PDF file - 53K, Validation of gene expression data using QPCR compared to microarray values (data reported as fold change).

PDF file - 60K, Kaplan-Meier estimates of (A)PFS and (B)OS in patients in the ITT population (N-38).

PDF file - 72K, Most common all-grade and grade ≥3 AEs during DoVeD induction and bortezomib-based stem cell mobilization.

PDF file - 59K, Responses rates after DoVeD induction, bortezomib- or non-bortezomib-based mobilization, and SCT.

PDF file - 58K, Study design and patient flow by intent to treat (ITT).

Abstract Purpose: This phase II study evaluated bortezomib-based secondary induction and stem cell mobilization in 38 transplant-eligible patients with myeloma who had an incomplete and stalled response to, or had relapsed after, previous immunomodulatory drug-based induction. Experimental Design: Patients received up to six 21-day cycles of bortezomib plus dexamethasone, with added liposomal doxorubicin for patients not achieving partial response or better by cycle 2 or very good partial response or better (≥VGPR) by cycle 4 (DoVeD), followed by bortezomib, high-dose cyclophosphamide, and filgrastim mobilization. Gene expression/signaling pathway analyses were conducted in purified CD34+ cells after bortezomib-based mobilization and compared against patients who received only filgrastim ± cyclophosphamide. Plasma samples were similarly analyzed for quantification of associated protein markers. Results: The response rate to DoVeD relative to the pre-DoVeD baseline was 61%, including 39% ≥VGPR. Deeper responses were achieved in 10 of 27 patients who received bortezomib-based mobilization; postmobilization response rate was 96%, including 48% ≥VGPR, relative to the pre-DoVeD baseline. Median CD34+ cell yield was 23.2 × 106 cells/kg (median of 1 apheresis session). After a median follow-up of 46.6 months, median progression-free survival was 47.1 months from DoVeD initiation; 5-year overall survival rate was 76.4%. Grade ≥3 adverse events included thrombocytopenia (13%), hand–foot syndrome (11%), peripheral neuropathy (8%), and neutropenia (5%). Bortezomib-based mobilization was associated with modulated expression of genes involved in stem cell migration. Conclusion: Bortezomib-based secondary induction and mobilization could represent an alternative strategy for elimination of tumor burden in immunomodulatory drug-resistant patients that does not impact stem cell yield. Clin Cancer Res; 19(6); 1534–46. ©2013 AACR.

Abstract Abstract 4349 Background The combination of lenalidomide (Len, Revlimid®), bortezomib (Bz, Velcade®), and dexamethasone (dex; RVD) has shown excellent efficacy in relapsed/refractory multiple myeloma (MM) patients, with overall response rates (ORR) of 69%, including 26% complete/near complete responses (CR/nCR), and manageable toxicities (Anderson et al. ASCO 2009). The phase I portion of the study (Richardson et al. IMW 2009) found the maximum tolerated dose (MTD) of this combination in newly diagnosed MM patients to be Len 25 mg/day, Bz 1.3 mg/m2, and dex 20 mg. In all phase I patients, the ORR (PR or better) was 100%, including 31% CR, 9% nCR, and 75% ≥very good partial response (VGPR). Results reported here are for patients treated in the phase II portion of the study. Methods Patients were treated with Len 25 mg/day (days 1–14), Bz 1.3 mg/m2 (days 1, 4, 8, 11), and dex 20 mg (cycles 1–4) and 10 mg (cycles 5–8) on the day of and day after Bzfor up to eight 21-day cycles. Patients received prophylactic anticoagulants. Responses were assessed by modified EBMT and Uniform criteria to include nCR and VGPR. Patients with at least partial response (≥PR) could proceed to ASCT after ≥4 cycles; responding patients who did not go on to ASCT could continue therapy at their physician's discretion. Patients with ≥grade 2 peripheral neuropathy (PNY) by CTCAE v3 were excluded. Thirty five patients were enrolled in the phase II portion of this study and were evaluable for both efficacy and safety. Results Median age was 59 years (range 22-86), 54% were men, 34% / 54% / 11% were ISS Stage I / II / III, and 57% / 31% had IgG / IgA MM, respectively. Patients received a median of 8 cycles of Bz and dex and 11 cycles of Len; 11 (31%) patients remain on therapy. Among the 24 patients who have gone off therapy, 5 (21%) completed treatment per protocol, 8 (33%) proceeded to ASCT, 3 (13%) had progressive disease (all during cycle 14 or later), 1 (4%) withdrew due to toxicities, 1 (4%) received non-protocol therapy, and the remaining (n=6; 25%) withdrew consent or stopped treatment due to physician decision. All patients (100%) had a best confirmed pre-ASCT response of ≥PR, with 54% CR/nCR and 69% ≥VGPR (Table). Response rates in the 31 and 24 patients who completed 4 and 8 cycles, respectively, are shown in the Table. Among the 24 patients without CR at cycle 4, response improved between cycles 4 and 8 in 16 (67%) patients. Fifteen of the 35 (43%) patients were mobilized for ASCT, with a median stem cell yield of 4.4 × 106 (2.3–6.6 × 106) CD34+ cells/kg. After median follow-up of 19.3 months, median time to progression (TTP), progression-free survival (PFS), and overall survival (OS) have not been reached; the estimated 1-year TTP and PFS are 76% and the estimated OS is 100%. Treatment-emergent grade 3 and 4 adverse events that occurred in >1 patient included lymphopenia (n=7; 20%), hypokalemia (n=3; 9%), and fatigue and neutropenia (n=2; 6% each). Sensory PNY of any grade occurred in 27 (77%) patients, which was grade 1 (n=18; 67%) and grade 2 (n=8; 30%) in the majority of patients; only one patient had grade 3 sensory PNY. Neuropathic pain and motor PNY were reported in 10 (29%; all grade 1 and 2) and 6 (17%; 1 grade 3) patients, respectively, with no grade 3 PNY seen. Importantly, PNY was reversible with dose reduction, supportive care, and/or completion of therapy. Thrombosis/thromboembolism was reported in just 2 (6%) patients. No treatment-related mortality was seen. Conclusion These phase II results suggest that RVD is a highly effective combination, with a pre-ASCT ORR of 100% and high rates of CR/nCR, and encouraging time-to-event analyses to date. RVD was well tolerated, with limited rates of grade 3 PNY and DVT/PE despite prolonged use of Bz and Len. Data from patients treated at the MTD in phase I and the impact of adverse risk factors (including advanced stage and high-risk cytogenetics) on outcome, as well as following ASCT, will be reported at the meeting. Based upon these promising results, phase II/III studies of RVD and RVD-based combinations are either planned or ongoing. Disclosures: Mark: Celgene: Research Funding, Speakers Bureau. Skerrett:Angioblast Systems, Inc.: Consultancy, Equity Ownership; Mesoblast Ltd: Consultancy, Equity Ownership; Council of Human Blood and Transfusion Services for NYS DOH: Membership on an entity's Board of Directors or advisory committees. Schuster:Celgene: Speakers Bureau; Genzyme: Membership on an entity's Board of Directors or advisory committees; Millennium Pharmaceuticals, Inc.: Speakers Bureau. Shore:Millennium: Membership on an entity's Board of Directors or advisory committees. Zafar:Celgene Corp: Speakers Bureau; Millenium: Speakers Bureau. Niesvizky:Celgene: Consultancy, Research Funding, Speakers Bureau; Millennium Pharmaceuticals, Inc.: Consultancy, Research Funding, Speakers Bureau; Proteolix: Consultancy, Research Funding.

Abstract 1861 Poster Board I-886 Background: BiRD therapy (clarithromycin/[Biaxin®], lenalidomide/[Revlimid®], dexamethasone) for use as upfront therapy in symptomatic multiple myeloma in 72 patients yielded impressive results: over 90% achieved at least a partial response (PR), with nearly 40% in complete response (CR). We hypothesized that we could safely increase the immunomodulatory benefit of the BiRD combination with the addition of low-dose thalidomide to the regimen, since these drugs have non-overlapping toxicities. A trial of T-BiRD (thalidomide, clarithromycin/[Biaxin®], lenalidomide/[Revlimid®], dexamethasone) therapy for use in up-front treatment of symptomatic multiple myeloma (MM) was initiated to test safety and efficacy. Methods: Eighteen patients were enrolled in a single-institution trial of T-BiRD therapy for symptomatic MM. The T-BiRD regimen consists of clarithromycin 500mg twice daily, dexamethasone on days 1,8,15,22 of a 28-day cycle, and lenalidomide 25mg for days 1–21 of a 28-day cycle. Thalidomide is given at a dose of 50mg daily for the first week and thereafter at 100mg daily. Thromboprophylaxis with aspirin (162 mg once weekly, 81mg on subsequent days) was used for all subjects. Serum protein electrophoresis/immunofixation as well as free light chain determinations were done monthly. Bone marrow biopsy and either skeletal imaging were done at to confirm disease progression or CR. This protocol continues to accrue with a planned enrollment of 25 patients. Results: The median number of T-BiRD cycles was 5.5 (range 1–6). Twelve patients (67%) had achieved at least a partial response (PR) by cycle 1, compared to a median response time of 2 cycles for BiRD. Mean percent drop in M-protein for evaluable patients at each cycle is as follows: Cycle 1 – 61%, Cycle 2 – 77%, Cycle 3 – 79%, Cycle 4 – 81%, Cycle 5 – 93%, Cycle 6 – 92%. For 9 subjects who received 5 cycles of therapy, the overall response rate was 100%, with all but one subject achieving a VGPR or better. On an intent to treat basis, the VGPR or better rate was 55% because of patient withdrawal due to toxicity. A total of 10 subjects (56%) experienced an adverse event (AE), some study-drug related (RAE) during treatment. Seven subjects (39%) withdrew from the study due to drug toxicity: 2 had grade 2 skin rash prior to initiation of full-dose thalidomide (RAE), 1 patient had grade 4 skin rash (Stevens-Johnsons syndrome, SJS) during cycle 1 of T-BiRD (RAE), 1 had a TIA in cycle 2, 1 developed renal failure in cycle 1, 1 developed chest pain in cycle 3. Other toxicities include 1 patient with Grade 2 steroid myopathy (RAE), 1 patient with DVT of the leg (RAE), and 1 patient with atrial fibrillation. 1 subject died of progressive myeloma prior to completion of 1 cycle. Conclusions: T-BiRD is a highly effective first-line regimen for rapid and profound treatment response of multiple myeloma. Toxicity from T-BiRD may preclude its long-term use since many of the enrolled patients experienced an adverse event. Disclosures: Mark:Celgene: Research Funding, Speakers Bureau. Zafar:Celgene Corp: Speakers Bureau; Millenium: Speakers Bureau. Crann:Milllennium: Membership on an entity9s Board of Directors or advisory committees. Niesvizky:Celgene: Consultancy, Research Funding, Speakers Bureau; Millennium Pharmaceuticals, Inc.: Consultancy, Research Funding, Speakers Bureau; Proteolix: Consultancy, Research Funding.

Abstract Abstract 2311 Poster Board II-288 Improved quality of response to induction therapy has been shown to be associated with improved long-term outcomes, including prolonged progression-free (PFS), event-free, and overall survival (OS), in newly diagnosed multiple myeloma (MM) patients (pts). Induction regimens incorporating the proteasome inhibitor bortezomib and the immunomodulatory drugs (IMiDs) thalidomide and lenalidomide have demonstrated high overall response rates (ORR), and substantial complete response (CR) and very good partial response (VGPR) rates in MM; however, while a large majority of pts respond, a proportion does not achieve ≥VGPR. Per the Norton–Simon hypothesis, the sequential, dose dense, use of agents or regimens that are not cross-resistant may improve the proportion of pts achieving CR or VGPR to induction therapy, and subsequently improve long-term outcomes. This phase II pilot study investigated the efficacy and safety of bortezomib + dexamethasone ± liposomal doxorubicin (DoVeD) in MM pts who had reached a response plateau (<25% change in M-protein level for three successive assessments) after achieving a partial response (PR) to initial induction with IMiD-containing therapy. All pts proceeded to high-dose therapy and stem cell transplantation. Pts received six 3-week cycles of bortezomib 1.3 mg/m2 on days 1, 4, 8, and 11, plus dexamethasone 40 mg on days 1–4, 8–11, and 15–18. Pts achieving Table Patient baseline demographics and disease characteristics Characteristic* N=34 Age, years 60.5 (27-76) Male, n (%) 19 (56) B2-microglobulin, mg/L 2.1 (1.0-10.2) Albumin, g/dL 3.5 (2.0-4.3) Durie-Salmon Stage Ia / IIa / IIIa / IIIb, n 2 / 14 / 17 / 1 ISS Stage I / II / III, n 16 / 15 / 3 Abnormalities by FISH, n (%) del 13q14 13 (38) Trisomy 11 6 (18) Hyperdiploidy 5 (15) t(4;14) 4 (12) p53 3 (9) t(11;14) 2 (6) t(14;16) 2 (6) None 16 (47) * Median (range) shown unless stated Disclosures: Mark: Celgene: Membership on an entity's Board of Directors or advisory committees, Research Funding. Zafar:Celgene Corp: Speakers Bureau; Millenium: Speakers Bureau. Crann:Milllennium: Membership on an entity's Board of Directors or advisory committees. Leonard:Milllennium: Consultancy; Johnson & Johnson: Consultancy. Coleman:Celgene Corp: Speakers Bureau; Millenium: Speakers Bureau; Immunomedics: Membership on an entity's Board of Directors or advisory committees. Niesvizky:Celgene: Consultancy, Research Funding, Speakers Bureau; Millennium Pharmaceuticals, Inc.: Consultancy, Research Funding, Speakers Bureau; Proteolix: Consultancy, Research Funding.

Abstract Abstract 1877 Poster Board I-902 Background: PD 0332991 (PD) a potent orally bioavailable small molecule, is the only known CDK4/CDK6-specific inhibitor. Through selective inhibition of CDK4/6, PD induces G1 cell cycle arrest thereby preventing DNA replication. As PD acts reversibly, it can induce synchronous G1-S progression upon its discontinuation. It has been shown that PD potently induces G1 arrest in primary human bone marrow (BM) myeloma cells/lines in the presence of BM stroma and prevents tumor growth in animal models (IC50, ∼60 nM) (Baughn et al 2006). Moreover, it has been shown that induction of prolonged G1 arrest and synchronous S phase entry by PD profoundly enhances bortezomib (B) and dexamethasone (D) killing of primary BM myeloma cells in vitro and in animal models (Huang et al, unpublished). The synergistic anti-myeloma effect provides a compelling rationale for evaluating two methods of targeting CDK4/6 using PD in combination with B and D: a “concurrent regimen” aims at enhancing B killing during prolonged G1 arrest and a “sequential regimen” to enhance B killing during both G1 arrest and synchronous progression to S phase. Methods: Patients (pts) who had relapsed and refractory myeloma after at least 2 previous treatments and who were Rb positive were eligible. This phase 1 dose escalation study is being conducted to assess the safety, tolerability and pharmacokinetics of the combination including dose limiting toxicities (DLTs). PD was given orally once a day for 3 weeks (21 days) followed by one week (7 days) off (Schedule A), starting on Day 1 of each cycle. B was given during G1 arrest by IV bolus together with 20 mg PO of D on Days 8, 11, 15 and 18 of each cycle (up to a maximum of 10 cycles). The study design followed a 3+3 dose-escalation scheme, with planned doses of PD/B starting from 100 mg/1.0 mg/m2 and escalating up to a maximum dose of 125 mg/1.3 mg/m2, respectively. Alternatively, in case of toxicity, de-escalation was planned to a minimum dose of 50 mg/0.7 mg/m2 for PD/B, respectively. Results: Nine patients were enrolled in Schedule A. Pt characteristics included 90% > SD stage II, 50% > ISS stage II with median β2 M 4.0 (range 1.6–10.5), median serum albumin 3.8 (2.2–4.6), median Hgb 10.5 (8.1–14.4) and median calcium 9.9 (8.7–10.7) values at screening. The median number of prior therapies was 6 (2–10) with 7/9 pts showing progression to their latest prior therapy. One patient achieved VGPR (12.5%) while 1 patient each achieved MR and SD respectively for an ORR 25%. The VGPR and MR were achieved with the lowest dose combination (75 mg/0.7 mg/m2 PD/B). Six pts had progression of disease while on therapy. The most commonly reported adverse events were >Grade 3 reversible uncomplicated cytopenias. PD was absorbed relatively slowly with a median Tmax of 4 hours (range 2–8 hours). PD plasma exposures (normalized to the 100 mg dose level) ranged from 345–1128 ng.hr/mL for AUC 0–12 and from 36–111 ng/mL for Cmax and were consistent with those observed in prior solid tumor studies. Immunohistochemistry of BM on Day 8 (prior to initiation of BD) in 7/8 pts demonstrated preferential and complete inhibition of CDK4/6-specific phosphorylation of Rb and Ki67 in tumor cells. Follow up BMs after 21 days, showed G1-S cell cycle progression upon PD withdrawal, confirming PDs synchronization effect. Conclusions: Targeting CDK4/6 with PD to induce prolonged G1 arrest in combination with B/D represents the first mechanism-based targeting of the cell cycle in cancer, and it appears to be effective in MM. Pts are being actively accrued to Schedule B consisting of sequential PD-B/D (12 days of PD followed by B/D as in Schedule A) to assess the safety of this novel schedule and the efficacy following cell cycle synchronization. Disclosures: Niesvizky: Celgene: Consultancy, Research Funding, Speakers Bureau; Millennium Pharmaceuticals, Inc.: Consultancy, Research Funding, Speakers Bureau; Proteolix: Consultancy, Research Funding. Courtney:Pfizer: Employment. DuFresne:Pfizer: Employment. Wilner:Pfizer: Employment. Chen:Pfizer: Employment. Mark:Celgene: Speakers Bureau; Millenium: Speakers Bureau. Coleman:Bristol-Myers Squibb Research & Development: Consultancy.