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Ciftciler R, Goker H, Buyukasık Y, Aladag E, Demiroglu H. Impact of Pre-transplant and Post-transplant Remission Status of Patients on Survival in Newly Diagnosed Multiple Myeloma. Indian J Hematol Blood Transfus 2019; 35:655-661. [PMID: 31741617 DOI: 10.1007/s12288-019-01108-7] [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: 10/22/2018] [Accepted: 02/27/2019] [Indexed: 10/27/2022] Open
Abstract
The overall survival (OS) in patients with multiple myeloma (MM) has increased in the last decade due to the introduction of proteasome inhibitors, immunomodulatory drugs and monoclonal antibodies as well as an extensive combination of autologous stem cell transplantation (ASCT) for suitable patients. The objective of this study was to examine the impact of pre-transplant and post-transplant remission status of patients on survival in newly diagnosed multiple myeloma. Two hundred and four patients with newly diagnosed MM who received an ASCT in our HSC transplant center at Hacettepe University Hospital between the years of 2001 and 2018 were evaluated in a retrospective manner. The median follow-up period was 35.9 months (range 4.2-206.4) for the entire group. The 5-year OS for pre-transplant remission status CR/VGPR patients and pre-transplant remission status PR or less patients were 79% and 68%, respectively (p = 0.09). The 5-year PFS for pre-transplant remission status CR/VGPR patients and pre-transplant remission status PR or less patients were 62% and 45%, respectively (p = 0.23). The 5-year OS for post-transplant remission status CR/VGPR group was 72% and for post-transplant remission status PR or less group was 60% (p = 0.02). The 5-year PFS in post-transplant remission status CR/VGPR patients was 48% and post-transplant remission status PR or less patients was 36% (p = 0.03). This study focuses on determination of survival outcome based on the best response obtained before and after ASCT and particularly highlights the significance of reaching CR and VGPR.
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Affiliation(s)
- Rafiye Ciftciler
- Departments of Hematology, Faculty of Medicine, Hacettepe University, 06100 Ankara, Turkey
| | - Hakan Goker
- Departments of Hematology, Faculty of Medicine, Hacettepe University, 06100 Ankara, Turkey
| | - Yahya Buyukasık
- Departments of Hematology, Faculty of Medicine, Hacettepe University, 06100 Ankara, Turkey
| | - Elifcan Aladag
- Departments of Hematology, Faculty of Medicine, Hacettepe University, 06100 Ankara, Turkey
| | - Haluk Demiroglu
- Departments of Hematology, Faculty of Medicine, Hacettepe University, 06100 Ankara, Turkey
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2
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Ripani D, Caldarella C, Za T, Pizzuto DA, Rossi E, De Stefano V, Giordano A. Prognostic significance of normalized FDG-PET parameters in patients with multiple myeloma undergoing induction chemotherapy and autologous hematopoietic stem cell transplantation: a retrospective single-center evaluation. Eur J Nucl Med Mol Imaging 2018; 46:116-128. [PMID: 30054697 DOI: 10.1007/s00259-018-4108-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2018] [Accepted: 07/23/2018] [Indexed: 12/20/2022]
Abstract
PURPOSE The purpose of this study was to determine retrospectively, through a single-center evaluation, whether FDG PET-CT normalized semi-quantitative parameters may predict response to induction chemotherapy (iChT) and hematopoietic stem cell transplantation (HSCT), as well as disease progression and progression-free survival in multiple myeloma (MM) patients, thus becoming a tool of personalized medicine. METHODS Patients undergoing iChT and HSCT with baseline and post-treatment FDG PET-CTs from January 2008 to July 2015 were included. The following baseline and post-treatment parameters were obtained: SUVmax, SUVmean, SUVpeak, MTVsum, TLGsum, rPET (lesion SUVmax/liver SUVmax) and qPET (lesion SUVpeak/liver SUVmean). Baseline-to-post-treatment changes (Δ) were also calculated. Metabolic and clinical laboratory progression or response at follow-up were noted; time-to-metabolic-progression (TMP) was defined as the interval from post-treatment scan to eventual progression at follow-up FDG PET-CTs. Possible association between each functional parameter and metabolic/clinical-laboratory progression or response was determined. Kaplan-Meier curves allowed to depict the TMP trend according to FDG PET-CT parameters. RESULTS Twenty-eight patients were included. Significantly higher ΔrPET and ΔqPET values were observed in ten patients with "metabolic response", with respect to 18 patients having "metabolic progression" (median 0.62 [IQR 0.32 - 1.34] vs median 0.00 [IQR -0.25 - 0.49] for ΔrPET; P = 0.045; median 0.51 [IQR 0.32 - 1.13] vs median 0.00 [IQR -0.31 - 0.67] for ΔqPET; P = 0.035). Neither normalized nor non normalized parameters differed significantly between the 20 patients with "clinical-laboratory response" and the eight patients with "clinical-laboratory progression". ΔrPET value lower than 0.38 and ΔqPET value lower than 0.27 predicted a significantly shorter TMP (P = 0.003 and P = 0.005, respectively). CONCLUSIONS Normalized semi-quantitative parameters are effective in predicting persistent response to treatment and shorter TMP in patients with MM undergoing iChT and HSCT.
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Affiliation(s)
- Daria Ripani
- Istituto di Medicina Nucleare, Fondazione Policlinico Universitario A. Gemelli IRCCS-Università Cattolica del Sacro Cuore, Rome, Italy
| | - Carmelo Caldarella
- U.O.C. Medicina Nucleare e Centro PET-TC, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli, 8, 00168, Rome, Italy.
| | - Tommaso Za
- Istituto di Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Daniele Antonio Pizzuto
- Istituto di Medicina Nucleare, Fondazione Policlinico Universitario A. Gemelli IRCCS-Università Cattolica del Sacro Cuore, Rome, Italy
| | - Elena Rossi
- Istituto di Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS-Università Cattolica del Sacro Cuore, Rome, Italy
| | - Valerio De Stefano
- Istituto di Ematologia, Fondazione Policlinico Universitario A. Gemelli IRCCS-Università Cattolica del Sacro Cuore, Rome, Italy
| | - Alessandro Giordano
- Istituto di Medicina Nucleare, Fondazione Policlinico Universitario A. Gemelli IRCCS-Università Cattolica del Sacro Cuore, Rome, Italy
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Solmaz Medeni Ş, Türkyılmaz D, Acar C, Sevindik ÖG, Yüksel F, Pişkin Ö, Özcan MA, Demirkan F, Ündar B, Alacacıoğlu İ, Özsan GH. Does Reinfusion of Stem Cell Products on Multiple Days Affect Engraftment? Turk J Haematol 2018; 35:271-276. [PMID: 29923493 PMCID: PMC6256826 DOI: 10.4274/tjh.2018.0071] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Objective: High-doses of melphalan treatment with autologous stem cell transplantation in multiple myeloma (MM) remains a major treatment modality in suitable patients. A minimal dose of 2x106/kg CD34+ cells is preferred to achieve engraftment. Some patients need multiple leukapheresis procedures to achieve the necessary number of CD34+ cells, but this can cause a high volume of stem cell product that cannot be given in a single day. Whether or not the number of infusion days affects engraftment has not been studied before. We aimed to evaluate the impact of reinfusion of stem cells on multiple days on engraftment results. Materials and Methods: Demographic features, CD34+ cell doses, neutrophil and platelet engraftment days, hospitalization days, and number of infusion days of 149 autologous transplantations of 143 MM patients were evaluated retrospectively. Results: The data of 143 MM patients who were transplanted were analyzed retrospectively. Median age was 55±8.5 (range: 26-70) years with a male/female ratio of 91/58. Hospitalization days for all patients were 24±6 (range: 14-50) days. Mean CD34+ cell number was (7.5±5.3)x106/kg (range: 1.5-31x106/kg). CD34+ cells were reinfused in 1 day in 80.5% (n=120) of the patients, 2 days in 18.2% of the patients (n=27), and 3 days in 1.3% of the patients (n=2). For 29 patients, reinfusion was applied in more than 1 day because of the high volume of stem cell product. We did not see any dimethyl sulfoxide toxicity, cardiac arrhythmia, or volume overload complications. Hypertensive attacks during infusion were easily controlled by furosemide treatment. In the group with multiple infusions, the infused CD34+ cell numbers had a mean of (4.8±2.8)x106/kg, and in the single infusion group the mean was (8.1±5.5)x106/kg. There were no statistical differences between the two groups regarding platelet and neutrophil engraftment days (p=0.850, r=0.820 and p=0.500, r=0.440). There was no statistical difference between the two groups for hospitalization days (p=0.060, r=0.050). Conclusion: In cases with a high volume of stem cell product to acquire adequate stem cells, reinfusion can be safely applied across multiple days without any delay in engraftment.
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Affiliation(s)
- Şerife Solmaz Medeni
- University of Health Sciences, İzmir Bozyaka Training and Research Hospital, Clinic of Hematology, İzmir, Turkey
| | - Doğuş Türkyılmaz
- Dokuz Eylül University Faculty of Medicine, Department of Hematology, İzmir, Turkey
| | - Celal Acar
- University of Health Sciences, İzmir Bozyaka Training and Research Hospital, Clinic of Hematology, İzmir, Turkey
| | | | - Faize Yüksel
- Dokuz Eylül University Faculty of Medicine, Department of Hematology, İzmir, Turkey
| | - Özden Pişkin
- Dokuz Eylül University Faculty of Medicine, Department of Hematology, İzmir, Turkey
| | - Mehmet Ali Özcan
- Dokuz Eylül University Faculty of Medicine, Department of Hematology, İzmir, Turkey
| | - Fatih Demirkan
- Dokuz Eylül University Faculty of Medicine, Department of Hematology, İzmir, Turkey
| | - Bülent Ündar
- Dokuz Eylül University Faculty of Medicine, Department of Hematology, İzmir, Turkey
| | - İnci Alacacıoğlu
- Dokuz Eylül University Faculty of Medicine, Department of Hematology, İzmir, Turkey
| | - Güner Hayri Özsan
- Dokuz Eylül University Faculty of Medicine, Department of Hematology, İzmir, Turkey
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Randall K, Kaparou M, Xenou E, Paneesha S, Kishore B, Kanellopoulos A, Lovell R, Holder K, Suhr J, Baker L, Ryan L, Nikolousis E. Reduced-intensity conditioning allogeneic transplantation after salvage treatment with DT-PACE in myeloma patients relapsing early after autologous transplant. Eur J Haematol 2017. [PMID: 28632322 DOI: 10.1111/ejh.12917] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE In this retrospective single-centre study, we have looked into the transplant outcomes(overall survival OS, progression-free survival PFS, GvHD) and the role of chimerism, DLI and pretransplant characteristics in patients who had a suboptimal response (<12 months) to an autologous stem cell transplant for myeloma and underwent an alemtuzumab T-cell depleted reduced-intensity allograft(RIC). METHODS Twenty-four patients were salvaged with two cycles of DT-PACE and received a RIC transplant with fludarabine, melphalan and alemtuzumab. All the patients received PBSC grafts, eight patients had a sibling donor, and 16 had a graft from a fully matched unrelated donor. The median follow-up was 65.3 months (6-132 months). RESULTS The median overall survival was 55.4 months. DLI administration was associated with a trend towards better overall survival (P=.05). Disease status at allo-HCT, PR or VGPR, ISS score and CMV serostatus was not significant predictors of OS and PFS. Full donor whole blood chimerism (≥98%) at 3 months post-transplant was associated with PFS (P=.04) but did not have a significant impact on OS(P=.45). CONCLUSION Reduced-intensity alemtuzumab-conditioned allograft for myeloma after DT-PACE salvage chemotherapy is an efficient and low toxicity treatment for those who had a suboptimal response postautologous stem cell transplant for myeloma.
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Affiliation(s)
- Kate Randall
- Haematology Department, Warwick District general hospital, Warwick, UK
| | - Maria Kaparou
- Haematology Department, Heart of England NHS Trust, Birmingham, UK
| | - Evgenia Xenou
- Haematology Department, Heart of England NHS Trust, Birmingham, UK
| | | | - Bhuvan Kishore
- Haematology Department, Heart of England NHS Trust, Birmingham, UK
| | | | - Richard Lovell
- Haematology Department, Heart of England NHS Trust, Birmingham, UK
| | - Kathy Holder
- Haematology Department, Heart of England NHS Trust, Birmingham, UK
| | - Julie Suhr
- Haematology Department, Heart of England NHS Trust, Birmingham, UK
| | - Lynda Baker
- Haematology Department, Heart of England NHS Trust, Birmingham, UK
| | - Lynn Ryan
- Haematology Department, Heart of England NHS Trust, Birmingham, UK
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5
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The effect of salvage autologous stem-cell transplantation on overall survival in patients with relapsed multiple myeloma (final results from BSBMT/UKMF Myeloma X Relapse [Intensive]): a randomised, open-label, phase 3 trial. LANCET HAEMATOLOGY 2016; 3:e340-51. [DOI: 10.1016/s2352-3026(16)30049-7] [Citation(s) in RCA: 91] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2016] [Revised: 05/13/2016] [Accepted: 05/17/2016] [Indexed: 11/21/2022]
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Paviglianiti A, Xavier E, Ruggeri A, Ceballos P, Deconinck E, Cornelissen JJ, Nguyen-Quoc S, Maillard N, Sanz G, Rohrlich PS, Garderet L, Volt F, Rocha V, Kroeger N, Gluckman E, Fegueux N, Mohty M. Outcomes of unrelated cord blood transplantation in patients with multiple myeloma: a survey on behalf of Eurocord, the Cord Blood Committee of Cellular Therapy and Immunobiology Working Party, and the Chronic Leukemia Working Party of the EBMT. Haematologica 2016; 101:1120-7. [PMID: 27229716 DOI: 10.3324/haematol.2015.138917] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Accepted: 05/24/2016] [Indexed: 12/11/2022] Open
Abstract
Although allogeneic stem cell transplantation is not a standard therapy for multiple myeloma, some patients can benefit from this intense therapy. There are few reports on outcomes after umbilical cord blood transplantation in multiple myeloma, and investigation of this procedure is warranted. We retrospectively analyzed 95 patients, 85 with multiple myeloma and 10 with plasma cell leukemia, receiving single or double umbilical cord blood transplantation from 2001 to 2013. Median follow up was 41 months. The majority of patients received a reduced intensity conditioning. The cumulative incidence of neutrophil engraftment was 97%±3% at 60 days, and that of 100-day acute graft-versus-host disease grade II-IV was 41%±5%. Chronic graft-versus-host disease at two years was 22%±4%. Relapse and non-relapse mortality was 47%±5% and 29%±5% at three years, respectively. Three-year progression-free survival and overall survival were 24%±5% and 40%±5%, respectively. Anti-thymocyte globulin was associated with decreased incidence of acute graft-versus-host disease, higher non-relapse mortality, decreased overall and progression-free survival. Patients with high cytogenetic risk had higher relapse, and worse overall and progression-free survival. In conclusion, umbilical cord blood transplantation is feasible for multiple myeloma patients.
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Affiliation(s)
- Annalisa Paviglianiti
- Eurocord, APHP, University Paris Diderot, Hôpital Saint Louis, Paris, France Monacord, Centre Scientifique de Monaco, France
| | - Erick Xavier
- Eurocord, APHP, University Paris Diderot, Hôpital Saint Louis, Paris, France Monacord, Centre Scientifique de Monaco, France
| | - Annalisa Ruggeri
- Eurocord, APHP, University Paris Diderot, Hôpital Saint Louis, Paris, France Monacord, Centre Scientifique de Monaco, France Service d'Hématologie et Thérapie Cellulaire, Hôpital Saint Antoine, AP-HP, Paris, France
| | - Patrice Ceballos
- Département d'Hématologie Clinique, CHU Lapeyronie, Montpellier, France
| | | | - Jan J Cornelissen
- Department of Hematology, Erasmus MC-Daniel den Hoed Cancer Centre, Rotterdam, the Netherlands
| | - Stephanie Nguyen-Quoc
- Department Hematology, University Paris IV, Hôpital la Pitié-Salpêtrière, Paris, France
| | - Natacha Maillard
- Bone Marrow Transplant Unit Clinical Hematology, Hôpital La Miletrie, Poitiers, France
| | - Guillermo Sanz
- Servicio de Hematologia, Hospital Universitario y Politecnico La Fe, Valencia, Spain
| | | | - Laurent Garderet
- Service d'Hématologie et Thérapie Cellulaire, Hôpital Saint Antoine, AP-HP, Paris, France
| | - Fernanda Volt
- Eurocord, APHP, University Paris Diderot, Hôpital Saint Louis, Paris, France Monacord, Centre Scientifique de Monaco, France
| | - Vanderson Rocha
- Eurocord, APHP, University Paris Diderot, Hôpital Saint Louis, Paris, France Monacord, Centre Scientifique de Monaco, France Department Hematology, Churchill Hospital, Oxford, UK
| | - Nicolaus Kroeger
- Dept. Stem Cell Transplantation, University Hospital of Hamburg, Germany
| | - Eliane Gluckman
- Eurocord, APHP, University Paris Diderot, Hôpital Saint Louis, Paris, France Monacord, Centre Scientifique de Monaco, France
| | - Nathalie Fegueux
- Département d'Hématologie Clinique, CHU Lapeyronie, Montpellier, France
| | - Mohamad Mohty
- Service d'Hématologie et Thérapie Cellulaire, Hôpital Saint Antoine, AP-HP, Paris, France INSERM, UMRs 938, Paris, France
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7
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Cornell RF, Kassim AA. Evolving paradigms in the treatment of relapsed/refractory multiple myeloma: increased options and increased complexity. Bone Marrow Transplant 2016; 51:479-91. [PMID: 26726946 PMCID: PMC4827007 DOI: 10.1038/bmt.2015.307] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2015] [Revised: 10/08/2015] [Accepted: 10/22/2015] [Indexed: 12/12/2022]
Abstract
The use of modern therapies such as thalidomide, bortezomib and lenalidomide coupled with upfront high-dose therapy and autologous stem cell transplant (ASCT) has resulted in improved survival in patients with newly diagnosed multiple myeloma (MM). However, patients with relapsed/refractory multiple myeloma (RRMM) often have poorer clinical outcomes and might benefit from novel therapeutic strategies. Emerging therapies, such as deacetylase inhibitors, monoclonal antibodies and new proteasome inhibitors, appear promising and may change the therapeutic landscape in RRMM. A limited number of studies has shown a benefit with salvage ASCT in patients with RRMM, although there remains ongoing debate about its timing and effectiveness. Improvement in transplant outcomes has re-ignited a debate on the timing and possible role for salvage ASCT and allogeneic stem cell transplant in RRMM. As the treatment options for management of patients with RRMM become increasingly complex, physicians must consider both disease- and patient-related factors in choosing the appropriate therapeutic approach, with the goal of improving efficacy while minimizing toxicity.
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Affiliation(s)
- R F Cornell
- Department of Medicine, Division of Hematology/Oncology, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - A A Kassim
- Department of Medicine, Division of Hematology/Oncology, Vanderbilt University School of Medicine, Nashville, TN, USA
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8
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Mai EK, Benner A, Bertsch U, Brossart P, Hänel A, Kunzmann V, Naumann R, Neben K, Egerer G, Ho AD, Hillengass J, Raab MS, Neubauer A, Peyn A, Ko YD, Peter N, Scheid C, Goldschmidt H. Singleversustandem high-dose melphalan followed by autologous blood stem cell transplantation in multiple myeloma: long-term results from the phase III GMMG-HD2 trial. Br J Haematol 2016; 173:731-41. [DOI: 10.1111/bjh.13994] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Accepted: 12/28/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Elias K. Mai
- Department of Internal Medicine V; University Clinic Heidelberg; Heidelberg Germany
| | - Axel Benner
- Division of Biostatistics; German Cancer Research Centre (DKFZ); Heidelberg Germany
| | - Uta Bertsch
- Department of Internal Medicine V; University Clinic Heidelberg; Heidelberg Germany
- Nationales Centrum für Tumorerkrankungen (NCT) Heidelberg; Heidelberg Germany
| | - Peter Brossart
- Medical Clinic and Polyclinic III; University Hospital Bonn; Bonn Germany
| | - Annette Hänel
- Department of Internal Medicine III; Klinikum Chemnitz; Chemnitz Germany
| | - Volker Kunzmann
- Department of Internal Medicine II; University Clinic Würzburg; Würzburg Germany
| | - Ralph Naumann
- Department of Medicine I; University Hospital Dresden Carl Gustav Carus; Dresden Germany
| | - Kai Neben
- Department of Haematology and Oncology; Klinikum Baden Baden; Baden Baden Germany
| | - Gerlinde Egerer
- Department of Internal Medicine V; University Clinic Heidelberg; Heidelberg Germany
| | - Anthony D. Ho
- Department of Internal Medicine V; University Clinic Heidelberg; Heidelberg Germany
| | - Jens Hillengass
- Department of Internal Medicine V; University Clinic Heidelberg; Heidelberg Germany
| | - Marc S. Raab
- Department of Internal Medicine V; University Clinic Heidelberg; Heidelberg Germany
| | - Andreas Neubauer
- Department of Haematology and Oncology; University Clinic Gießen/Marburg; Marburg Germany
| | - Astrid Peyn
- Department of Internal Medicine I; Klinikum Bremen Mitte; Bremen Germany
| | - Yon-Dschun Ko
- Department of Haematology and Oncology; Evangelische Kliniken Bonn; Bonn Germany
| | - Norma Peter
- Department of Internal Medicine II; Carl-Thiem Klinikum Cottbus; Cottbus Germany
| | - Christof Scheid
- Department of Internal Medicine I; University Hospital Köln; Köln Germany
| | - Hartmut Goldschmidt
- Department of Internal Medicine V; University Clinic Heidelberg; Heidelberg Germany
- Nationales Centrum für Tumorerkrankungen (NCT) Heidelberg; Heidelberg Germany
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Abstract
Survival outcomes of patients with Multiple Myeloma (MM) have improved over the last decade due to the introduction of novel agents such as the immunomodulatory drugs thalidomide, lenalidomide (Len) and pomalidomide, and the proteasome inhibitors bortezomib (BTZ) and carfilzomib [1, 2]. However, despite these major advances, MM remains largely incurable and almost all patients relapse and require additional therapy [3]. The successful introduction of next generation novel agents including oral proteasome inhibitors, deacetylase inhibitors, and especially monoclonal antibodies as part of immunotherapy promises to further improve outcome.
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Affiliation(s)
- Paola Neri
- Southern Alberta Cancer Research Institute, University of Calgary, Calgary, AB, Canada
| | - Nizar J Bahlis
- Southern Alberta Cancer Research Institute, University of Calgary, Calgary, AB, Canada
| | - Claudia Paba-Prada
- Jerome Lipper Multiple Myeloma Center, Dana-Farber Cancer Institute, Boston, MA, USA
| | - Paul Richardson
- Jerome Lipper Multiple Myeloma Center, Dana-Farber Cancer Institute, Boston, MA, USA.
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10
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Laubach J, Kumar S. Management of Transplant-Eligible Patients with Newly Diagnosed Multiple Myeloma. Cancer Treat Res 2016; 169:145-167. [PMID: 27696262 DOI: 10.1007/978-3-319-40320-5_9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Treatment approaches for newly diagnosed myeloma have changed considerably during the past decade, along with a better understanding of the disease heterogeneity. Availability of new drug classes such as proteasome inhibitors and immunomodulatory drugs, and use of these drugs in combinations have led to higher response rates and deeper responses in the vast majority of patients with newly diagnosed myeloma. In addition to improved efficacy, these regimens are tolerated better than those with conventional chemotherapy drugs, which have reduced the early mortality seen in MM, while allowing for successful stem cell collection in patients undergoing stem cell transplant consolidation. Ongoing clinical trials with newer drugs such as monoclonal antibodies are being explored as options for newly diagnosed MM. The optimal regimen continues to evolve and is often dictated by the intent to transplant, age and comorbidities. Despite the increasing response rates seen with the new regimens, autologous stem cell transplantation remains an effective modality for consolidation, further deepening the responses seen with the initial therapy. Post-transplant approaches have further added to the efficacy of this platform with both post-transplant consolidation and maintenance demonstrating value in clinical trials. Currently, the combination of an effective initial therapy followed by one or two autologous stem cell transplants, with or without consolidation followed by maintenance appear to provide the maximum benefit in terms of duration of disease control for patients with newly diagnosed MM.
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11
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Singh Abbi KK, Zheng J, Devlin SM, Giralt S, Landau H. Second autologous stem cell transplant: an effective therapy for relapsed multiple myeloma. Biol Blood Marrow Transplant 2014; 21:468-72. [PMID: 25529381 DOI: 10.1016/j.bbmt.2014.11.677] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Accepted: 11/13/2014] [Indexed: 11/29/2022]
Abstract
Therapeutic options for patients with multiple myeloma (MM) whose disease has relapsed after a prior autologous stem cell transplant (ASCT) include an expanding armamentarium of novel agents, often combined with traditional chemotherapy, or a second ASCT, with no clear standard of care. We retrospectively analyzed the outcomes of 75 patients who underwent salvage melphalan-based ASCT for relapsed MM at Memorial Sloan-Kettering Cancer Center between 1995 and 2012. Conditioning was performed with melphalan 200 mg/m(2) (n = 43), 180 mg/m(2) (n = 1), 140 mg/m(2) (n = 22), and 100 mg/m(2) (n = 9). The median age at second ASCT was 59 years (range, 36 to 75), and 58% (n = 35) were men. Of those with available data, 19% had high-risk cytogenetics (including t (4;14), p53 loss, or del 13q by karyotype) at the time of second ASCT. Median interval between first and salvage ASCT was 37.5 months (range, 6.9 to 111.4). Of 72 assessable patients, 57% had chemotherapy-sensitive disease before to salvage ASCT and 43% were chemoresistant. Four patients died within 100 days of ASCT. Response was assessed at 2 to 3 months post-ASCT, and of 71 assessable patients, 82% achieved at least a partial response, 15% had stable disease, and 3% progressed despite salvage ASCT. After salvage ASCT, 38 patients received maintenance therapy and 14 went on to allogeneic ASCT. The median progression-free survival (PFS) after second autograft was 10.1 months (95% confidence interval [CI], 7.6 to 13.4) and median overall survival (OS) 22.7 months (95% CI, 19.2 to 41.2). Patients with chemosensitive relapse had a trend toward better PFS (hazard ratio [HR], .60 [95% CI, .36 to 1.02]; P = .058) and significantly longer OS (HR, .49 [95% CI, .27 to .88]; P = .017) than patients with resistant relapse. Those with high-risk cytogenetics at the time of second ASCT had higher risk of death (HR, 2.98 [95% CI, 1.28 to 6.97]; P = .012) compared with patients with standard-risk cytogenetics. Salvage ASCT is an effective strategy for relapsed MM with chemosensitive disease and results in comparable PFS and OS to other salvage strategies.
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Affiliation(s)
- Kamal Kant Singh Abbi
- Division of Hematology, Oncology and Bone Marrow Transplantation, University of Iowa Hospitals and Clinic, Iowa City, Iowa.
| | - Junting Zheng
- Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Sean M Devlin
- Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, New York
| | - Sergio Giralt
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Heather Landau
- Adult Bone Marrow Transplantation Service, Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York
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High-dose chemotherapy plus autologous stem-cell transplantation as consolidation therapy in patients with relapsed multiple myeloma after previous autologous stem-cell transplantation (NCRI Myeloma X Relapse [Intensive trial]): a randomised, open-label, phase 3 trial. Lancet Oncol 2014; 15:874-85. [PMID: 24948586 DOI: 10.1016/s1470-2045(14)70245-1] [Citation(s) in RCA: 104] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Relapsed multiple myeloma has no standard treatment, and the role of autologous stem-cell transplantation (ASCT) has not been fully defined. We aimed to compare high-dose melphalan plus salvage ASCT with cyclophosphamide in patients with relapsed multiple myeloma who had previously undergone ASCT. METHODS This multicentre, randomised, open-label, phase 3 study recruited patients aged at least 18 years with multiple myeloma who needed treatment for first progressive or relapsed disease at least 18 months after a previous ASCT from 51 centres across the UK. Before randomisation, eligible patients received bortezomib, doxorubicin, and dexamethasone (PAD) induction therapy and then underwent peripheral blood stem-cell mobilisation and harvesting if applicable. Eligible patients (with adequate stem-cell harvest) were randomly assigned (1:1), using an automated telephone randomisation line, to either high-dose melphalan 200 mg/m(2) plus salvage ASCT or oral cyclophosphamide (400mg/m(2) per week for 12 weeks). Randomisation was stratified by length of first remission or plateau and response to PAD re-induction therapy. The primary endpoint was time to disease progression, analysed by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00747877, and EudraCT, number 2006-005890-24. FINDINGS Between April 16, 2008, and Nov 19, 2012, 297 patients were registered, of whom 293 received PAD re-induction therapy. Between Aug 26, 2008, and Nov 16, 2012, 174 patients with sufficient PBSCs were randomised to salvage ASCT (n=89) or cyclophosphamide (n=85). After a median follow-up of 31 months (IQR 19-42), median time to progression was significantly longer in the salvage ASCT than in the cyclophosphamide group (19 months [95% CI 16-25] vs 11 months [9-12]; hazard ratio 0·36 [95% CI 0·25-0·53]; p<0·0001). Frequently reported (in >10% of patients) grade 3-4 adverse events with PAD induction, salvage ASCT, and cyclophosphamide were: neutropenia (125 [43%] of 293 patients after PAD, and 63 [76%] of 83 patients in the salvage ASCT group vs 11 [13%] of 84 patients in the cyclophosphamide group), thrombocytopenia (150 [51%] after PAD, and 60 [72%] vs four [5%], respectively), and peripheral neuropathy (35 [12%] after PAD, and none vs none, respectively). INTERPRETATION This study provides evidence for the improved efficacy of high-dose melphalan plus salvage ASCT when compared with cyclophosphamide in patients with relapsed multiple myeloma eligible for intensive therapy, which might help to guide clinical decisions regarding the management of such patients. FUNDING Cancer Research UK.
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Castelli R, Orofino N, Losurdo A, Gualtierotti R, Cugno M. Choosing treatment options for patients with relapsed/refractory multiple myeloma. Expert Rev Anticancer Ther 2013; 14:199-215. [PMID: 24329153 DOI: 10.1586/14737140.2014.863153] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Multiple myeloma (MM) is a clonal plasma cell disorder that is still incurable using conventional treatments. Over the last decade, advances in front-line therapy have led to an increase in survival, but there are still some doubts in the case of relapsed/refractory disease. We searched the PubMed database for articles on treatment options for patients with relapsed/refractory MM published between 1996 and 2013. These treatments included hematopoietic cell transplantation (HCT), rechallenges using previous chemotherapy regimens, and trials of new regimens. The introduction of new agents such as the immunomodulatory drugs (IMIDs) thalidomide and lenalidomide, and the first-in-its-class proteasome inhibitor bortezomib, has greatly improved clinical outcomes in patients with relapsed/refractory MM, but not all patients respond and those that do may eventually relapse or become refractory to treatment. The challenge is therefore to select the optimal treatment for each patient by balancing efficacy and toxicity. To do this, it is necessary to consider disease-related factors, such as the quality and duration of responses to previous therapies, and the aggressiveness of the relapse, and patient-related factors such as age, comorbidities, performance status, pre-existing toxicities and cytogenetic patterns. The message from the trials reviewed in this article is that the new agents may be used to re-treat relapsed/refractory disease, and that the sequencing of their administration should be modulated on the basis of the various disease and patient-related factors. Moreover, our understanding of the pharmacology and molecular action of the new drugs will contribute to the possibility of developing tailored treatment.
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Affiliation(s)
- Roberto Castelli
- Department of Pathophysiology and Transplantation, Internal Medicine, University of Milan, Milan, Italy
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Castelli R, Gualtierotti R, Orofino N, Losurdo A, Gandolfi S, Cugno M. Current and emerging treatment options for patients with relapsed myeloma. Clin Med Insights Oncol 2013; 7:209-19. [PMID: 24179412 PMCID: PMC3813615 DOI: 10.4137/cmo.s8014] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Multiple myeloma (MM) is a neoplastic disorder. It results from proliferation of clonal plasma cells in bone marrow with production of monoclonal proteins, which are detectable in serum or urine. MM is clinically characterized by destructive bone lesions, anemia, hypercalcemia and renal insufficiency. Its prognosis is severe, with a median survival after diagnosis of approximately 3 years due to frequent relapses. Treatments for patients with relapsed/refractory MM include hematopoietic cell transplantation, a rechallenge using a previous chemotherapy regimen or a trial of a new regimen. The introduction of new drugs such as thalidomide, lenalidomide and bortezomib has markedly improved MM outcomes. When relapse occurs, the clinician's challenge is to select the optimal treatment for each patient while balancing efficacy and toxicity. Patients with indolent relapse can be first treated with a 2-drug or a 3-drug combination. Patients with more aggressive relapse often require therapy with a combination of multiple active agents. Autologous stem cell transplantation should be considered as salvage therapy at first relapse for patients who have cryopreserved stem cells early in the disease course. The aim of this review is to provide an overview on the pharmacological and molecular action of treatments used for patients with relapsed/refractory multiple myeloma.
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Affiliation(s)
- Roberto Castelli
- Internal Medicine, Department of Pathophysiology and Transplantation, University of Milan, and Department of Medicine, IRCCS Fondazione Ca’ Granda Policlinico, Milan, Italy
| | - Roberta Gualtierotti
- Internal Medicine, Department of Pathophysiology and Transplantation, University of Milan, and Department of Medicine, IRCCS Fondazione Ca’ Granda Policlinico, Milan, Italy
| | - Nicola Orofino
- Internal Medicine, Department of Pathophysiology and Transplantation, University of Milan, and Department of Medicine, IRCCS Fondazione Ca’ Granda Policlinico, Milan, Italy
| | - Agnese Losurdo
- Internal Medicine, Department of Pathophysiology and Transplantation, University of Milan, and Department of Medicine, IRCCS Fondazione Ca’ Granda Policlinico, Milan, Italy
| | - Sara Gandolfi
- Internal Medicine, Department of Pathophysiology and Transplantation, University of Milan, and Department of Medicine, IRCCS Fondazione Ca’ Granda Policlinico, Milan, Italy
| | - Massimo Cugno
- Internal Medicine, Department of Pathophysiology and Transplantation, University of Milan, and Department of Medicine, IRCCS Fondazione Ca’ Granda Policlinico, Milan, Italy
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Michaelis LC, Saad A, Zhong X, Le-Rademacher J, Freytes CO, Marks DI, Lazarus HM, Bird JM, Holmberg L, Kamble RT, Kumar S, Lill M, Meehan KR, Saber W, Schriber J, Tay J, Vogl DT, Wirk B, Savani BN, Gale RP, Vesole DH, Schiller GJ, Abidi M, Anderson KC, Nishihori T, Kalaycio ME, Vose JM, Moreb JS, Drobyski W, Munker R, Roy V, Ghobadi A, Holland HK, Nath R, To LB, Maiolino A, Kassim AA, Giralt SA, Landau H, Schouten HC, Maziarz RT, Mikhael J, Kindwall-Keller T, Stiff PJ, Gibson J, Lonial S, Krishnan A, Dispenzieri A, Hari P. Salvage second hematopoietic cell transplantation in myeloma. Biol Blood Marrow Transplant 2013; 19:760-6. [PMID: 23298856 PMCID: PMC3816739 DOI: 10.1016/j.bbmt.2013.01.004] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2012] [Accepted: 01/02/2013] [Indexed: 12/22/2022]
Abstract
Autologous hematopoietic cell transplantation (AHCT) as initial therapy of patients with multiple myeloma (MM) improves survival. However, data to support this approach for relapsed/progressive disease after initial AHCT (AHCT1) are limited. Using Center for International Blood and Marrow Transplant Research data, we report the outcomes of 187 patients who underwent a second AHCT (AHCT2) for the treatment of relapsed/progressive MM. Planned tandem AHCT was excluded. Median age at AHCT2 was 59 years (range, 28 to 72), and median patient follow-up was 47 months (range, 3 to 97). Nonrelapse mortality after AHCT2 was 2% at 1 year and 4% at 3 years. Median interval from AHCT1 to relapse/progression was 18 months, and median interval between transplantations was 32 months. After AHCT2, the incidence of relapse/progression at 1 and 3 years was 51% and 82%, respectively. At 3 years after AHCT2, progression-free survival was 13%, and overall survival was 46%. In multivariate analyses, those relapsing ≥36 months after AHCT1 had superior progression-free (P = .045) and overall survival (P = .019). Patients who underwent AHCT2 after 2004 had superior survival (P = .026). AHCT2 is safe and feasible for disease progression after AHCT1. In this retrospective study, individuals relapsing ≥36 months from AHCT1 derived greater benefit from AHCT2 compared with those with a shorter disease-free interval. Storage of an adequate graft before AHCT1 will ensure that the option of a second autologous transplantation is retained for patients with relapsed/progressive MM.
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Affiliation(s)
| | - Ayman Saad
- University of Alabama, Birmingham, Alabama
| | - Xiaobo Zhong
- Center for International Blood and Marrow Transplant Research, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jennifer Le-Rademacher
- Center for International Blood and Marrow Transplant Research, Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | | | | | | | - Leona Holmberg
- Fred Hutchinson Cancer Research Center, Seattle, Washington
| | - Rammurti T. Kamble
- Baylor College of Medicine Center for Cell and Gene Therapy, Houston, Texas
| | | | - Michael Lill
- Cedars-Sinai Medical Center, Los Angeles, California
| | | | - Wael Saber
- Center for International Blood and Marrow Transplant Research, Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Jason Tay
- University of Ottawa, Ottawa, Canada
| | - Dan T. Vogl
- Abramson Cancer Center University of Pennsylvania Medical Center, Philadelphia, Pennsylvania
| | - Baldeep Wirk
- Shands Healthcare and University of Florida, Gainesville, Florida
| | | | - Robert P. Gale
- Imperial College, Section of Hematology, London, United Kingdom
| | - David H. Vesole
- Hackensack University Medical Center, Hackensack, New Jersey
| | | | - Muneer Abidi
- Kamanos Cancer Institute—Wayne State University, Detroit, Michigan
| | | | - Taiga Nishihori
- H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | | | | | - Jan S. Moreb
- Shands Healthcare and University of Florida, Gainesville, Florida
| | | | - Reinhold Munker
- Louisiana State University Health Sciences Center, Shreveport, Louisiana
| | - Vivek Roy
- Mayo Clinic Jacksonville, Jacksonville, Florida
| | - Armin Ghobadi
- Washington University, St. Louis Children’s Hospital, St. Louis, Missouri
| | - H. Kent Holland
- Blood and Marrow Transplant Program at Northside Hospital, Atlanta, Georgia
| | - Rajneesh Nath
- UMass Memorial Medical Center, Worcester, Massachusetts
| | - L. Bik To
- Royal Adelaide Hospital, Adelaide, Australia
| | - Angelo Maiolino
- Hospital Universitario Clementino Fraga Filho, Rio de Janeiro, Brazil
| | | | | | - Heather Landau
- Memorial Sloan Kettering Cancer Center, New York, New York
| | | | | | - Joseph Mikhael
- Mayo Clinic Arizona and Phoenix Children’s Hospital, Scottsdale, Arizona
| | | | | | - John Gibson
- Royal Prince Alfred Hospital, Institute of Haematology, Camperdown, Australia
| | | | | | | | - Parameswaran Hari
- Center for International Blood and Marrow Transplant Research, Medical College of Wisconsin, Milwaukee, Wisconsin
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Naumann-Winter F, Greb A, Borchmann P, Bohlius J, Engert A, Schnell R. First-line tandem high-dose chemotherapy and autologous stem cell transplantation versus single high-dose chemotherapy and autologous stem cell transplantation in multiple myeloma, a systematic review of controlled studies. Cochrane Database Syst Rev 2012; 10:CD004626. [PMID: 23076906 DOI: 10.1002/14651858.cd004626.pub3] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Several clinical studies have compared single with tandem (also called double) autologous stem cell transplantation (ASCT) as first-line treatment in patients with symptomatic multiple myeloma (MM), one of the leading indications for ASCT worldwide. OBJECTIVES The present Cochrane Review compares tandem autologous stem cell transplantation (TASCT) with single autologous stem cell transplantation (SASCT) as first-line treatment in patients with symptomatic MM with respect to overall survival (OS), event-free survival (EFS), quality of life (QoL) and treatment- or transplantation-related mortality. SEARCH METHODS We systematically identified controlled trials published between January 1995 and May 2011 in two bibliographic databases (MEDLINE and CENTRAL) and in clinical trial registries. SELECTION CRITERIA One researcher screened references for controlled trials to determine eligibility for the systematic review (SR) according to pre-specified inclusion and exclusion criteria, reflecting characteristics of disease and the interventions. We required a minimal set of details to be reported for observational studies for the studies to be included. DATA COLLECTION AND ANALYSIS We critically evaluated eligible trials with respect to quality of design and actual performance. One researcher extracted individual trial results, which were checked by another researcher. We recapitulated the results of the individual trials in a standardised way for the SR in order to allow a systematic assessment of potential sources of bias. MAIN RESULTS Overall, we identified 14 controlled studies. One registered randomised controlled trial (RCT) is still recruiting patients at the time of this review and no clinical results have been published. Two registered RCTs have remained unpublished despite their termination. Publications on one RCT had been retracted. We excluded five observational studies since neither patients nor treatment regimens were sufficiently characterised to allow an assessment of potential confounding by indication. We conducted a SR of study designs, definition of endpoints, treatment regimens and baseline characteristics of patients in the five included RCTs (two full-text publications, three conference presentations) enrolling1506 patients in total. Because we identified substantial clinical and methodological heterogeneity, we refrained from conducting a formal meta-analysis.While we included only previously untreated, symptomatic patients with MM the treatment regimens differed notably with respect to acute toxicity, between trials and also between study arms. Compared to state of the art treatment standards, the treatment regimens applied in all trials have to be considered as below standard from a contemporary perspective in at least one component.Three trials were likely to have the potential of being highly biased while two RCTs had a moderate potential for bias. The observed treatment effects in the set of included trials may have been influenced by a steep decrease in compliance with the second ASCT and the concomitant selection of patients. In addition, OS data were confounded by the treatment subsequent to first-line therapy.OS was statistically significantly improved in one trial only. While EFS was prolonged in four of the five trials, the median prolongation ranged between three to 12 months, with an uncertain direction of bias in the individual trials. QoL was not reported in any study. Results concerning treatment- or transplantation-related mortality could not be adequately assessed due to substantial differences in definitions between trials and low reporting quality. AUTHORS' CONCLUSIONS We did not consider any study to be sufficiently informative for contemporary treatment decisions concerning the question single versus tandem ASCT in view of inherent biases. In addition, none of the trials integrated the so-called "novel agents" which are now considered standard treatment for MM. To improve the quality of future studies, sample size calculations should consider the potentially steep decrease in compliance with the second ASCT. Reporting of results of treatment- or transplantation-related mortality should clearly specify the type and number of events (the numerator) in a well-defined population (the denominator).
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Bird JM, Owen RG, D'Sa S, Snowden JA, Pratt G, Ashcroft J, Yong K, Cook G, Feyler S, Davies F, Morgan G, Cavenagh J, Low E, Behrens J. Guidelines for the diagnosis and management of multiple myeloma 2011. Br J Haematol 2011; 154:32-75. [PMID: 21569004 DOI: 10.1111/j.1365-2141.2011.08573.x] [Citation(s) in RCA: 205] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- Jennifer M Bird
- Bristol Haematology and Oncology Centre, University Hospitals Bristol NHS Foundation Trust, Bristol, UK.
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Factors influencing the outcome of a second autologous stem cell transplant (ASCT) in relapsed multiple myeloma: a study from the British Society of Blood and Marrow Transplantation Registry. Biol Blood Marrow Transplant 2011; 17:1638-45. [PMID: 21565277 DOI: 10.1016/j.bbmt.2011.04.005] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2011] [Accepted: 04/14/2011] [Indexed: 01/06/2023]
Abstract
Autologous stem cell transplant as primary (first ASCT) therapy in multiple myeloma (MM) is standard practice. The role of a second ASCT as management of relapsed disease remains uncertain. We conducted a retrospective case-matched control analysis on patients (n = 106) who underwent a second ASCT compared with conventional chemotherapy (CCT) as for relapsed MM. The median age was 53 years (range: 26-75) and median follow-up 48 months (range: 8, 136). The cumulative incidence of 1 and 5 years nonrelapse mortality (NRM) was 7% (95% confidence interval [CI] 3%-13%) and 12% (95% CI 7%-19%), with a second ASCT inducing a greater partial remission (PR) rate of 63%. The 4-year overall survival (OS) rate was 33% (95% CI 24%-45%). Factors associated with improved OS and progression-free survival (PFS) included younger age (<55 years), β(2)MG <2.5 mg/L at diagnosis, a remission duration of >9 months from first ASCT, and a greater PR in response to their first ASCT. In a matched-cohort analysis with patients receiving conventional chemotherapy (CCT), the same factors were associated with improved OS, with the exception of a longer remission duration (>18 months) from first ASCT. Second ASCT in relapsed MM is associated with superior OS and PFS compared with CCT, offering a potential consolidative option for selected patients.
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Morris C, Drake M, Apperley J, Iacobelli S, van Biezen A, Bjorkstrand B, Goldschmidt H, Harousseau JL, Morgan G, de Witte T, Niederwieser D, Gahrton G. Efficacy and outcome of autologous transplantation in rare myelomas. Haematologica 2010; 95:2126-33. [PMID: 20971818 DOI: 10.3324/haematol.2010.022848] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND As rare myelomas, i.e. the IgD, IgE, IgM and non-secretory forms, constitute only a small proportion of any study, relatively little is known about their prognosis in the era of peripheral stem cell transplantation. DESIGN AND METHODS We used the European Group for Blood and Marrow Transplantation Myeloma Database to compare the outcome following autologous transplantation of over 20,000 patients with common myelomas (IgG, IgA and light chain myeloma) with the outcome of patients with rare myelomas: 379 IgD, 13 IgE, 72 IgM and 976 non-secretory cases. RESULTS The study confirms the multiple adverse prognostic factors seen in IgD myeloma. Somewhat surprisingly, patients with IgD and non-secretory myeloma both had higher complete remission rates before and after transplantation than patients with common myelomas. However, while the overall survival of patients with non-secretory myeloma was similar to that of the patients with common myelomas, the survival of patients with IgD myeloma was significantly worse (although better than survival rates reported for non-transplanted patients); this was due to higher transplant-related mortality and relapse/progression rates. The post-transplantation survival of patients with IgE or IgM myeloma appears to be very poor. CONCLUSIONS This study provides data on the biological features of rare myelomas. The overall survival of patients with IgD, IgE or IgM myeloma is poor following autologous transplantation but substantially better than that reported for patients who were not transplanted.
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Affiliation(s)
- Curly Morris
- Haematology Department, Belfast City Hospital, Lisburn Road, Belfast BT9 7AD, UK.
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Cooling L, Hoffmann S, Herrst M, Muck C, Armelagos H, Davenport R. A prospective randomized trial of two popular mononuclear cell collection sets for autologous peripheral blood stem cell collection in multiple myeloma. Transfusion 2010; 50:100-19. [DOI: 10.1111/j.1537-2995.2009.02350.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Abstract
PURPOSE OF REVIEW Autologous stem cell transplantation (SCT) has been an integral part of the management of multiple myeloma, especially for younger patients. During the past decade, several highly effective therapies have become available for treatment of myeloma, raising questions about the role of SCT for its management. This review focuses on recent findings in the context of previous studies demonstrating a benefit for SCT compared with conventional therapies. RECENT FINDINGS Recent clinical trials have primarily focused on improving patient outcome by integrating the novel agents into various stages of myeloma therapy, including initial therapy resulting in improvement of disease control at the time of SCT, incorporation into conditioning regimens and finally, using maintenance approaches to prolong the response from SCT. In addition, recent trials also have demonstrated a potential role for tandem SCT in selected patients. However, the role of allogeneic SCT still remains to be better defined. SUMMARY Patients with myeloma have more effective choices for therapy today and better outcome. Recent and ongoing trials will allow better selection of therapy, preferably in an individualized fashion, potentially translating into prolonged survival.
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Burzynski JA, Toro JJ, Patel RC, Lee S, Greene RE, Ochoa-Bayona JL, Frei CR, Freytes CO. Toxicity of a second autologous peripheral blood stem cell transplant in patients with relapsed or recurrent multiple myeloma. Leuk Lymphoma 2009; 50:1442-7. [DOI: 10.1080/10428190903085936] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Liseth K, Ersvaer E, Abrahamsen JF, Nesthus I, Ryningen A, Bruserud Ø. Long-term cryopreservation of autologous stem cell grafts: a clinical and experimental study of hematopoietic and immunocompetent cells. Transfusion 2009; 49:1709-19. [DOI: 10.1111/j.1537-2995.2009.02180.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Abstract
The treatment of multiple myeloma (MM), a largely incurable B-cell hematologic malignancy, is changing dramatically. Autologous stem cell transplantation (SCT) and the approval of two new classes of drugs, immunomodulators and proteosome inhibitors, have resulted in improved response rates and increased overall survivals. Thalidomide, bortezomib and lenalidomide have been combined with corticosteroids, alkylators and anthracyclines in front-line MM treatment. Phase 2 and preliminary phase 3 studies have reported very high response rates and complete response rates formerly seen only with SCT. When patients with MM who have received these new drugs then proceed to transplant, major response rates are further increased. Owing to limited follow-up, it is unclear whether these higher response rates translate into increased survival. Despite these improvements, the disease remains incurable for all but a small fraction of patients. Allogeneic SCT is potentially curative, due in part to a graft-versus-myeloma effect but is limited by mortality. Mortality can be reduced through the use of lower intensity conditioning regimens but this comes at a cost of higher rates of disease progression and relapse. Strategies to improve outcomes of allogeneic transplants include more intensive, yet non-myeloablative conditioning regimens, tandem transplants, peripheral blood cells, graft engineering, post-transplant maintenance and targeted conditioning therapies.
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Affiliation(s)
- W I Bensinger
- Division of Oncology, Fred Hutchinson Cancer Research Center, University of Washington, Seattle, WA 98109, USA.
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Assessment of the role of timing of second transplantation in multiple myeloma by multistate modeling. Exp Hematol 2008; 36:1567-71. [DOI: 10.1016/j.exphem.2008.06.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2008] [Revised: 05/29/2008] [Accepted: 06/17/2008] [Indexed: 10/21/2022]
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Popat R, Oakervee HE, Hallam S, Curry N, Odeh L, Foot N, Esseltine DL, Drake M, Morris C, Cavenagh JD. Bortezomib, doxorubicin and dexamethasone (PAD) front-line treatment of multiple myeloma: updated results after long-term follow-up. Br J Haematol 2008; 141:512-6. [PMID: 18371113 DOI: 10.1111/j.1365-2141.2008.06997.x] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Bortezomib, doxorubicin and dexamethasone (PAD) was evaluated as induction before stem cell transplantation in newly diagnosed multiple myeloma (MM) patients, using bortezomib 1.3 mg/m(2) (PAD1, N = 21) or 1.0 mg/m(2) (PAD2, N = 20). Complete/very good partial response rates with PAD1/PAD2 were 62%/42% postinduction and 81%/53% post-transplant. Progression-free survival (29 vs. 24 months), time to re-treatment (36 vs. 29 months) and overall survival (1 year: 100% vs. 95%; 2 years: 95% vs. 73%) were statistically similar but favoured PAD1 versus PAD2. Toxicity was lower in PAD2; bortezomib dose reduction may help manage toxicities while retaining efficacy. PAD is highly active as front-line induction in MM.
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Affiliation(s)
- Rakesh Popat
- Department of Haematology, St. Bartholomew's Hospital, London, UK
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Björkstrand B, Gahrton G. High-dose treatment with autologous stem cell transplantation in multiple myeloma: past, present, and future. Semin Hematol 2008; 44:227-33. [PMID: 17961721 DOI: 10.1053/j.seminhematol.2007.08.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
High-dose chemotherapy (HDT) with autologous stem cell transplantation (ASCT) has been used in the treatment of multiple myeloma since the early 1980s. Its present position as the backbone of first-line treatment in patients up to 60 to 65 years of age is the result of several controlled randomized trials, where its superiority over standard chemotherapy has been demonstrated. However, the method is not considered to have curative potential, with the possible exception of a small proportion of about 5% to 10% of patients with very long-standing complete remissions (CRs) of more than 8 years. Over the years, there have been several attempts to improve the technique, where, for example, tandem transplants and post-transplant maintenance treatment have been successful, at least in certain subgroups of patients, while others, such as graft purging, have been of no value. Treatment results need further improvement, particularly in poor-prognosis disease--based on abnormal karyotype and high beta2-microglobulin--and the future will show if the introduction of novel drugs like bortezomib, thalidomide, and lenalidomide will lead to longer survival and prolongation of disease control in multiple myeloma.
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Affiliation(s)
- Bo Björkstrand
- Department of Hematology, Karolinska Institute at Karolinska University Hospital Huddinge, Stockholm, Sweden.
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Abdelkefi A, Ladeb S, Torjman L, Othman TB, Lakhal A, Romdhane NB, Omri HE, Elloumi M, Belaaj H, Jeddi R, Aissaouï L, Ksouri H, Hassen AB, Msadek F, Saad A, Hsaïri M, Boukef K, Amouri A, Louzir H, Dellagi K, Abdeladhim AB. Single autologous stem-cell transplantation followed by maintenance therapy with thalidomide is superior to double autologous transplantation in multiple myeloma: results of a multicenter randomized clinical trial. Blood 2007; 111:1805-10. [PMID: 17875806 DOI: 10.1182/blood-2007-07-101212] [Citation(s) in RCA: 99] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
From April 2003 to December 2006, 195 patients with de novo symptomatic myeloma and younger than 60 years of age were randomly assigned to receive either tandem transplantation up front (arm A, n = 97) or one autologous stem-cell transplantation followed by a maintenance therapy with thalidomide (day + 90, 100 mg per day during 6 months) (arm B, n = 98). Patients included in arm B received a second transplant at disease progression. In both arms, autologous stem-cell transplantation was preceded by first-line therapy with thalidomide-dexamethasone and subsequent collection of peripheral blood stem cells with high-dose cyclophosphamide (4 g/m(2)) and granulocyte colony stimulating factor. Data were analyzed on an intent-to-treat basis. With a median follow-up of 33 months (range, 6-46 months), the 3-year overall survival was 65% in arm A and 85% in arm B (P = .04). The 3-year progression-free survival was 57% in arm A and 85% in arm B (P = .02). Up-front single autologous transplantation followed by 6 months of maintenance therapy with thalidomide (with second transplant in reserve for relapse or progression) is an effective therapeutic strategy to treat multiple myeloma patients and appears superior to tandem transplant in this setting. This study was registered at www.ClinicalTrials.gov as (NCT 00207805).
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Gahrton G. I04 Stem cell transplantation in multiple myeloma. Blood Rev 2007. [DOI: 10.1016/s0268-960x(07)70005-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Kumar S. Role of autologous stem cell transplantation in multiple myeloma. Curr Hematol Malig Rep 2007; 2:121-7. [PMID: 20425360 DOI: 10.1007/s11899-007-0017-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
High-dose chemotherapy with autologous stem cell transplantation (ASCT) has been shown to improve survival in patients with multiple myeloma in randomized trials and is the standard of care for eligible patients. Recent randomized trials suggest a survival benefit with tandem ASCT, notably for patients failing to achieve a very good response to initial transplantation. Other randomized trials, as well as smaller phase II trials and retrospective studies, have allowed us to improve the process of ASCT in terms of the stem cell collection, conditioning regimens, and extension of the therapy to a wider patient population. The introduction of thalidomide, lenalidomide, and bortezomib have changed the paradigm for treatment of myeloma and significantly improved the outcome for these patients. The role of ASCT will clearly be redefined in the coming years with improvements in other therapies.
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Affiliation(s)
- Shaji Kumar
- Division of Hematology, Mayo Clinic, First Street SW, Rochester, MN 55905, USA.
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Eom KS, Min CK, Lee S, Kim YJ, Kim SY, Kim HJ, Lee JW, Min WS, Kim CC. Efficacy of up-front treatment with a double stem cell transplantation in multiple myeloma. Jpn J Clin Oncol 2006; 36:432-8. [PMID: 16782727 DOI: 10.1093/jjco/hyl041] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND We report the outcome of 53 patients with multiple myeloma (MM), who received autologous stem cell transplantation (ASCT) from April 1996 to September 2004 at our institution and who survived for more than 3 months after the transplant. METHODS Following the first ASCT, 36 patients underwent an up-front second SCT, which consisted of either an ASCT (n = 24) or a reduced-intensity conditioning allogeneic stem cell transplant (RIST) (n = 12). Seventeen patients were given maintenance treatment. RESULTS Seventy-seven percent of the patients (n = 41) showed an objective response to the initial therapy prior to the first ASCT. Overall, 60.4% (32 out of 53) and 32.1% (17 out of 53) of the patients had a complete response (CR) and partial response (PR) after the first ASCT, respectively. At the time of analysis, 34 patients (64.2%) were still alive. With a median follow-up of 32 months (range 9-98), the estimated progression-free survival (PFS) and overall survival (OS) at 5 years were 17.0 and 34.9%, respectively. Multivariate analysis revealed that the second SCT, normal hemoglobin and <50% marrow plasma cells were associated with an improved PFS. A second SCT, CR to the first SCT, female gender and an absence of advanced bone lesions were associated with a better OS. CONCLUSIONS A second SCT is the most significant factor for an improved PFS and OS after the first ASCT (P < 0.001, respectively). Up-front double SCT is needed to improve the OS and PFS in patients with MM.
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Affiliation(s)
- Ki-Seong Eom
- Catholic Hematopoietic Stem Cell Transplantation Center, St Mary's Hospital, Catholic University of Korea, Youngdungpo-Gu, Seoul 150-713, South Korea
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O'Shea D, Giles C, Terpos E, Perz J, Politou M, Sana V, Naresh K, Lampert I, Samson D, Narat S, Kanfer E, Olavarria E, Apperley JF, Rahemtulla A. Predictive factors for survival in myeloma patients who undergo autologous stem cell transplantation: a single-centre experience in 211 patients. Bone Marrow Transplant 2006; 37:731-7. [PMID: 16501593 DOI: 10.1038/sj.bmt.1705307] [Citation(s) in RCA: 87] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
High-dose therapy with autologous stem cell therapy (ASCT) has become the treatment of choice for eligible patients with myeloma. We analysed retrospectively the prognostic influence of pre-transplant characteristics and transplant modalities on response and survival in 211 myeloma patients who were transplanted in our centre between 1994 and 2004. All patients received peripheral blood stem cell support after conditioning with melphalan alone (183 patients), or melphalan and total blood irradiation (28 patients). We evaluated the influence of age, type of multiple myeloma, status prior and post ASCT, previous treatment regimens, time of ASCT from diagnosis, year of autograft, dose of re-infused CD34(+) cells, plasma cell infiltration and beta2-microglobulin at diagnosis on overall survival (OS) and event-free survival (EFS) to define patients with better prognosis. Median OS and EFS from transplantation were 50.9 and 20.1 months, respectively. Median OS from diagnosis was 68.8 months. Transplant-related mortality was 1.4%. Lower beta2-microglobulin levels, achievement of complete remission (CR) post transplant and lower plasma cell infiltration at diagnosis and transplant correlated with longer EFS and OS, whereas CR at transplant and low international prognostic index at transplant correlated with better EFS. Higher CD34(+) cell dose correlated with improved OS. We conclude that ASCT is safe and effective and the outcome is independent of age, time from diagnosis, previous treatment and conditioning regimen.
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Affiliation(s)
- D O'Shea
- Department of Haematology, Faculty of Medicine, Imperial College of Science, Technology and Medicine, Hammersmith Hospital, London, UK
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Gahrton G, Iacobelli S, Björkstrand B, Bourhis J, Corradini P, Crawley C, Morris C, Niederwieser D. Role of stem cell transplantation in myeloma. ACTA ACUST UNITED AC 2006; 10 Suppl 1:127-8. [PMID: 16276618 DOI: 10.1080/10245330512331390168] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- G Gahrton
- Department of Medicine, Karolinska Institute Huddinge, Stockholm, Sweden
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Abstract
Randomized studies have firmly established the role of autologous transplant as initial therapy in multiple myeloma (MM). Indeed, MM has emerged as the commonest indication for autologous SCT in North America. The conceptual basis for high-dose therapy is the goal of complete remission (CR) through steep reduction in tumor burden affected by single and tandem transplants. Careful analysis of the data challenges the notion of CR as a surrogate to success. Intrinsically aggressive MM, defined by known unfavorable biologic risk factors, overrides the benefit of CR. In contrast, subgroups of patients with favorable biological risk factors may achieve prolonged survival, often without ever achieving CR. Unfortunately, even with tandem transplants, there is no plateau in survival curves. To this end, sequential autologous followed by nonmyeloablative allotransplants are a novel attempt at 'curing' myeloma, but the results thus far have failed to show a definite plateau in survival. Given the improvements in supportive care and concomitant reduction in transplant-related mortality, conventional myeloablative allogeneic transplants need to be re-examined as an option in high-risk aggressive myeloma. At the same time, novel antimyeloma therapies, newer risk stratification and staging tools are transforming the treatment algorithm. We examine the changing role of transplantation in myeloma in the context of novel drug therapy, biologic risk stratification and improving supportive care while arguing that the current 'one size fits all' transplant approaches are far from a cure.
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Affiliation(s)
- P Hari
- Medical College of Wisconsin, Milwaukee, WI 53226, USA.
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Abstract
PURPOSE OF REVIEW An attempt is made to value the place of autologous and allogeneic hematopoietic stem cell transplantation in the treatment of multiple myeloma. Recent progress with each treatment modality has significantly changed the outcome for myeloma patients. RECENT FINDINGS The gold standard for conditioning treatment before autologous transplantation is melphalan 200 mg/m, and the use of peripheral blood stem cells is superior to that of bone marrow. Tandem autologous transplantation is superior to single autologous transplantation, at least for patients who do not respond with complete remission to the first transplant. Allogeneic transplantation using standard high-dose myeloablative conditioning reduces the relapse rate in comparison with autologous transplantation; however, treatment-related mortality is significantly higher. Progress in allogeneic transplantation has been significant, and transplant-related mortality has been reduced. The recent use of nonmyeloablative reduced-intensity conditioning has significantly decreased transplant-related mortality; however, the relapse rate is higher than with standard conditioning, and therefore no significant improvement in overall survival has as yet been seen. Relapse following allogeneic transplantation can be counteracted by donor lymphocyte infusions, but the survival results are so far inconclusive. SUMMARY Autologous transplantation is still the first choice for most myeloma patients, but it does not seem to be curative. Therefore, allogeneic transplantation should be continued in clinical trials exploring new conditioning methods, the graft-versus-myeloma effect of new cell types, and its combination with new targeted drugs such as bortezomib and lenalidomide.
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Affiliation(s)
- Gösta Gahrton
- Department of Medicine, Karolinska Institute, Huddinge Karolinska University Hospital, Stockholm, Sweden.
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Björkstrand B. Stem cell transplantation in multiple myeloma. Hematology 2005; 10 Suppl 1:26-8. [PMID: 16188627 DOI: 10.1080/10245330512331389809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Current Awareness in Hematological Oncology. Hematol Oncol 2005. [DOI: 10.1002/hon.720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Abstract
In most cases multiple myeloma is an incurable plasma cell malignancy. Despite the use of conventional therapy or high-dose chemotherapy with autologous stem cell transplantation (ASCT), patients continue to relapse at a constant rate. A small minority of patients are cured by allogeneic transplantation. Novel drugs targeting not only the myeloma cell but also its interactions with the malignant microenvironment have recently been used in patients with relapsed/refractory disease. So far, ASCT has been the treatment of choice for eligible myeloma patients. However, many questions regarding the management of myeloma patients remain unanswered. How safe is ASCT in elderly patients? Is there a role for non-myeloablative allogeneic transplantation in multiple myeloma? What is the role of novel agents, such as thalidomide, its analogues and bortezomib, in the treatment of newly diagnosed patients or as maintenance post-ASCT? This review summarises all available data for the current treatment options for myeloma providing a useful algorithm for its management.
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Affiliation(s)
- Evangelos Terpos
- Department of Haematology, 1251 General Air Force Hospital, 5 Marathonomahon Street, Drossia Attikis, 14572, Greece.
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