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Hughes CFM, Shah GL, Paul BA. Autologous hematopoietic stem cell transplantation for multiple myeloma in the age of CAR T cell therapy. Front Oncol 2024; 14:1373548. [PMID: 38601770 PMCID: PMC11004402 DOI: 10.3389/fonc.2024.1373548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 03/15/2024] [Indexed: 04/12/2024] Open
Abstract
Chimeric antigen receptor (CAR) T cell therapy has revolutionized the management of relapsed and refractory myeloma, with excellent outcomes and a tolerable safety profile. High dose chemotherapy with autologous hematopoietic stem cell transplantation (AHCT) is established as a mainstream of newly diagnosed multiple myeloma (NDMM) management in patients who are young and fit enough to tolerate such intensity. This standard was developed based on randomized trials comparing AHCT to chemotherapy in the era prior to novel agents. More recently, larger studies have primarily shown a progression free survival (PFS) benefit of upfront AHCT, rather than overall survival (OS) benefit. There is debate about the significance of this lack of OS, acknowledging the potential confounders of the chronic nature of the disease, study design and competing harms and benefits of exposure to AHCT. Indeed upfront AHCT may not be as uniquely beneficial as we once thought, and is not without risk. New quadruple-agent regimens are highly active and effective in achieving a deep response as quantified by measurable residual disease (MRD). The high dose chemotherapy administered with AHCT imposes a burden of short and long-term adverse effects, which may alter the disease course and patient's ability to tolerate future therapies. Some high-risk subgroups may have a more valuable benefit from AHCT, though still ultimately suffer poor outcomes. When compared to the outcomes of CAR T cell therapy, the question of whether AHCT can or indeed should be deferred has become an important topic in the field. Deferring AHCT may be a personalized decision in patients who achieve MRD negativity, which is now well established as a key prognostic factor for PFS and OS. Reserving or re-administering AHCT at relapse is feasible in many cases and holds the promise of resetting the T cell compartment and opening up options for immune reengagement. It is likely that personalized MRD-guided decision making will shape how we sequence in the future, though more studies are required to delineate when this is safe and appropriate.
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Affiliation(s)
- Charlotte F. M. Hughes
- Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Gunjan L. Shah
- Adult Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, NY, United States
- Cellular Therapy Service, Memorial Sloan Kettering Cancer Center, New York, NY, United States
| | - Barry A. Paul
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute, Atrium Health/Wake Forest Baptist, Charlotte, NC, United States
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Slade M, Fiala MA, Kirchmeyer M, King J, Gao F, Schroeder MA, Stewart AK, Stockerl-Goldstein K, Chen C, Vij R. Continuous Elotuzumab, Pomalidomide, and Dexamethasone Maintenance Following Second Autologous Transplantation for Multiple Myeloma: Results of a Prospective Phase 2 Multicenter Trial. Transplant Cell Ther 2023; 29:764.e1-764.e7. [PMID: 37741459 DOI: 10.1016/j.jtct.2023.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 08/14/2023] [Accepted: 09/18/2023] [Indexed: 09/25/2023]
Abstract
Second autologous hematopoietic cell transplantation (AHCT2) is a useful therapeutic modality for fit patients with multiple myeloma who have durable remission after upfront AHCT. Retrospective studies have suggested a significant benefit of incorporating maintenance therapy post-AHCT2, but prospective data on specific regimens are lacking. The purpose of this study was to investigate the use of elotuzumab, pomalidomide, and dexamethasone (EPd) as salvage therapy prior to and maintenance after AHCT2 for relapsed multiple myeloma. This prospective single-arm phase II trial investigating the use of EPd in combination with AHCT2 in patients with relapsed multiple myeloma was conducted at 2 academic centers in North America. The primary outcome was 1-year progression-free survival (PFS). Twenty-five patients were enrolled on the study. Sixteen patients received EPd induction; six patients (38%) progressed during salvage therapy and were removed from the trial prior to AHCT2. Following a planned safety analysis, the protocol was amended, and EPd induction was removed from the study schema. An additional 9 patients underwent induction off-study and were enrolled on trial for AHCT2 and EPd maintenance. A total of 18 patients underwent AHCT2 and received EPd maintenance. Two patients discontinued treatment because of toxicity, one attributed to elotuzumab and the other to pomalidomide. The 1-year PFS was 72%, and the median PFS was 19 months. The study was closed early owing to poor accrual; 6 patients remained on therapy at time of analysis. EPd maintenance after AHCT2 was safe and tolerable. The 1-year PFS and median PFS were similar to values in previous retrospective reports of outcomes following AHCT2. Further studies are needed to define the optimal use of and protocol for AHCT2 in fit patients with relapsed multiple myeloma.
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Affiliation(s)
- Michael Slade
- Bone Marrow Transplantation & Leukemia Section, Division of Oncology, Washington University School of Medicine, St. Louis, Missouri.
| | - Mark A Fiala
- Bone Marrow Transplantation & Leukemia Section, Division of Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Marie Kirchmeyer
- Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Jeff King
- Bone Marrow Transplantation & Leukemia Section, Division of Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Feng Gao
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Mark A Schroeder
- Bone Marrow Transplantation & Leukemia Section, Division of Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - A Keith Stewart
- University Health Network, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Keith Stockerl-Goldstein
- Bone Marrow Transplantation & Leukemia Section, Division of Oncology, Washington University School of Medicine, St. Louis, Missouri
| | - Christine Chen
- Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Ravi Vij
- Bone Marrow Transplantation & Leukemia Section, Division of Oncology, Washington University School of Medicine, St. Louis, Missouri
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Jantunen E, Partanen A, Turunen A, Varmavuo V, Silvennoinen R. Mobilization Strategies in Myeloma Patients Intended for Autologous Hematopoietic Cell Transplantation. Transfus Med Hemother 2023; 50:438-447. [PMID: 37899993 PMCID: PMC10603622 DOI: 10.1159/000531940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Accepted: 06/21/2023] [Indexed: 10/31/2023] Open
Abstract
Background Multiple myeloma is currently the leading indication for autologous hematopoietic cell transplantation (AHCT). A prerequisite for AHCT is mobilization and collection of adequate blood graft to support high-dose therapy. Current mobilization strategies include granulocyte colony-stimulating factor (G-CSF) alone or in combination with chemotherapy most commonly cyclophosphamide (CY). More recently, plerixafor has become into agenda especially in patients who mobilize poorly. In the selection of a mobilization method, several factors should be considered. Summary Preplanned collection target is important as G-CSF plus plerixafor is more effective in the mobilization of CD34+ cells than G-CSF alone. On the other hand, CY plus G-CSF is superior to G-CSF only mobilization. Previous therapy and age of the patients are important considerations as G-CSF alone may not be effective enough in patients with risk factors for poor mobilization. These factors include extensive lenalidomide exposure, irradiation to bone marrow-bearing sites, higher age, or a previous mobilization failure. Also, local preferences and experiences as well as the number of apheresis needed are important issues as well as cost-effectiveness considerations. Mobilization method used may have implication for cellular composition of collected grafts, which might have an impact on posttransplant events such as hematologic and immune recovery in addition to also potential long-term outcomes. Key Message Currently, G-CSF alone and preemptive plerixafor if needed might be considered as a standard mobilization strategy in MM patients intended for AHCT.
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Affiliation(s)
- Esa Jantunen
- Institute of Clinical Medicine/Internal Medicine, University of Eastern Finland, Kuopio, Finland
- Department of Medicine, Kuopio University Hospital, Kuopio, Finland
| | - Anu Partanen
- Department of Medicine, Kuopio University Hospital, Kuopio, Finland
| | - Antti Turunen
- Department of Medicine, Kuopio University Hospital, Kuopio, Finland
| | - Ville Varmavuo
- Department of Medicine, Kymenlaakso Central Hospital, Kotka, Finland
| | - Raija Silvennoinen
- Department of Hematology, Comprehensive Cancer Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Yassine F, Kharfan-Dabaja MA, Tsalantsanis A, Roy V, Zubair AC, Murthy HS, Ayala E, Iqbal M, Sher T, Ailawadhi S, Parrondo RD. Trends in utilization of stored cryopreserved autologous peripheral hematopoietic cells intended for a second (or beyond) autologous hematopoietic cell transplantation in patients with multiple myeloma: a single center experience. Bone Marrow Transplant 2023; 58:1130-1136. [PMID: 37479753 PMCID: PMC10555832 DOI: 10.1038/s41409-023-02035-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 06/04/2023] [Accepted: 06/21/2023] [Indexed: 07/23/2023]
Abstract
Due to the advent of effective novel therapies for multiple myeloma (MM), the use of cryopreserved autologous peripheral blood hematopoietic cells (APBHC) for a salvage autologous transplant (auto-HCT) is in decline. We evaluated utilization trends and costs associated with cryopreserved APBHC in patients with MM. We retrospectively evaluated the clinicopathologic data from 440 patients with MM who underwent APBHC mobilization and collection at Mayo Clinic Florida between 2010 and 2019. Based on institution-specific charges as of May 2021, the cost of 1 session of APBHC collection/apheresis was $4,680 and the cost of 1 year of APBHC cryopreservation was $4,790 per patient. Out of 347 patients who had APBHC in cryopreservation, 5 (1.4%) underwent a salvage auto-HCT and 61% of patients had ≥1 excess collection sessions for APBHC that ultimately went unused. The median cost of excess collection sessions was $4,680 per patient (range, $4,680-$32,760) and the median total cost for excess collection sessions plus costs for storage was $23,840 per patient (range, $4,680-$85,450). The sum of costs of excess collection sessions was $2,077,920 and the sum of costs of cryopreservation was $5,812,665. Institutional policies regarding universal APBHC collection and long-term storage should be reevaluated in the era of novel therapeutics.
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Affiliation(s)
- Farah Yassine
- Division of Hematology-Oncology and Blood and Marrow Transplantation Program, Mayo Clinic, Jacksonville, FL, USA
| | - Mohamed A Kharfan-Dabaja
- Division of Hematology-Oncology and Blood and Marrow Transplantation Program, Mayo Clinic, Jacksonville, FL, USA
| | - Athanasios Tsalantsanis
- Program for Comparative Effectiveness Research, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Vivek Roy
- Division of Hematology-Oncology and Blood and Marrow Transplantation Program, Mayo Clinic, Jacksonville, FL, USA
| | - Abba C Zubair
- Department of Pathology and Laboratory Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Hemant S Murthy
- Division of Hematology-Oncology and Blood and Marrow Transplantation Program, Mayo Clinic, Jacksonville, FL, USA
| | - Ernesto Ayala
- Division of Hematology-Oncology and Blood and Marrow Transplantation Program, Mayo Clinic, Jacksonville, FL, USA
| | - Madiha Iqbal
- Division of Hematology-Oncology and Blood and Marrow Transplantation Program, Mayo Clinic, Jacksonville, FL, USA
| | - Taimur Sher
- Division of Hematology-Oncology and Blood and Marrow Transplantation Program, Mayo Clinic, Jacksonville, FL, USA
| | - Sikander Ailawadhi
- Division of Hematology-Oncology and Blood and Marrow Transplantation Program, Mayo Clinic, Jacksonville, FL, USA
| | - Ricardo D Parrondo
- Division of Hematology-Oncology and Blood and Marrow Transplantation Program, Mayo Clinic, Jacksonville, FL, USA.
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Yadav N, Mirgh SP, Aggarwal M, Agrawal N, Mehta P, Khushoo V, Kapoor J, Bhatia N, Agrawal P, Ahmed R, Bhurani D. Second stem cell transplantation for treatment of relapsed/refractory multiple myeloma after first autologous stem cell transplant: A 15-year retrospective institutional analysis. Indian J Cancer 2023; 60:316-324. [PMID: 37787191 DOI: 10.4103/ijc.ijc_272_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
Background Multiple myeloma remains an incurable disease, with the majority of patients relapsing after autologous stem cell transplant (ASCT). After relapse, second transplant remains one of the therapeutic options, along with novel agents. Methods We reviewed the data of our patients who underwent ASCT for myeloma (N = 202) over the last two decades (2004-2019). Of these, 12 patients underwent a second transplant. Results Out of 12 patients, nine underwent second autologous stem cell transplant, whereas three received an allogeneic stem cell transplantation (Allo-SCT). Median progression-free survival (PFS) after the first ASCT was 32 months (5-84 months). Median interval between both the transplants was 35 months (4-159 months). Median age of our cohort which underwent second transplant was 56 years. Overall response rate (ORR) post-second transplant on day +100 was 83.3%, without any transplant-related mortality (TRM). With the use of preemptive plerixafor, none of our patients required a second day for stem cell harvest. Median CD34 dose of stem cells infused was 4.11 × 106/kg. Similar to the first ASCT, the median time to neutrophil and platelet engraftment was 11 and 12 days, respectively. At a median follow-up of 41 months, estimated 3-year PFS and overall survival (OS) was 37% ± 15% and 63% ± 15%, respectively. Conclusion ">Among all relapsed myeloma patients who were transplant eligible, 11% underwent a second transplant. Second transplant is well tolerated with similar time to engraftment after first ASCT. Hence, we believe that second transplant is a feasible, cost-effective option in a resource-limited setting, which should be more widely utilized.
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Affiliation(s)
- Neha Yadav
- Department of Hematology and BMT Unit, Rajiv Gandhi Cancer Institute and Research Centre, Sector 5, Rohini, Delhi, India
| | - Sumeet P Mirgh
- Department of Hematology and BMT Unit, Rajiv Gandhi Cancer Institute and Research Centre, Sector 5, Rohini, Delhi; Adult Hematolymphoid and BMT Unit, Tata Memorial Centre, ACTREC, Mumbai, Maharashtra, India (Present Affiliation); Homi Bhabha National Institute, Mumbai, Maharashtra, India (Present Afiliation)
| | - Mukul Aggarwal
- Department of Hematology and BMT Unit, Rajiv Gandhi Cancer Institute and Research Centre, Sector 5, Rohini, Delhi, India
| | - Narendra Agrawal
- Department of Hematology and BMT Unit, Rajiv Gandhi Cancer Institute and Research Centre, Sector 5, Rohini, Delhi, India
| | - Pallavi Mehta
- Department of Hematology and BMT Unit, Rajiv Gandhi Cancer Institute and Research Centre, Sector 5, Rohini, Delhi, India
| | - Vishvdeep Khushoo
- Department of Hematology and BMT Unit, Rajiv Gandhi Cancer Institute and Research Centre, Sector 5, Rohini, Delhi, India
| | - Jyotsna Kapoor
- Department of Hematology and BMT Unit, Rajiv Gandhi Cancer Institute and Research Centre, Sector 5, Rohini, Delhi, India
| | - Niharika Bhatia
- Department of Hematology and BMT Unit, Rajiv Gandhi Cancer Institute and Research Centre, Sector 5, Rohini, Delhi, India
| | - Pragya Agrawal
- Department of Hematology and BMT Unit, Rajiv Gandhi Cancer Institute and Research Centre, Sector 5, Rohini, Delhi, India
| | - Rayaz Ahmed
- Department of Hematology and BMT Unit, Rajiv Gandhi Cancer Institute and Research Centre, Sector 5, Rohini, Delhi, India
| | - Dinesh Bhurani
- Department of Hematology and BMT Unit, Rajiv Gandhi Cancer Institute and Research Centre, Sector 5, Rohini, Delhi, India
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Khan S, Reece D, Atenafu EG, Bhella S, Chen C, Masih-Khan E, Paul H, Prica A, Tiedemann R, Trudel S, Kukreti V. Post Salvage Therapy Autologous Transplant for Relapsed Myeloma, Ongoing Relevance within Modern Treatment Paradigms? Clin Lymphoma Myeloma Leuk 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] [What about the content of this article? (0)] [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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Devarakonda S, Sharma N, Efebera Y. The first relapse in multiple myeloma: how to pick the next best thing. Hematology Am Soc Hematol Educ Program 2022; 2022:560-8. [PMID: 36485087 DOI: 10.1182/hematology.2022000356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The choice of treatment for patients with multiple myeloma (MM) at first relapse/progression is based on many factors: (1) treatment-related factors, which include the regimen used during first induction, the quality and duration of first response achieved, toxicities from the first treatment, whether the patient underwent autologous stem cell transplant, and whether the patient was on maintenance at the time of relapse/progression; (2) disease-related factors, including disease presentation and pace of progression; and (3) patient-related factors, including functional age and performance status. The learning objectives are to present the treatment options for patients with MM upon their first relapse and to learn about various strategies for selecting an optimal treatment regimen.
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Drozd-Sokołowska J, Waszczuk-Gajda A, Biecek P, Kobylińska K, Mańko J, Hus I, Szmigielska-Kapłon A, Nowicki M, Romejko-Jarosińska J, Kozioł M, Sędzimirska M, Sachs W, Mądry K, Boguradzki P, Król M, Hus M, Basak G, Dwilewicz-Trojaczek J. Salvage autologous hematopoietic stem cell transplantation for multiple myeloma performed with stem cells procured after previous high dose therapy - a multicenter report by the Polish Myeloma Study Group. Leuk Lymphoma 2021; 62:3226-3234. [PMID: 34396931 DOI: 10.1080/10428194.2021.1950712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Salvage autologous hematopoietic stem cell transplantation (auto-HSCT) constitutes a therapeutic option for a group of well-selected patients with relapsed multiple myeloma (MM). However, if an insufficient number of stem cells were harvested and stored before the first auto-HSCT, stem cells need to be remobilized. Patients diagnosed with MM who following relapse after auto-HSCT, had remobilization and afterward, auto-HSCT with remobilized cells were included in this retrospective analysis. Thirty-three patients, 61% males, the median age 61 years, were included. With a median follow-up of 1.8 years, 2-year progression-free survival was 56.2%, non-relapse mortality 4.8%. The 2-year cumulative incidence of t-MDS was 4.9%. Factors important for the outcome were: the quality of response, previous radiotherapy, the time between the first and salvage auto-HSCT. To conclude, salvage auto-HSCT performed with cells procured after the previous auto-HSCT can be efficacious in relapsed MM, especially if a sufficiently long response had been obtained to the first auto-HSCT(s).
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Affiliation(s)
- Joanna Drozd-Sokołowska
- Department of Hematology, Transplantation and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Anna Waszczuk-Gajda
- Department of Hematology, Transplantation and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Przemysław Biecek
- Faculty of Mathematics and Information Science, Warsaw University of Technology, Warsaw, Poland
| | - Katarzyna Kobylińska
- Faculty of Mathematics and Information Science, Warsaw University of Technology, Warsaw, Poland
| | - Joanna Mańko
- Department of Hematooncology and Bone Marrow Transplantation, Medical University of Lublin, Lublin, Poland.,Department of Hematology, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Iwona Hus
- Department of Hematology, Institute of Hematology and Transfusion Medicine, Warsaw, Poland.,Department of Clinical Transplantology, Medical University of Lublin, Lublin, Poland
| | | | - Mateusz Nowicki
- Department of Hematology, Copernicus Memorial Hospital in Lodz Comprehensive Cancer Center and Traumatology, Lodz, Poland
| | - Joanna Romejko-Jarosińska
- Department of Lymphoid Malignancies, Maria Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology, Warsaw, Poland
| | - Magdalena Kozioł
- Department of Hematooncology and Bone Marrow Transplantation, Medical University of Lublin, Lublin, Poland
| | - Mariola Sędzimirska
- Lower Silesian Center for Cellular Transplantation with National Bone Marrow Donor Registry, Wroclaw, Poland
| | - Wojciech Sachs
- Department of Hematology, Transplantation and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Krzysztof Mądry
- Department of Hematology, Transplantation and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Piotr Boguradzki
- Department of Hematology, Transplantation and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Małgorzata Król
- Department of Hematology, Transplantation and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Marek Hus
- Department of Hematooncology and Bone Marrow Transplantation, Medical University of Lublin, Lublin, Poland
| | - Grzegorz Basak
- Department of Hematology, Transplantation and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
| | - Jadwiga Dwilewicz-Trojaczek
- Department of Hematology, Transplantation and Internal Medicine, Medical University of Warsaw, Warsaw, Poland
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Yarlagadda L, Gundarlapalli S, Parikh R, Landes RD, Kottarathara M, Ogunsesan Y, Hoque S, Mitma AA, Bailey C, Hill KM, Thanendrarajan S, Graziutti M, Mohan M, Zangari M, van Rhee F, Tricot G, Schinke C. Salvage Autologous Stem Cell Transplantation in Daratumumab-Refractory Multiple Myeloma. Cancers (Basel) 2021; 13:4019. [PMID: 34439174 DOI: 10.3390/cancers13164019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 07/29/2021] [Accepted: 08/05/2021] [Indexed: 11/17/2022] Open
Abstract
Daratumumab, a CD38-targeting monoclonal antibody, has significantly improved survival rates in multiple myeloma (MM), yet patients who progress on Daratumumab have dismal clinical outcomes with an overall median of less than 10 months. While emerging novel modalities have shown promising results, the current study explores the use of high-dose chemotherapy followed by autologous stem cell transplantation (ASCT) in heavily pretreated Daratumumab-refractory MM patients. We retrospectively investigated the outcome of 69 consecutive patients who received upfront ASCT. The median progression-free survival (PFS) for the entire patient cohort was 7.2 months with a median overall survival (OS) of 19.3 months. For patients with ≥very good partial response (VGPR), median PFS and OS improved to 9 months and 34 months, respectively. Achievement of MRD negativity in ≥VGPR did not further improve the outcome. A better performance status, younger age, longer time interval from initial MM diagnosis/initial ASCT to salvage ASCT and low-risk GEP70 were all associated with improved PFS and OS after salvage ASCT. Our results suggest a role for salvage ASCT in selected heavily pretreated and Daratumumab-refractory patients.
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10
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Drozd-Sokołowska J, Waszczuk-Gajda A, Topczewska M, Mańko J, Hus I, Szmigielska-Kapłon A, Nowicki M, Grygoruk-Wiśniowska I, Krawczyk-Kuliś M, Romejko-Jarosińska J, Frączak E, Wróbel T, Piątkowska-Jakubas B, Mądry K, Boguradzki P, Król M, Kozioł M, Hus M, Kopińska A, Dmoszyńska A, Basak GW, Dwilewicz-Trojaczek J. Stem cell mobilization in multiple myeloma patients relapsing after previous autologous hematopoietic stem cell transplantation: A multicenter report by the Polish Myeloma Study Group. J Clin Apher 2021; 36:443-453. [PMID: 33592119 DOI: 10.1002/jca.21885] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 12/05/2020] [Accepted: 02/01/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND Salvage autologous hematopoietic stem cell transplantation (autoHSCT) may be used to treat relapse of multiple myeloma occurring after previous autoHSCT. When insufficient number of hematopoietic stem cells was stored from the initial harvest, remobilization of stem cells is necessary. PURPOSE The analysis of stem cell remobilization after previous autoHSCT. PATIENTS AND METHODS Fifty-eight patients, 60% males, median 59 years, were included. Median time interval between autoHSCT and remobilization was 42 months. The first remobilization was performed mostly after chemotherapy: cyclophosphamide (33%), cytarabine (43%), and etoposide (19%). RESULTS The first remobilization was successful in 67% patients. About 19% patients required plerixafor rescue, among whom it allowed for successful harvesting in 14%. Use of cyclophosphamide, cytarabine, and etoposide allowed for successful remobilization in 53%, 84%, and 55% patients, respectively. Patients treated with cytarabine had the highest yield of CD34+ cells (median 7.5 × 106 /kg vs 5.8 and 2.4 for etoposide and cyclophosphamide, P = .001). Higher percentage of patients was able to collect ≥2 × 106 CD34+ cells/kg during one leukapheresis after cytarabine (76% vs 21% for cyclophosphamide vs 36% for etoposide, P = .001). Cytarabine use was associated with lower risk of remobilization failure OR = 0.217, P = .02. Toxicity comprised mostly hematological toxicity (thrombocytopenia and neutropenia). One patient succumbed to septic shock. CONCLUSION Remobilization after previous autoHSCT is feasible only in a proportion of patients. Cytarabine is associated with the highest rate of successful mobilization and the highest yield of mobilized CD34+ cells. The toxicity requires careful surveillance of these patients.
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Affiliation(s)
- Joanna Drozd-Sokołowska
- Department of Hematology, Transplantation and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Anna Waszczuk-Gajda
- Department of Hematology, Transplantation and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Magdalena Topczewska
- Faculty of Computer Science, Bialystok University of Technology, Bialystok, Poland
| | - Joanna Mańko
- Department of Hematooncology and Bone Marrow Transplantation, Medical University of Lublin, Lublin, Poland.,Department of Hematology, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | - Iwona Hus
- Department of Hematooncology and Bone Marrow Transplantation, Medical University of Lublin, Lublin, Poland.,Department of Hematology, Institute of Hematology and Transfusion Medicine, Warsaw, Poland
| | | | - Mateusz Nowicki
- Department of Hematology, Copernicus Memorial Hospital in Lodz Comprehensive Cancer Center and Traumatology, Lodz, Poland
| | - Iwona Grygoruk-Wiśniowska
- Department of Hematology and Bone Marrow Transplantation, Medical University of Silesia, Katowice, Poland
| | - Małgorzata Krawczyk-Kuliś
- Department of Hematology and Bone Marrow Transplantation, Medical University of Silesia, Katowice, Poland.,Department of Bone Marrow Transplantation and Oncohematology, Maria Sklodowska-Curie Institute-Cancer Center, Gliwice, Poland
| | - Joanna Romejko-Jarosińska
- Department of Lymphoid Malignancies, Maria Sklodowska-Curie Memorial Cancer Centre and Institute of Oncology, Warsaw, Poland
| | - Ewa Frączak
- Department of Hematology, Wroclaw Medical University, Wroclaw, Poland
| | - Tomasz Wróbel
- Department of Hematology, Wroclaw Medical University, Wroclaw, Poland
| | | | - Krzysztof Mądry
- Department of Hematology, Transplantation and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Piotr Boguradzki
- Department of Hematology, Transplantation and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Małgorzata Król
- Department of Hematology, Transplantation and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Magdalena Kozioł
- Department of Hematooncology and Bone Marrow Transplantation, Medical University of Lublin, Lublin, Poland
| | - Marek Hus
- Department of Hematooncology and Bone Marrow Transplantation, Medical University of Lublin, Lublin, Poland
| | - Anna Kopińska
- Department of Hematology and Bone Marrow Transplantation, Medical University of Silesia, Katowice, Poland
| | - Anna Dmoszyńska
- Department of Hematooncology and Bone Marrow Transplantation, Medical University of Lublin, Lublin, Poland
| | - Grzegorz Władysław Basak
- Department of Hematology, Transplantation and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
| | - Jadwiga Dwilewicz-Trojaczek
- Department of Hematology, Transplantation and Internal Diseases, Medical University of Warsaw, Warsaw, Poland
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11
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Malkan UY, Demiroglu H, Buyukasik Y, Karatas A, Aladag E, Goker H. Comparison of single and double autologous stem cell transplantation in multiple myeloma patients. Open Med (Wars) 2021; 16:192-197. [PMID: 33585695 PMCID: PMC7862995 DOI: 10.1515/med-2021-0216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 10/31/2020] [Accepted: 11/03/2020] [Indexed: 11/23/2022] Open
Abstract
Background Autologous stem cell transplantation (ASCT) is one of the standard treatments of choice for eligible multiple myeloma (MM) patients. Herein, we aimed to analyze MM patients at our center and compare the clinical outcomes of single and double ASCT patients. Materials and methods Patients who were diagnosed as having MM and had undergone single or double ASCT in our clinic between the years 2003 and 2020 were retrospectively examined. Results In this study, the median time of second ASCT is approximately 3.6 years from the first ASCT. Overall survival (OS) duration of the single and double transplanted groups was 4,011 ± 266 vs 3,526 ± 326 days, respectively (p: 0.33). Progression-free survival (PFS) duration of the single and double transplanted groups was 2,344 ± 228 vs 685 ± 120 days, respectively (p: 0.22). Disease assessment after ASCT stable or progressive disease, partial remission, and very good partial or complete remission (CR) in single and double ASCT groups was 62/44/105 and 8/4/5, respectively (p: 0.22). Conclusion The present study points out that the second ASCT treatment option for MM patients may not be effective as suggested, especially in the era of novel MM drugs, since our results come from the past data that novel drugs were not exist. In conclusion, we found no benefit with second ASCT in MM patients in terms of PFS and OS or CR rates, and the novel anti-myeloma drugs might decrease the need for a second transplant.
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Affiliation(s)
- Umit Yavuz Malkan
- Department of Hematology, University of Health Sciences, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Haluk Demiroglu
- Department of Hematology, Faculty of Medicine, Hacettepe University, 06230, Ankara, Turkey
| | - Yahya Buyukasik
- Department of Hematology, Faculty of Medicine, Hacettepe University, 06230, Ankara, Turkey
| | - Ayse Karatas
- Department of Hematology, Faculty of Medicine, Hacettepe University, 06230, Ankara, Turkey
| | - Elifcan Aladag
- Department of Hematology, Faculty of Medicine, Hacettepe University, 06230, Ankara, Turkey
| | - Hakan Goker
- Department of Hematology, Faculty of Medicine, Hacettepe University, 06230, Ankara, Turkey
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12
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Dai Y, Guo X, Yang C. Effect of bortezomib on proliferation and apoptosis of myeloma cells by activating Wnt/β-catenin signaling pathway. Oncol Lett 2020; 20:1295-1299. [PMID: 32724371 PMCID: PMC7377063 DOI: 10.3892/ol.2020.11678] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 11/14/2019] [Indexed: 11/19/2022] Open
Abstract
Effect of bortezomib on proliferation and apoptosis of myeloma cells by activating Wnt/β-catenin signaling pathway was investigated. Myeloma cells RPMI-8226 treated with different concentrations of bortezomib were used as experimental groups, and the untreated cells were used as the control group. The proliferation and apoptosis in all groups of cells were detected, as well as the expression levels of Wnt/β-catenin signaling pathway-related proteins, β-catenin and c-Myc. The results revealed that bortezomib could inhibit the proliferation of myeloma cells. The apoptotic rates of RPMI-8226 cells in the groups treated with 20, 50 and 80 nmol/l of bortezomib were 12.08±0.61, 35.97±3.11 and 57.22±5.47%, respectively, which were significantly higher than that in the control group (8.28±0.39%) (P<0.05). The expression levels of β-catenin and c-Myc in the experimental groups were significantly lower than those in the control group (P<0.05). Bortezomib can reduce the expression level of Wnt/β-catenin signaling pathway-related proteins, β-catenin and c-Myc, and may inhibit cell proliferation and accelerate apoptosis by activating the Wnt/β-catenin signaling pathway.
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Affiliation(s)
- Yanling Dai
- Department of Medical Laboratory Technology, Chuxiong Medical College, Chuxiong, Yunnan 675000, P.R. China
| | - Xiaomin Guo
- School of Nursing, Chuxiong Medical College, Chuxiong, Yunnan 675000, P.R. China
| | - Chunyan Yang
- Department of Pharmacy, Chuxiong Medical College, Chuxiong, Yunnan 675000, P.R. China
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13
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Schjesvold F. Evolution of diagnostic workup and treatment for multiple myeloma 2013-2019. Eur J Haematol 2020; 105:434-448. [PMID: 32557833 DOI: 10.1111/ejh.13464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 06/01/2020] [Accepted: 06/03/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To evaluate changes in diagnostic and therapeutic approach in multiple myeloma among Norwegian hematologists in the current decade. METHODS This nationwide study in Norway is based on results of surveys conducted among professionally active hematologists from 2013 to 2019. Every year, respondents participating in the survey suggested treatment regimens used in typical clinical situations in patients with multiple myeloma, as well as diagnostic routines. RESULTS The use of regimens containing alkylators and thalidomide was common at the beginning of the studied period. Later, lenalidomide became the most preferred treatment in most first-line patients. Bortezomib maintained a stable position in the treatment of myeloma in patients with renal insufficiency. The lenalidomide, bortezomib, and dexamethasone combination became the preferred frontline triplet for transplant-ineligible patients and induction therapy before transplant. Nowadays, the relapse after lenalidomide-based treatment is managed using both bortezomib-based therapies and combinations with the newest agents. Together with the therapeutic landscape, the use of diagnostic criteria and workup as well as supportive care changed in the period influenced by local and international guidelines and recommendations. CONCLUSION Norwegian hematologists gradually adopt new clinical concepts, guidelines, and recommendations in their practice.
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Affiliation(s)
- Fredrik Schjesvold
- Oslo Myeloma Center, Oslo University Hospital, Oslo, Norway.,KG Jebsen Center for B cell Malignancies, University of Oslo, Oslo, Norway
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14
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Ikeda T, Mori K, Kawamura K, Mori T, Hagiwara S, Ueda Y, Kahata K, Uchida N, Tsukada N, Murakami S, Yamamoto M, Takahashi T, Ichinohe T, Onizuka M, Atsuta Y, Kanda Y, Okamoto S, Sunami K, Takamatsu H. Comparison between autologous and allogeneic stem cell transplantation as salvage therapy for multiple myeloma relapsing/progressing after autologous stem cell transplantation. Hematol Oncol 2019; 37:586-594. [DOI: 10.1002/hon.2688] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 09/22/2019] [Accepted: 10/01/2019] [Indexed: 11/05/2022]
Affiliation(s)
- Takashi Ikeda
- Division of Hematology and Stem Cell TransplantationShizuoka Cancer Center Shizuoka Japan
| | - Keita Mori
- Division of Hematology and Stem Cell TransplantationShizuoka Cancer Center Shizuoka Japan
| | - Koji Kawamura
- Division of HematologyJichi Medical University Saitama Medical Center Saitama Japan
| | - Takehiko Mori
- Division of Hematology, Department of MedicineKeio University School of Medicine Tokyo Japan
| | - Shotaro Hagiwara
- Department of HematologyTokyo Women's Medical University Tokyo Japan
| | - Yasunori Ueda
- Department of Hematology/Oncology and Transfusion and Hemapheresis CenterKurashiki Central Hospital Okayama Japan
| | - Kaoru Kahata
- Department of HematologyHokkaido University Hospital Hokkaido Japan
| | - Naoyuki Uchida
- Department of HematologyFederation of National Public Service Personnel Mutual Aid Associations Toranomon Hospital Tokyo Japan
| | - Nobuhiro Tsukada
- Division of HematologyJapanese Red Cross Medical Center Tokyo Japan
| | - Satoshi Murakami
- Department of HematologyJapan Community Health Care Organization Kyoto Kuramaguchi Medical Center Kyoto Japan
| | - Masahide Yamamoto
- Department of HematologyTokyo Medical and Dental University Tokyo Japan
| | - Tsutomu Takahashi
- Department of Oncology/HematologyShimane University Hospital Shimane Japan
| | - Tatsuo Ichinohe
- Department of Hematology and Oncology, Research Institute for Radiation Biology and MedicineHiroshima University Hiroshima Japan
| | - Makoto Onizuka
- Department of Hematology and OncologyTokai University School of Medicine Kanagawa Japan
| | - Yoshiko Atsuta
- Japanese Data Center for Hematopoietic Cell Transplantation Aichi Japan
- Department of Healthcare AdministrationNagoya University Graduate School of Medicine Aichi Japan
| | - Yoshinobu Kanda
- Division of HematologyJichi Medical University Saitama Medical Center Saitama Japan
- Division of Hematology, Department of MedicineJichi Medical University Tochigi Japan
| | - Shinichiro Okamoto
- Division of Hematology, Department of MedicineKeio University School of Medicine Tokyo Japan
| | - Kazutaka Sunami
- Department of HematologyNational Hospital Organization Okayama Medical Center Okayama Japan
| | - Hiroyuki Takamatsu
- Department of Hematology/Respiratory Medicine, Faculty of Medicine, Institute of Medical, Pharmaceutical and Health SciencesKanazawa University Ishikawa Japan
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15
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Mina R, Lonial S. Is there still a role for stem cell transplantation in multiple myeloma? Cancer 2019; 125:2534-2543. [PMID: 30985927 DOI: 10.1002/cncr.32060] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 07/16/2018] [Accepted: 07/23/2018] [Indexed: 12/16/2022]
Abstract
High-dose chemotherapy and autologous stem cell transplantation (ASCT) are a standard of care for transplant-eligible patients with newly diagnosed multiple myeloma (MM). The introduction of novel agents, which range from immunomodulatory drugs and proteasome inhibitors to monoclonal antibodies and have now been integrated into both induction and salvage regimens, has dramatically revolutionized the treatment landscape of MM and challenged the role of high-dose chemotherapy and ASCT in treating MM. These advances have led to a number of provocative questions. First, what is the current role of stem cell transplantation (SCT) in comparison with standard-dose therapy incorporating novel agents? Second, should ASCT be performed upfront ("early") or later ("delayed") in the course of the disease? Third, should single or double ASCT be performed? Fourth, is allogeneic SCT still an option for patients with MM? This article provides an overview of available data and evidence-based responses regarding the role of SCT in MM.
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Affiliation(s)
- Roberto Mina
- Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Sagar Lonial
- Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
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16
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Hagen PA, Stiff P. The Role of Salvage Second Autologous Hematopoietic Cell Transplantation in Relapsed Multiple Myeloma. Biol Blood Marrow Transplant 2019; 25:e98-e107. [DOI: 10.1016/j.bbmt.2018.12.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 12/05/2018] [Indexed: 10/27/2022]
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17
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Abstract
Despite significant progress in our understanding and the development of novel therapies, most patients with multiple myeloma will experience relapse of their disease. Therapy of relapsed myeloma has improved due to the availability of novel agents that are highly active against the disease. However, the selection of therapy can be challenging due to the emergence of toxicities, comorbidities and frailty. In the following we discuss our approach to the treatment of the patient with relapsed myeloma.
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Affiliation(s)
- Mohammed A Aljama
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - M Hasib Sidiqi
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - David Dingli
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA -
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18
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Manjappa S, Fiala MA, King J, Kohnen DA, Vij R. The efficacy of salvage autologous stem cell transplant among patients with multiple myeloma who received maintenance therapy post initial transplant. Bone Marrow Transplant 2018; 53:1483-1486. [PMID: 29795420 DOI: 10.1038/s41409-018-0216-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 03/14/2018] [Accepted: 04/15/2018] [Indexed: 11/09/2022]
Affiliation(s)
- Shivaprasad Manjappa
- Division of Hospital Medicine, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Mark A Fiala
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Justin King
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Daniel A Kohnen
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Ravi Vij
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA.
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19
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Garderet L, Iacobelli S, Koster L, Goldschmidt H, Johansson JE, Bourhis JH, Krejci M, Leleu X, Potter M, Blaise D, Koenecke C, Peschel C, Radocha J, Metzner B, Lenain P, Schäfer-Eckart K, Pohlreich D, Grasso M, Caillot D, Einsele H, Ladetto M, Schönland S, Kröger N. Outcome of a Salvage Third Autologous Stem Cell Transplantation in Multiple Myeloma. Biol Blood Marrow Transplant 2018; 24:1372-1378. [PMID: 29408334 DOI: 10.1016/j.bbmt.2018.01.035] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2017] [Accepted: 01/26/2018] [Indexed: 11/16/2022]
Abstract
To evaluate the outcomes of salvage third autologous stem cell transplantation (ASCT) in patients with relapsed multiple myeloma. We analyzed 570 patients who had undergone a third ASCT between 1997 and 2010 (European Society for Blood and Marrow Transplantation data), of whom 482 patients underwent tandem ASCT and a third ASCT at first relapse (AARA group) and 88 patients underwent an upfront ASCT with second and third transplantations after subsequent relapses (ARARA group). With a median follow-up after salvage third ASCT of 61 months in the AARA group and 48 months in the ARARA group, the day +100 nonrelapse mortality in the 2 groups was 4% and 7%, the incidence of second primary malignancy was 6% and 7%, the median progression-free survival was 13 and 8 months, and median overall survival (OS) was 33 and 15 months. In the AARA group, according to the relapse-free interval (RFI) from the second ASCT, the median OS after the third ASCT was 17 months if the RFI was <18 months, 37 months if the RFI was between 18 and 36 months, and 64 months if the RFI was ≥36 months (P < .001). In the ARARA group, the median OS after the third ASCT was 7 months if the RFI was <6 months, 13 months if the RFI was between 6 and 18 months, and 27 months if the RFI was ≥18 months (P < .001). In a multivariate analysis of the AARA group, the favorable prognostic factor was an RFI after second ASCT of ≥18 months. Progressive disease and a Karnofsky Performance Status score of <70 at third ASCT were unfavorable factors. A salvage third ASCT is of value for patients with relapsed myeloma, particularly for those with a long duration of response and chemosensitive disease at the time of transplantation.
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Affiliation(s)
| | - Simona Iacobelli
- Department of Statistics, Rome University Tor Vergata, Rome, Italy
| | - Linda Koster
- European Society for Blood and Marrow Transplantation, Leiden, The Netherlands
| | | | - Jan-Erik Johansson
- Department of Hematology, Sahlgrenska University Hospital, Goeteborg, Sweden
| | - Jean Henri Bourhis
- Department of Hematology, Gustave Roussy Institut de Cancérologie, Villejuif, France
| | - Marta Krejci
- Department of Hematology, University Hospital Brno, Brno, Czech Republic
| | - Xavier Leleu
- Department of Hematology, Hôpital La Miletrie, Poitiers, France
| | - Michael Potter
- Department of Hematology, Royal Marsden Hospital, London Surrey, United Kingdom
| | - Didier Blaise
- Department of Hematology, Institut Paoli Calmettes, Marseille, France
| | | | | | - Jakub Radocha
- Department of Hematology, Charles University Hospital, Hradec Králové, Czech Republic
| | - Bernd Metzner
- Department of Hematology, Klinikum Oldenburg, Oldenburg, Germany
| | - Pascal Lenain
- Department of Hematology, Centre Henri Becquerel, Rouen, France
| | | | - David Pohlreich
- Department of Hematology, Charles University Hospital, Prague, Czech Republic
| | - Mariella Grasso
- Department of Hematology, Azienda Ospedaliera S Croce e Carle, Cuneo, Italy
| | - Denis Caillot
- Department of Hematology, Centre Hospitalier Universitaire de Dijon, Dijon, France
| | - Herman Einsele
- Department of Internal Medicine II, Universitätsklinikum Würzburg, Würzburg, Germany
| | - Marco Ladetto
- Department of Hematology, Azienda Ospedaliera SS Antonio e Biagio, Alessandria, Italy
| | - Stefan Schönland
- Department of Hematology, University of Heidelberg, Heidelberg, Germany
| | - Nicolaus Kröger
- Department of Hematology, Eppendorf University Hospital, Hamburg, Germany
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20
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Gay F, Engelhardt M, Terpos E, Wäsch R, Giaccone L, Auner HW, Caers J, Gramatzki M, van de Donk N, Oliva S, Zamagni E, Garderet L, Straka C, Hajek R, Ludwig H, Einsele H, Dimopoulos M, Boccadoro M, Kröger N, Cavo M, Goldschmidt H, Bruno B, Sonneveld P. From transplant to novel cellular therapies in multiple myeloma: European Myeloma Network guidelines and future perspectives. Haematologica 2018; 103:197-211. [PMID: 29217780 PMCID: PMC5792264 DOI: 10.3324/haematol.2017.174573] [Citation(s) in RCA: 91] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 12/05/2017] [Indexed: 12/20/2022] Open
Abstract
Survival of myeloma patients has greatly improved with the use of autologous stem cell transplantation and novel agents, such as proteasome inhibitors, immunomodulatory drugs and monoclonal antibodies. Compared to bortezomib- and lenalidomide-based regimens alone, the addition of high-dose melphalan followed by autologous transplantation significantly improves progression-free survival, although an overall survival benefit was not observed in all trials. Moreover, follow up of recent trials is still too short to show any difference in survival. In the light of these findings, novel agent-based induction followed by autologous transplantation is considered the standard upfront treatment for eligible patients (level of evidence: 1A). Post-transplant consolidation and maintenance treatment can further improve patient outcome (1A). The availability of several novel agents has led to the development of multiple combination regimens such as salvage treatment options. In this context, the role of salvage autologous transplantation and allotransplant has not been extensively evaluated. In the case of prolonged remission after upfront autologous transplantation, another autologous transplantation at relapse can be considered (2B). Patients who experience early relapse and/or have high-risk features have a poor prognosis and may be considered as candidates for clinical trials that, in young and fit patients, may also include an allograft in combination with novel agents (2B). Ongoing studies are evaluating the role of novel cellular therapies, such as inclusion of antibody-based triplets and quadruplets, and chimeric antigen receptor-T cells. Despite encouraging preliminary results, longer follow up and larger patient numbers are needed before the clinical use of these novel therapies can be widely recommended.
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Affiliation(s)
- Francesca Gay
- Myeloma Unit, Division of Hematology, University of Torino, Azienda-Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Italy
| | - Monika Engelhardt
- Universitätsklinikum Freiburg, Medical Department, Hematology, Oncology & Stem Cell Transplantation, Freiburg, Germany
| | - Evangelos Terpos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Greece
| | - Ralph Wäsch
- Universitätsklinikum Freiburg, Medical Department, Hematology, Oncology & Stem Cell Transplantation, Freiburg, Germany
| | - Luisa Giaccone
- Department of Oncology, A.O.U Città della Salute e della Scienza di Torino, and Department of Molecular Biotechnology and Health Sciences, University of Torino, Italy
| | - Holger W Auner
- Centre for Haematology, Department of Medicine, Imperial College London, UK
| | - Jo Caers
- Department of Clinical Hematology, Centre Hospitalier Universitaire de Liège, Domaine Universitaire du Sart Tilman, Liège, Belgium
| | - Martin Gramatzki
- Division of Stem Cell Transplantation and Immunotherapy, 2 Medical Department, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Niels van de Donk
- Department of Hematology, VU University Medical Center, Amsterdam, the Netherlands
| | - Stefania Oliva
- Myeloma Unit, Division of Hematology, University of Torino, Azienda-Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Italy
| | - Elena Zamagni
- Seragnoli Institute of Hematology, Bologna University School of Medicine, Italy
| | - Laurent Garderet
- INSERM, UMR_S 938, Proliferation and Differentiation of Stem Cells, Paris, AP-HP, Hôpital Saint Antoine, Département d'Hématologie et de Thérapie Cellulaire; Sorbonne Universités, UPMC Univ Paris 06, France
| | | | - Roman Hajek
- Department of Hematooncology, University Hospital Ostrava, Czech Republic and Faculty of Medicine University of Ostrava, Czech Republic
| | - Heinz Ludwig
- Wilhelminen Cancer Research Institute, c/o Department of Medicine I, Center of Oncology, Hematology and Palliative Care, Vienna, Austria
| | - Herman Einsele
- Department of Internal Medicine II, University Hospital Würzburg, Germany
| | - Meletios Dimopoulos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Greece
| | - Mario Boccadoro
- Myeloma Unit, Division of Hematology, University of Torino, Azienda-Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Italy
| | - Nicolaus Kröger
- Department of Stem cell Transplantation, University Medical Center Hamburg-Eppendorf, Germany
| | - Michele Cavo
- Seragnoli Institute of Hematology, Bologna University School of Medicine, Italy
| | - Hartmut Goldschmidt
- Medizinische Klinik, Abteilung Innere Medizin V, Universitätsklinikum Heidelberg und National Centrum für Tumorerkrankungen (NCT), Heidelberg, Germany
| | - Benedetto Bruno
- Department of Oncology, A.O.U Città della Salute e della Scienza di Torino, and Department of Molecular Biotechnology and Health Sciences, University of Torino, Italy
| | - Pieter Sonneveld
- Department of Hematology, Erasmus Medical Center, Rotterdam, the Netherlands
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21
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Gössi U, Jeker B, Mansouri Taleghani B, Bacher U, Novak U, Betticher D, Egger T, Zander T, Pabst T. Prolonged survival after second autologous transplantation and lenalidomide maintenance for salvage treatment of myeloma patients at first relapse after prior autograft. Hematol Oncol 2018; 36:436-444. [DOI: 10.1002/hon.2490] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 12/08/2017] [Accepted: 12/11/2017] [Indexed: 11/07/2022]
Affiliation(s)
- Ursina Gössi
- Department of Medical Oncology; Inselspital, University Hospital of Bern; Bern Switzerland
| | - Barbara Jeker
- Department of Medical Oncology; Inselspital, University Hospital of Bern; Bern Switzerland
| | | | - Ulrike Bacher
- Department of Hematology; Inselspital, University Hospital of Bern; Bern Switzerland
| | - Urban Novak
- Department of Medical Oncology; Inselspital, University Hospital of Bern; Bern Switzerland
| | - Daniel Betticher
- Department of Oncology; Kantonsspital Fribourg; Fribourg Switzerland
| | - Thomas Egger
- Department of Oncology; Kantonsspital Solothurn; Solothurn Switzerland
| | - Thilo Zander
- Department of Oncology; Kantonsspital Lucerne; Lucerne Switzerland
| | - Thomas Pabst
- Department of Medical Oncology; Inselspital, University Hospital of Bern; Bern Switzerland
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Muta T, Miyamoto T, Kamimura T, Kanda Y, Nohgawa M, Ueda Y, Iwato K, Sasaki O, Mori T, Uchida N, Iida S, Fukuda T, Atsuta Y, Sunami K. Significance of Salvage Autologous Stem Cell Transplantation for Relapsed Multiple Myeloma: A Nationwide Retrospective Study in Japan. Acta Haematol 2018; 139:35-44. [PMID: 29339642 DOI: 10.1159/000484652] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 10/24/2017] [Indexed: 12/20/2022]
Abstract
Autologous stem cell transplantation (ASCT) has been employed for patients with relapsed multiple myeloma (MM) after up-front ASCT. The present retrospective study aimed to examine the survival benefit from salvage ASCT. Among 446 patients with relapsed MM after up-front single ASCT, 70 patients received salvage ASCT, the employment of which reduced the risk of mortality after relapse (p = 0.041). Using the parameters before initial ASCT, the advantage of salvage ASCT compared to standard therapy was confirmed in the subgroup with an international staging system stage of I or II (p = 0.040), good performance status (PS; p = 0.043), or no/mild renal comorbidity (p = 0.029). The advantage of salvage ASCT was also confirmed in the subgroup excluding those with early relapse within 7 months after initial ASCT (p = 0.026). Among patients who received salvage ASCT, a favorable prognosis is apparent for those with a time to relapse after initial ASCT of longer than 24 months. The overall survival after salvage ASCT was favorable excluding patients with the following factors: early relapse, poor PS, moderate/severe renal comorbidity, and progressive disease (p < 0.001). In conclusion, our results reinforced the evidence for encouraging salvage ASCT for eligible patients.
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Affiliation(s)
- Tsuyoshi Muta
- Department of Hematology/Oncology, Japan Community Health Care Organization (JCHO), Kyushu Hospital, Kita-Kyushu, Japan
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Hari P, Romanus D, Luptakova K, Blazer M, Yong C, Raju A, Farrelly E, Labotka R, Morrison VA. The impact of age and comorbidities on practice patterns and outcomes in patients with relapsed/refractory multiple myeloma in the era of novel therapies. J Geriatr Oncol 2018; 9:138-44. [PMID: 29056336 DOI: 10.1016/j.jgo.2017.09.007] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 08/29/2017] [Accepted: 09/28/2017] [Indexed: 12/25/2022]
Abstract
OBJECTIVES One-third of patients with multiple myeloma (MM) are diagnosed at age≥75years. Older patients have increased incidence of cardiovascular disease (CVD) and renal insufficiency (RI), hallmark complications of MM. We examined cumulative incidence of CVD and RI in relapsed/refractory MM (RRMM) and outcomes by age and RI/CVD. MATERIALS AND METHODS Retrospective cohort study using a large US electronic medical records database of adult patients with RRMM initiating first- and second-line therapy (2LT) between 1/2008-06/2015. RI and CVD comorbidities were based on diagnosis codes and/or lab values. RESULTS Among 628 patients, 37.1% were ≥75years. Cumulative incidence of CVD and/or RI increased from 47.7% at MM diagnosis to 67.8% at first relapse. Age≥75years had a trend toward higher risk of relapse post 2LT, proxied by time to next treatment (TTNT), (adjusted HR: 1.28; 95% CI: 1.00, 1.65; P=0.05). TTNT was significantly higher with comorbid CVD+RI (adjusted HR: 1.50; 95% CI: 1.11, 2.02; P<0.01). Age≥75years, RI, CVD, and CVD+RI were associated with increased mortality risk from 2LT initiation; adjusted HR: 1.66 (95% CI: 1.19, 2.33; P<0.01), 1.51 (95% CI: 1.01, 2.26; P=0.04), 1.75 (95% CI: 1.03, 2.96; P=0.04), and 1.95 (95% CI: 1.29, 2.93; P<0.01), respectively. CONCLUSION Despite treatment with novel agents for RRMM in 86% of patients, an outcome gap persists for older patients and those with RI and/or CVD. Personalized treatment approaches that account for age and comorbidities, and further evaluation of innovative regimens and dosing schedules, are needed to improve outcomes for these patients.
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Tremblay D, Lancman G, Moshier E, Bar N, Jagannath S, Chari A. Outcomes of salvage autologous stem cell transplantation for multiple myeloma with cytopenias and exposure to novel agents. Bone Marrow Transplant 2017; 52:1468-70. [DOI: 10.1038/bmt.2017.160] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Abstract
In the current evolving landscape of myeloma therapies, no recommended salvage strategy exists for patients with relapsed multiple myeloma (MM) after initial successful autologous stem cell transplantation (ASCT) and therapeutic options extend from conventional chemotherapy and novel agents to second autologous and allogeneic transplants. In this article, we summarize the documented evidence about the utilization of second ASCT in patients with relapsed MM after a primary auto-graft and discuss the correct timing for such a salvage approach, the individual characteristics of patients who will benefit more, as well as the therapeutic role of second ASCT in the modern era of forthcoming anti-myeloma treatments.
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Affiliation(s)
- Dimitrios C Ziogas
- a Department of Clinical Therapeutics , Alexandra General Hospital, National and Kapodistrian University of Athens, School of Medicine , Athens , Greece
| | - Evangelos Terpos
- a Department of Clinical Therapeutics , Alexandra General Hospital, National and Kapodistrian University of Athens, School of Medicine , Athens , Greece
| | - Meletios A Dimopoulos
- a Department of Clinical Therapeutics , Alexandra General Hospital, National and Kapodistrian University of Athens, School of Medicine , Athens , Greece
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26
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Garderet L, Cook G, Auner HW, Bruno B, Lokhorst H, Perez-Simon JA, Sahebi F, Scheid C, Morris C, van Biezen A, Sobh M, Michallet M, Gahrton G, Schönland S, Kröger N. Treatment options for relapse after autograft in multiple myeloma – report from an EBMT educational meeting. Leuk Lymphoma 2016; 58:797-808. [DOI: 10.1080/10428194.2016.1228926] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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27
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Varmavuo V, Silvennoinen R, Anttila P, Säily M, Sankelo M, Putkonen M, Ahonen J, Mahlamäki E, Mäntymaa P, Savolainen ER, Remes K, Jantunen E. Cost analysis of a randomized stem cell mobilization study in multiple myeloma. Ann Hematol 2016; 95:1653-9. [DOI: 10.1007/s00277-016-2772-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 07/26/2016] [Indexed: 02/07/2023]
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28
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Cook G, Ashcroft AJ, Cairns DA, Williams CD, Brown JM, Cavenagh JD, Snowden JA, Parrish C, Yong K, Cavet J, Hunter H, Bird JM, Pratt G, Chown S, Heartin E, O'connor S, Drayson MT, Hockaday A, Morris TCM. 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. The 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] [What about the content of this article? (0)] [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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Abstract
INTRODUCTION Despite the progress made in the treatment of patients with multiple myeloma over recent decades, a significant cohort with high-risk disease as defined by specific clinical and genetic criteria continue to respond poorly to standard treatment. These patients represent a particular challenge to the treating physician and require early identification as well as personalized treatment strategies. AREAS COVERED In this review, we discuss the prognostic impact of adverse clinical, radiological and genetic factors, evaluate available scoring systems and highlight key aspects of the therapeutic management of high-risk myeloma. MEDLINE and recent scientific meetings' databases were searched for the keywords 'high-risk' and 'multiple myeloma' and relevant studies relating to both diagnostic and therapeutic approaches were identified. Expert commentary: A case is made for intensive induction using combinations of novel agents, early high-dose therapy supported by autologous stem cell transplantation and the widespread use of maintenance therapies. Novel therapeutic options, especially in the field of immunotherapy, are currently explored in clinical trials and have the potential to further improve outcomes for patients with high-risk multiple myeloma.
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Affiliation(s)
- Nicola Lehners
- a Department of Hematology , University Hospital of Heidelberg , Heidelberg , Germany
| | - Patrick J Hayden
- b Academic Department of Haematology , St. James's Hospital, Trinity College Dublin, College Green , Dublin 2 , Ireland
| | - Hartmut Goldschmidt
- a Department of Hematology , University Hospital of Heidelberg , Heidelberg , Germany
| | - Marc-Steffen Raab
- a Department of Hematology , University Hospital of Heidelberg , Heidelberg , Germany
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30
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Franssen LE, Raymakers RAP, Buijs A, Schmitz MF, van Dorp S, Mutis T, Lokhorst HM, van de Donk NWCJ. Outcome of allogeneic transplantation in newly diagnosed and relapsed/refractory multiple myeloma: long-term follow-up in a single institution. Eur J Haematol 2016; 97:479-488. [DOI: 10.1111/ejh.12758] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Laurens E. Franssen
- Department of Hematology; University Medical Center Utrecht; Utrecht the Netherlands
- Department of Hematology; VU University Medical Center; Amsterdam the Netherlands
| | | | - Arjan Buijs
- Department of Genetics; University Medical Center Utrecht; Utrecht the Netherlands
| | - Marian F. Schmitz
- Department of Hematology; University Medical Center Utrecht; Utrecht the Netherlands
| | - Suzanne van Dorp
- Department of Hematology; Radboud University Medical Center; Nijmegen the Netherlands
| | - Tuna Mutis
- Department of Hematology; VU University Medical Center; Amsterdam the Netherlands
| | - Henk M. Lokhorst
- Department of Hematology; University Medical Center Utrecht; Utrecht the Netherlands
- Department of Hematology; VU University Medical Center; Amsterdam the Netherlands
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31
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Giralt S, Garderet L, Durie B, Cook G, Gahrton G, Bruno B, Hari P, Lokhorst H, McCarthy P, Krishnan A, Sonneveld P, Goldschmidt H, Jagannath S, Barlogie B, Mateos M, Gimsing P, Sezer O, Mikhael J, Lu J, Dimopoulos M, Mazumder A, Palumbo A, Abonour R, Anderson K, Attal M, Blade J, Bird J, Cavo M, Comenzo R, de la Rubia J, Einsele H, Garcia-Sanz R, Hillengass J, Holstein S, Johnsen HE, Joshua D, Koehne G, Kumar S, Kyle R, Leleu X, Lonial S, Ludwig H, Nahi H, Nooka A, Orlowski R, Rajkumar V, Reiman A, Richardson P, Riva E, San Miguel J, Turreson I, Usmani S, Vesole D, Bensinger W, Qazilbash M, Efebera Y, Mohty M, Gasparreto C, Gajewski J, LeMaistre CF, Bredeson C, Moreau P, Pasquini M, Kroeger N, Stadtmauer E. American Society of Blood and Marrow Transplantation, European Society of Blood and Marrow Transplantation, Blood and Marrow Transplant Clinical Trials Network, and International Myeloma Working Group Consensus Conference on Salvage Hematopoietic Cell Transplantation in Patients with Relapsed Multiple Myeloma. Biol Blood Marrow Transplant 2015; 21:2039-2051. [PMID: 26428082 PMCID: PMC4757494 DOI: 10.1016/j.bbmt.2015.09.016] [Citation(s) in RCA: 121] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Accepted: 09/21/2015] [Indexed: 12/14/2022]
Abstract
In contrast to the upfront setting in which the role of high-dose therapy with autologous hematopoietic cell transplantation (HCT) as consolidation of a first remission in patients with multiple myeloma (MM) is well established, the role of high-dose therapy with autologous or allogeneic HCT has not been extensively studied in MM patients relapsing after primary therapy. The International Myeloma Working Group together with the Blood and Marrow Transplant Clinical Trials Network, the American Society of Blood and Marrow Transplantation, and the European Society of Blood and Marrow Transplantation convened a meeting of MM experts to: (1) summarize current knowledge regarding the role of autologous or allogeneic HCT in MM patients progressing after primary therapy, (2) propose guidelines for the use of salvage HCT in MM, (3) identify knowledge gaps, (4) propose a research agenda, and (5) develop a collaborative initiative to move the research agenda forward. After reviewing the available data, the expert committee came to the following consensus statement for salvage autologous HCT: (1) In transplantation-eligible patients relapsing after primary therapy that did NOT include an autologous HCT, high-dose therapy with HCT as part of salvage therapy should be considered standard; (2) High-dose therapy and autologous HCT should be considered appropriate therapy for any patients relapsing after primary therapy that includes an autologous HCT with initial remission duration of more than 18 months; (3) High-dose therapy and autologous HCT can be used as a bridging strategy to allogeneic HCT; (4) The role of postsalvage HCT maintenance needs to be explored in the context of well-designed prospective trials that should include new agents, such as monoclonal antibodies, immune-modulating agents, and oral proteasome inhibitors; (5) Autologous HCT consolidation should be explored as a strategy to develop novel conditioning regimens or post-HCT strategies in patients with short (less than 18 months remissions) after primary therapy; and (6) Prospective randomized trials need to be performed to define the role of salvage autologous HCT in patients with MM relapsing after primary therapy comparing it to "best non-HCT" therapy. The expert committee also underscored the importance of collecting enough hematopoietic stem cells to perform 2 transplantations early in the course of the disease. Regarding allogeneic HCT, the expert committee agreed on the following consensus statements: (1) Allogeneic HCT should be considered appropriate therapy for any eligible patient with early relapse (less than 24 months) after primary therapy that included an autologous HCT and/or high-risk features (ie, cytogenetics, extramedullary disease, plasma cell leukemia, or high lactate dehydrogenase); (2) Allogeneic HCT should be performed in the context of a clinical trial if possible; (3) The role of postallogeneic HCT maintenance therapy needs to be explored in the context of well-designed prospective trials; and (4) Prospective randomized trials need to be performed to define the role salvage allogeneic HCT in patients with MM relapsing after primary therapy.
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Affiliation(s)
- Sergio Giralt
- Weill Cornell Medical College, Memorial Sloan Kettering Cancer Center, New York, New York.
| | | | - Brian Durie
- International Myeloma Foundation, Los Angeles, California
| | - Gordon Cook
- St. James University Hospital, Leed, United Kingdom
| | | | | | | | | | | | | | | | | | | | | | - Maria Mateos
- Hospital Universitario de Salamanca, Salamanca, Spain
| | | | | | | | - Jin Lu
- Peking University Institute of Hematology, People's Hospital, Beijing, Peoples Republic of China
| | - Meletios Dimopoulos
- National and Kapodistrian University of Athens Alexandra Hospital, Athens, Greece
| | | | | | - Rafat Abonour
- Indiana University Melvin and Bren Simon Cancer Center, Indianapolis, Indiana
| | - Kenneth Anderson
- Dana Farber Cancer Institute, Harvard University, Boston, Massachusetts
| | | | - Joan Blade
- Hospital Clinic, IDIBAPS, Barcelona, Spain
| | - Jenny Bird
- University Hospital Bristol, Bristol, United Kingdom
| | - Michele Cavo
- Seragnoli Institut of Hematology, Bologna University School of Medicine, Bologna, Italy
| | | | | | | | | | | | | | | | - Douglas Joshua
- Royal Prince Alfred Hospital, Sydney University Medical School, Sydney, Australia
| | - Guenther Koehne
- Weill Cornell Medical College, Memorial Sloan Kettering Cancer Center, New York, New York
| | | | | | | | - Sagar Lonial
- Emory University School of Medicine, Winship Cancer Institute, Atlanta, Georgia
| | - Heinz Ludwig
- Wilhelminenkrebsforschungsinstituts, Vienna, Austria
| | | | - Anil Nooka
- Emory University School of Medicine, Winship Cancer Institute, Atlanta, Georgia
| | - Robert Orlowski
- University of Texas MD Anderson Cancer Center, Houston, Texas
| | | | - Anthony Reiman
- Dalhousie University Medical School, Dalhousie, Nova Scotia, Canada
| | - Paul Richardson
- Dana Farber Cancer Institute, Harvard University, Boston, Massachusetts
| | | | | | | | - Saad Usmani
- Levine Cancer Institute, Charlotte, North Carolina
| | - David Vesole
- John Theurer Cancer Center, Hackensack, New Jersey
| | | | | | | | - Mohamed Mohty
- University Marie and Pierre Curie, Hospital St Antoine, Paris, France
| | | | | | | | - Chris Bredeson
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | | | | | | | - Edward Stadtmauer
- University of Pennsylvania Abramson Cancer Center, Philadelphia, Pennsylvania
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