 5.5; G4: from 5.51 to 10. There was a greater uterine thickness with the progression of the follicular phase (P < 0.05). Six distinct regions were identified in the uterine wall. The ovarian dimensions increased (P < 0.05) as stage of the follicular phase advanced. There was fluid detected around the ovaries after ovulation. There was a characteristic fat tissue hyperechogenicity around the ovaries at all timepoints. There was a difference in the number of ovarian structures of each dimension group at each time there were assessments (P < 0.05). There was a difference in diameter of the largest ovarian structure and in average value of wall thickness at all timepoints when there were evaluations (P < 0.05). The HD ultrasonography technique provides for excellent image resolution, allowing for a more precise characterization of the bitch's reproductive structures and changes occurring during the follicular phase of the estrous cycle.

Contrast-enhanced ultrasound evaluation of placental perfusion in brachicephalic bitches.

The present study aimed to investigate placental hemodynamics to determine quantitative and qualitative parameters for pregnant brachycephalic bitches as well as describe placental vascularization and perfusion in females with fetal abnormalities close to delivery. Forty-four healthy fetuses from 22 brachycephalic bitches and 9 fetuses with gestational abnormalities (anasarca and hydrocephalus) from 8 brachycephalic bitches were evaluated. All female dogs were artificially inseminated intravaginally and underwent cesarean section at the end of gestation. Pregnancy diagnosis was made on the 25th day and experimental evaluations were performed on Days 25 (M1), 45 (M2), and 58 (M3) of gestation in normal pregnancies. Fetuses with gestational abnormalities were evaluated at the last time point. Biometric values of the fetuses were determined by B-mode and vascular indices by Doppler fluxometry of the umbilical artery, whereas qualitative assessment of contrast filling and quantitative parameters of placental perfusion were performed using CEUS. Parameter comparisons among the examined fetuses (normal and abnormal) and between the moments (M1, M2, and M3) were performed by Student's t-test and ANOVA tests, and then correlated using the Spearman test. In healthy fetuses, systolic and diastolic velocities as well as the time averages of minimum and maximum velocities increased significantly from M2 to M3 (P < 0.05), whereas the pulsatility index (P < 0.043) and vascular resistance (P < 0.001) decreased. Contrast distribution was always homogeneous in placental tissues and CEUS filling parameters remained constant during the evaluated periods (P < 0.05). In fetuses with hydrops, Doppler values were similar to those obtained in healthy subjects (P > 0.05), but CEUS evaluation demonstrated a heterogeneous distribution with lower intensity of placental tissue filling and a delay in perfusion time (P < 0.05) with a diagnostic accuracy of 75%. The association of dopplerfluxometry and CEUS allowed evaluation of qualitative and quantitative parameters of physiological pregnancy hemodynamics in all gestational thirds without evidence of significant changes in the physiology of the maternal-fetal binomial, and CEUS was shown to be applicable in the detection of failures in placental vascular filling (tissue dysfunction) in fetuses with anasarca and hydrocephaly.

Carfilzomib, bendamustine, and dexamethasone in patients with advanced multiple myeloma: The EMN09 phase 1/2 study of the European Myeloma Network.

BACKGROUND: Combined therapy with carfilzomib, bendamustine, and dexamethasone was evaluated in this multicenter phase 1/2 trial conducted within the European Myeloma Network (EMN09 trial). METHODS: Sixty-three patients with relapsed/refractory multiple myeloma who had received ≥2 lines of prior therapy were included. The phase 1 portion of the study determined the maximum tolerated dose of carfilzomib with bendamustine set at 70 mg/m2 on days 1 and 8. After 8 cycles, responding patients received maintenance therapy with carfilzomib and dexamethasone until progression. RESULTS: On the basis of the phase 1 results, the recommended phase 2 dose for carfilzomib was 27 mg/m2 twice weekly in weeks 1, 2, and 3. Fifty-two percent of patients achieved a partial response or better, and 32% reached a very good partial response or better. The clinical benefit rate was 93%. After a median follow-up of 21.9 months, the median progression-free survival was 11.6 months, and the median overall survival was 30.4 months. The reported grade ≥3 hematologic adverse events (AEs) were lymphopenia (29%), neutropenia (25%), and thrombocytopenia (22%). The main nonhematologic grade ≥3 AEs were pneumonia, thromboembolic events (10%), cardiac AEs (8%), and hypertension (2%). CONCLUSIONS: In heavily pretreated patients who have relapsed/refractory multiple myeloma, combined carfilzomib, bendamustine, and dexamethasone is an effective treatment option administered in the outpatient setting. Infection prophylaxis and attention to patients with cardiovascular predisposition are required.

Contrast-Enhanced Ultrasound Imaging of Prostate Gland in Neutered Dogs.

Prostatic neoplasia (PN) occurs in 5-7% of dogs with prostatic disease, with castrated dogs having the same or higher prevalence when compared to intact dogs. Considering the promising results achieved by performing contrast-enhanced ultrasound (CEUS) in intact dogs to detect PN, the present study aimed to acquire data on the prostatic perfusion pattern in neutered dogs. CEUS was performed in 64 neutered dogs, using a 5-7.5 MHz linear transducer with coded harmonic capability, dedicated analytical software, and a second-generation contrast agent, SonoVue. After B-mode evaluation was performed to assess mean prostate volume, the CEUS examination was undertaken. The flow of contrast agent was visible 10 s after injection. The subcapsular vessels were highlighted and produced rapid peripheral rim enhancement. Subsequently, the contrast agent reached the prostatic urethra via the parenchymal arterioles and gradually reached the entire prostate. Perfusion peak intensity (PPI) and time to peak (TTP) values were respectively 45.3% and 34.1 s. The measured parameters were compared with those obtained in previous studies on intact dogs with normal and with pathological patterns. In this study, CEUS showed features that may be promising for its use as a diagnostic tool for early detection of PN in neutered dogs.

A serine protease secreted from Bacillus subtilis cleaves human plasma transthyretin to generate an amyloidogenic fragment.

Aggregation of human wild-type transthyretin (hTTR), a homo-tetrameric plasma protein, leads to acquired senile systemic amyloidosis (SSA), recently recognised as a major cause of cardiomyopathies in 1-3% older adults. Fragmented hTTR is the standard composition of amyloid deposits in SSA, but the protease(s) responsible for amyloidogenic fragments generation in vivo is(are) still elusive. Here, we show that subtilisin secreted from Bacillus subtilis, a gut microbiota commensal bacterium, translocates across a simulated intestinal epithelium and cleaves hTTR both in solution and human plasma, generating the amyloidogenic fragment hTTR(59-127), which is also found in SSA amyloids in vivo. To the best of our knowledge, these findings highlight a novel pathogenic mechanism for SSA whereby increased permeability of the gut mucosa, as often occurs in elderly people, allows subtilisin (and perhaps other yet unidentified bacterial proteases) to reach the bloodstream and trigger generation of hTTR fragments, acting as seeding nuclei for preferential amyloid fibrils deposition in the heart.

Emerging Roles of RNA 3'-end Cleavage and Polyadenylation in Pathogenesis, Diagnosis and Therapy of Human Disorders.

A crucial feature of gene expression involves RNA processing to produce 3' ends through a process termed 3' end cleavage and polyadenylation (CPA). This ensures the nascent RNA molecule can exit the nucleus and be translated to ultimately give rise to a protein which can execute a function. Further, alternative polyadenylation (APA) can produce distinct transcript isoforms, profoundly expanding the complexity of the transcriptome. CPA is carried out by multi-component protein complexes interacting with multiple RNA motifs and is tightly coupled to transcription, other steps of RNA processing, and even epigenetic modifications. CPA and APA contribute to the maintenance of a multitude of diverse physiological processes. It is therefore not surprising that disruptions of CPA and APA can lead to devastating disorders. Here, we review potential CPA and APA mechanisms involving both loss and gain of function that can have tremendous impacts on health and disease. Ultimately we highlight the emerging diagnostic and therapeutic potential CPA and APA offer.

Lenalidomide-based induction and maintenance in elderly newly diagnosed multiple myeloma patients: updated results of the EMN01 randomized trial.

n the EMN01 trial, the addition of an alkylator (melphalan or cyclophosphamide) to lenalidomide-steroid induction therapy was prospectively evaluated in transplant-ineligible patients with multiple myeloma. After induction, patients were randomly assigned to maintenance treatment with lenalidomide alone or with prednisone continuously. The analysis presented here (median follow-up of 71 months) is focused on maintenance treatment and on subgroup analyses defined according to the International Myeloma Working Group Frailty Score. Of the 654 evaluable patients, 217 were in the lenalidomide-dexamethasone arm, 217 in the melphalan-prednisone-lenalidomide arm and 220 in the cyclophosphamide-prednisone-lenalidomide arm. With regards to the Frailty Score, 284 (43%) patients were fit, 205 (31%) were intermediate-fit and 165 (25%) were frail. After induction, 402 patients were eligible for maintenance therapy (lenalidomide arm, n=204; lenalidomide-prednisone arm, n=198). After a median duration of maintenance of 22.0 months, progression-free survival from the start of maintenance was 22.2 months with lenalidomide-prednisone vs 18.6 months with lenalidomide (hazard ratio 0.85, P=0.14), with no differences across frailty subgroups. The most frequent grade ≥3 toxicity was neutropenia (10% of lenalidomide-prednisone and 21% of lenalidomide patients; P=0.001). Grade ≥3 non-hematologic adverse events were rare (<15%). In fit patients, melphalan-prednisone-lenalidomide significantly prolonged progression-free survival compared to cyclophosphamide-prednisone-lenalidomide (hazard ratio 0.72, P=0.05) and lenalidomide-dexamethasone (hazard ratio 0.72, P=0.04). Likewise, a trend towards a better overall survival was noted for patients treated with melphalan-prednisone-lenalidomide or cyclophosphamide-prednisone-lenalidomide, as compared to lenalidomide-dexamethasone. No differences were observed in intermediate-fit and frail patients. This analysis showed positive outcomes of maintenance with lenalidomide-based regimens, with a good safety profile. For the first time, we showed that fit patients benefit from a full-dose triplet regimen, while intermediate-fit and frail patients benefit from gentler regimens. ClinicalTrials.gov registration number: NCT01093196.

First-line therapy with either bortezomib-melphalan-prednisone or lenalidomide-dexamethasone followed by lenalidomide for transplant-ineligible multiple myeloma patients: a pooled analysis of two randomized trials.

Bortezomib-melphalan-prednisone (VMP) and continuous lenalidomide-dexamethasone (Rd) represent the standard treatment of transplant-ineligible patients with newly diagnosed multiple myeloma (MM). To date, no randomized trial has compared VMP to Rd, and there is no evidence of the optimal treatment for newly diagnosed MM, particularly in patients with high-risk cytogenetics [del(17p), t(4;14) or t(14;16)]. We pooled together data from patients with newly diagnosed MM treated with VMP or Rd induction followed by lenalidomide maintenance 10 mg (Rd-R) enrolled in the GIMEMA-MM-03-05 and EMN01 trials, to evaluate the efficacy of these treatments in different subgroups of patients, focusing on those with standard- and high-risk cytogenetics. Overall, 474 patients were analyzed (VMP: 257 patients; Rd-R: 217 patients). No differences in progression-free survival (hazard ratio=0.96) and overall survival (hazard ratio=1.08) were observed between standard-risk patients treated with VMP or Rd-R, whereas among the high-risk patients, the probabilities of progression (hazard ratio=0.54) and death (hazard ratio=0.73) were lower in the patients treated with VMP than in those treated with Rd-R. In particular, standard-risk patients >75 years benefited less from VMP than from Rd-R (hazard ratio for progression-free survival=0.96; hazard ratio for overall survival=1.81). In this non-randomized analysis, VMP and Rd-R were equally effective in younger (≤75 years), standard-risk patients, while older ones (>75 years) benefited more from Rd-R. In high-risk patients, VMP improved progression-free survival and overall survival irrespective of age. The source trials are registered at ClinicalTrials.gov (NCT01063179 and NCT01093196).

Outcome of paraosseous extra-medullary disease in newly diagnosed multiple myeloma patients treated with new drugs.

Extramedullary disease is relatively frequent in multiple myeloma, but our knowledge on the subject is limited and mainly relies on small case series or single center experiences. Little is known regarding the role of new drugs in this setting. We performed a meta-analysis of eight trials focused on the description of extramedullary disease characteristics, clinical outcome, and response to new drugs. A total of 2,332 newly diagnosed myeloma patients have been included; 267 (11.4%) had extramedullary disease, defined as paraosseous in 243 (10.4%), extramedullary plasmocytoma in 12 (0.5%), and not classified in 12 (0.5%) patients. Median progression-free survival was 25.3 months and 25.2 in extramedullary disease and non-extramedullary disease patients, respectively. In multivariate analysis the presence of extramedullary disease did not impact on progression-free survival (hazard ratio 1.15, P=0.06), while other known prognostic factors retained their significance. Patients treated with immunomodulatory drugs, mainly lenalidomide, or proteasome inhibitors had similar progression-free survival and progression-free survival-2 regardless of extramedullary disease presence. Median overall survival was 63.5 months and 79.9 months (P=0.01) in extramedullary and non-extramedullary disease patients, respectively, and in multivariate analysis the presence of extramedullary disease was associated with a reduced overall survival (hazard ratio 1.41, P<0.001), in line with other prognostic factors. With the limits of the use of low sensitivity imaging techniques, that lead to an underestimation of extramedullary disease, we conclude that in patients treated with new drugs the detrimental effect of extramedullary disease at diagnosis is limited, that lenalidomide is effective as are proteasome inhibitors, and that these patients tend to acquire a more aggressive disease in later stages. (EUDRACT2005-004714-32, NCT01063179 NCT00551928, NCT01091831, NCT01093196, NCT01190787, NCT01346787, NCT01857115).

Lenalidomide Maintenance with or without Prednisone in Newly Diagnosed Myeloma Patients: A Pooled Analysis.

: We conducted a pooled analysis of two phase III trials, RV-MM-EMN-441 and EMN01, to compare maintenance with lenalidomide-prednisone vs. lenalidomide in newly diagnosed transplant-eligible and -ineligible myeloma patients. Primary endpoints were progression-free survival, progression-free survival 2 and overall survival with both regimens. A secondary aim was to evaluate the impact of duration of maintenance on overall survival and on outcome after relapse. A total of 625 patients (lenalidomide-prednisone arm, n = 315; lenalidomide arm, n = 310) were analyzed. The median follow-up was 58 months. Median progression-free survival (25 vs. 19 months; p = 0.08), progression-free survival 2 (56 vs. 49 months; p = 0.9) and overall survival (73 months vs. NR; p = 0.08) were not significantly different between the two arms. Toxicity profiles of lenalidomide-prednisone and lenalidomide were similar, with the exception of neutropenia that was higher in the lenalidomide arm (grade ≥ 3: 9% vs. 19%, p < 0.001), without an increase in the rate of infections. Overall survival (median NR vs. 49 months, p < 0.001), progression-free survival from relapse (median 35 vs. 24 months, p = 0.004) and overall survival from relapse (median not reached vs. 41 months, p = 0.002) were significantly longer in patients continuing maintenance for ≥2 years. We showed that the addition of prednisone at 25 or 50 mg every other day (eod) to lenalidomide maintenance did not induce any significant advantage.

Once-weekly versus twice-weekly carfilzomib in patients with newly diagnosed multiple myeloma: a pooled analysis of two phase I/II studies.

Twice-weekly carfilzomib is approved at 27 and 56 mg/m2 to treat relapsed multiple myeloma patients. In the phase III study ARROW, once-weekly 70 mg/m 2 carfilzomib prolonged the median progression-free survival of relapsed multiple myeloma patients in comparison with twice-weekly 27 mg/m2 carfilzomib, without adding significant toxicity. Data were pooled from two phase I/II studies of newly diagnosed multiple myeloma patients who received nine induction cycles of carfilzomib (either 70 mg/m2 once-weekly or 36 mg/m2 twice-weekly), cyclophosphamide and dexamethasone, followed by carfilzomib maintenance. Overall, 121 transplant-ineligible patients with newly diagnosed multiple myeloma were analyzed (once-weekly, n=63; twice-weekly, n=58). We found no significant difference in median progression-free survival [35.7 months (95%CI: 23.7-not reached, NR) vs 35.5 months (95%CI: 24.3-NR); HR: 1.39; P=0.26] and 3-year overall survival [70% [95%CI: 59%-84%) vs 72% (95%CI: 60%-85%); HR: 1.27; P=0.5] between once-weekly and twice-weekly carfilzomib. From the start of maintenance, 3-year progression-free survival [47% (95%CI: 33%-68%) vs 51% (95%CI: 38%-70%); HR: 1.04; P=0.92] and overall survival [72% (95%CI: 58%-89%) vs 73% (95%CI: 59%-90%); HR: 0.82; P=0.71] were similar in the once- versus twice-weekly carfilzomib. The rate of grade 3-5 hematologic (24% vs 30%; P=0.82) and non-hematologic (38% vs 41%; P=0.83) adverse events was similar in the two groups. Once-weekly 70 mg/m2 carfilzomib as induction and maintenance therapy for newly diagnosed multiple myeloma patients was as safe and effective as twice-weekly 36 mg/m2 carfilzomib and provided a more convenient schedule. The trials are registered at clinicaltrials.gov identifiers: 01857115 (IST-CAR-561) and 01346787 (IST-CAR-506).

Minimal residual disease by flow cytometry and allelic-specific oligonucleotide real-time quantitative polymerase chain reaction in patients with myeloma receiving lenalidomide maintenance: A pooled analysis.

BACKGROUND: Minimal residual disease (MRD) is one of the most relevant prognostic factors in patients with multiple myeloma (MM); however, the impact of maintenance therapy on MRD levels remains unclear. Among patients with newly diagnosed MM (NDMM) who received lenalidomide maintenance until they developed disease progression, the role of MRD status as a predictor of progression-free survival (PFS) was evaluated by multiparameter flow cytometry (MFC) and allelic-specific oligonucleotide real-time quantitative polymerase chain reaction (ASO-RQ-PCR) analysis. METHODS: Seventy-three patients with NDMM enrolled in the RV-MM-EMN-441 (clinical trials.gov identifier, NCT01091831) and RV-MM-COOP-0556 (clinicaltrials.gov identifier, NCT01208766; European Myeloma Network EMN02/HO95 MM Trial) phase 3 trials who achieved at least a very good partial response after intensification/consolidation were included. The median patient age was 57 years (interquartile range, 53-61 years), and all patients received lenalidomide maintenance until they developed progression. MRD was evaluated on bone marrow after intensification/consolidation, after 6 courses of maintenance, and every 6 months thereafter until clinical relapse using both ASO-RQ-PCR (sensitivity, 10-5 ) and MFC (sensitivity, from 10-4 to 10-5 ). RESULTS: After intensification/consolidation, 33 of 72 patients (46%) achieved a molecular complete response (m-CR), and 44 of 70 (63%) achieved a flow complete response (flow-CR). Almost 27% of patients who were MRD-positive after consolidation became MRD-negative during maintenance. After a median follow-up of 38 months, PFS was prolonged in patients who achieved negative MRD status during maintenance according to results from both ASO-RQ-PCR analysis (hazard ratio, 0.29; 95% confidence interval, 0.14-0.62; P = .0013) and MFC (hazard ratio, 0.19; 95% confidence interval, 0.09-0.41; P < .001). The impact of negative MRD status on PFS was similar in all subgroups (ASCT and no-ASCT; International Staging System stages I, II, and III; high-risk and standard-risk cytogenetics), and the two techniques were highly correlated. CONCLUSIONS: MRD status is a stronger predictor of PFS than standard risk factors, and lenalidomide maintenance further increases the rate of negative MRD results.

Continuous therapy in standard- and high-risk newly-diagnosed multiple myeloma: A pooled analysis of 2 phase III trials.

BACKGROUND: Risk-adapted therapy is a common strategy in curable hematologic malignancies: standard-risk patients receive less intensive treatment, whereas high-risk patients require a more intensive approach. This model cannot be applied in multiple myeloma (MM), which is still incurable. Continuous treatment (CT) is a key strategy for MM treatment, since it improves duration of remission. However, the role of CT according to standard- or high-risk baseline prognosis remains an open question. PATIENTS AND METHODS: We performed a pooled analysis of 2 phase III trials (GIMEMA-MM-03-05 and RV-MM-PI-209) that randomized patients to CT vs fixed-duration therapy (FDT). RESULTS: In the overall patient population (n = 550), CT improved progression-free survival1 (PFS1) (HR 0.54), PFS2 (HR 0.61) and overall survival (OS) (HR 0.71) vs FDT. CT improved PFS1 both in R-ISS I (HR 0.49) and R-ISS II/III patients (HR 0.55). Four-year PFS1 was 38% in R-ISS II/III patients receiving CT and 25% in R-ISS I patients receiving FDT, with similar trends for PFS2 and OS. High-risk patients benefited more from proteasome-inhibitor plus immunomodulatory-based CT than immunomodulatory alone. CONCLUSION: Good prognosis patients receiving FDT lose their prognostic advantage over high-risk patients receiving CT and high-risk patients may benefit from more intensive maintenance including proteasome inhibitors and immunomodulators.

Early mortality in myeloma patients treated with first-generation novel agents thalidomide, lenalidomide, bortezomib at diagnosis: A pooled analysis.

INTRODUCTION: Early toxic death (≤60 days of diagnosis) in elderly multiple myeloma (MM) patients is attributable to active disease, age and co-morbidities. Rate of early toxic deaths is 10% with conventional chemotherapy mainly due to infection and renal failure. Novel agents have improved MM outcome at the expense of newer toxicity. METHODS: We analyzed 1146 individual patient data to assess toxic deaths during induction treatment with first-generation novel agents thalidomide, lenalidomide, bortezomib. RESULTS: During first-line therapy, 119/1146 patients (10%) died for any cause, and 47/1146 (4%) due to toxicity, including 12/1146 (1%) early deaths. The 24-month cumulative incidence was 4.1% without any difference between bortezomib (18/503 patients, 4%) and lenalidomide (29/643patients, 5%; p = 0.31). Toxic deaths occurred in 34/1039 (3%) patients <80 years and 13/107 (12%) patients ≥80 years. Causes were cardiac events (28%), infections (26%) and vascular complications (15%). In a multivariate analysis, older age and unfavorable ISS stage increased the risk of death. CONCLUSION: First-generation novel agents significantly reduced toxic deaths compared to conventional chemotherapy. One third of deaths during first-line therapy were due to cumulative drug-related toxicities, thus supportive approaches and prevention strategies should be optimized. The higher mortality rate for toxicity in octogenarians confirms the need for a careful frailty assessment.