Abstract: Abstract 309 Background: Novel insights into the biology of myeloma cells have led to the identification of relevant prognosis factors. CA has become one of the most important prognostic factors, and the presence of t(4;14), t(14;16) or del(17p) are associated with poor prognosis. DNA ploidy is another important prognostic factor with non-hyperdiploid cases being associated with a poor outcome. There are some controversies about whether or not bortezomib-based combinations are able to overcome the poor prognosis of CA. In the VISTA trial, bortezomib plus melphalan and prednisone (VMP) appeared to overcome the poor prognosis of CA in terms of response rate (RR) and survival; however, the number of patients with CA was rather small. Here we report a subanalysis, in a series of elderly newly diagnosed myeloma patients included in the Spanish GEM05MAS65 trial, in order to evaluate the influence of CA by FISH as well as DNA ploidy status on RR and survival. Patients and methods: Patients included in this study were randomized to receive 6 cycles of VMP vs bortezomib, thalidomide and prednisone (VTP) as induction therapy consisting on one 6-week cycle of bortezomib using a bi-weekly schedule (1·3 mg/m2 on days 1, 4, 8, 11, 22, 25, 29 and 32) plus either melphalan 9 mg/ m2 on days 1 to 4 or oral daily thalidomide 100 mg, and prednisone 60 mg/ m2 on days 1 to 4; this first cycle was followed by five 5-week cycles of once-weekly bortezomib (1·3 mg/ m2 on days 1, 8, 15 and 22) plus the same doses of MP and TP. After induction therapy, patients were subsequently randomised to maintenance therapy with VP or VT, consisting of one convencional 3-week cycle of bortezomib (1·3 mg/ m2 on days 1, 4, 8 and 11) every 3 months, plus either prednisone 50 mg every other day or thalidomide 50 mg/day, for up to 3 years. FISH analysis for del(13q), t(11;14), t(4;14), t(14;16) and del(17p) was performed at diagnosis according to standard procedures using purified plasma cells, and DNA ploidy status was analysed following induction therapy by multiparametric FCM using propidium Iodide and specific markers for discrimination between myelomatous and normal cells. Result: In 231 out of the 260 patients included in the trial, FISH analysis at diagnosis were available and two groups were identified: high-risk group (n= 44 patients with t(4;14) and/or t(14;16) and/or del(17p)) and standard-risk group (n=187 patients without CA, and/or del(13q) and/or t(11;14)). There weren't differences in the rates of CA according to the treatment arm. RR was the same in the high-risk vs standard-risk groups, both after induction (21% vs 27% CR) and maintenance (39% vs 45% CR). However, high-risk patients showed shorter PFS as compared to standard risk both from first (24 versus 33 months, p=0·04, HR 0·6, 95% IC 0·4-0·9) and second randomization (17 versus 27 months, p=0·01, HR 0·5, 95% IC 0·2-0·8). This also translated into shorter OS for high risk patients (3-year OS rate: 55% versus 77% from first randomization, p=0·001, HR 0·4, 95% IC 0·2-0·7) and 60% versus 85% from second randomization, p 〈 0·001, HR 0·2, 95% IC 0·1-0·5). This adverse prognosis applied to either t(4;14) or del(17p), without differences in terms of PFS from the first (24 months for del(17p) patients and 20 months for t(4;14)) and second randomization (16 months for both CA); in addition, the outcome was not modified by the treatment scheme used. When we analyzed the influence on survival of the DNA ploidy status (224 patients) by comparing patients with hyperdiploid (132 patients) versus non-hyperdiploid DNA content (92 patients) assessed by FCM, it was found that the former group showed longer OS (77% versus 63% at 3 years, p=0·04), and this difference was more evident in patients treated with VTP (77% versus 53% at 3 years, p=0·02), while no significant differences were observed in the VMP arm. Conclusion: The present schema, particularly after month sixth (using maintenance with bortezomib every 3 months) doesn't overcome the negative prognosis of high-risk cytogenetics in terms of PFS and OS in elderly myeloma patients, and this applied to either patients with t(4;14) or del(17p), and it was independent of the induction treatment arm. Our data also show that non-hyperdiploid cases displayed worse outcome than hyperdiploid patients, particularly under VTP induction treatment. These results suggest that continuous efforts are still required in order to overcome the dismal prognosis of high-risk patients. Disclosures: Mateos: Janssen Cilag: Honoraria; Celgene: Honoraria. Off Label Use: VTP is not approved for the treatment of elderly newly diagnosed myeloma patients. VT and VP are not approved for maintenance therapy. Gutierrez:Janssen Cilag: Honoraria; Celgene: Honoraria. Oriol:Janssen Cilag: Honoraria; Celgene: Honoraria. Martínez-López:Janssen Cilag: Honoraria; Celgene: Honoraria. Garcia-Laraña:Janssen Cilag: Honoraria; Celgene: Honoraria. Palomera:Janssen Cilag: Honoraria. Hernández:Janssen Cilag: Honoraria. García-Sanz:Janssen Cilag: Honoraria; Celgene: Honoraria. Cibeira:Janssen-Cilag: Honoraria, Membership on an entity's Board of Directors or advisory committees; Celgene: Honoraria, Membership on an entity's Board of Directors or advisory committees. Lahuerta:Janssen Cilag: Honoraria; Celgene: Honoraria. Blade:Janssen cilag: Honoraria; Celgene: Honoraria. San Miguel:Janssen Cilag: Honoraria; Celgene: Honoraria.

Abstract: Cytogenetic abnormalities (CAs) such as t(4;14), t(14;16) or del(17p), and nonhyperdiploidy are associated with poor prognosis in multiple myeloma. We evaluated the influence of CAs by FISH and DNA ploidy by flow cytometry on response and survival in 232 elderly, newly diagnosed multiple myeloma patients receiving an induction with weekly bortezomib followed by maintenance therapy with bortezomib-based combinations. Response was similar in the high-risk and standard-risk CA groups, both after induction (21% vs 27% complete responses [CRs]) and maintenance (39% vs 45% CR). However, high-risk patients showed shorter progression-free survival (PFS) than standard-risk patients, both from the first (24 vs 33 months; P = .04) and second randomization (17 vs 27 months; P = .01). This also translated into shorter overall survival (OS) for high-risk patients (3-year OS: 55% vs 77%; P = .001). This adverse prognosis applied to either t(4;14) or del(17p). Concerning DNA ploidy, hyperdiploid patients showed longer OS than nonhyperdiploid patients (77% vs 63% at 3 years; P = .04), and this was more evident in patients treated with bortezomib, thalidomide, and prednisone (77% vs 53% at 3 years; P = .02). The present schema does not overcome the negative prognosis of high-risk CAs and nonhyperdiploidy. This trial was registered with www.ClinicalTrials.gov as NCT00443235.

Abstract: Minimal residual disease monitoring is becoming increasingly important in multiple myeloma ( MM ), but multiparameter flow cytometry ( MFC ) and allele‐specific oligonucleotide polymerase chain reaction ( ASO ‐ PCR ) techniques are not routinely available. This study investigated the prognostic influence of achieving molecular response assessed by fluorescent‐ PCR (F‐ PCR ) in 130 newly diagnosed MM patients from G rupo E spañol M ultidisciplinar de M elanoma ( GEM )2000/ GEM 05 trials ( NCT 00560053, NCT 00443235, NCT 00464217) who achieved almost very good partial response after induction therapy. As a reference, we used the results observed with simultaneous MFC . F‐ PCR at diagnosis was performed on DNA using three different multiplex PCR s: IGH D‐J, IGK V‐J and KDE rearrangements. The applicability of F‐ PCR was 91·5%. After induction therapy, 64 patients achieved molecular response and 66 non‐molecular response; median progression‐free survival ( PFS ) was 61 versus 36 months, respectively ( P  =   0·001). Median overall survival ( OS ) was not reached ( NR ) in molecular response patients (5‐year survival: 75%) versus 66 months in the non‐molecular response group ( P  =   0·03). The corresponding PFS and OS values for patients with immunophenotypic versus non‐immunophenotypic response were 67 versus 42 months ( P  =   0·005) and NR (5‐year survival: 95%) versus 69 months ( P  =   0·004), respectively. F‐ PCR analysis is a rapid, affordable, and easily performable technique that, in some circumstances, may be a valid approach for minimal residual disease investigations in MM .

Abstract: Background: VMP and Rd are two of the most effective regimens in the treatment of elderly newly diagnosed MM pts. In order to further improve its outcome, one possibility would be to use regimens including all these drugs simultaneously, but this may result toxic. Alternatively, the use of these regimens (VMP and Rd) in a sequential or alternating scheme could improve the treatment of these pts. We hypothesized the alternating scheme would minimize the emergence of resistant clones, and would reduce the cumulative toxicity. In order to test this hypothesis we decided to compare VMP and Rd in a sequential vs an alternating scheme. Pts and methods: 242 pts were randomized to receive a sequential scheme consisting on 9 cycles of VMP followed by 9 cycles of Rd or the same regimens in an alternating approach (one cycle of VMP alternating with one Rd, up to 18 cycles. VMP included the iv administration of weekly bortezomib (except in the first cycle that was given twice weekly) at 1.3 mg/m2 in combination with oral melphalan 9 mg/m2 and prednisone 60 mg/m2 once daily on days 1–4. Rd treatment consisted on lenalidomide 25 mg daily on days 1-21 plus dexamethasone 40 mg weekly. Results: 233 pts were evaluable for safety and efficacy (118 in the sequential and 115 in the alternating arm). Both arms were well balanced according to the baseline characteristics. Of note, 55% of pts in the sequential and 44% in the alternating arm were older than 75 yrs. Fifty-one percent in the sequential arm and 52% in the alternating had high risk cytogenetic abnormalities (t(4;14), t(14;16), del17p or 1q gains). After 9 cycles, the sCR/CR rate was lower in the sequential (20%) than in the alternating arm (32%)(p=0.02). However, among the 179 pts that were evaluable for efficacy after the 18 planned cycles of treatment, the pattern reversed: 51% achieved sCR/CR in the sequential vs 38% in the alternating arm (p=0,05). The flow-CR rate among patients in sCR/CR was 66% and 48% in the sequential vs alternating arms, respectively (P=0.16). To achieve flow-CR was associated with a significantly longer TTP (median not reached vs 15 months since the end of treatment; P=.01). After a median f/u of 27 months, median PFS was of 30 months in both sequential and alternating arms (p=NS). Median OS has not been reached, and 68% and 67% of pts are alive at 3 yrs (p=NS). Pts who achieved sCR/CR had significantly longer PFS and OS as compared with pts who did not (3-yrs PFS for sCR/CR of 76% vs 18% for 〈 CR (p 〈 0.0001), and 3-yrs OS of 94% vs 53% for sCR/CR vs 〈 CR (p 〈 0.0001)) in both arms. The achievement of flow-CR has been also associated with 3-yrs PFS of 84% vs 38% months for pts who did not achieve flow-CR. This benefit has been observed in both arms. Pts younger than 75 yrs showed a significantly longer survival as compared to pts ≥75y (3-yrs PFS of 55% vs 27m, p=0.04) and 3-yrs OS of 89% vs 35m, p 〈 0.0001 ) , with no significant differences between sequential and alternating arms. No differences were observed in overall response rates and sCR/CR rates in standard and high risk pts, but there was a trend toward shorter PFS and OS in the subgroup of high-risk CA (median PFS of 28 months and 3-yrs OS of 64%, pNS) vs standard-risk (3-yrs PFS of 54% and 3-yrs OS of 80%, pNS). Regarding hematologic toxicity, no significant differences were observed between the sequential and alternating arms in the frequency of G3-4 neutropenia (19% and 22%) or thrombocytopenia (21% and 20%). Concerning non-hematologic toxicity, 3% and 6% of the pts in the sequential and alternating arms had G3-4 infections. No differences were observed neither in the the incidence of peripheral neuropathy in the sequential and alternating arms (4% and 3%, respectively) nor in the rate of grade 3-4 thrombotic events (1% and 2%). The rate of early discontinuations (15%) and deaths (4%) before the cycle 9 were identical in both arms; of note 71% of early discontinuations occurred in pts aged over 75 yrs and all early deaths but one were also in pts older than 75 yrs. Conclusions: The alternating regimen has demonstrated to be not superior to the sequential approach. Toxicity profile is acceptable. This Total Therapy approach, including the four active anti-myeloma agents (melphalan, bortezomib, lenalidomide and steroids) is particularly active in pts between 65-75 years old, with similar survival to that of transplant candidate pts with outstanding outcome when sCR/CR is achieved. Disclosures Mateos: Celgene: Honoraria, Membership on an entity's Board of Directors or advisory committees; Janssen: Honoraria, Membership on an entity's Board of Directors or advisory committees. Off Label Use: Lenalidomide as first-line combination therapy for AL amyloidosis.. Rosiñol:Janssen: Honoraria; Celgene: Honoraria. Ocio:Celgene Corporation: Honoraria, Research Funding. Pérez de Oteyza:Janssen: Research Funding, Speakers Bureau; Celgene: Consultancy, Speakers Bureau. Oriol:Celgene Corporation: Consultancy. De La Rubia:Janssen: Honoraria; Celgene: Honoraria. Bladé:Janssen: Grant support Other, Honoraria, Membership on an entity's Board of Directors or advisory committees; Celgene: Grant support, Grant support Other, Honoraria, Membership on an entity's Board of Directors or advisory committees. Lahuerta:Janssen: Honoraria; Celgene: Honoraria. San Miguel:Janssen: Honoraria; Celgene: Honoraria.

Abstract: Abstract 3951 Aim: The aims of this study were on one hand, to evaluate the significance of achieving molecular response (MR) by fluorescent-PCR (F-PCR) of Ig genes in a prospective way, particularly in patients with singular cytogenetics' features. On the other hand, to compared MR with immunophenotypic response (IR) and complete remission by immunofixation (CR). Patients: 130 new MM patients who had achieved CR or VGPR were analyzed by PCR, multiparametric flow cytometry (MFC) and immunofixation at diagnosis, and after induction therapy or transplantation: 48 patients received conventional chemotherapy as induction therapy followed with ASCT and were included in the GEM2000 trial and the other 82 patients were enrolled in the GEM2005 clinical trials in which the induction and maintenance therapy were based on Bortezomib and/or Thalidomide. Methods: The molecular analysis of Immunoglobulin (Ig) gene rearrangements at diagnosis was carried out by fluorescent PCR in DNA from bone marrow samples according to the Biomed-2 protocols. Briefly three different multiplex PCRs: DHJ; Ig Kappa light chain (IGK) rearrangements K-VJ and Kappa deleting element (KDE). DHJ and light chain rearrangements detected at the diagnosis were used in the follow-up. The sensitivity of PCR was between 1/103 and 1/104 as Martínez P. et al previously published in BJH, 2008. Regarding MFC the following monoclonal antibody combinations (FITC/PE/PerCP-Cy5.5/APC) were used at the diagnosis to identify different aberrant plasma cells phenotypes which were used as patient-specific probes for Minimal Residual Disease. Results: 64 patients had negative F-PCR and 66 patients had positive F-PCR after induction therapy. The OS was 77.32% and 59.18%, respectively and the medians OS were 116 and 67 months for each group (P= 0.03). Regarding the PFS, 28 of the 64 F-PCR negative patients relapsed while there were 44 relapses in the group of positive F-PCR. The 5y PFS was 56.44% and 27.43% respectively; the medians PFS were 60 and 36 months respectively (P= 0.0005). The multivariate analysis showed that achieving molecular response by F-PCR had a independent prognostic value in PFS (P=0.003, HR 2.3). Interestingly amongst patients who achieved CR, F-PCR identified a population of patient with a better PFS, figure A (P= 0.04, HR 2.179).The applicability of the F-PCR was almost equivalent to that observed by MFC (91.5 vs. 92%). Nevertheless we found discordant results between these two response criteria. Approximately the 20% of patients who had achieved a MR no obtained IR. The opposite pattern also was observed (IR/noMR) in 10% of the patients. In order to see if the PCR showed differences in terms of survival in patients with high or low risk cytogenetics features at the diagnosis, we made two independent analysis: in one hand we analyzed 14 patients with high-risk cytogenetics [t(4;14), t(14;16) and/or del(17p)] and on the other hand 72 patients with standard-risk cytogenetics. In the former analysis, 4 of the 8 who had negative F-PCR relapsed after the induction therapy while the totality of the other six with positive F-PCR did. The medians PFS were 32 and 17 months respectively (P= 0.0002). In connection with the 72 patients with standard-risk cytogenetics, 13 of the 34 who had negative F-PCR relapsed while 24 of the 38 with positive F-PCR did. The medians PFS times were 75 and 38 months respectively, figure B (P= 0.01). Conclusion: F-PCR of IgH rearrangements is a simple, cheap and feasible method for evaluating response in MM patients after induction therapy or transplantation. Additionally achieving MR provides a similar prognostic value to IR in patients differentially treated, and particularly in patients with singular cytogenetics' features as well as in patients with CR by immunofixation. Disclosures: Paiva: Jansen-Cillag: Honoraria; Celgene: Honoraria. Rosiñol:Janssen: Honoraria; Celgene: Honoraria. Alegre:Janssen: Honoraria; Celgene: Honoraria. Blade:Centocor Ortho Biotech Research & Development: Research Funding. San Miguel:Janssen-Cilag: Honoraria; Celgene: Honoraria. Lahuerta:Celgene: Honoraria; Janssen: Honoraria.

Abstract: Melphalan, in combination with bortezomib, should be maintained as one of the standards of care for the treatment of elderly MM patients. Complete response and particularly flow complete response should be an important goal in the treatment of elderly myeloma patients.