18F-Fluciclovine PET/CT in Multiple Myeloma

Background:

• Multiple myeloma (MM) is an incurable malignancy of plasma cells that leads to destructive bone lesions, renal damage, anemia, and hypercalcemia. MM is the second most common hematologic malignancy. The American Cancer Society estimates that annually over 34,000 new cases of MM will occur in the U.S. and over 12,000 deaths due to MM in 2022.
• Overall survival (OS) has improved significantly over the past 20 years with the development of proteasome inhibitors (PIs), immunomodulatory agents (IMiDs) and anti-CD38 monoclonal antibodies. However, despite these advances, patients ultimately relapse requiring multiple subsequent lines of therapy. As MM evolves, it generally becomes more refractory, and patients ultimately succumb to their disease.
• With multiple lines of efficacious therapies, the correct early identification of relapsed disease is important to trigger initiation of a new line of therapy.
• Limitations in conventional imaging highlight a need for molecular imaging agents with better sensitivity for detecting and measuring tumor burden to improve staging and treatment selection for patients with MM and plasma cell dyscrasias.
• 18F-fluciclovine is a radionuclide approved by the FDA for evaluating suspected prostate cancer recurrence but has shown additional ability in detecting MM lesions.

Objective:

To determine the concordance between 18F-fluciclovine PET/CT and 18F-FDG PET/CT in participants with multiple myeloma

Eligibility:

• Participants >= 18 years old
• Eastern Cooperative Oncology Group (ECOG) Performance score of 0 to 2
• Participants must have a documented diagnosis of MM defined by the International Myeloma Working Group (IMWG) Criteria
• Participants fit criteria for one of the following categories:

• Newly diagnosed multiple myeloma (NDMM) without previous treatment (or within the first 3 cycles of front-line treatment)
• Relapsed and/or Refractory multiple myeloma (RRMM) with at least 1 prior line of therapy

Design:

This is an open-label, single center phase 2 study evaluating 18F-fluciclovine PET/CT imaging in up to 50 participants with multiple myeloma. Participants will be enrolled into one of two cohorts based on disease status; newly diagnosed multiple myeloma (NDMM) participants will be enrolled into Cohort 1 and relapsed refractory multiple myeloma (RRMM) participants will be enrolled into Cohort 2. All subjects will undergo an 18F-fluciclovine injection followed by a static whole-body PET/CT at three time points: Timepoint #1, Timepoint #2 (after induction for NDMM or at 6 months for RRMM) and Timepoint #3 (at progression or at 5 years). Results will be compared to 18F-FDG PET/CT imaging at those same timepoints.

• INCLUSION CRITERIA:
• Participants must have a documented diagnosis of MM defined by the IMWG Criteria. Participants at diagnosis must have had a serum M-protein >= 3 g/dL and/or bone marrow plasma cells >= 10% and at least one of the following:

• Anemia: Hemoglobin <=10 g/dL, or
• Renal Failure: serum creatinine >= 2.0 mg/dL, or
• Hypercalcemia: Ca >= 10.5 mg/dL, or
• Lytic bone lesions on X-ray, CT, or PET/CT, or
• >= 2 focal lesions on spinal MRI, or
• >= 60% bone marrow plasma cells, or
• Involved/un-involved serum free light chain ration >= 100
• Participants must have measurable disease defined by any one of the following:

• Monoclonal bone marrow plasma cells > 5%
• Serum monoclonal protein >= 0.2 g/dl
• Urine monoclonal protein > 200 mg/24 hr
• Serum immunoglobulin free light chain > 10 mg/dL AND abnormal kappa/lambda ratio
• A measurable lesion on PET/CT or MRI
• Participants fit criteria for one of the following categories:

• Newly diagnosed multiple myeloma (NDMM)
• Relapsed and/or refractory multiple myeloma (RRMM) with at least 1 prior line of therapy
• Age >=18 years.
• ECOG performance status <= 2
• Negative serum or urine pregnancy test at screening for WOCBP.
• Women of child-bearing potential and men must agree to use effective contraception (hormonal or barrier method of birth control; abstinence) 24 hours prior to and for the 24 hours after each 18F-fluciclovine administration.
• Ability of subject to understand and the willingness to sign a written informed consent document.

Exclusion criteria

• History of allergic reactions attributed to compounds of similar chemical or biologic composition to 18F-FDG
• History of allergic reactions attributed to compounds of similar chemical or biologic composition to 18F-fluciclovine or other similar agents.
• Subjects with severe claustrophobia unresponsive to oral anxiolytics or unwilling to take them.
• Uncontrolled intercurrent illness including, psychiatric illness/social situations that would limit compliance with study requirements.
• Because there is an unknown but potential risk for adverse events in nursing infants secondary to treatment of the mother with 18F-fluciclovine, breastfeeding should be discontinued if the mother is treated with 18F-fluciclovine until 3 days after 18F-fluciclovine.