`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`ANTITUMOR ACTIVITY OF THALIDOMIDE IN REFRACTORY MULTIPLE MYELOMA
`
`ANTITUMOR ACTIVITY OF THALIDOMIDE IN REFRACTORY
`MULTIPLE MYELOMA
`
`S
`EEMA
`
` R
`, M.S., P
` A
`, M.D., D
` D
`, M.D., R
` M
`, M.D., J
` S
`OBERSON
`AULA
`YERS
`AN
`ESIKAN
`AMAN
`EHTA
`AYESH
`INGHAL
`P
` E
`, B.S., N
` M
`, M.D., E
` A
`, M.D., C
` W
`, M.D., P
`.D.,
`LIAS
`UNSHI
`IKHIL
`AUL
`DDLEMON
`NAISSIE
`ARLA
`ILSON
`H
`M
` D
`, M.D., J
` Z
`, M.D.,
` B
` B
`, M.D., P
`.D.
`ADHAV
`HODAPKAR
`EROME
`ELDIS
`AND
`ART
`ARLOGIE
`H
`
`, P
`H
`
`.D.,
`
`A
`BSTRACT
`Background
`Patients with myeloma who relapse
`after high-dose chemotherapy have few therapeutic
`options. Since increased bone marrow vascularity
`imparts a poor prognosis in myeloma, we evaluated
`the efficacy of thalidomide, which has antiangiogenic
`properties, in patients with refractory disease.
`Methods
`Eighty-four previously treated patients
`with refractory myeloma (76 with a relapse after high-
`dose chemotherapy) received oral thalidomide as a
`single agent for a median of 80 days (range, 2 to 465).
`The starting dose was 200 mg daily, and the dose was
`increased by 200 mg every two weeks until it reached
`800 mg per day. Response was assessed on the ba-
`sis of a reduction of the myeloma protein in serum
`or Bence Jones protein in urine that lasted for at least
`six weeks.
`Results
`The serum or urine levels of paraprotein
`were reduced by at least 90 percent in eight patients
`(two had a complete remission), at least 75 percent
`in six patients, at least 50 percent in seven patients,
`and at least 25 percent in six patients, for a total rate
`of response of 32 percent. Reductions in the parapro-
`tein levels were apparent within two months in 78
`percent of the patients with a response and were as-
`sociated with decreased numbers of plasma cells in
`bone marrow and increased hemoglobin levels. The
`microvascular density of bone marrow did not change
`significantly in patients with a response. At least one
`third of the patients had mild or moderate constipa-
`tion, weakness or fatigue, or somnolence. More se-
`vere adverse effects were infrequent (occurring in less
`than 10 percent of patients), and hematologic effects
`were rare. As of the most recent follow-up, 36 pa-
`tients had died (30 with no response and 6 with a re-
`sponse). After 12 months of follow-up, Kaplan–Meier
`estimates of the mean (±SE) rates of event-free sur-
`vival and overall survival for all patients were 22±5
`percent and 58±5 percent, respectively.
`Conclusions
`Thalidomide is active against ad-
`vanced myeloma. It can induce marked and durable
`responses in some patients with multiple myeloma,
`including those who relapse after high-dose chemo-
`therapy. (N Engl J Med 1999;341:1565-71.)
`©1999, Massachusetts Medical Society.
`
`M
`
`ULTIPLE myeloma accounts for ap-
`proximately 1 percent of all cancers and
`10 percent of hematologic cancers. It
`is incurable with conventional chemo-
` Melphalan-based high-dose chemotherapy
`therapy.
`1
`with hematopoietic stem-cell support increases the
`rate of complete remission and extends event-free and
`overall survival.
` However, many patients still relapse,
`2-4
`and options for salvage therapy are limited.
`5,6
`Angiogenesis is important in embryogenesis, wound
`healing, diabetic retinopathy, and tumor progression.
`7,8
`The immunomodulatory drug thalidomide can inhib-
`it angiogenesis and induce apoptosis of established
`neovasculature in experimental models.
` For these
`9,10
`reasons, angiogenesis-inhibiting drugs such as tha-
`lidomide may be useful for treating cancers that de-
`pend on neovascularization.
`Prominent bone marrow vascularization occurs in
`multiple myeloma. It correlates positively with a high
`plasma-cell–labeling index (a poor prognostic sign)
`and disease activity and independently confers a poor
`prognosis.
` Plasma levels of various angiogenic cy-
`11-16
`tokines, such as basic fibroblast growth factor and
`vascular endothelial growth factor, are elevated in pa-
` In 1965, Olson et al.
`tients with active myeloma.
`11-13,16
`reported slowing of disease progression in one pa-
`tient who was treated with thalidomide.
` These con-
`17
`siderations led us to administer thalidomide to five
`patients with end-stage myeloma through a compas-
`sionate-use protocol. One patient with a large tumor
`burden (as indicated by an IgA level of 8.4 g per dec-
`iliter, the presence of more than 95 percent plasma
`cells in bone marrow, and the need for transfusion),
`who had had no response to two cycles of high-dose
`chemotherapy followed by multiple salvage therapies,
`had a nearly complete remission within three months
`after the initiation of thalidomide therapy. This ob-
`servation prompted a phase 2 investigation of tha-
`
`From the Myeloma and Lymphoma Program, South Carolina Cancer
`Center, University of South Carolina, Columbia (S.S., J.M.); the Myeloma
`and Transplantation Research Center, University of Arkansas for Medical
`Sciences, Little Rock (R.D., D.A., P.R., P.E., N.M., E.A., C.W., J.Z., B.B.);
`and the Laboratory of Cellular Physiology and Immunology, Rockefeller
`University, New York (M.D.). Address reprint requests to Dr. Barlogie at
`the Myeloma and Transplantation Research Center, University of Arkansas
`for Medical Sciences, 4301 W. Markham, Slot 623, Little Rock, AR 72205.
`Other authors were David Siegel, M.D., Ph.D., University of Arkansas
`for Medical Sciences, Little Rock, and John Crowley, Ph.D., Fred Hutch-
`inson Cancer Research Center, Seattle.
`
`Volume 341 Number 21
`
`·
`
`1565
`
`The New England Journal of Medicine
`
`
`
`
`
`
`
`DR. REDDY’S LABS., INC. EX. 1031 PAGE 1
`
`

`

`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`The New England Journal of Medicine
`
`lidomide in patients with advanced and refractory
`myeloma.
`
`METHODS
`Patients and Treatments
`Between December 1997 and June 1998, 84 consecutive, eligi-
`ble patients with previously treated and progressive myeloma began
`treatment with oral thalidomide as a single agent after providing
`written informed consent. No patients were excluded on the basis
`of renal or cardiopulmonary function, whereas patients could be
`excluded if the results of liver-function tests were more than twice
`the upper limit of normal levels. All patients were treated at a single
`center according to a phase 2 protocol approved by the institution-
`al review board and the Food and Drug Administration (FDA).
`Thalidomide was supplied in 50-mg capsules by Celgene (War-
`ren, N.J.) and was administered nightly at a dose of 200 mg. The
`dose was increased by 200 mg every two weeks for six weeks, so
`that the final dose was 800 mg per day. Data were analyzed as of
`June 17, 1999, when the duration of treatment ranged from 2 to
`465 days (median, 80) and the median follow-up of surviving
`patients was 13 months.
`Table 1 summarizes the characteristics of the patients and de-
`tails of prior therapy. Seventy-six patients (90 percent) had received
`at least one cycle of high-dose chemotherapy with autologous hem-
`atopoietic stem-cell support, and 58 (69 percent) had received two
`or more cycles of intensive chemotherapy. The median time from
`the last course of high-dose chemotherapy to the beginning of
`treatment with thalidomide was 14 months. A high-risk cyto-
`genetic abnormality (deletion of chromosome 13) was present in
` One patient had received an allograft
`35 patients (42 percent).
`20
`as a second intervention, with evidence of full donor-type chi-
`merism in normal lymphohematopoietic cells. At the time of en-
`rollment, all patients had progressive disease, with an increase in
`paraprotein levels of at least 25 percent or at least 50 percent plas-
`ma cells in bone marrow. Approximately half the patients had been
`retreated with dexamethasone or other regimens, but the disease
`had progressed before thalidomide treatment was begun.
`
`Evaluation
`The pretreatment evaluation included complete blood counts,
`tests of renal and liver function, serum and urine protein electro-
`phoresis, and measurements of serum levels of immunoglobulins,
`-microglobulin, and C-reactive protein. Bone marrow aspi-
`beta
`2
`rates were obtained and biopsies were performed to determine
`the percentage of plasma cells in bone marrow, to identify kary-
`otypic abnormalities (Giemsa-banded cells in metaphase), and to
`assess the proliferative activity in plasma cells according to the
`bromodeoxyuridine method to derive the plasma-cell–labeling
`index.
` Follow-up studies included a weekly estimation of para-
`18
`protein levels — the myeloma protein in serum and Bence Jones
`protein in urine — for the first two months, followed thereafter
`by monthly measurements. Whenever possible, bone marrow was
`examined at the time of the maximal response or when patients
`with no response left the study.
`The microvascularity of bone marrow was studied in a semi-
`quantitative fashion in biopsy samples that were obtained with
`a trephine and stained with an anti-CD34 monoclonal antibody
`(prediluted Clone QBEnd/10, Cell Marque, Austin, Tex.). The
`results were expressed as the number of vessels per high-power
`field (400¬).
`
`Assessment of Response
`The primary end point of the study was the finding of a decline
`in the level of paraprotein in serum or urine of at least 25 percent,
`50 percent, 75 percent, or 90 percent on two occasions at least
`six weeks apart. Among patients with detectable levels of both
`urine and serum paraprotein, the response was judged on the ba-
`sis of the component showing the smaller decline. Patients with
`
`1566
`
`·
`
`November 18, 1999
`
`T
`
`ABLE
`
` 1.
`
` C
`
`HARACTERISTICS
`
`
`
`OF
`
`
`
`THE
`
` P
`
`ATIENTS
`
`.
`
`C
`HARACTERISTIC
`
`Male sex
`Durie–Salmon stage III multiple myeloma
`IgG paraprotein
`Duration of prior therapy >60 mo
`Prior high-dose chemotherapy
`Receipt of >1 cycle of high-dose chemotherapy
`Interval between last cycle of high-dose chemotherapy
`and initiation of thalidomide >12 mo
`Age >60 yr
`Hemoglobin <9 g/dl
`/mm
`Platelet count <50¬10
`3
`3
`Serum albumin <3.5 g/dl
`Serum creatinine >1.5 mg/dl (133 µmol/liter)
`-microglobulin >6 mg/liter
`Serum beta
`2
`Serum C-reactive protein >3 mg/liter
`Serum monoclonal immunoglobulin >1 g/dl
`Urine Bence Jones protein >1 g/day
`>50% Plasma cells in bone marrow on biopsy
`Plasma-cell–labeling index >1%*
`Bartl grade II†
`Deletion of chromosome 13
`Outcome
`Completion of study
`Withdrawal from study
`Progression
`Intolerance of thalidomide
`Death of patient with a response‡
`Personal reasons
`Final dose of thalidomide
`400 mg/day
`600 mg/day
`800 mg/day
`
`
`.
`N
`OF
`O
`P
` (%)
`ATIENTS
`
`61 (73)
`51 (61)
`51 (61)
`18 (21)
`76 (90)
`58 (69)
`43 (57)
`
`32 (38)
`19 (23)
`17 (20)
`22 (26)
`22 (26)
`24 (29)
`20 (24)
`51 (61)
`44 (52)
`18 (21)
`13 (15)
`19 (23)
`35 (42)
`
`19 (23)
`
`54 (64)
`9 (11)
`1 (1)
`1 (1)
`
`72 (86)
`57 (68)
`46 (55)
`
`*The plasma-cell–labeling index represents the percentage of light-chain–
`restricted plasma cells incorporating bromodeoxyuridine.
`18
`†The Bartl grading system distinguishes myeloma cells according to their
`morphologic maturation.
` Grade II refers to immature plasma cells of
`19
`cleaved, asynchronous, or polymorphous appearance.
`‡This patient had a response to treatment but died on day 37 of treatment.
`
`a reduction of less than 25 percent and those who discontinued
`treatment before a response could be assessed were considered to
`have had no response to thalidomide. Thus, the results were eval-
`uated on an intention-to-treat basis. In patients with a response,
`an increase in serum or urine paraprotein levels by more than 25
`percent above the nadir value was considered evidence of relapse.
`In patients who had a complete remission, evidence of reemer-
`gence of the monoclonal protein (determined by immunofixation)
`on at least two occasions was considered to indicate a relapse. In
`patients who had a complete remission or a nearly complete re-
`mission (»90 percent reduction in serum or urine paraprotein lev-
`els), a bone marrow response was defined as the finding of less
`than 5 percent plasma cells in the biopsy specimen or aspirate. For
`the remaining patients with a paraprotein response, the percent-
`age of plasma cells had to decrease by at least 50 percent to qual-
`ify as a bone marrow response.
`
`Assessment of Adverse Effects
`All patients, irrespective of the duration of therapy, were in-
`cluded in the evaluation of adverse effects. All patients received
`diaries after providing informed consent, and 83 patients (99 per-
`
`The New England Journal of Medicine
`
`
`
`
`
`
`
`DR. REDDY’S LABS., INC. EX. 1031 PAGE 2
`
`

`

`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`ANTITUMOR ACTIVITY OF THALIDOMIDE IN REFRACTORY MULTIPLE MYELOMA
`
`cent) reported having adverse effects. A comprehensive checklist
`of the adverse effects associated with thalidomide therapy was
`provided by Celgene; it was based on previous experience in treat-
`ing patients with leprosy and had been reviewed by the FDA. The
`data were verified by the patients by direct or telephone interviews.
`Hematologic values and other laboratory-based measures of ad-
`verse effects were assessed at least monthly by the data-manage-
`ment office.
`
`Statistical Analysis
`
`The primary end point for this phase 2 study was a diminution
`in the plasma level of the myeloma protein or the urine level of
`Bence Jones protein. Other end points included the time to a re-
`sponse, the time to disease progression, event-free survival, overall
`survival, the microvascularity of bone marrow, and improvements in
`other laboratory values. Response was treated as a categorical var-
`iable. Comparisons of the response according to other categorical
`variables were assessed with use of the chi-square test or Fisher’s
`exact test, as appropriate. The times to response and disease pro-
`gression were calculated with the use of the competing-risk meth-
` The time to response was defined as the interval between
`ods.
`21
`the start of therapy and a given response (i.e., a decline in the serum
`or urine level of paraprotein of at least 25 percent, 50 percent, 75
`percent, or 90 percent or a complete remission). Competing risks
`with respect to the time to response included discontinuation of
`treatment because of progression or a lack of response, an inabil-
`ity to tolerate thalidomide, or death or personal reasons. The time
`to progression was calculated only for patients with a paraprotein
`response and was defined as the time from the start of therapy to
`disease progression. Competing risks with respect to the time to
`progression included discontinuation of treatment because of ad-
`verse effects or death or for personal reasons. Event-free survival
`and overall survival were estimated according to the method of
` Event-free survival was calculated from the
`Kaplan and Meier.
`22
`start of therapy to disease progression, removal from the study for
`any reason, death from any cause, or the last follow-up visit, which-
`ever occurred first. Overall survival was calculated from the start
`of therapy to death from any cause or the last follow-up visit. Data
`on patients who had not had an event by the time of the last fol-
`low-up were censored at that time with respect to times to response
`and progression, event-free survival, and overall survival. Survival
` Univariate and mul-
`was compared with use of the log-rank test.
`23
`tivariate (stepwise) logistic-regression methods were used to eval-
`uate the prognostic importance of various characteristics with re-
`spect to the likelihood of achieving at least a 25 percent or 50
`percent reduction in serum or urine paraprotein levels. Univariate
`and multivariate (stepwise) proportional-hazards regression analy-
`ses were used to evaluate the prognostic importance of various char-
`acteristics with respect to event-free survival and overall survival.
`Since the microvascular density of bone marrow was used as a
`measure of the antiangiogenic action of thalidomide, this variable
`was extensively modeled. To account for the need for multiple
`measurements of each patient over time and missing data, we used
`mixed-models repeated-measures analysis of variance to evaluate
`The use of compound
`the microvascular density of bone marrow.
`24
`symmetry and first-order autoregressive covariance structures was
`compared, and the results were found to be similar according to
`Akaike’s criterion. Therefore, the values obtained with the com-
`pound-symmetry models are reported. Measurements of the mi-
`crovascular density of bone marrow were grouped according to
`the length of treatment, and values were measured every 50 days
`for a total of seven times, including the pretreatment value. The
`natural logarithm of the values for the microvascular density of
`bone marrow was used in the analysis. Estimates for patients with
`no response and patients with a complete or nearly complete re-
`sponse (»90 percent reduction in serum or urine paraprotein lev-
`els) were used to predict the response in terms of the microvas-
`cular density of bone marrow over time.
`Improvements in important clinical measures were evaluated on
`the basis of the percent change from base line to the time of the
`
`maximal response or, for those without a response, the time at
`which treatment was discontinued. Spearman correlations were
`used to assess whether the changes within response groups were
`significant. For variables with no significant correlations, the signed-
`rank test was used to test the hypothesis within response groups
`that the change was significantly different from zero. All statistical
`tests were two-sided.
`
`RESULTS
`Decline in Paraprotein Levels
`Timely escalations in the daily dose of thalidomide
`to 400 mg, 600 mg, and 800 mg were possible in 83
`percent, 62 percent, and 47 percent of the patients, re-
`spectively; the proportions of patients who eventually
`reached these levels were 86 percent, 68 percent, and
`55 percent, respectively (Table 1). In 27 patients (32
`percent), the serum or urine paraprotein level declined
`by at least 25 percent, including 7 (8 percent) with a
`decline of at least 50 percent, 6 (7 percent) with a de-
`cline of at least 75 percent, and 6 (7 percent) with a
`decline of at least 90 percent; 2 patients had a com-
`plete remission (Table 2). The median interval be-
`tween the start of treatment and a decrease in the
`paraprotein level of at least 25 percent was 29 days
`(range, 4 days to 6 months) (Fig. 1). Seventy-eight
`percent of the responses of this magnitude were ap-
`parent within two months; they were observed with-
`in four months in all but two patients with a re-
`sponse. More marked reductions in paraprotein, by at
`least 50 percent and 75 percent, occurred after a me-
`dian of two and three months of therapy, respectively.
`A low plasma-cell–labeling index (assessed as a con-
`tinuous variable) was the only statistically significant
`variable associated with a response among both the
`group with at least a 25 percent decrease in parapro-
`tein levels (P=0.01) and the group with at least a 50
`percent decrease (P=0.01). Using the median plasma-
`cell–labeling index of 0.2 percent as a cutoff value,
`we found that 46 percent of patients with values be-
`low the median had a reduction in paraprotein levels
`of at least 25 percent, as compared with 9 percent
`of patients with higher values (P<0.05). On univari-
`ate analysis, deletion of chromosome 13 was predic-
`tive of an unfavorable response, but not on multi-
`variate analysis.
`
`Bone Marrow Response
`Bone marrow samples were obtained after one to
`nine months of therapy (median, three) in 48 patients.
`A paraprotein response was associated with a bone
`marrow response in 81 percent of the patients who
`could be evaluated (Table 2). In seven of the eight
`patients with at least a 90 percent reduction in para-
`protein levels, the concurrently examined bone mar-
`row specimens contained less than 5 percent plasma
`cells. A decline in the percentage of plasma cells in
`bone marrow by at least 50 percent occurred in only
`4 of 27 patients with no paraprotein response (15 per-
`cent) who had follow-up bone marrow examinations.
`
`Volume 341 Number 21
`
`·
`
`1567
`
`The New England Journal of Medicine
`
`.
`
`
`
`
`
`DR. REDDY’S LABS., INC. EX. 1031 PAGE 3
`
`

`

`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`The New England Journal of Medicine
`
`T
`
`ABLE
`
` 2.
`
` P
`
`ARAPROTEIN
`
` R
`
`ESPONSE
`
`
`
`AND
`
` B
`
`ONE
`
` M
`
`ARROW
`
` R
`
`ESPONSE
`
`.
`
`P
`ARAPROTEIN
`
` R
`ESPONSE
`
`
`.
`N
`OF
`O
`P
`
`ATIENTS
`(%
`
`OF
`TOTAL
`
`)
`
`
`
` B
`
`A
`ONE
`OF
`SSESSMENT
`M
` R
`ARROW
`ESPONSE
`
`.
`WITH
`TOTAL
`NO
`.*
` (%)†
`RESPONSE
`NO
`
`C
`URRENT
`.
`
`WITH
`NO
` (%)
`RELAPSE
`
` S
`TATUS
`.
`WHO
`NO
` (%)
`DIED
`
`0 2 1 0 3
`
`0 2 3 3 4
`
`12 (44)
`—
`
`6 (22)
`30 (53)
`
`2 (100)
`5 (83)
`3 (60)
`4 (100)
`3 (75)
`17 (81)
`4 (15)
`
`2 6 5 4 4
`
`21
`27
`
`Complete remission
`»90% decrease in paraprotein
`»75% decrease in paraprotein
`»50% decrease in paraprotein
`»25% decrease in paraprotein
`Total
`No response
`
`2 (2)
`6 (7)
`6 (7)
`7 (8)
`6 (7)
`27 (32)
`57 (68)
`
`*The response could not be evaluated in 6 of the patients with a paraprotein response and in 30
`of the patients with no paraprotein response.
`†A bone marrow response was defined as the presence of less than 5 percent plasma cells in bone
`marrow in patients who had a complete paraprotein response or at least a 90 percent reduction in
`paraprotein levels and as a reduction in plasma cells of at least 50 percent in patients with all other
`types of paraprotein responses.
`
`»25% reduction in paraprotein
`»50% reduction in paraprotein
`
`»75% reduction in paraprotein
`
`»90% reduction in paraprotein
`
`0
`
`Complete response
`14
`12
`10
`8
`6
`4
`2
`16
`Months after the Start of Thalidomide
`
`0.5
`
`0.4
`
`0.3
`
`0.2
`
`0.1
`
`0.0
`
`Cumulative Incidence
`
`Figure 1.
` Times to Various Paraprotein Responses.
`Among patients with a response, the median times to a reduction in the serum or urine paraprotein
`level of at least 25 percent, 50 percent, 75 percent, and 90 percent were one, two, four, and four
`months, respectively. Seventy-eight percent of the responses at the lowest level (»25 percent reduc-
`tion) were apparent within two months after the initiation of treatment.
`
`Microvascular Density of Bone Marrow
`The microvascular density of bone marrow was
`scheduled to be assessed every 50 days for a total of
`seven measurements, including the pretreatment val-
`ue. At least one measurement of the microvascular
`density of bone marrow was made in 74 patients (88
`percent); two or more measurements were made in
`37 patients (44 percent). In all, measurements were
`made in 69 patients before treatment and (in 50-
`day increments) in 17 at time 2, in 22 at time 3, in
`11 at time 4, in 12 at time 5, in 4 at time 6, and in
`3 at time 7. The microvascular density of bone mar-
`row and the percentage of plasma cells in bone mar-
`row correlated significantly at all times except the last
`(r>0.5, P«0.01). Although the microvascular den-
`sity of bone marrow decreased markedly in some pa-
`
`tients with a complete or nearly complete remission,
`estimates of the slope were not significantly different
`from zero among those with a response (P=0.39)
`and those without a response (P=0.22).
`
`Other Changes
`The percent changes from base line to the time of
`the maximal response among patients with a response
`and the time of the last follow-up visit among those
`-micro-
`without a response were assessed for beta
`2
`globulin, C-reactive protein, lactic dehydrogenase,
`creatinine, albumin, and hemoglobin levels and the
`platelet count. Hemoglobin levels increased only in
`patients with a response (median increase, 11 percent;
`P<0.001 for the comparison with base-line values).
`Serum levels of beta
`-microglobulin rose (median in-
`2
`
`1568
`
`·
`
`November 18, 1999
`
`The New England Journal of Medicine
`
`.
`
`
`
`
`
`DR. REDDY’S LABS., INC. EX. 1031 PAGE 4
`
`

`

`ANTITUMOR ACTIVITY OF THALIDOMIDE IN REFRACTORY MULTIPLE MYELOMA
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`
`crease, 43 percent; P<0.001) and serum albumin lev-
`els fell (median decrease, 4 percent; P<0.001) signifi-
`cantly in patients with no response. Serum creatinine
`levels did not change significantly in patients with a
`response, and they increased by a median of 13 per-
`cent in those without a response (P<0.001).
`
`Adverse Effects
`Side effects reported by at least 10 percent of pa-
`tients at most dose levels are listed in Table 3. Most
`adverse effects were mild or moderate (grade 1 or
`2 according to the system of classification of the
`World Health Organization). Constipation, weakness
`or fatigue, and somnolence occurred in one third or
`more of the patients. Reports of grade 3 or 4 adverse
`effects were infrequent (less than 10 percent in all
`cases). One quarter of the patients had no appreciable
`side effects at the 200-mg dose, whereas virtually all
`patients had adverse effects of grade 1 or 2 at higher
`doses. Fewer than 5 percent of patients had grade 1 or
`2 leukopenia at any dose, and grade 3 or 4 thrombo-
`cytopenia or anemia occurred in only three patients.
`In most of the patients who had no response, pre-
`treatment anemia or thrombocytopenia did not wor-
`sen, whereas significant increases in the hemoglobin
`levels occurred in patients with a response. Nine pa-
`tients could not tolerate thalidomide (four with a re-
`sponse and five with no response) and discontinued
`treatment after a median of 36 days (range, 10 to
`241). In eight patients, an increase in serum creati-
`nine levels of more than 50 percent was related to
`progressive disease, with increasing Bence Jones pro-
`teinuria. One of the patients with a response died
`suddenly on day 37 of treatment. The death was
`thought to be related to sepsis, although a possible
`contribution of thalidomide could not be ruled out.
`
`Time to Progression, Event-free Survival,
`and Overall Survival
`Of the 27 patients with a decrease in paraprotein
`levels of at least 25 percent, 12 had a recurrence of
`the disease. After a median follow-up of 14.5 months
`(range, 12 to 16), the median time to progression
`had not been reached. The disease in a mean (±SE)
`of 44±10 percent of patients was judged to have pro-
`gressed at 12 months. The median event-free survival
`for all 84 patients was three months (Fig. 2). After 12
`months of follow-up, 22±5 percent of the 84 patients
`remained event-free and 58±5 percent were alive.
`Nineteen patients were still receiving thalidomide 4 to
`15 months after starting the treatment (median, 13),
`including 15 patients with a response and 4 with no
`response who had had some improvement in various
`disease indicators but who had not had a decrease in
`paraprotein levels of at least 25 percent. Multivariate
`analysis indicated that increases in lactic dehydrogen-
`ase levels (P=0.001), the plasma-cell–labeling index
`(P=0.006), and C-reactive protein levels (P=0.007)
`
`T
`
`ABLE
`
` 3.
`
` I
`
`NCIDENCE
`
`
`
`OF
`
` G
`
`RADE
`
` 1
`
`OR
`
` 2 A
`
`DVERSE
`
` E
`
`FFECTS
`
`.*
`
`A
`DVERSE
`
` E
`FFECT
`
`200 mg/DAY
`(N=83)
`
` T
`
`D
`HALIDOMIDE
`OF
`OSE
`400 mg/DAY
`600 mg/DAY
`(N=72)
`(N=57)
`
`800 mg/DAY
`(N=46)
`
`percentage of patients†
`
`Constipation
`Weakness or
`fatigue
`Somnolence
`Tingling or
`numbness
`Dizziness
`Rash
`Mood changes
`or depression
`Incoordination
`Tremors
`Edema
`Nausea
`Headache
`
`35
`29
`
`34
`12
`
`17
`16
`16
`
`16
`10
`6
`12
`12
`
`44
`31
`
`43
`14
`
`25
`18
`24
`
`17
`13
`10
`15
`10
`
`44
`39
`
`40
`19
`
`23
`21
`23
`
`14
`19
`12
`23
`14
`
`59
`48
`
`43
`28
`
`28
`26
`22
`
`22
`22
`22
`11
`11
`
`*The classification system of the World Health Organization was used.
`Grade 1 effects are mild, and grade 2 are moderate.
`†Values are the percentages of patients at each dose level.
`
`were all predictive of a brief period of event-free sur-
`vival, whereas low albumin levels (P<0.001), the de-
`letion of chromosome 13 (P=0.004), and high num-
`bers of plasma cells in bone marrow (P=0.05) were
`associated with a relatively short overall survival.
`Thalidomide was discontinued after a median of
`52 days (range, 2 to 286) because of a lack of response
`in 53 patients (4 patients continued to receive the
`drug without a response) and because of relapse in
`12 patients who had had a response. One patient who
`had a decrease in the paraprotein level of at least 25
`percent and who had not previously received high-
`dose therapy subsequently underwent autologous
`stem-cell transplantation at his own request. As of
`June 17, 1999, 36 patients had died, including 30 pa-
`tients without a response who died of progressive
`disease or complications of subsequent salvage ther-
`apy, as well as 6 patients with a response who subse-
`quently relapsed and died of progressive disease (3) or
`toxicity from salvage therapy (3).
`
`DISCUSSION
`We found that thalidomide had substantial antitu-
`mor activity in patients with advanced myeloma. Ten
`percent of patients had complete or nearly complete
`remission, and 32 percent had a reduction in serum
`or urine paraprotein levels of at least 25 percent. In
`most patients, the decline in paraprotein levels was
`accompanied by a reduction in the percentage of plas-
`ma cells in bone marrow and an increase in hemo-
`globin levels, both of which are consistent with the
`
`Volume 341 Number 21
`
`·
`
`1569
`
`The New England Journal of Medicine
`
`
`
`
`
`
`
`DR. REDDY’S LABS., INC. EX. 1031 PAGE 5
`
`

`

`The New England Journal of Medicine
`
`Overall survival
`
`Event-free survival
`
`0
`
`2
`
`14
`12
`10
`8
`6
`4
`Months after the Start of Thalidomide
`
`16
`
`18
`
`1.0
`
`0.8
`
`0.6
`
`0.4
`
`0.2
`
`0.0
`
`Proportion of Patients
`
`NO. AT RISK
`Overall survivalI
`Event-free survival
`
`84I
`84
`
`78I
`65
`
`69I
`39
`
`64I
`32
`
`58I
`24
`
`56I
`19
`
`51I
`18
`
`34I
`11
`
`Figure 2. Kaplan–Meier Estimates of Overall Survival and Event-free Survival.
`Event-free survival was calculated from the start of thalidomide therapy to progression, removal from
`the study for any reason, death from any cause, or the last follow-up visit, whichever occurred first. I bars
`indicate standard errors at 12 months.
`
`presence of a true antitumor effect. Although not ex-
`amined quantitatively, bone pain decreased markedly
`in patients with a response. We did not evaluate lytic
`bone lesions, which seldom heal, even in patients with
`a sustained complete remission.
`Thalidomide has a number of properties that could
`explain its activity in myeloma; it can alter the expres-
`sion of adhesion molecules,25 suppress the production
`of tumor necrosis factor a,26 increase the production
`of interleukin-10,27 and enhance cell-mediated im-
`munity by directly stimulating cytotoxic T cells.28 Its
`interactions with type 1 and type 2 helper T cells pro-
`duce complex effects on the levels of cytokines such as
`interleukin-4, interleukin-5, and interferon-g.29 Tha-
`lidomide also increases the total number of lympho-
`cytes as well as CD8+ and CD4+ T-cell counts, along
`with substantially increasing mean plasma levels of
`soluble interleukin-2 receptor.29
`Thalidomide has been shown to inhibit angiogen-
`esis induced by fibroblast growth factor and vascular
`endothelial growth factor in a rabbit-cornea micro-
`pocket assay9 and a murine model of corneal vascu-
`larization.10 It has also been shown to cause apoptosis
`of established tumor-associated angiogenesis in exper-
`imental models.10 The bone marrow of patients with
`hematologic cancers shows extensive vascularity,12,13
`which has prognostic implications in myeloma.14 The
`apparent lack of a consistent decrease in the microvas-
`cular density of bone marrow in patients in whom
`thalidomide had a marked antitumor effect requires
`further study. The persistence of extensive vascular-
`ization in some patients with a response is consistent
`with the finding of persistent neovascularity in pa-
`tients with multiple myeloma who had a response to
`high-dose chemotherapy.15 The production of an-
`
`1570 · November 18, 1999
`
`giogenic cytokines such as fibroblast growth factor
`and vascular endothelial growth factor by undetect-
`able residual myeloma cells may sustain the increased
`microvascular density of bone marrow in patients con-
`sidered to be in remission on the basis of bone mar-
`row findings. The persistence of extensive vasculariza-
`tion in patients with a response makes it seem likely
`that the antimyeloma action of thalidomide depends
`on more than one of the actions of the drug out-
`lined above. The mouse model of severe combined
`immunodeficiency, which can be used for the in vivo
`growth of primary human myeloma cells, is ideally
`suited to study the mechanisms by which thalidomide
`induces responses in myeloma.30
`The antitumor properties of thalidomide are being
`evaluated in various malignant diseases,31-35 although
`only limited efficacy data are available so far. Pro-
`longed responses to thalidomide in some patients with
`advanced refractory disease suggest that