Bortezomib-Induced Perimyocarditis in a Multiple Myeloma Patient: A Case Report

Bortezomib (BTZ) is a proteasome inhibitor used in the treatment of multiple myeloma (MM) and other hematological malignancies. Although carfilzomib, a second-generation proteasome inhibitor, is most strongly associated with cardiotoxicity, BTZ has been associated with several cardiovascular complications including congestive heart failure, arrhythmias, and rarely myocarditis. Here, we report the first case of a BTZ-induced perimyocarditis. The patient was a 40-year-old woman with recently diagnosed MM who was admitted to the hospital with syncope at the start of her second cycle of induction therapy with BTZ, lenalidomide, and dexamethasone. She had a witnessed syncopal event in the emergency room with the telemetry showing sustained ventricular tachycardia. Laboratory workup showed elevated N-terminal pro B-type natriuretic peptide and normal troponin I. Transthoracic echocardiogram (TTE) showed a low ejection fraction of 40% with global hypokinesis of the left ventricle and trace pericardial effusion. Cardiac magnetic resonance imaging with gadolinium was consistent with acute myocarditis. The patient had recurrent pleuritic chest pain, and a repeat TTE showed worsening pericardial effusion consistent with pericarditis. Endomyocardial biopsy was done which showed nonspecific myocyte hypertrophy and foci of fibrosis, but was negative for giant cell myocarditis, hemochromatosis, and amyloidosis. Extensive infectious disease workup ruled out known infectious causes for perimyocarditis. Given the close timing between BTZ treatment (5 subcutaneous doses with a cumulative dose of 6.5 mg/m²), the absence of other iatrogenic or infectious causes, and probable or likely association with BTZ as assessed by the validated causality assessment scoring tools, it was concluded that the acute perimyocarditis was secondary to BTZ exposure. Here, we report the first case of BTZ-induced perimyocarditis and discuss the incidence and pathophysiology of BTZ-cardiovascular toxicity.

Integrative multi-omics identifies high risk multiple myeloma subgroup associated with significant DNA loss and dysregulated DNA repair and cell cycle pathways

Background Despite significant therapeutic advances in improving lives of multiple myeloma (MM) patients, it remains mostly incurable, with patients ultimately becoming refractory to therapies. MM is a genetically heterogeneous disease and therapeutic resistance is driven by a complex interplay of disease pathobiology and mechanisms of drug resistance. We applied a multi-omics strategy using tumor-derived gene expression, single nucleotide variant, copy number variant, and structural variant profiles to investigate molecular subgroups in 514 newly diagnosed MM (NDMM) samples and identified 12 molecularly defined MM subgroups (MDMS1-12) with distinct genomic and transcriptomic features. Results Our integrative approach let us identify NDMM subgroups with transversal profiles to previously described ones, based on single data types, which shows the impact of this approach for disease stratification. One key novel subgroup is our MDMS8, associated with poor clinical outcome [median overall survival, 38 months (global log-rank p-value < 1 × 10−6)], which uniquely presents a broad genomic loss (> 9% of entire genome, t-test p value < 1e−5) driving dysregulation of various transcriptional programs affecting DNA repair and cell cycle/mitotic processes. This subgroup was validated on multiple independent datasets, and a master regulator analyses identified transcription factors controlling MDMS8 transcriptomic profile, including CKS1B and PRKDC among others, which are regulators of the DNA repair and cell cycle pathways. Conclusion Using multi-omics unsupervised clustering we were able to discover a new high-risk multiple myeloma patient segment. This high-risk group presents diverse previously known genetic markers, but also a new characteristic defined by accumulation of genomic loss which seems to drive transcriptional dysregulation of cell cycle, DNA repair and DNA damage. Finally, our work identified various master regulators, including E2F2 and CKS1B as the genes controlling these key biological pathways.

Primary anti-infective prophylaxis during routine treatment of lymphoma in the United States: A large real-world cohort analysis.

268 Background: While infectious complications contribute to considerable morbidity and mortality in patients with cancer, most scenarios lack evidence to guide optimal anti-infective prophylaxis (AIP). We evaluated a large real-world dataset to identify baseline utilization and factors associated with AIP in patients with non-Hodgkin lymphoma (NHL) treated in the US-community setting. Methods: Using the nationwide Flatiron Health de-identified electronic health record-derived database (from ≈ 280 US cancer clinics), we selected patients treated prior to 7/1/2020 with 1) R-CHOP for DLBCL, 2) bendamustine and rituximab (BR) for CLL/SLL, or 3) ibrutinib for CLL/SLL. We limited our analysis to patients treated by providers with documented prescribing of guideline recommended anti-viral prophylaxis (ppx) during proteasome inhibitor administration to ≥1 multiple myeloma patient. Our main outcome was the documented use of primary AIP defined as anti-viral and/or pneumocystis jiroveci (PJP) ppx within +/- 14 days of treatment initiation. We also report the delayed documented AIP use from day 15 to 60. We applied separate multivariable logistic regression models to each setting to examine the associations of patient-level characteristics with primary AIP (including age, sex, race, region, insurance, ECOG, year of treatment initiation). Results: A total of 3,142 (R-CHOP for DLBCL), 2,180 (BR for CLL/SLL), and 3,590 (ibrutinib for CLL/SLL) patients were included, with median age of 69, 69, and 72 years, respectively. Primary AIP was most common during BR for CLL/SLL, with 16.8% receiving any AIP (antiviral 15.6%, PJP 7.3%). Primary AIP was used in 10.5% of DLBCL patients initiating R-CHOP (antiviral 7.6%, PJP 5.6%), with the lowest utilization of AIP during ibrutinib for CLL/SLL (any 6.4%, antiviral 5.6%, PJP 2.6%). In the delayed setting, an additional 4-6% and 2-5% received viral and PJP ppx, respectively. Across all three of our multivariable analyses, higher provider rate of anti-viral ppx during proteosome inhibitor administration in MM, residing in the Midwest (vs. Northeast), and more recent treatment initiation were associated with greater odds of AIP. Other patient characteristics (age, race, ECOG) were less consistently associated with AIP across models. Furthermore, C-statistics were <0.7 in all three models (0.660-0.685), suggesting suboptimal discrimination for AIP based on patient-level characteristics alone. Conclusions: We observed low utilization of primary AIP during treatment in three common NHL settings that lack clear consensus on AIP. Variation was not well explained by measured patient characteristics, and future studies should consider provider and system attributes. Ultimately, robust evidence generation (e.g. pragmatic clinical trials) and quality improvement measures are needed to optimize ppx during routine lymphoma management.

Integrative multi-omics identifies high risk Multiple Myeloma subgroup associated with significant DNA loss and dysregulated DNA repair and cell cycle pathways

Background Despite significant therapeutic advances in improving lives of Multiple Myeloma (MM) patients, it remains mostly incurable, with patients ultimately becoming refractory to therapies. MM is a genetically heterogeneous disease and therapeutic resistance is driven by a complex interplay of disease pathobiology and mechanisms of drug resistance. We applied a multi-omics strategy using tumor-derived gene expression, single nucleotide variant, copy number variant, and structural variant profiles to investigate molecular subgroups in 514 newly diagnosed MM (NDMM) samples and identified 12 molecularly defined MM subgroups (MDMS1-12) with distinct genomic and transcriptomic features. Results Our integrative approach let us identify ndMM subgroups with transversal profiles to previously described ones, based on single data types, which shows the impact of this approach for disease stratification. One key novel subgroup is our MDMS8, associated with poor clinical outcome [median overall survival, 38 months (global log-rank pval < 1x10− 6)], which uniquely presents a broad genomic loss (> 9% of entire genome, t.test pval < 1e-5) driving dysregulation of various transcriptional programs affecting DNA repair and cell cycle/mitotic processes. This subgroup was validated on multiple independent datasets, and a master regulator analyses identified transcription factors controlling MDMS8 transcriptomic profile, including CKS1B and PRKDC among others, which are regulators of the DNA repair and cell cycle pathways. Conclusion Using multi-omics unsupervised clustering we were able to discover a new high-risk multiple myeloma patient segment. This high-risk group presents diverse previously known genetic markers, but also a new characteristic defined by accumulation of genomic loss which seems to drive transcriptional dysregulation of cell cycle, DNA repair and DNA damage. Finally, our work identified various master regulators, including E2F2 and CKS1B as the genes controlling these key biological pathways.

Nocardia farcinica Brain Abscess in a Multiple Myeloma Patient Treated with Proteasome Inhibitor: A Case Report and Review of the Literature

Nocardia brain abscess is relatively rare, accounting for about 1–2% of all brain abscesses, and its mortality rate is three times higher than of other types of bacterial brain abscesses; thus, early diagnosis and treatment are essential. Nocardia brain abscess generally occurs in immunodeficient patients. We report a case of Nocardia farcinica brain abscess in a multiple myeloma patient treated with proteasome inhibitor (bortezomib and ixazomib), cyclophosphamide, and corticosteroid. The patient was treated with ceftriaxone and trimethoprim-sulfamethoxazole, together with drainage of the brain abscess. Regular brain MRI follow-ups showed that intracranial lesions were gradually absorbed and improved.