A comparison of allografting with autografting for newly diagnosed myeloma

Engineering antitumor immunity by T-cell adoptive immunotherapy

The adoptive transfer of antigen-specific T cells has been used successfully to treat experimental tumors in animal models and viral infections in humans, but harnessing the exquisite specificity and potency of T cells to treat human malignancy has proven challenging. The efforts to use T cells to treat patients with cancer have often been informative in identifying limitations that must be overcome to improve therapeutic efficacy, and a clearer picture of the requirements for successful adoptive T-cell transfer is gradually emerging. Indolent and a subset of aggressive B-cell lymphomas in humans have been shown to be susceptible to eradication by T cells in clinical settings where highly immunogenic minor histocompatibility or viral antigens are presented by tumor cells. In this article, we will review how recent advances in our understanding of the properties of antigen-specific T cells that facilitate their long-term persistence in vivo and reversion to the memory pool after in vitro culture, combined with approaches to molecularly engineer T cells with receptors that target molecules expressed by B-cell lymphoma, are providing opportunities to broaden the application of T-cell therapy and improve its efficacy for this disease.

Strategies for risk-adapted therapy in myeloma

It is clear that the clinical heterogeneity of multiple myeloma (MM) is dictated, in large part, by disease biology, predominantly genetics.(1) As novel therapeutics have emerged, and augmented our treatment armamentarium against the disease, it is increasingly important to introduce a risk-adapted approach for the optimal management of patients.(2) The selection of ideal candidates for high-dose chemotherapy with stem cell support (HDT) and maintenance will undoubtedly have to include baseline knowledge of the genetic nature of the individual. The limited duration of responses after HDT for patients with t(4;14)(p16;q32), t(14;16)(q32;q23) and 17p13 deletions highlight the need to develop a risk-adapted treatment strategy.(3)(-)(5) Novel ways of determining outcome such as the use of gene expression profiling have demonstrated differentiating capabilities not previously observed.(6) Likewise, the order of introduction of novel therapeutic agents (during induction and in the relapsing patient) will be potentially directed by similar information. As we have previously stated, MM is not only multiple but also "many."(7) Accordingly, treatment strategies will be tailored based on risk determination, genetic composition and host features.

Reduced-Intensity Stem Cell Transplantation

The recognition that the immune system can play a major role in the control and cure of transplantable disorders led to the development of reduced-intensity allogeneic transplantation. The notion is that a compromise can be made between the intensity of conditioning and the fostering of graft-versus-host disease/ graft-versus-leukemia (GVHD/GVL), allowing the use of less intense conditioning with concomitantly less intense immediate toxicity. Reduced-intensity conditioning regimens have allowed the application of transplantation to older patients and to patients with underlying medical problems that preclude full-dose transplantation. Clearly, in some settings in which dose intensity is important, reduced-intensity regimens are less useful. However, for diseases that are either indolent, highly susceptible to GVL, or under good control before entering transplantation, this approach appears to have substantial benefits. Although the therapy appears to be valuable, concerns about delayed immune reconstitution and GVHD remain.

Stem cell transplantation in multiple myeloma

Multiple myeloma (MM) is one of the key hematologic malignancies in which the impact of dose intensity has been demonstrated. Consequently, in 2005, MM was the most common disease for which autologous stem cell transplantation (ASCT) was indicated both in Europe and in the U.S. However, ASCT is not curative, and most patients relapse within a median of 3 years. Novel agents such as thalidomide (Thalidomid), bortezomib (Velcade), or lenalidomide (Revlimid) have been introduced to improve high-dose therapy, and promising results have been reported. Conversely, results from myeloablative allogeneic stem cell transplantation remain disappointing due to high transplantation-related mortality, justifying the exploration of strategies such as reduced-intensity conditioning, which have been shown to be feasible but for which proof of efficacy requires continued study.