",isbn:"978-1-80356-963-5",printIsbn:"978-1-80356-962-8",pdfIsbn:"978-1-80356-964-2",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!0,isSalesforceBook:!1,isNomenclature:!1,hash:"8eeb7ab232fa8d5c723b61e0da251857",bookSignature:"Dr. Soumen Dhara and Dr. Gorachand Dutta",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/11513.jpg",keywords:"Fabrication Technologies, Applications, Characterizations, Case Studies, Various Gas Sensors, Improvement of Lifestyle, Societal Benefit, Bio-Sensors, Bioreceptor Molecules, Integration, Packaging, Lab-on-Chip",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:null,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"April 8th 2022",dateEndSecondStepPublish:"June 17th 2022",dateEndThirdStepPublish:"August 16th 2022",dateEndFourthStepPublish:"November 4th 2022",dateEndFifthStepPublish:"January 3rd 2023",dateConfirmationOfParticipation:null,remainingDaysToSecondStep:"2 months",secondStepPassed:!0,areRegistrationsClosed:!1,currentStepOfPublishingProcess:4,editedByType:null,kuFlag:!1,biosketch:"A pioneering researcher in nanowire heterostructures and laser spectroscopy, recipient of JSPS (Govt. of Japan) and NPDF (Govt. of India) fellowships, and member of MRS(USA), MRS(India), IPA(India).",coeditorOneBiosketch:"Assistant Professor with the School of Medical Science and Technology, Indian Institute of Technology Kharagpur with research interests that include the design and characterization of portable biosensors, biodevices, and sensor interfaces for miniaturized systems and biomedical applications for point-of-care testing.",coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"196334",title:"Dr.",name:"Soumen",middleName:null,surname:"Dhara",slug:"soumen-dhara",fullName:"Soumen Dhara",profilePictureURL:"https://mts.intechopen.com/storage/users/196334/images/system/196334.jpeg",biography:"Dr. Dhara received his Ph. D in Physics in 2012 from Indian Institute of Technology Guwahati, India. Presently, he is associated with the Faculty of Science, Sri Sri University, India as an Assistant Professor in Physics. Prior to joining the current\naffiliation, he was a postdoctoral fellow at different renowned institutions, Kobe University Japan, S. N. Bose National Centre for Basic Sciences, India and Cardiff University, United Kingdom. He was awarded prestigious JSPS postdoctoral fellowship based on his research contribution on semiconducting nanowires. He has published more than 32 research articles including 1 review article in high profile international journals and 3 book chapters to his credit. His research trust areas of interests are semiconductor nanostructures, optoelectronics, solid state lighting and light sensors, spectroscopy of nanomaterials, thin-film transistors (TFTs) etc.",institutionString:"Sri Sri University",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"2",totalChapterViews:"0",totalEditedBooks:"0",institution:{name:"Sri Sri University",institutionURL:null,country:{name:"India"}}}],coeditorOne:{id:"442408",title:"Dr.",name:"Gorachand",middleName:null,surname:"Dutta",slug:"gorachand-dutta",fullName:"Gorachand Dutta",profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:"Dr. Gorachand Dutta, PhD is an Assistant Professor with the School of MedicalScience and Technology, Indian Institute of Technology Kharagpur. His research interests include the design and characterization of portable\r\nbiosensors, biodevices and sensor interfaces for miniaturized systems and biomedical applications for point-of-care testing. He received his Ph.D in Biosensor and Electrochemistry from Pusan National University, South Korea,\r\nwhere he developed different class of electrochemical sensors and studied the electrochemical properties of gold, platinum, and palladium based metal electrodes. He completed his Post-doctoral fellowships in the Department of\r\nMechanical Engineering, Michigan State University, USA and Department of Electronic and Electrical Engineering at University of Bath, UK. He has expertise on label-free multichannel electrochemical biosensors, electronically\r\naddressable biosensor arrays, aptamer- and DNA-based sensors and surface bio-functionalization.",institutionString:"Indian Institute of Technology Kharagpur",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"0",totalChapterViews:"0",totalEditedBooks:"0",institution:{name:"Indian Institute of Technology Kharagpur",institutionURL:null,country:{name:"India"}}},coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"11",title:"Engineering",slug:"engineering"}],chapters:null,productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},personalPublishingAssistant:{id:"429341",firstName:"Paula",lastName:"Gavran",middleName:null,title:"Ms.",imageUrl:"//cdnintech.com/web/frontend/www/assets/author.svg",email:"paula@intechopen.com",biography:null}},relatedBooks:[{type:"book",id:"10198",title:"Response Surface Methodology in Engineering Science",subtitle:null,isOpenForSubmission:!1,hash:"1942bec30d40572f519327ca7a6d7aae",slug:"response-surface-methodology-in-engineering-science",bookSignature:"Palanikumar Kayaroganam",coverURL:"https://cdn.intechopen.com/books/images_new/10198.jpg",editedByType:"Edited by",editors:[{id:"321730",title:"Prof.",name:"Palanikumar",surname:"Kayaroganam",slug:"palanikumar-kayaroganam",fullName:"Palanikumar Kayaroganam"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"1591",title:"Infrared Spectroscopy",subtitle:"Materials Science, Engineering and Technology",isOpenForSubmission:!1,hash:"99b4b7b71a8caeb693ed762b40b017f4",slug:"infrared-spectroscopy-materials-science-engineering-and-technology",bookSignature:"Theophile Theophanides",coverURL:"https://cdn.intechopen.com/books/images_new/1591.jpg",editedByType:"Edited by",editors:[{id:"37194",title:"Dr.",name:"Theophile",surname:"Theophanides",slug:"theophile-theophanides",fullName:"Theophile Theophanides"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"3161",title:"Frontiers in Guided Wave Optics and Optoelectronics",subtitle:null,isOpenForSubmission:!1,hash:"deb44e9c99f82bbce1083abea743146c",slug:"frontiers-in-guided-wave-optics-and-optoelectronics",bookSignature:"Bishnu Pal",coverURL:"https://cdn.intechopen.com/books/images_new/3161.jpg",editedByType:"Edited by",editors:[{id:"4782",title:"Prof.",name:"Bishnu",surname:"Pal",slug:"bishnu-pal",fullName:"Bishnu Pal"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"371",title:"Abiotic Stress in Plants",subtitle:"Mechanisms and Adaptations",isOpenForSubmission:!1,hash:"588466f487e307619849d72389178a74",slug:"abiotic-stress-in-plants-mechanisms-and-adaptations",bookSignature:"Arun Shanker and B. 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1. Introduction
Typically, a resistive switching material changes its resistance between two states: High Resistive State (HRS or OFF‐state) and Low Resistive State (LRS or ON‐state). The most common structure for a resistive switching devices is an insulator between two metals or metal/insulator/metal (MIM) structure. One of the most important applications of these kind of devices is for non‐volatile memories or Resistive RAMs (ReRAMs).
The metal elements of the MIM structure are called top and bottom electrodes. An electrical stimulus is necessary to apply between these electrodes to change the resistive state of the insulator material. In order to determine the resistive state (HRS or LRS), a low voltage is applied on the electrodes, and the current, which flows through the insulator, is measured (IHRS or ILRS). There are several orders of magnitudes of difference between IHRS and ILRS currents. The change from the HRS to the LRS is called SET process and the change from the LRS to the HRS is called RESET process.
Depending on the voltage polarity applied on the electrodes, there are two schemes to change the resistive state: unipolar and bipolar. On the one hand, in the unipolar scheme, the resistive state change does not depend on the voltage polarity and there are two threshold voltages: one for the RESET process (VRESET) and one for the SET process (VSET) with the same polarity as we can see in Figure 1. On the other hand, in the bipolar scheme, VRESET and VSET have different polarities (Figure 2).
Figure 1.
SET and RESET process for unipolar behaviour.
Figure 2.
SET and RESET process for bipolar behaviour.
There is no universal theory or model which explains the electron conduction in the two resistive states and the SET and RESET processes because there are many factors that affect the switching behaviour, such as the type of the insulator material, fabrication process, nature of the dielectric breakdown, among others. However, Waser and Wutting proposed a classification based on the type of the resistive switching mechanisms, such as nanochemical materials, ferroelectric tunnelling, electrostatics effects, phase change mechanism, thermochemical mechanism, redox‐based effect, electrochemical effect, molecular switching effect and magnetoresistive effect [1].
Chalcogonides are one of the most used materials in the fabrication of resistive memory devices. The switching mechanisms related to these materials are: phase change memory effect, thermochemical memory effect, redox‐based memory effect and interface defect modulation. The phase change mechanism affects the complete volume of the insulator material and it is considered as a 3D mechanism. A 2D resistive switching mechanism is the modulation of the defect density at the metal/insulator interface. Finally, when the resistivity material depends on the formation of a conduction filament (CF), 1D mechanisms are involved in the resistive switching process. Thermochemical diffusion of oxygen, reduction/oxidation of the CF and quantum point contact effects are typical 1D mechanisms.
2. Phase change model
Heavier chalcogonides, such as tellurides and selenides, show different electrical and optical properties in their amorphous and crystalline phases (Figure 3). The resistive switching of these materials is unipolar. On the one hand, the amorphous phase of these materials has high resistivity and low reflectivity and, on the other hand, crystalline phase has low resistivity and high reflectivity [2]. These properties are being exploited in the development of optical storage products, such as compact disks (CD), digital versatile disks (DVD), high‐definition digital versatile disks (HD‐DVD) and Blu‐ray disks (BR). The first kind of materials used for optical storage were good glasses, such as Te‐based alloys like Te85Ge13 doped with Sb, S and P. These materials show good electrical switching properties in the amorphous and crystalline phases but the crystallization time was in the order of microseconds, too high to be considered for optical storage. The second generation of these materials shows shorter crystallization time and good optical properties. Among these materials, we have GeTe, Ge11Te80Sn4Au23, GeTe‐Sb2Te3, GeBiTe and GeInSbTe. After, a third family of materials was later discovered which includes alloys of Sb2Te doped with Ag, In and Ge [2].
Figure 3.
Phase change mechanism: the phase material changes from (a) amorphous phase to (b) crystalline phase (and vice versa) to have different resistivity and reflectivity.
There are two important temperature thresholds in these materials: the melting temperature (Tm) and the glass‐transition temperature (Tg) with Tm > Tg. The process to change the material phase from crystalline to amorphous and vice versa is as follows [2]:
To write a bit, a short high‐pulse laser or current is applied on the crystalline material to reach Tm temperature.
The material is cooling down rapidly with a rate higher than 109 K/s. In a very short time, the material reaches the amorphous phase without passing through the crystalline one.
To erase the bit, a long short‐pulse laser or current is applied on the amorphous material. The material temperature increases over Tg. There is an increment of the electron mobility and the material changes to the crystalline phase.
For electrical storage devices, the resistive switching property is fundamental and all these materials have it. However, not all these materials have the reflectivity switching property. To have this property, a very short time (few tens of nanoseconds) is needed for cooling down the material from the liquid phase to amorphous phase (step 2) [2].
When a low voltage is applied to the material in the amorphous phase, a very low current is measured due to the high resistance. When the voltage reaches a value around 0.7 V, the resistivity decreases and the material reach the so‐called ON‐amorphous phase [1, 2]. In these phases, the current increases significantly and enables enough heat to recrystallize the material. During the phase change, material defects play an important role. In the amorphous phase, the current is controlled by the Pool‐Frenkel conduction, where carriers are trapped in defect sites according to the following equation (electron hopping mechanism) [1]:
I=2qANTΔzτ0e−(EC−EF)/kTsinh(qVΔz2kTth)E1
where A is the contact area, V the applied voltage, NT the integral of the trap distribution, Δz the intertrap distance, τ0 the scape time for a trapping electron, EF the Fermi energy, EC the conduction band energy, q the elementary electron charge and th the thickness of the material. Because of the total conduction is presented in the complete material volume, this mechanism is called 3D. Experimental results show that the defect density in the material is very high and most of the defects are negative U‐centres [1]. On the other hand, computational simulations show that in the crystalline phase, vacancy defects predominate with a concentration of 25% [1].
3. Metal/insulator interface modulation model
In this model, the resistive switching is presented at the metal/insulator interface. In other words, there is a contact resistance switching behaviour. This interface depending mechanism is presented in Peroskite oxides in which the material resistivity strongly depends on the interface area and the switching mechanism is always bipolar. A typical material that shows this behaviour is the Nb‐doped SrTiO3 [3].
The origin of this resistivity change can be understood by examining the metal/insulator interface band diagram as shown in Figure 4. The insulator oxide is usually doped with different metals. Depending of doped metal and its density, the insulator behaves as semiconductor at the interface. This provokes a Schottky barrier contact instead of a pure ohmic contact [3].
Figure 4.
Band diagrams at the Metal/Insulator interfaces. For a p‐type semiconductor, the presence of oxygen vacancies increases Wd. For an n‐type semiconductor, the presence of oxygen vacancies decreases Wd.
An electric field applied on the metal electrodes can electrochemically modify the oxygen vacancy density at the interface. For an n‐type semiconductor, an increment of the oxygen vacancies density reduces the depletion layer, Wd, in the energy band diagram provoking an increment of the tunnel electron conduction and, therefore, a decrement of the contact resistance (LRS). If an electric field is applied on the opposite direction, the number of oxygen vacancies in the n‐type semiconductor decreases and provokes an increment of Wd and, therefore, the contact resistance increases (HRS). On the other hand, for a p‐type semiconductor, the increment of oxygen vacancies increases Wd and the contact resistance (HRS), and a diminution of the oxygen vacancies decreases Wd and the contact resistance (LRS). In this model, the metal work function plays a very important role because the band bending strongly depends on this parameter.
Sawa showed very good resistive switching results for Ti/Pr07Ca0.3MnO3/SrRuO3 (Ti/PCMO/SRO) cells, where SRO has metal properties and PCMO acts as p‐type semiconductor. As well, the SRO/SrTi0.99Nb0.01O3/Ag (SRO/Nb:STO/Ag) cell showed a good resistive switching behaviour where Nb:STO acts as an n‐type semiconductor [3].
Another way to change the contact resistance is by adding a thin semiconductor layer of an oxide material between the metal and the insulator materials [3]. The semiconductor layer transforms the contact resistance from ohmic to a Schottky barrier. Without this layer, there is no switching resistance for some insulators. Sawa shows experimental results for Ti/Sm0.7Ca0.3MnO3(n unit cells)/La0.7Sr0.3MnO3/SRO (Ti/SCMO(n)/LSMO/SRO) where SCMO is a p‐type semiconductor [3]. It was demonstrated that for n = 5 unit cells, there was a very good hysteresis in the I‐V curve. As well, the SRO/SrTiO3/SrTi0.99Nb0.01O3/Ag (SRO/STO/Nb:STO) cell showed a resistivity changes but not a good hysteresis in the I‐V curve [3].
4. One dimensional models for resistive switching materials
In several transition metal oxides, when a voltage is applied on the electrodes of a pristine MIM cell, the current measured is very low. When the voltage increases up to a threshold value, the electric field applied provokes a dielectric breakdown. When this occurs, a conduction filament (CF) is formed in the insulator as shown in Figure 5. The necessary potential to form this filament is called forming voltage (VF). The CF is formed due to the Joule‐heating effect, which leads a temperature increment in the insulator. The dielectric breakdown is driven by a thermal runway. When a voltage is applied on a transition metal oxide, the resistance starts to decrease but not in a permanent way. In this process, the material temperature increases up to certain value (related to a threshold voltage) when a local redox reaction begins and causes structural defects (grain boundaries or dislocations) [4].
Figure 5.
Left: virgin cell. Right: Cell with conduction filament formed.
The voltage polarity to change states in cells with CF can be unipolar or bipolar. For unipolar behaviour, the electron conduction mechanism is related to thermochemical changes in the filament due to the Joule‐heating effect. On the other hand, for bipolar behaviour, the electron conduction through the CF depends on redox effects or quantum point contact effects. In both cases, the switching mechanisms (SET and RESET processes) are related to the thermochemical oxygen diffusion in the CF. We can consider the CF as a 1D parameter because the material resistivity is area independent. It is very important to note that in CF programmable devices, there exist a variability problem because not all filaments are equal or similar [5].
4.1. Thermochemical oxygen diffusion model
Ielmeni, Nardi and Cagli have been developed a physical model for NiO cells with very good concordance with experimental results [4]. In this material, the RESET process happens in small steps, whereas the change of states occurs suddenly during the SET process. The VRESETand IRESET parameters depend on the resistance material in the HRS. IRESET always decreases when the resistance increases. On the other hand, the VRESET in function of R curve has an U behaviour. That is, for low values of R, VRESET decreases when R increases, and for high values of R, VRESET increases when R increases. For the RESET process, the CF temperature depends on the square of the applied voltage as follows [4]:
T=T0+RthRV2E2
where T0 is the room temperature and Rth is the effective thermal resistance. By using Eq. (2), we can obtain the VRESET voltage:
VRESET=RΔTRESETRthE3
where ΔTRESET is the critical temperature increment for the onset oxidation. The ratio R/Rth is almost constant according to the Wiedemann‐Franz law for metals [4]. This means that VRESET is almost constant and IRESET decreases with respect to R. This is not true in experimental results. For explaining the increment of VRESET with respect to high values of R, we have to study the size‐dependent Joule‐heating effect. The parameter Rth is the parallel of two resistances: Rth′ and Rth′′, where Rth′ only depends on the CF and Rth′′ depends on the rest of the material (bulk oxide). Rth′ can be computed by considering the thermal nanofilament conductivity, kth, as follows [4]:
Rth\'=th8kthACFE4
where th is the oxide thickness and ACF is CF area. As Rth is inverse proportional to ACF, for high values of ACF (low resistance) Rth is approximately Rth′. On the other hand, for low values of ACF, we have that Rth ≈ Rth′′. As well, when kth increases, Rth′ predominates over Rth′′.
For explaining the behaviour of the VRESET‐R curve for low values of R, we have to consider that the ratio R/Rth is almost constant in Eq. (3) and ΔTRESET must increase in order to obtain a metal diffusion in the filament, which is a filament area dependent process. Hence, VRESET increases for low values of R. This size‐dependent diffusion is considering in following Arrhenius expression developed in Ref. [4]:
TRESET=EAklog(tRESETt0(φ0φ)2)E5
where EA is the activation energy, k the Boltzmann constant, t0 and ϕ0 are constants, ϕ is the CF diameter and tRESET= 1s is the reset time. Ielmini et al. showed very good results between their model and experimental data of NiO devices [4].
The electron conduction mechanism in the LRS strongly depends on the activation energy. For low values of EA, the filament has a metallic behaviour and the resistance is given by:
R=R0m(1+α(T−T0))E6
where T0 is the room temperature, R0m is the metallic resistant at T0 and α is the temperature coefficient. On the other hand, for high values of EA, electron conduction is driven by the Pool‐Frenkel model in semiconductors and the resistance follows the following equation:
R=R0sexp(EACkT)E7
where R0s is the extrapolated resistance at infinite T, k is the Boltzmann constant and EAC is the activation energy for conduction. Both conduction behaviours are related to position of Fermi level (EF). Inside the CF filament, there are oxygen vacancies, whereas the bulk oxide is doped by oxygen. An insulator doped by oxygen behaves as a p‐type semiconductor and, on the other hand, oxygen vacancies provoke an n‐type behaviour. Therefore, the conduction filament in LRS behaves as an n‐type semiconductor and the electron conduction is modulated by the concentration of oxygen vacancies, which is directly related to the EF position. When the oxygen vacancies concentration is too high, the CF behaves as a degenerately doped semiconductor and EF is very close or above the conduction band [4].
As was mentioned before, the SET process happens suddenly and it strongly depends on the resistance of the HRS (before the SET process). The HRS resistance can be described by the Pool‐Frenkel model and is given by Ielmini et al. [4]:
R=kTτ0thq2ACFNTΔz2exp(EACkT)E8
where τ0 is the attempt‐to‐escape characteristic time for a carrier from a specific state, th is the material thickness (or filament length), NT is the dopant density, ACF is the filament area and Δz is the distance between positive charged defects. Ielmini et al. showed, from experimental data, that necessary power for the setting process (PSET) is directly proportional to R−0.5, which means that [4]:
VSET=PSETISET=PSETR∝R0.25E9
ISET=PSETVSET=PSETR∝R−0.75E10
The tendencies for VSET and ISET parameters in function of R were experimentally confirmed the Ielmini group in Ref. [4].
4.2. Trap‐assisted‐tunnelling model
In bipolar cells, the transition between the LRS and the HRS is commonly related to the formation and rupture of the CF. A typical material which presents a CF with bipolar behaviour is the HfO2. As well as in unipolar cells, oxygen vacancies play an important role. The most accepted theory for forming the CF in a virgin cell is that the oxygen atoms migrate from the CF to the insulator/metal interface due to the Joule‐heating effect. When the CF is already formed, to change from the LRS to the HRS, the CF is oxidized (oxygen atoms migrate from the electrode to the CF), whereas to change from the HRS to the LRS, the CF is reduced leaving oxygen vacancies and forming percolation paths (oxygen atoms migrate from the CF to the electrode).
Guan, Yu and Wong have developed a model for explaining the carrier conduction through the CF in bipolar cells where the principal transport mechanism is the trap‐assisted‐tunnelling (TAT). The continuity transport equation in the oxide region is given by Guan et al. [6]:
where fn is the electron occupation probability of the nth trap, Rmn is the electron hopping rate from trap m to trap n, RnoL/RnoR are the electron hopping rate from trap n to the right/left electrode and RniL/RniR the electron hopping rate from the right/left electrode to trap n. It is well known that oxygen vacancies contribute to the TAT. In quasi‐steady state, Eq. (11) transform to [6]:
The hopping rate can be computed by the Mott hopping model as [7]:
Rmn=R0exp(−rmna0+qVmnHkT)E14
where R0 ≈ 1012Hz is the vibration electron frequency, rmn = |rm−rn| is the distance between vacancies n and m, a0 is the attenuation length wave function, VmnH≈ −FH(rm−rn) ≈ VH(rm)−VH(rn) is the barrier change due to an external electric field and VH(rn) is the homogeneous component of the potential solution of the Poisson equation. The hopping rates from a trap to an electrode are [6]:
where e R0tunnel is the tunnel coupling strength between a trap and an electrode, NL,R is the number of states at a given energy in an electrode and Ev+/Ev• are the energy of an empty/filled trap given by Guan et al. [6]:
Ev+,•(rn)=Ev+,•−qVH(rn)E16
TnL,R,+• is the tunnel probability from the left/right electrode into a trap given by the Wentzel‐Kramers‐Brilloin approximation [6]:
where xn is the xth component of rn, L is the oxide thickness and m* is the tunnelling effective mass in the oxide. FinL,R is the Fermi integral which represents the filled states in an electrode above Ev+ and takes into account the inject electrons from the electrode into the trap n:
where EFL,R is the Fermi level of the right/left electrode and VL,R is the applied voltage on the left/right electrode. On the other hand, FoutL,R is the Fermi integral which takes into account the number of empty states in an electrode bellow Ev− which can accept electrons from the trap n:
According to Guan et al. model, the generation oxygen vacancies are given by [7]:
PG(Feq,T,t)=tt0exp(−(Ea−γ|Feq|)/kT)E20
where the time, t, is within the interval [τ, τ + t], Feq is the local electric field of an ion, 1/t0≈ 1013Hz is the oxygen vibration frequency, Ea ≈ 1eV is a parameter related to the height of the potential barrier and γ is a coefficient which represents the local enhancement due to the electric field. This rate dominates the SET process.
On the other hand, during the equilibrium state (absence of Feq), the oxygen vacancy recombination rate is given by Guan et al. [6]:
PR0=PG(Feq=0,T,t)=tt0exp(−Ea/kT)E21
Therefore, the recombination rate for a non‐equilibrium state is [7]:
PR=βPR0E34
where β is a parameter related to concentration of oxygen ions which can be computed by the following approximation [6]:
β(x,t)=β0exp(−vtLp)u(x,t)E22
where Lp is decaying length of ion concentration, u(x,t) is a function related to the oxygen diffusion and can be approximated by the complementary error function. v is velocity of the oxygen ions waveform given by Yu et al. [7]:
v=at0exp(−Em/kT)sinh(qγdriftF/kT)E23
where a is the lattice constant, Em is the migration barrier, γdrift is the enhancement coefficient related to the dielectric material and F is the electric field left by an oxygen ion. Eq. (13) is coupled with the solution of the Poisson equation to obtain the potential distribution in the cell:
−∇2V=ρεE24
where ρ is the volumetric charge density and ε is the material permittivity. The border conditions for Eq. (24) are: V(x=0)=VL and V(x=L)=VR. Guan et al. showed very god results of their model for experimental data of HfOx devices [7].
4.3. Quantum point contact model
The complete quantum point contact (QPC) model was developed by Miranda and Suñe [8]. Originally, the model was developed for explaining the soft and hard‐dielectric‐breakdown in SiO2. If the dimension of the narrowest point of the CF is in the order of the Fermi wavelength, λF, quantum point contact effects are presented. There are some experimental works, where the QPC model could explain well the transport conduction in the HRS and LRS for HfO2 devices [9, 10, 11].
According to the QPC model, the first quantized sub‐band behaves as a potential barrier for the incoming electrons as shown in Figure 6. We used a parabolic potential as potential barrier with the following physical parameters: Φ being the potential barrier height measured at the Fermi level, tB is the potential thickness at the Fermi level, R is a series resistance external to the constriction, V is the applied voltage on the electrodes, q is the elementary electron charge and I is the filament current that flows in the x direction.
Figure 6.
Energy band diagram of the narrow constriction, where V is the applied voltage on the electrodes, R is an external series resistance that takes into account the non‐idealities of the model, I is the filament current, e(V‐IR) is the energy window associated to the electron conduction (shaded region), EF is the Fermi level, Φ is the potential height with respect to EF, tB is the potential thickness at EF and e is the elementary electron charge. The conduction is in the x direction. The top of the potential barrier is above or inside the energy window for the HRS and below for the LRS.
The potential barrier height is defined by the cross‐sectional area of the constriction and determines two conduction states. For the HRS, the top of the potential barrier is above or inside the energy window and the dominant conduction mechanism is tunnelling (this description is valid only for low‐voltages). On the other hand, if the top of the potential barrier is below the energy window, the cell is in the LRS and the conduction mechanism is essentially ballistic (transmission probability close to 1). The conduction in the LRS is independent of the potential barrier. By assuming a parabolic potential barrier in the narrow constriction and by using the Landauer formalism for 1D quantum conductors and the zero‐temperature limit for the parabolic potential barrier, the current through the filament is [9, 10]:
I=2ehN∫−e(V−IR)/2e(V−IR)/2T(E)dEE25
where T(E) is the electron transmission probability, N is the number of active channels in the filament and h is the Planck’s constant. For a parabolic potential barrier, there is an analytical expression for T(E):
T(E)=(1+exp(−α(E−Φ))−1E26
where α is a shape parameter related to tB. By integrating over the total energy window, we have that the filament current is [9, 10]:
For the LRS, we suppose an ideally ballistic transport that (T(E) ≈ 1) and the current is [9, 10]:
I≈NGo1+NGoRVE29
where G0= 2q2/h is the quantum conductance unit.
We show in Figure 7 experimental results of I‐V curves for the HRS and LRS and its fitting with the QPC model for HfO2 cells. We have found in Ref. [10] that α∝Φn with n = −0.35. There is a QPC expression which relates Φ and α by considering tB constant [9, 10]:
Figure 7.
Experimental and theoretical I‐V characteristics for the (a) HRS and (b) LRS. The QPC model (Eqs. (28) and (29)) was used for theoretical curves.
tB=hα2π22Φm*E30
where m* is the electron effective mass in the constriction. Moreover, the constriction radius, rB, can be extracted by using another QPC equation [9, 10]:
rB=hzo2π2m*ΦE31
where z0= 2.404 is the first zero of the Bessel function J0. In Ref. [10], we have experimentally found that rB= 1.14 nm with a standard deviation of 0.06 nm for bipolar HfO2 cells, which agrees with the quantum approach of this model. Miranda et al. showed that Φ has a linear dependence with respect to the temperature given by Avellán et al. [12]:
Φ(T)=Φ0−γTE32
where Φ0 is a potential height at a T0 temperature (a given temperature) and γ is a temperature coefficient. For extracting γ, we can use the following expression [12]:
d(log[I/1A])dTln(10)=αγE33
This dependence has been probed in experimental results of HfO2 cells in Ref. [10].
5. Conclusions
We have presented a classification of physical models for explaining the resistive switching mechanisms in chalcogonides materials. In the literature, there are many physical models proposed for explaining the electron conduction and switching mechanism in specific materials and fabrication process conditions. In the present work, we divide the models according to the number of material dimensions involved on the resistive switching mechanism. The phase change mechanism (PCM) is presented in some Te‐alloys used an optical storage devices. In this switching mechanism, the material changes from the amorphous phase to the crystalline phase. Because of the resistivity affects the complete cell volume, the phase change mechanism is considered a 3D model. On the other hand, the modulation of the resistive contact is a 2D model because the defect concentration only affects the metal/insulator interface. This mechanism is presented in some perovskite materials.
The principal component of 1D models is the presence of a conduction filament. The filament is formed in a virgin cell by applying a certain threshold voltage. Depending on the cell polarity, the transport mechanisms can be: thermochemical diffusion of oxygen, filament oxidation‐reduction or quantum point contact. For unipolar cells (like NiO cells), the resistive switching and the carrier conduction are controlled by the thermochemical diffusion of oxygen in the CF due to the Joule‐heating effect. For bipolar cells (like HfO2), the switching mechanism is related to the oxidation/reduction of CF. If the CF radius at the narrowest part of the CF is in the order of the Fermi wavelength, the transport is driven by the quantum point contact effect, otherwise the transport depends on the oxidation/reduction of CF.
\n',keywords:"chalcogonides, resistive switching, physical models",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/55666.pdf",chapterXML:"https://mts.intechopen.com/source/xml/55666.xml",downloadPdfUrl:"/chapter/pdf-download/55666",previewPdfUrl:"/chapter/pdf-preview/55666",totalDownloads:1408,totalViews:370,totalCrossrefCites:0,totalDimensionsCites:0,totalAltmetricsMentions:0,introChapter:null,impactScore:0,impactScorePercentile:38,impactScoreQuartile:2,hasAltmetrics:0,dateSubmitted:"December 5th 2016",dateReviewed:"April 6th 2017",datePrePublished:"December 20th 2017",datePublished:"April 4th 2018",dateFinished:"May 27th 2017",readingETA:"0",abstract:"We present a classification and description of the principal resistive switching and transport mechanisms in chalcogonides materials. We classify the model according to how many material dimensions are involved in the resistive switching mechanism. In this way, we describe the phase change model (3D), the interface modulation model (2D) and models where the switching mechanism depends on the formation of a conduction filament (1D). Among the conduction filament models, we include the thermochemical oxygen diffusion mechanism, the oxidation/reduction mechanism and the quantum point effect.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/55666",risUrl:"/chapter/ris/55666",book:{id:"5973",slug:"memristor-and-memristive-neural-networks"},signatures:"Luis‐Miguel Procel‐Moya",authors:[{id:"203297",title:"Prof.",name:"Luis-Miguel",middleName:null,surname:"Procel-Moya",fullName:"Luis-Miguel Procel-Moya",slug:"luis-miguel-procel-moya",email:"lprocel@usfq.edu.ec",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institution:{name:"Universidad San Francisco de Quito",institutionURL:null,country:{name:"Ecuador"}}}],sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_2",title:"2. Phase change model",level:"1"},{id:"sec_3",title:"3. Metal/insulator interface modulation model",level:"1"},{id:"sec_4",title:"4. One dimensional models for resistive switching materials",level:"1"},{id:"sec_4_2",title:"4.1. Thermochemical oxygen diffusion model",level:"2"},{id:"sec_5_2",title:"4.2. Trap‐assisted‐tunnelling model",level:"2"},{id:"sec_6_2",title:"4.3. Quantum point contact model",level:"2"},{id:"sec_8",title:"5. Conclusions",level:"1"}],chapterReferences:[{id:"B1",body:'Waser R, Wuttig M. Function by defects at the atomic scale ‐ new concepts for non‐volatile memories. In: Proceedings of ESSCIRC; IEEE.org, USA. Athens, Greece. 14–18 November 2009. pp. 65-72'},{id:"B2",body:'Wuttig M, Yamada N. Phase‐change materials for rewriteable data storage. Nature Materials. 2007;6:824-832'},{id:"B3",body:'Sawa A. Resistive switching in transition metal oxides. Materials Today. 2008;11:28-36'},{id:"B4",body:'Ielmini D, Nardi F, Cagli C. Physical models of size‐dependent nanofilament formation and rupture in NiO resistive switching memories. Nanotechnology. 2011;22:254022‐1‐254022‐12'},{id:"B5",body:'Degraeve R, Fantini A, Raghavan N, Goux L, Clima S, Govoreanu B, Belmonte A, Linten D, Jurczak M. Causes and consequences of the stochastic aspect of filamentary RRAM. Microelectronic Engineering. 2015;147:171-175'},{id:"B6",body:'Guan X, Yu S, Philip Wong H ‐S. On the switching parameter variation of metal‐oxide RRAM—Part I: Physical modeling and simulation methodology. Transactions on Electron Devices. 2012;59:1172-1182'},{id:"B7",body:'Yu S, Guan X, Philip Wong H‐S. On the switching parameter variation of metal oxide RRAM—Part II: Model corroboration and device design strategy. IEEE Transactions on Electron Devices. 2012;59:1183-1188'},{id:"B8",body:'Miranda E, Suñé J. Analytic modeling of leakage current through multiple breakdown paths in SiO2 films. In: IEEE International Proceedings Reliability Physics Symposium. IEEE.org, USA; Orlando. USA. 30 April–3 May 2001. pp. 367-379'},{id:"B9",body:'Miranda E, Walczyk C, Wenger C, Schroeder T. Model for the resistive switching effect in HfO2 MIM structures based on the transmission properties of narrow constrictions. IEEE Electron Device Letters. 2010;31:609-611'},{id:"B10",body:'Procel LM, Trojman L, Moreno J, Crupi F, Maccaronio V, Degraeve R, Goux L, Simoen E. Experimental evidence of the quantum point contact theory in the conduction mechanism of bipolar HfO2‐based resistive random access memories. Journal of Applied Physics. 2012;074509:074509 (1-5)'},{id:"B11",body:'Degraeve R, Roussel Ph, Goux L, Wouters D, Kittl J, Altimime L, Jurczak M, Groeseneken G Generic learning of TDDB applied to RRAM for improved understanding of conduction and switching mechanism through multiple filaments. In: IEEE International Electron Devices Meeting. IEEE.org, USA; San Francisco. USA. 6–8 December 2010. pp. 632-635'},{id:"B12",body:'Avellán A, Miranda E, Schroeder D, Krautschneider W Model for the voltage and temperature dependence of the soft breakdown current in ultrathin gate oxides. Journal of Applied Physics. 2005;014104:014104‐1‐014104‐5'}],footnotes:[],contributors:[{corresp:"yes",contributorFullName:"Luis‐Miguel Procel‐Moya",address:"lprocel@usfq.edu.ec",affiliation:'
Instituto de Micro‐Nanoelectrónica, Universidad San Francisco de Quito, Quito, Ecuador
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1. Introduction
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Multiple Myeloma is characterized by the upregulation and expansion of plasma cells malignant clones in the bone marrow [1]. The introduction of novel agents such as immunomodulatory drugs (IMiDs) and proteasome inhibitors (PIs) has led to significant improvement of disease prognosis and survival. However, the disease remains incurable, and all patients will relapse. Patients who are refractory to both Imids and PIs have poor survival outcomes, with a median overall survival of 9–13 months [2, 3]. The identification of novel therapeutic approaches for this group of patients represents an unmet medical need. In addition to that, patients with advanced disease characteristics and high-risk cytogenetics have a poor prognosis [4, 5]. Immune dysregulation represents a hallmark of MM pathophysiology. A better understanding of mechanisms that govern immune impairment in MM, has led to the development of several immunotherapeutic agents such as monoclonal antibodies, bispecific antibodies (BiTEs), and chimeric antigen receptor (CAR) T-cells.
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2. Monoclonal antibodies
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2.1 Daratumumab
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2.1.1 Daratumumab mechanism of action
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Daratumumab (Dara) is the first in class humanized IgG1-κ monoclonal antibody targeting CD38 through binding to a unique epitope which includes amino acids 233–246 and 267–280 [6]. Following binding to CD38, Dara exerts its action through canonical (classical) and noncanonical mechanisms [7]. Canonical mechanisms are immune-mediated, dependent on Dara binding to CD38 on the tumor cell, and include complement-mediated cytotoxicity (CDC), antibody-dependent cell-mediated cytotoxicity (ADCC), antibody-dependent cell-mediated phagocytosis (ADCP), direct cytotoxicity upon secondary cross-linking, and inhibition of CD38 enzymatic activity. Canonical mechanisms could be either Fcgamma receptor (FcgR) dependent or independent [6, 8, 9]. Whilst the canonical mechanisms explain the activity of Dara against CD38+ cells, noncanonical mechanisms are independent of Dara binding to CD38 and based on modulation of immune cells [10]. Dara targets three main categories of immunosuppressor cells that express CD38. These categories are Regulatory B cells (Bregs), which promote tumor growth and immune escape, a subset of regulatory T cells (Tregs), and Myeloid-derived suppressor cells (MDSC). After Dara binding to the CD38 in the surface of the above-mentioned cells causes depletion of their population [11]. Following the depletion of regulatory cells, there is a significant increase in the populations of CD4+ and CD8+ effector T-cells [12, 13, 14, 15]. Effector T-cells have increased levels of granzyme-B, which results in enhanced killing capacity [12, 16].
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2.1.2 Daratumumab combinations in the newly diagnosed setting
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2.1.2.1 Transplant-ineligible patients
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The combination of bortezomib melphalan and prednisone (VMP) is considered a standard of care regimen for patients who are not candidates for transplant. ALCYONE (NCT02195479) is a phase 3 trial in which patients with NDMM were randomized to receive bortezomib melphalan and prednisone either alone or in combination with Dara. The primary endpoint was PFS. The comparison of PFS rates at 16.5 and 40.08 months showed a sustained superiority of Dara-VMP versus VMP groups. At 16.5 and 40.08 months, PFS rates for Dara VMP and VMP groups were 71.6% (95% [CI], 65.5 to 76.8) vs. 50.2% (95% CI, 43.2 to 56.7) and 36.4 vs. 19.3 months respectively [17, 18]. At the time point of 40.08 months, the median PFS2 was not reached versus 42.3 months for the Dara-VMP and the VMP arm, respectively 32376237. The combination of Dara-VMP also demonstrated a significant reduction in the risk of death by 40% in comparison with VMP (HR 0.60 95% CI 0.46–0.80; p = 0·0003) [19]. At the time point of 42 months, the estimated overall survival rate in Dara-VMP and VMP groups was 75% vs. 62% (median not reached in either group HR: 0.60; 95% CI: 0.46 to 0.80; P = 0.0003) respectively [17, 18, 20]. The proportion of patients achieving MRD negativity was better in the Dara-VMP group (28% versus 7%) 32376237 After a median follow-up of 40.1 months, Dara-VMP increased the ORR (90.9% vs. 73.9%) and the rates of ≥VGPR (73% vs. 50%), ≥CR (46% vs. 25%), MRD-negativity (28% vs. 7%; all P < 0.0001), and ≥ CR with MRD-negativity (27% vs. 7%) vs. VMP. Time to subsequent therapy, OS, and PFS was prolonged for patients with deeper responses in both groups Alcyone 2020.
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MAIA trial (NCT02252172) is a phase 3 trial in which the addition of Dara to Rd. was compared to Rd. alone. Seven hundred thirty-seven patients who were ineligible for transplant were recruited. Patients were randomly assigned to receive Rd. with or without Dara in 28-day cycles until disease progression or unacceptable toxicity. The primary end-point was progression-free survival [21]. Results from the primary analysis (median follow-up 28 months) showed that the addition of Dara to Rd. improved PFS and MRD-negativity rates. After a longer follow up period (36.4 months), patients in the DRd arm maintained deeper and durable response along with PFS benefit [22]. After a median follow-up of 47.9 months, patients in the DRd arm had better PFS in comparison with the control group (median, not reached [NR] vs. 34 mo; HR, 0.54; 95% CI, 0.43–0.67; P < 0.0001). Median PFS2 was not reached for DRd vs. 51 months in the Rd. arm. (HR, 0.65; 95% CI, 0.52–0.83; P = 0.0005). The addition of Dara to Rd. resulted in deeper responses with higher rates of CR or better and VGPR or better. The median duration of response was not reached for responders in the DRd arm vs. 44 months in the Rd. arm [23].
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2.1.2.2 Transplant-eligible patients
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The combination of Dara Bortezomib, cyclophosphamide, and dexamethasone (Dara-VCD) resulted in ORR and VGPR or better rates of 81% and 56%, respectively, in NDMM patients enrolled in the LYRA (NCT02951819) study 30828799. After 6–8 cycles of Dara-VCD induction, eligible patients underwent ASCT. All patients received Dara maintenance. The administration of Dara as maintenance therapy improved the depth of response and was associated with prolongation of both PFS and OS [24].
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GRIFFIN (NCT02874742) is a phase 2 trial evaluating the addition of Dara to the induction regimen Bortezomib Lenalidomide and Dexamethasone (VRD) in NDMM transplant eligible patients. Patients were randomized to receive Dara-VRD or VRD as induction regimen, ASCT, two cycles of Dara-VRD or VRD consolidation, and Revlimid alone or in combination with Dara as maintenance for 24 cycles. The primary endpoint was the rate of s CR post-consolidation. Regarding the randomized phase of the trial, results indicated that the combination of Dara-VRD was safe and potent. Regarding the primary endpoint results favored the quadruplet regimen (D-VRD)) 42 patients (42.4%) in the D-VRD and 31 patients (32.0%) in the VRD group achieved sCR by the end of consolidation (odds ratio, 1.57; 95% [CI], 0.87–2.82 1-sided P = .068) Response improved over time. After a median follow up of 22.1 months, the sCR (62.6% vs. 45.4%; P = .0177) and MRD negativity (51.0% vs. 20.4%; P < .0001, threshold 10−5) improved in the D-VRD arm in the intent to treat population [25]. In the final analysis of the safety run-in cohort, at the end of consolidation, 9 (56.3%) patients achieved sCR, and 8 (50.0%) were MRD negative (10–5 threshold). After maintenance, 15 (93.8%) patients achieved sCR, and 13 (81.3%) were MRD (10−5) negative. Estimated 36-month overall and progression-free survival rates were 93.8% and 78.1%, respectively. Results showed that the addition of Dara to R AND VRD resulted in durable responses and sustained MRD negativity. The depth of response improved over time [26].
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CASSIOPEIA (NCT02541383) is an ongoing phase III clinical trial in newly diagnosed transplant eligible MM patients divided into two parts. Patients were randomized to receive four pre-transplant induction and two post-transplant consolidation cycles of VTd with (VTd group) or without daratumumab (D-VTd group). The primary endpoint of part 1 was the Scr rate assessed 100 days after transplantation. Part 2 (maintenance) is ongoing. After completion of induction and consolidation, the sCR rate in the D-VTd group was 28.9% vs. 20.3% in the VTd group (odds ratio 1.60, 95%CI 1.21–2.12, p = 0.0010). Additionally, the D-VTd group had significantly prolonged PFS in comparison with VTd (HR: 0.47; 95%CI: 0.33–0.67, p < 0.0001) [27].
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MASTER (NCT03224507) is an ongoing phase II clinical trial. Newly diagnosed transplant eligible MM patients received four cycles of Dara-Carfilzomib Dexamethasone (Dara-KRD) induction, followed by autologous stem cell transplantation (ASCT) and consolidation with Dara-KRD based on the MRD status. The MRD assessment method was next-generation sequencing (NGS), and the threshold was 10−5. Evaluation of MRD status was performed at specific time points. At the end of the induction, post ASCT and post cycles 4 and 8 of consolidation. Patients with two consecutive negative MRD results stopped treatment. Patients who concluded treatment underwent imaging. The administration of Dara-KRD resulted in rapid and durable responses. More than 90% of patients achieved VGPR or better response by the end of induction. The MRD negative rates at the end of induction at ASCT and at best response were 34%, 70%, and 80% (threshold 10−5) and 28%, 45%, and 65% (threshold 10−6), respectively. Until today 11 patients have concluded treatment after achieving MRD negativity without evidence of relapse. The trial is ongoing, and long term follow up results are awaited [28].
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PERSEUS (NCT03710603) is a randomized, phase 3 study comparing DARA-VRd vs. VRd in transplant eligible NDMM patients, which has recently concluded its enrollment of patients. PFS is the primary endpoint, while key secondary endpoints include, ORR, MRD-negative rate and OS.
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2.1.3 Daratumumab combinations in the R/R setting
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POLLUX (NCT02076009) is a phase III clinical trial that compared the combination of Lenalidomide Dexamethasone with or without daratumumab in MM patients who had received at least one prior line of treatment and were not refractory to Lenalidomide [15]. The addition of Dara significantly improved PFS at 12 (83.2%, 95% CI, 78.3 to 87.2 vs. 60.1%, 95% CI, 54.0 to 65.7), 25,4 (median not reached vs. 17.5 months; HR 0.41; 95% CI,0.31–0.53; P < 0.0001) and 44,3 (median 44.5 vs. 17.5 months; HR, 0.44; 95% CI, 0.35–0.55; P < 0.0001) months follow up in comparison with the control group [15, 29, 30]. The overall response rate was significantly better in the DRd group (92.9% vs. 76.4%, P < 0.001) 30237262. Post hoc analyses revealed that Dara improved PFS independently of the prior lines of treatment and high-risk cytogenetics [29]. At 25.4 months, the assessment of MRD status (threshold 10−5) revealed deeper responses in the DRd arm (26.2% vs. 6.4% P < 0.0001) [29].
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CASTOR study (NCT02136134) compared the combination of Dara Vd (Dvd) versus Vd in 498 patients who had received at least one prior line of therapy (median of 2, range, 1–10; 10% three or more) and were not Bortezomib refractory. The study met its primary endpoint with a significant prolongation of PFS in the Dvd group after 7.4 months follow up (not reached in the Dvd versus 7.2 months in the Vd group), along with a significant reduction (61%) regarding the risk of disease progression or death (HR: 0.39; 95% CI, 0.28–0.53; p < 0.001). ORR was 82.9% in the Dvd vs. 63.2% in the Vd group, P < 0.001 [31]. Updated results of this trial after 40 months, reinforce the tolerability and effectiveness of Dvd. PFS was improved in all subgroups (16.7 vs. 7.1 months, [HR], 0.31; 95% [CI], 0.25–0.40; P < .0001). 32482541. The addition of Dara to Vd manage to overcome the impact of high-risk cytogenetic abnormalities (12.6 vs. 6.2 months; HR, 0.41; 95% CI, 0.21–0.83; P = 0.0106) 32819447 Patients in the Dvd group had 2.5 fold higher MRD negativity rate (10–5 threshold) [31]. Based on the results of CASTOR trial FDA and EMA approved in 2016 Dvd for RRMM patients who had received at least one prior line of treatment.
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In a phase 1b study (MMY1001), the addition of Dara to Pomalidomide and Dexamethasone was tested. The study included 103 patients with a median age of 64 years and a median of four prior lines of therapy. Notably, 89% were refractory to Lenalidomide, 71% to Bortezomib, and 30% to Carfilzomib. The median OS and PFS were 17,5 and 8,8 months, respectively. The ORR was 60%. The combination of Dara Pom Dex was clearly safe and effective in this group of heavily pretreated patients [32]. Based on these results, FDA approved this triple combination for patients who had received at least two prior lines, including both a PI and Lenalidomide [32].
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APOLLO trial (NCT03180736) explored the addition of Dara to Pomalidomide and dexamethasone (Pd) in 304 patients with RRMM who had received ≥one prior line of therapy, including a PI and Lenalidomide. PFS was the primary endpoint. Patients received Pomalidomide 4 mg d1–21, dexamethasone 40 mg (20 mg for patients ≥75 years of age) on 28 days cycles. Patients initially received Daratumumab iv 16 mg/kg. After protocol amendment, patients continued with Dara sc 1800 mg. Administration of Dara every week for cycles one and two, every two weeks for cycles 3–6, and every month thereafter. Prior Pomalidomide or anti-CD-38 administration was not permitted. The patient’s median age was 67 (35–90) years, 35% had high-risk cytogenetics, and 63% were refractory to both Len and PI. The study met its primary endpoint. The addition of Dara to Pd led to a significant prolongation of PFS (12.4 months) versus 6.9 months in the Pd arm (HR 0.63 (95% CI, 0.47–0.85; P = 0.0018), which represents a 37% reduction in the risk of death or progression. Data regarding OS are immature, and longer follow-up is warranted. No new safety signals have emerged. Additionally, the sc formulation of Dara shortens the duration of administration. These data suggest that the D-Pd combination is safe, effective, and convenient in the RR setting [33].
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CANDOR (NCT03158688) is another phase 3 trial exploring the addition of Dara to Carfilzomib and dexamethasone (Kd). Four hundred sixty-six patients were randomized to receive Dara Carfilzomib dexamethasone (DKd) vs. Kd. All patients received iv Dara at 16 mg/kg, every week for the first two cycles (the first dose was administered on days 1 and 2 of the first cycle), every two weeks for cycles 3–6, and every month thereafter, Carfilzomib, twice per week at 20 mg/m2 on days 1 and 2 of cycle 1 and at 56 mg/m2 thereafter and dexamethasone 40 mg every week (20 mg for patients 75 years or older). After an initial follow up of 17 months, median PFS was not reached in the DKd group versus 15.8 months in the Kd group (HR 0.63; 95% CI 0.46–0.85; two-sided p = 0.0027) [34]. Data presented in the last ASH meeting showed further improvement in PFS for patients in the KRd arm. After 28 months of follow-up, the median PFS for KRd and Kd group were 28.6 and 15.2 months, respectively (HR, 0.59, 95% CI, 0.45–0.78]. PFS benefit was consistent among subgroups, especially in Lenalidomide refractory patients. Additionally, the MRD negativity rate at 12 months was significantly better in the DKd arm at 12.5% vs. 1.3% P < 0.0001. No new safety alerts have emerged [35].
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2.2 Isatuximab
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2.2.1 Mechanism of action
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Isatuximab (SAR650984) is another chimeric IgG1κ monoclonal antibody, which binds on human CD38 by targeting a different epitope in comparison with Daratumumab [36]. Isatuximab and Daratumumab have several differences regarding the mechanism of action. 1/Isatuximab anti-tumor activity is mainly dependent on ADCC [37, 38] 2/Isatuximab induces direct apoptosis of CD-38 even in the absence of cross-linking agents [39] 3/Isatuximab inhibits CD-38 enzymatic activity in a dose-dependent manner [40].
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2.2.2 Isatuximab clinical trials
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In a phase I dose-escalation study, 84 patients with RRMM (median 5, range 1–13 prior lines of therapy) received Isatuximab monotherapy. Isatuximab administration showed clinical activity and a manageable safety profile. ORR was 24%, median PFS was 3.7 months. IRRs were mainly grade 1 or 2 that occurred during the first cycle [40]. These results were confirmed in a dose-finding phase II trial. Patients with RRMM who had received three or more prior lines of therapy were allocated to four different dosing schedules of isatuximab monotherapy: 3 mg/kg or 10 mg/kg every two weeks, 10 mg/kg every two weeks for one month and every month thereafter, and 20 mg/kg every week for one month and every two weeks thereafter. At doses ≥10 mg/kg 10 mg/kg OS and PFS were 18.7 and 4.6 months respectively, whereas ORR was 24.3% [41]. During the second part of the same study, patients with RRMM (median 4, range 2–10 prior lines of therapy) were randomized to receive isatuximab 20 mg/kg every week for one month, followed by 20 mg/kg every two weeks, with (n = 109) or without (n = 55) dexamethasone. Median PFS and OS were 4.9 and 18.9 and 10.2 for Isatuximab monotherapy and 10.2 and 17.3 for Isatuximab DEX group, respectively [42].
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Isatuximab has also shown a synergistic effect when combined with Lenalidomide and dexamethasone. Fifty-seven patients with RRMM (median 5, range 1–12 prior lines of therapy) with 83% refractory to Lenalidomide received Isatuximab in combination with Lenalidomide and dexamethasone in this phase Ib dose-escalation study. The primary objective of the study was the determination of maximum tolerated dose (MTD) of Isatuximabwithin the combination with Lenalidomide and dexamethasone. The ORR was similar in both cohorts, 56%. Only one dose-limiting toxicity was reported (pneumonia grade II at 20 mg/kg/QW/Q2W), which resolved after discontinuation of treatment. The MTD was not reached. IRRs occurred mostly during the first infusion and were mild (grade I or II) regarding severity. These results demonstrate that the combination of Isatuximab with standard doses of Lenalidomide and Dexamethasone was active and well-tolerated in patients with RRMM [43].
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Another phase Ib trial (NCT02283775) evaluated the tolerability and safety of Isatuximab in combination with Pomalidomide and low-dose dexamethasone in patients with RRMM, who had received prior treatment with a PI and Lenalidomide. Forty-five patients with a median of three (range 1–10) prior lines of therapy were recruited. 91% of patients were refractory to their last line of therapy, 84% were PI refractory, and 82% Lenalidomide refractory. Patients received Isatuximab at 5, 10, or 20 mg/kg (every week for four weeks and every two weeks thereafter), Pomalidomide 4 mg (days 1–21), and dexamethasone 40 mg weekly, in 28-days cycles until progressive disease or unacceptable toxicity. The primary objective was the determination of the recommended dose of Isatuximab within this combination, along with safety. Secondary objectives included evaluation of efficacy, pharmacokinetics, and immunogenicity. Among 45 enrolled patients, 8 received Isatuximab at 5 mg/kg, 31 at 10 mg/kg and 6 at 20 mg/kg for median duration of 9.6 months. The most common adverse events included fatigue (62%), infusion reactions (42%), and upper respiratory tract infections. Infusion-related reactions, which were mainly grade I or II, occurred mostly during the first administration of the drug and were manageable with corticosteroids and antihistamines. Median PFS and median duration of response were 17.6 and 18.7 months, respectively. ORR was 62%. These results demonstrated that the combination of Isatuximab with Pomalidomide and dexamethasone was safe and effective in heavily pretreated patients with MM [44].
\n
Based on these encouraging results, the phase III ICARIA trial (NCT02990338) compared the combination Of Isatuximab Pom Dex (IPd) versus Pom dex (Pd) in 307 patients with RRMM who had received at least two prior lines of treatment, including Lenalidomide and a proteasome inhibitor (median three range 2–4). Patients received Isatuximab 10 mg/kg every week for the first cycle and on days 1 and 15 in the subsequent cycles, plus pomalidomide 4 mg/day (day 1–21) and dexamethasone 40 mg (or 20 mg for patients >75 years) weekly on 28 days cycles. Progression-free survival was the primary endpoint. After a median follow-up of 11.6 months, median progression-free survival was 11.5 months (95% CI 8.9–13.9) in the IPd group versus 6.5 months (4.5–8.3) in the Pd group;(HR 0.596, 95% CI 0.44–0.81; p = 0·001). Responses in the IPd arm occurred faster with a significantly longer duration in comparison with the IPd arm. Additionally, patients in the IPd arm achieved a higher percentage of MRD negativity. The addition of Isatuximab to Pom dex, resulted in significant improvement of PFS [45]. The consistency of the results from the primary analysis was evaluated in patients with soft tissue plasmacytomas. Data presented at the last ASH meeting showed that PFS and ORR were improved from the addition of Isatuximab to Pd in the subgroup of patients with extramedullary disease. Median PFS was 4.57 (95% CI: 2.40, not calculable) vs. 1.56 (95% CI: 0.95, 4.47) months in the IPd and Pd arm, respectively, whereas ORR was 50% (7/14 responders) and 10% (1/10 responders) in the IPd and Pd group. ASH 2289 Based on the results of the ICARIA trial, FDA and EMA approved the combination of IPd, in patients with RRMM.
\n
The combination of Isatuximab with Carfilzomib has been evaluated in a phase Ib clinical trial (NCT02332850) [46]. In the dose-escalation part of the study, patients with RRMM who had received at least two prior (median three range 2–8) lines of treatment were randomized to receive Isatuximab in 3 different dose levels (DL) 10/kg every two weeks, 10 mg/kg every week for a month and every two weeks thereafter and 20 mg/kg every week for a month and every two weeks thereafter, in combination with K at dose 27 mg/m 2. Fifteen patients received treatment in the dose-escalation and 18 in the dose-expansion cohort at DL2. The primary objective was the determination of the maximum tolerated dose (MTD). Secondary objectives included the assessment of efficacy and safety. Preliminary results showed a 66% ORR in all dose levels. Median PFS was not reached. Based on these results, the phase III IKEMA study (NCT03275285) compared the combination of IKd vs. Kd in the RR setting. Three hundred two patients with RRMM were randomized to receive IKd (n = 179) or Kd (n = 123). The administration of Isatuximab was 10 mg/kg iv weekly during the first month and every two weeks thereafter, whereas administration of Carfilzomib was 20 mg/m2 and 56 mg/m2 thereafter. The primary endpoint was PFS, and the secondary endpoints were OS and ORR [47]. Preliminary data were presented in the last ASH meeting. After a median follow-up of 20.7 months there was a statistically significant improvement of PFS in the IKd group (median PFS was not reached for IKd vs. 19.15 months for Kd; HR 0.531 (99% CI 0.318–0.889), one-sided p = 0.0007, with consistency among subgroups. ORR was 86.6% IKd vs. 82.9% for Kd, one-sided p = 0.1930. MRD negativity (10–5) in the intent to treat population (ITT) was 29.6% (53/179) vs. 13.0% (16/123) in the IKd and Kd groups, respectively descriptive p = 0.0004. Data regarding OS were immature at the time of primary analysis. The percentages of AES and SAEs were similar between the two groups. To conclude, the addition of Isatuximab to Kd lead to a significant improvement in PFS and depth of response. IKD may represent a new standard of care regimen for patients with RRMM [48].
\n
Isatuximab is currently under investigation in the upfront setting. In transplant-ineligible patients, IMROZ trial (NCT03319667) is comparing the quadruplet combination Isatuximab-VRd with VRD, while another ongoing trial is comparing Isatuximab-VRd to Isatuximab VCD(NCT02513186). In transplant-eligible patients, ISKIA trial is currently investigating the combination of Isatuximab-KRd vs. KRd as part of induction and consolidation regimen (NCT04483739).
\n
\n
\n
\n
2.3 Elotuzumab
\n
\n
2.3.1 Elotuzumab mechanism of action
\n
SLAMF7 (signaling lymphocytic activation molecule family 7) or CD319 is a cell surface glycoprotein CD2/subset 1 (CS1). SLAMF7 expression is restricted to normal and abnormal plasma cells and NK lymphocytes [49]. Activation of SLAMf7 pathway promotes cell growth and survival. It also plays a critical role in the interaction with the bone marrow microenvironment [49, 50]. Elotuzumab is humanized, first in class IgG1 monoclonal antibody targeting SLAMF7. Elotuzumab primarily activates NK cells promoting antibody-dependent cellular cytotoxicity (ADCC). Elotuzumab has shown no activity when used as a single agent in MM patients.
\n
\n
\n
2.3.2 Elotuzumab clinical trials
\n
The large phase III ELOQUENT 2 trial (NCT01239797) evaluated the addition of Elotuzumab at the dose of 10 mg/kg to Lenalidomide and dexamethasone (Rd) in 646 patients with RRMM (94% lenalidomide naïve patients) who had received 1–3 prior lines of treatment. Patients received Lenalidomide 25 mg for days 1–21 and dexamethasone 40 mg on a weekly basis on 28-day cycles. Elotuzumab administration was 10 mg/kg weekly for the first two cycles, and 20 mg/kg on a monthly basis thereafter. Primary endpoints included PFS and ORR. OS was one of the key secondary endpoints. After an initial follow-up of 24.5 months, the rates of median PFS and ORR were 19.4 versus 14.9 months (HR for progression or death 0.70; 95% CI 0.57 to 0.85; P < 0.001) and 79%, versus 66% in the ELO Rd. and Rd. groups respectively. 26035255. PFS rates demonstrate sustained improvement after two (52%) and three (44%) years of follow-up (relative risk of disease progression or death by 30% and 27% respectively) 30204239. More recent data, after a 4-year follow-up, demonstrate sustained OS benefit (50 months for ELO Rd. versus 43 months for Rd. HR: 0.78; 95%CI: 0.63–0.96). 30719202 Administration of Elotuzumab was relatively safe. Most common grade 3 or 4 AEs in both arms included lymphopenia, neutropenia, pneumonia, and fatigue. Based on this trial Elotuzumab was granted approval by the FDA in December 2015 and EMA in 2016, in combination with Rd., for patients with RRMM, who had received at least one prior line of treatment [51].
\n
Elotuzumab has also been evaluated in combination with Pomalidomide and dexamethasone (Pd). Eloquent 3 (NCT02654132) is a randomized phase II trial, comparing the combination of ELO Pd versus Pd in 117 patients who were refractory or relapsed and refractory to Lenalidomide and a proteasome inhibitor. Patients received Pomalidomide 4 mg for day 1–21 and dexamethasone 40 mg on a weekly basis on 28-day cycles. Elotuzumab administration was 10 mg/kg weekly for the first two cycles and 20 mg/kg on a monthly basis thereafter. Sixty patients were assigned to the ELO Pd group and 57 patients to the Pd group. After a follow up of 9.1 months, patients in the ELO Pd group had significantly increased PFS (10.3 vs. 4.7 months HR 0.54 CI0.34 to 0.86; P = 0.008) and ORR (53% vs. 26% odds ratio, 3.25; 95% CI, 1.49 to 7.11) in comparison with the Pd group. No significant differences were reported in the safety profiles of the two arms. Based on the results of the ELOQUENT III trial, Elotuzumab granted approval by the FDA in 2018 for RR patients who had received at least two prior lines of treatment, including Lenalidomide and a PI [52].
\n
\n
\n
\n
2.4 Antibody drug conjugates (ADCs)
\n
BCMA, is a and member of the tumor necrosis factor receptors (TNFR) superfamily [53, 54]. BCMA is primarily expressed in late-stage B-lineage cells, normal and malignant plasma cells, and B-lymphocytes, with very low expression on non-hematologic cells [55]. BCMA has two main ligands: a proliferation-inducing ligand (APRIL) and B-cell activating factor (BAFF) [56, 57, 58]. Following binding of APRIL and BAFF, BCMA expression is selectively upregulated during malignant transformation of plasma cells, playing a critical role in survival, drug resistance, and tumor cell growth through activation of intracellular signal transduction pathways such as STAT3, phosphoinositide 3-kinase (PI3K), AKT, NFB and MAPK [59, 60, 61, 62, 63]. As demonstrated in BCMA knock-down mouse models, BCMA is not required for normal B-cell differentiation and homeostasis [64]. The shedding of BCMA from the cell surface is mediated by γ-secretase and results in a soluble form (soluble BCMA, sBCMA). Higher sBCMA levels have been associated with inferior clinical outcomes. In preclinical models, inhibition of BCMA, with specific antibodies, showed significant anti-myeloma activity. The aforementioned facts make BCMA an ideal therapeutic target for the treatment of Multiple Myeloma and provide the rationale for the development of anti-BCMA monoclonal antibodies.
\n
GSK2857916 (Belantamab Mafodotin) is the first anti-BCMA ADC that has been investigated in clinical trials. This afucosylated, humanized, IgG1 monoclonal antibody is conjugated to monomethyl auristatin F (MMAF), an inhibitor of tubulin polymerization, through a protease-resistant maleimidocaproyl linker. Following binding to the plasma cell surface, GSK2857916 is internalized and the active cytotoxic drug (cys-mcMMAF) is released following enzymatic cleavage leading to cell death. Mechanisms of action include NK-cell mediated ADCC and ADCP [65].
\n
DREAMM 1 (NCT02064387) is a first in human phase I, open-label study, which evaluated the administration of GSK2857916 in patients with RRMM and other hematologic malignancies expressing BCMA in terms of efficacy and safety. Dose escalation cohort (part I) included solely patients with MM who have failed previous treatment regimens, including stem cell transplant (if eligible) IMiDs, PIs, and alkylators, while the dose-expansion cohort (part2) included both patients with MM and relapsed follicular lymphoma or diffuse large B-cell lymphoma. Regarding MM patients in the expansion cohort, 57% had five or more prior lines of therapy; 89% were double (PI and IMiD) and 34% triple (PI, IMiD, and daratumumab) refractory. GSK2857916 was administered intravenously every three weeks as a 1 hr. infusion in 38 patients at different dose levels (0.03–4.6 mg/kg). Primary endpoints were safety, determination of maximum tolerated dose (MTD), and recommended phase 2 dose. Secondary objectives were the determination of pharmacodynamics and pharmacokinetics parameters, anti-drug antibodies, and clinical activity. In dose-expansion, patients received the selected recommended phase 2 dose of 3.4 mg/kg. Overall, 73 patients were recruited, thirty-eight in dose escalation and thirty-five in the dose-expansion cohort. Notably, BCMA expression was not included in the eligibility criteria of study [66].
\n
Updated results of this study, after an extended median follow-up of 12.5 months, demonstrate that was effective in this heavily pretreated group of patients [67]. Achievement of response occurred early during the study after the first or second infusion. Interestingly, dose reduction did not affect the depth and duration of response. 21/65 patients in the dose-expansion part achieve partial or better response, including 2PRs, 14VGPRs, 3CRs, and two sCRs. 18/32 (56.3%) patients who were double refractory (IMiDs and PIs) achieved response to treatment. For double refractory patients (IMiDs and PIs), with prior Daratumumab exposure, OR was 38.5%. The median PFS and DOR were 12 and 14.3 months, respectively. Among double refractory patients, the median PFS was 7.9 months. For patients with and without prior Daratumumab exposure, median PFS was 6.8 and 15.7 months, respectively. For double refractory patients with prior Daratumumab exposure, median PFS was 6.2 months [67].
\n
The most frequent AEs were fatigue, nausea, chills, anemia, pyrexia, hypercalcemia, thrombocytopenia, and dry eye, while the most common grade 3 or 4 toxicities included neutropenia, anemia, and thrombocytopenia. Infusion-related reactions (IRRs) (Grade 1 or 2) were reported in 7 patients across all dose levels, and all of them occurred during the first dose. Of note, there were no dose-limiting toxicities (DLT) and no MTD identified in the dose-escalation phase. Ocular toxicity, including blurred vision, foreign body sensation, and photophobia, were common presented in 53% of patients in part 1 and in 63% in part 2. Most common findings during eye examination under a slim lamp included keratitis and corneal microcystic changes. All AEs were reversible. The median time to onset was 23 days (range 1–84). Management included dose reductions and/or delays, artificial tears, and steroid eye drops. The median time to resolution was 30 days (range 5–224). Even though the exact pathophysiologic mechanism of keratopathy is unknown, it may be attributed to the uptake of the payload (MMAF) in the basal epithelial layer of the cornea 2938270. Ocular toxicity resulted in two treatment discontinuations in part 1 and no discontinuations in part 2 of the study. The main reasons for treatment discontinuation were disease progression (n = 15) and AEs (n = 2). Based on these promising results, FDA granted GSK2857916 a breakthrough therapy designation for the treatment of RRMM patients who had receive three prior lines of treatment, including an anti-CD38 antibody, and were refractory to both an IMiD and a PI [68].
\n
Following the encouraging results of DREAMM-1 study, the subsequent DREAMM-2 trial (NCT03525678) further explored the safety and activity of Belantamab mafodotin (GSK2857916) in the RR setting. Patients were refractory to PI, IMiD and an anti-CD38 mAb alone or in combination and randomized 1:1 to receive 2.5 mg/kg (n = 97) or 3.4 mg/kg (n = 99) Belantamab Mafodotin iv, every three weeks until disease progression or unacceptable toxicity. Regarding refractoriness to previous lines of treatment, 76% and 75% were refractory to bortezomib, 65% and 58% to Carfilzomib, 90% and 89% to Lenalidomide, 87% and 78% to Pomalidomide and 100% and 92% to Daratumumab in the 2.5 and 3.4 mg/kg dose arms, respectively. Patients had receive a median of 6 (range 3–21) and 7(range 3–21) prior lines of treatment, respectively [69].
\n
Overall response rate (ORR) was the primary objective of the study. After a median follow up of 6.5 months (6.3 in the 2.5 mg cohort and 6.9 in the 3.4 mg cohort), median PFS was 2.9(95% CI: 2.1–3.7) and 4.9(95% CI: 2.3–6.2) months in the two groups while the ORR was 31% (30/97 97.5% CI 20.8–42.6) and 34% (34/99CI 23.9–46) respectively 31859245. At this time point, OS data were not mature. Updated analysis of this trial, with a median, follow up of 9 months, demonstrated a median PFS of 2.8 and 3.9 months in the two cohorts with one year OS probability of 53% 21/48 and similar ORR among the group of patients with 3–6 (34%) and seven or more (30%) prior lines of therapy [69]. Two post hoc analyses demonstrate the efficacy of Belantamab mafodotin in the subgroups of patients with high-risk cytogenetics and impaired renal function (EGFR 30 ml/min) [70, 71].
\n
Regarding AEs, this study confirmed the frequent occurrence of corneal events. 72% of patients developed keratopathy of any grade, while 31% developed keratopathy grade 3–4. Keratopathy was attributed to the MMAF payload and was reversible after temporary discontinuation of the drug. Other frequent adverse events grade 3–4 were anemia (21%) and thrombocytopenia (22%). Infusion-related reactions (IRRs) were reported in 21% and 16% in the two treatment arms and were mostly grade 1 or 2. Serious AEs occurred in 40% and 47% in the 2.5 mg/kg and 3.4 mg/kg cohorts respectively. Two reported cases lead to death, potentially connected to study drug. One case of sepsis in the 2.5 mg/kg and one of haemophagocytic lymphohistiocytosis in the 3.4 mg/kg cohort.
\n
Currently, the role of Belantamab Mafodotin (GSK2857916) is being evaluated in the RRMM setting.
\n
DREAMM-6 (NCT03544281) is an ongoing Phase I/II, a two-part study of GSK2857916 in combination with lenalidomide/dexamethasone (Arm A) or BorDex (Arm B) in patients with RRMM who had received ≥one prior therapy. Refractory to Bortezomib patients were not excluded. Preliminary results from Arm B, presented in the last ASH meeting, have shown a high ORR of 78% (95% CI 52.4–93.6). No new safety signals have emerged.
\n
Three-phase III studies are currently ongoing, evaluating the safety and efficacy of belantamab mafodotin in combination with Pomalidomide (NCT04162210; DREAMM-3) daratumumab plus bortezomib (NCT04246047; DREAMM-7) or Pomalidomide plus Bortezomib (NCT04484623: DREAMM-8). The results are eagerly awaited.
\n
MEDI2228 is another antibody-drug conjugate (ADC) composed of fully human monoclonal antibody, conjugated to a dimeric cross-linking pyrrolobenzodiazepine (PBD) dimer (tesirine) via a protease-cleavable dipeptide (valine-alanine) linker8/42 MEDI2228 has shown potent antitumor activity in preclinical models, including cell lines resistant to Lenalidomide. Based on these reports, a phase I open-label, dose-escalation, and expansion first in-human study (NCT03489525) evaluated safety, clinical activity, and pharmacokinetics of MEDI2228 in patients with RRMM. All patients had progressive disease after treatment with an IMiD, a PI, and a monoclonal antibody. In the dose-escalation part of the study, MEDI2228 was administered iv every three weeks in five sequentially ascending dose levels (0.0125, 0.025, 0.05, 0.1, and 0.2 mg/kg). DLTS lead to dose de-escalation from 0.2 mg/kg to 0.14 mg/kg. Primary endpoints included safety and tolerability. 0.14 mg/kg Q3W was determined as the maximum tolerated dose (MTD). In the 0.14 mg/kg cohort 53.7% experienced photophobia and 19.5% eye dryness. There were no incidents of visual acuity loss or keratopathy in the 0.14 mg/kg cohort. Other treatment-related AEs included thrombocytopenia (31.7%) rash (29.3%), increased gamma-glutamyltransferase (24.4%) and pleural effusion (19.5%). In the 0.14 mg/kg cohort, ORR was 61.0% (95% [CI]: 44.5%, 75.8%), including 10 (24.4%) VGPRs and 15 (36.6%) PR. These data suggest that MEDI2228 is clinically efficient in this heavily pretreated group of patients [72].
\n
\n
\n
2.5 Bispecific antibodies
\n
Bispecific T-cell engagers (BiTEs) are monoclonal antibodies with two separate antigen recognition domains. One with a high affinity to an antigen in the surface of tumor cell and another targeting CD-3 in the surface of T-cells. Binding to those two distinct epitopes leads to the formation of an immunologic synapse. Binding to the CD3e epitope augments the t-cell recruitment and activation, leading to cell death. In MM, the majority of BiTEs targeting BCMA in the surface of plasma cells.
\n
AMG-420, formerly known as BI 836909, is the first BiTE demonstrating clinical activity. It is comprised of two single-chain variable fragments (scFvs), one targeting BCMA and one targeting CD3. AMG-420 is the compound with the most available data to date. In a first in human dose-escalation study, AMG420 was administered in 42 patients with RRMM (NCT02514239). Eligible patients had progressed after a minimum of 2 prior lines of treatment, including a PI and an IMiD 31895611. The median number of prior lines of therapy was 4 (range 2–13). 31% of patients were double refractory to IMiDs and PIs, and 21% were daratumumab refractory. AMG420 was administered at different dose levels, 0.2-800 μg/d, through a continuous iv infusion for four weeks in 6-week cycles due to its low molecular weight and short half-life. Patients received treatment for up to 10 cycles Monitoring of toxicities required hospitalization at the beginning of cycles one (4 days) and two (1 day) [73].
\n
There were two deaths reported from adverse events: One patient in the 50 μg/d cohort died after the first cycle due to respiratory distress syndrome caused by concurrent influenza and aspergillosis, and one from hepatic failure from adenovirus. None of these incidents were considered related to treatment. There were no grade 3 or greater CNS toxicities reported. At the 800 μg/d dose level, two-thirds of the patients experienced DLTs. One patient had gr 3 CRS and one gr 3 peripheral polyneuropathy, which included progressive dysfunction of the peripheral motor and sensory nerves. Following the interruption of the study drug, both toxicities resolved. No DLTs were observed up to the level of 400 μg/d. In the most recent follow-up of the study, 40 patients discontinued treatment. Twenty-five due to disease progression, seven due to AEs, four died, three completed treatment (10 cycles), and 1 withdraw consent [73]. ORR was 31% (13/42patients). At the MTD of 400 μg/d, the response rate was 70% (7/10). In the 400 μg/d group, five patients achieved MRD negativity, one achieved PR, and one VGPR.
\n
As mentioned, because of its low molecular weight and short half-life, AMG420 was administered through a continuous iv infusion for four weeks in 6-week cycles due to its low molecular weight and short half-life. AMG 701, a BiTE with an extended half-life allowing once-weekly subcutaneous administration, was developed and is currently under investigation (NCT03287908).
\n
PF-06863135 (PF-3135) is a humanized Ig-like Bispecific antibody targeting both BCMA and CD3. PF-06863135 has been administered intravenously at 0.1–50 μg/kg weekly in patients with RRMM. Preliminary results demonstrate antimyeloma activity. The maximum tolerated dose was not reached [74]. In order to reduce the maximum concentration (Cmax) of the drug, which was possibly associated with inflammatory response and cytokine release syndrome (CRS), subcutaneous administration of the drug was tested. Preliminary results were reported in the last ASH meeting [75]. 2 6/8(75%) patients achieved a response at the two highest dose levels evaluated. The sc administration modulates Cmax. This could allow the administration of higher doses without increased incidence of CRS. The trial is ongoing.
\n
\n
\n
\n
3. Immune checkpoint inhibitors
\n
The programmed death-1 (PD-1) receptor is a type-1 transmembrane glycoprotein, expressed on antigen-activated B-cells, T-cells, and NK-cells. The binding of PD-1 ligands (PD-L1 and PD-L2) on PD-1 receptor results in downregulation of immune functions mediated by T-cells such as cytokine production, t-cell proliferation, and cytotoxicity [76]. The overexpression of PD-L1 and PD-L2 is a well recognizable mechanism of immune evasion. Preclinical data from MM patients have shown an increased expression of PD-L1 and PD-1 on malignant plasma cells and T and NK cells respectively [77, 78]. The deciphering of this particular mechanism of action has lead to the development of immune checkpoint inhibitors that block receptors (PD-1) and ligands (PD-L1 and PD-L2), resulting in the recovery of immune response.
\n
Pembrolizumab is a humanized IgG4 monoclonal antibody with high specificity against PD-1 receptors. Pembrolizumab was evaluated in combination with Lenalidomide and low dose dexamethasone in a phase I dose-escalation study (KEYNOTE-023 trial NCT02036502). Sixty-six patients with RRMM were recruited. Pembrolizumab was treatment-related AEs. Grade 3 AEs (mainly cytopenias fatigue and diarrhea) occurred in 37 (59,7%) patients. ORR OS and median PFS were 44%, not reached, and 7.2 months respectively [79, 80]. Pembrolizumab has also been evaluated in combination with Pomalidomide and dexamethasone in another phase II study (NCT02289222). Forty-eight patients with RRMM were recruited. Patients had received 2–5 (median 3) prior lines of treatment. 73% were refractory to both IMIDs and PIs. ORR was 60%. The percentage of SCR and CR, VGPR, and PR were 8%, 19%, and 33%, respectively. After a median follow-up of 15.6 months, OS and PFS were not reached and 17.4 months, respectively.(40%) [81].
\n
Based on these results, two-phase three trials were designed to evaluate the combination of Pembrolizumab dexamethasone with Lenalidomide (KEYNOTE-185 NCT02579863) or Pomalidomide (KEYNOTE-183 NCT02576977) in ND and RR setting respectively. Interim analysis of both studies showed excessive administered for a median of 7 cycles (range 1–67). Overall, 95% of patients experienced unanticipated deaths attributed to the combination of Pembrolizumab Dexamethasone with Lenalidomide or Pomalidomide. These results showed that the risk profile of these novel combinations was unfavorable, and both trials were terminated early [82, 83].
\n
Nivolumab is a fully human IgG4 Moab targeting PD-1 receptors. Investigation of Nivolumab with IMiDS has been placed on clinical hold after reviewing data regarding Pembrolizumab. Nivolumab is currently under investigation in combination with daratumumab (NCT03184194), Elotuzumab (NCT02612779), Pomalidomide (NCT02726581), and Carfilzomib (NCT03605719) in phase 2 trials.
\n
In \nTable 1\n, we present selected clinical trials conducted with monoclonal antibodies in the newly diagnosed and relapsed refractory setting.
\n
\n
\n
\n
\n
\n\n
\n
Description
\n
Phase
\n
NCT number
\n
Population
\n
\n\n\n
\n
DARATUMUMAB
\n
\n
\n
\n
\n
\n
A Study of Daratumumab Plus Lenalidomide Versus Lenalidomide Alone as Maintenance Treatment in Participants With Newly Diagnosed Multiple Myeloma Who Are Minimal Residual Disease Positive After Frontline Autologous Stem Cell Transplant (AURIGA)
\n
3
\n
NCT03901963
\n
NDMM
\n
\n
\n
Study of Melphalan Flufenamide (Melflufen) in Combination With Daratumumab in Relapsed Refractory Multiple Myeloma (LIGHTHOUSE)
\n
3
\n
NCT04649060
\n
RRMM
\n
\n
\n
Daratumumab, VELCADE (Bortezomib), Lenalidomide and Dexamethasone Compared to VELCADE, Lenalidomide and Dexamethasone in Subjects With Previously Untreated Multiple Myeloma (PERSEUS)
\n
3
\n
NCT03710603
\n
NDMM
\n
\n
\n
ISATUXIMAB
\n
\n
\n
\n
\n
\n
Isatuximab Bortezomib, Lenalidomide and Dexamethasone Combination in NDMM Patients Not Eligible for Transplant (IMROZ)
\n
3
\n
NCT03319667
\n
NDMM
\n
\n
\n
Isa-KRd vs. KRd in Newly Diagnosed Multiple Myeloma Patients Eligible for Autologous Stem Cell Transplantation (IsKia)
\n
3
\n
NCT04483739
\n
NDMM
\n
\n
\n
ANTIBODY-DRUG CONJUGATES
\n
\n
\n
\n
\n
\n
Study of Single Agent Belantamab Mafodotin Versus Pomalidomide Plus Low-dose Dexamethasone (Pom/Dex) in Participants With Relapsed/Refractory Multiple Myeloma (DREAMM-3)
\n
3
\n
NCT04162210
\n
RRMM
\n
\n
\n
Study Evaluating Safety, Tolerability and Clinical Activity of GSK2857916 in Combination With Pembrolizumab in Subjects With Relapsed/Refractory Multiple Myeloma (DREAMM-4)
\n
1/2
\n
NCT03848845
\n
RRMM
\n
\n
\n
Platform Study of Belantamab Mafodotin as Monotherapy and in Combination With Anti-cancer Treatments in Participants With Relapsed/Refractory Multiple Myeloma (RRMM) (DREAMM 5)
\n
1/2
\n
NCT04126200
\n
RRMM
\n
\n
\n
To Evaluate Safety, Tolerability, and Clinical Activity of the Antibody-drug Conjugate, GSK2857916 Administered in Combination With Lenalidomide Plus Dexamethasone (Arm A), or in Combination With Bortezomib Plus Dexamethasone (Arm B) in Participants With Relapsed/Refractory Multiple Myeloma (DREAMM-6)
\n
1/2
\n
NCT03544281
\n
RRMM
\n
\n
\n
Evaluation of Efficacy and Safety of Belantamab Mafodotin, Bortezomib and Dexamethasone Versus Daratumumab, Bortezomib and Dexamethasone in Participants With Relapsed/Refractory Multiple Myeloma (DREAMM-7)
\n
3
\n
NCT04246047
\n
RRMM
\n
\n
\n
Belantamab Mafodotin Plus Pomalidomide and Dexamethasone (Pd) Versus Bortezomib Plus Pd in Relapsed/Refractory Multiple Myeloma (DREAMM-8)
\n
3
\n
NCT04484623
\n
RRMM
\n
\n
\n
Study of Belantamab Mafodotin Plus Standard of Care (SoC) in Newly Diagnosed Multiple Myeloma (DREAMM-9)
\n
1
\n
NCT04091126
\n
NDMM
\n
\n
\n
A Study of Belantamab Mafodotin (GSK2857916) in Multiple Myeloma Participants With Normal and Varying Degree of Impaired Renal Function (DREAMM-12)
\n
1
\n
NCT04398745
\n
RRMM
\n
\n
\n
A Study of Belantamab Mafodotin (GSK2857916) in Multiple Myeloma Participants With Normal and Impaired Hepatic Function (DREAMM-13)
\n
1
\n
NCT04398680
\n
RRMM
\n
\n
\n
BISPECIFIC ANTIBODIES
\n
\n
\n
\n
\n
\n
PF-06863135 As Single Agent And In Combination With Immunomodulatory Agents In Relapse/Refractory Multiple Myeloma
\n
1
\n
NCT03269136
\n
RRMM
\n
\n
\n
MagnetisMM-3: Study Of Elranatamab (PF-06863135) Monotherapy in Participants With Multiple Myeloma Who Are Refractory to at Least One PI, One IMiD and One Anti-CD38 mAb
\n
2
\n
NCT04649359
\n
RRMM
\n
\n
\n
First in Human (FIH) Study of REGN5458 in Patients With Relapsed or Refractory Multiple Myeloma
\n
1/2
\n
NCT03761108
\n
RRMM
\n
\n
\n
A Study of Teclistamab, in Participants With Relapsed or Refractory Multiple Myeloma
\n
2
\n
NCT04557098
\n
RRMM
\n
\n
\n
A Study of Talquetamab in Participants With Relapsed or Refractory Multiple Myeloma
\n
2
\n
NCT04634552
\n
RRMM
\n
\n\n
Table 1.
Ongoing clinical trials.
\n
\n
\n
4. Conclusion
\n
Despite therapeutic improvements Multiple Myeloma remain an incurable disease. The treatment of patients with RR remains a challenging issue. Antibody therapy has significantly enhanced the armamentarium of therapeutic options. Further research should focus on tailoring the combination regimens based on disease and patient characteristics in order to optimize the efficacy and safety.
\n
\n\n',keywords:"Monoclonal Antibodies, Antibody Drug Conjugates, Daratumumab, Belantamab Mafodotin",chapterPDFUrl:"https://cdn.intechopen.com/pdfs/77271.pdf",chapterXML:"https://mts.intechopen.com/source/xml/77271.xml",downloadPdfUrl:"/chapter/pdf-download/77271",previewPdfUrl:"/chapter/pdf-preview/77271",totalDownloads:185,totalViews:0,totalCrossrefCites:0,dateSubmitted:"September 25th 2020",dateReviewed:"May 31st 2021",datePrePublished:"July 7th 2021",datePublished:"July 28th 2021",dateFinished:"June 23rd 2021",readingETA:"0",abstract:"Multiple Myeloma (MM) is characterized by the abberant proliferation and expansion of plasma cells in the Bone marrow. Despite the broad use of proteasome inhibitors and IMiDs, Multiple Myeloma remains an incurable disease. The introduction of Monoclonal antibodies, along with bi-specific antibodies and check point inhibitors, has significantly enhanced the armamentarium of available therapeutic options in the relapsed setting. The incorporation of the above-mentioned novel agents in triplet or quadruplet therapeutic regimens has led to significant prolongation of overall survival (OS) and progression free survival (PFS), without adding significant toxicity. Anti-CD38 monoclonal antibodies has become the cornerstone of antimyeloma therapy in both the newly diagnosed and relapsed setting.",reviewType:"peer-reviewed",bibtexUrl:"/chapter/bibtex/77271",risUrl:"/chapter/ris/77271",signatures:"Nikolaos Kanellias, Maria Gavriatopoulou and Evangelos Terpos",book:{id:"9791",type:"book",title:"Multiple Myeloma",subtitle:null,fullTitle:"Multiple Myeloma",slug:"multiple-myeloma",publishedDate:"July 28th 2021",bookSignature:"Ota Fuchs",coverURL:"https://cdn.intechopen.com/books/images_new/9791.jpg",licenceType:"CC BY 3.0",editedByType:"Edited by",isbn:"978-1-83968-621-4",printIsbn:"978-1-83968-620-7",pdfIsbn:"978-1-83968-622-1",isAvailableForWebshopOrdering:!0,editors:[{id:"36468",title:"Dr.",name:"Ota",middleName:null,surname:"Fuchs",slug:"ota-fuchs",fullName:"Ota Fuchs"}],productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"}},authors:[{id:"52484",title:"Prof.",name:"Evangelos",middleName:null,surname:"Terpos",fullName:"Evangelos Terpos",slug:"evangelos-terpos",email:"eterpos@hotmail.com",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institution:null},{id:"332827",title:"M.D.",name:"Nikolaos",middleName:null,surname:"Kanellias",fullName:"Nikolaos Kanellias",slug:"nikolaos-kanellias",email:"nick.kanellias@gmail.com",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institution:null},{id:"419708",title:"Prof.",name:"Maria",middleName:null,surname:"Gavriatopoulou",fullName:"Maria Gavriatopoulou",slug:"maria-gavriatopoulou",email:"mariagabria@gmail.com",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",institution:null}],sections:[{id:"sec_1",title:"1. Introduction",level:"1"},{id:"sec_2",title:"2. Monoclonal antibodies",level:"1"},{id:"sec_2_2",title:"2.1 Daratumumab",level:"2"},{id:"sec_2_3",title:"2.1.1 Daratumumab mechanism of action",level:"3"},{id:"sec_3_3",title:"2.1.2 Daratumumab combinations in the newly diagnosed setting",level:"3"},{id:"sec_3_4",title:"2.1.2.1 Transplant-ineligible patients",level:"4"},{id:"sec_4_4",title:"2.1.2.2 Transplant-eligible patients",level:"4"},{id:"sec_6_3",title:"2.1.3 Daratumumab combinations in the R/R setting",level:"3"},{id:"sec_8_2",title:"2.2 Isatuximab",level:"2"},{id:"sec_8_3",title:"2.2.1 Mechanism of action",level:"3"},{id:"sec_9_3",title:"2.2.2 Isatuximab clinical trials",level:"3"},{id:"sec_11_2",title:"2.3 Elotuzumab",level:"2"},{id:"sec_11_3",title:"2.3.1 Elotuzumab mechanism of action",level:"3"},{id:"sec_12_3",title:"2.3.2 Elotuzumab clinical trials",level:"3"},{id:"sec_14_2",title:"2.4 Antibody drug conjugates (ADCs)",level:"2"},{id:"sec_15_2",title:"2.5 Bispecific antibodies",level:"2"},{id:"sec_17",title:"3. Immune checkpoint inhibitors",level:"1"},{id:"sec_18",title:"4. Conclusion",level:"1"}],chapterReferences:[{id:"B1",body:'\nPalumbo A, Anderson K. Multiple myeloma. N Engl J Med 2011; 364: 1046-1060\n'},{id:"B2",body:'\nKumar SK, Lee JH, Lahuerta JJ et al. Risk of progression and survival in multiple myeloma relapsing after therapy with IMiDs and bortezomib: a multicenter international myeloma working group study. Leukemia 2012; 26: 149-157\n'},{id:"B3",body:'\nKumar SK, Dimopoulos MA, Kastritis E et al. Natural history of relapsed myeloma, refractory to immunomodulatory drugs and proteasome inhibitors: a multicenter IMWG study. Leukemia 2017; 31: 2443-2448\n'},{id:"B4",body:'\nvan de Donk NW, Sonneveld P. Diagnosis and risk stratification in multiple myeloma. Hematol Oncol Clin North Am 2014; 28: 791-813\n'},{id:"B5",body:'\nSonneveld P, Avet-Loiseau H, Lonial S et al. Treatment of multiple myeloma with high-risk cytogenetics: a consensus of the International Myeloma Working Group. Blood 2016; 127: 2955-2962\n'},{id:"B6",body:'\nde Weers M, Tai YT, van der Veer MS et al. Daratumumab, a novel therapeutic human CD38 monoclonal antibody, induces killing of multiple myeloma and other hematological tumors. J Immunol 2011; 186: 1840-1848\n'},{id:"B7",body:'\nPelton JG, Wemmer DE. Structural modeling of the distamycin A-d(CGCGAATTCGCG)2 complex using 2D NMR and molecular mechanics. Biochemistry 1988; 27: 8088-8096\n'},{id:"B8",body:'\nOverdijk MB, Verploegen S, Bogels M et al. Antibody-mediated phagocytosis contributes to the anti-tumor activity of the therapeutic antibody daratumumab in lymphoma and multiple myeloma. MAbs 2015; 7: 311-321\n'},{id:"B9",body:'\nPhipps C, Chen Y, Gopalakrishnan S, Tan D. Daratumumab and its potential in the treatment of multiple myeloma: overview of the preclinical and clinical development. Ther Adv Hematol 2015; 6: 120-127\n'},{id:"B10",body:'\nJain A, Ramasamy K. Evolving Role of Daratumumab: From Backbencher to Frontline Agent. 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Daratumumab, Lenalidomide, and Dexamethasone for Multiple Myeloma. N Engl J Med 2016; 375: 1319-1331\n'},{id:"B16",body:'\nChatterjee S, Daenthanasanmak A, Chakraborty P et al. CD38-NAD(+)Axis Regulates Immunotherapeutic Anti-Tumor T Cell Response. Cell Metab 2018; 27: 85-100 e108\n'},{id:"B17",body:'\nMateos MV, Dimopoulos MA, Cavo M et al. Daratumumab plus Bortezomib, Melphalan, and Prednisone for Untreated Myeloma. N Engl J Med 2018; 378: 518-528\n'},{id:"B18",body:'\nTerpos E, Ntanasis-Stathopoulos I, International Myeloma S. Clinical Updates Regarding Multiple Myeloma From the 2019 American Society of Hematology Annual Meeting. Clin Lymphoma Myeloma Leuk 2020; 20: 499-508\n'},{id:"B19",body:'\nMateos MV, Cavo M, Blade J et al. Overall survival with daratumumab, bortezomib, melphalan, and prednisone in newly diagnosed multiple myeloma (ALCYONE): a randomised, open-label, phase 3 trial. Lancet 2020; 395: 132-141\n'},{id:"B20",body:'\nSan-Miguel JF, Avet-Loiseau H, Paiva B et al. Sustained Minimal Residual Disease (MRD) Negativity and Clinical Efficacy in Transplant-Ineligible (TIE) Newly Diagnosed Multiple Myeloma (NDMM) Patients (Pts) Treated with Daratumumab-Based Regimens: Analysis of Maia and Alcyone. Blood 2020; 136: 18-20\n'},{id:"B21",body:'\nFacon T, Kumar S, Plesner T et al. Daratumumab plus Lenalidomide and Dexamethasone for Untreated Myeloma. N Engl J Med 2019; 380: 2104-2115\n'},{id:"B22",body:'\nBahlis N, Facon T, Usmani SZ et al. Daratumumab Plus Lenalidomide and Dexamethasone (D-Rd) Versus Lenalidomide and Dexamethasone (Rd) in Patients with Newly Diagnosed Multiple Myeloma (NDMM) Ineligible for Transplant: Updated Analysis of Maia. Blood 2019; 134: 1875-1875\n'},{id:"B23",body:'\nKumar SK, Facon T, Usmani SZ et al. Updated Analysis of Daratumumab Plus Lenalidomide and Dexamethasone (D-Rd) Versus Lenalidomide and Dexamethasone (Rd) in Patients with Transplant-Ineligible Newly Diagnosed Multiple Myeloma (NDMM): The Phase 3 Maia Study. Blood 2020; 136: 24-26\n'},{id:"B24",body:'\nChari A, Martinez-Lopez J, Mateos M-V et al. Daratumumab plus carfilzomib and dexamethasone in patients with relapsed or refractory multiple myeloma. Blood 2019; 134: 421-431\n'},{id:"B25",body:'\nVoorhees PM, Kaufman JL, Laubach J et al. Daratumumab, lenalidomide, bortezomib, and dexamethasone for transplant-eligible newly diagnosed multiple myeloma: the GRIFFIN trial. Blood 2020; 136: 936-945\n'},{id:"B26",body:'\nVoorhees PM, Rodriguez C, Reeves B et al. Daratumumab plus RVd for newly diagnosed multiple myeloma: final analysis of the safety run-in cohort of GRIFFIN. Blood Advances 2021; 5: 1092-1096\n'},{id:"B27",body:'\nMoreau P, Attal M, Hulin C et al. Bortezomib, thalidomide, and dexamethasone with or without daratumumab before and after autologous stem-cell transplantation for newly diagnosed multiple myeloma (CASSIOPEIA): a randomised, open-label, phase 3 study. Lancet 2019; 394: 29-38\n'},{id:"B28",body:'\nCosta LJ, Chhabra S, Godby KN et al. Daratumumab, Carfilzomib, Lenalidomide and Dexamethasone (Dara-KRd) Induction, Autologous Transplantation and Post-Transplant, Response-Adapted, Measurable Residual Disease (MRD)-Based Dara-Krd Consolidation in Patients with Newly Diagnosed Multiple Myeloma (NDMM). Blood 2019; 134: 860-860\n'},{id:"B29",body:'\nDimopoulos MA, San-Miguel J, Belch A et al. Daratumumab plus lenalidomide and dexamethasone versus lenalidomide and dexamethasone in relapsed or refractory multiple myeloma: updated analysis of POLLUX. Haematologica 2018; 103: 2088-2096\n'},{id:"B30",body:'\nBahlis NJ, Dimopoulos MA, White DJ et al. Daratumumab plus lenalidomide and dexamethasone in relapsed/refractory multiple myeloma: extended follow-up of POLLUX, a randomized, open-label, phase 3 study. Leukemia 2020; 34: 1875-1884\n'},{id:"B31",body:'\nPalumbo A, Chanan-Khan A, Weisel K et al. Daratumumab, Bortezomib, and Dexamethasone for Multiple Myeloma. N Engl J Med 2016; 375: 754-766\n'},{id:"B32",body:'\nChari A, Suvannasankha A, Fay JW et al. Daratumumab plus pomalidomide and dexamethasone in relapsed and/or refractory multiple myeloma. Blood 2017; 130: 974-981\n'},{id:"B33",body:'\nDimopoulos MA, Terpos E, Boccadoro M et al. Apollo: Phase 3 Randomized Study of Subcutaneous Daratumumab Plus Pomalidomide and Dexamethasone (D-Pd) Versus Pomalidomide and Dexamethasone (Pd) Alone in Patients (Pts) with Relapsed/Refractory Multiple Myeloma (RRMM). Blood 2020; 136: 5-6\n'},{id:"B34",body:'\nUsmani SZ, Quach H, Mateos M-V et al. Carfilzomib, Dexamethasone, and Daratumumab Versus Carfilzomib and Dexamethasone for the Treatment of Patients with Relapsed or Refractory Multiple Myeloma (RRMM): Primary Analysis Results from the Randomized, Open-Label, Phase 3 Study Candor (NCT03158688). Blood 2019; 134: LBA-6-LBA-6\n'},{id:"B35",body:'\nDimopoulos MA, Quach H, Mateos M-V et al. Carfilzomib, Dexamethasone, and Daratumumab Versus Carfilzomib and Dexamethasone in Relapsed or Refractory Multiple Myeloma: Updated Efficacy and Safety Results of the Phase 3 Candor Study. Blood 2020; 136: 26-27\n'},{id:"B36",body:'\nDeckert J, Wetzel MC, Bartle LM et al. SAR650984, a novel humanized CD38-targeting antibody, demonstrates potent antitumor activity in models of multiple myeloma and other CD38+ hematologic malignancies. Clin Cancer Res 2014; 20: 4574-4583\n'},{id:"B37",body:'\nNijhof IS, Groen RW, Noort WA et al. Preclinical Evidence for the Therapeutic Potential of CD38-Targeted Immuno-Chemotherapy in Multiple Myeloma Patients Refractory to Lenalidomide and Bortezomib. Clin Cancer Res 2015; 21: 2802-2810\n'},{id:"B38",body:'\nvan der Veer MS, de Weers M, van Kessel B et al. Towards effective immunotherapy of myeloma: enhanced elimination of myeloma cells by combination of lenalidomide with the human CD38 monoclonal antibody daratumumab. 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Blood 2017; 129: 3294-3303\n'},{id:"B44",body:'\nMikhael J, Richardson P, Usmani SZ et al. A phase 1b study of isatuximab plus pomalidomide/dexamethasone in relapsed/refractory multiple myeloma. Blood 2019; 134: 123-133\n'},{id:"B45",body:'\nAttal M, Richardson PG, Rajkumar SV et al. Isatuximab plus pomalidomide and low-dose dexamethasone versus pomalidomide and low-dose dexamethasone in patients with relapsed and refractory multiple myeloma (ICARIA-MM): a randomised, multicentre, open-label, phase 3 study. Lancet 2019; 394: 2096-2107\n'},{id:"B46",body:'\nChari A, Richter JR, Shah N et al. Phase I-b study of isatuximab + carfilzomib in relapsed and refractory multiple myeloma (RRMM). Journal of Clinical Oncology 2018; 36: 8014-8014\n'},{id:"B47",body:'\nMoreau P, Dimopoulos MA, Yong K et al. Isatuximab plus carfilzomib/dexamethasone versus carfilzomib/dexamethasone in patients with relapsed/refractory multiple myeloma: IKEMA Phase III study design. Future Oncol 2020; 16: 4347-4358\n'},{id:"B48",body:'\nMartin T, Mikhael J, Hajek R et al. Depth of Response and Response Kinetics of Isatuximab Plus Carfilzomib and Dexamethasone in Relapsed Multiple Myeloma: Ikema Interim Analysis. Blood 2020; 136: 7-8\n'},{id:"B49",body:'\nTai YT, Dillon M, Song W et al. Anti-CS1 humanized monoclonal antibody HuLuc63 inhibits myeloma cell adhesion and induces antibody-dependent cellular cytotoxicity in the bone marrow milieu. Blood 2008; 112: 1329-1337\n'},{id:"B50",body:'\nPazina T, James AM, MacFarlane AWt et al. The anti-SLAMF7 antibody elotuzumab mediates NK cell activation through both CD16-dependent and -independent mechanisms. Oncoimmunology 2017; 6: e1339853\n'},{id:"B51",body:'\nLonial S, Dimopoulos M, Palumbo A et al. Elotuzumab Therapy for Relapsed or Refractory Multiple Myeloma. N Engl J Med 2015; 373: 621-631\n'},{id:"B52",body:'\nDimopoulos MA, Dytfeld D, Grosicki S et al. Elotuzumab plus Pomalidomide and Dexamethasone for Multiple Myeloma. N Engl J Med 2018; 379: 1811-1822\n'},{id:"B53",body:'\nMadry C, Laabi Y, Callebaut I et al. The characterization of murine BCMA gene defines it as a new member of the tumor necrosis factor receptor superfamily. Int Immunol 1998; 10: 1693-1702\n'},{id:"B54",body:'\nSanchez E, Li M, Kitto A et al. Serum B-cell maturation antigen is elevated in multiple myeloma and correlates with disease status and survival. Br J Haematol 2012; 158: 727-738\n'},{id:"B55",body:'\nCarpenter RO, Evbuomwan MO, Pittaluga S et al. B-cell maturation antigen is a promising target for adoptive T-cell therapy of multiple myeloma. Clin Cancer Res 2013; 19: 2048-2060\n'},{id:"B56",body:'\nThompson JS, Schneider P, Kalled SL et al. BAFF binds to the tumor necrosis factor receptor-like molecule B cell maturation antigen and is important for maintaining the peripheral B cell population. J Exp Med 2000; 192: 129-135\n'},{id:"B57",body:'\nNovak AJ, Darce JR, Arendt BK et al. Expression of BCMA, TACI, and BAFF-R in multiple myeloma: a mechanism for growth and survival. Blood 2004; 103: 689-694\n'},{id:"B58",body:'\nGavriatopoulou M, Ntanasis-Stathopoulos I, Dimopoulos MA, Terpos E. Anti-BCMA antibodies in the future management of multiple myeloma. Expert Rev Anticancer Ther 2019; 19: 319-326\n'},{id:"B59",body:'\nShen X, Guo Y, Qi J et al. Binding of B-cell maturation antigen to B-cell activating factor induces survival of multiple myeloma cells by activating Akt and JNK signaling pathways. Cell Biochem Funct 2016; 34: 104-110\n'},{id:"B60",body:'\nDemchenko YN, Kuehl WM. A critical role for the NFkB pathway in multiple myeloma. Oncotarget 2010; 1: 59-68\n'},{id:"B61",body:'\nChatterjee M, Jain S, Stuhmer T et al. 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Novel anti-B-cell maturation antigen antibody-drug conjugate (GSK2857916) selectively induces killing of multiple myeloma. Blood 2014; 123: 3128-3138\n'},{id:"B66",body:'\nTrudel S, Lendvai N, Popat R et al. Targeting B-cell maturation antigen with GSK2857916 antibody-drug conjugate in relapsed or refractory multiple myeloma (BMA117159): a dose escalation and expansion phase 1 trial. Lancet Oncol 2018; 19: 1641-1653\n'},{id:"B67",body:'\nTrudel S, Lendvai N, Popat R et al. Antibody-drug conjugate, GSK2857916, in relapsed/refractory multiple myeloma: an update on safety and efficacy from dose expansion phase I study. Blood Cancer J 2019; 9: 37\n'},{id:"B68",body:'\nTzogani K, Penttila K, Lahteenvuo J et al. EMA Review of Belantamab Mafodotin (Blenrep) for the Treatment of Adult Patients with Relapsed/Refractory Multiple Myeloma. Oncologist 2021; 26: 70-76\n'},{id:"B69",body:'\nLonial S, Lee HC, Badros A et al. Belantamab mafodotin for relapsed or refractory multiple myeloma (DREAMM-2): a two-arm, randomised, open-label, phase 2 study. Lancet Oncol 2020; 21: 207-221\n'},{id:"B70",body:'\nCohen AD, Trudel S, Lonial S et al. DREAMM-2: Single-agent belantamab mafodotin (GSK2857916) in patients with relapsed/refractory multiple myeloma (RRMM) and high-risk (HR) cytogenetics. Journal of Clinical Oncology 2020; 38: 8541-8541\n'},{id:"B71",body:'\nLee HC, Cohen AD, Chari A et al. DREAMM-2: Single-agent belantamab mafodotin (GSK2857916) in patients with relapsed/refractory multiple myeloma (RRMM) and renal impairment. Journal of Clinical Oncology 2020; 38: 8519-8519\n'},{id:"B72",body:'\nKumar SK, Migkou M, Bhutani M et al. Phase 1, First-in-Human Study of MEDI2228, a BCMA-Targeted ADC in Patients with Relapsed/Refractory Multiple Myeloma. Blood 2020; 136: 26-27\n'},{id:"B73",body:'\nTopp MS, Duell J, Zugmaier G et al. Anti-B-Cell Maturation Antigen BiTE Molecule AMG 420 Induces Responses in Multiple Myeloma. J Clin Oncol 2020; 38: 775-783\n'},{id:"B74",body:'\nLesokhin AM, Raje N, Gasparetto CJ et al. A Phase I, Open-Label Study to Evaluate the Safety, Pharmacokinetic, Pharmacodynamic, and Clinical Activity of PF-06863135, a B-Cell Maturation Antigen/CD3 Bispecific Antibody, in Patients with Relapsed/Refractory Advanced Multiple Myeloma. Blood 2018; 132: 3229-3229\n'},{id:"B75",body:'\nLesokhin AM, Levy MY, Dalovisio AP et al. Preliminary Safety, Efficacy, Pharmacokinetics, and Pharmacodynamics of Subcutaneously (SC) Administered PF-06863135, a B-Cell Maturation Antigen (BCMA)-CD3 Bispecific Antibody, in Patients with Relapsed/Refractory Multiple Myeloma (RRMM). Blood 2020; 136: 8-9\n'},{id:"B76",body:'\nParry RV, Chemnitz JM, Frauwirth KA et al. CTLA-4 and PD-1 receptors inhibit T-cell activation by distinct mechanisms. Mol Cell Biol 2005; 25: 9543-9553\n'},{id:"B77",body:'\nPaiva B, Azpilikueta A, Puig N et al. PD-L1/PD-1 presence in the tumor microenvironment and activity of PD-1 blockade in multiple myeloma. Leukemia 2015; 29: 2110-2113\n'},{id:"B78",body:'\nChen D, Tang P, Liu L et al. Bone marrow-derived mesenchymal stem cells promote cell proliferation of multiple myeloma through inhibiting T cell immune responses via PD-1/PD-L1 pathway. Cell Cycle 2018; 17: 858-867\n'},{id:"B79",body:'\nMateos M-V, Orlowski RZ, Siegel DSD et al. Pembrolizumab in combination with lenalidomide and low-dose dexamethasone for relapsed/refractory multiple myeloma (RRMM): Final efficacy and safety analysis. Journal of Clinical Oncology 2016; 34: 8010-8010\n'},{id:"B80",body:'\nMateos MV, Orlowski RZ, Ocio EM et al. Pembrolizumab combined with lenalidomide and low-dose dexamethasone for relapsed or refractory multiple myeloma: phase I KEYNOTE-023 study. Br J Haematol 2019; 186: e117-e121\n'},{id:"B81",body:'\nBadros A, Hyjek E, Ma N et al. Pembrolizumab, pomalidomide, and low-dose dexamethasone for relapsed/refractory multiple myeloma. Blood 2017; 130: 1189-1197\n'},{id:"B82",body:'\nMateos MV, Blacklock H, Schjesvold F et al. Pembrolizumab plus pomalidomide and dexamethasone for patients with relapsed or refractory multiple myeloma (KEYNOTE-183): a randomised, open-label, phase 3 trial. Lancet Haematol 2019; 6: e459-e469\n'},{id:"B83",body:'\nUsmani SZ, Schjesvold F, Oriol A et al. Pembrolizumab plus lenalidomide and dexamethasone for patients with treatment-naive multiple myeloma (KEYNOTE-185): a randomised, open-label, phase 3 trial. Lancet Haematol 2019; 6: e448-e458\n'}],footnotes:[],contributors:[{corresp:"yes",contributorFullName:"Nikolaos Kanellias",address:"nick.kanellias@gmail.com",affiliation:'
Department of Clinical Therapeutics, Medical School, Alexandra General Hospital, National and Kapodistrian University of Athens, Athens, Greece
Department of Clinical Therapeutics, Medical School, Alexandra General Hospital, National and Kapodistrian University of Athens, Athens, Greece
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As this section deals with legal issues pertaining to the rights of individual Authors and IntechOpen, for the avoidance of doubt, each category of publication is dealt with separately. Consequently, much of the information, for example definition of terms used, is repeated to ensure that there can be no misunderstanding of the policies that apply to each category.
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DISCLAIMER: Neither the CC BY 3.0 license, CC BY 4.0, nor any other license IntechOpen currently uses or has used before, applies to figures and tables reproduced from other works, as they may be subject to different terms of reuse. In such cases, if the copyright holder is not noted in the source of a figure or table, it is the responsibility of the User to investigate and determine the exact copyright status of any information utilised. Users requiring assistance in that regard are welcome to send an inquiry to permissions@intechopen.com.
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All rights to Books and Journals and all other compilations published on the IntechOpen platform and in print are reserved by IntechOpen.
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All content included on IntechOpen Websites not forming part of contributed materials (such as text, images, logos, graphics, design elements, videos, sounds, pictures, trademarks, etc.), are subject to copyright and are property of, or licensed to, IntechOpen. Any other use, including the reproduction, modification, distribution, transmission, republication, display, or performance of the content on this site is strictly prohibited.
Copyright is the term used to describe the rights related to the publication and distribution of original Works. Most importantly from a publisher's perspective, copyright governs how Authors, publishers and the general public can use, publish, and distribute publications.
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IntechOpen only publishes manuscripts for which it has publishing rights. This is governed by a publication agreement between the Author and IntechOpen. This agreement is accepted by the Author when the manuscript is submitted and deals with both the rights of the publisher and Author, as well as any obligations concerning a particular manuscript. However, in accepting this agreement, Authors continue to retain significant rights to use and share their publications.
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By accepting the agreement terms Authors retain their copyright on their Work but grant broad publishing and distribution rights to the publisher.
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Depending on the type of publication (Chapter or Long Form Monograph/Compacts; see definitions below), IntechOpen applies a Creative Commons license to the publication, allowing readers to use and share it freely.
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IntechOpen makes the publication available online under an appropriate license.
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Agreement samples are listed here for the convenience of prospective Authors:
The following definitions apply in this Copyright Policy:
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Author - in order to be identified as an Author, three criteria must be met: (i) Substantial contribution to the conception or design of the Work, or the acquisition, analysis, or interpretation of data for the Work; (ii) Participation in drafting or revising the Work; (iii) Approval of the final version of the Work to be published.
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Video Lecture – an audiovisual recording of a lecture or a speech given by a Lecturer, recorded, edited, owned and published by IntechOpen.
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TERMS
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All Works published on the IntechOpen platform and in print are licensed under a Creative Commons Attribution 3.0 Unported and Creative Commons 4.0 International License, a license which allows for the broadest possible reuse of published material.
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Adapt — remix, transform, and build upon the material
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An Attribution, giving appropriate credit and providing a link to the license, with an indication as to whether changes to the original were made
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A commitment not to add additional restrictions. In effect, this prohibits the application of legal conditions or technological measures that legally restrict others from doing anything that the license permits.
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All Works are published under the CC BY 3.0 and CC BY 4.0 license. However, please note that book Chapters may fall under a different CC license, depending on their publication date as indicated in the table below:
Creative Commons Attribution 3.0 Unported (CC BY 3.0)
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5 October 2011 (2011-10-05)
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The CC BY 3.0 and CC BY 4.0 license permits Works to be freely shared in any medium or format, as well as the reuse and adaptation of the original contents of Works (e.g. figures and tables created by the Authors), as long as the source Work is cited and its Authors are acknowledged in the following manner:
Originally published in {full citation}. Available from: {DOI}
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The same principles apply to Works published under the CC BY-NC-SA 3.0 license, with the caveats that (1) the content may not be used for commercial purposes, and (2) derivative works building on this content must be distributed under the same license. The restrictions contained in these license terms may, however, be waived by the copyright holder(s). Users wishing to circumvent any of the license terms are required to obtain explicit permission to do so from the copyright holder(s).
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DISCLAIMER: Neither the CC BY 3.0 license, CC BY 4.0, nor any other license IntechOpen currently uses or has used before, applies to figures and tables reproduced from other works, as they may be subject to different terms of reuse. In such cases, if the copyright holder is not noted in the source of a figure or table, it is the responsibility of the User to investigate and determine the exact copyright status of any information utilised. Users requiring assistance in that regard are welcome to send an inquiry to permissions@intechopen.com.
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All rights to Books and Journals and all other compilations published on the IntechOpen platform and in print are reserved by IntechOpen.
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The copyright to Books, Journals and other compilations is subject to separate copyright from those that exist in the included Works.
Copyright to the individual Works (Chapters) belongs to their specific Authors, subject to an agreement with IntechOpen and the Creative Common license granted to all others to:
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Share — copy and redistribute the material in any medium or format
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No additional restrictions that apply legal terms or technological measures that restrict others from doing anything the license permits are allowed.
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The CC BY-NC 4.0 license permits Works to be freely shared in any medium or format, as well as reuse and adaptation of the original contents of Works (e.g. figures and tables created by the Authors), as long as it is not used for commercial purposes. The source Work must be cited and its Authors acknowledged in the following manner:
Originally published in {full citation}. Available from: {DOI}
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All Book cover design elements, as well as Video image graphics are subject to copyright by IntechOpen.
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Every reproduction of a front cover image must be accompanied by an appropriate Copyright Notice displayed adjacent to the image. The exact Copyright Notice depends on who the Author of a particular cover image is. Users wishing to reproduce cover images should contact permissions@intechopen.com.
Share — copy and redistribute the material in any medium or format
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Under the following terms:
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Attribution — give appropriate credit, provide a link to the license, and indicate if changes were made.
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NonCommercial use only - you may not use the material for commercial purposes. Commercial rights are reserved to IntechOpen or its licensees.
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Distribution of remixed or transformed material building on the original termed derivatives is not permitted.
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No additional restrictions — you may not apply legal terms or technological measures that legally restrict others from doing anything the license permits.
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Users wishing to repost and share the Video Lectures are welcome to do so as long as they acknowledge the source in the following manner:
Users wishing to reuse, modify, or adapt the Video Lectures in a way not permitted by the license are welcome to contact us at permissions@intechopen.com to discuss waiving particular license terms.
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All software used on the IntechOpen platform, any used during the publishing process, and the copyright in the code constituting such software, is the property of IntechOpen or its software suppliers. As such, it may not be downloaded or copied without permission.
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Unless otherwise indicated, all IntechOpen websites are the property of IntechOpen.
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All content included on IntechOpen Websites not forming part of contributed materials (such as text, images, logos, graphics, design elements, videos, sounds, pictures, trademarks, etc.), are subject to copyright and are property of, or licensed to, IntechOpen. Any other use, including the reproduction, modification, distribution, transmission, republication, display, or performance of the content on this site is strictly prohibited.
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\r\n\tTransforming our World: the 2030 Agenda for Sustainable Development endorsed by United Nations and 193 Member States, came into effect on Jan 1, 2016, to guide decision making and actions to the year 2030 and beyond. Central to this Agenda are 17 Goals, 169 associated targets and over 230 indicators that are reviewed annually. The vision envisaged in the implementation of the SDGs is centered on the five Ps: People, Planet, Prosperity, Peace and Partnership. This call for renewed focused efforts ensure we have a safe and healthy planet for current and future generations.
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\r\n\t
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\r\n\tThis Series focuses on covering research and applied research involving the five Ps through the following topics:
\r\n
\r\n\t
\r\n
\r\n\t1. Sustainable Economy and Fair Society that relates to SDG 1 on No Poverty, SDG 2 on Zero Hunger, SDG 8 on Decent Work and Economic Growth, SDG 10 on Reduced Inequalities, SDG 12 on Responsible Consumption and Production, and SDG 17 Partnership for the Goals
\r\n
\r\n\t
\r\n
\r\n\t2. Health and Wellbeing focusing on SDG 3 on Good Health and Wellbeing and SDG 6 on Clean Water and Sanitation
\r\n
\r\n\t
\r\n
\r\n\t3. Inclusivity and Social Equality involving SDG 4 on Quality Education, SDG 5 on Gender Equality, and SDG 16 on Peace, Justice and Strong Institutions
\r\n
\r\n\t
\r\n
\r\n\t4. Climate Change and Environmental Sustainability comprising SDG 13 on Climate Action, SDG 14 on Life Below Water, and SDG 15 on Life on Land
\r\n
\r\n\t
\r\n
\r\n\t5. Urban Planning and Environmental Management embracing SDG 7 on Affordable Clean Energy, SDG 9 on Industry, Innovation and Infrastructure, and SDG 11 on Sustainable Cities and Communities.
\r\n
\r\n\t
\r\n
\r\n\tThe series also seeks to support the use of cross cutting SDGs, as many of the goals listed above, targets and indicators are all interconnected to impact our lives and the decisions we make on a daily basis, making them impossible to tie to a single topic.
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The preliminary objectives of the study are to understand and develop the evidence-based tools and interventions for the control and prevention of malaria in different sites of the INDIA. Alongside, with the help of next-generation genomics study, the team has studied the antimalarial drug resistance in India. Further, he has extended his research in the development of Humanized mice for the study of liver-stage malaria and identification of molecular marker(s) for the Artemisinin resistance. At present, his research focuses on understanding the role of B cells in the activation of CD8+ T cells in malaria. Received the CSIR-SRF (Senior Research Fellow) award-2018, FIMSA (Federation of Immunological Societies of Asia-Oceania) Travel Bursary award to attend the IUIS-IIS-FIMSA Immunology course-2019',institutionString:"Nirma University",institution:{name:"Nirma University",country:{name:"India"}}},{id:"334383",title:"Ph.D.",name:"Simone",middleName:"Ulrich",surname:"Ulrich Picoli",slug:"simone-ulrich-picoli",fullName:"Simone Ulrich Picoli",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/334383/images/15919_n.jpg",biography:"Graduated in Pharmacy from Universidade Luterana do Brasil (1999), Master in Agricultural and Environmental Microbiology from Federal University of Rio Grande do Sul (2002), Specialization in Clinical Microbiology from Universidade de São Paulo, USP (2007) and PhD in Sciences in Gastroenterology and Hepatology (2012). She is currently an Adjunct Professor at Feevale University in Medicine and Biomedicine courses and a permanent professor of the Academic Master\\'s Degree in Virology. She has experience in the field of Microbiology, with an emphasis on Bacteriology, working mainly on the following topics: bacteriophages, bacterial resistance, clinical microbiology and food microbiology.",institutionString:null,institution:{name:"Universidade Feevale",country:{name:"Brazil"}}},{id:"229220",title:"Dr.",name:"Amjad",middleName:"Islam",surname:"Aqib",slug:"amjad-aqib",fullName:"Amjad Aqib",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/229220/images/system/229220.png",biography:"Dr. Amjad Islam Aqib obtained a DVM and MSc (Hons) from University of Agriculture Faisalabad (UAF), Pakistan, and a PhD from the University of Veterinary and Animal Sciences Lahore, Pakistan. Dr. Aqib joined the Department of Clinical Medicine and Surgery at UAF for one year as an assistant professor where he developed a research laboratory designated for pathogenic bacteria. Since 2018, he has been Assistant Professor/Officer in-charge, Department of Medicine, Manager Research Operations and Development-ORIC, and President One Health Club at Cholistan University of Veterinary and Animal Sciences, Bahawalpur, Pakistan. He has nearly 100 publications to his credit. His research interests include epidemiological patterns and molecular analysis of antimicrobial resistance and modulation and vaccine development against animal pathogens of public health concern.",institutionString:"Cholistan University of Veterinary and Animal Sciences",institution:{name:"University of Agriculture Faisalabad",country:{name:"Pakistan"}}},{id:"333753",title:"Dr.",name:"Rais",middleName:null,surname:"Ahmed",slug:"rais-ahmed",fullName:"Rais Ahmed",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/333753/images/20168_n.jpg",biography:null,institutionString:null,institution:{name:"University of Agriculture Faisalabad",country:{name:"Pakistan"}}},{id:"62900",title:"Prof.",name:"Fethi",middleName:null,surname:"Derbel",slug:"fethi-derbel",fullName:"Fethi Derbel",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/62900/images/system/62900.jpeg",biography:"Professor Fethi Derbel was born in 1960 in Tunisia. He received his medical degree from the Sousse Faculty of Medicine at Sousse, University of Sousse, Tunisia. He completed his surgical residency in General Surgery at the University Hospital Farhat Hached of Sousse and was a member of the Unit of Liver Transplantation in the University of Rennes, France. He then worked in the Department of Surgery at the Sahloul University Hospital in Sousse. Professor Derbel is presently working at the Clinique les Oliviers, Sousse, Tunisia. His hospital activities are mostly concerned with laparoscopic, colorectal, pancreatic, hepatobiliary, and gastric surgery. He is also very interested in hernia surgery and performs ventral hernia repairs and inguinal hernia repairs. He has been a member of the GREPA and Tunisian Hernia Society (THS). During his residency, he managed patients suffering from diabetic foot, and he was very interested in this pathology. For this reason, he decided to coordinate a book project dealing with the diabetic foot. Professor Derbel has published many articles in journals and collaborates intensively with IntechOpen Access Publisher as an editor.",institutionString:"Clinique les Oliviers",institution:null},{id:"300144",title:"Dr.",name:"Meriem",middleName:null,surname:"Braiki",slug:"meriem-braiki",fullName:"Meriem Braiki",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/300144/images/system/300144.jpg",biography:"Dr. Meriem Braiki is a specialist in pediatric surgeon from Tunisia. She was born in 1985. She received her medical degree from the University of Medicine at Sousse, Tunisia. She achieved her surgical residency training periods in Pediatric Surgery departments at University Hospitals in Monastir, Tunis and France.\r\nShe is currently working at the Pediatric surgery department, Sidi Bouzid Hospital, Tunisia. Her hospital activities are mostly concerned with laparoscopic, parietal, urological and digestive surgery. She has published several articles in diffrent journals.",institutionString:"Sidi Bouzid Regional Hospital",institution:null},{id:"229481",title:"Dr.",name:"Erika M.",middleName:"Martins",surname:"de Carvalho",slug:"erika-m.-de-carvalho",fullName:"Erika M. de Carvalho",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/229481/images/6397_n.jpg",biography:null,institutionString:null,institution:{name:"Oswaldo Cruz Foundation",country:{name:"Brazil"}}},{id:"186537",title:"Prof.",name:"Tonay",middleName:null,surname:"Inceboz",slug:"tonay-inceboz",fullName:"Tonay Inceboz",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/186537/images/system/186537.jfif",biography:"I was graduated from Ege University of Medical Faculty (Turkey) in 1988 and completed his Med. PhD degree in Medical Parasitology at the same university. I became an Associate Professor in 2008 and Professor in 2014. I am currently working as a Professor at the Department of Medical Parasitology at Dokuz Eylul University, Izmir, Turkey.\n\nI have given many lectures, presentations in different academic meetings. I have more than 60 articles in peer-reviewed journals, 18 book chapters, 1 book editorship.\n\nMy research interests are Echinococcus granulosus, Echinococcus multilocularis (diagnosis, life cycle, in vitro and in vivo cultivation), and Trichomonas vaginalis (diagnosis, PCR, and in vitro cultivation).",institutionString:"Dokuz Eylül University",institution:{name:"Dokuz Eylül University",country:{name:"Turkey"}}},{id:"71812",title:"Prof.",name:"Hanem Fathy",middleName:"Fathy",surname:"Khater",slug:"hanem-fathy-khater",fullName:"Hanem Fathy Khater",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/71812/images/1167_n.jpg",biography:"Prof. Khater is a Professor of Parasitology at Benha University, Egypt. She studied for her doctoral degree, at the Department of Entomology, College of Agriculture, Food and Natural Resources, University of Missouri, Columbia, USA. She has completed her Ph.D. degrees in Parasitology in Egypt, from where she got the award for “the best scientific Ph.D. dissertation”. She worked at the School of Biological Sciences, Bristol, England, the UK in controlling insects of medical and veterinary importance as a grant from Newton Mosharafa, the British Council. Her research is focused on searching of pesticides against mosquitoes, house flies, lice, green bottle fly, camel nasal botfly, soft and hard ticks, mites, and the diamondback moth as well as control of several parasites using safe and natural materials to avoid drug resistances and environmental contamination.",institutionString:null,institution:{name:"Banha University",country:{name:"Egypt"}}},{id:"99780",title:"Prof.",name:"Omolade",middleName:"Olayinka",surname:"Okwa",slug:"omolade-okwa",fullName:"Omolade Okwa",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/99780/images/system/99780.jpg",biography:"Omolade Olayinka Okwa is presently a Professor of Parasitology at Lagos State University, Nigeria. She has a PhD in Parasitology (1997), an MSc in Cellular Parasitology (1992), and a BSc (Hons) Zoology (1990) all from the University of Ibadan, Nigeria. She teaches parasitology at the undergraduate and postgraduate levels. She was a recipient of a Commonwealth fellowship supported by British Council tenable at the Centre for Entomology and Parasitology (CAEP), Keele University, United Kingdom between 2004 and 2005. She was awarded an Honorary Visiting Research Fellow at the same university from 2005 to 2007. \nShe has been an external examiner to the Department of Veterinary Microbiology and Parasitology, University of Ibadan, MSc programme between 2010 and 2012. She is a member of the Nigerian Society of Experimental Biology (NISEB), Parasitology and Public Health Society of Nigeria (PPSN), Science Association of Nigeria (SAN), Zoological Society of Nigeria (ZSN), and is Vice Chairperson of the Organisation of Women in Science (OWSG), LASU chapter. She served as Head of Department of Zoology and Environmental Biology, Lagos State University from 2007 to 2010 and 2014 to 2016. She is a reviewer for several local and international journals such as Unilag Journal of Science, Libyan Journal of Medicine, Journal of Medicine and Medical Sciences, and Annual Research and Review in Science. \nShe has authored 45 scientific research publications in local and international journals, 8 scientific reviews, 4 books, and 3 book chapters, which includes the books “Malaria Parasites” and “Malaria” which are IntechOpen access publications.",institutionString:"Lagos State University",institution:{name:"Lagos State University",country:{name:"Nigeria"}}},{id:"273100",title:"Dr.",name:"Vijay",middleName:null,surname:"Gayam",slug:"vijay-gayam",fullName:"Vijay Gayam",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/273100/images/system/273100.jpeg",biography:"Dr. Vijay Bhaskar Reddy Gayam is currently practicing as an internist at Interfaith Medical Center in Brooklyn, New York, USA. He is also a Clinical Assistant Professor at the SUNY Downstate University Hospital and Adjunct Professor of Medicine at the American University of Antigua. He is a holder of an M.B.B.S. degree bestowed to him by Osmania Medical College and received his M.D. at Interfaith Medical Center. His career goals thus far have heavily focused on direct patient care, medical education, and clinical research. He currently serves in two leadership capacities; Assistant Program Director of Medicine at Interfaith Medical Center and as a Councilor for the American\r\nFederation for Medical Research. As a true academician and researcher, he has more than 50 papers indexed in international peer-reviewed journals. He has also presented numerous papers in multiple national and international scientific conferences. His areas of research interest include general internal medicine, gastroenterology and hepatology. He serves as an editor, editorial board member and reviewer for multiple international journals. His research on Hepatitis C has been very successful and has led to multiple research awards, including the 'Equity in Prevention and Treatment Award” from the New York Department of Health Viral Hepatitis Symposium (2018) and the 'Presidential Poster Award” awarded to him by the American College of Gastroenterology (2018). He was also awarded 'Outstanding Clinician in General Medicine” by Venus International Foundation for his extensive research expertise and services, perform over and above the standard expected in the advancement of healthcare, patient safety and quality of care.",institutionString:"Interfaith Medical Center",institution:{name:"Interfaith Medical Center",country:{name:"United States of America"}}},{id:"93517",title:"Dr.",name:"Clement",middleName:"Adebajo",surname:"Meseko",slug:"clement-meseko",fullName:"Clement Meseko",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/93517/images/system/93517.jpg",biography:"Dr. Clement Meseko obtained DVM and PhD degree in Veterinary Medicine and Virology respectively. He has worked for over 20 years in both private and public sectors including the academia, contributing to knowledge and control of infectious disease. Through the application of epidemiological skill, classical and molecular virological skills, he investigates viruses of economic and public health importance for the mitigation of the negative impact on people, animal and the environment in the context of Onehealth. \r\nDr. Meseko’s field experience on animal and zoonotic diseases and pathogen dynamics at the human-animal interface over the years shaped his carrier in research and scientific inquiries. He has been part of the investigation of Highly Pathogenic Avian Influenza incursions in sub Saharan Africa and monitors swine Influenza (Pandemic influenza Virus) agro-ecology and potential for interspecies transmission. He has authored and reviewed a number of journal articles and book chapters.",institutionString:"National Veterinary Research Institute",institution:{name:"National Veterinary Research Institute",country:{name:"Nigeria"}}},{id:"158026",title:"Prof.",name:"Shailendra K.",middleName:null,surname:"Saxena",slug:"shailendra-k.-saxena",fullName:"Shailendra K. Saxena",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRET3QAO/Profile_Picture_2022-05-10T10:10:26.jpeg",biography:"Professor Dr. Shailendra K. Saxena is a vice dean and professor at King George's Medical University, Lucknow, India. His research interests involve understanding the molecular mechanisms of host defense during human viral infections and developing new predictive, preventive, and therapeutic strategies for them using Japanese encephalitis virus (JEV), HIV, and emerging viruses as a model via stem cell and cell culture technologies. His research work has been published in various high-impact factor journals (Science, PNAS, Nature Medicine) with a high number of citations. He has received many awards and honors in India and abroad including various Young Scientist Awards, BBSRC India Partnering Award, and Dr. JC Bose National Award of Department of Biotechnology, Min. of Science and Technology, Govt. of India. Dr. Saxena is a fellow of various international societies/academies including the Royal College of Pathologists, United Kingdom; Royal Society of Medicine, London; Royal Society of Biology, United Kingdom; Royal Society of Chemistry, London; and Academy of Translational Medicine Professionals, Austria. He was named a Global Leader in Science by The Scientist. He is also an international opinion leader/expert in vaccination for Japanese encephalitis by IPIC (UK).",institutionString:"King George's Medical University",institution:{name:"King George's Medical University",country:{name:"India"}}},{id:"94928",title:"Dr.",name:"Takuo",middleName:null,surname:"Mizukami",slug:"takuo-mizukami",fullName:"Takuo Mizukami",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/94928/images/6402_n.jpg",biography:null,institutionString:null,institution:{name:"National Institute of Infectious Diseases",country:{name:"Japan"}}},{id:"233433",title:"Dr.",name:"Yulia",middleName:null,surname:"Desheva",slug:"yulia-desheva",fullName:"Yulia Desheva",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/233433/images/system/233433.png",biography:"Dr. Yulia Desheva is a leading researcher at the Institute of Experimental Medicine, St. Petersburg, Russia. She is a professor in the Stomatology Faculty, St. Petersburg State University. She has expertise in the development and evaluation of a wide range of live mucosal vaccines against influenza and bacterial complications. Her research interests include immunity against influenza and COVID-19 and the development of immunization schemes for high-risk individuals.",institutionString:'Federal State Budgetary Scientific Institution "Institute of Experimental Medicine"',institution:null},{id:"238958",title:"Mr.",name:"Atamjit",middleName:null,surname:"Singh",slug:"atamjit-singh",fullName:"Atamjit Singh",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/238958/images/6575_n.jpg",biography:null,institutionString:null,institution:null},{id:"252058",title:"M.Sc.",name:"Juan",middleName:null,surname:"Sulca",slug:"juan-sulca",fullName:"Juan Sulca",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/252058/images/12834_n.jpg",biography:null,institutionString:null,institution:null},{id:"191392",title:"Dr.",name:"Marimuthu",middleName:null,surname:"Govindarajan",slug:"marimuthu-govindarajan",fullName:"Marimuthu Govindarajan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/191392/images/5828_n.jpg",biography:"Dr. M. Govindarajan completed his BSc degree in Zoology at Government Arts College (Autonomous), Kumbakonam, and MSc, MPhil, and PhD degrees at Annamalai University, Annamalai Nagar, Tamil Nadu, India. He is serving as an assistant professor at the Department of Zoology, Annamalai University. His research interests include isolation, identification, and characterization of biologically active molecules from plants and microbes. He has identified more than 20 pure compounds with high mosquitocidal activity and also conducted high-quality research on photochemistry and nanosynthesis. He has published more than 150 studies in journals with impact factor and 2 books in Lambert Academic Publishing, Germany. He serves as an editorial board member in various national and international scientific journals.",institutionString:null,institution:null},{id:"274660",title:"Dr.",name:"Damodar",middleName:null,surname:"Paudel",slug:"damodar-paudel",fullName:"Damodar Paudel",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/274660/images/8176_n.jpg",biography:"I am DrDamodar Paudel,currently working as consultant Physician in Nepal police Hospital.",institutionString:null,institution:null},{id:"241562",title:"Dr.",name:"Melvin",middleName:null,surname:"Sanicas",slug:"melvin-sanicas",fullName:"Melvin Sanicas",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/241562/images/6699_n.jpg",biography:null,institutionString:null,institution:null},{id:"117248",title:"Dr.",name:"Andrew",middleName:null,surname:"Macnab",slug:"andrew-macnab",fullName:"Andrew Macnab",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of British Columbia",country:{name:"Canada"}}},{id:"322007",title:"Dr.",name:"Maria Elizbeth",middleName:null,surname:"Alvarez-Sánchez",slug:"maria-elizbeth-alvarez-sanchez",fullName:"Maria Elizbeth Alvarez-Sánchez",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"Universidad Autónoma de la Ciudad de México",country:{name:"Mexico"}}},{id:"337443",title:"Dr.",name:"Juan",middleName:null,surname:"A. Gonzalez-Sanchez",slug:"juan-a.-gonzalez-sanchez",fullName:"Juan A. Gonzalez-Sanchez",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Puerto Rico System",country:{name:"United States of America"}}},{id:"337446",title:"Dr.",name:"Maria",middleName:null,surname:"Zavala-Colon",slug:"maria-zavala-colon",fullName:"Maria Zavala-Colon",position:null,profilePictureURL:"//cdnintech.com/web/frontend/www/assets/author.svg",biography:null,institutionString:null,institution:{name:"University of Puerto Rico, Medical Sciences Campus",country:{name:"United States of America"}}}]}},subseries:{item:{id:"27",type:"subseries",title:"Multi-Agent Systems",keywords:"Collaborative Intelligence, Learning, Distributed Control System, Swarm Robotics, Decision Science, Software Engineering",scope:"Multi-agent systems are recognised as a state of the art field in Artificial Intelligence studies, which is popular due to the usefulness in facilitation capabilities to handle real-world problem-solving in a distributed fashion. The area covers many techniques that offer solutions to emerging problems in robotics and enterprise-level software systems. Collaborative intelligence is highly and effectively achieved with multi-agent systems. Areas of application include swarms of robots, flocks of UAVs, collaborative software management. Given the level of technological enhancements, the popularity of machine learning in use has opened a new chapter in multi-agent studies alongside the practical challenges and long-lasting collaboration issues in the field. It has increased the urgency and the need for further studies in this field. We welcome chapters presenting research on the many applications of multi-agent studies including, but not limited to, the following key areas: machine learning for multi-agent systems; modeling swarms robots and flocks of UAVs with multi-agent systems; decision science and multi-agent systems; software engineering for and with multi-agent systems; tools and technologies of multi-agent systems.",coverUrl:"https://cdn.intechopen.com/series_topics/covers/27.jpg",hasOnlineFirst:!0,hasPublishedBooks:!1,annualVolume:11423,editor:{id:"148497",title:"Dr.",name:"Mehmet",middleName:"Emin",surname:"Aydin",slug:"mehmet-aydin",fullName:"Mehmet Aydin",profilePictureURL:"https://mts.intechopen.com/storage/users/148497/images/system/148497.jpg",biography:"Dr. Mehmet Emin Aydin is a Senior Lecturer with the Department of Computer Science and Creative Technology, the University of the West of England, Bristol, UK. His research interests include swarm intelligence, parallel and distributed metaheuristics, machine learning, intelligent agents and multi-agent systems, resource planning, scheduling and optimization, combinatorial optimization. Dr. Aydin is currently a Fellow of Higher Education Academy, UK, a member of EPSRC College, a senior member of IEEE and a senior member of ACM. In addition to being a member of advisory committees of many international conferences, he is an Editorial Board Member of various peer-reviewed international journals. He has served as guest editor for a number of special issues of peer-reviewed international journals.",institutionString:null,institution:{name:"University of the West of England",institutionURL:null,country:{name:"United Kingdom"}}},editorTwo:null,editorThree:null,series:{id:"14",title:"Artificial Intelligence",doi:"10.5772/intechopen.79920",issn:"2633-1403"},editorialBoard:[{id:"275140",title:"Dr.",name:"Dinh Hoa",middleName:null,surname:"Nguyen",slug:"dinh-hoa-nguyen",fullName:"Dinh Hoa Nguyen",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRbnKQAS/Profile_Picture_1622204093453",institutionString:null,institution:{name:"Kyushu University",institutionURL:null,country:{name:"Japan"}}},{id:"20259",title:"Dr.",name:"Hongbin",middleName:null,surname:"Ma",slug:"hongbin-ma",fullName:"Hongbin Ma",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRhDJQA0/Profile_Picture_2022-05-02T08:25:21.jpg",institutionString:null,institution:{name:"Beijing Institute of Technology",institutionURL:null,country:{name:"China"}}},{id:"28640",title:"Prof.",name:"Yasushi",middleName:null,surname:"Kambayashi",slug:"yasushi-kambayashi",fullName:"Yasushi Kambayashi",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002aYOQxQAO/Profile_Picture_1625660525470",institutionString:null,institution:{name:"Nippon Institute of Technology",institutionURL:null,country:{name:"Japan"}}}]},onlineFirstChapters:{paginationCount:7,paginationItems:[{id:"82777",title:"Sustainability and Social Investment: Community Microhydropower Systems in the Dominican Republic",doi:"10.5772/intechopen.105995",signatures:"Michela Izzo, Alberto Sánchez and Rafael Fonseca",slug:"sustainability-and-social-investment-community-microhydropower-systems-in-the-dominican-republic",totalDownloads:4,totalCrossrefCites:0,totalDimensionsCites:0,authors:null,book:{title:"Globalization and Sustainability - Recent Advances, New Perspectives and Emerging Issues",coverURL:"https://cdn.intechopen.com/books/images_new/11476.jpg",subseries:{id:"91",title:"Sustainable Economy and Fair Society"}}},{id:"82387",title:"Kept Promises? 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