Single-agent bortezomib in previously untreated multiple myeloma: efficacy, characterization of peripheral neuropathy, and molecular correlations with response and neuropathy

Abstract

PURPOSE To assess efficacy and safety of single-agent bortezomib in previously untreated patients with multiple myeloma, investigate prevalence of baseline and treatment-emergent polyneuropathy, and identify molecular markers associated with response and neuropathy. PATIENTS AND METHODS Patients received bortezomib 1.3 mg/m(2) on days 1, 4, 8, and 11, for up to eight 21-day cycles. A subset of patients underwent neurophysiologic evaluation pre- and post-treatment. Bone marrow aspirates were performed at baseline for exploratory whole-genome analyses. Results Among 64 patients, 41% had partial response or better, including 9% complete/near-complete responses; median duration of response was 8.4 months. Response rates did not differ in the presence or absence of adverse cytogenetics. After median follow-up of 29 months, median time to progression was 17.3 months. Median overall survival had not been reached; estimated 1-year survival was 92%. Thirty-two patients successfully underwent optional stem-cell transplantation. Bortezomib treatment was generally well tolerated. At baseline, 20% of patients had sensory polyneuropathy. Sensory polyneuropathy developed during treatment in 64% of patients (grade 3 in 3%), but proved manageable and resolved in 85% within a median of 98 days. Neurologic examination, neurophysiologic testing, and measurements of epidermal nerve fiber densities in 35 patients confirmed pretreatment sensory neuropathy in 20% and new or worsening neuropathy in 63%. Pharmacogenomic analyses identified molecular markers of response and treatment-emergent neuropathy, which will require future study. CONCLUSION Single-agent bortezomib is effective in previously untreated myeloma. Baseline myeloma-associated neuropathy seems more common than previously reported, and bortezomib-associated neuropathy, although a common toxicity, is reversible in most patients.

Fig 1.

(A) Kaplan-Meier estimates of time to progression (TTP), progression-free survival (PFS), and event-free survival (EFS). (B) Kaplan-Meier estimates of overall survival.

Fig 2.

Representative PGP9.5 immuno-labeled pretreatment images of axons in vertically sectioned punch skin biopsies from patients; stratum corneum of the epidermis is uppermost with dermis below. (A) Biopsy from a 46-year-old man that is devoid of expected axonal innervation at baseline. Quantitation of intraepidermal nerve fibers identified a neurite density of 65/mm² skin surface area, at the third centile for age and diagnostic of small-fiber polyneuropathy. (B) Biopsy from a 54-year-old woman before therapy. Quantitation of intraepidermal nerve fibers identified a neurite density of 325/mm² skin surface area, at the 78th centile for age, which is within the normal range. These tissues were photographed using a Leica Microsystems (Wetzlar, Germany) DM/LS light microscope (40x objective) coupled to an Olympus (Tokyo, Japan) DP25 Microscope Digital Camera. No digital processing was performed.