BACKGROUND AND RATIONALE. Multiple myeloma (MM) is an incurable disease that is characterized
by the accumulation of clonal plasma cells in the bone marrow [1]. The median overall
survival for patients with myeloma is approximately 4-5 years, and MM remains an incurable
disease. Despite front line treatment approaches, the disease eventually relapses. While
patients with relapsed disease may achieve responses to subsequent antimyeloma therapies, the
duration of response decreases with successive relapses until resistant disease develops.
Until recently, the median survival following relapse after induction therapy was
approximately one year. The recent US Food and Drug Administration approvals of bortezomib
(2003) and combination lenalidomide plus dexamethasone (2006) therapies for the treatment of
previously treated MM has provided effective therapeutic options that give patients with
relapsed or refractory MM the prospect for a prolongation of overall and progression-free
survival times [2-4].
Although the introduction of novel agents to the autologous transplant procedure in patients
less than 65 years old or to the Melphalan Prednisone regimen in elderly patients has
significantly improved response rates and survival times, MM is a heterogeneous disease with
divergent outcomes driven by the biologic characteristics, especially cytogenetic
characteristics [5, 6]. Various studies have demonstrated that cytogenetic characteristic as
detected by fluorescent in situ hybridization (FISH) was one of the most powerful prognostic
marker in MM, especially presence of deletion of 17p13 (del17p) [6, 7] and translocation
t(4;14) [6, 7] that represent approximately 20% to 25% of patients in the series [8]. The
del(17p) and t(4;14) chromosomal abnormalities are associated with poor progression-free
survival and shorter overall survival in newly diagnosed MM patients treated with traditional
chemotherapy … The conclusion of recent studies were that a clear unmet medical need still
exists for additional novel therapeutic options for the treatment of MM with del17p and
t(4;14) and that novel agents should be proposed earlier in the patient evolution.
Pomalidomide belongs to the immunomodulators compounds which thalidomide is the parent
compound and lenalidomide the most recently approved agent [14]. It is derived from
thalidomide and shares a number of the beneficial pharmacologic properties with thalidomide.
The efficacy of thalidomide has been limited by adverse effects, which include sedation,
neuropathy, constipation, and deep vein thrombosis. This toxicity profile seems dose and
duration-related,which have the potential of improved potency and reduced toxicity. By
modifying the thalidomide structure through the addition of an amino group at the 4 position
of the phthaloyl ring, pomalidomide was generated.
… A phase 2 randomised open label study of 2 modalities of Pomalidomide plus low-dose
Dexamethasone in patients with Multiple Myeloma, refractory to both lenalidomide and
bortezomib was conducted. This study was addressed to patients with MM who were symptomatic
and progressive following at least two cycles of lenalidomide and two cycles of bortezomib
(either separately or in combination). This study provides further evidence that pomalidomide
has no-cross resistance with lenalidomide and suggests that it can provide benefit for
patients who have relapsed after other novel therapies. This data demonstrated that
pomalidomide has significant efficacy in MM and can be safely administered to myeloma
patients.
STUDY RATIONALE. There is an increasing number of patients with adverse karyotypic
abnormalities, such as del17p and t(4;14), that requires new therapeutic options to improve
progression free survival and ultimately overall survival. Based on recent studies, we
hypothesized that these patients might benefit from the combination of pomalidomide and
dexamethasone. We have therefore designed a Multicenter Open label Phase II study of
Pomalidomide and Dexamethasone in Progressive Relapsed or refractory Multiple Myeloma
patients with deletion 17p or translocation (4;14) Adverse Karyotypic Abnormalities. This
study will determine the efficacy and toxicity profile of pomalidomide and dexamethasone in
patients with adverse prognostic factors as determined using adverse karyotypic abnormalities
and that are in desperate need of novel therapeutics. This study will be conducted in
accordance with "good clinical practice" and all applicable regulatory requirements,
including, where applicable, the 2008 version of the Declaration of Helsinki.
STUDY INDICATION In relapsed and refractory MM patients, who are progressive, with MM
characterized by Deletion 17p or translocation (4;14) Adverse Karyotypic Abnormalities STUDY
DESIGN Overall design. This study is a Multicenter, Open-label, Single arm, Phase 2 study of
pomalidomide and dexamethasone in relapsed or refractory MM patients with deletion 17p and
translocation (4;14). Eligible patients must have a progressive, relapsed or refractory MM, a
deletion 17p and/or translocation (4;14) using FISH technique and a measurable disease. There
is no escalation dose study, the Maximum Tolerated Dose has already been determined in
previous phase 1-2 escalation dose studies as 4 mg/day on day 1 to 21 of a 28 days cycle. The
proposed dose of dexamethasone is considered standard. Patients will receive the pomalidomide
and dexamethasone regimen until progression. This study will eventually improve time to
disease progression and response rates, with no additional toxicity, as compared to other
available regimens, in this subgroup of patients with myeloma characterized with an adverse
prognosis.
Regimen Pomalidomide 4mg/day, oral route, from day 1 to 21 per 28 days cycle Dexamethasone
40mg weekly, oral route, on day 1, 8, 15, 22 per 28 days cycle for patients aged less than 75
years, and 20 mg once weekly oral route per 28 days cycle for patients aged 75 years and
above.
Until progression either relapse or refractory.
Potentially eligible patients and informed of their rights and how to achieve the study will
sign informed consent prior to undergoing any study-related procedures. Patients will undergo
screening assessments for protocol eligibility within 28 days of randomization.
For all patients who enroll into this study, study visits and serial measurements of safety
and efficacy will be performed on a monthly basis for the first 12 months then on a 2-months
basis thereafter. Tumor response, including progressive Disease, will be assessed according
to the IMWG criteria. The severity of Adverse Events will be graded according to the National
Cancer Institute Common Terminology Criteria for Adverse Events version 3.0. In this study, a
central laboratory will analyze serum and urine protein electrophoresis tests (myeloma
[M]-protein levels), serum and urine immunofixation studies (CHRU Lille). FISH cytogenetic
will be performed in Nantes for all patients in the study.
Efficacy assessments will occur on a monthly basis (28 days, designated as Study Day) for the
first 12 months then on a 2-months basis thereafter, regardless of current cycle day, and can
be performed within 3 days to day one of the cycle. Study of vital signs and performance
status is requested at Study Day.
Study Day 1 of Open-Label Treatment will occur on the day the patient starts the
pomalidomide-dexamethasone regimen. This regimen is given on oral route for the 2 therapeutic
agents tested. complete blood (cell) count will be monitored at least every 7 days (weekly)
during the first cycle. It will also be monitored at the first day of each cycle thereafter.
Recommended concomitant therapy. All medications (prescription and non-prescription),
treatments and therapies taken from 28 days prior to initiation of the study through the last
dose of study drug, must be recorded in the case report form. Any treatments or therapies
used to treat a Serious Adverse Event that occur within 28 days of discontinuation of study
drug must also be documented.
In addition, all patients will be given prophylactic anti-thrombotic treatment, either
aspirin daily (commercial supply) if the patient has no prior history of thrombosis events or
low molecular weight heparin according to hospital guidelines or physician preference. All
prophylactic antithrombotic treatment unless contraindicated according to hospital guidelines
or physician preference must be recorded. All patients will be monitored for signs and
symptoms of venous thromboembolism while on Pomalidomide.
The use of hematopoietic growth factors is permitted during the study. The use of
bisphosphonates is permitted throughout the study at the discretion of the Investigator.
Other therapies considered necessary for the patient's well being may be administered at the
discretion of the Investigator. These therapies may include antibiotics, analgesics,
antihistamines, or other medications and transfusions of red blood cells, platelets, or fresh
frozen plasma given to assist in the management of complications associated with multiple
myeloma or its therapy.
Prohibited concomitant therapy Concomitant use of sargramostim, other anti-cancer therapies,
including thalidomide, or other investigational agents is not permitted while subjects are
receiving study drug of the study. The need for radiation therapy is considered to be a
treatment failure. However, an exception (that is patients allowed to remain in the treatment
phase of the study) is made for radiation therapy to a pathological fracture site to enhance
bone healing or to treat post-fracture pain that is refractory to narcotic analgesics because
pathologic bone fractures do not by themselves fulfill a criterion for disease progression
End of study treatment. Patients may continue study treatment until Progression develops
(last study drug intake of pomalidomide-dexamethasone regimen) at which time they will
complete a Treatment Discontinuation visit as outlined in Table 2.
Follow-Up. Upon discontinuation from pomalidomide-dexamethasone study treatment for
Progression or any other reason, patients will be assessed for 28 days. Serious Adverse
Events will continue to be collected on patients during the first 28 days in Follow-Up. FCBP
will have a final pregnancy test 28 days after the last dose of study drug if they have
regular or no menstrual cycles; or 14 and 28 days after the last dose if menstrual cycles are
irregular. In addition, patients who are discontinued from study treatment will be followed
for overall survival and subsequent MM treatment regimens.
Patients who discontinue treatment for other reason than Progression will have response
determined until Progression or until start of further myeloma therapy.
All patients will have survival data entered in the Case Report Form after progression, along
with subsequent myeloma treatments.
Dose Interruption and Modification. Dose interruption and reduction for
pomalidomide-dexamethasone regimen will be provided.
PHASE OF DEVELOPMENT 2 STUDY PRODUCTS This is a single arm phase 2 study. Each patient will
receive 28 day cycles of Pomalidomide and Dexamethasone treatment until progression, either
relapse or refractory.
Pomalidomide 4mg/day, oral route, from day 1 to 21 per 28 days cycle Dexamethasone 40mg
weekly, oral route, on day 1, 8, 15, 22 per 28 days cycle for patients aged less than 75
years, and 20 mg once weekly oral route per 28 days cycle for patients aged 75 years and
above.
Dose adaptation will be provided within the protocol
