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  • 1
    In: New England Journal of Medicine, Massachusetts Medical Society, Vol. 370, No. 4 ( 2014-01-23), p. 362-373
    Type of Medium: Online Resource
    ISSN: 0028-4793 , 1533-4406
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    Language: English
    Publisher: Massachusetts Medical Society
    Publication Date: 2014
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  • 2
    In: Blood, American Society of Hematology, Vol. 118, No. 21 ( 2011-11-18), p. 3966-3966
    Abstract: Abstract 3966 Background. Lenalidomide plus dexamethasone is approved for the treatment of relapsed and/or refractory multiple myeloma following prior therapy. Everolimus, an oral mTOR inhibitor, has been studied as a single agent in multiple myeloma but does not have significant activity. Based on previous preclinical studies showing synergistic anti-myeloma activity of mTOR inhibitors when combined with lenalidomide, we studied this combination as a non-steroid containing oral regimen in advanced multiple myeloma. In order to help determine the molecular mechanisms of response, we comprehensively assessed patient samples using gene expression analysis, western blotting, and immunohistochemistry of the mTOR pathway as well as cytokine analysis and measurement of T cell subsets. Methods. Patients with relapsed and refractory multiple myeloma were assigned to lenalidomide and everolimus for 21 days out of a 28 day cycle until disease progression or unacceptable toxicity (NCT00729638). We measured levels of p70S6K phosphorylated protein in peripheral blood mononuclear cells by western blotting before and during treatment. Immunohistochemical analysis for target proteins of the mTOR/AKT pathway was performed on bone marrow (BM) aspirates. Gene expression of CD138+ selected BM aspirates was analyzed on Affymetrix expression arrays prior to treatment. IGF-1 and IL-6 cytokine levels were determined by ELISA. T cell subsets were defined immunophenotypically over the course of treatment. Results. Twenty-six patients were evaluable for toxicity. The MTD was lenalidomide 15 mg and everolimus 5 mg for 21 days with a 7 day rest period. Nineteen patients finished at least two cycles of treatment and were evaluable for response. The overall response (OR) was 58% (1 CR + 3 PR + 7 MR). Three patients had SD and 5 patients had PD. The median progression free survival was 6.3 month at a median follow-up of 8.2 months. Biomarker data demonstrated that treatment with everolimus and lenalidomide consistently downregulated protein expression of phosphorylated p70S6K, a downstream target of mTOR. Microarray gene expression data was available for 12 patients, including 9 responders (MR, PR, SD) and 3 non-responders (PD). Gene set enrichment analysis showed enrichment for genes in the mTOR pathway gene set among the responders (p = 0.033, FDR 0.026). At the individual gene level, expression of members of the mTOR pathway, e.g. IGF1 (p = 0.034, FDR = 0.20) and RICTOR (p = 0.016, FDR = 0.15) was significantly higher in responding patients than non-responding patients. IHC for p-Akt (Ser 473) was evaluable in 10 patients, and 7 patients scored positively for pAkt expression. Given the small numbers, we were unable to correlate pAkt expression with response. DEPTOR was evaluable in 12 cases and strongly expressed in the majority of tumors. Quantification of T cell subsets was available for 25 patients. Treatment with everolimus and lenalidomide did not affect populations of CD4+ or CD8+ T cells or NK cells. Of the patients where IGF-1 levels were available, IGF-1 levels rose in the non-responding patients (N = 2) over the course of treatment; conversely, IGF-1 levels had an initial peak followed by decrease at time of best response in 4 of 5 responders. There was no difference in IL-6 levels between responders and non-responders. Conclusions. The combination of lenalidomide and everolimus showed durable responses in a heavily pretreated population. The doses of lenalidomide and everolimus used in this phase I study inhibited the downstream target of mTOR, p70S6K; was active in cases of constitutive mTOR activation; did not alter T cell subsets; and modulated IGF-1, but not IL-6 levels. With confirmation in larger patient numbers, this analysis may serve as a framework for guiding patient selection for future clinical trials investigating the role of mTOR inhibition in multiple myeloma. Disclosures: Off Label Use: The combination of everolimus and lenalidmoide is an off-label use for multiple myeloma. Richardson:Millennium Pharmaceuticals, Inc.: Consultancy; Celgene: Consultancy; Johnson & Johnson: Consultancy. Hideshima:Acetylon: Consultancy. Ghobrial:Noxxon: Research Funding; Bristol-Myers Squibb: Research Funding; Millennium: Research Funding; Noxxon: ; Millennium: ; Celegene: ; Novartis:. Munshi:Celgene: Consultancy; Millenium: Consultancy; Novartis: Consultancy; Onyx: Consultancy. Anderson:Celgene: Membership on an entity's Board of Directors or advisory committees; Millennium: Membership on an entity's Board of Directors or advisory committees; Onyx: Membership on an entity's Board of Directors or advisory committees; Merck: Membership on an entity's Board of Directors or advisory committees; Bristol Myers Squibb: Membership on an entity's Board of Directors or advisory committees; Novartis: Membership on an entity's Board of Directors or advisory committees; Acetylon: Membership on an entity's Board of Directors or advisory committees. Raje:Celgene: Membership on an entity's Board of Directors or advisory committees; Novartis: Membership on an entity's Board of Directors or advisory committees; Millenium: Membership on an entity's Board of Directors or advisory committees; Astra Zeneca: Research Funding; Amgen: Membership on an entity's Board of Directors or advisory committees; Acetylon: Research Funding.
    Type of Medium: Online Resource
    ISSN: 0006-4971 , 1528-0020
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    Language: English
    Publisher: American Society of Hematology
    Publication Date: 2011
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  • 3
    In: British Journal of Haematology, Wiley, Vol. 166, No. 3 ( 2014-08), p. 401-409
    Abstract: Everolimus, an oral mammalian target of rapamycin ( mTOR ) inhibitor, has been studied in multiple myeloma (MM) but lacks significant single agent activity. Based on preclinical studies showing synergistic activity of mTOR inhibitors with lenalidomide, we studied the combination of lenalidomide and everolimus in relapsed or refractory MM in a phase I clinical trial. We assessed patient samples using gene expression, Western blotting and immunohistochemistry to probe the mTOR pathway. Twenty‐six patients were evaluable for toxicity. Dose‐limiting toxicities included grade 4 neutropenia and thrombocytopenia. The maximum tolerated dose was lenalidomide 15 mg and everolimus 5 mg for 21 d with a 7 d rest period. Grade 3/4 adverse events included thrombocytopenia (35%) and neutropenia (42%). The overall response rate was 65% (1 complete response + 4 partial response + 10 minimal response). The median progression‐free survival was 5·5 months and median overall survival was 29·5 months. Biomarker data demonstrated downregulation of phosphorylated p70S6K. Gene expression profiling suggested activation of mTOR in responders versus non‐responders. The combination of lenalidomide and everolimus was well tolerated with predictable toxicities and showed responses in a heavily pretreated population. When confirmed with larger patient numbers, this analysis may guide patient selection for future clinical trials of mTOR inhibition in MM.
    Type of Medium: Online Resource
    ISSN: 0007-1048 , 1365-2141
    URL: Issue
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    Language: English
    Publisher: Wiley
    Publication Date: 2014
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  • 4
    In: Blood, American Society of Hematology, Vol. 118, No. 21 ( 2011-11-18), p. 1590-1590
    Abstract: Abstract 1590 Background: The occurrence of a secondary lymphoma in patients with a prior history of B-cell lymphomas has been reported.1, 2 There are few reported occurrences of Multiple Myeloma (MM) in patients (pts) with a prior history of lymphoma and the biologic relationship between the two neoplasms in such cases is unknown. Methods: We queried our IRB approved clinicopathologic database of hematologic malignancies for patients with lymphoma and MM. Of the 4165 pts with B-cell lymphoma and 804 pts with MM, 6 pts with a history of B-cell lymphoma developed MM and 1 patient with a prior history of MM developed a B-cell lymphoma. We describe the morphology, immunophenotype, and clinical features of the 7 pts. The clonal relationship of the 2 components was analyzed using sequencing analysis of immunoglobulin heavy chain variable region (IgVH) genes and by light chain restriction. Results: There were 5 men and 2 women (median age of diagnosis of lymphoma, 65 years; median age of diagnosis of MM, 71 years). The pts with lymphoma included 2 pts with diffuse large B cell lymphoma, 2 pts with small lymphocytic lymphoma, 2 pts with follicular lymphoma and 1 patient with lymphoplasmacytic lymphoma. The development of MM was metachronous in 5 cases, following B-cell lymphoma by 3 years to 23 years and synchronous in 1 case. In 1 patient, the B-cell lymphoma developed 6 years after the diagnosis of MM. 6 pts achieved complete remission after treatment for lymphoma and 1 patient is ongoing treatment. 6 of the 7 pts required treatment for MM soon after diagnosis. 1 patient has smoldering MM and continues to be observed 57 months after diagnosis. FISH analysis indicated IgH rearrangement in 3 pts with MM; 1 patient with 17p deletion and monosomy 13; 3 pts had normal FISH and metaphase cytogenetics. In 3 pts, both neoplasms were kappa light chain restricted; in 1 patient both were lambda restricted; in 1 patient, the lymphoma was lambda light chain restricted while the MM was kappa light chain restricted and the reverse in another pt; in 1 patient the B-cell lymphoma was light chain negative and the MM was kappa restricted. IgVH rearrangement studies in 4 patients in whom tissue samples were available indicated that the two were clonally unrelated in 3 patients and related in only 1 patient. Conclusion: Clonality analysis of rearranged immunoglobulin genes from patients with both B-cell lymphoma and MM provide evidence of separate clonal origins of the two tumors in the majority of cases, thus excluding secondary transformation of the original B-cell clone. The presence or absence of a genetic predisposition to the development of multiple B cell malignancies requires further study.3 Disclosures: Off Label Use: The combination of lenalidomide and everolimue is an off label use in multiple myeloma. Abramson:Genentech: Consultancy; Novartis: Consultancy. Raje:Amgen: Membership on an entity's Board of Directors or advisory committees; Astra Zeneca: Research Funding; Millenium: Membership on an entity's Board of Directors or advisory committees; Novartis: Membership on an entity's Board of Directors or advisory committees; Celgene: Membership on an entity's Board of Directors or advisory committees; Acetylon: Research Funding.
    Type of Medium: Online Resource
    ISSN: 0006-4971 , 1528-0020
    RVK:
    RVK:
    Language: English
    Publisher: American Society of Hematology
    Publication Date: 2011
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  • 5
    Online Resource
    Online Resource
    AME Publishing Company ; 2017
    In:  Translational Cancer Research Vol. 6, No. 1 ( 2017-02), p. 109-116
    In: Translational Cancer Research, AME Publishing Company, Vol. 6, No. 1 ( 2017-02), p. 109-116
    Type of Medium: Online Resource
    ISSN: 2218-676X , 2219-6803
    Language: Unknown
    Publisher: AME Publishing Company
    Publication Date: 2017
    detail.hit.zdb_id: 2901601-0
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  • 6
    In: Blood, American Society of Hematology, Vol. 118, No. 21 ( 2011-11-18), p. 3716-3716
    Abstract: Abstract 3716 Background: Rituximab monotherapy as initial treatment for low-grade B-cell lymphomas produces responses in approximately 70% of patients with one third achieving a complete response, and progression-free survival (PFS) of approximately 2 years. Maintenance rituximab appears to prolong initial remissions after rituximab alone. Current dosing for rituximab is largely empiric, so we sought to investigate whether increased doses of rituximab induction would increase the complete response rate (CRR) over that expected from standard dose rituximab. We also sought to assess whether high-dose induction followed by standard maintenance would produce a PFS comparable with that of combination chemoimmunotherapy strategies. Methods: We conducted a phase II trial of increased-dose rituximab monotherapy induction, followed by a standard maintenance schedule. Eligible patients were adults with previously untreated low-grade B-cell lymphomas with measurable disease 〉 2cm and were not candidates for potentially curative radiotherapy to localized disease. Subjects were treated with induction rituximab at a dose of 750 mg/m2 on days 1,8,15, and 22. Patients without progressive disease were then treated with maintenance rituximab at 375mg/m2 every 3 months for 8 doses or until disease progression. The primary end point was CRR as defined by the International Workshop Response Criteria (1999). Secondary endpoints included overall response rate (ORR), PFS, and toxicity. The study was designed with 90% power to show a 50% CRR, with a 30% CRR considered unworthy of further study. Results: Between August 2009 and August 2010, 40 eligible subjects were enrolled (31 grade 1–2 follicular lymphomas, 4 marginal zone lymphomas, 3 small lymphocytic lymphomas, and 2 indolent B cell lymphoma not otherwise specified). The median age was 60 (range 36–88) All subjects had advanced Ann Arbor stage disease. Twenty-two subjects (55%) had involvement of 〉 4 nodal sites, 6 (15%) had a Hgb 〈 12 and 9 (23%) had an elevated LDH. Six subjects (15%) were low risk by the follicular lymphoma prognostic index(FLIPI), 15 (38%) were intermediate risk, and 17 (43%) were high risk. The FLIPI was not available for 2 patients. One patient was not evaluable for the 4 week response assessment in induction due to withdrawal of consent after 3 weeks of therapy. After induction therapy, 1 subject had a CR (3%), 18 had a PR (46%), and 20 had SD (51%). No subjects had progressive disease after induction and all evaluable patients had a reduction in tumor size. With a median number of 4 (range 1–6) maintenance cycles, the CRR increased to 30%, with PRR of 38% and SD in 15% (fig. 1). The PFS at 12 months was 89% [95% CI, 73– 96]. A total of 5 subjects progressed during maintenance therapy, 2 subjects after 3 cycles, 1 after 2 cycles and 2 after 1 cycle. Treatment was well tolerated with only 3 cases (7.5%) of grade 3/4 neutropenia. Twenty three (58%) subjects had allergic reactions with infusions but only 2 (5%) were grade 3 reactions. Conclusions: Increased dose rituximab monotherapy is well tolerated, but does not improve the CRR compared to what would be expected from rituximab at standard doses. Significant improvement in the CRR occurred with ongoing maintenance therapy, and the vast majority of patients remain in remission after 1 year. Ongoing follow-up will determine whether this approach produces a PFS comparable to a chemoimmunotherapy treatment program. Disclosures: Hochberg: Genentech: Consultancy. Fisher:Genentech: Consultancy. Abramson:Genentech: Consultancy.
    Type of Medium: Online Resource
    ISSN: 0006-4971 , 1528-0020
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    Language: English
    Publisher: American Society of Hematology
    Publication Date: 2011
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  • 7
    In: Blood, American Society of Hematology, Vol. 118, No. 21 ( 2011-11-18), p. 2916-2916
    Abstract: Abstract 2916 Inhibition of the PI3K/mTOR pathway is a promising therapeutic strategy in targeting multiple myeloma (MM) cells in the bone marrow (BM) microenvironment, which abnormally activates PI3K/mTOR signaling cascade mediating proliferation, anti-apoptosis and drug resistance. Exploring the targeting of PI3K/mTOR pathway has led to the development of different therapeutic approaches; however, mTORC1 inhibitors (i.e., temsirolimus and everolimus) have demonstrated only modest activity as single agents. In this regard, several mechanisms underlying rapamycin resistance, including mTOR/S6K1-mediated feedback loops resulting in activation of PI3K/Akt and ERK signaling, have been proposed. Importantly, recent studies have identified mTOR kinase and the mTOR-DEPTOR counter-regulatory cascade as key mediators of mTORC1 and mTORC2 multi-protein complexes, with differential sensitivity to rapamycin. Indeed, targeting DEPTOR/mTORC1/mTORC2 signaling by inhibition of mTOR kinase proved an effective strategy to overcome some of the limitations of TORC1 inhibition in MM cells, evidenced in our studies of the novel dual mTORC1 and mTORC2 selective inhibitor AZD8055. Unlike rapamycin, AZD8055 induced apoptosis and inhibited MM cell growth even when co-cultured with cytokines (i.e., IL-6, IGF1) or BMSCs, presumably through simultaneous suppression of mTORC1 and mTORC2 signaling including the rapamycin-resistant 4E-BP1 (downstream of mTORC1) and Akt as well as NDRG1 (effectors of mTORC2). We examined mRNA and protein level of DEPTOR in MM cell lines treated with AZD8055 versus rapamycin and observed no significant changes. To examine the functional significance of DEPTOR in response to mTOR inhibitors, we utilized lentiviral shRNA to knockdown DEPTOR in OPM1 MM cells. DEPTOR-knockdown cells acquired resistance to AZD8055 treatment, suggesting that DEPTOR is a key modulator of mTORC1/2 signaling. Moreover, DEPTOR knockdown triggered decrease in Akt phosphorylation (Ser473), associated with suppression of Rictor phosphorylation (Thr1135). DEPTOR co-immunoprecipitation with Rictor was also abrogated by both AZD8055 and rapamycin treatment. Taken together, our results indicate the role of DEPTOR, either alone or as an mTOR/Rictor interacting molecule, in mediating the anti-MM activity induced by mTOR kinase inhibitors in MM cells. These data therefore both provide insights into the molecular profiles that may predict sensitivity/resistance to second generation of mTOR inhibitors in MM, and may be useful to select MM patients for mTOR inhibitor therapy. Disclosures: Hideshima: Acetylon: Consultancy. Anderson:Celgene: Membership on an entity's Board of Directors or advisory committees; Millennium: Membership on an entity's Board of Directors or advisory committees; Onyx: Membership on an entity's Board of Directors or advisory committees; Merck: Membership on an entity's Board of Directors or advisory committees; Bristol Myers Squibb: Membership on an entity's Board of Directors or advisory committees; Novartis: Membership on an entity's Board of Directors or advisory committees; Acetylon: Membership on an entity's Board of Directors or advisory committees. Guichard:AstraZeneca, UK: Employment, Shares from AstraZeneca, UK. Raje:Celgene: Membership on an entity's Board of Directors or advisory committees; Novartis: Membership on an entity's Board of Directors or advisory committees; Millenium: Membership on an entity's Board of Directors or advisory committees; Astra Zeneca: Research Funding; Amgen: Membership on an entity's Board of Directors or advisory committees; Acetylon: Research Funding.
    Type of Medium: Online Resource
    ISSN: 0006-4971 , 1528-0020
    RVK:
    RVK:
    Language: English
    Publisher: American Society of Hematology
    Publication Date: 2011
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  • 8
    In: Leukemia Research, Elsevier BV, Vol. 74 ( 2018-11), p. 130-136
    Type of Medium: Online Resource
    ISSN: 0145-2126
    Language: English
    Publisher: Elsevier BV
    Publication Date: 2018
    detail.hit.zdb_id: 2008028-1
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  • 9
    In: Biology of Blood and Marrow Transplantation, Elsevier BV, Vol. 24, No. 2 ( 2018-02), p. 228-241
    Type of Medium: Online Resource
    ISSN: 1083-8791
    Language: English
    Publisher: Elsevier BV
    Publication Date: 2018
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    detail.hit.zdb_id: 2057605-5
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  • 10
    In: Bone Marrow Transplantation, Springer Science and Business Media LLC, Vol. 53, No. 5 ( 2018-05), p. 535-555
    Type of Medium: Online Resource
    ISSN: 0268-3369 , 1476-5365
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    Language: English
    Publisher: Springer Science and Business Media LLC
    Publication Date: 2018
    detail.hit.zdb_id: 2004030-1
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