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Blood. 2016 Nov 10;128(19):2297-2306. doi: 10.1182/blood-2016-07-729236. Epub 2016 Sep 19.

Phase 1/2 study of lenalidomide combined with low-dose cyclophosphamide and prednisone in lenalidomide-refractory multiple myeloma.

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Department of Hematology, VU University Medical Center, Amsterdam, The Netherlands.
Department of Hematology, University Medical Center Utrecht Cancer Center, Utrecht, The Netherlands.
Department of Internal Medicine, Albert Schweitzer Hospital, Dordrecht, The Netherlands.
Department of Hematology, Maastricht University Medical Center, Maastricht, The Netherlands.
Department of Hematology, Erasmus Medical Center, Rotterdam, The Netherlands.
Department of Internal Medicine, Meander Medical Center, Amersfoort, The Netherlands.
Department of Hematology, St. Antonius Hospital, Nieuwegein, The Netherlands.
Laboratory for Translational Immunology, University Medical Center Utrecht, Utrecht, The Netherlands.
Department of Internal Medicine, Spaarne Hospital, Hoofddorp, The Netherlands.
Department of Internal Medicine, Rode Kruis Hospital, Beverwijk, The Netherlands.
Department of Internal Medicine, Rijnstate Hospital, Arnhem, The Netherlands.
Department of Internal Medicine, HagaZiekenhuis, Den Haag, The Netherlands; and.
Department of Hematology, Radboud University Medical Center, Nijmegen, The Netherlands.


The prognosis of multiple myeloma (MM) patients who become refractory to lenalidomide and bortezomib is very poor, indicating the need for new therapeutic strategies for these patients. Next to the development of new drugs, the strategy of combining agents with synergistic activity may also result in clinical benefit for patients with advanced myeloma. We have previously shown in a retrospective analysis that lenalidomide combined with continuous low-dose cyclophosphamide and prednisone (REP) had remarkable activity in heavily pretreated, lenalidomide-refractory MM patients. To evaluate this combination prospectively, we initiated a phase 1/2 study to determine the optimal dose and to assess its efficacy and safety in lenalidomide-refractory MM patients. The maximum tolerated dose (MTD) was defined as 25 mg lenalidomide (days 1-21/28 days), combined with continuous cyclophosphamide (50 mg/d) and prednisone (20 mg/d). At the MTD (n = 67 patients), the overall response rate was 67%, and at least minimal response was achieved in 83% of the patients. Median progression-free survival and overall survival were 12.1 and 29.0 months, respectively. Similar results were achieved in the subset of patients with lenalidomide- and bortezomib-refractory disease as well as in patients with high-risk cytogenetic abnormalities, defined as t(4;14), t(14;16), del(17p), and/or ampl(1q) as assessed by fluorescence in situ hybridization. Neutropenia (22%) and thrombocytopenia (22%) were the most common grade 3-4 hematologic adverse events. Infections (21%) were the most common grade 3-5 nonhematologic adverse events. In conclusion, the addition of continuous low-dose oral cyclophosphamide to lenalidomide and prednisone offers a new therapeutic perspective for multidrug refractory MM patients. This trial was registered at as #NCT01352338.

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