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Gertz MA. Is There Still a Role for Stem Cell Transplantation in Multiple Myeloma? Hematol Oncol Clin North Am 2024; 38:407-420. [PMID: 38151401 DOI: 10.1016/j.hoc.2023.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2023]
Abstract
No therapy in multiple myeloma has been as extensively investigated as stem cell transplantation following high-dose chemotherapy. A search of the national library of medicine in February 2023 revealed over 27,000 publications covering stem cell transplantation. No other treatment for multiple myeloma has been so vigorously investigated. However, given the rapid advances seen in the treatment of multiple myeloma, it is legitimate to ask whether the technique first introduced in 1983 by Thomas McIlwain still has relevance. In 1984,Barlogie introduced infusional vincristine, doxorubicin, and dexamethasone and in 1986 published a first series on high-dose therapy with autologous marrow-derived stem cells. At this point, the only available therapies were melphalan, prednisone, other intensive steroids such as methylprednisolone, and interferon. Cyclophosphamide was used both orally and parenterally. VBMCP was introduced as a combination therapy at Memorial Hospital subsequently shown not to be superior to melphalan and prednisone.
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Affiliation(s)
- Morie A Gertz
- Mayo Clinic, 200 SW First street, Rochester, MN 55905, USA.
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Bostankolu Değirmenci B, Yegin ZA, Akdemir ÜÖ, Dede A, Gündem GG, Özkurt ZN, Atay LÖ, Yağcı M. Clinical factors associated with autologous stem cell transplantation outcomes in multiple myeloma: upfront transplant with MEL200 remains the standard of care. Ann Hematol 2024; 103:269-283. [PMID: 37880484 DOI: 10.1007/s00277-023-05511-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 10/12/2023] [Indexed: 10/27/2023]
Abstract
Autologous stem cell transplantation (ASCT) remains the mainstay of the treatment in newly diagnosed transplant-eligible multiple myeloma (MM) patients. This retrospective study was performed to investigate the potential prognostic markers which may modify transplant course in a total of 256 ASCT recipients [median age: 58 (30-74) years; male/female: 138/118], including pretransplant (PET0) and day + 60 (PET2) PET/CT assessments and comparative analysis of melphalan (Mel) dose. Better responses with significantly higher complete response/very good partial response rates were achieved in patients who proceeded to transplant within 301 days from diagnosis (p < 0.001). Patients who had received < 1.5 lines of treatment prior to transplant had significantly higher probability of overall survival (OS) (p = 0.004) and progression-free survival (PFS) (p < 0.001). The probability of OS was significantly higher in patients with low Eastern Cooperative Oncology Group (ECOG) performance score (PS = 0-1) (p = 0.003) and HCT-Comorbidity Index (HCT-CI = 0) (p = 0.011). The number of involved areas (p = 0.028) and maximum standardized uptake value (SUVmax) (p = 0.021) in PET0 represented significant impact on OS. The probabilities of OS (p < 0.001) and PFS (p = 0.01) were significantly better with Mel200 mg/m2 conditioning compared to Mel140 mg/m2. Conditioning with Mel200 mg/m2, early and upfront ASCT and low pretransplant treatment burden were found to be significantly associated with ASCT outcome in MM patients. Despite its predictor impact on survival and prognosis, further studies are warranted to standardize PET/CT-based response assessments before being used as a guide for treatment decisions in clinical practice.
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Affiliation(s)
| | - Zeynep Arzu Yegin
- Department of Hematology, Gazi University Faculty of Medicine, Ankara, Turkey.
| | - Ümit Özgür Akdemir
- Department of Nuclear Medicine, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Ali Dede
- Department of Internal Medicine, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Gonca Gül Gündem
- Department of Internal Medicine, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Zübeyde Nur Özkurt
- Department of Hematology, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Lütfiye Özlem Atay
- Department of Nuclear Medicine, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Münci Yağcı
- Department of Hematology, Gazi University Faculty of Medicine, Ankara, Turkey
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3
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Mo CC, Hartley-Brown MA, Midha S, Richardson PG. Upfront or Deferred Autologous Stem Cell Transplantation for Newly Diagnosed Multiple Myeloma in the Era of Triplet and Quadruplet Induction and Minimal Residual Disease/Risk-Adapted Therapy. Cancers (Basel) 2023; 15:5709. [PMID: 38136255 PMCID: PMC10741557 DOI: 10.3390/cancers15245709] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 11/23/2023] [Accepted: 11/28/2023] [Indexed: 12/24/2023] Open
Abstract
The standards of care for the initial treatment of patients with newly diagnosed multiple myeloma (NDMM) who are eligible for high-dose melphalan and autologous stem cell transplantation (HDM-ASCT) include highly active triplet and quadruplet regimens based on proteasome inhibitors, immunomodulatory drugs, and monoclonal antibodies. These regimens are resulting in improved outcomes and increasingly high rates of minimal residual disease (MRD)-negative responses without HDM-ASCT as part of the upfront therapy. Furthermore, recent randomized studies have shown that, while transplant-based approaches as a frontline therapy result in significantly longer progression-free survival compared to non-transplant approaches, this has not translated into an overall survival benefit. Given these developments, and in the context of the treatment burden of undergoing HDM-ASCT, in addition to the acute toxicities and long-term sequelae of HDM, which are associated with the genotoxicity of melphalan, there is an increasing rationale for considering deferring upfront HDM-ASCT in select transplant-eligible patients and saving it as a treatment option for later salvage therapy. Here, we review the latest clinical trial data on upfront or deferred HDM-ASCT and on the activity of quadruplet induction regimens, including rates of MRD-negative responses, and summarize emerging treatment approaches in the upfront setting such as the use of MRD-directed therapy and alternatives to HDM-ASCT.
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Affiliation(s)
| | | | | | - Paul G. Richardson
- Department of Medical Oncology, Dana-Farber Cancer Institute, Jerome Lipper Center for Multiple Myeloma Research, Harvard Medical School, 450 Brookline Avenue, Dana 1B02, Boston, MA 02115, USA; (C.C.M.); (M.A.H.-B.); (S.M.)
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João C, Bergantim R, Santos J, Afonso C, Bernardo P, Coelho H, Costa C, Esteves G, Freitas JG, Gerivaz R, Jorge A, Macedo A, Montalvão A, Neves M, Pedrosa CL, Pereira S, Roque A, Seabra P, M Silva H, Silveira MP, Tomé A, Trigo F, Sarmento AB, Lúcio P, Geraldes C. [Multiple Myeloma Treatment Guidelines by the Portuguese Group of Multiple Myeloma]. ACTA MEDICA PORT 2023; 36:517-526. [PMID: 37429590 DOI: 10.20344/amp.19037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Accepted: 04/11/2023] [Indexed: 07/12/2023]
Abstract
The treatment of multiple myeloma has profoundly changed with the introduction of several innovative therapies. The optimization of therapeutic sequencing through the combined use of the various drugs developed in recent years and the attention given to the characteristics of patients have allowed the reduction of toxicities and increased survival and quality of life of patients with multiple myeloma. These treatment recommendations from the Portuguese Multiple Myeloma Group offer guidance for first-line treatment and progression/relapse situations. These recommendations are given highlighting the data that justify each choice and referring to the respective levels of evidence that support these options. Whenever possible, the respective national regulatory framework is presented. These recommendations constitute an advance towards the best treatment of multiple myeloma in Portugal.
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Affiliation(s)
- Cristina João
- Serviço de Hemato-Oncologia. Fundação Champalimaud. Lisboa; NOVA Medical School. Universidade NOVA de Lisboa. Lisboa. Portugal
| | - Rui Bergantim
- Serviço de Hematologia. Centro Hospitalar São João. Porto; i3S - Instituto de Investigação e Inovação em Saúde. Universidade do Porto. Porto; Cancer Drug Resistance Group. IPATIMUP - Instituto the Patologia Molecular e Imunologia. Universidade do Porto. Porto. Portugal
| | - Joana Santos
- Serviço de Hematologia. Centro Hospitalar Lisboa Central. Lisboa. Portugal
| | - Celina Afonso
- Serviço de Hematologia Clínica. Centro Hospitalar Lisboa Ocidental. Lisboa. Portugal
| | - Paulo Bernardo
- Serviço de Hematologia Clínica. Hospital da Luz Lisboa. Lisboa. Portugal
| | - Henrique Coelho
- Serviço de Hematologia Clínica. Centro Hospitalar Vila Nova Gaia. Gaia. Portugal
| | - Carlos Costa
- Hematologia Clínica. Instituto CUF Oncologia. Lisboa. Portugal
| | - Graça Esteves
- Serviço de Hematologia e Transplante de Medula. Centro Hospitalar Universitário Lisboa Norte. Lisboa. Portugal
| | | | - Rita Gerivaz
- Serviço de Hematologia. Hospital Garcia de Orta. Almada. Portugal
| | - Ana Jorge
- Serviço de Hematologia Clínica. Centro Hospitalar Lisboa Ocidental. Lisboa. Portugal
| | - Ana Macedo
- Serviço de Hematologia. Centro Hospitalar Universitário do Algarve. Algarve; Faculdade de Ciências da Saúde. Universidade da Beira Interior. Covilhã. Portugal
| | - Ana Montalvão
- Unidade de Hematologia-Oncologia. Unidade Local de Saúde do Baixo Alentejo. Beja; Hospital de José Joaquim Fernandes. Beja. Portugal
| | - Manuel Neves
- Serviço de Hemato-Oncologia. Fundação Champalimaud. Lisboa. Portugal
| | - Claúdia L Pedrosa
- Serviço de Hematologia Clínica. Centro Hospitalar Universitário do Porto. Porto. Portugal
| | - Susana Pereira
- Serviço de Hematologia. Hospital Santo António dos Capuchos. Centro Hospitalar Universitário Lisboa Central. Lisboa. Portugal
| | - Adriana Roque
- Serviço de Hematologia Clínica. Centro Hospitalar e Universitário de Coimbra. Coimbra; Instituto de Fisiologia. Faculdade de Medicina. Universidade de Coimbra. Coimbra. Portugal
| | - Patrícia Seabra
- Serviço de Hematologia Clínica. Centro Hospitalar Universitário do Porto. Porto. Portugal
| | - Helena M Silva
- Serviço de Hematologia. Centro Hospitalar Tondela-Viseu. Viseu. Portugal
| | - Maria P Silveira
- Hematologia Clínica. Clínica de Oncologia e Radioterapia. Centro Clínico SAMS. Lisboa; Serviço de Imuno-Hemoterapia. Hospital Prof. Doutor Fernando da Fonseca. Amadora. Portugal
| | - Ana Tomé
- Serviço de Hematologia. Hospital Garcia de Orta. Almada. Portugal
| | - Fernanda Trigo
- Serviço de Hematologia. Centro Hospitalar São João. Porto. Portugal
| | - Ana Bela Sarmento
- Serviço de Hematologia Clínica. Centro Hospitalar e Universitário de Coimbra. Coimbra; Laboratório de Oncobiologia e Hematologia. Clínica Universitária de Hematologia e Instituto de Investigação Clínica e Biomédica de Coimbra. Grupo de Investigação em Ambiente, Genética e Oncobiologia. Faculdade de Medicina. Universidade de Coimbra. Coimbra; Centro Académico Clínico de Coimbra. Coimbra. . Portugal
| | - Paulo Lúcio
- Serviço de Hemato-Oncologia. Fundação Champalimaud. Lisboa. Portugal
| | - Catarina Geraldes
- Serviço de Hematologia Clínica. Centro Hospitalar e Universitário de Coimbra. Coimbra; Laboratório de Oncobiologia e Hematologia. Clínica Universitária de Hematologia e Instituto de Investigação Clínica e Biomédica de Coimbra. Grupo de Investigação em Ambiente, Genética e Oncobiologia. Faculdade de Medicina. Universidade de Coimbra. Coimbra; Centro Académico Clínico de Coimbra. Coimbra. Portugal
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Post Salvage Therapy Autologous Transplant for Relapsed Myeloma, Ongoing Relevance within Modern Treatment Paradigms? CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2023; 23:e97-e106. [PMID: 36564313 DOI: 10.1016/j.clml.2022.11.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 10/20/2022] [Accepted: 11/18/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Salvage transplant has been historically considered effective therapy for myeloma patients relapsing after first transplant, if they achieved adequate remission duration. However, the efficacy of novel agent combinations has called this paradigm into question. MATERIALS AND METHODS We performed a retrospective analysis in a homogeneously treated cohort of 106 patients undergoing ASCT2 at our institution, all of whom received novel agent-based chemotherapy (immunomodulatory agent [IMiD] and/or proteasome inhibitor [PI]) for both induction and relapse. As an exploratory objective we assessed whether predictive thresholds of progression free survival post first transplant (ASCT1) for benefit post ASCT2 vary with use of IMiD maintenance post ASCT1. RESULTS The overall response rate (ORR) was 98% post-ASCT2 and treatment-related mortality (TRM) was low at 1.8%. With a median follow-up of 26 months (range 0.5-85) from ASCT2, median overall survival (OS) is estimated at 80 months (95% CI: ≥ 49-months) and median progression-free survival after ASCT2 (PFS2) at 24 months (95% CI 19-39). PFS post first transplant (PFS1) at >/= 50 months was associated with improved OS. Predictors of PFS2 included PFS1 ≤42 months and progression on IMiD-based maintenance post- ASCT1. CONCLUSION ASCT2 continues to offer acceptable outcomes for most patients treated within modern day treatment paradigms, with longer PFS after ASCT1 and IMiD non-refractory disease being associated with improved outcomes.
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Mouhieddine TH, Moshier E, Thibaud S, Puliafito B, Rattu M, Jakubowski R, Sanchez L, Rossi A, Rodriguez C, Richard S, Cho HJ, Parekh S, Chari A, Steinberg A, Richter J. Bridging advanced myeloma patients to subsequent treatments and clinical trials with classical chemotherapy and stem cell support. Bone Marrow Transplant 2023; 58:80-86. [PMID: 36261708 DOI: 10.1038/s41409-022-01848-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 10/02/2022] [Accepted: 10/06/2022] [Indexed: 01/12/2023]
Abstract
Rapidly progressing relapsed/refractory multiple myeloma (RRMM) patients with compromised marrow have limited treatment options. Thus, non-myeloablative chemotherapy with a stem cell boost (SCB) may provide disease control and hematopoietic improvement as bridge to subsequent therapies. We identified 96 patients who received a SCB between January 2011 and December 2019 at the Mount Sinai Hospital. Patients had a median age of 64 years, received a median of 7 prior lines of therapy and 68 and 42% were triple-class and penta-drug refractory, respectively. Chemotherapy included melphalan (MEL) (n = 16), melphalan + carmustine (BCNU/MEL) (n = 52) or a variant of DCEP (dexamethasone, cyclophosphamide, etoposide, cisplatin) (n = 28). Median time to neutrophil recovery was 10 days and was significantly lower with DCEP (8 days) compared to MEL and BCNU/MEL (10-11 days) (p = 0.0047). Time to progression, progression-free survival and overall survival were 3.19, 2.7 and 8.38 months, respectively. The BCNU/MEL group had the highest response rate of 85% (p = 0.05), clinical benefit rate of 94% (p = 0.0014), progression-free survival of 3.3 months (p = 0.4) and overall survival of 8.7 months (p = 0.5). Sixty-six patients (69%) were bridged to new lines of therapy, including clinical trials. Non-myeloablative chemotherapy with SCB provides rapid disease control and marrow recovery with potential to receive further therapy.
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Affiliation(s)
- Tarek H Mouhieddine
- Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Erin Moshier
- Department of Population Health Science and Policy, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Santiago Thibaud
- Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Benjamin Puliafito
- Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Mohammad Rattu
- Department of Pharmacy, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Rita Jakubowski
- Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Larysa Sanchez
- Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Adriana Rossi
- Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Cesar Rodriguez
- Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Shambavi Richard
- Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Hearn Jay Cho
- Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Samir Parekh
- Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Ajai Chari
- Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Amir Steinberg
- Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Joshua Richter
- Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA.
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Haverkort D, Kersten B, van Rhenen A, van der Velden W, Vonk M. Case report: A successful second autologous hematopoietic stem cell transplantation in refractory systemic sclerosis, with positive effect on skin involvement, pulmonary function and microcirculation. Front Immunol 2022; 13:925776. [PMID: 36505455 PMCID: PMC9727152 DOI: 10.3389/fimmu.2022.925776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 11/07/2022] [Indexed: 11/24/2022] Open
Abstract
Background Systemic sclerosis (SSc) is a complex autoimmune disease characterized by inflammation, vasculopathy and fibrosis of the skin and internal organs. Treatment with autologous hematopoietic cell transplantation (HCT) for progressive SSc has improved overall and event-free survival rates significantly, but unfortunately disease progression after HCT is seen in a subset of patients. Data on the efficacy and safety of second HCT is scarce. Case We present a patient with diffuse cutaneous SSc and associated interstitial lung disease (ILD) who successfully underwent a second HCT for progressive disease five years after a first HCT. We describe changes in skin involvement and pulmonary involvement as well as the changes observed in sequential nailfold microcapillaroscopy (NCM), performed from first presentation up to this moment. Conclusion This case adds to the current limited literature on efficacy and safety of a second HCT in SSc refractory cases. Furthermore it outlines the potential of HCT on amelioration of microvasculopathy in SSc.
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Affiliation(s)
- D.A. Haverkort
- Department of Rheumatology, Radboud University Medical Center, Nijmegen, Netherlands,*Correspondence: D.A. Haverkort,
| | - B.E. Kersten
- Department of Rheumatology, Radboud University Medical Center, Nijmegen, Netherlands
| | - A. van Rhenen
- Department of Hematology, University Medical Center, Utrecht, Netherlands
| | | | - M.C. Vonk
- Department of Rheumatology, Radboud University Medical Center, Nijmegen, Netherlands
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Yan ZL, Wang YW, Chang YJ. Cellular Immunotherapies for Multiple Myeloma: Current Status, Challenges, and Future Directions. Oncol Ther 2022; 10:85-103. [PMID: 35103936 PMCID: PMC9098731 DOI: 10.1007/s40487-022-00186-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Accepted: 01/20/2022] [Indexed: 11/25/2022] Open
Abstract
Multiple myeloma (MM) remains incurable due to relapse, although the use of proteasome inhibitors, immunomodulatory drugs, CD38-targeting antibodies, and autologous stem cell transplantation (auto-SCT) significantly improve the clinical outcomes of patients with newly diagnosed MM. In recent years, the introduction of chimeric antigen receptor T-cell (CAR T-cell) therapy has brought hope to patients with refractory and relapsed MM. The graft-versus-myeloma effect of allogeneic SCT provides the possibility for curing a subset of MM patients. In this review, we summarize the recent advances and challenges of cellular immunotherapies for MM, focusing on auto-SCT, allogeneic SCT, and CAR T-cell approaches. We also discuss future directions, and propose a specific algorithm for cellular therapies for MM and probability of minimal residual disease-directed therapy.
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Affiliation(s)
- Zhi-Ling Yan
- Deparment of Hematology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Yue-Wen Wang
- Peking University People's Hospital & Peking University Institute of Hematology, No 11 Xizhimen South Street, Beijing, 100044, China
- National Clinical Research Center for Hematologic Disease, Beijing, China
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China
- Collaborative Innovation Center of Hematology, Peking University, Beijing, People's Republic of China
| | - Ying-Jun Chang
- Peking University People's Hospital & Peking University Institute of Hematology, No 11 Xizhimen South Street, Beijing, 100044, China.
- National Clinical Research Center for Hematologic Disease, Beijing, China.
- Beijing Key Laboratory of Hematopoietic Stem Cell Transplantation, Beijing, China.
- Collaborative Innovation Center of Hematology, Peking University, Beijing, People's Republic of China.
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