aroerW;

arz

sel can beNI nts withluc us infu-do nded tobo eriencedmo ted radi-ox ncolyticge cer.nda 4;nn(n):1-8

diffusely inltrate the bone marrow as well as highly expressed on humanmyeloma cells, mak-

Department ofr Medicine (S.J.R.,W.P., C.T., D.D.,vision of Hema-.J.R., D.D., R.A.K.,.R., M.A.G.,.D.), Departmenttory Medicineology (W.G.M.,partment of(V.L., M.K.O.),

ion ofgy and

Hypertension (N.L.), MayoClinic, Rochester, MN.

BRIEF REPORTform skeletal and/or soft tissue plasmacytomas(focal lesions). Multiple myeloma typically re-sponds well to alkylator-, corticosteroid-, andimmune-modulatory drugs and proteasome in-hibitors but eventually becomes refractory to

ing them abnormally susceptible to MV-NISinfection, syncytium formation, and cell killing.8

The antimyeloma efcacy of systemic MV-NIS therapy was found to be dose dependentwhen the virus was administered intravenouslythe oncolytic paradigm, whereby a systemi-cally administered OV targets a disseminatedcancer and initiates a spreading infection thatmediates the cancers destruction, has not yetbeen clinically documented.1

Multiple myeloma (MM) is a malignancy ofterminally differentiated plasma cells that

mediate the entry of the virus into susceptibletarget cells but also drive the fusion of infectedcells with adjacent uninfected cells.6 Unlike natu-rally occurring measles, MV-Edm, and henceMV-NIS, targets CD46 as a cell-entry and cell-fusion receptor.5-7 CD46 is a ubiquitous comple-ment regulatory protein that, fortuitously, isO ncolytic viruses (OVs) are promisingexperimental anticancer agents that,because of their complexity anddiversity, can incorporate a variety of noveltumor-targeting and cell-killing mechanisms.1

Oncolytic viruses have already shown clinicalpromise as immunotherapeutic agents, drivingimmune-mediated tumor destruction afterintratumoral administration in patients withmetastatic melanoma.2,3 Also, there have beenreports of localized tumors responding to anintravenously administered virus.1 However,

MV-NIS is a recombinant oncolytic measlesvirus (MV) derived from an attenuated Edmon-ston lineage vaccine strain (MV-Edm) that wasadapted to grow on human cancer (HeLa) cells,then engineered to express the human thyroidalsodium iodide symporter (NIS) so that its in vivospread can be noninvasively monitored by radio-iodine single-photon emission computed tomog-raphy (SPECT)ecomputed tomography (CT)imaging.5 Measles is an enveloped lymphotropicparamyxovirus with a negative-sense RNAgenome whose surface glycoproteins not only

From theMoleculaM.J.F., K.-A.D.), Ditology (SF.K.B., S.VM.Q.L., Aof Laboraand PathA.D.), DeRadiologyand DivisNephroloRemission of DisseminSystemic Oncolytic ViStephen J. Russell, MD, PhD; Mark J. FedCaili Tong, MS; David Dingli, MD, PhD;Val Lowe, MD; Michael K. OConnor, PhDFrancis K. Buadi, MD; S. Vincent RajkumMartha Q. Lacy, MD; and Angela Dispen

Abstract

MV-NIS is an engineered measles virus that ismonitored by noninvasive radioiodine imaging ofrelapsing drug-refractory myeloma and multiple gsion of 1011 TCID50 (50% tissue culture infectioustherapywithMprotein reduction and resolution ofdurable complete remission at all disease sites. Tuoiodineuptake in virus-infectedplasmacytomas.Tviruses offer a promising new modality for the tar

2014 Mayo Fouthese treatments and is rarely cured.4 NewMM treatment modalities such as oncolytic viro-therapy are therefore being actively explored.

Mayo Clin Proc. n XXX 2014;nn(n):1-8 n http://dx.doi.org/10.1016/jwww.mayoclinicproceedings.org n 2014 Mayo Foundation for Mted Cancer Aftertherapy

spiel, PhD; Kah-Whye Peng, PhD;illiam G. Morice, MD, PhD;Robert A. Kyle, MD; Nelson Leung, MD;, MD; Morie A. Gertz, MD;ieri, MD

ectively destructive to myeloma plasma cells andS gene expression. Two measles-seronegative patieose-avid plasmacytomas were treated by intravenose) infectious units of MV-NIS. Both patients responemarrowplasmacytosis. Further, one patient expr targeting was clearly documented by NIS-mediaicities resolvedwithin therstweek after therapy.Oted infection and destruction of disseminated cantion for Medical Education and Research n Mayo Clin Proc. 201inmyeloma xenograft models.7 Antitumor activ-ity was lost in mice that were passively immu-nized with antimeasles antiserum.9,10 MV-NIS

.mayocp.2014.04.003edical Education and Research

1

had relapsing myeloma refractory to approved

2therapies.In this current report, we provide prelimi-

nary data on 2 patients from the phase 1 trial.These patients were selected for immediatereporting because (1) they were the rst 2 pa-tients studied at the highest feasible dose levelwho were also seronegative for prior measlesexposure and (2) they both had no responseto multiple rounds of conventional therapyfor MM and were therefore at risk for immi-nent death. Thus, these 2 patients provided aunique opportunity to determine the systemicadverse effects of oncolytic virotherapy in theabsence of a preexisting antiviral immuneresponse, as well as the resulting effect on tu-mor burden. Collectively, these patients pro-vided heretofore unreported insights into thefeasibility and risk-to-benet prole of thisnovel approach to cancer therapy.

PATIENTS AND METHODS

Selected Study PatientsPatient 1. Patient 1 was a 49-year-old womanwith heavily pretreated light chain MM whoexperienced relapse while receiving no therapy9 months after her second autologous stem celltransplant (ASCT). Multiple myeloma had beendiagnosed 9 years earlier and treated withthalidomide and dexamethasone followed byconsolidative ASCT12; lenalidomide and dexa-methasone13; cyclophosphamide, bortezomib,and dexamethasone14; and a second ASCT.Immediately before receiving MV-NIS, she hadtoxicities were not encountered in preclinicaldose-nding studies in CD46 transgenic miceand nonhuman primates, even at the maximumfeasible intravenous dose.7 A phase 1 clinicaltrial was therefore initiated to determine themaximum tolerated dose of intravenously ad-ministered MV-NIS in patients with advanced,refractory MM.11 The trial, which is now almostcompleted and will be reported in detail else-where, has a standard cohorts-of-3 design witha rst dose level of 106 TCID50 (50% tissue cul-ture infectious dose) of MV-NIS, increasingby 10-fold dose increments to a maximumfeasible dose of 1011 TCID50. Eligible patientsa rapidly enlarging rm, nontender 3-cm-diameter plasmacytoma emanating from theleft frontal bone. The serum l free light chainlevel had increased substantially from 2.5 to 8.0

Mayo Clin Proc. n XXX 2mg/dL (to convert to mg/L, multiply by 10)since her previous clinic visit 2 months earlier.Positron emission tomography (PET)eCTrevealed multifocal osseous progression of herMM when compared with the previous scanobtained immediately before her second ASCT,with enlargement of the glucose-avid lesion inthe left frontal bone and new glucose-avid le-sions in the left sternal manubrium, rightfrontal bone, medial right clavicle, and T11vertebral body. Bone marrow biopsy, whichhad yielded completely negative results on day100 following the ASCT, revealed 3% inltra-tion with l light chainerestricted clonalplasma cells.

Patient 2. Patient 2 was a 65-year-old womanwith relapsing IgA k MM refractory to allapproved antimyeloma drugs who experienceddisease progression while receiving carlzomib,pomalidomide, and dexamethasone therapy.Her MM had been diagnosed 7 years earlier andhad been treated with local radiotherapy;high-dose dexamethasone; lenalidomide anddexamethasone; single-agent bortezomib; cyclo-phosphamide, bortezomib, and dexamethasone;ASCT; lenalidomide, bendamustine, and dexa-methasone; bortezomib, cyclophosphamide,lenalidomide, and dexamethasone; carlzomibplus dexamethasone; bortezomib, dexametha-sone, thalidomide, cisplatin, doxorubicin,cyclophosphamide, and etoposide; and severalexperimental therapies. Before MV-NIS ther-apy, she had innumerable palpable (rm,nontender) soft tissue plasmacytomas, espe-cially in the muscles of her lower extremities,ranging in diameter from 2 to 7 cm. Her he-moglobin level was 8.9 g/dL (to convert to g/L,multiply by 10), and her serum k free lightchain value had increased from 6.5 mg/dL to31.1 mg/dL (to convert to mg/L, multiply by10) over the previous month. PET-CT revealednumerous uorodeoxyglucose (FDG)eavidnodules and mass lesions, most prominentbelow the level of the diaphragm and especiallyin the soft tissues of the legs. Several of theselesions had increased in size and FDG activitysince the previous scan 6 weeks earlier. Thelargest lesion, located in the left hamstring

MAYO CLINIC PROCEEDINGSmusculature, measured 74 46 mm with amaximum standard uptake value of 8.0. Bonemarrow biopsy revealed 1% inltration with klight chainerestricted clonal plasma cells.

014;nn(n):1-8 n http://dx.doi.org/10.1016/j.mayocp.2014.04.003www.mayoclinicproceedings.org

hydramine and acetaminophen. Two hours

OVirus Dose and Location of InfusionIn both patients, the virus, at a dose of 1011

TCID50, was infused into a supercial armvein in 100 mL of normal saline over 60minutes.

Assessment of Response to OncolyticVirotherapyThe following methods were used to assess theimmediate and delayed effects of the virother-apy as well as its pharmacokinetic prole andits ability to target sites of tumor growth.

Measurement of Temperature, Heart Rate,and Blood Pressure. Measurement of physio-logic variables during and immediately after vi-rus infusion was performed with the patient inthe sitting position. Heart rate was determinedfrom the radial pulse, and blood pressure wasdetermined from a mechanically cycled PhilipsIntelliVue MP50 sphygmomanometer. Sublin-gual temperature was measured using a WelchAllyn SureTemp Plus 690 Device.

Pharmacokinetic Studies. Blood samples forearly pharmacokinetic studies were obtained atbaseline, at 1, 30, 60, 120, and 240 minutes aftercompletion of theMV-NIS infusion, and again ondays 3, 8, 15, and 42. RNA was extracted andanalyzed by quantitative reverse transcriptionepolymerase chain reaction to determine thenumber of circulating viral genomes (early timepoints) or N gene messenger RNA transcripts(later time points) in the blood at each timepoint.7

Antimeasles Antibody Titers. Neutralizingantimeasles antibody titers were determinedusing a standard plaque reduction neutraliza-tion assay in which serial dilutions of serumwere mixed with 250 infectious units of an in-dicator virus (MV-GFP).9

SPECT-CT Imaging Studies. Radioiodine up-take was visualized on SPECT-CT obtained 6hours after oral administration of 5 mCi ofiodine 123. The scans were obtained at base-line and on days 8, 15, and 28 after virusadministration using a Philips BrightView

REMISSION OF CANCER AFTER ONCOLYTIC VIRSPECT-CT scanner. To suppress thyroidalNIS expression, liothyronine sodium (25 mg,3 times daily) was administered orally for4 days before the rst (baseline) scan and was

Mayo Clin Proc. n XXX 2014;nn(n):1-8 n http://dx.doi.org/10.1016/jwww.mayoclinicproceedings.orglater, the patient became febrile (temperature,40.5

C), tachycardic (maximum heart rate,

175 beats/min), and hypotensive (minimumblood pressure, 73/33 mm Hg) with severenausea and vomiting that responded to acet-aminophen, meperidine, metoclopramide, lor-azepam, and a cooling blanket. Fever recurredover the next few days, and a supercial venousthrombosis extending from the wrist to the up-per humerus was detected. The thrombosis wasmanaged conservatively and resolved over theensuing weeks. At no time following administra-tion of MV-NIS, nor for the preceding 9months,did she receive corticosteroids or any drug withknown antimyeloma activity.

Patient 2. MV-NIS was infused into a super-cial forearm vein. Two hours after infusion, thepatient became febrile (maximum temperature,40.0

C), tachycardic (maximum heart rate, 119continued until completion of the day 28scan.

Eight-Color Plasma Cell Flow Cytometry.Mononuclear cells isolated from aspirated bonemarrow by Ficoll gradient were stained withantibodies to CD38 (APC), CD138 (PerCP-Cy5.5), CD19 (PE-Cy7), andCD45 (APC-Cy7).Theywere then xed-permeabilized and treatedwith RNAse, followed by staining with anti-bodies to k (FITC) and l (PE) immunoglobulinlight chains and a 15-mM solution of 40,60-diamidino-2-phenylindole. A total of 500,000events were collected on BD FACSCanto II in-struments (BD Biosciences) and analyzed us-ing BD FACSDiva software (BD Biosciences)for surface immunophenotype, cytoplasmicimmunoglobulin light chain restriction, andDNA content and S phase through analysis of40,60-diamidino-2-phenylindole staining.

RESULTS

Systemic Response to Virus InfusionsPatient 1. MV-NIS was infused into a super-cial vein on the left forearm. The infusion timeof 60 minutes included a brief interruption forsevere headache that responded to diphenyl-

THERAPYbeats/min), and hypotensive (minimum bloodpressure, 85/44 mm Hg). The fever respondedto acetaminophen. The hypotension was attrib-uted to dehydration and was effectively treated

.mayocp.2014.04.003 3

with intravenous hydration. Headache withoutneurologic decit responded to intravenousmorphine. Recurrences of fever during the rstweek after virus infusion resolved spontane-ously within a few hours.

Antiviral Antibody ResponseNeither of the patients had detectable neutral-izing antimeasles antibodies before therapy,but both of them had high serum titers 6weeks after virus administration (Table).

Effect on Tumor BurdenResponse data are summarized in Figure 1. Thelevel of the involved serum free light chaindecreased considerably in both patients(Figure 1, A). In patient 1, the l free light chainlevel declined rapidly into the reference range;it remained normal at 7 months after therapybut was minimally increased (2.9 mg/dL) 9

TABLE. Measles GenomeInfusiona,b

Variable

Time from infusion1 min30 min60 min120 min240 minDay 3Day 8Day 15Day 423 mo5 mo

PRN titerPre-MVPost-MV (day 42)

aMV measles virus; MV-N neutralization.bAntimeasles antibody titers werfor before and after MV treatm

4months posttherapy. In patient 2, the k free lightchain level decreased rapidly to 25% of its initialvalue, but this decline was not maintained at the6-week time point. Bone marrow aspirates andbiopsies were obtained 6 weeks after therapyand were compared with baseline samples(Figure 1, B). In both patients, the bone marrowplasmacytosis resolved completely, leaving no

Copy Numbers in Peripheral Blood After MV-NIS

MV-N RNA copy number (103/mg)Patient 1 Patient 2

7650.0 317.0890.0 401.0

2140.0 338.01270.0 307.0638.0 173.020.5 4.05.2 17.9

13.1 4.94.9 01.1 ND0 ND

CGlucose-avid frontal lobe plasmacytoma pre- and post-MV (patient 1)

Nov

FL

C (m

g/dL

)

987

3456

21

Feb June

2nd ASCT

Reference range

UNL = 2.6

BMPET-CT

**

MV-NIS

Involved free light chain pre- and post-MV

A

Patient 1

Sep Dec Mar Jul Oct Jan

F

LC (m

g/dL

)

Jul Aug Sep Oct Nov Dec

Patient 250

40

30

20

10

0UNL = 1.9

Post-MV BM

pre-MV BM

MV-NIS

B

Hyperdiploid cells in bone marrow

50

01.420 103

CD19 PE-Cy7

Patient 1 (pre-MV)

Clonal PCsClonal PCs

Normal PCs Nonormal PCs

No clonal PCs Noclonal PCsNormal PCs

Normal PCs

Patient 1 (post-MV)

104 105 0738 103

CD19 PE-Cy7104 105

100

DA

PI V

450

DA

PI V

450-

A

150

200

250

50

100

150

200

250Patient 2 (pre-MV)

0626 103

CD19 PE-Cy7-A104 105

50

100

150

200

250 Patient 2 (post-MV)

01.161 103

CD19 PE-Cy7-A104 105

50

100

150

200

250

FIGURE 1. Clinical response to systemically administered MV-NIS. A, Serial free light chain (FLC) mea-surements in patients 1 and 2 as a surrogate of myeloma tumor burden, increasing at myeloma relapse anddecreasing after successful therapy. Asterisks indicate the timing of relevant bone marrow (BM) and positronemission tomographyecomputed tomography (PET-CT) examinations. B, High-sensitivity 8-color plasmacell (PC) ow cytometry performed on pretherapy BM samples from both patients (left panels) showsCD38- and CD138-positive, CD19-negative monoclonal PCs (l-restricted in patient 1, k-restricted in pa-tient 2) with hyperdiploid DNA content. In these same studies performed on BM samples obtained 6 weeksafter therapy (right panels), the abnormal PCs are not present. C, Alternate coronal PET-CT sections at thelevel of the left frontal plasmacytoma in patient 1 before and 7 weeks after MV-NIS therapy. Far right panelshows higher magnication of the middle sections, focusing on the plasmacytoma. Note the pretherapycerebral compression and altered skin contour that normalize after therapy. ASCT autologous stem celltransplant; DAPI 40 ,60-diamidino-2-phenylindole; MV measles virus; UNL upper normal limit.

REMISSION OF CANCER AFTER ONCOLYTIC VIROTHERAPY

Mayo Clin Proc. n XXX 2014;nn(n):1-8 n http://dx.doi.org/10.1016/j.mayocp.2014.04.003www.mayoclinicproceedings.org

5

FIGURE 2. Intratumoral propagation of systemically administered MV-NIS. A,Serial single-photon emission computed tomography (SPECT)ecomputedtomography (CT) images from patient 1 at baseline (d-1) and on days 8 (d8)and 15 (d15) afterMV-NIS infusion at the level of the left frontal plasmacytoma.Two adjacent transaxial slices from 6 hours after isotope administration areshown for each time point. There is a small area of increased uptake in theplasmacytoma visible in the lower slice on the day 8 scan (circle). This area ofincreased uptake is more extensive, and visible in both slices (circles), on theday 15 scan. B, Serial SPECT-CT images from patient 2 at baseline and on days8, 15, and 28 (d28) after MV-NIS infusion at the level of the inguinal region.Compared with the baseline images, there is greatly increased radioiodineuptake in a deep-seated intramuscular plasmacytoma in the right hemipelvis onday 8 after MV-NIS administration, which is diminishing by day 15 and is back tobaseline by day 28 (arrows). On the same transaxial slices, there is moderatelyincreased radioiodine uptake in the large left inguinal lymph node on day 8,which again is diminishing by day 15 and back to baseline by day 28 (arrow-heads). C, Anteroposterior uorodeoxyglucose positron emission tomogra-phy (PET)eCT image obtained before MV-NIS administration and thecorresponding iodine 123 SPECT-CT images obtained 8 days and 28 days aftervirus administration. All areas of intense radioiodine uptake (aside from thebladder) in the day 8 SPECT-CT scan are seen to correspond to glucose-avidplasmacytomas in the PET-CT image (circles).

6 Mayo Clin Proc. n XXX 2no evidence for virus spread from plasmacyto-mas to adjacent normal tissues. In patient 2,the day 8 scan revealed striking radioiodineuptake in several plasmacytomas that wasnot present at baseline. Uptake diminishedconsiderably by day 15 and was no longerdetectable on day 28 posttherapy (Figure 2, B).Comparing day 8 radioiodine SPECT-CT andbaseline FDG PET-CT scans, there was variableuptake of radioiodine by tumors of similar size(Figure 2, C), indicating heterogeneity of viralpropagation in different plasmacytomas in thesame patient.

DISCUSSIONWe report the tumor-specic infection and clin-ical responses of the rst 2 measles-seronegativepatients with treatment-refractory myeloma tobe treated intravenously with the oncolytic mea-sles virus MV-NIS at the maximum feasible doselevel. Targeted infection of virus-infected plas-macytomas was clearly documented (usingSPECT-CT imaging in both patients) by theappearance and later disappearance of NIS-mediated radioiodine uptake signals that wereabsent at baseline. After virotherapy, NIS expres-sion was heterogeneous among the plasmacyto-mas of patient 2. Resolution of bone marrowplasmacytosis and regression of identiable plas-macytomas in patient 1 led to complete diseaseremission that lasted 9 months. This responseoccurred after only a single intravenous admin-istration of the virus. Bone marrow plasma-cytosis resolved in patient 2 and remainedundetectable at 6 weeks after therapy, but herplasmacytomas were progressing by that time,and her free light chain level was increasing.

Despite the long history of the eld ofoncolytic virotherapy, complete remission of adisseminated malignancy mediated by a system-ically administered virus has not previously beendocumented in a human subject, nor has thespecic targeting of OV infection to sites of tu-mor growth. Although there have been manywell-documented immune-mediated completeremissions (most frequently of metastatic MM)after intratumoral OV administration,3 this hasnot been the case for intravenous virotherapy.1

Another OV (vaccinia virus JX-594) was recently

MAYO CLINIC PROCEEDINGSrecovered from biopsied tumors following intra-venous delivery in a phase 1 clinical trial,15 butonly one partial clinical response at a single tu-mor site was seen at the highest dose level

014;nn(n):1-8 n http://dx.doi.org/10.1016/j.mayocp.2014.04.003www.mayoclinicproceedings.org

Peng and Mayo Clinic have a nancial interest in the tech-

targets high CD46 expression on multiple myeloma cells. Exp

O(approximately 109 TCID50) in that study, andvirus biodistribution was not evaluated because,unlike MV-NIS, the virus was not designed fornoninvasive imaging. The current report istherefore the rst to establish feasibility of thesystemic oncolytic virotherapy paradigm.

In contrast to conventional drug therapies,OVs are designed to self-amplify at sites of tu-mor growth, which greatly complicates thestudy of their pharmacology. In the case ofMV-NIS, this concern was addressed by engi-neering the virus to drive high-level NIS reportergene expression in infected target cells such thatits biodistribution and pharmacokinetics can benoninvasively monitored by radioiodine imag-ing.5 Preclinical studies have also found thatthe antimyeloma potency ofMV-NIS can be syn-ergistically boosted by appropriately timedadministration of iodine 131, which localizesto intratumoral sites of virus propagation depos-iting a tissue-destructive dose of beta radiation.5

Based on the clinical outcome and imaging data,particularly from patient 2, there is now a strongrationale for combining MV-NIS with iodine131 (radiovirotherapy) in a future clinical trial.

One key factor that may have contributedto the successful outcome in these 2 patientswas their low pretreatment serum titers of anti-measles antibodies.9,10,16-18 Another factor ofprobable relevance was the high dose of virusadministered. Dose-response relationships forantitumor efcacy and virus delivery havebeen well documented in previous virotherapystudies,7,15,19,20 and a dose-threshold effect canbe mathematically predicted.20 Also, measlesvirus transcripts were still detectable in thecirculating cells of patient 1 at 6 weeks after vi-rus infusion, by which time there had been asubstantial boost to her antimeasles antibodytiter, suggesting the possibility of continuingongoing oncolytic activity even at that late time.

CONCLUSIONOn the basis of this demonstration of tumor-selective MV-NIS replication and, in onecase, durable tumor regression in heavily pre-treated patients who have myeloma with bulkydisease, OVs offer a promising new modalityfor the targeted infection and destruction of

REMISSION OF CANCER AFTER ONCOLYTIC VIRdisseminated cancer. Additional MV-NIS isnow being manufactured to support a plannedphase 2 expansion of the clinical trial inmeasles-seronegative patients.

Mayo Clin Proc. n XXX 2014;nn(n):1-8 n http://dx.doi.org/10.1016/jwww.mayoclinicproceedings.orgHematol. 2006;34(6):713-720.9. Ong HT, Hasegawa K, Dietz AB, Russell SJ, Peng KW. Evalua-

tion of T cells as carriers for systemic measles virotherapy inthe presence of antiviral antibodies. Gene Ther. 2007;14(4):324-333.nology used in this research.

Correspondence: Address to Angela Dispenzieri, MD, Divi-sion of Hematology, Mayo Clinic, 200 First St SW, Roches-ter, MN 55905 (Dispenzieri.angela@mayo.edu).

REFERENCES1. Russell SJ, Peng KW, Bell JC. Oncolytic virotherapy. Nat Bio-

technol. 2012;30(7):658-670.2. Vacchelli E, Eggermont A, Sauts-Fridman C, et al. Trial watch:

oncolytic viruses for cancer therapy. Oncoimmunology. 2013;2(6):e24612.

3. Tong AW, Senzer N, Cerullo V, Templeton NS, Hemminki A,Nemunaitis J. Oncolytic viruses for induction of anti-tumor im-munity. Curr Pharm Biotechnol. 2012;13(9):1750-1760.

4. Kyle RA, Rajkumar SV. An overview of the progress in the treat-ment of multiple myeloma. Exp Rev Hematol. 2014;7(1):5-7.

5. Dingli D, Peng KW, Harvey ME, et al. Image-guided radioviro-therapy for multiple myeloma using a recombinant measles vi-rus expressing the thyroidal sodium iodide symporter. Blood.2004;103(5):1641-1646.

6. Bellini WJ, Rota JS, Rota PA. Virology of measles virus. J InfectDis. 1994;170(suppl 1):S15-S23.

7. Myers RM, Greiner SM, Harvey ME, et al. Preclinical pharma-cology and toxicology of intravenous MV-NIS, an oncolyticmeasles virus administered with or without cyclophosphamide.Clin Pharmacol Ther. 2007;82(6):700-710.

8. Ong HT, Timm MM, Greipp PR, et al. Oncolytic measles virusACKNOWLEDGMENTSWe thank Kaaren K. Reichard, MD, for owcytometric analysis of bone marrow.

Abbreviations and Acronyms: ASCT = autologous stemcell transplant; Edm = Edmonston; FDG = uorodeox-yglucose; GFP = green uorescent protein; M-protein =monoclonal protein; MM = multiple myeloma; MV = measlesvirus; MV-NIS = measles virus encoding human sodium io-dide symporter; NIS = sodium iodide symporter; OV =oncolytic virus; PET = Positron emission tomography; PRN =plaque reduction neutralization; SPECT = single-photonemission computed tomography; TCID50 = 50% tissue cul-ture infectious dose

Grant Support: This work was supported by funds from theNational Institutes of Health/National Cancer Institute (grantsR01CA125614 and R01CA168719), Al and Mary AgnesMcQuinn, the HaroldW. Siebens Foundation, and the RichardM. Schulze Family Foundation. The National Cancer InstituteRAID (Rapid Access to Intervention Development) Programsupported MV-NIS manufacture and toxicology/pharma-cology studies.

Potential Competing Interests: Drs Russell, Federspiel, and

THERAPY10. Liu C, Russell SJ, Peng KW. Systemic therapy of disseminatedmyeloma in passively immunized mice using measles virus-infected cell carriers. Mol Ther. 2010;18(6):1155-1164.

11. Vaccine Therapy With or Without Cyclophosphamide in Treat-ing Patients With Recurrent or Refractory Multiple Myeloma.

.mayocp.2014.04.003 7

ClinicalTrials.gov Identier: NCT00450814. ClinicalTrials.govwebsite. http://clinicaltrials.gov/show/NCT00450814%20MC038C%20P30CA015083%20MC038C%2006-005263%20NCI-2009-01194%20NCT00450814. Updated March 20, 2014.Accessed April 14, 2014.

12. Mikhael JR, Dingli D, Roy V, et al. Management of newlydiagnosed symptomatic multiple myeloma: updated MayoStratication of Myeloma and Risk-Adapted Therapy(mSMART) consensus guidelines 2013. Mayo Clin Proc.2013;88(4):360-376.

13. Rajkumar SV, Jacobus S, Callander NS, et al; Eastern Coopera-tive Oncology Group. Lenalidomide plus high-dose dexameth-asone versus lenalidomide plus low-dose dexamethasone asinitial therapy for newly diagnosed multiple myeloma: anopen-label randomised controlled trial [published correctionappears in Lancet Oncol. 2010;11(1):14]. Lancet Oncol. 2010;11(1):29-37.

14. Reeder CB, Reece DE, Kukreti V, et al. Cyclophosphamide, bor-tezomib and dexamethasone induction for newly diagnosedmultiple myeloma: high response rates in a phase II clinical trial.Leukemia. 2009;23(7):1337-1341.

15. Breitbach CJ, Burke J, Jonker D, et al. Intravenous delivery of amulti-mechanistic cancer-targeted oncolytic poxvirus inhumans. Nature. 2011;477(7362):99-102.

16. Power AT, Wang J, Falls TJ, et al. Carrier cell-based delivery ofan oncolytic virus circumvents antiviral immunity. Mol Ther.2007;15(1):123-130.

17. Alcayaga-Miranda F, Cascallo M, Rojas JJ, Pastor J, Alemany R.Osteosarcoma cells as carriers to allow antitumor activity ofcanine oncolytic adenovirus in the presence of neutralizing an-tibodies. Cancer Gene Ther. 2010;17(11):792-802.

18. Guo ZS, Parimi V, OMalley ME, et al. The combination ofimmunosuppression and carrier cells signicantly enhancesthe efcacy of oncolytic poxvirus in the pre-immunized host.Gene Ther. 2010;17(12):1465-1475.

19. Berry LJ, Au GG, Barry RD, Shafren DR. Potent oncolytic activ-ity of human enteroviruses against human prostate cancer. Pros-tate. 2008;68(6):577-587.

20. Bailey K, Kirk A, Naik S, et al. Mathematical model for radialexpansion and conation of intratumoral infectious centerspredicts curative oncolytic virotherapy parameters. Plos One.2013;8(9):e73759.

MAYO CLINIC PROCEEDINGS

8 Mayo Clin Proc. n XXX 2014;nn(n):1-8 n http://dx.doi.org/10.1016/j.mayocp.2014.04.003www.mayoclinicproceedings.org

Remission of Disseminated Cancer After Systemic Oncolytic VirotherapyPatients and MethodsSelected Study PatientsPatient 1Patient 2

Virus Dose and Location of InfusionAssessment of Response to Oncolytic VirotherapyMeasurement of Temperature, Heart Rate, and Blood PressurePharmacokinetic StudiesAntimeasles Antibody TitersSPECT-CT Imaging StudiesEight-Color Plasma Cell Flow Cytometry

ResultsSystemic Response to Virus InfusionsPatient 1Patient 2

Antiviral Antibody ResponseEffect on Tumor BurdenSPECT-CT Imaging Studies to Monitor Virus Spread

DiscussionConclusionAcknowledgmentsReferences