Depsipeptide in the Treatment of Relapsed and Refractory Multiple Myeloma (MM): A Prospective Evaluation of the Cell Cycle.

Background: Dysregulation of the cell cycle and apoptosis are two critical events in the pathophysiology of MM. This notion is supported by: 1)A high tumor burden is often present despite a low rate of tumor cell proliferation. 2)G1 arrest is common in MM cells while normal plasma cells are permanently withdrawn from cell cycle. 3) Cyclin D1 is often overexpressed without a defined genetic substrate. Herein, we show that cell cycle evaluation in vivo is feasible and that the histone-deacetylase inhibitor depsipeptide might be effective in selected patients with MM.

Patients and Methods: In vitro studies were performed in 12 human MM cell lines with defined cytogenetic abnormalities. The IC50 for depsipeptide was determined by evaluation of apoptosis by standard methods. In vivo studies where done as correlates in a phase II protocol. These include: Immunohistochemistry (IHC) for co-expression of CD138/Ki-67 as a proliferation index (PCPI), cyclin D1, D3, caspase 3 cleavege, CD31 and bcl-2 before treatment and at 24 hrs and 30 days after treatment. Gene array studies are being performed on selected patients at those timepoints. To date, four stage III patients (PTS) with relapsed MM with four or fewer prior lines of therapy have been treated with one to three cycles of depsipeptide at a dose of 13mg/m²,as a 4-hour infusion on days 1, 8, and 15, repeated every 28 days. Mean age was 63 years (range, 56 to 72). KPS of >80%. Mean albumin was 3.5, (range, 3.2 to 4), mean LDH was 243 (range, 179 to 315).

Results: 1)Depsipeptide induces apoptosis in several MM cell lines. All lines were susceptible to depsipeptide, however, differential sensitivities were noted. Three cell lines (ie U266) that contained 11q13 translocation (cyclin D1 overexpression) were the most sensitive with IC50s at least 2 fold lower than other lines. 2) Cell cycle changes are induced by depsipeptide: In 2/4 PTS, a significant increase of the PCPI was seen, whereas a marked reduction in the PCPI in a patient with cyclin D3 overexpression (27% to 16%) was also noted. One patient had an increase of cyclin D1 post treatment. No changes where seen in bcl-2, CD-31, or cleaved caspase-3 expression. 3) Depsipeptide is safe in a limited cohort of MM PTS: Grade 2 fatigue and anorexia were the most common toxicities. Mild thrombocytopenia (mean of 67) did not require transfusions. One patient had stable disease after 3 cycles of treatment, one patient had progression of disease after 3 cycles, one patient progressed after the 1st cycle, and one patient is too early for evaluation.

Conclusions: 1)Patients with 11q13 translocation should be a target for treatment with depsipeptide. 2)Depsipeptide given on this schedule is safe and can stabilize tumor-mass in PTS with otherwise progressive relapsed and refractory disease.3) Evidence of cell cycle modulation can be seen during treatment with depsipeptide. No profound changes in apoptosis is evident.4)Further studies may help to understand the mechanism of transcriptional regulation by depsipeptide and will help design rational therapy and combinations. This study continues to accrue patients as part of New York Phase II Consortium. Supported by NCI grant (SAIC1N01-CO-12400-02) and a SCOR for Myeloma grant from the Leukemia and Lymphoma Society of America.