51
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Goswami C, Poonia S, Kumar L, Sengupta D. Staging System to Predict the Risk of Relapse in Multiple Myeloma Patients Undergoing Autologous Stem Cell Transplantation. Front Oncol 2019; 9:633. [PMID: 31355145 PMCID: PMC6640159 DOI: 10.3389/fonc.2019.00633] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 06/26/2019] [Indexed: 02/06/2023] Open
Abstract
Over the last decade autologous stem cell transplantation (ASCT) has emerged as the standard of care in the management of Multiple Myeloma (MM). However, the cases of early relapse (within 36 months) after the stem cell rescue remains a significant challenge. For a lot of practical purposes, it is crucial to identify whether a patient undergoing ASCT falls into the high-risk group (likely to relapse within 36 months) or a low risk one. Our analysis showed that existing MM staging systems (International Staging System or ISS and Durie Salmon Staging or DSS) are not sufficient to discriminate between the risk groups significantly. To address this, we gathered a total of 39 clinical and laboratory parameters of 347 patients from the Department of Medical Oncology of All India Institute of Medical Sciences (AIIMS). We employed a stacked machine learning model consisting spectral clustering and Fast and Frugal Tree (FFT) technique to come up with a 3-factor multivariate 2-stage staging scheme, which turns out to be extremely decisive about the outcome of the stem cell rescue. Our model comes up with a three-factor (1. if patients has relapsed following remission, 2. response to induction, 3. pre-transplant Glomerular Filtration Rate or GFR) staging scheme. The resulting model stratifies patients into high-risk and low-risk groups with markedly distinct progression-free (median survival—24 months vs. 91 months) and overall survival (median survival—51 months vs. 135 months) patterns.
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Affiliation(s)
- Chitrita Goswami
- Department of Computer Science and Engineering, Indraprastha Institute of Information Technology, New Delhi, India
| | - Sarita Poonia
- Department of Computational Biology, Indraprastha Institute of Information Technology, New Delhi, India
| | - Lalit Kumar
- Department of Medical Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Debarka Sengupta
- Department of Computer Science and Engineering, Indraprastha Institute of Information Technology, New Delhi, India.,Department of Computational Biology, Indraprastha Institute of Information Technology, New Delhi, India.,Infosys Center for Artificial Intelligence, Indraprastha Institute of Information Technology, New Delhi, India
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52
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Biran N, Rowley SD, Vesole DH, Zhang S, Donato ML, Skarbnik AP, Richter J, Pecora A, Siegel DS. A phase I/II study of escalating doses of thalidomide in conjunction with bortezomib and high-dose melphalan as a conditioning regimen for autologous stem cell transplantation in patients with multiple myeloma. Bone Marrow Transplant 2019; 54:1881-1891. [PMID: 31101891 DOI: 10.1038/s41409-019-0534-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 02/27/2019] [Accepted: 04/12/2019] [Indexed: 11/09/2022]
Abstract
A regimen of escalating doses of thalidomide, in combination with bortezomib and high-dose melphalan (mel/vel/thal), was evaluated as a conditioning regimen for autologous stem cell transplantation (ASCT) in multiple myeloma (MM) patients with a prior transplant who had relapsed or achieved less than a complete remission following a prior ASCT. Thalidomide was dose escalated starting from 600 mg to 1000 mg on days -5 to -1 in a 3 × 3 design, bortezomib was administered at 1.6 mg/m2 intravenously on days -4 and -1 and melphalan 200 mg/m2 was administered on day -2. No dose-limiting toxicity was seen in the phase I portion of the trial. An additional 20 patients were enrolled at the maximum tolerated dose of thalidomide of 1000 mg daily. The overall response rate was 69% with 38% complete remission. Median PFS and OS were 9.3 and 65.4 months, respectively, with a median follow-up of 17.8 months. The most common grade 3-4 adverse events (AEs) were neutropenic fever (58.6%), mucositis (6.9%), and diarrhea (6.9%). Serious AEs included somnolence (13.8%) and tumor lysis syndrome (3.4%). The addition of high-dose thalidomide to bortezomib and melphalan as conditioning for salvage ASCT was well tolerated and was an effective conditioning regimen.
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Affiliation(s)
- Noa Biran
- John Theurer Cancer Center at Hackensack Meridian, Seton Hall University School of Medicine, Hackensack, NJ, USA.
| | - Scott D Rowley
- John Theurer Cancer Center at Hackensack Meridian, Seton Hall University School of Medicine, Hackensack, NJ, USA
| | - David H Vesole
- John Theurer Cancer Center at Hackensack Meridian, Seton Hall University School of Medicine, Hackensack, NJ, USA
| | - Shijia Zhang
- University of Minnesota School of Medicine, Minneapolis, MN, USA
| | - Michele L Donato
- John Theurer Cancer Center at Hackensack Meridian, Seton Hall University School of Medicine, Hackensack, NJ, USA
| | | | - Joshua Richter
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Andrew Pecora
- John Theurer Cancer Center at Hackensack Meridian, Seton Hall University School of Medicine, Hackensack, NJ, USA
| | - David S Siegel
- John Theurer Cancer Center at Hackensack Meridian, Seton Hall University School of Medicine, Hackensack, NJ, USA
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53
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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] [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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54
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Mikhael J, Ismaila N, Cheung MC, Costello C, Dhodapkar MV, Kumar S, Lacy M, Lipe B, Little RF, Nikonova A, Omel J, Peswani N, Prica A, Raje N, Seth R, Vesole DH, Walker I, Whitley A, Wildes TM, Wong SW, Martin T. Treatment of Multiple Myeloma: ASCO and CCO Joint Clinical Practice Guideline. J Clin Oncol 2019; 37:1228-1263. [PMID: 30932732 DOI: 10.1200/jco.18.02096] [Citation(s) in RCA: 177] [Impact Index Per Article: 35.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
PURPOSE To provide evidence-based recommendations on the treatment of multiple myeloma to practicing physicians and others. METHODS ASCO and Cancer Care Ontario convened an Expert Panel of medical oncology, surgery, radiation oncology, and advocacy experts to conduct a literature search, which included systematic reviews, meta-analyses, randomized controlled trials, and some phase II studies published from 2005 through 2018. Outcomes of interest included survival, progression-free survival, response rate, and quality of life. Expert Panel members used available evidence and informal consensus to develop evidence-based guideline recommendations. RESULTS The literature search identified 124 relevant studies to inform the evidence base for this guideline. RECOMMENDATIONS Evidence-based recommendations were developed for patients with multiple myeloma who are transplantation eligible and those who are ineligible and for patients with relapsed or refractory disease.
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Affiliation(s)
- Joseph Mikhael
- 1 City of Hope Cancer Center, Phoenix, AZ.,2 International Myeloma Foundation, North Hollywood, CA
| | | | | | | | | | | | | | - Brea Lipe
- 8 University of Rochester Medical Center, Rochester, NY
| | | | - Anna Nikonova
- 10 Juravinski Cancer Center, Hamilton, Ontario, Canada
| | - James Omel
- 11 Education and Advocacy, Grand Island, NE
| | | | - Anca Prica
- 13 Princess Margaret Cancer Centre, Toronto, Ontario, Canada
| | - Noopur Raje
- 14 Massachusetts General Hospital, Boston, MA
| | - Rahul Seth
- 15 Upstate Medical University, Syracuse, NY
| | - David H Vesole
- 16 Hackensack University Medical Center, Hackensack, NJ.,17 Georgetown University, Washington, DC
| | - Irwin Walker
- 18 McMaster University, Hamilton, Ontario, Canada
| | | | | | - Sandy W Wong
- 21 University of California San Francisco, San Francisco, CA
| | - Tom Martin
- 21 University of California San Francisco, San Francisco, CA
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55
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Gonsalves WI, Buadi FK, Ailawadhi S, Bergsagel PL, Chanan Khan AA, Dingli D, Dispenzieri A, Fonseca R, Hayman SR, Kapoor P, Kourelis TV, Lacy MQ, Larsen JT, Muchtar E, Reeder CB, Sher T, Stewart AK, Warsame R, Go RS, Kyle RA, Leung N, Lin Y, Lust JA, Russell SJ, Zeldenrust SR, Fonder AL, Hwa YL, Hobbs MA, Mayo AA, Hogan WJ, Rajkumar SV, Kumar SK, Gertz MA, Roy V. Utilization of hematopoietic stem cell transplantation for the treatment of multiple myeloma: a Mayo Stratification of Myeloma and Risk-Adapted Therapy (mSMART) consensus statement. Bone Marrow Transplant 2019; 54:353-367. [PMID: 29988062 PMCID: PMC6463224 DOI: 10.1038/s41409-018-0264-8] [Citation(s) in RCA: 68] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Revised: 05/10/2018] [Accepted: 05/11/2018] [Indexed: 12/22/2022]
Abstract
Over the last two decades, the utilization of various novel therapies in the upfront or salvage settings has continued to improve survival outcomes for patients with Multiple Myeloma (MM). Thus, the conventional role for hematopoietic stem cell transplantation (HSCT) in MM either in the form of an autologous stem cell transplant (ASCT) or an allogeneic stem cell transplant (Allo-SCT) warrants re-evaluation, given the aforementioned clinical advances. Here, we present a consensus statement of our multidisciplinary group of over 30 Mayo Clinic physicians with a special interest in the care of patients with MM and provide evidence-based recommendations on the use of HSCT in MM. We specifically address topics that include the role and timing of an ASCT for MM in the era of novel agents, eligibility for an ASCT, post-ASCT consolidation, and maintenance options, and finally the utility of an upfront tandem ASCT, salvage second ASCT, and an allo-SCT in MM.
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Affiliation(s)
| | - Francis K Buadi
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Sikander Ailawadhi
- Division of Hematology and Medical Oncology, Mayo Clinic, Jacksonville, Florida, USA
| | - P Leif Bergsagel
- Division of Hematology and Medical Oncology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Asher A Chanan Khan
- Division of Hematology and Medical Oncology, Mayo Clinic, Jacksonville, Florida, USA
| | - David Dingli
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Rafael Fonseca
- Division of Hematology and Medical Oncology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Susan R Hayman
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Prashant Kapoor
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Martha Q Lacy
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jeremy T Larsen
- Division of Hematology and Medical Oncology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Eli Muchtar
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Craig B Reeder
- Division of Hematology and Medical Oncology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Taimur Sher
- Division of Hematology and Medical Oncology, Mayo Clinic, Jacksonville, Florida, USA
| | - A Keith Stewart
- Division of Hematology and Medical Oncology, Mayo Clinic, Scottsdale, Arizona, USA
| | - Rahma Warsame
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ronald S Go
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Robert A Kyle
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Nelson Leung
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Yi Lin
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - John A Lust
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | - Amie L Fonder
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Yi L Hwa
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Miriam A Hobbs
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Angela A Mayo
- Division of Hematology and Medical Oncology, Mayo Clinic, Scottsdale, Arizona, USA
| | - William J Hogan
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Shaji K Kumar
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Morie A Gertz
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Vivek Roy
- Division of Hematology and Medical Oncology, Mayo Clinic, Jacksonville, Florida, USA
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56
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Pros and cons of frontline autologous transplant in multiple myeloma: the debate over timing. Blood 2019; 133:652-659. [DOI: 10.1182/blood-2018-08-825349] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Accepted: 12/15/2018] [Indexed: 02/06/2023] Open
Abstract
Abstract
The treatment landscape for multiple myeloma has dramatically changed over the past decade with the introduction of several new classes of drugs, which are very effective at controlling the disease for prolonged periods of time, especially when used in multidrug combinations. Prior to the advent of these new agents, peripheral blood autologous stem cell transplantation (ASCT) was the mainstay of therapy for patients who were eligible to undergo the procedure, with deep and durable responses in the majority of patients. Despite the introduction of more effective therapies, ASCT continues to play an important role in overall management of younger patients, where it has been integrated with the other therapeutic approaches to provide maximum benefit. Recent phase 3 trials have once again confirmed the survival benefit associated with ASCT in myeloma. Retrospective studies have also demonstrated the feasibility of using ASCT at the time of first relapse rather than as a component of the initial treatment. Significant geographical variations exist in the use of ASCT, especially between the United States and Europe in terms of its use as part of upfront therapy. Much of these differences are driven by the availability of drugs and drug combinations for initial therapy of myeloma as well as maintenance approaches post-ASCT. It is amply clear from these trials that ASCT will continue to play an important role in management of myeloma and is likely to be used as a platform for enhancing the efficacy of other treatment modalities that are currently in development.
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57
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Jain T, Sonbol MB, Firwana B, Kolla KR, Almader-Douglas D, Palmer J, Fonseca R. High-Dose Chemotherapy with Early Autologous Stem Cell Transplantation Compared to Standard Dose Chemotherapy or Delayed Transplantation in Patients with Newly Diagnosed Multiple Myeloma: A Systematic Review and Meta-Analysis. Biol Blood Marrow Transplant 2019; 25:239-247. [DOI: 10.1016/j.bbmt.2018.09.021] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2018] [Accepted: 09/14/2018] [Indexed: 11/17/2022]
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58
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Rossi G, Falcone AP, Minervini MM, De Cillis GP, De Waure C, Sisti LG, Giambra V, Valente D, Chiello V, Scalzulli PR, Carella AM, Cascavilla N. Minimal residual disease and log-reduction of plasma cells are associated with superior response after double autologous stem cell transplant in younger patients with multiple myeloma. CYTOMETRY PART B-CLINICAL CYTOMETRY 2018; 96:195-200. [PMID: 30549231 DOI: 10.1002/cyto.b.21755] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 10/15/2018] [Accepted: 11/14/2018] [Indexed: 11/10/2022]
Abstract
BACKGROUND Optimization of chemotherapy regimens in the treatment of multiple myeloma (MM) has led to increase the frequency of cases with complete response (CR). Nonetheless, many MM patients still experience relapse, suggesting that CR represents a suboptimal response criteria, and that new therapeutic strategies are needed after single transplant. However, the role of double autologous stem cell transplant (ASCT) as new adjunctive strategy remains to be elucidated. Indeed, we investigated the role of minimal residual disease (MRD) and log-reduction of plasma cells (PCs) as predictors of outcome and in quantifying the degree of tumor reduction after any ASCT. METHODS MRD and log-reduction were assessed by a six-color flow cytometry (FC) at different time-points: post induction, post first-, and post-second ASCT. RESULTS A significant difference was evidenced among the three time points for both log-reduction (P < 0.001) and MRD (P = 0.005). MRD levels after double ASCT were lower than MRD levels achieved after single ASCT (P = 0.005) and after induction (P < 0.001). Frequency of MRD positive patients after double ASCT was significantly lower rather than after the first ASCT (P = 0.008) and after induction (P = 0.004). Interestingly, a significant reduction of PFS was observed in patients with an unfavorable-risk cytogenetic (P < 0.001) and patients with MRD over 0.01% (P = 0.001) as well as log-reduction lower than 2.57 (P = 0.018) after double ASCT. CONCLUSIONS Our results show that a better clearance of myeloma cells is observed after the double ASCT, and a longer PFS is associated with a lower MRD. © 2018 International Clinical Cytometry Society.
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Affiliation(s)
- Giovanni Rossi
- Department of Hematology and Stem Cell Transplant Unit, Fondazione IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo, Italy
| | - Antonietta Pia Falcone
- Department of Hematology and Stem Cell Transplant Unit, Fondazione IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo, Italy
| | - Maria Marta Minervini
- Department of Hematology and Stem Cell Transplant Unit, Fondazione IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo, Italy
| | - Giovanni Pio De Cillis
- Department of Hematology and Stem Cell Transplant Unit, Fondazione IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo, Italy
| | - Chiara De Waure
- Department of Hygiene, Catholic University of Sacred Heart, Rome, Italy
| | | | - Vincenzo Giambra
- Institute of Stem Cells Biology, Regenerative Medicine and Innovative Therapies (ISBReMIT), Fondazione IRCCS "Casa Sollievo della Sofferenza-IRCCS", San Giovanni Rotondo, Italy
| | - Daniela Valente
- Department of Hematology and Stem Cell Transplant Unit, Fondazione IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo, Italy
| | - Vincenzo Chiello
- Department of Hematology and Stem Cell Transplant Unit, Fondazione IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo, Italy
| | - Potito Rosario Scalzulli
- Department of Hematology and Stem Cell Transplant Unit, Fondazione IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo, Italy
| | - Angelo Michele Carella
- Department of Hematology and Stem Cell Transplant Unit, Fondazione IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo, Italy
| | - Nicola Cascavilla
- Department of Hematology and Stem Cell Transplant Unit, Fondazione IRCCS "Casa Sollievo della Sofferenza", San Giovanni Rotondo, Italy
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59
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Maffini E, Storer BE, Sandmaier BM, Bruno B, Sahebi F, Shizuru JA, Chauncey TR, Hari P, Lange T, Pulsipher MA, McSweeney PA, Holmberg L, Becker PS, Green DJ, Mielcarek M, Maloney DG, Storb R. Long-term follow up of tandem autologous-allogeneic hematopoietic cell transplantation for multiple myeloma. Haematologica 2018; 104:380-391. [PMID: 30262560 PMCID: PMC6355483 DOI: 10.3324/haematol.2018.200253] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 09/24/2018] [Indexed: 12/22/2022] Open
Abstract
We previously reported initial results in 102 multiple myeloma (MM) patients treated with sequential high-dose melphalan and autologous hematopoietic cell transplantation followed by 200 cGy total body irradiation with or without fludarabine 90 mg/m2 and allogeneic hematopoietic cell transplantation. Here we present long-term clinical outcomes among the 102 initial patients and among 142 additional patients, with a median follow up of 8.3 (range 1.0-18.1) years. Donors included human leukocyte antigen identical siblings (n=179) and HLA-matched unrelated donors (n=65). A total of 209 patients (86%) received tandem autologous-allogeneic upfront, while thirty-five patients (14%) had failed a previous autologous hematopoietic cell transplantation before the planned autologous-allogeneic transplantation. Thirty-one patients received maintenance treatment at a median of 86 days (range, 61-150) after allogeneic transplantation. Five-year rates of overall survival (OS) and progression-free survival (PFS) were 54% and 31%, respectively. Ten-year OS and PFS were 41% and 19%, respectively. Overall non-relapse mortality was 2% at 100 days and 14% at five years. Patients with induction-refractory disease and those with high-risk biological features experienced shorter OS and PFS. A total of 152 patients experienced disease relapse and 117 of those received salvage treatment. Eighty-three of the 117 patients achieved a clinical response, and for those, the median duration of survival after relapse was 7.8 years. Moreover, a subset of patients who became negative for minimal residual disease (MRD) by flow cytometry experienced a significantly lower relapse rate as compared with MRD-positive patients (P=0.03). Our study showed that the graft-versus-myeloma effect after non-myeloablative allografting allowed long-term disease control in standard and high-risk patient subsets. Ultra-high-risk patients did not appear to benefit from tandem autologous/allogeneic hematopoietic cell transplantation because of early disease relapse. Incorporation of newer anti-MM agents into the initial induction treatments before tandem hematopoietic cell transplantation and during maintenance might improve outcomes of ultra-high-risk patients. Clinical trials included in this study are registered at: clinicaltrials.gov identifiers: 00075478, 00005799, 01251575, 00078858, 00105001, 00027820, 00089011, 00003196, 00006251, 00793572, 00054353, 00014235, 00003954.
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Affiliation(s)
- Enrico Maffini
- Fred Hutchinson Cancer Research Center, Clinical Research Division, Seattle, WA, USA
| | - Barry E Storer
- Fred Hutchinson Cancer Research Center, Clinical Research Division, Seattle, WA, USA.,University of Washington School of Public Health, Seattle, WA, USA
| | - Brenda M Sandmaier
- Fred Hutchinson Cancer Research Center, Clinical Research Division, Seattle, WA, USA.,Department of Medicine, Seattle, WA, USA
| | - Benedetto Bruno
- University of Turin, Department of Molecular Biotechnology and Health Sciences, Turin, Italy
| | - Firoozeh Sahebi
- City of Hope National Medical Center/Southern California Kaiser Permanente Medical Group, Duarte, CA, USA
| | | | - Thomas R Chauncey
- Fred Hutchinson Cancer Research Center, Clinical Research Division, Seattle, WA, USA.,Department of Medicine, Seattle, WA, USA.,VA Puget Sound Medical Health Care System, Seattle, WA, USA
| | | | | | | | | | - Leona Holmberg
- Fred Hutchinson Cancer Research Center, Clinical Research Division, Seattle, WA, USA.,University of Washington School of Public Health, Seattle, WA, USA
| | - Pamela S Becker
- Fred Hutchinson Cancer Research Center, Clinical Research Division, Seattle, WA, USA.,Department of Medicine, Seattle, WA, USA
| | - Damian J Green
- Fred Hutchinson Cancer Research Center, Clinical Research Division, Seattle, WA, USA.,Department of Medicine, Seattle, WA, USA
| | - Marco Mielcarek
- Fred Hutchinson Cancer Research Center, Clinical Research Division, Seattle, WA, USA.,Department of Medicine, Seattle, WA, USA
| | - David G Maloney
- Fred Hutchinson Cancer Research Center, Clinical Research Division, Seattle, WA, USA.,Department of Medicine, Seattle, WA, USA
| | - Rainer Storb
- Fred Hutchinson Cancer Research Center, Clinical Research Division, Seattle, WA, USA .,Department of Medicine, Seattle, WA, USA
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60
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Farag S, Jeker B, Bacher U, Mansouri Taleghani B, Mueller BU, Novak U, Pabst T. Dose-intensified bendamustine and melphalan (BenMel) conditioning before second autologous transplantation in myeloma patients. Hematol Oncol 2018; 36:671-678. [PMID: 30110717 DOI: 10.1002/hon.2546] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Revised: 08/02/2018] [Accepted: 08/02/2018] [Indexed: 12/13/2022]
Abstract
Consolidation in myeloma patients with high-dose melphalan chemotherapy (Mel HDCT) and autologous transplantation (ASCT) is standard of care since more than 2 decades. However, definite cure remains exceptional despite intensive treatment, and improving effectiveness of HDCT remains an unmet clinical need. Combining intensified bendamustine with melphalan may represent an option. We analyzed safety and efficacy of combining dose-intensified bendamustine (200 mg/m2 on days -4/-3) with high-dose melphalan (100 mg/m2 on days -2/-1) before a second (tandem) ASCT in adverse risk myeloma patients after Mel HDCT/ASCT1. Twelve patients received BenMel conditioning before ASCT2 because of high-risk cytogenetics and/or failure to achieve complete remission (CR) after Mel HDCT/ASCT1. Comparing Mel HDCT/ASCT1 and BenMel HDCT/ASCT2, we observed no differences in hematologic recovery and tolerance. Acute renal injury after BenMel conditioning occurred in 3 (25%) patients, but was reversible in all patients, and there were no treatment related deaths. Complete remission rates were increasing from 42% after Mel/ASCT1 to 75% after BenMel/ASCT2. PFS 1 year after ASCT2 was 67%, and OS was 83%. These data suggest that dose-intensified bendamustine with melphalan conditioning is safe and warrants a prospective randomized comparison to standard melphalan HDCT in myeloma patients.
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Affiliation(s)
- Sarah Farag
- Department of Medical Oncology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Barbara Jeker
- Department of Medical Oncology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Ulrike Bacher
- Department of Hematology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | | | - Beatrice U Mueller
- Department of Biomedical Research, University of Bern, Bern, Switzerland
| | - Urban Novak
- Department of Medical Oncology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Thomas Pabst
- Department of Medical Oncology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
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61
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How I treat the young patient with multiple myeloma. Blood 2018; 132:1114-1124. [PMID: 29967130 DOI: 10.1182/blood-2017-05-693606] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 06/01/2018] [Indexed: 02/06/2023] Open
Abstract
The treatment landscape for multiple myeloma has been transformed by the introduction of novel agents, including immunomodulatory drugs, proteasome inhibitors, and monoclonal antibodies. These have been shown to be more effective and generally better tolerated than conventional chemotherapy, with their introduction into clinical practice leading to improved survival. Furthermore, a better understanding of disease biology, improved diagnostic criteria, and the development of sensitive and specific tools for disease prognostication have contributed to better outcome. Treatment in the younger patient can now be individualized based on host and disease features with enhanced monitoring of response and use of high-sensitivity techniques for evaluating residual disease. The current standard of care has been significantly enhanced by novel agents with a paradigm shift toward optional or delayed autologous stem cell transplant as a reasonable choice in selected patients. Conversely, extended treatment with induction of remission followed by maintenance strategies is now a standard of care, conferring prolonged disease control with more manageable toxicities in both the short and long term, as well as improved quality of life.
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Mahajan S, Tandon N, Kumar S. The evolution of stem-cell transplantation in multiple myeloma. Ther Adv Hematol 2018; 9:123-133. [PMID: 29713445 DOI: 10.1177/2040620718761776] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Accepted: 02/06/2018] [Indexed: 12/11/2022] Open
Abstract
Autologous stem-cell transplantation (ASCT) remains an integral part of treatment for previously untreated, and may have value in the treatment of relapsed patients with, multiple myeloma (MM). The addition of novel agents like immunomodulators and proteasome inhibitors as induction therapy before and as consolidation/maintenance therapy after ASCT has led to an improvement in complete response (CR) rates, progression-free survival (PFS) and overall survival (OS). With advances in supportive care, older patients and patients with renal insufficiency are now able to safely undergo the procedure. The data concerning the timing of ASCT (early in the disease course or at first relapse), single versus tandem (double) ASCT and the role and duration of consolidation and maintenance therapy post ASCT remain conflicting. This review aims to discuss the evolution of stem-cell transplant over the past 3 decades and its current role in the context of newer, safer and more effective therapeutic agents.
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Affiliation(s)
| | - Nidhi Tandon
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Shaji Kumar
- Professor of Medicine, Division of Hematology, Mayo Clinic, 200 First Street SW, Rochester, MN 55906, USA
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Bozdağ SC, Yüksel MK, Demirer T. Adult Stem Cells and Medicine. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018; 1079:17-36. [DOI: 10.1007/5584_2018_184] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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64
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Sivaraj D, Bacon W, Long GD, Rizzieri DA, Horwitz ME, Sullivan KM, Kang Y, Li Z, Chao NJ, Gasparetto C. High-dose BCNU/Melphalan conditioning regimen before autologous stem cell transplantation in newly diagnosed multiple myeloma. Bone Marrow Transplant 2017; 53:34-38. [DOI: 10.1038/bmt.2017.208] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Revised: 07/08/2017] [Accepted: 08/16/2017] [Indexed: 01/31/2023]
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Sahin U, Demirer T. Current strategies for the management of autologous peripheral blood stem cell mobilization failures in patients with multiple myeloma. J Clin Apher 2017; 33:357-370. [DOI: 10.1002/jca.21591] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 09/09/2017] [Accepted: 09/11/2017] [Indexed: 12/22/2022]
Affiliation(s)
- Ugur Sahin
- Department of Hematology; Ankara University Medical School; Ankara Turkey
| | - Taner Demirer
- Department of Hematology; Ankara University Medical School; Ankara Turkey
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Solovyev MV, Mendeleeva LP, Pokrovskaya OS, Nareyko MV, Firsova MV, Galtseva IV, Davydova YO, Kapranov NM, Kuzmina LA, Gemdzhian EG, Savchenko VG. [Multiple myeloma: Maintenance therapy after autologous hematopoietic stem cell transplantation, depending on minimal residual disease]. TERAPEVT ARKH 2017; 89:25-31. [PMID: 28766537 DOI: 10.17116/terarkh201789725-31] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
AIM To determine the efficiency of maintenance therapy with bortezomib in patients with multiple myeloma (MM) who have achieved complete remission (CR) after autologous hematopoietic stem cell (auto-HSCT), depending on the presence of minimal residual disease (MRD). SUBJECTS AND METHODS In January 2014 to February 2016, fifty-two MM patients (19 men and 33 women) aged 24 to 66 years (median 54 years), who had achieved CR after auto-HSCT, were randomized to perform maintenance therapy with bortezomib during a year. On day 100 after auto-HSCT, all the patients underwent immunophenotyping of bone marrow plasma cells by 6-color flow cytometry to detect MRD. Relapse-free survival (RFS) was chosen as a criterion for evaluating the efficiency of maintenance therapy. RESULTS After auto-HSCT, MRD-negative patients had a statistically significantly higher 2-year RFS rate than MRD-positive patients: 52.9% (95% confidence interval (CI), 35.5 to 70.5%) versus 37.2% (95% CI, 25.4 to 49.3%) (p=0.05). The presence of MRD statistically significantly increased the risk of relapse (odds ratio 1.7; 95% CI, 1.2 to 3.4; p=0.05). Two-year cumulative risk of relapse (using the Kaplan-Meier) after auto-HSCT did not statistically significantly differ in MRD-negative patients receiving (n=15) and not receiving (n=10) maintenance therapy with bortezomib (p=0.58). After completion of maintenance treatment, 42% of the MRD-positive patients achieved a negative status. In the MRD-positive patients who had received maintenance therapy, the average time to recurrence was 5 months longer than that in the naïve patients: 17.3 versus 12.3 months. CONCLUSION The MRD status determined in MM patients who have achieved CR after auto-HSCT is an important factor for deciding on the use of maintenance therapy.
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Affiliation(s)
- M V Solovyev
- National Research Center for Hematology, Ministry of Health of Russia, Moscow, Russia
| | - L P Mendeleeva
- National Research Center for Hematology, Ministry of Health of Russia, Moscow, Russia
| | - O S Pokrovskaya
- National Research Center for Hematology, Ministry of Health of Russia, Moscow, Russia
| | - M V Nareyko
- National Research Center for Hematology, Ministry of Health of Russia, Moscow, Russia
| | - M V Firsova
- National Research Center for Hematology, Ministry of Health of Russia, Moscow, Russia
| | - I V Galtseva
- National Research Center for Hematology, Ministry of Health of Russia, Moscow, Russia
| | - Yu O Davydova
- National Research Center for Hematology, Ministry of Health of Russia, Moscow, Russia
| | - N M Kapranov
- National Research Center for Hematology, Ministry of Health of Russia, Moscow, Russia
| | - L A Kuzmina
- National Research Center for Hematology, Ministry of Health of Russia, Moscow, Russia
| | - E G Gemdzhian
- National Research Center for Hematology, Ministry of Health of Russia, Moscow, Russia
| | - V G Savchenko
- National Research Center for Hematology, Ministry of Health of Russia, Moscow, Russia
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Esma F, Salvini M, Troia R, Boccadoro M, Larocca A, Pautasso C. Melphalan hydrochloride for the treatment of multiple myeloma. Expert Opin Pharmacother 2017; 18:1127-1136. [DOI: 10.1080/14656566.2017.1349102] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Fabrizio Esma
- Myeloma Unit, Division of Hematology, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Marco Salvini
- Myeloma Unit, Division of Hematology, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Rossella Troia
- Myeloma Unit, Division of Hematology, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Mario Boccadoro
- Myeloma Unit, Division of Hematology, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Alessandra Larocca
- Myeloma Unit, Division of Hematology, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - Chiara Pautasso
- Myeloma Unit, Division of Hematology, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
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Moreb JS, Byrne M, Shugarman I, Zou F, Xiong S, May WS, Norkin M, Hiemenz J, Brown R, Cogle C, Wingard JR, Hsu JW. Poor peripheral blood stem cell mobilization affects long-term outcomes in multiple myeloma patients undergoing autologous stem cell transplantation. J Clin Apher 2017; 33:29-37. [DOI: 10.1002/jca.21556] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 05/02/2017] [Accepted: 05/08/2017] [Indexed: 12/22/2022]
Affiliation(s)
- Jan S. Moreb
- Division of Hematology/Oncology; University of Florida; Gainesville Florida
| | - Michael Byrne
- Division of Hematology/Oncology and Vanderbilt Ingram Comprehensive Cancer Center; Vanderbilt University; Nashville Tennessee
| | - Ilicia Shugarman
- Division of Hematology/Oncology; University of Florida; Gainesville Florida
| | - Fei Zou
- Biostatistics; University of Florida; Gainesville Florida
| | - Sican Xiong
- Biostatistics; University of Florida; Gainesville Florida
| | - William S. May
- Division of Hematology/Oncology; University of Florida; Gainesville Florida
| | - Maxim Norkin
- Division of Hematology/Oncology; University of Florida; Gainesville Florida
| | - John Hiemenz
- Division of Hematology/Oncology; University of Florida; Gainesville Florida
| | - Randall Brown
- Division of Hematology/Oncology; University of Florida; Gainesville Florida
| | - Christopher Cogle
- Division of Hematology/Oncology; University of Florida; Gainesville Florida
| | - John R. Wingard
- Division of Hematology/Oncology; University of Florida; Gainesville Florida
| | - Jack W. Hsu
- Division of Hematology/Oncology; University of Florida; Gainesville Florida
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Ri M, Matsue K, Sunami K, Shimazaki C, Hayashi A, Sunaga Y, Sasaki T, Suzuki K. Efficacy and safety of plerixafor for the mobilization/collection of peripheral hematopoietic stem cells for autologous transplantation in Japanese patients with multiple myeloma. Int J Hematol 2017; 106:562-572. [PMID: 28527129 DOI: 10.1007/s12185-017-2255-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Revised: 05/10/2017] [Accepted: 05/14/2017] [Indexed: 10/19/2022]
Abstract
To evaluate the efficacy and safety of plerixafor for the mobilization/collection of peripheral hematopoietic stem cells (HSCs) for autologous transplantation in Japanese patients with multiple myeloma (MM). In a randomized study, patients received G-CSF (filgrastim, 400 µg/m2/day) for 4 days prior to the first dose of plerixafor. Starting on Day 4 evening and for up to 4 days, patients received either plerixafor (240 µg/kg/day) + G-CSF group (PG group) or G-CSF alone (G group). Daily apheresis started on Day 5 for up to 4 days, or until ≥6 × 106 CD34+ cells/kg were collected. A total of 7 patients were randomized in each treatment group. Five patients in PG group and no patients in G group achieved a collection of ≥6 × 106 CD34+ cells/kg in ≤2 days of apheresis [difference of 71.4% (90%CI 29-100%)]. These results were supported by the shorter median time to collect ≥6 × 106 CD34+ cells/kg (2 days in PG group; no patient in G group). The incidence of treatment emergent adverse events (TEAEs) was higher in PG group than in G group. Plerixafor was well tolerated, and effective for the mobilization/collection of peripheral HSCs for autologous transplantation in Japanese patients with MM.
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Affiliation(s)
- Masaki Ri
- Department of Hematology and Oncology, Nagoya City University Hospital, 1-Kawasumi, Mizuho-cho, Mizuho-ku, Nagoya, Aichi, Japan.
| | - Kosei Matsue
- Department of Hematology and Oncology, Kameda Medical Center, Chiba, Japan
| | - Kazutaka Sunami
- Department of Hematology, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Chihiro Shimazaki
- Department of Hematology, Japan Community Health care Organization Kyoto Kuramaguchi Medical Center, Kyoto, Japan
| | | | | | | | - Kenshi Suzuki
- Department of Hematology, Japanese Red Cross Medical Center, Tokyo, Japan
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Dhakal B, Nelson A, Guru Murthy GS, Fraser R, Eastwood D, Hamadani M, Pasquini M, D'Souza A, Hari P. Autologous Hematopoietic Cell Transplantation in Patients With Multiple Myeloma: Effect of Age. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2017; 17:165-172. [DOI: 10.1016/j.clml.2016.11.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Revised: 11/04/2016] [Accepted: 11/08/2016] [Indexed: 01/23/2023]
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71
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Gassiot S, Motlló C, Llombart I, Morgades M, González Y, Garcia-Caro M, Ribera JM, Oriol A. Impact of induction treatment before autologous stem cell transplantation on long-term outcome in patients with newly diagnosed multiple myeloma. Eur J Haematol 2017; 98:569-576. [PMID: 28208219 DOI: 10.1111/ejh.12869] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Clinical trials for patients with multiple myeloma (MM) using novel agent (NA)-based regimens before autologous stem cell transplantation (SCT) have shown improvement in response rates and progression-free survival (PFS); however they have failed to identify a significant overall survival (OS) benefit. The aim of this study was to analyze the potential impact of initial induction on the feasibility and outcome of subsequent treatment lines in a real clinical practice setting. METHODS Patients with consecutive MM <70 years of age diagnosed between 1999 and 2009 were prospectively registered and classified as having received conventional chemotherapy induction regimens with new agents available at relapse (CC cohort, 89 patients) or as treated with NAs upfront (NA cohort, 65 patients). RESULTS Patients in the NA cohort demonstrated a superior median PFS (2.8 years vs 1.6 years, P=.03) and also a median PFS from diagnosis to second progression (5.2 years vs 2.7 years, P=.003). After a median follow-up of 7 years, clear differences in OS were observed (7.97 years in NA cohort compared to 3.35 years in CC cohort, P<.001). CONCLUSIONS New agent-based first-line induction treatments provide benefits in both PFS and beyond that point, contributing to a significant improvement in OS.
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Affiliation(s)
- Susanna Gassiot
- ICO-Hospital Germans Trias i Pujol, Josep Carreras Research Institute, Badalona, Spain.,Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain
| | - Cristina Motlló
- ICO-Hospital Germans Trias i Pujol, Josep Carreras Research Institute, Badalona, Spain.,Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain
| | | | - Mireia Morgades
- ICO-Hospital Germans Trias i Pujol, Josep Carreras Research Institute, Badalona, Spain
| | | | - Montse Garcia-Caro
- ICO-Hospital Germans Trias i Pujol, Josep Carreras Research Institute, Badalona, Spain
| | - Josep-Maria Ribera
- ICO-Hospital Germans Trias i Pujol, Josep Carreras Research Institute, Badalona, Spain.,Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain
| | - Albert Oriol
- ICO-Hospital Germans Trias i Pujol, Josep Carreras Research Institute, Badalona, Spain.,Universitat Autònoma de Barcelona, Cerdanyola del Vallès, Spain
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Gay F, Oliva S, Petrucci MT, Montefusco V, Conticello C, Musto P, Catalano L, Evangelista A, Spada S, Campbell P, Ria R, Salvini M, Offidani M, Carella AM, Omedé P, Liberati AM, Troia R, Cafro AM, Malfitano A, Falcone AP, Caravita T, Patriarca F, Nagler A, Spencer A, Hajek R, Palumbo A, Boccadoro M. Autologous transplant vs oral chemotherapy and lenalidomide in newly diagnosed young myeloma patients: a pooled analysis. Leukemia 2016; 31:1727-1734. [PMID: 28008174 DOI: 10.1038/leu.2016.381] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Revised: 10/28/2016] [Accepted: 11/07/2016] [Indexed: 12/22/2022]
Abstract
In newly diagnosed myeloma patients, upfront autologous transplant (ASCT) prolongs progression-free survival 1 (PFS1) compared with chemotherapy plus lenalidomide (CC+R). Salvage ASCT at first relapse may still effectively rescue patients who did not receive upfront ASCT. To evaluate the long-term benefit of upfront ASCT vs CC+R and the impact of salvage ASCT in patients who received upfront CC+R, we conducted a pooled analysis of 2 phase III trials (RV-MM-209 and EMN-441). Primary endpoints were PFS1, progression-free survival 2 (PFS2), overall survival (OS). A total of 268 patients were randomized to 2 courses of melphalan 200 mg/m2 and ASCT (MEL200-ASCT) and 261 to CC+R. Median follow-up was 46 months. MEL200-ASCT significantly improved PFS1 (median: 42 vs 24 months, HR 0.53; P<0.001), PFS2 (4 years: 71 vs 54%, HR 0.53, P<0.001) and OS (4 years: 84 vs 70%, HR 0.51, P<0.001) compared with CC+R. The advantage was noticed in good and bad prognosis patients. Only 53% of patients relapsing from CC+R received ASCT at first relapse. Upfront ASCT significantly reduced the risk of death (HR 0.51; P=0.007) in comparison with salvage ASCT. In conclusion, these data confirm the role of upfront ASCT as the standard approach for all young myeloma patients.
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Affiliation(s)
- F Gay
- Myeloma Unit, Division of Hematology, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - S Oliva
- Myeloma Unit, Division of Hematology, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - M T Petrucci
- Division of Hematology, Department of Cellular Biotechnologies and Hematology, Sapienza University of Roma, Roma, Italy
| | - V Montefusco
- Department of Hematology, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | - C Conticello
- Division of Hematology, Azienda Policlinico 'Vittorio Emanuele', University of Catania, Catania, Italy
| | - P Musto
- Scientific Direction, IRCCS-CROB, Referral Cancer Center of Basilicata, Rionero in Vulture, Potenza, Italy
| | - L Catalano
- Hematology, Department of Clinical Medicine and Surgery, AOU Federico II, Napoli, Italy
| | - A Evangelista
- Unit of Clinical Epidemiology, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino and CPO Piemonte, Torino, Italy
| | - S Spada
- Myeloma Unit, Division of Hematology, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - P Campbell
- Haematology Department, Cancer Services, Barwon Health, Geelong, Australia
| | - R Ria
- Department of Biomedical Science, University of Bari 'Aldo Moro' Medical School, Internal Medicine 'G. Baccelli' Policlinico, Bari, Italy
| | - M Salvini
- Myeloma Unit, Division of Hematology, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - M Offidani
- Hematology Department, AOU Ospedali Riuniti di Ancona, Ancona, Italy
| | - A M Carella
- Hematology and Bone Marrow Transplantation Unit, IRCCS San Martino-Ist, Genova, Italy
| | - P Omedé
- Myeloma Unit, Division of Hematology, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - A M Liberati
- Department of Oncohematology, AO S.Maria di Terni, Terni, Italy
| | - R Troia
- Myeloma Unit, Division of Hematology, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - A M Cafro
- Division of Hematology, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | - A Malfitano
- Myeloma Unit, Division of Hematology, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - A P Falcone
- Division of Hematology, Casa Sollievo della Sofferenza Hospital, IRCCS, San Giovanni Rotondo, Italy
| | - T Caravita
- UOC Ematologia S. Eugenio ASL RM2 Roma, Roma, Italy
| | - F Patriarca
- Department of Hematology, Azienda Ospedaliera-Universitaria di Udine, DISM, Università di Udine, Udine, Italy
| | - A Nagler
- Hematology Division, Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - A Spencer
- Department of Clinical Haematology, Alfred Health-Monash University, Melbourne, Australia
| | - R Hajek
- Blood Cancer Research Group, Department of Haematooncology, Faculty Hospital Ostrava, Ostrava, Czech Republic.,Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
| | - A Palumbo
- Myeloma Unit, Division of Hematology, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
| | - M Boccadoro
- Myeloma Unit, Division of Hematology, Azienda Ospedaliero-Universitaria Città della Salute e della Scienza di Torino, Torino, Italy
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van de Velde H, Londhe A, Ataman O, Johns HL, Hill S, Landers E, Berlin JA. Association between complete response and outcomes in transplant-eligible myeloma patients in the era of novel agents. Eur J Haematol 2016; 98:269-279. [PMID: 27859769 DOI: 10.1111/ejh.12829] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/05/2016] [Indexed: 01/09/2023]
Abstract
OBJECTIVES Achieving complete response (CR) has been linked to improved progression-free (PFS) and overall (OS) survival in myeloma. A meta-analysis was conducted to investigate whether this holds true in the era of novel agents (bortezomib, lenalidomide, thalidomide). METHODS A total of 24 studies in newly diagnosed patients undergoing autologous stem cell transplantation (ASCT) that reported associations between responses and long-term outcomes (PFS/OS rates post-ASCT by response, or hazard ratios with 95% confidence intervals from Cox models) were identified and analyzed. RESULTS Achievement of CR vs. <CR post-ASCT reduced risk of progression/death by 38% [risk ratio (RR): 0.62, P < 0.0001]; risk of death was 41% lower (RR: 0.59, P < 0.0001). Subgroup meta-analyses showed significant PFS risk reduction with CR post-ASCT with novel (RR: 0.32, P < 0.006) and non-novel (RR: 0.72, P < 0.0001) agents, and corresponding OS risk reduction with novel (RR: 0.33, P = 0.0013) and non-novel (RR: 0.64, P < 0.0001) agents. Risk reduction was greater with novel vs. non-novel agents (PFS: P = 0.047; OS: P = 0.058). CONCLUSIONS Achieving CR during first-line therapy remains important in the novel-agent era; magnitude of association between achieving CR and outcomes appears higher for CR obtained using novel vs. non-novel agents.
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Affiliation(s)
- Helgi van de Velde
- Millennium Pharmaceuticals, Inc., a wholly owned subsidiary of Takeda Pharmaceutical Company Limited, Cambridge, MA, USA
| | - Anil Londhe
- Janssen Research and Development, Horsham, PA, USA
| | - Ozlem Ataman
- Janssen Research & Development, High Wycombe, UK
| | - Helen L Johns
- FireKite, an Ashfield Company, part of UDG Healthcare plc, Maidenhead, UK
| | - Stephen Hill
- FireKite, an Ashfield Company, part of UDG Healthcare plc, Maidenhead, UK
| | - Emma Landers
- FireKite, an Ashfield Company, part of UDG Healthcare plc, Maidenhead, UK
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Moehler TM, Merz M, Kellermann L, Goldschmidt H, Knauf W. Diagnostic and therapeutic approaches to multiple myeloma patients: 'Real-world' data from representative multicentre treatment surveys in Germany between 2008 and 2011. Oncol Lett 2016; 12:5043-5051. [PMID: 28105211 PMCID: PMC5228488 DOI: 10.3892/ol.2016.5375] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2015] [Accepted: 04/29/2016] [Indexed: 12/23/2022] Open
Abstract
A survey was conducted to investigate the standard of care for multiple myeloma in Germany, in order to clarify the status of implementation of international and national treatment guidelines. In addition, the changes in disease management over time were investigated by comparison with surveys conducted in 2008 and 2009. The survey captured a representative sample of 478 myeloma patients with a mean age of 67.9 years across various stages of the disease. Diagnostic approaches, prognostic aspects and treatment decisions were evaluated based on a survey conducted in 2011 in 58 representative centres in Germany, including university and non-university hospitals and office-based haematologists. Data were collected from chart reviews and were analysed retrospectively. Over time, an increasing number of patients were investigated for cytogenetic abnormalities (53%). Age <69 years and lack of comorbid conditions were major determinants for cytogenetic testing. Bortezomib/chemotherapy-based regimens have become the preferred first-line treatments independent of planning autologous blood stem cell transplantation (ASCT) in first-line therapy. Thalidomide- and lenalidomide-based combination therapies are typically used as second-line treatments in 31% of patients. Compared with previous reviews, the frequency of ASCT was stable, at ~30% of patients. Younger age and indicators of more severe disease, such as the presence of CRAB criteria, influenced the decision in favour of performing ASCT. Compared to previous surveys, the requirement for erythropoietin and granulocyte colony-stimulating factor, as well as transfusions of red blood cells and platelets, respectively, have decreased considerably. In summary, novel agents have led to a substantial change in the first-line and relapsed treatment approaches. Age and comorbidities remain major factors influencing treatment decisions, but cytogenetic testing to investigate myeloma-related risk profiles is increasingly integrated. The use of novel agents has affected supportive care, with reduced necessity for substitute blood products and reduced administration of bone marrow-stimulating factors.
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Affiliation(s)
- Thomas M Moehler
- Department of Medicine V, University of Heidelberg, Heidelberg 69120, Germany
| | - Maximilian Merz
- Department of Medicine V, University of Heidelberg, Heidelberg 69120, Germany
| | | | - Hartmut Goldschmidt
- Department of Medicine V, University of Heidelberg, Heidelberg 69120, Germany; National Center for Tumor Diseases, Heidelberg 69120, Germany
| | - Wolfgang Knauf
- Onkologische Gemeinschaftspraxis, Frankfurt 60389, Germany
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Remenyi P, Varga G, Mikala G, Reti M, Gopcsa L, Batai A, Csukly Z, Lengyel L, Torbagyi E, Barta A, Fabian J, Levai D, Szombath G, Andrikovics H, Masszi T. Early Versus Delayed Autologous Stem Cell Transplantation and Interferon Maintenance in Multiple Myeloma: Single-Center Experience of 18 Years. Transplant Proc 2016; 48:177-84. [PMID: 26915865 DOI: 10.1016/j.transproceed.2015.12.031] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Revised: 12/14/2015] [Accepted: 12/30/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND Autologous stem cell transplantation (ASCT) has become the mainstay of 1st-line treatment in younger patients with multiple myeloma (MM), but statistical confirmation of its superiority over other therapies, especially in the era of novel agents, is still lacking. METHODS We reviewed the results of all 548 myeloma ASCTs performed in our institute over the past 18 years. RESULTS More than one-half of the patients had access to novel agents before their transplantations. Although the age of the transplanted patients increased significantly over the years, treatment-related mortality (TRM) was remarkably low, especially in 1st-line transplanted patients (100-day TRM, 0.3%). The median overall survival (OS) of the entire cohort was 98.4 months. Patients transplanted within 12 months from the start of their therapy had significantly better responses than those having delayed ASCT (complete response rate, 58.1% vs 46.8%; P = .016) and significant post-ASCT progression-free survival (PFS) benefit (30.2 [26.1-34.3] mo vs 23.3 [16.8-29.8] mo; P = .036), but we found no significant overall survival difference. The results were similar in patients treated with or without novel agents before ASCT. During a period of time, interferon maintenance was our standard approach to post-ASCT maintenance. Our analysis showed not only a significant PFS advantage with interferon, but also a highly significant overall survival benefit (150.4 [105.1-195.8] mo vs 86.1 [72.5-99.7] mo; P = .003). CONCLUSIONS Our findings demonstrate that delayed ASCT can be feasible in selected patients.
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Affiliation(s)
- P Remenyi
- Department of Hematology and Stem Cell Transplantation, St Istvan and St Laszlo Hospital, Budapest, Hungary
| | - G Varga
- 3rd Department of Internal Medicine, Semmelweis University, Budapest, Hungary.
| | - G Mikala
- Department of Hematology and Stem Cell Transplantation, St Istvan and St Laszlo Hospital, Budapest, Hungary
| | - M Reti
- Department of Hematology and Stem Cell Transplantation, St Istvan and St Laszlo Hospital, Budapest, Hungary
| | - L Gopcsa
- Department of Hematology and Stem Cell Transplantation, St Istvan and St Laszlo Hospital, Budapest, Hungary
| | - A Batai
- Department of Hematology and Stem Cell Transplantation, St Istvan and St Laszlo Hospital, Budapest, Hungary
| | - Z Csukly
- Department of Hematology and Stem Cell Transplantation, St Istvan and St Laszlo Hospital, Budapest, Hungary
| | - L Lengyel
- Department of Hematology and Stem Cell Transplantation, St Istvan and St Laszlo Hospital, Budapest, Hungary
| | - E Torbagyi
- Department of Hematology and Stem Cell Transplantation, St Istvan and St Laszlo Hospital, Budapest, Hungary
| | - A Barta
- Department of Hematology and Stem Cell Transplantation, St Istvan and St Laszlo Hospital, Budapest, Hungary
| | - J Fabian
- Department of Hematology and Stem Cell Transplantation, St Istvan and St Laszlo Hospital, Budapest, Hungary
| | - D Levai
- 3rd Department of Internal Medicine, Semmelweis University, Budapest, Hungary
| | - G Szombath
- 3rd Department of Internal Medicine, Semmelweis University, Budapest, Hungary
| | - H Andrikovics
- Laboratory of Molecular Diagnostics, Hungarian National Blood Transfusion Service, Budapest, Hungary; Institute of Pathophysiology, Semmelweis University, Budapest, Hungary
| | - T Masszi
- 3rd Department of Internal Medicine, Semmelweis University, Budapest, Hungary; Department of Hematology and Stem Cell Transplantation, St Istvan and St Laszlo Hospital, Budapest, Hungary
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77
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Peripheral blood stem cell mobilization in multiple myeloma comparison of two consecutive regimens in a limited resources country. Bone Marrow Transplant 2016; 52:222-227. [DOI: 10.1038/bmt.2016.246] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 07/23/2016] [Accepted: 08/10/2016] [Indexed: 02/04/2023]
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78
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Outcome with lenalidomide plus dexamethasone followed by early autologous stem cell transplantation in patients with newly diagnosed multiple myeloma on the ECOG-ACRIN E4A03 randomized clinical trial: long-term follow-up. Blood Cancer J 2016; 6:e466. [PMID: 27588519 PMCID: PMC5056965 DOI: 10.1038/bcj.2016.68] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 06/20/2016] [Indexed: 12/22/2022] Open
Abstract
In Eastern Cooperative Oncology Group-ACRIN E4A03, on completion of four cycles of therapy, newly diagnosed multiple myeloma patients had the option of proceeding to autologous peripheral blood stem cell transplant (ASCT) or continuing on their assigned therapy lenalidomide plus low-dose dexamethasone (Ld) or lenalidomide plus high-dose dexamethasone (LD). This landmark analysis compared the outcome of 431 patients surviving their first four cycles of therapy pursuing early ASCT to those continuing on their assigned therapy. Survival distributions were estimated using the Kaplan–Meier method and compared with log-rank test. Ninety patients (21%) opted for early ASCT. The 1-, 2-, 3-, 4- and 5-year survival probability estimates were higher for early ASCT versus no early ASCT at 99, 93, 91, 85 and 80% versus 94, 84, 75, 65 and 57%, respectively. The median overall survival (OS) in the early versus no early ASCT group was not reached (NR) versus 5.78 years. In patients <65 years of age, median OS in the early versus no early ASCT groups was NR in both, hazard ratio 0.79, 95% confidence interval: (0.50, 0.25). In patients ⩾65 years of age, median OS in the early versus no early ASCT was NR versus 5.11 years. ASCT dropped out of statistical significance (P=0.080). Patients opting for ASCT after induction Ld/LD had a higher survival probability and improvement in OS regardless of dexamethasone dose density.
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79
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A Phase I/II Study of Escalating Doses of Bortezomib in Conjunction with High-Dose Melphalan as a Conditioning Regimen for Salvage Autologous Peripheral Blood Stem Cell Transplantation in Patients with Multiple Myeloma. Biol Blood Marrow Transplant 2016; 22:2165-2171. [PMID: 27590107 DOI: 10.1016/j.bbmt.2016.08.017] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2016] [Accepted: 08/18/2016] [Indexed: 01/01/2023]
Abstract
Escalating doses of bortezomib with high-dose melphalan was evaluated as as a conditioning regimen for autologous stem cell transplantation (ASCT) in patients with relapsed or refractory multiple myeloma (MM). MM patients with less than a partial remission (PR) (or 50% reduction) compared to their pretransplantation paraprotein parameters after a prior ASCT with melphalan conditioning, or who were in relapse after a prior autologous transplantation, were eligible for study. Bortezomib was dose escalated in steps of 1, 1.3, and 1.6 mg/m2 (3 × 3 design) on days -4 and -1 before transplantation with melphalan 200 mg/m2 given on day -2. Thirty-two patients were enrolled: 12 in the phase I dose escalation phase and an additional 20 in phase II to gain additional experience with the regimen. Twenty-four (75%) patients were Durie Salmon stage III, and 12 (37.5%) had >2 prior lines of therapy. The overall response rate (≥PR) was 44% with 22% complete remission. Two-year overall survival and progression-free survival were 76% and 39%, respectively, with a median follow-up of 31.7 months. The most common grade 3 and 4 nonhematologic adverse events were neutropenic fever (25%), nausea (18.8%), and mucositis (9.4%). Serious adverse events included intensive care unit admission (9.4%), seizure (3.1%), prolonged diarrhea (3.1%), and Guillain-Barre syndrome (3.1%). Two patients (6%) died of sepsis. There was no emergent peripheral neuropathy nor increase in any pre-existing peripheral neuropathy. The addition of bortezomib to melphalan as conditioning for salvage ASCT was well tolerated. More importantly, it can provide durable remission for patients who have a suboptimal response to prior single-agent melphalan conditioning for ASCT, without requiring a reduction in the dose of melphalan. Larger randomized prospective studies to determine the effect of combination conditioning are being conducted.
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80
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Nath CE, Trotman J, Tiley C, Presgrave P, Joshua D, Kerridge I, Kwan YL, Gurney H, McLachlan AJ, Earl JW, Nivison‐Smith I, Zeng L, Shaw PJ. High melphalan exposure is associated with improved overall survival in myeloma patients receiving high dose melphalan and autologous transplantation. Br J Clin Pharmacol 2016; 82:149-59. [PMID: 26879446 PMCID: PMC4917807 DOI: 10.1111/bcp.12906] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Revised: 02/01/2016] [Accepted: 02/09/2016] [Indexed: 11/28/2022] Open
Abstract
AIM High dose melphalan (HDM) and autologous stem cell transplantation (ASCT) retains a central role in the treatment of myeloma. The aim of this study was to determine whether HDM exposure (area under the concentration vs. time curve, AUC), is significantly associated with transplant outcomes. METHODS Melphalan concentrations were measured in six to 11 plasma samples collected after HDM (median 192 mg m(-) (2) ) to determine melphalan AUC for a total of 114 patients. Binary logistic regression was used to assess whether melphalan AUC was associated with severe (≥ grade 3) oral mucositis. Multivariate Cox regression was used to assess whether melphalan AUC was significantly associated with time to progression, progression-free survival and overall survival (OS). RESULTS Melphalan AUC ranged from 4.9 to 24.6 mg l(-1) h, median 12.84 mg l(-1) h. Melphalan AUC above the median was a risk factor for severe mucositis (HR 1.21, 95% CI 1.06, 1.38, P = 0.004) but was also associated with significantly improved overall survival (OS) (HR 0.40, 95% CI 0.20, 0.81, P = 0.001), with an estimated median survival of 8.50 years vs. 5.38 years for high vs. low AUC groups. Multivariate analysis did not identify melphalan AUC as being significantly associated with time to progression or progression-free survival. CONCLUSIONS This large scale pharmacodynamic analysis of HDM demonstrates that high melphalan exposure is associated with improved survival, with an acceptable increase in transplant toxicity. These results suggest studies targeting a higher AUC are warranted in patients undergoing HDM and ASCT for myeloma.
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Affiliation(s)
- Christa E. Nath
- The Children's Hospital at WestmeadHawkesbury RdWestmead2145
| | - Judith Trotman
- Concord HospitalHospital RoadConcordNSW2139
- University of SydneySydneyNSW2006
| | - Campbell Tiley
- Gosford HospitalHolden StGosfordNSW2250
- University of Newcastle, University DrCallaghanNSW2308
| | - Peter Presgrave
- Wollongong HospitalLoftus StWollongongNSW2500
- University of WollongongNorthfields AveWollongongNSW2522
| | - Douglas Joshua
- University of SydneySydneyNSW2006
- Royal Prince Alfred HospitalMissenden RdCamperdownNSW2050
| | - Ian Kerridge
- University of SydneySydneyNSW2006
- Westmead HospitalHawkesbury RdWestmeadNSW2145
| | | | - Howard Gurney
- University of SydneySydneyNSW2006
- Westmead HospitalHawkesbury RdWestmeadNSW2145
| | - Andrew J. McLachlan
- Concord HospitalHospital RoadConcordNSW2139
- University of SydneySydneyNSW2006
| | - John W. Earl
- The Children's Hospital at WestmeadHawkesbury RdWestmead2145
- University of SydneySydneyNSW2006
| | - Ian Nivison‐Smith
- Australasian Bone Marrow Transplant Recipient Registry370 Victoria StreetDarlinghurstNSW2010Australia
| | - Lihua Zeng
- The Children's Hospital at WestmeadHawkesbury RdWestmead2145
| | - Peter J. Shaw
- The Children's Hospital at WestmeadHawkesbury RdWestmead2145
- University of SydneySydneyNSW2006
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81
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Katragadda L, McCullough LM, Dai Y, Hsu J, Byrne M, Hiemenz J, May S, Cogle CR, Norkin M, Brown RA, Wingard JR, Chang M, Moreb JS. Effect of melphalan 140 mg/m2vs 200 mg/m2on toxicities and outcomes in multiple myeloma patients undergoing single autologous stem cell transplantation-a single center experience. Clin Transplant 2016; 30:894-900. [DOI: 10.1111/ctr.12762] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/18/2016] [Indexed: 11/30/2022]
Affiliation(s)
| | | | - Yunfeng Dai
- Department of Biostatistics; University of Florida; Gainesville FL USA
| | - Jack Hsu
- Department of Medicine; University of Florida; Gainesville FL USA
| | - Michael Byrne
- Department of Medicine; University of Vanderbilt; Nashville TN USA
| | - John Hiemenz
- Department of Medicine; University of Florida; Gainesville FL USA
| | - Stratford May
- Department of Medicine; University of Florida; Gainesville FL USA
| | | | - Maxim Norkin
- Department of Medicine; University of Florida; Gainesville FL USA
| | - Randy A. Brown
- Department of Medicine; University of Florida; Gainesville FL USA
| | - John R. Wingard
- Department of Medicine; University of Florida; Gainesville FL USA
| | - Myron Chang
- Department of Biostatistics; University of Florida; Gainesville FL USA
| | - Jan S. Moreb
- Department of Medicine; University of Florida; Gainesville FL USA
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82
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Tan Y, Xu S, Li X, Chen J. The effects of allogeneic stem cell transplantation with matched sibling donor versus autologous stem cell transplantation for newly diagnosed multiple myeloma. Hippokratia 2016. [DOI: 10.1002/14651858.cd010484.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Ya Tan
- Southwest Hospital, Third Military Medical University; Center for Hematology; 38 Gao Tanyan Street Chongqing China 400038
| | - ShuangNian Xu
- Southwest Hospital, Third Military Medical University; Center for Hematology; 38 Gao Tanyan Street Chongqing China 400038
| | - Xi Li
- Southwest Hospital, Third Military Medical University; Center for Hematology; 38 Gao Tanyan Street Chongqing China 400038
| | - JiePing Chen
- Southwest Hospital, Third Military Medical University; Center for Hematology; 38 Gao Tanyan Street Chongqing China 400038
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83
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Augmenting Autologous Stem Cell Transplantation to Improve Outcomes in Myeloma. Biol Blood Marrow Transplant 2016; 22:1926-1937. [PMID: 27288955 DOI: 10.1016/j.bbmt.2016.06.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 06/03/2016] [Indexed: 01/07/2023]
Abstract
Consolidation with high-dose chemotherapy and autologous stem cell transplantation (ASCT) is the standard of care for transplantation-eligible patients with multiple myeloma, based on randomized trials showing improved progression-free survival with autologous transplantation after combination chemotherapy induction. These trials were performed before novel agents were introduced; subsequently, combinations of immunomodulatory drugs and proteasome inhibitors as induction therapy have significantly improved rates and depth of response. Ongoing randomized trials are testing whether conventional autologous transplantation continues to improve responses after novel agent induction. Although these results are awaited, it is important to review strategies for improving outcomes after ASCT. Conditioning before ASCT with higher doses of melphalan and combinations of melphalan with other agents, including radiopharmaceuticals, has been explored. Tandem ASCT, consolidation, and maintenance therapy after ASCT have been investigated in phase III trials. Experimental cellular therapies using ex vivo-primed dendritic cells, ex vivo-expanded autologous lymphocytes, Killer Immunoglobulin Receptor (KIR)-mismatched allogeneic natural killer cells, and genetically modified T cells to augment ASCT are also in phase I trials. This review summarizes these strategies and highlights the importance of exploring strategies to augment ASCT, even in the era of novel agent induction.
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84
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Parrish C, Morris CT, Williams CD, Cairns DA, Cavenagh J, Snowden JA, Ashcroft J, Cavet J, Hunter H, Bird JM, Chalmers A, Brown JM, Yong K, Schey S, Chown S, Cook G. Stem Cell Harvesting after Bortezomib-Based Reinduction for Myeloma Relapsing after Autologous Transplantation: Results from the British Society of Blood and Marrow Transplantation/United Kingdom Myeloma Forum Myeloma X (Intensive) Trial. Biol Blood Marrow Transplant 2016; 22:1009-1016. [DOI: 10.1016/j.bbmt.2016.01.016] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Accepted: 01/11/2016] [Indexed: 12/20/2022]
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85
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Reule S, Sexton DJ, Solid CA, Chen SC, Foley RN. ESRD due to Multiple Myeloma in the United States, 2001-2010. J Am Soc Nephrol 2016; 27:1487-94. [PMID: 26516209 PMCID: PMC4849810 DOI: 10.1681/asn.2014090876] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Accepted: 07/21/2015] [Indexed: 11/03/2022] Open
Abstract
Although management of multiple myeloma has changed substantially in the last decade, it is unknown whether the burden of ESRD due to multiple myeloma has changed, or whether survival of patients with multiple myeloma on RRT has improved. Regarding ESRD due to multiple myeloma necessitating RRT in the United States, we evaluated temporal trends between 2001 and 2010 for demography-adjusted incidence ratios, relative to rates in 2001-2002, and mortality hazards from RRT initiation, relative to hazards in 2001-2002. In this retrospective cohort study, we used the US Renal Data System database (n=1,069,343), 2001-2010, to identify patients with ESRD due to multiple myeloma treated with RRT (n=12,703). Demography-adjusted incidence ratios of ESRD from multiple myeloma decreased between 2001-2002 and 2009-2010 in the overall population (demography-adjusted incidence ratio 0.82; 95% confidence interval, 0.79 to 0.86) and in most demographic subgroups examined. Mortality rates were 86.7, 41.4, and 34.4 per 100 person-years in the first 3 years of RRT, respectively, compared with 32.3, 20.6, and 21.3 in matched controls without multiple myeloma. Unadjusted mortality hazards ratios declined monotonically after 2004 to a value of 0.72; 95% confidence interval, 0.67 to 0.77 in 2009-2010, and declines between 2001-2002 and 2008-2009 were observed (P<0.05) in most demographic subgroups examined. Findings were similar when adjustment was made for demographic characteristics, comorbidity markers, and laboratory test values. These data suggest the incidence of RRT from multiple myeloma in the United States has decreased in the last decade, and clinically meaningful increases in survival have occurred for these patients.
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Affiliation(s)
- Scott Reule
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota; and Minneapolis Medical Research Foundation, Minneapolis, Minnesota
| | - Donal J Sexton
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota; and Minneapolis Medical Research Foundation, Minneapolis, Minnesota
| | - Craig A Solid
- Minneapolis Medical Research Foundation, Minneapolis, Minnesota
| | - Shu-Cheng Chen
- Minneapolis Medical Research Foundation, Minneapolis, Minnesota
| | - Robert N Foley
- Department of Medicine, University of Minnesota, Minneapolis, Minnesota; and Minneapolis Medical Research Foundation, Minneapolis, Minnesota
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86
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Lum LG, Thakur A, Kondadasula SV, Al-Kadhimi Z, Deol A, Tomaszewski EN, Yano H, Schalk DL, Ayash L, Zonder JA, Uberti JP, Abidi MH, Ratanatharathorn V. Targeting CD138-/CD20+ Clonogenic Myeloma Precursor Cells Decreases These Cells and Induces Transferable Antimyeloma Immunity. Biol Blood Marrow Transplant 2016; 22:869-78. [PMID: 26827660 PMCID: PMC6820521 DOI: 10.1016/j.bbmt.2015.12.030] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Accepted: 12/31/2015] [Indexed: 12/22/2022]
Abstract
This phase Ib clinical trial evaluated whether pretargeting of CD20(+) clonogenic myeloma precursor cells (CMPCs) with anti-CD3 × anti-CD20 bispecific antibody-armed T cells (BATs) before autologous stem cell transplantation (SCT) in patients with standard-risk and high-risk multiple myeloma would induce antimyeloma immunity that could be detected and boosted after SCT. All 12 patients enrolled in this study received 2 BATs infusions before SCT, and 4 patients received a booster infusion of BATs after SCT. Pretargeting CD138(-)/CD20(+) CMPCs with BATs before SCT was safe and reduced levels of CMPCs by up to 58% in the postinfusion bone marrow in patients who remained in remission. Four of 5 patients who remained in remission had a >5-fold increase in IFN-γ enzyme-linked immunospot responses. SOX2 antibody increased after BATs infusions and persisted after SCT. The median anti-SOX2 level at 3 months after SCT was 28.1 ng/mL (range, 4.6 to 256 ng/mL) in patients who relapsed and 46 ng/mL (range, 28.3 to 73.3 ng/mL) in patients who remained in remission. The immune correlates suggest that infusions of targeted T cells given before SCT were able to reduce CMPC levels and induced cellular and humoral antimyeloma immunity that could be transferred and boosted after SCT.
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Affiliation(s)
- Lawrence G Lum
- Department of Oncology, Wayne State University, Detroit, Michigan; Department of Medicine, Wayne State University, Detroit, Michigan; Department of Immunology and Microbiology, Wayne State University, Detroit, Michigan.
| | - Archana Thakur
- Department of Oncology, Wayne State University, Detroit, Michigan.
| | | | - Zaid Al-Kadhimi
- Department of Oncology, Wayne State University, Detroit, Michigan; Department of Medicine, Wayne State University, Detroit, Michigan
| | - Abhinav Deol
- Department of Oncology, Wayne State University, Detroit, Michigan
| | | | - Hiroshi Yano
- Department of Oncology, Wayne State University, Detroit, Michigan
| | - Dana L Schalk
- Department of Oncology, Wayne State University, Detroit, Michigan
| | - Lois Ayash
- Department of Oncology, Wayne State University, Detroit, Michigan; Department of Medicine, Wayne State University, Detroit, Michigan
| | - Jeffrey A Zonder
- Department of Oncology, Wayne State University, Detroit, Michigan
| | - Joseph P Uberti
- Department of Oncology, Wayne State University, Detroit, Michigan; Department of Medicine, Wayne State University, Detroit, Michigan
| | - Muneer H Abidi
- Department of Oncology, Wayne State University, Detroit, Michigan; Department of Medicine, Wayne State University, Detroit, Michigan
| | - Voravit Ratanatharathorn
- Department of Oncology, Wayne State University, Detroit, Michigan; Department of Medicine, Wayne State University, Detroit, Michigan
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87
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Martino M, Tripepi G, Messina G, Vincelli ID, Console G, Recchia AG, Gentile M, Molica S, Morabito F. A phase II, single-arm, prospective study of bendamustine plus melphalan conditioning for second autologous stem cell transplantation in de novo multiple myeloma patients through a tandem transplant strategy. Bone Marrow Transplant 2016; 51:1197-203. [DOI: 10.1038/bmt.2016.94] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2015] [Revised: 01/27/2016] [Accepted: 02/26/2016] [Indexed: 11/09/2022]
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88
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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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Martino M, Recchia AG, Fedele R, Neri S, Vincelli ID, Moscato T, Gentile M, Morabito F. The role of tandem stem cell transplantation for multiple myeloma patients. Expert Opin Biol Ther 2016; 16:515-34. [PMID: 26698133 DOI: 10.1517/14712598.2016.1136285] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Autologous Stem Cell Transplantation (ASCT) represents the standard treatment in eligible "de-novo" multiple myeloma (MM) patients. AREAS COVERED ASCT may be single or tandem, and a single ASCT can be followed by an allogeneic (Allo)-SCT. A systematic review has been conducted to examine the current evidence for the efficacy of using a tandem transplant strategy in MM. EXPERT OPINION A tandem ASCT approach should be considered for all patients, although the benefit from the second ASCT in patients who are in complete remission or experience a very good partial response should be answered in a clinical trial. Recent results with the new induction regimens indicate that there is a role for tandem ASCT in the presence of adverse cytogenetic abnormalities. Planned AlloSCT after ASCT has not been found to be superior in the majority of studies and is not recommended outside of a clinical trial. However, single or tandem ASCT are both appropriate options and participation in prospective clinical trials should be encouraged to resolve the debate in the era of novel agents for MM.
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Affiliation(s)
- Massimo Martino
- a Hematology, Stem Cell Collection and Transplant Unit, Oncology and Hematology Department , Azienda Ospedaliera BMM , Reggio Calabria , Italy
| | - Anna Grazia Recchia
- b Biotechnology Research Unit , Azienda Sanitaria Provinciale di Cosenza , Aprigliano (CS) , Italy
| | - Roberta Fedele
- a Hematology, Stem Cell Collection and Transplant Unit, Oncology and Hematology Department , Azienda Ospedaliera BMM , Reggio Calabria , Italy
| | - Santo Neri
- c Hematology Unit , Azienda Ospedaliera 'Papardo' , Messina , Italy
| | | | - Tiziana Moscato
- a Hematology, Stem Cell Collection and Transplant Unit, Oncology and Hematology Department , Azienda Ospedaliera BMM , Reggio Calabria , Italy
| | - Massimo Gentile
- e Hematology Unit , Azienda Ospedaliera Cosenza , Cosenza , Italy
| | - Fortunato Morabito
- b Biotechnology Research Unit , Azienda Sanitaria Provinciale di Cosenza , Aprigliano (CS) , Italy.,e Hematology Unit , Azienda Ospedaliera Cosenza , Cosenza , Italy
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90
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Jacobs RW, Saliba RM, Sasaki K, Farhan S, Armas A, Shah ND, Bashir Q, Qureshi S, Rondon G, Hosing C, Popat U, Parmar S, Shah JJ, Wang M, Weber DM, Thomas SK, Orlowski RZ, Champlin RE, Qazilbash MH. Outcome of Patients With Nonsecretory Multiple Myeloma After Autologous Hematopoietic Stem Cell Transplantation. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2016; 16:36-42. [DOI: 10.1016/j.clml.2015.11.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Revised: 11/05/2015] [Accepted: 11/11/2015] [Indexed: 12/29/2022]
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Abstract
Multiple myeloma is a disorder characterized by accumulation of malignant plasma cells in the bone marrow, hypercalcemia, monoclonal protein, and end organ damage. Recently newer generation proteosome inhibitors, monoclonal antibodies and novel agents have been approved by FDA, which is undoubtedly increasing life expectancy of the patients. However, hematopoietic stem cell transplantation still remains the cornerstone of the treatment. In this chapter, we are discussing the autologous stem cell transplant, allogeneic stem cell transplant and total therapy trials with outcomes.
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Affiliation(s)
- Yogesh S Jethava
- Stem Cell and Allogeneic Transplant, Department of Hematology/Oncology, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
| | - Frits van Rhee
- Stem Cell and Allogeneic Transplant, Department of Hematology/Oncology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
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92
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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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93
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WANG YAN, XU PENGPENG, CHEN YUBAO, FAN QINGYE, LI JUNMIN, ZHAO WEILI, MI JIANQING, YAN HUA. Novel agent induction therapy alone or followed by autologous stem cell transplantation in younger patients with multiple myeloma: A single-center retrospective study of 114 cases. Mol Clin Oncol 2016; 4:107-113. [PMID: 26870367 PMCID: PMC4727084 DOI: 10.3892/mco.2015.658] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Accepted: 10/05/2015] [Indexed: 12/20/2022] Open
Abstract
To define the role of autologous stem cell transplantation (ASCT) in newly diagnosed multiple myeloma (MM) in the era of novel agents, we analyzed follow-up data of patients treated by these agents alone or followed by ASCT. From January, 2008 to December, 2012, 136 patients with de novo MM, aged <65 years, completed bortezomib- or thalidomide-based induction therapy and 114 patients achieved at least a partial response (PR). A total of 42 patients underwent ASCT. After a median follow-up of 39 months (range, 5-74 months), the median progression-free survival (PFS) was 23 months in the non-ASCT group vs. 42 months in the ASCT group (P=0.001), and the 5-year overall survival (OS) rate was 58.9 vs. 81.2%, respectively (P=0.03). The multivariate analysis revealed that complete response (CR) and maintenance therapy (MT) were independent factors of improved OS in both groups. Moreover, a subgroup analysis was performed according to the response status to evaluate the role of ASCT and MT. In the CR subgroup, neither ASCT nor MT exerted a significant effect on PFS or OS. In the very good PR subgroup, ASCT after MT (ASCT/MT) significantly improved PFS, but not OS. In patients exhibiting PR, ASCT/MT significantly prolonged PFS and OS. Therefore, ASCT in the era of novel agents maintains an important role in younger MM patients, particularly those achieving a PR after induction therapy. Furthermore, MT is a key factor associated with long-term survival in all MM patients.
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Affiliation(s)
- YAN WANG
- Department of Hematology, Ruijin Hospital, Shanghai Jiao-Tong University School of Medicine, Shanghai 200025, P.R. China
| | - PENGPENG XU
- Department of Hematology, Ruijin Hospital, Shanghai Jiao-Tong University School of Medicine, Shanghai 200025, P.R. China
| | - YUBAO CHEN
- Department of Hematology, Ruijin Hospital, Shanghai Jiao-Tong University School of Medicine, Shanghai 200025, P.R. China
| | - QINGYE FAN
- Department of Hematology, Ruijin Hospital, Shanghai Jiao-Tong University School of Medicine, Shanghai 200025, P.R. China
| | - JUNMIN LI
- Department of Hematology, Ruijin Hospital, Shanghai Jiao-Tong University School of Medicine, Shanghai 200025, P.R. China
| | - WEILI ZHAO
- Department of Hematology, Ruijin Hospital, Shanghai Jiao-Tong University School of Medicine, Shanghai 200025, P.R. China
| | - JIANQING MI
- Department of Hematology, Ruijin Hospital, Shanghai Jiao-Tong University School of Medicine, Shanghai 200025, P.R. China
| | - HUA YAN
- Department of Hematology, Ruijin Hospital, Shanghai Jiao-Tong University School of Medicine, Shanghai 200025, P.R. China
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94
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Aznab M, Rezaei M, Navabi J, Moieni A. Evaluation of low-dose thalidomide as induction and maintenance therapy in patients with multiple myeloma not eligible for stem cell transplantation. Asia Pac J Clin Oncol 2015; 13:e138-e143. [PMID: 26531225 DOI: 10.1111/ajco.12418] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/24/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND The role of thalidomide in induction and long-term maintenance therapy in patients with multiple myeloma not eligible for stem cell transplantation remains unclear. The aim of the present study was to evaluate the effect of low-dose thalidomide as induction therapy and as maintenance therapy for 24 months in patients with a complete remission after the induction chemotherapy and to monitor the survival and relapse rates. METHODS Between October 2005 and September 2013, 50 patients with multiple myeloma received six courses of Cyclophosphamide-Vincristine Adriamycin and Dexamethazone (c-VAD) and pamidronate, and thalidomide 100 mg daily during induction, then thalidomide 100 mg daily for 24 months as maintenance. The effects of thalidomide were assessed objectively and subjectively. Whenever necessary, electromyography and nerve capacity volume were performed monthly for 6 months, then once every 3 months until the end of treatment. RESULTS Primary response was 96% (CR or very good PR in 48/50 patients). Fifteen out of the remaining 48 patients relapsed during the follow-up period. Nine out of the 15 patients who relapsed showed very good partial response to treatment and four patients showed partial response. Survival rate was 81% in these patients. The primary outcome measures showed a mean and median progression-free survival of 33 and 27 months, respectively, and a mean and median overall survival of 43 and 39 months, respectively. CONCLUSION Low-dose thalidomide during induction therapy combined with conventional chemotherapy and a 2-year maintenance may be effective in preventing the relapse and improving the overall survival.
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Affiliation(s)
- Mozaffar Aznab
- Internal Medicine Department, Talaghani Hospital, Kermanshah University of Medical Science, Kermanshah, Iran
| | - Mansour Rezaei
- Department of Biostatistics, Social Development and Health Promotion Research Center, Public Health College, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Jafar Navabi
- Internal Medicine Department, Talaghani Hospital, Kermanshah University of Medical Science, Kermanshah, Iran
| | - Ali Moieni
- Internal Medicine Department, Talaghani Hospital, Kermanshah University of Medical Science, Kermanshah, Iran
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95
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Anderson KC, Alsina M, Atanackovic D, Biermann JS, Chandler JC, Costello C, Djulbegovic B, Fung HC, Gasparetto C, Godby K, Hofmeister C, Holmberg L, Holstein S, Huff CA, Kassim A, Krishnan AY, Kumar SK, Liedtke M, Lunning M, Raje N, Singhal S, Smith C, Somlo G, Stockerl-Goldstein K, Treon SP, Weber D, Yahalom J, Shead DA, Kumar R. Multiple Myeloma, Version 2.2016: Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw 2015; 13:1398-435. [PMID: 26553768 PMCID: PMC4891187 DOI: 10.6004/jnccn.2015.0167] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Multiple myeloma (MM) is a malignant neoplasm of plasma cells that accumulate in bone marrow, leading to bone destruction and marrow failure. Recent statistics from the American Cancer Society indicate that the incidence of MM is increasing. The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) included in this issue address management of patients with solitary plasmacytoma and newly diagnosed MM.
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96
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Mueller BU, Keller S, Seipel K, Mansouri Taleghani B, Rauch D, Betticher D, Egger T, Pabst T. Stem cell mobilization chemotherapy with gemcitabine is effective and safe in myeloma patients with bortezomib-induced neurotoxicity. Leuk Lymphoma 2015; 57:1122-9. [DOI: 10.3109/10428194.2015.1079315] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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97
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Lin TL, Wang PN, Kuo MC, Hung YH, Chang H, Tang TC. Cyclophosphamide plus granulocyte-colony stimulating factor for hematopoietic stem cell mobilization in patients with multiple myeloma. J Clin Apher 2015; 31:423-8. [PMID: 26340986 DOI: 10.1002/jca.21421] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2014] [Accepted: 07/14/2015] [Indexed: 11/09/2022]
Abstract
We retrospectively reviewed the results of cyclophosphamide (3 g/m(2) ), doxorubicin and dexamethasone plus granulocyte-colony stimulating factor (G-CSF) (ID-CY/DOX group), low-dose cyclophosphamide (2 g/m(2) ) plus G-CSF (LD-CY group) and G-CSF alone (G-CSF group) for stem cell mobilization in patients with multiple myeloma. A total of 89 patients with 93 mobilizations were included. Apheresis was started when total white blood cell (WBC) count >10 × 10(9) /L for ID-CY/DOX and LD-CY groups and after eight doses of G-CSF (5 μg/kg twice daily) for G-CSF group. For five mobilizations in ID-CY/DOX group, the rate of successful mobilization (≥4.0 × 10(6) /kg CD34+ cells) was 80%. For 78 mobilizations in LD-CY group, the successful rate was 80.8%. For 10 mobilizations in the G-CSF group, the successful rate was 50%. The mean yield of CD34+ cells was higher in ID-CY/DOX and LD-CY groups as compared with that in G-CSF group (P = 0.026 and 0.020, respectively). There was no difference in the yield of CD34+ cells between ID-CY/DOX and LD-CY groups (P = 0.831). After autologous stem cell transplantation, the days to neutrophil and platelet engraftment were similar in these three groups (P = 0.713 and 0.821, respectively). In conclusion, we observed that ID-CY/DOX and LD-CY plus G-CSF for stem cell mobilization resulted in a higher successful rate and higher stem cell yields than G-CSF alone and their engraftment time were similar. Total WBC count >10 × 10(9) /L can be used as a guide to start apheresis in CY-based stem cell mobilization. J. Clin. Apheresis 31:423-428, 2016. © 2015 Wiley Periodicals, Inc.
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Affiliation(s)
- Tung-Liang Lin
- Department of Internal Medicine, Division of Hematology-Oncology, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Po-Nan Wang
- Department of Internal Medicine, Division of Hematology-Oncology, Chang Gung Memorial Hospital, Taoyuan City, Taiwan.
| | - Ming-Chung Kuo
- Department of Internal Medicine, Division of Hematology-Oncology, Chang Gung Memorial Hospital, Taoyuan City, Taiwan.,College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Yu-Hsing Hung
- Department of Internal Medicine, Division of Hematology-Oncology, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Hung Chang
- Department of Internal Medicine, Division of Hematology-Oncology, Chang Gung Memorial Hospital, Taoyuan City, Taiwan.,College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Tzung-Chih Tang
- Department of Internal Medicine, Division of Hematology-Oncology, Chang Gung Memorial Hospital, Taoyuan City, Taiwan.,College of Medicine, Chang Gung University, Taoyuan City, Taiwan
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McCann KJ, Godeseth R, Chudley L, Mander A, Di Genova G, Lloyd-Evans P, Kerr JP, Malykh VB, Jenner MW, Orchard KH, Stevenson FK, Ottensmeier CH. Idiotypic DNA vaccination for the treatment of multiple myeloma: safety and immunogenicity in a phase I clinical study. Cancer Immunol Immunother 2015; 64:1021-32. [PMID: 25982371 PMCID: PMC4506484 DOI: 10.1007/s00262-015-1703-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Accepted: 04/21/2015] [Indexed: 11/26/2022]
Abstract
We report on the safety and immunogenicity of idiotypic DNA vaccination in a phase I, non-randomised, open-label study in patients with multiple myeloma. The study used DNA fusion gene vaccines encoding patient-specific single chain variable fragment, or idiotype (Id), linked to fragment C (FrC) of tetanus toxin. Patients in complete or partial response following high-dose chemotherapy and autologous stem cell transplant were vaccinated intramuscularly with 1 mg DNA on six occasions, beginning at least 6 months post-transplant; follow-up was to week 52. Fourteen patients were enrolled on study and completed vaccinations. Idiotypic DNA vaccines were well tolerated with vaccine-related adverse events limited to low-grade constitutional symptoms. FrC- and Id-specific T-cell responses were detected by ex vivo ELISPOT in 9/14 and 3/14 patients, respectively. A boost of pre-existing anti-FrC antibody (Ab) was detected by ELISA in 8/14 patients, whilst anti-Id Ab was generated in 1/13 patients. Overall, four patients (29 %) made an immune response to FrC and Id, with six patients (43 %) responding to FrC alone. Over the 52-week study period, serum paraprotein was undetectable, decreased or remained stable for ten patients (71 %), whilst ongoing CR/PR was maintained for 11 patients (79 %). The median time to progression was 38.0 months for 13/14 patients. Overall survival was 64 % after a median follow-up of 85.6 months.
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Affiliation(s)
- Katy J McCann
- Experimental Cancer Medicine Centre Southampton and Cancer Sciences Unit, Faculty of Medicine, University of Southampton, Somers Cancer Research Building, Mailpoint 824, Southampton General Hospital, Tremona Road, Southampton, SO16 6YD, UK,
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Lamm W, Wohlfarth P, Bojic M, Schörgenhofer C, Drach J, Gisslinger H, Worel N, Schiefer A, Schulenburg A, Agis H, Kalhs P, Greinix HT, Schellongowski P, Rabitsch W. Outcome in Multiple Myeloma Patients Eligible for Stem Cell Transplantation: A Single-Center Experience. Oncology 2015; 89:196-204. [PMID: 26228581 DOI: 10.1159/000437055] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Accepted: 06/16/2015] [Indexed: 11/19/2022]
Abstract
Autologous hematopoietic stem cell transplantation (ASCT) is the standard of care for selected patients with multiple myeloma (MM). Many data exist on ASCT in the era of novel agents. We retrospectively analyzed 189 patients (108 males and 81 females) with biopsy-proven MM, who had received ASCT after induction therapy with either conventional chemotherapy alone or in combination with novel agents at our department. The outcomes of both groups and the risk factors for shorter survival were investigated. The most commonly used induction chemotherapy prior to ASCT was VAD (vincristine, doxorubicin and dexamethasone, 42%), followed by PAD (bortezomib, doxorubicin and dexamethasone, 21%). One-hundred and twenty-nine patients (68%) received cyclophosphamide-recombinant human granulocyte colony-stimulating factor for stem cell mobilization. No differences were observed for progression-free survival in terms of the number of transplanted CD34+ cells (p = 0.261). A trend in improved overall survival (OS) was seen for the use of novel agents when compared to conventional chemotherapy (164.3 vs. 82.0 months; p = 0.046). The International Staging System stages had a significant (p = 0.036) impact on OS. The novel agents improved OS in our patients with MM undergoing ASCT when compared to conventional chemotherapy regimens. The number of transplanted CD34+ cells had no significant impact on hematopoietic reconstitution.
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Affiliation(s)
- Wolfgang Lamm
- Clinical Division of Oncology, Medical University of Vienna, Vienna, Austria
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Keller S, Seipel K, Novak U, Mueller BU, Taleghani BM, Leibundgut K, Pabst T. Neurotoxicity of stem cell mobilization chemotherapy with vinorelbine in myeloma patients after bortezomib treatment. Leuk Res 2015; 39:786-92. [DOI: 10.1016/j.leukres.2015.03.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2014] [Revised: 02/13/2015] [Accepted: 03/20/2015] [Indexed: 11/30/2022]
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