Cesar Rodriguez, MD, 
Wake Forest University 
Interview Date: December 14, 2018

Each myeloma patient’s tumor is unique and can change over time. Dr. Rodriguez is using a new 3D organoid tumor modeling platform which allows the testing of over 50 myeloma treatment combinations against your specific tumor (including your bone marrow microenvironment) to identify which treatments will work best for your type of myeloma. This personalized approach will help you find useful drug combinations that will have the most impact and avoid treatments that will be ineffective. Learn more in this fascinating show. 

Cesar Rodriguez, MD, of Wake Forest University was recently selected as a Myeloma Crowd Research Initiative (MCRI) award recipient. The goal of the MCRI is to help optimize myeloma therapy for individual patients.

The Myeloma Crowd created the MCRI because we “Can’t Wait for a Cure.” Through the MCRI we want to help find the right treatment for the right patient at the right time. The MCRI is funding three research projects – each with a different focus – that will also integrate with HealthTree, a new tool for myeloma patients. Learn more about HealthTree here.

 

 

Thanks to our episode sponsor

Jenny: Welcome to today's episode of Myeloma Crowd Radio, a show that connects patients with myeloma researchers. I'm your host, Jenny Ahlstrom. Thanks to our episode sponsor, Takeda Oncology for their support of Myeloma Crowd Radio.

Now, today is the third show in a series of three on Myeloma Crowd Radio for the Myeloma Crowd Research Initiative or as we'd like to call the MCRI.

You've heard about this because we've just had two recent shows. But when we started the foundation and after we built our scientific advisory board, we were asking them what we could do as the Myeloma Crowd to fill gaps in research funding. The first time we did this, they told us we should go fund high risk research which we did. We were the first group to crowdsource and crowdfund two immunotherapy projects. One was a CAR-T project from the University of Wurzburg in Germany going after two targets for CAR-T cells (CS1 and BCMA). The other was an immunotherapy called MILs from Dr. Ivan Borrello at Johns Hopkins.

The second year, we asked the same question because we knew there were existing foundations and good groups out there doing wonderful things in myeloma. We really just decided to find the unmet needs and fill those needs. Dr. Fonseca at our meeting suggested that with so many new treatments in the myeloma landscape that we really needed a tool for patients who were not seeing myeloma experts to be able to understand different treatment options they had that were more personally relevant because so many -- over 80% of us are treated in community oncology settings and we might not be seeing a myeloma specialist.

Now, it is still the best thing you can do for your own care to find a myeloma specialist and consult with them as you're making these key treatment decisions. But his idea sparked the idea to develop this tool called HealthTree, which we have now built and have over 2,500 patients using. There are three purposes really or benefits to joining HealthTree. First, you can understand personalized treatments options to have better discussions with your doctors. Second, you can find clinical trials that you're eligible to join. Then third, just by aggregating our data even in a de-identified or anonymized way, researchers can help identify new potential hypothesis for different types of patients. The show today is a little bit about that theme.

Now, our focus for the second Myeloma Crowd Research Initiative, we're calling it Optimizing Myeloma Care, is very complementary what we've done for HealthTree. We wanted to see how else we can come to more personalized or optimized medicine. Precision medicine has been stressed so much lately going after specific genetics. We'll talk about that sometime today. But some of it is also getting this more holistic view of the patient and not just first and only the genetics but a broader view of the patient. You've recently heard from Dr. Chung on his testing of the immune system. Earlier even this week, we heard from Dr. Zhan and Dr. Jethava to learn about killing these precursor myeloma stem cells.

Today is our third project that we are funding with Dr. Cesar Rodriguez. He is working on 3D tumor modelling. Each of these three projects bring a unique and different approach to personalized care for you as a myeloma patient. Now, if you'd like to support these projects, you can go to give.crowdcare.org/mcri and you can donate or you can create a page or you can create a team fundraising page and then you can share it in any way you want. The holidays are a great time to do that. With that, we would like to welcome Dr. Rodriguez today who is doing some truly remarkable and unique work. Welcome to the show.

Dr. Rodriguez: Thank you very much for having me. Thank you very much to your organization for supporting research that's outside of the box like the one we're doing here.

Jenny: Well we think it's super cool, so we're excited to hear more about it. Let me just give a little bit of a bio background on you before we get started. Dr. Rodriguez is originally from Mexico and has done significant training at Mount Sinai, the Cleveland Clinic, Harvard Medical School, Memorial Sloan Kettering, Massachusetts General, Seattle Cancer Care Alliance. He is currently Assistant Professor in the section of hematology/oncology in the Blood and Marrow Transplant Division at Wake Forest University in Winston-Salem, North Carolina.

He is an associate member of a Graduate Faculty of the University of North Carolina at Charlotte. He is a committee leader for immunotherapy in myeloma for the CTN Myeloma Intergroup. He is lead for the myeloma research at Wake Forest School of Medicine. He is on the ASH Leadership Institute. He is a CTN Myeloma Intergroup member. His awards include the first place Junior Faculty Category for Internal Medicine Research at Wake Forest. He has also been awarded the National Patients' Choice Award and the Leukemia and Lymphoma Society Man of the Year Award.

We are really grateful that you are taking an out-of-the-box approach to myeloma care because patients still are not cured yet. It's becoming clear that even as good as the therapies are, that relapse still happens and that we need new thinking around this. Thank you so much for all you're doing. It's just really incredible.

Dr. Rodriguez: It's a pleasure. It is true what you're saying that drug resistance is a big challenge when dealing with multiple myeloma. That's kind of what stemmed the concept of this research. A lot of the times, we all have a pretty general idea of what to do when somebody has a new diagnosis for multiple myeloma. But then once somebody relapses, that's when everybody starts having trouble determining which is the next best therapy. We're hoping that this study and the results of this study is going to help answer this question for not just the specialists, but any oncologist in the community that is treating a patient with multiple myeloma.

Jenny: It's not really clear the causes of resistance in all situations, is it?

Dr. Rodriguez: Resistance has a lot of factors. It could be a multifactorial thing. A nice way to understand resistance in multiple myeloma is that there are two things that need to be understood. One is that when we're dealing with multiple myeloma, we're not just dealing with one strain of cancer cells but we are dealing with a variety of strains of myeloma cells. There are different groups of cells that have certain characteristics but not all of the myeloma in a patient's body is going to be the same.

Whenever we do chemotherapy, we might be targeting just a percentage of those strains and not all of them. It's almost like when we have a pest control problem at home and we are trying to get rid of whether it'd be cockroaches or bugs or whatever, and we are selectively choosing the most resistant bugs to pesticides. That is kind of what happens with chemotherapy. There are mechanisms for the myeloma cell to develop resistance, either by protecting and shielding itself from the environment that's providing the chemotherapy so that the chemotherapy doesn't penetrate into that cancer cell. It also causes the same shielding process can prevent the immune system in the body to identify the myeloma cell and be able to flag it so it could be destroyed.

It's a combination of us not treating all of the different strains of myeloma and then letting the remaining strains grow without any opposition from the dominant strains that were there before. Also, the mechanisms of mutations and the ability for the myeloma cell to guard itself from whatever is trying to attack it, whether it be chemotherapy or their own immune system. But there's definitely still a lot to learn about the exact mechanisms of resistance. Hopefully, this model, 3D model, is going to help answer some of those questions.

Jenny: I believe it will. When you look at myeloma, you talk about the genetics of these different strains of myeloma. How important would you say it is in terms of personally treating myeloma? Is it the only factor? Are there other factors that we need to be considering like the immune system or other things like that? Or do you think the best approach is to target these, like figure out the genetics of each clone and then go after those particular genetics? Can you just give a broad overview of what you believe as a researcher?

Dr. Rodriguez: Sure. The genetics of a type of cancer are important. It is something that we can never ignore because depending on what mutations are present in the cancer cell, we can have an idea or can predict how that cancer is going to respond. If it's going to be a very aggressive type of cancer that's going to be hard to treat or if it's going to be one of those cancers that might be treatable but then going to want to come back and relapse sooner. But having said that, the genetics is not the only thing that determines how aggressive a cancer is. We cannot ignore other factors because -- and I'm pretty sure patients who have multiple myeloma and have talked to other patients with myeloma have seen that they might have some aggressive mutation and still achieve a remission. Then there's other patients who have mutations that are not considered aggressive and still behave like a stubborn disease that is hard to treat.

There's a series of factors, but one thing that we're trying to gravitate is towards personalized medicine and also to targeted medicine. When we talk about targeted medicine, we are focusing on actual specific mutations that a particular drug can target. Let's say somebody has an aggressive mutation like a 17p or has a mutation like a 13q and we identify a therapy that can target that particular mutation. At the current time, we don't have one that targets those particular mutations. But we do now have therapy that can target translocation 11;14, and that would be venetoclax. It's still not FDA approved. It's still on study, but it is the example of the first targeted therapy that we can potentially be seeing in multiple myeloma. That's very exciting.

But we also need to understand that -- like I had said earlier, because multiple myeloma is a series of strains and not just one single type of myeloma pattern, if we were to target just cells that have the translocation 11;14, we could be missing a therapy for other strains of myeloma cells that don't have that translocation. I think targeted therapy does have a future in myeloma but it's always going to be important to combine it with other agents so that we can target those particular mutations but not ignore other strains that might not have those mutations.

Jenny: That makes a lot of sense and that makes a lot of sense why doctors are using triplet combinations and even four therapies in newly diagnosed myeloma as well as relapse myeloma because it sounds like you're just trying to go after all the clones, right?

Dr. Rodriguez: True. The more ways or the more angles you target the cancer, there is a better chance that we might actually be able to cover all of the different strains. Even if it was just one main strain that a patient might have, which is rare, but let's assume that there could be just one predominant strain. It would still apply using a combination therapy, triplets, or now that we have monoclonal antibodies, the whole concept of going back to quads which was debunked years ago. But it is good to target a cell from different angles so that we can have a better chance of destroying the largest amount of cells possible because the deeper the response and the more we clean the bone marrow from myeloma cells, the better the probability that we can keep a patient in remission for a longer period of time.

Jenny: Well, I am so excited for people to hear about what you're working on because I just think it's brilliant work. Maybe you want to describe first the current problem with studying myeloma drugs. In trying to study drugs, when you take the myeloma cell out of the body, what typically happens when you're trying to compare therapies against that?

Dr. Rodriguez: Let me go back a little bit to anatomy. In multiple myeloma, it comes from an abnormal plasma cell. The myeloma cells can still live inside the bone marrow. The reason why that is, is that the bone marrow has all these nutrients that make the myeloma cell be able to survive. It feeds off of those nutrients. It actually interacts with the cells that are surrounding it in the bone marrow environment. By communicating with the cells around it, it kind of manipulates the environment there to its advantage. It has the ability to get the nutrients that it needs to grow and divide and multiply. But it also has the ability to protect itself and make the shield that I was mentioning earlier that gives it resistance from the immune system and resistance from chemotherapy itself.

If you were to look at the cancer cell in its natural environment, you would have the cell that is touching other cells around it and it's communicating with all of the cells around it. Imagine you being in subway rush hour and you're jammed in one of the cars and you have people all around you that are touching you. You're going to push a little bit to make yourself some space and that's going to influence and affect the person next to you. They might either yell back at you or they might actually push away, but you're going to influence your surrounding based on what you do when you're there touching just around these people. That's kind of what the myeloma cell does in their natural habitat.

Now, when we're studying chemotherapy and new agents to treat multiple myeloma, we use myeloma cells and we put them in a petri dish. The problem with that is that it is a two-dimensional culture that we're doing, or a two-dimensional plate. You don't get to see the interaction of the myeloma surface in all of its areas with the surrounding cells. You have very little interaction between cell and cell and they tend to be myeloma cells the way we grow things. You're actually already altering how the cell behaves in its environment. When you expose it to chemotherapy or new agents to see if it kills the myeloma cell or not, you're not really seeing how the myeloma is in its true environment and how the myeloma can actually protect itself using the cells around it and the environment around it.

A lot of the times when we do trials that are done in the lab to test new compounds and we see good results, it doesn't necessarily translate to the actual clinical setting. Once we start trying it in patients and in humans, we might not necessarily see the same behavior that we saw in the lab. That has to do with the fact that it's not really representative of what the environment really is and what it looks like. The study that we're doing right now using this 3D model organoids is going to hopefully get rid of that problem and be able for us to see how the myeloma cell is in a 3D suspended environment where the myeloma cell can actually interact with other myeloma cells and with the cells that are normally seen in the bone marrow itself. In that way, we kind of get a good picture of what the cancer is doing in real life. So when we expose it to different chemotherapy combinations or with new therapies or agents that we're testing, we can have a more realistic result. That's the whole theory of this study.

Jenny: When somebody sends you a bone marrow biopsy sample, you're not just taking out the myeloma cells, you're taking the whole bone marrow micro environment with the myeloma cell. Then maybe you can explain the basics of what a 3D organoid is because it's kind of a new term for patients.

Dr. Rodriguez: True. Let me explain what an organoid is. An organoid is basically a miniature version of an organ that's produced in the lab from tissue cells from a patient or from a cell line that can be purchased and bought. It has the three-dimensional form. It mimics the organ's structure and function. Up until now here at Wake Forest, WFIRM Department has been able to do these organoids and reproduce either pancreas or stomach or lung or liver. That has helped a lot of scientists study the cell behavior of the normal organs, the biological process and the interactions of the cells within a healthy organ.

It seemed pretty natural to evolve this technology and say, "Well, if we can actually build healthy organs and healthy tissue from a patient, well, can we actually use this technology and do a tumor?" The way we do this is whenever somebody is diagnosed with myeloma or relapses from myeloma, the most common thing to do is to do blood tests and to do a bone marrow aspirate and biopsy. That aspirate and biopsy helps us determine what percentage of myeloma is involved in the bone marrow and what mutations it has to give us an idea of how aggressive this myeloma is behaving.

What we can do is with that same aspirate at the time of diagnosis or when assessing relapse, we can take a portion of that aspirate and we take all the cells that are inside the aspirate so that the cells would include not just that myeloma cells but all the cells that are inside the bone marrow which is called stromal cells. They can be endothelial cells and the mesenchymal stromal cells. These combination of cells are then mixed with substances like hyaluronic acids, gelatin, things that are going to give nutrients to these cells so that these cells can stay alive and continue to interact as if they were still inside of the patient's body. That's the material that we use to actually do the organoids.

How exactly do we do the organoids? The process is little bit complex, but to make it simple, once we have this syrup as you want to call it, of the mix of myeloma cells with all the other cells that are inside the bone marrow mixed with the nutrients and the hyaluronic acids so that these cells can stay alive, we use a 3D printer. Instead of using regular ink for a printer, we use the cells with this medium and we call this a bio-ink. Then the printer allows to print this substance into wells. Once it's in the well, we fill it with liquid so that it can be suspended inside the well. By having it suspended inside the well, it maintains this three-dimensional pattern and it stays as clump. You have all of the cells together in a little cluster and they can survive as a cluster and interact with each other and continue to behave as if they were inside the patient's bone marrow. That's basically what an organoid is.

Now, because we're doing it in very small size, we can actually do many of these just from one single bone marrow aspirate. That's what makes this concept of using bone marrow aspirates to do organoids, a great technique so that we can then study chemotherapy sensitivity and also study mechanisms of resistance. If I can make many small replicas of a patient's tumor with the cells that it lives with in the bone marrow, then that gives that same amount of opportunities to test different chemotherapy combinations.

That is one of the biggest challenges that we have right now in the world of myeloma. There have been so many new concepts that have come out in the last ten years. Because we'd like to combine therapies and do triplets or doublets or now quads, we have a flow of combinations. There are more than 40 treatment combination options that we can play with at the time of relapse. Which one of those 40 would be the best one to use? We could use cytogenetics and the cytogenetics can help lead us – for example you may want to focus on proteasome inhibitors or you want to stay away from these because the patient progressed while they were on this therapy. But you're still going to have a big number of treatment options that you're not going to know which to choose from. There are many studies that have been published in the last couple of years showing the efficacy of all these novel agents, but all of these studies are comparing one combination to a control. But there are no studies that compare head to head what one of these novel combinations would do compared to another novel combination. If we wanted to see out of these 40 combinations which one is going to be the best, you can imagine how complex a clinical trial would be and the number of patients that we would have to enroll in order to get results to see which one out of all these is the best.

Jenny: Right. Even when you're studying them across the board and you're comparing all these different combinations in the same type of patient, that's difficult because your studies -- now, people are living so much longer. Your studies are taking you five, eight, ten years. You have no way of doing the cycling that's enough.

Dr. Rodriguez: Exactly, if I'm realistic to do that. Yes, I agree. Then it's not representative of what a single patient is going to do and how it's going to behave. The opportunity of using organoids to try to find what the best therapy is at a time of relapse or at a time of diagnosis or at a time of the third relapse, is a very unique way, because if we can form 30 organoids or 40 organoids or 20 organoids from one single bone marrow aspirate, then we can test that number of combinations and we have a result within five to seven days.

Then if we get a result within a week out of the combinations that we tested, which one tends to kill myeloma cells the best and which one tends to kill myeloma cells the least, then we can line them up from best to worst and say, okay, the best combination was this triplet. Is there a contraindication for the patient to have this triplet? If there is not, then we can use that combination. If there is a contraindication because they have heart failure or because they have pulmonary hypertension or because they have vertebrae collapse in the past, then you go to your second option or the second best and see if that one has any contraindications. If it doesn't, then you can use that one.

It's a very nice way of giving the oncologist a nice template out of all the treatment options that are available, a guideline as to which one is the best recommended option for them. You can do that in an academic institution or in a community setting. It won't discriminate where you are if this is something that can be done on a national level.

Jenny: I just think this is so needed because myeloma is so different in every one of us and then there are some changes over time even in the same patient. I could foresee at different time points sending samples to your facility, and a newly diagnosed patient sends a sample -- I love how you're saying you can see things basically in a ranked order or like an optimal score order where something looks the best for you is going to kill the maximum number of your particular types of myeloma cells and then having a second and third and all these different options. But then when you relapse, your myeloma might not be the same. So you can go back and do it again because you're going to get a bone marrow biopsy anyway.

Dr. Rodriguez: Correct.

Jenny: I just love this idea. Let's talk about some of the details. How long can you keep it alive? How long do you really need to keep the bone marrow biopsy material alive to be able to test all these treatments against it?

Dr. Rodriguez: Right now, the test that we've had done, the preliminary test that we've done, we have kept the cells alive for a week. But what we've been doing is, once we formed the organoids, 24 hours after, we put the chemotherapy to it and then we test one day and then three days after being exposed to chemotherapy to see what happened to the myeloma cells. That is enough time to see a difference between one chemotherapy regimen and another. We're hoping that this is going to continue as we expand the project and test more patients. But keeping the cells alive for five to seven days is more than enough to be able to have an answer as to how well the chemotherapy kills the myeloma cells.

Jenny: You mentioned this at the beginning of the show, but I think you might want to expand on it because Wake Forest really had a lot of experience with these 3D organoids and you brought it to them and said, "Hey, why don't we do this for blood cancers?" Do you want to go into the depth of the experience of your facility, because I think it's really pretty amazing?

Dr. Rodriguez: Our facility, Wake Forest has a facility called WFIRM. WFIRM actually stands for Wake Forest Institute of Regenerative Medicine under the leadership of Dr. Atala who developed this institute. He started to do organs like kidneys, heart valves, arteries and vessels from tissue in the laboratory and using 3D printers and using scaffolds to make these tissues and organs. That gradually started to evolve into then playing with miniature versions of these. That's how organoids started to develop.

Aleksander Skardal who is the scientist that I worked with and leads the organoid, I guess has more experience with the organoids here at Wake Forest, is the one that started to play with solid tumors first. He started testing with mesothelioma and see what happened with mesothelioma. He also tested another solid tumor that he told me about. When he was telling me about that information, that's when I said, "Well, that sounds great." But the difference between a solid tumor and a liquid tumor is that in the solid tumor, you need to do surgery in order to get tissue and you cannot be going back and forth and doing surgery repeatedly and kind of have a time lapse as to how the tumor is doing.

But the beauty about blood cancers whether it be leukemia, multiple myeloma or a lymphoma, is that bone marrow aspirate can be done at any time. Yes, it is invasive and yes, patients hate me for doing bone marrow biopsies, but it is not as invasive as an actual surgery for let's say, lung cancer or mesothelioma or something like that. That's a year ago is when we started to play with myeloma cells. We had a very hard time keeping the myeloma cells alive using patient's myeloma cells and the patient's stromal cells. If you combine myeloma cells that are off the shelf or cell lines, these are cells that are not coming from patients but cells that you can actually purchase -- we normally use them for testing.

That's a little bit different because those cells are already immortal and they tend to stay alive very easily. But patient's myeloma cells, they haven't become immortal yet. Those are harder to keep alive so it took us about a year to be able to find the good combination of nutrients and hyaluronic acid to make sure that these cells stay alive long enough so that we can then be able to test the different chemotherapy combinations and be able to get a result. Otherwise, we would get wells full of cells that had died, but they were all dying regardless of whether you put them on chemotherapy or not.

Jenny: That makes sense. You're starting, I'm assuming, with patients at your own facility for samples?

Dr. Rodriguez: Correct.

Jenny: Then are you doing just relapsed patients to start or who will you start with?

Dr. Rodriguez: At the moment, I think the people who would benefit the most would be the relapsed patients until we perfect the technique a little bit better. I'm going to tell you why. It's not that I don't want to short sell the newly diagnosed patients, but when you have a new diagnosis of multiple myeloma, the chances of having a response with current therapies is excellent. It's more than 90% whether you use combination with bortezomib, lenalidomide and dexamethasone or carfilzomib with lenalidomide and dexamethasone or if you're in one of the clinical trials that are adding the monoclonal antibody to these backbones. The majority of the patients are going to have a great response to that.

In a setting like that, if we were to test 30 different combinations, odds are that all 30 combinations are going to give us a very similar result. The difference between one combination and another is going to be so small that it's going to be hard to measure the difference. If we focus on relapsed patients instead of the newly diagnosed, then we're dealing with a little bit more complex disease. At relapse,  you start to have more variability in terms of how people are going to respond to that chemotherapy combination. If we test different chemotherapy combinations, then we are going to have more variability in terms of the efficacy of the therapy and we're going to be able to have a more reliable way of measuring differences between one combination and another combination.

At the moment, we'd like to start with relapsed disease and it can be the first relapse, second relapse, third relapse or any amount of relapses. But that way, we can calibrate things a little bit better. We can make sure that the process is done properly so that once we have that mastered, then we can zone in more into detail and go and tackle the newly diagnosed myeloma. We can always test newly diagnosed myeloma patients and we can have that as a baseline, but I don't think we're going to have any result in newly diagnosed patients at the moment that are actually going to change or impact what therapy we're going to use. If you talk to a myeloma doctor and you ask him, "What's your first frontline therapy?" The majority are going to give you one of three answers, either VRd or CyBorD or carfilzomib, lenalidomide, dexamethasone. Nobody veers off of that unless they're very frail or they have medical conditions that prohibit triplet regimen.

But the relapsed setting, that's when things get tricky and that's when everybody starts to wonder, "Okay, what is next?" That is the big headache for the doctor in terms of choosing the next regimen. It's a new blessing for myeloma patients because before, we didn't have that many options. But at the same time, we don't know if the one that we're choosing is actually the best one for that particular patient. A tool like this is going to help avoid getting therapy that can cause toxicities or side effects. And then two months down the line or down the road, realize, "Oh, this was not the right combination. Let's go back to the drawing board and try a different combination."

Jenny: Yes, I mean the time, the side effects and the cost and just the time to have your disease grow out of control, this seems to be so much more efficient than that.

Dr. Rodriguez: We're hoping that once it gets validated, it can become a standard of care. What we've done right now with the samples that we've tested is on purpose, we have kept them overnight sitting in our lab and have not done the test until the next day. The reason why we did that is if this test does function and it's something that we can actually take to the clinic and start using them in patients, we want to be able to offer this test to anyone who has myeloma. Let's say somebody in California or somebody in Fargo or somebody in a big city, anybody who is anywhere in the United States has myeloma and they do a bone marrow biopsy. They can always overnight a sample and we can process it the next day and be able to give reliable information.

Jenny: Right. Dr. Ghobrial started doing this with her PCROWD study and it works really well. You just send them a sample and they send it back to you and you just make sure you don't get your bone marrow test done on a Friday.

Dr. Rodriguez: Exactly. That is very true.

Jenny: So you can run the test on any other day during the week, so it's awesome. You talked a little bit about how you get the sample and then how you grow it up and what you do with it. Then we talked about the timeframe a little bit. In your proposal, you talked about evaluating the tumor markers at different time points of the tumor. What do you mean by that?

Dr. Rodriguez: There are several things that we can do when we're playing with a model like this. One is something that patients are going to want and benefit the patient the quickest or the best, is know what is the best chemotherapy for that particular patient. But the other thing that we can take advantage of is because we're replicating the environment of the bone marrow with the myeloma cells in it, we can actually study the behavior of the myeloma cells within the environment. Let's say we tested 20 different combinations in a particular patient, we want to do a baseline before we actually expose them to chemotherapy or anything. We want to do a testing for tumor markers and a gene expression to have an idea of what that cancer looks like.

Then after exposing it to chemotherapy, we can see which combinations work the best. But the ones that didn't work, then those organoids, we can actually repeat the tests and see if there were any changes in the genes or if there were any new mutations or any changes in the surface markers of the myeloma cells that could explain why the patient was resistant to that combination. By getting that information and comparing it with the baseline information, maybe it can shed some information as to, is the cell being changed as it's being exposed to chemotherapy and developing its resistance or is there something else? Are we just choosing the strong cells? That can hopefully shed some light as to more mechanisms of resistance of the myeloma cells.

Jenny: Wow. That makes sense like, did the chemo actually change the cells so that they're behaving differently?

Dr. Rodriguez: Differently, yes.

Jenny: It makes a lot of sense.

Dr. Rodriguez: We know that when myeloma relapses, that it has a whole slew of new mutations or different mutations. As it tends to come back and as time progresses, there's going to be more evolution in the myeloma itself. But we don't know exactly if the chemotherapy or if the exposure to the chemotherapy alters the cell at that moment, and if there's anything that we could potentially identify to help prevent that resistance.

Jenny: That's amazing. Then you're testing the tumor against how many different drug combinations. Are those existing drug combinations or are those clinical trial type? Could you test a bITE against it or CAR-T or antibody drug conjugate together or things like that against it?

Dr. Rodriguez: Right now, we would like to focus on existing chemotherapy combinations for this particular study. The reason why we want to do that is, the same time we're testing in the lab that chemotherapy combinations, the patient whose sample we got is going to be getting chemotherapy of some type. We want to be able to go back and compare how the results in the lab compared to how the patient actually did with the treatment that they got. If we started to play with novel therapies or things that are not standard, then we wouldn't be able to extrapolate that with what the patient actually received.

Now that doesn't mean that we cannot play with new compounds or BiTEs therapy or CAR-T. We can definitely do that, but that is something that we will probably do with a separate study or a separate brand, because it is true. It would be very silly of us not to take advantage of this model and be able to test new combinations or new compounds or such things as BiTEs and CAR-Ts to see how it's going to behave more in real life model compared to identical 2D model. Drug companies are very excited about this study and they actually have reached out to try to do some collaboration and also to compare the results that we obtained with the results that they have obtained using the standard models that they used when they were testing drugs and see if there are any differences that might warrant further testing with these new models.

Jenny: Well, you can imagine that it would cut their drug development significantly if they can start testing some drugs that are in development against these samples. You just see what kind of responses they have. It's amazing.=

Dr. Rodriguez: Imagine, you could potentially even skip testing in mice instead of you're seeing such great results and you're actually validating data with these organoids. That would be such a great breakthrough. I don't know if we can do that right now. It would definitely take a long time for science to take such a big leap, but who knows.=

Jenny: No, I think it's a great theory because a lot of people say, "Well, we can kill myeloma in a lot of mice." But then once you start using it in human studies, then it's usually different.

Dr. Rodriguez: Exactly.

Jenny: As part of the process, so you test a sample, you do a gene expression profile test, you're testing the genetics, then you're evaluating the responses after one day and three days like you mentioned before. Do you do another gene expression or do you just do one?=

Dr. Rodriguez: Yes. So we are entertaining the possibility of doing the gene expression or RNA sequencing at the end. But we would only use the organoids that were very resistant to chemotherapy. The reason why that is, is you obviously need to have live myeloma cells in order to test them. We would be focusing on those chemotherapy combinations that were not effective. Hopefully, that will give us a better answer as to why, why that is, what's happening that could potentially explain this, the mechanism of resistance.

Jenny: That makes sense. Okay. Let me see. Well, I have a technical question but I don't know if it's worth answering or not because it was the “chemobiogram”. That was in your proposal but I didn't know what that meant, so.

Dr. Rodriguez: Okay. That's just me playing with words. The reason why I used that word is basically, if somebody has a urine infection or if they have a blood infection or skin infection, the first thing that we do is we take a culture or we do a culture of either the urine or the blood or a swab of the skin. When we send it for culture, a lot of percentage of the time, not all the time, but a percentage of time, we get a result back with an organism that's growing, a bacteria or -- normally, the bacteria that's causing the infection. Then also the laboratory also gives you a result as to what antibiotics is sensitive to and what antibiotic it's resistant to. That is called an antibiogram which of the antibiotics are sensitive to this and can kill that and infection.

Jenny: Oh, I get it. Okay.

Dr. Rodriguez: It's a play on words with the chemotherapy. I'm trying to form this chemobiogram for myeloma itself and see which combination of chemotherapy is going to kill this better and which ones are going to more resistant to it.

Jenny: Okay, that makes a lot of sense. I had a question because I've heard a lot of myeloma experts say you can have a really big lesion in your shoulder and you're doing a bone marrow biopsy, that the genetics of that myeloma can be different in your shoulder than it can be coming out of your hip. How do you deal with that when you look at a test like this? Is the sample that you're getting representative of that myeloma or would you ultimately maybe just go get two samples?

Dr. Rodriguez: That's an excellent question. It's very true. Arkansas actually did a study. What they did is they did imaging studies, and wherever they saw lesions and whether it be plasmacytomas or lytic lesions, they went ahead and biopsied each one of those lesions and did a bone marrow biopsy and they compared the results. The results were pretty interesting because you could see that there were different clones of myeloma and different mutations in different parts of the body which goes with the name multiple myeloma. You're not dealing with just one myeloma. You're dealing with many.

Right now, we rely on one bone marrow biopsy to tell us what mutations the patient has and we go off of it. A lot of the times, if we do a bone marrow biopsy, it might tell us that it's, let's say, 60% bone marrow involvement with myeloma. But there is a good chance that if we did a biopsy next to it or on the other hip or in the sternum, we might actually find a different percentage of myeloma cell involvement and also different mutations. That raises the question, so what do we do? We're not going to be poking all over the body for a patient because patients already --

Jenny: Yes, it sounds really painful.

Dr. Rodriguez: Once we do a bone marrow biopsy, it's painful enough. Yes, I don't think somebody would want to be willing to do that unless they like torture. At this point, we do have to rely on one bone marrow biopsy. We need to make sure that if we get one bone marrow biopsy, that it is very adequate sample and that it has good cellularity and that it has a good representation of the marrow itself. If the bone marrow biopsy is suboptimal sample or if it's just the cortex of the bone or it's crushed or there's a lot of aspirate or it's a diluted sample, then I would encourage to repeat the bone marrow biopsy so that we can at least be dealing with a good sample knowing that it might not be representative of all of the myeloma in the body but it will help us at least hopefully identify mutations that would help us with prognosis.

Going back to your question, I don't think it would be prudent at this time to be biopsying everything. If there is a different lesion or if you received treatment and then you repeat a PET scan to check for response and you see that there is an area that is not responding to therapy, then that area would warrant a biopsy so that we can learn what's going on in there. Is it a more aggressive type of myeloma? Does it have different types of mutations so that it can help us guide us in terms of what therapy we should be using to target that?

Going back to when we were talking about targeted therapy, it raises the big conundrum. If we are relying only on one bone marrow biopsy and it might not be representative of other parts of the body, are we doing a disservice just by using a single targeted agent? I think that that it's true. I think that's why combining targeted therapy with more generic therapy is probably going to be the answer going forward.

Jenny: Yes, that really makes sense. Well, I'm glad you're thinking about that because I know it's confusing and frustrating that this disease is so complicated. But it is what it is, right?

Dr. Rodriguez: Yes, it is. Hopefully, those liquid biopsies might be able to change them from the future.

Jenny: Right.

Dr. Rodriguez: I mean, that's something everybody is looking forward to and we're hoping that it would be representative. We're not quite there yet. Still needs some tweaking but hopefully, it will be a change there in the future.

Jenny: Yes, because you could take same sample, right, and use it in your organized model.

Dr. Rodriguez: Exactly.

Jenny: You would think so. How many patients are you planning to test? Then when do you expect to have certain results? I'm just assuming you're not going to ship bone marrow biopsy samples from the get-go. That might be later on.

Dr. Rodriguez: We are wanting to do 40 patients at the moment. The way we're going to be doing this test is, if a patient gets a bone marrow biopsy, we take an aspirate. We process that aspirate with organoids. We get a result from the organoid by the end of seven days, and we're going to keep that information there confidential. In the meantime, the patient is going to be getting therapy. At the end of two cycles of chemotherapy, we're going to see how they responded to treatment. At that point, we're going to compare it with the organoid results.

In that way, we can start doing some type of validation but at the same time, not influence results with the patient nor with the lab because at this point even though we're very tempted to -- if we see that one regimen is much more effective than another and try to use it with a patient, it doesn't necessarily mean that it's going to translate to the patient. We need to make sure that this test is validated and that the results that we get actually do translate to what's going to happen with our patients. Every two months, we will have results from that. The patient that gets enrolled, we should have results of that particular in two months. The amount of time it takes us to enroll these 40 patients, I'm hoping that it will be within a year because I don't see why it would -- but I'm hoping.

Jenny: I think this will not take a lot of time.

Dr. Rodriguez: I don't think so either. I think people are going to be excited to volunteer and to be willing to donate some of the aspirates. I'm hoping that we will have results in everything much less than a year and be able to present some preliminary data halfway through and go from there.

Jenny: Yes, that would be fabulous if you could do that. Is this ultimately going to become a commercial type of test that you could run kind of like they do, you know, this guideline test or the My PRS test or other types of tests? This might just be another type of test, right?

Dr. Rodriguez: Yes, this is our goal. Our goal is that if this organoid works to tell us which is the next best therapy in somebody who has multiple myeloma, then we want this to be available for everybody. We would start providing it here nationally and make it commercial. I know that we're not the only site that has organoids. We might be the only site at the moment that I'm aware of that actually plays with patient's myeloma cells, with patient's stromal cells and doing this test. But I know that there are other sites here in the United States that have some ability to do organoids If this does work and it's validated and we want to commercialize it, we can always then expand it to other institutions or other labs so that it could be available nationwide. Even if we cannot expand it to other labs at the beginning, it can always be shipped overnight and we can process the sample and then give an answer one week later.

Jenny: That's fast.

Dr. Rodriguez: Yes. Then eventually move it globally if possible. But the idea of this is to not just keep it here, but to share it with everybody so that everybody can benefit from it.

Jenny: Yes, it's wonderful. I think that would really change the course of this approach for personalized medicine or even just optimizing with what we have today.

Dr. Rodriguez: Exactly.

Jenny: Now, each of these projects are integrating with HealthTree. Do you want to describe just how you might integrate this with HealthTree?

Dr. Rodriguez: Sure. So HealthTree. What exactly is HealthTree? It is a nice platform for a patient to be in control of all of their information. You have in HealthTree a patient's personal data, patient's disease history whether it be laboratory numbers for myeloma markers like in M-spike and light change and CBCs, CMP, bone marrow biopsy, imaging studies. You have all this information throughout the course of the disease. At the same time, HealthTree allows you to put the different chemotherapies that you've been exposed to.

One nice way of incorporating the results in this study with HealthTree is that every time somebody has a bone marrow biopsy, we can perform this chemobiogram test using the organoids and it will give a result of a large number of combination therapies that are going to tell at that moment what it's sensitive to and what it is not. That can be incorporated as part of the HealthTree disease data so that anybody who is managing that patient can look at the chart and say, oh, in the first relapse, the patient received a combination with let's say, a proteasome inhibitor and a monoclonal antibody and dexamethasone or an immune modulator with monoclonal antibody and dexamethasone. But the patient also was sensitive to all these other combinations.

Then when they relapsed the second time, the study showed that all of the ones the patient was sensitive to at the first relapse, half of them are still sensitive or none of them are sensitive. But amongst the ones that were resistant are now sensitive. That is going to help the decision -- have a 360-view of the disease. Right now, we rely only on, okay, the patient relapsed, got cyst therapy, they responded or they were resistant to it or they stayed in remission for two years or six months, and then they relapsed again. It's a linear view that we're seeing of the disease. But information like this with the chemobiogram and organoids, it's going to give a more 360-view of, okay, that's the path that they took, but these are the other paths that could have been taken. Out of those paths when they relapsed again, some of these paths are still available and can be options or they haven't. They have changed drastically. That's one way that it can help with HealthTree.

But then another unique way that it can help is, and hopefully, this will not be the case but let's say somebody relapses and gets a bone marrow biopsy and they get treated and they -- and we do the chemobiogram and the organoid testing, so we have a list of chemotherapy combinations for that patient. Then down the road, they either become intolerant to the chemotherapy or they have a reaction to it or they relapse but they can't get a bone marrow biopsy. They can always look back at the chemobiogram or the results of this test and choose something else from that combination. Because the reality is that there are some patients that are going to have intolerance to a therapy or are going to react and get a rash or diarrhea or too much nausea or get too weak. I would hate for them to require another bone marrow biopsy. You can always go to the results and choose the next one in the line of options.

Jenny: Right. That makes a lot of sense. Well, this is such a fascinating project in my opinion because it really gets to the heart of the issue for patients, what do we do next?

Dr. Rodriguez: Exactly.

Jenny: It's so difficult to figure that out and to -- you just wonder, are we choosing the right things and I just feel like each time we're making these decisions, we're making these life and death decisions that really affect the future and some of our potential opportunities for treatment. So getting it right the first time, anything we can do to help accelerate that is just what we want to do. I will open it up for caller questions. I know we're at our time, so we'll ask people to keep it short. But if you could call 347-637-2631 and press 1 on your keypad if you have a question for Dr. Rodriguez.  Go ahead with your question.

Caller: Hi, Jenny.  Thanks so much for taking my call. Appreciate it. Hi, Dr. Rodriguez. Your out-of-the-box research is just so very much appreciated and super exciting to know we may one day put those little mice out of business and actually move the clinical trial research timetable dial to fast forward. It's just so exciting to have listened to your presentation. I'm a smoldering patient, so I'm really in the phase of just trying to learn about all of my potential treatment options going forward when I'll need to make those decisions. I always am so baffled by that one-size treatment fits all approach or let's see which sticks to the wall treatment approach that we currently are really stuck with. I understand why because the field continues to obviously learn more but it still remains baffling, so thank you.

As I stated, I'm a smoldering patient with a primary predominant 11;14 abnormality. My bone marrow biopsies have not really detected any others yet. I understand that it's likely they just haven't hit the right spot to extract the subclonal cells that are probably lurking about. I appreciated your explanation of how you are trying to overcome this uneven distribution in the marrow. Just for the record as a patient, I've already gone through four bone marrow biopsies. I know that pales in comparison to many of the myeloma patients. But as unpleasant as they are, in my experience, the experience of the practitioner matters. Multiple sample sites would be agreeable to me and probably a lot of other patients to capture optimal distribution of these cells.

I'm just really kind of throwing that out there for you to consider because I think it's important for patients to understand that, yeah, these are unpleasant practices but they're necessary to really help new brilliant researches help sort it out. There are many of us that are willing to be part just numerous times. Can you actually foresee doing the chemobiogram testing earlier in myeloma? I know you said that at this point, you're really focusing on the relapse patients. But I honestly -- from my mind, to be able to avoid the standard of care approach, which is really that one-size fits all that I respect and understand would likely work for a majority of newly diagnosed patients. If I can avoid that step, I'm all for it.

Dr. Rodriguez: I think I definitely see us playing early on in disease staging. I think that after we understand chemotherapy in myeloma, playing with smoldering myeloma and playing with MGUS, which I know is something that people are going to think, well, what the heck is he talking about, but I think that's where this is going to be very key. MGUS and smoldering are going to be unique things not so much in terms of chemotherapy but in understanding the biology of the disease and trying to understand what it is that makes that MGUS jump to smoldering or what makes that smoldering jump to active myeloma. If we can find something that we can trigger early and prevent it from evolving, that'll be the jackpot.

Caller: Really. It's like the Holy Grail so to speak. It really, really is.

Dr. Rodriguez: Yes. Right now, I have to be honest and I have to say that one of the limiting factors in playing that early in the disease is that in order for us to make a good organoid, we need to have a good number of cells. So that's going to be something that I haven't looked at yet but we are definitely considering as we go forward to try to find a way to make sure that we can do a good organoid with smoldering and a good organoid with MGUS.

Caller: Now, when you say a good number of cells, are you saying percentage-wise like in other words, I'm told that I have 20% myeloma cells based on flow. Do you have more or less a metric to make this a successful test?

Dr. Rodriguez: Yes, exactly because let's say somebody has a very small percentage of myeloma cells and we do that organoid and we're starting with -- and just to give you an example, we're starting with 10 myeloma cells. Then when we compare after exposing them to therapy, we're going have very low cells to play with and to make a good measurement. That's the one thing that we're going to have to figure out how to play with for MGUS and people who have low tumor burden.

Caller: It would be incredible to think that someday, you could do this on smoldering patients, even earlier with an MGUS patient who ends up progressing, that we would actually have a roadmap to follow to initiate treatment beyond standard of care. Standard of care is wonderful but it's certainly not curative. Hopefully, we could get closer to that goal with this type of testing. It's fascinating. It really was. I was so excited when I was listening to your explanation. I for one would love to be able to follow your research. Do you have any website or something that you're going to be sharing updates on? Are you going to be doing it through HealthTree or give Jenny regular updates?

Dr. Rodriguez: I don't have a direct website to give updates but I can definitely give Jenny updates which I'm sure she would be glad to share.

Jenny: Oh, yes, we'll share that for sure.

Caller: Great. Because, you know, we open up if you're ready for smoldering patients. I think it's fascinating. So many of us would jump at the chance. I'm enrolled in the PCROWD Study and I've already donated two bone marrow samples to them and I'm probably on my 14th blood sample to them.

Dr. Rodriguez: That's great.

Caller: Well, it's important for me. If I want to find the real help down the road, it's important for me to give you guys these samples. It's really nothing exciting for me to do. It's just my standard of care, so I look forward to really keeping on top of this and see what you end up discovering. So thank you.

Dr. Rodriguez: Thank you, and thanks to donations that help fund research like this that we can be able to explore other questions that come up as we start doing this research because I'm pretty sure that this is going to generate many more questions.

Caller: Oh, absolutely. It always does. One door opens up, 10 more in myeloma it seems. But it's a terrific starting point, that's for sure. It's an exciting starting point. I donate to Myeloma Crowd Research Initiative. It's just a worthy cause. I mean patient driven. It's just been terrific because you know, Jenny wants a cure too. She wants to be around and she is really our incentive. It's just been terrific and thank you for collaborating and thank you for applying for this grant because it's super exciting. Good luck to you and I look forward to really keeping track of your research. Thank you, Jenny, for entertaining my long-winded set of questions. Appreciate it.

Jenny: Sure thing.

Caller: Thank you, everyone.

Jenny: Thanks, okay, bye.

Dr. Rodriguez, thank you so much for explaining your work. It is just absolutely outstanding and excellent. We're so thrilled to see what you learn from this. We will for sure be giving regular updates on your project. When you have information, please feel free to reach out. We will also be creating a short video about his work so you can watch that later and we'll be including that on the campaign link that we talked about earlier. We appreciate you considering sharing these types of projects because family and friends, they want to know what they can do for you and this is something that they can do for you. They can help. We thank you for joining us so much.

Dr. Rodriguez: Thank you. It's been a pleasure.

Jenny: We thank you for listening to Myeloma Crowd Radio. We encourage you to tune in next time to learn more about myeloma research and what it means for you.