Join hosts Eddie, Ashwin, and Raj as they welcome Dr. Michelle Yong and Dr. Gemma Reynolds, academic infectious diseases physicians from the Peter MacCallum Cancer Centre and the National Centre for Infections in Cancer, for an in-depth discussion on cytomegalovirus (CMV) management in immunocompromised hematology patients.

Key Topics Covered

Fundamentals of CMV Management

• Distinguishing CMV reactivation from CMV disease
• Treatment thresholds and target viral loads
• Prophylaxis strategies in non-allograft settings
• Valaciclovir dosing in general hematology populations
• High-risk patient populations

First-Line Therapies

• Valganciclovir: advantages, disadvantages, and myelosuppression
• Foscarnet: indications and monitoring strategies
• Treatment-resistant CMV

Allogeneic Transplant Patients

• High-risk populations and timing of reactivation
• Monitoring protocols post-transplant

Randomized Controlled Trials

AURORA Trial: Maribavir vs. Valganciclovir

• Design: RCT comparing maribavir to valganciclovir for pre-emptive CMV therapy post-allogeneic transplant [https://pubmed.ncbi.nlm.nih.gov/38036487/]

NEJM Letermovir Prophylaxis Trial

• Design: Double-blind, placebo-controlled RCT of letermovir prophylaxis post-allogeneic transplant [https://pubmed.ncbi.nlm.nih.gov/29211658/]

Emerging Patient Populations

• CMV in lymphoma and myeloma patients receiving CAR T-cell therapy and T-cell engaging bispecific antibodies
• Monitoring and prophylaxis strategies for novel immunotherapies
• Impact of CMV on post-CAR T mortality-https://pubmed.ncbi.nlm.nih.gov/40203190/

This episode provides comprehensive coverage of key clinical trial updates from the 2025 International Myeloma Society (IMS) Annual Meeting in Toronto, with special focus on bispecific antibodies and novel immunotherapies across the multiple myeloma disease continuum—from smoldering disease through relapsed/refractory settings. Dr. Alfred Garfall provides expert commentary on study design, efficacy, safety considerations, and clinical implications.

Topics Covered

1. SMOLDERING MULTIPLE MYELOMA

LINKER-SMM1

Phase 2, open-label study of linvoseltamab monotherapy (200 mg) in patients with high-risk smoldering multiple myeloma by 20/2/20 or PETHEMA criteria, with 2-year treatment duration.

Discussion Points:

• Appropriateness of 2-year treatment duration for precursor condition
• Efficacy and MRD-negative rates
• Safety considerations in asymptomatic population
• Patient selection if available today

2. NEWLY DIAGNOSED MULTIPLE MYELOMA

MajesTEC-5

Phase 2 trial evaluating three teclistamab-daratumumab-based induction regimens in 49 transplant-eligible NDMM patients, followed by auto-transplant and fixed-duration Tec-Dara maintenance.

Discussion Points:

• Post-induction MRD-negativity rates with Tec-DR and Tec-DVR
• Grade 3-5 infection rates and infection-related deaths
• Questionable utility of bortezomib and need for ASCT with 100% MRD-negativity
• High infection prophylaxis requirements

MagnetisMM-6

Phase 1/2 dose-finding study of fixed-dose elranatamab 76 mg Q4W with Dara-Len in 37 transplant-ineligible NDMM patients (median age 75 years).

Discussion Points:

• VGPR or better rates
• Safety profile including infections and CRS/ICANS
• Risk of continuous therapy in elderly/frail population

LINKER-MM4

Phase 1/2 study of linvoseltamab monotherapy in NDMM with both transplant-eligible and transplant-ineligible pathways, exploring three dose levels (50, 100, 200 mg).

Discussion Points:

• Efficacy of single-agent Linvo in NDMM
• Whether any NDMM population could achieve long-term control with single-agent BCMA BsAb
• Safety profile

3. RELAPSED/REFRACTORY MULTIPLE MYELOMA

CAMMA-1

Phase 1b randomized dose-expansion study of cevostamab (FcRH5×CD3 bispecific) combined with pomalidomide-dexamethasone in BCMA-naïve patients with median 2 prior lines of therapy.

Discussion Points:

• Efficacy and safety results
• Positioning in treatment paradigm
• Use before BCMA BsAbs?

Sonrotoclax + Dexamethasone in t(11;14) R/R MM

Phase 1/2 study of sonrotoclax (next-generation BCL2 inhibitor) plus dexamethasone as an all-oral regimen in patients with t(11;14) R/R MM (median 3 prior lines, ~75% triple-exposed).

Discussion Points:

• Efficacy including response rate and PFS
• Safety profile
• Future of BCL2 inhibitors in t(11;14) myeloma in the era of BsAbs and CAR T

RedirecTT-1

Phase 2 trial combining teclistamab + talquetamab in 90 heavily pretreated patients with R/R extraosseous extramedullary disease (84% triple-class refractory, 36% penta-refractory, 20% prior BCMA CAR T).

Discussion Points:

• Response rate and durability in difficult-to-treat population
• Safety concerns with dual bispecific combination
• Off-label use considerations

4. CAR T-CELL THERAPY TOXICITIES

CAR T Immune-Related Adverse Events (UPenn Study - Ho et al)

Large cohort study of 198 patients (125 cilta-cel, 73 ide-cel) examining all adverse events other than CRS, ICANS, IEC-HS, and IECAHT.

Discussion Points:

• Landscape of CAR T IRAEs: incidence, types, and timing
• Risk factors identified for CirAEs
• Mechanism of toxicities and role of CD4+ CAR T-cells
• Clinical implications: Should prophylactic corticosteroids be used? What ALC threshold? Optimal dose/duration? Prospective studies needed?

In this episode of Blood Cancer Talks, hosts Eddie, Ashwin, and Raj welcome two distinguished experts to explore the cutting-edge field of circulating tumor DNA (ctDNA) in B-cell lymphomas. Dr. David Russler-Germain, a lymphoma clinician from Siteman Cancer Centre at Washington University in St. Louis, returns as a familiar voice to the podcast audience. Joining him is Dr. Ash Alizadeh, the Moghadam Family Professor of Medicine, Oncology, and Hematology at Stanford University and leader of the Cancer Genomics Program at Stanford Cancer Institute. Dr. Alizadeh has been instrumental in advancing our understanding of lymphomagenesis and lymphoma genetics over the past two decades, pioneering multiple ctDNA techniques that are revolutionizing cancer care. Together, they discuss the transformative potential of ctDNA technology in B-cell lymphomas, particularly DLBCL, covering everything from the technical evolution of biomarker detection to groundbreaking clinical data that may reshape how we monitor and treat these aggressive cancers.

Key Discussion Topics

1. Genetic Heterogeneity in B-Cell Lymphomas

Complex genetic landscape of DLBCL

Implications for treatment strategies

Need for personalized approaches

2. Clinical Need for ctDNA in Lymphoma

Why ctDNA is needed in aggressive lymphomas:

Curative vs. non-curative treatment settings

Limitations of current PET imaging

Additional prognostic information beyond imaging

Risk stratification capabilities

Potential to avoid overtreatment

Therapy adaptation opportunities

3. Challenges in Lymphoma MRD Assessment

Why lymphoma MRD is more complex than other hematologic malignancies:

Differences from acute leukemias, CLL, and myeloma

Technical challenges specific to lymphoid tumors

Lower circulating tumor burden compared to liquid tumors

4. ClonoSEQ Technology

Mechanism: Immunoglobulin sequencing approach

Advantages: Established platform with regulatory approval

Disadvantages: Limited sensitivity in peripheral blood, requires adequate tumor sample

5. CAPP-Seq Technology

Full Name: Cancer Personalized Profiling by Deep Sequencing

Innovation: Developed ~10 years ago by Dr. Alizadeh's group

Mechanism: Targeted sequencing of cancer-specific mutations

Advantages: High sensitivity, personalized approach

6. PhasED-Seq Technology

Evolution: Next-generation advancement of CAPP-Seq

Key Improvements: Enhanced sensitivity and specificity

Technical Advances: Phased variant detection

Clinical Data Highlights

1. Remission Assessment by ctDNA in LBCL on 5 prospective studies of frontline anthracycline-based chemo-immunotherapy: https://pubmed.ncbi.nlm.nih.gov/40802906/

2. Prospective validation of end of treatment ctDNA-MRD by PhasED-Seq in DLBCL patients from HOVON-902 clinical trial: https://ascopubs.org/doi/10.1200/JCO.2025.43.16_suppl.7000

3. Korean data on prognostic utility of ctDNA: https://ashpublications.org/blood/article/142/Supplement%201/69/501573