1
|
Yassine F, Kharfan-Dabaja MA, Tsalantsanis A, Roy V, Zubair AC, Murthy HS, Ayala E, Iqbal M, Sher T, Ailawadhi S, Parrondo RD. Trends in utilization of stored cryopreserved autologous peripheral hematopoietic cells intended for a second (or beyond) autologous hematopoietic cell transplantation in patients with multiple myeloma: a single center experience. Bone Marrow Transplant 2023; 58:1130-1136. [PMID: 37479753 PMCID: PMC10555832 DOI: 10.1038/s41409-023-02035-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 06/04/2023] [Accepted: 06/21/2023] [Indexed: 07/23/2023]
Abstract
Due to the advent of effective novel therapies for multiple myeloma (MM), the use of cryopreserved autologous peripheral blood hematopoietic cells (APBHC) for a salvage autologous transplant (auto-HCT) is in decline. We evaluated utilization trends and costs associated with cryopreserved APBHC in patients with MM. We retrospectively evaluated the clinicopathologic data from 440 patients with MM who underwent APBHC mobilization and collection at Mayo Clinic Florida between 2010 and 2019. Based on institution-specific charges as of May 2021, the cost of 1 session of APBHC collection/apheresis was $4,680 and the cost of 1 year of APBHC cryopreservation was $4,790 per patient. Out of 347 patients who had APBHC in cryopreservation, 5 (1.4%) underwent a salvage auto-HCT and 61% of patients had ≥1 excess collection sessions for APBHC that ultimately went unused. The median cost of excess collection sessions was $4,680 per patient (range, $4,680-$32,760) and the median total cost for excess collection sessions plus costs for storage was $23,840 per patient (range, $4,680-$85,450). The sum of costs of excess collection sessions was $2,077,920 and the sum of costs of cryopreservation was $5,812,665. Institutional policies regarding universal APBHC collection and long-term storage should be reevaluated in the era of novel therapeutics.
Collapse
Affiliation(s)
- Farah Yassine
- Division of Hematology-Oncology and Blood and Marrow Transplantation Program, Mayo Clinic, Jacksonville, FL, USA
| | - Mohamed A Kharfan-Dabaja
- Division of Hematology-Oncology and Blood and Marrow Transplantation Program, Mayo Clinic, Jacksonville, FL, USA
| | - Athanasios Tsalantsanis
- Program for Comparative Effectiveness Research, Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Vivek Roy
- Division of Hematology-Oncology and Blood and Marrow Transplantation Program, Mayo Clinic, Jacksonville, FL, USA
| | - Abba C Zubair
- Department of Pathology and Laboratory Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Hemant S Murthy
- Division of Hematology-Oncology and Blood and Marrow Transplantation Program, Mayo Clinic, Jacksonville, FL, USA
| | - Ernesto Ayala
- Division of Hematology-Oncology and Blood and Marrow Transplantation Program, Mayo Clinic, Jacksonville, FL, USA
| | - Madiha Iqbal
- Division of Hematology-Oncology and Blood and Marrow Transplantation Program, Mayo Clinic, Jacksonville, FL, USA
| | - Taimur Sher
- Division of Hematology-Oncology and Blood and Marrow Transplantation Program, Mayo Clinic, Jacksonville, FL, USA
| | - Sikander Ailawadhi
- Division of Hematology-Oncology and Blood and Marrow Transplantation Program, Mayo Clinic, Jacksonville, FL, USA
| | - Ricardo D Parrondo
- Division of Hematology-Oncology and Blood and Marrow Transplantation Program, Mayo Clinic, Jacksonville, FL, USA.
| |
Collapse
|
2
|
Khan AM, Ozga M, Bhatt H, Faisal MS, Ansari S, Zhao Q, Bumma N, Cottini F, Devarakonda S, Rosko A, Sharma N, Umyarova E, Benson D. Outcomes After Salvage Autologous Hematopoietic Cell Transplant for Patients With Relapsed/Refractory Multiple Myeloma: A Single-Institution Experience. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2023; 23:e182-e189. [PMID: 36581554 DOI: 10.1016/j.clml.2022.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 11/25/2022] [Accepted: 12/02/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND The role of salvage autologous hematopoietic cell transplantation (sAHCT2) for patients with relapsed/refractory multiple myeloma (RRMM) in the era of modern therapeutics is unclear. As prospective data is limited, we conducted a retrospective analysis to determine the outcomes of sAHCT2. PATIENTS AND METHODS We conducted a single-institution, retrospective analysis of patients who received sAHCT2 at The Ohio State University from 2000 to 2018. Patients who received a second transplant as part of a planned tandem or autologous-allogeneic transplant were excluded. RESULTS Fifty-seven patients were treated with sAHCT2. Patients had a median of 2 lines of therapy after AHCT1 prior to their sAHCT2; 70% had prior immunomodulatory imide drugs, 82% had prior proteasome inhibitor, and 20% had prior anti-CD38 monoclonal antibodies as part of re-induction therapy. Forty-two percent of patients attained ≥VGPR prior to sAHCT2. Seventy-four were treated with melphalan 200 mg/m2 as conditioning regimen before infusion of a median of 3.8 × 106 CD34+ cells/kg. Fifty-eight percent patients had maintenance therapy and 81% patients attained CR/VGPR as the best response after sAHCT2. The median PFS and OS after sAHCT2 were 1.6 and 3.6 years, respectively. On multivariable analysis, high-risk cytogenetics, not having attained CR/VGPR, and having more than 2 lines of therapy post-AHCT1 were associated with inferior PFS. Melphalan 140 mg/m2 compared to melphalan 200 mg/m2 and no maintenance therapy compared to maintenance therapy were not associated with inferior PFS. There was no transplant-related mortality in this patient cohort. CONCLUSIONS For MM patients deriving durable remission after their AHCT1, sAHCT2 was safe and resulted in deep and durable remissions.
Collapse
Affiliation(s)
- Abdullah M Khan
- Division of Hematology, The Ohio State University Wexner Medical Center, Columbus, OH.
| | - Michael Ozga
- Division of Hematology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Harshil Bhatt
- Division of Hematology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Muhammad S Faisal
- Roswell Park Comprehensive Cancer Center, Division of Hematology, Rochester, NY
| | - Sadia Ansari
- Division of Hematology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Qiuhong Zhao
- Division of Hematology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Naresh Bumma
- Division of Hematology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Francesca Cottini
- Division of Hematology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Srinivas Devarakonda
- Division of Hematology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Ashley Rosko
- Division of Hematology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Nidhi Sharma
- Division of Hematology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Elvira Umyarova
- Division of Hematology, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Don Benson
- Division of Hematology, The Ohio State University Wexner Medical Center, Columbus, OH
| |
Collapse
|
3
|
Post Salvage Therapy Autologous Transplant for Relapsed Myeloma, Ongoing Relevance within Modern Treatment Paradigms? CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2023; 23:e97-e106. [PMID: 36564313 DOI: 10.1016/j.clml.2022.11.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 10/20/2022] [Accepted: 11/18/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Salvage transplant has been historically considered effective therapy for myeloma patients relapsing after first transplant, if they achieved adequate remission duration. However, the efficacy of novel agent combinations has called this paradigm into question. MATERIALS AND METHODS We performed a retrospective analysis in a homogeneously treated cohort of 106 patients undergoing ASCT2 at our institution, all of whom received novel agent-based chemotherapy (immunomodulatory agent [IMiD] and/or proteasome inhibitor [PI]) for both induction and relapse. As an exploratory objective we assessed whether predictive thresholds of progression free survival post first transplant (ASCT1) for benefit post ASCT2 vary with use of IMiD maintenance post ASCT1. RESULTS The overall response rate (ORR) was 98% post-ASCT2 and treatment-related mortality (TRM) was low at 1.8%. With a median follow-up of 26 months (range 0.5-85) from ASCT2, median overall survival (OS) is estimated at 80 months (95% CI: ≥ 49-months) and median progression-free survival after ASCT2 (PFS2) at 24 months (95% CI 19-39). PFS post first transplant (PFS1) at >/= 50 months was associated with improved OS. Predictors of PFS2 included PFS1 ≤42 months and progression on IMiD-based maintenance post- ASCT1. CONCLUSION ASCT2 continues to offer acceptable outcomes for most patients treated within modern day treatment paradigms, with longer PFS after ASCT1 and IMiD non-refractory disease being associated with improved outcomes.
Collapse
|
4
|
The first relapse in multiple myeloma: how to pick the next best thing. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2022; 2022:560-568. [PMID: 36485087 PMCID: PMC9821240 DOI: 10.1182/hematology.2022000356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The choice of treatment for patients with multiple myeloma (MM) at first relapse/progression is based on many factors: (1) treatment-related factors, which include the regimen used during first induction, the quality and duration of first response achieved, toxicities from the first treatment, whether the patient underwent autologous stem cell transplant, and whether the patient was on maintenance at the time of relapse/progression; (2) disease-related factors, including disease presentation and pace of progression; and (3) patient-related factors, including functional age and performance status. The learning objectives are to present the treatment options for patients with MM upon their first relapse and to learn about various strategies for selecting an optimal treatment regimen.
Collapse
|
5
|
Hernández-Rivas JÁ, Ríos-Tamayo R, Encinas C, Alonso R, Lahuerta JJ. The changing landscape of relapsed and/or refractory multiple myeloma (MM): fundamentals and controversies. Biomark Res 2022; 10:1. [PMID: 35000618 PMCID: PMC8743063 DOI: 10.1186/s40364-021-00344-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Accepted: 10/24/2021] [Indexed: 12/13/2022] Open
Abstract
The increase in the number of therapeutic alternatives for both newly diagnosed and relapsed/refractory multiple myeloma (RRMM) patients has widened the clinical scenario, leading to a level of complexity that no algorithm has been able to cover up to date. At present, this complexity increases due to the wide variety of clinical situations found in MM patients before they reach the status of relapsed/refractory disease. These different backgrounds may include primary refractoriness, early relapse after completion of first-line therapy with latest-generation agents, or very late relapse after chemotherapy or autologous transplantation. It is also important to bear in mind that many patient profiles are not fully represented in the main randomized clinical trials (RCT), and this further complicates treatment decision-making. In RRMM patients, the choice of previously unused drugs and the number and duration of previous therapeutic regimens until progression has a greater impact on treatment efficacy than the adverse biological characteristics of MM itself. In addition to proteasome inhibitors, immunomodulatory drugs, anti-CD38 antibodies and corticosteroids, a new generation of drugs such as XPO inhibitors, BCL-2 inhibitors, new alkylators and, above all, immunotherapy based on conjugated anti-BCMA antibodies and CAR-T cells, have been developed to fight RRMM. This comprehensive review addresses the fundamentals and controversies regarding RRMM, and discusses the main aspects of management and treatment. The basis for the clinical management of RRMM (complexity of clinical scenarios, key factors to consider before choosing an appropriate treatment, or when to treat), the arsenal of new drugs with no cross resistance with previously administered standard first line regimens (main phase 3 clinical trials), the future outlook including the usefulness of abandoned resources, together with the controversies surrounding the clinical management of RRMM patients will be reviewed in detail.
Collapse
Affiliation(s)
| | - Rafael Ríos-Tamayo
- Hospital Universitario Virgen de las Nieves, Instituto de Investigación Biosanitaria, Granada, Spain
| | - Cristina Encinas
- Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
| | - Rafael Alonso
- Hospital Universitario 12 de Octubre, Instituto de Investigación del Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Juan-José Lahuerta
- Hospital Universitario 12 de Octubre, Instituto de Investigación del Hospital Universitario 12 de Octubre, Madrid, Spain.
| |
Collapse
|
6
|
Gregersen H, Peceliunas V, Remes K, Schjesvold F, Abildgaard N, Nahi H, Andersen NF, Vangsted AJ, Klausen TW, Helleberg C, Carlson K, Frølund UC, Axelsson P, Stromberg O, Blimark CH, Crafoord J, Tsykunova G, Eshoj HR, Waage A, Hansson M, Gulbrandsen N. Carfilzomib and dexamethasone maintenance following salvage ASCT in multiple myeloma: A randomised phase 2 trial by the Nordic Myeloma Study Group. Eur J Haematol 2021; 108:34-44. [PMID: 34536308 PMCID: PMC9292771 DOI: 10.1111/ejh.13709] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Revised: 09/13/2021] [Accepted: 09/15/2021] [Indexed: 12/19/2022]
Abstract
Objective We investigated the efficacy and safety of carfilzomib‐containing induction before salvage high‐dose melphalan with autologous stem‐cell transplantation (salvage ASCT) and maintenance with carfilzomib and dexamethasone after salvage ASCT in multiple myeloma. Methods This randomised, open‐label, phase 2 trial included patients with first relapse of multiple myeloma after upfront ASCT who were re‐induced with four cycles of carfilzomib, cyclophosphamide and dexamethasone. Two months after salvage, ASCT patients were randomised to either observation or maintenance therapy with iv carfilzomib 27 → 56 mg/sqm and p.o. dexamethasone 20 mg every second week. The study enrolled 200 patients of which 168 were randomised to either maintenance with carfilzomib and dexamethasone (n = 82) or observation (n = 86). Results Median time to progression (TTP) after randomisation was 25.1 months (22.5‐NR) in the carfilzomib‐dexamethasone maintenance group and 16.7 months (14.4–21.8) in the control group (HR 0.46, 95% CI 0.30–0.71; P = .0004). The most common adverse events during maintenance were thrombocytopenia, anaemia, hypertension, dyspnoea and bacterial infections. Conclusion In summary, maintenance therapy with carfilzomib and dexamethasone after salvage ASCT prolonged TTP with 8 months. The maintenance treatment was in general well‐tolerated with manageable toxicity.
Collapse
Affiliation(s)
- Henrik Gregersen
- Department of Haematology, Aalborg University Hospital, Aalborg, Denmark
| | - Valdas Peceliunas
- Department of Haematology, Vilnius University Hospital Santaros Klinikos, Vilnius, Lithuania
| | - Kari Remes
- Department of Haematology, Turku University Hospital, Turku, Finland
| | - Fredrik Schjesvold
- Oslo Myeloma Center, Oslo University Hospital, Oslo, Norway.,KG Jebsen Center for B cell malignancies, University of Oslo, Oslo, Norway
| | - Niels Abildgaard
- Department of Haematology, Odense University Hospital, Odense, Denmark.,Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Hareth Nahi
- Department of Haematology, Karolinska University Hospital, Stockholm, Sweden
| | | | | | | | | | - Kristina Carlson
- Department of Haematology, Uppsala University Hospital, Uppsala, Sweden
| | | | - Per Axelsson
- Department of Haematology, Helsingborg Hospital, Helsingborg, Sweden
| | - Olga Stromberg
- Department of Haematology, Karolinska University Hospital, Stockholm, Sweden
| | | | - Jacob Crafoord
- Department of Haematology, Örebro University Hospital, Örebro, Sweden
| | - Galina Tsykunova
- Department of Haematology, Haukeland University Hospital, Bergen, Norway
| | - Henrik Rode Eshoj
- Quality of Life Research Center, Department of Haematology, Odense University Hospital, Odense, Denmark.,OPEN, Open Patient data Explorative Network, Odense University Hospital, Region of Southern Denmark, Denmark
| | - Anders Waage
- Department of Haematology, St Olavs hospital and Institute of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Markus Hansson
- Department of Haematology, Skåne University Hospital, Lund, Sweden
| | | |
Collapse
|
7
|
Lemieux C, Muffly LS, Iberri DJ, Craig JK, Johnston LJ, Lowsky R, Shiraz P, Rezvani AR, Frank MJ, Weng WK, Meyer E, Shizuru JA, Arai S, Liedtke M, Negrin RS, Miklos DB, Sidana S. Outcomes after delayed and second autologous stem cell transplant in patients with relapsed multiple myeloma. Bone Marrow Transplant 2021; 56:2664-2671. [PMID: 34163014 DOI: 10.1038/s41409-021-01371-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 05/17/2021] [Accepted: 05/27/2021] [Indexed: 12/22/2022]
Abstract
We evaluated the outcomes of 168 patients undergoing delayed or second autologous stem cell transplant (ASCT) for relapsed multiple myeloma (MM) from 2010 to 2019. Overall, 21% (n = 35) patients had received a prior transplant and 69% (n = 116) underwent transplant at first relapse. Overall, 27% patients had high-risk cytogenetics and 15% had ISS stage III disease. Stem cell collection was performed after relapse in 72% and 35% of patients received maintenance therapy. Median PFS from salvage treatment and transplant were 28 and 19 months, respectively. Median OS from salvage treatment and transplant was 69 and 55 months. Multivariate analysis revealed that ASCT in first relapse was associated with superior PFS (HR 0.63, p = 0.03) and OS (HR 0.59, p = 0.04) compared to later lines of therapy. In addition, PFS of ≥36 months with prior therapy was associated with improved PFS (HR 0.62, p = 0.04) and OS (HR 0.41, p = 0.01). Ninety-five patients underwent delayed transplant at first relapse, median PFS and OS from start of therapy was 30 and 69 months, and median OS from diagnosis was 106 months. These data may serve as a guide when counseling patients undergoing ASCT for relapsed MM and provide a benchmark in designing clinical trials of transplantation/comparative treatments for relapsed MM.
Collapse
Affiliation(s)
- Christopher Lemieux
- Department of Medicine, Stanford University, Stanford, CA, USA.,Division of Hematology and Medical Oncology, Department of Medicine, Université Laval, Québec, QC, Canada
| | - Lori S Muffly
- Department of Medicine, Stanford University, Stanford, CA, USA
| | - David J Iberri
- Department of Medicine, Stanford University, Stanford, CA, USA
| | - Juliana K Craig
- Department of Medicine, Stanford University, Stanford, CA, USA
| | | | - Robert Lowsky
- Department of Medicine, Stanford University, Stanford, CA, USA
| | - Parveen Shiraz
- Department of Medicine, Stanford University, Stanford, CA, USA
| | | | - Matthew J Frank
- Department of Medicine, Stanford University, Stanford, CA, USA
| | - Wen-Kai Weng
- Department of Medicine, Stanford University, Stanford, CA, USA
| | - Everett Meyer
- Department of Medicine, Stanford University, Stanford, CA, USA
| | | | - Sally Arai
- Department of Medicine, Stanford University, Stanford, CA, USA
| | | | - Robert S Negrin
- Department of Medicine, Stanford University, Stanford, CA, USA
| | - David B Miklos
- Department of Medicine, Stanford University, Stanford, CA, USA
| | - Surbhi Sidana
- Department of Medicine, Stanford University, Stanford, CA, USA.
| |
Collapse
|
8
|
Mohyuddin GR, Okoniewski M, Diab O, Ganguly S, Shune L, Abdallah AO, McGuirk J, McClune B. Maintenance regimens after a second autologous transplant for multiple myeloma. Leuk Lymphoma 2020; 62:758-760. [PMID: 33146051 DOI: 10.1080/10428194.2020.1842402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
| | - Maire Okoniewski
- Department of Internal Medicine, University of Kansas, Kansas City, KS, USA
| | - Osama Diab
- Division of Hematology Oncology, University of Kansas, Kansas City, KS, USA
| | - Siddhartha Ganguly
- Department of Hematological Malignancies and Cellular Therapeutics, University of Kansas, Kansas City, KS, USA
| | - Leyla Shune
- Department of Hematological Malignancies and Cellular Therapeutics, University of Kansas, Kansas City, KS, USA
| | - Al-Ola Abdallah
- Department of Hematological Malignancies and Cellular Therapeutics, University of Kansas, Kansas City, KS, USA
| | - Joseph McGuirk
- Department of Hematological Malignancies and Cellular Therapeutics, University of Kansas, Kansas City, KS, USA
| | - Brian McClune
- Division of Hematology and Hematologic Malignancies, Department of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| |
Collapse
|
9
|
Chhabra S, Thapa B, Szabo A, Konings S, D'Souza A, Dhakal B, Jerkins JH, Pasquini MC, Johnson BD, Hari PN, Hamadani M. Utilization and Cost Implications of Hematopoietic Progenitor Cells Stored for a Future Salvage Autologous Transplantation or Stem Cell Boost in Myeloma Patients. Biol Blood Marrow Transplant 2020; 26:2011-2017. [PMID: 32717431 DOI: 10.1016/j.bbmt.2020.07.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 07/04/2020] [Accepted: 07/15/2020] [Indexed: 01/24/2023]
Abstract
Autologous hematopoietic cell transplantation (autoHCT) is a standard initial treatment for multiple myeloma (MM). Consensus guidelines recommend collecting sufficient hematopoietic progenitor cells (HPCs) for 2 autoHCTs in all eligible patients. Despite a lack of published data on the utilization of HPCs stored for future use, it is common practice across transplantation programs to collect enough HPCs for 2 autoHCTs in MM patients. In this single-center retrospective study, we analyzed the utilization of HPCs collected and stored at the time of first autoHCT in patients with MM, along with the cost implications of HPC collection targets sufficient for 2 transplantations. In a cohort of 400 patients (median age, 63 years; range, 22 to 79 years), after a median follow-up of 50.4 months, 197 patients had relapsed and 36 had received HPC infusion as salvage autoHCT (n = 29) and/or HPC boost (n = 8). In this cohort, a median CD34+ cell dose of 4.3 × 106/kg (range, 1.1 to 12.94.3 × 106/kg) was used for first autoHCT, and a median of 4.4 × 106/kg (range, 1.0 to 20.2× 106/kg) CD34+ cells were stored for future use. At 6 years after the first autoHCT, the estimated cumulative incidence of salvage autoHCT was 12.0% without HPC boost and 13.9% with HPC boost. HPC utilization was significantly higher in the 60- to 64-year age group, whereas no patients who were age ≥70 years at the time of first autoHCT received salvage autoHCT. Using the CD34+ cell dose infused during the first autoHCT as the cutoff for individual patients, the estimated mean additional cost of HPC collection intended for subsequent use (over and above the HPCs used for first autoHCT) was $10,795 ($4.32 million for the entire cohort), an estimated 14% of which (ie, $583,600) was actually used up in salvage autoHCT by 6 years from first autoHCT. In conclusion, our results suggest the need for reappraisal of HPC collection targets for salvage autoHCT and argue against HPC collection and storage for salvage autoHCT in patients age ≥70 years at the time of first autoHCT.
Collapse
Affiliation(s)
- Saurabh Chhabra
- Division of Hematology and Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Blood and Marrow Transplant & Cellular Therapy Program, Froedtert & the Medical College of Wisconsin, Milwaukee, Wisconsin; Center for International Blood and Marrow Transplant Research, Milwaukee Campus, Milwaukee, Wisconsin.
| | - Bicky Thapa
- Division of Hematology and Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Aniko Szabo
- Department of Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Steve Konings
- Division of Hematology and Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Anita D'Souza
- Division of Hematology and Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Blood and Marrow Transplant & Cellular Therapy Program, Froedtert & the Medical College of Wisconsin, Milwaukee, Wisconsin; Center for International Blood and Marrow Transplant Research, Milwaukee Campus, Milwaukee, Wisconsin
| | - Binod Dhakal
- Division of Hematology and Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Blood and Marrow Transplant & Cellular Therapy Program, Froedtert & the Medical College of Wisconsin, Milwaukee, Wisconsin
| | - James H Jerkins
- Division of Hematology and Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Blood and Marrow Transplant & Cellular Therapy Program, Froedtert & the Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Marcelo C Pasquini
- Division of Hematology and Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Blood and Marrow Transplant & Cellular Therapy Program, Froedtert & the Medical College of Wisconsin, Milwaukee, Wisconsin; Center for International Blood and Marrow Transplant Research, Milwaukee Campus, Milwaukee, Wisconsin
| | - Bryon D Johnson
- Division of Hematology and Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Blood and Marrow Transplant & Cellular Therapy Program, Froedtert & the Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Parameswaran N Hari
- Division of Hematology and Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Blood and Marrow Transplant & Cellular Therapy Program, Froedtert & the Medical College of Wisconsin, Milwaukee, Wisconsin; Center for International Blood and Marrow Transplant Research, Milwaukee Campus, Milwaukee, Wisconsin
| | - Mehdi Hamadani
- Division of Hematology and Oncology, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Blood and Marrow Transplant & Cellular Therapy Program, Froedtert & the Medical College of Wisconsin, Milwaukee, Wisconsin; Center for International Blood and Marrow Transplant Research, Milwaukee Campus, Milwaukee, Wisconsin
| |
Collapse
|
10
|
Modi D, Chi J, Kim S, Ayash L, Alavi A, Kin A, Ratanatharathorn V, Uberti JP, Deol A. Lenalidomide maintenance after second autologous stem cell transplant improves overall survival in multiple myeloma. Leuk Lymphoma 2020; 61:1877-1884. [PMID: 32270725 DOI: 10.1080/10428194.2020.1749603] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Maintenance therapy after first autologous transplant (autoSCT) improves progression-free survival (PFS) and overall survival (OS) in multiple myeloma (MM). However, efficacy of maintenance therapy after second autoSCT is unknown. We retrospectively evaluated outcomes of 111 adult MM patients who underwent second autoSCT between January 2000 and December 2018. Lenalidomide up to 15 mg daily or subcutaneous bortezomib 1.3 mg/m2 every 2 weeks was considered maintenance therapy. Outcomes were compared among three groups: no-maintenance (n = 73), lenalidomide (n = 23), and bortezomib maintenance (n = 15). At a median follow-up of 58 months from second autoSCT for survival, 3-year PFS and OS for no-maintenance, lenalidomide, and bortezomib maintenance were 11.2%, 29.9%, and 0%, respectively; and 58.5%, 83.3%, and 67.5% respectively. Lenalidomide maintenance was associated with improved PFS (HR 0.46, p = 0.009) and OS (HR 0.25, p = 0.009) compared to no-maintenance. Lenalidomide maintenance therapy after second autoSCT appears to prolong PFS and OS.
Collapse
Affiliation(s)
- Dipenkumar Modi
- Department of Oncology, Blood and Marrow Stem Cell Transplant Program, Karmanos Cancer Institute, Wayne State University, Detroit, MI, USA
| | - Jie Chi
- Department of Internal Medicine, Wayne State University, Detroit, MI, USA
| | - Seongho Kim
- Department of Oncology, Biostatistics Core, Karmanos Cancer Institute, Wayne State University, Detroit, MI, USA
| | - Lois Ayash
- Department of Oncology, Blood and Marrow Stem Cell Transplant Program, Karmanos Cancer Institute, Wayne State University, Detroit, MI, USA
| | - Asif Alavi
- Department of Oncology, Blood and Marrow Stem Cell Transplant Program, Karmanos Cancer Institute, Wayne State University, Detroit, MI, USA
| | - Andrew Kin
- Department of Oncology, Blood and Marrow Stem Cell Transplant Program, Karmanos Cancer Institute, Wayne State University, Detroit, MI, USA
| | - Voravit Ratanatharathorn
- Department of Oncology, Blood and Marrow Stem Cell Transplant Program, Karmanos Cancer Institute, Wayne State University, Detroit, MI, USA
| | - Joseph P Uberti
- Department of Oncology, Blood and Marrow Stem Cell Transplant Program, Karmanos Cancer Institute, Wayne State University, Detroit, MI, USA
| | - Abhinav Deol
- Department of Oncology, Blood and Marrow Stem Cell Transplant Program, Karmanos Cancer Institute, Wayne State University, Detroit, MI, USA
| |
Collapse
|
11
|
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.
Collapse
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
| |
Collapse
|
12
|
Hagen PA, Stiff P. The Role of Salvage Second Autologous Hematopoietic Cell Transplantation in Relapsed Multiple Myeloma. Biol Blood Marrow Transplant 2019; 25:e98-e107. [DOI: 10.1016/j.bbmt.2018.12.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 12/05/2018] [Indexed: 10/27/2022]
|
13
|
Goldschmidt H, Ashcroft J, Szabo Z, Garderet L. Navigating the treatment landscape in multiple myeloma: which combinations to use and when? Ann Hematol 2019; 98:1-18. [PMID: 30470875 PMCID: PMC6334731 DOI: 10.1007/s00277-018-3546-8] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2017] [Accepted: 11/06/2018] [Indexed: 12/31/2022]
Abstract
Multiple myeloma is one of the most common hematological malignancies, affecting mainly elderly patients. The treatment landscape for the management of this disease has evolved significantly over the past 15 years, and a vast array of therapeutics is now available, including immunomodulatory drugs, proteasome inhibitors, histone deacetylase inhibitors, and monoclonal antibodies. As a result, deciding which drugs to use and when, and whether these should be used in a particular order or combination, can be challenging. Although combination regimens are often associated with deeper responses and better long-term outcomes than monotherapy, and are becoming the standard of care, they may result in significant incremental toxicity; hence, a sequential approach may be more appropriate for some patients. In particular, treatment choices can vary depending on whether the patient has newly diagnosed multiple myeloma, is eligible for transplant, has relapsed and/or refractory multiple myeloma, or is considered to have high-risk disease. In this review, we discuss factors to be taken into account when making treatment decisions in each of these settings. We also briefly discuss possible therapeutic strategies involving agents that may become available in the future.
Collapse
Affiliation(s)
- Hartmut Goldschmidt
- Internal Medicine V and National Center for Tumor Diseases (NCT), University Clinic Heidelberg, 69120, Heidelberg, Germany.
| | - John Ashcroft
- Department of Haematology, Mid Yorkshire Hospitals NHS Trust, Wakefield, UK
| | - Zsolt Szabo
- Clinical Development, Amgen (Europe) GmbH, Zug, Switzerland
| | - Laurent Garderet
- INSERM, UMR_S 938, Proliferation and Differentiation of Stem Cells, Paris, 75012, France
- AP-HP, Hôpital Saint Antoine, Département d'hématologie et de thérapie cellulaire, Sorbonne Université, Paris 6, Paris, France
| |
Collapse
|
14
|
Manjappa S, Fiala MA, King J, Kohnen DA, Vij R. The efficacy of salvage autologous stem cell transplant among patients with multiple myeloma who received maintenance therapy post initial transplant. Bone Marrow Transplant 2018; 53:1483-1486. [PMID: 29795420 DOI: 10.1038/s41409-018-0216-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 03/14/2018] [Accepted: 04/15/2018] [Indexed: 11/09/2022]
Affiliation(s)
- Shivaprasad Manjappa
- Division of Hospital Medicine, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Mark A Fiala
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Justin King
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Daniel A Kohnen
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Ravi Vij
- Division of Oncology, Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA.
| |
Collapse
|
15
|
Devadas SK, Khairnar M, Hiregoudar SS, Ojha S, Punatar S, Gupta A, Gokarn A, Bhole P, Kannan S, Khattry N. Is long term storage of cryopreserved stem cells for hematopoietic stem cell transplantation a worthwhile exercise in developing countries? Blood Res 2017; 52:307-310. [PMID: 29333408 PMCID: PMC5762742 DOI: 10.5045/br.2017.52.4.307] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Revised: 08/06/2017] [Accepted: 09/28/2017] [Indexed: 11/17/2022] Open
Abstract
Background Stem cell units (SCUs) that are cryopreserved prior to both autologous and allogeneic hematopoietic stem cell transplants (for donor lymphocyte infusion) remain unused or partially used several times, and become an increased burden to blood banks/SCU repositories. Because of the scarcity of data regarding the duration for which the storage is useful, there is no general consensus regarding disposal of SCUs. Methods We conducted a retrospective audit of SCU utilization in 435 patients who planned to undergo either autologous stem cell transplantation (auto-SCT) (N=239) or allogeneic stem cell transplantation (allo-SCT) (N=196) at a tertiary cancer care center between November 2007 to January 2015. Results Our cohort consisted of 1,728 SCUs stored for conducting auto-SCT and 729 SCUs stored for conducting donor lymphocyte infusions (DLIs) after allo-SCT. Stem cells were not infused in 12.5% of patients who had planned to undergo auto-SCT, and 80% of patients who underwent allo-SCT never received DLI. Forty-one percent of SCUs intended for use in auto-SCT remained unutilized, with a second auto-SCT being performed only in 4 patients. Ninety-four percent of SCUs intended for carrying out DLIs remained unused, with only minimal usage observed one year after undergoing allo-SCT. Conclusion The duration of storage of unused SCUs needs to be debated upon, so that a consensus can be reached regarding the ethical disposal of SCU.
Collapse
Affiliation(s)
- Santhosh Kumar Devadas
- Department of Medical Oncology and Bone Marrow Transplantation, Tata Memorial Center, Advanced Center for Treatment, Research and Education in Cancer (ACTREC), Mumbai, India
| | - Minal Khairnar
- Department of Transfusion Medicine, Tata Memorial Center, Advanced Center for Treatment, Research and Education in Cancer (ACTREC), Mumbai, India
| | - Sumathi S Hiregoudar
- Department of Transfusion Medicine, Tata Memorial Center, Advanced Center for Treatment, Research and Education in Cancer (ACTREC), Mumbai, India
| | - Shashank Ojha
- Department of Transfusion Medicine, Tata Memorial Center, Advanced Center for Treatment, Research and Education in Cancer (ACTREC), Mumbai, India
| | - Sachin Punatar
- Department of Medical Oncology and Bone Marrow Transplantation, Tata Memorial Center, Advanced Center for Treatment, Research and Education in Cancer (ACTREC), Mumbai, India
| | - Alok Gupta
- Department of Medical Oncology and Bone Marrow Transplantation, Tata Memorial Center, Advanced Center for Treatment, Research and Education in Cancer (ACTREC), Mumbai, India
| | - Anant Gokarn
- Department of Medical Oncology and Bone Marrow Transplantation, Tata Memorial Center, Advanced Center for Treatment, Research and Education in Cancer (ACTREC), Mumbai, India
| | - Pallavi Bhole
- Statistics, Tata Memorial Center, Advanced Center for Treatment, Research and Education in Cancer (ACTREC), Mumbai, India
| | - Sadhana Kannan
- Statistics, Tata Memorial Center, Advanced Center for Treatment, Research and Education in Cancer (ACTREC), Mumbai, India
| | - Navin Khattry
- Department of Medical Oncology and Bone Marrow Transplantation, Tata Memorial Center, Advanced Center for Treatment, Research and Education in Cancer (ACTREC), Mumbai, India
| |
Collapse
|
16
|
Zannetti BA, Tacchetti P, Pantani L, Gamberi B, Tosi P, Rocchi S, Cellini C, Ronconi S, Pezzi A, Mancuso K, Rizzello I, Caratozzolo I, Martello M, Dozza L, Cavo M, Zamagni E. Novel agent-based salvage autologous stem cell transplantation for relapsed multiple myeloma. Ann Hematol 2017; 96:2071-2078. [PMID: 29063955 DOI: 10.1007/s00277-017-3140-5] [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: 05/24/2017] [Accepted: 09/20/2017] [Indexed: 10/18/2022]
Abstract
High-dose chemotherapy followed by autologous stem cell transplantation (ASCT) is a standard frontline therapy for multiple myeloma (MM). Therapeutic options for patients with relapsed MM after ASCT include novel agents in different combos, salvage ASCT (sASCT), and allogeneic transplant, with no unique standard of care. We retrospectively analyzed 66 MM patients who relapsed after up-front single or double ASCT(s) and received novel agent-based sASCT at five Italian centers. Median event-free survival from up-front ASCT(s) to first relapse (EFS1) was 44 months. Seventy-three percent of patients received sASCT at first disease progression. Re-induction regimens were bortezomib based in 87% of patients. Response to re-induction therapy included complete response (CR) 18%, ≥ very good partial response (VGPR) 48%, and overall response rate (ORR) 83%. Response to sASCT included CR 44%, ≥ VGPR 77%, and ORR 94%. With a median follow-up of 24 months after sASCT, 39 patients experienced disease progression. Median EFS from sASCT (EFS2) was 17 months. Median overall survival from ASCT (OS1) and sASCT (OS2) was 166 and 43 months, respectively. EFS2 and OS2 were significantly shorter in patients with EFS1 ≤ 24 months, in patients who did not receive sASCT at first disease progression and in patients with extramedullary disease (EMD). In multivariate analysis, EFS1 ≤ 24 months was associated with shorter EFS2 and OS2, EMD was associated with shorter EFS2, and < CR after sASCT was associated with shorter OS2. Novel agent-based sASCT is a safe and effective procedure for relapsed MM.
Collapse
Affiliation(s)
- Beatrice Anna Zannetti
- "Seràgnoli" Institute of Hematology, Sant'Orsola-Malpighi University Hospital, Bologna, Italy
| | - Paola Tacchetti
- "Seràgnoli" Institute of Hematology, Sant'Orsola-Malpighi University Hospital, Bologna, Italy
| | - Lucia Pantani
- "Seràgnoli" Institute of Hematology, Sant'Orsola-Malpighi University Hospital, Bologna, Italy
| | - Barbara Gamberi
- Hematology Unit, "Arcispedale Santa Maria Nuova - IRCCS" Hospital, Reggio Emilia, Italy
| | | | - Serena Rocchi
- "Seràgnoli" Institute of Hematology, Sant'Orsola-Malpighi University Hospital, Bologna, Italy
| | - Claudia Cellini
- Hematology Unit, "S. Maria delle Croci" Hospital, Ravenna, Italy
| | - Sonia Ronconi
- Oncology and Hematology Unit, "Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori" Hospital, Meldola, Italy
| | - Annalisa Pezzi
- "Seràgnoli" Institute of Hematology, Sant'Orsola-Malpighi University Hospital, Bologna, Italy
| | - Katia Mancuso
- "Seràgnoli" Institute of Hematology, Sant'Orsola-Malpighi University Hospital, Bologna, Italy
| | - Ilaria Rizzello
- "Seràgnoli" Institute of Hematology, Sant'Orsola-Malpighi University Hospital, Bologna, Italy
| | - Isola Caratozzolo
- "Seràgnoli" Institute of Hematology, Sant'Orsola-Malpighi University Hospital, Bologna, Italy
| | - Marina Martello
- "Seràgnoli" Institute of Hematology, Sant'Orsola-Malpighi University Hospital, Bologna, Italy
| | - Luca Dozza
- "Seràgnoli" Institute of Hematology, Sant'Orsola-Malpighi University Hospital, Bologna, Italy
| | - Michele Cavo
- "Seràgnoli" Institute of Hematology, Sant'Orsola-Malpighi University Hospital, Bologna, Italy.
| | - Elena Zamagni
- "Seràgnoli" Institute of Hematology, Sant'Orsola-Malpighi University Hospital, Bologna, Italy
| |
Collapse
|
17
|
Abstract
Multiple myeloma (MM) is a plasma cell neoplasm that affects elderly individuals with two-thirds of patients over 65 years at diagnosis. However, data available are derived from clinical trials conducted in younger patients. Fewer studies investigated treatment options in the elderly. This review summarizes the clinical outcomes and toxicities associated with therapeutic regimens in older patients including doublet, triplet and high dose therapyin newly diagnosed patients and relapsed patients with MM. We highlight the importance of an approach tailored to individuals, incorporates the geriatric frailty assessment, considers comorbiditiess and commits to early recognition and management of toxicities ranging from myelosuppression to polypharmacy. To date, no trial has prospectively investigated a tailored treatment paradigm in older patients based on frailty and/or comorbidities. As the population ages, the proportion of MM patients with advanced age will grow. Studies are indicated to determine optimal treatment approaches in this increasingly heterogeneous geriatric population.
Collapse
Affiliation(s)
- Evan Diamond
- a Division of Hematologic Oncology, Department of Medicine , Memorial Sloan Kettering Cancer Center , New York , NY , USA
| | - Oscar B Lahoud
- a Division of Hematologic Oncology, Department of Medicine , Memorial Sloan Kettering Cancer Center , New York , NY , USA
| | - Heather Landau
- a Division of Hematologic Oncology, Department of Medicine , Memorial Sloan Kettering Cancer Center , New York , NY , USA
| |
Collapse
|
18
|
Outcomes of salvage autologous stem cell transplantation for multiple myeloma with cytopenias and exposure to novel agents. Bone Marrow Transplant 2017; 52:1468-1470. [DOI: 10.1038/bmt.2017.160] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
|
19
|
Ziogas DC, Terpos E, Dimopoulos MA. When to recommend a second autograft in patients with relapsed myeloma? Leuk Lymphoma 2016; 58:781-787. [PMID: 27894207 DOI: 10.1080/10428194.2016.1246729] [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] [Indexed: 10/20/2022]
Abstract
In the current evolving landscape of myeloma therapies, no recommended salvage strategy exists for patients with relapsed multiple myeloma (MM) after initial successful autologous stem cell transplantation (ASCT) and therapeutic options extend from conventional chemotherapy and novel agents to second autologous and allogeneic transplants. In this article, we summarize the documented evidence about the utilization of second ASCT in patients with relapsed MM after a primary auto-graft and discuss the correct timing for such a salvage approach, the individual characteristics of patients who will benefit more, as well as the therapeutic role of second ASCT in the modern era of forthcoming anti-myeloma treatments.
Collapse
Affiliation(s)
- Dimitrios C Ziogas
- a Department of Clinical Therapeutics , Alexandra General Hospital, National and Kapodistrian University of Athens, School of Medicine , Athens , Greece
| | - Evangelos Terpos
- a Department of Clinical Therapeutics , Alexandra General Hospital, National and Kapodistrian University of Athens, School of Medicine , Athens , Greece
| | - Meletios A Dimopoulos
- a Department of Clinical Therapeutics , Alexandra General Hospital, National and Kapodistrian University of Athens, School of Medicine , Athens , Greece
| |
Collapse
|
20
|
Hofmeister CC, Lonial S. How to Integrate Elotuzumab and Daratumumab Into Therapy for Multiple Myeloma. J Clin Oncol 2016; 34:4421-4430. [PMID: 27998219 DOI: 10.1200/jco.2016.69.5908] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose Treatment options and outcomes for patients with multiple myeloma have dramatically improved over the past decade with new agents and drug targets for patients at all stages of disease. Incorporation of newly approved monoclonal antibodies is a clinical challenge because the trials used to gain approval are relatively limited in scope and may be less helpful for patients treated in the United States. This article will review data on the use of elotuzumab and daratumumab and provide a foundation for their use in current clinical practice. Methods We performed a review of current published articles and abstract data from clinical trials as well as data on managing adverse events. Results Single-agent activity was seen when using daratumumab in refractory myeloma, and trials for both elotuzumab and daratumumab have demonstrated significant activity when combined with proteasome inhibitors and immunomodulatory agents. Unique antibody-related adverse events and challenges are reviewed and discussed. Conclusion These antibodies already have had and will continue to have a dramatic impact on myeloma treatment. Combination therapy likely represents the best approach for their use, and trials that evaluate optimal timing and duration of therapy are in progress as part of induction, salvage, and maintenance therapy.
Collapse
Affiliation(s)
- Craig C Hofmeister
- Craig C. Hofmeister, Ohio State University, Columbus, OH; and Sagar Lonial, Winship Cancer Institute of Emory University, Atlanta, GA
| | - Sagar Lonial
- Craig C. Hofmeister, Ohio State University, Columbus, OH; and Sagar Lonial, Winship Cancer Institute of Emory University, Atlanta, GA
| |
Collapse
|
21
|
Dowling M, Kelly M, Meenaghan T. Multiple myeloma: managing a complex blood cancer. ACTA ACUST UNITED AC 2016; 25:S18-28. [DOI: 10.12968/bjon.2016.25.s18] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Maura Dowling
- School of Nursing and Midwifery, National University of Ireland, Galway, Ireland
| | - Mary Kelly
- Advanced Nurse Practitioner (Haematology), Midlands Regional Hospitals, County Offaly, Ireland
| | - Teresa Meenaghan
- Advanced Nurse Practitioner (Haematology) Galway University Hospital, Galway, Ireland
| |
Collapse
|
22
|
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.
Collapse
|
23
|
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
| |
Collapse
|
24
|
Franssen LE, Raymakers RAP, Buijs A, Schmitz MF, van Dorp S, Mutis T, Lokhorst HM, van de Donk NWCJ. Outcome of allogeneic transplantation in newly diagnosed and relapsed/refractory multiple myeloma: long-term follow-up in a single institution. Eur J Haematol 2016; 97:479-488. [DOI: 10.1111/ejh.12758] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Laurens E. Franssen
- Department of Hematology; University Medical Center Utrecht; Utrecht the Netherlands
- Department of Hematology; VU University Medical Center; Amsterdam the Netherlands
| | | | - Arjan Buijs
- Department of Genetics; University Medical Center Utrecht; Utrecht the Netherlands
| | - Marian F. Schmitz
- Department of Hematology; University Medical Center Utrecht; Utrecht the Netherlands
| | - Suzanne van Dorp
- Department of Hematology; Radboud University Medical Center; Nijmegen the Netherlands
| | - Tuna Mutis
- Department of Hematology; VU University Medical Center; Amsterdam the Netherlands
| | - Henk M. Lokhorst
- Department of Hematology; University Medical Center Utrecht; Utrecht the Netherlands
- Department of Hematology; VU University Medical Center; Amsterdam the Netherlands
| | | |
Collapse
|
25
|
Baertsch MA, Schlenzka J, Mai EK, Merz M, Hillengaß J, Raab MS, Hose D, Wuchter P, Ho AD, Jauch A, Hielscher T, Kunz C, Luntz S, Klein S, Schmidt-Wolf IGH, Goerner M, Schmidt-Hieber M, Reimer P, Graeven U, Fenk R, Salwender H, Scheid C, Nogai A, Haenel M, Lindemann HW, Martin H, Noppeney R, Weisel K, Goldschmidt H. Rationale and design of the German-Speaking Myeloma Multicenter Group (GMMG) trial ReLApsE: a randomized, open, multicenter phase III trial of lenalidomide/dexamethasone versus lenalidomide/dexamethasone plus subsequent autologous stem cell transplantation and lenalidomide maintenance in patients with relapsed multiple myeloma. BMC Cancer 2016; 16:290. [PMID: 27114074 PMCID: PMC4845347 DOI: 10.1186/s12885-016-2321-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Accepted: 04/15/2016] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Despite novel therapeutic agents, most multiple myeloma (MM) patients eventually relapse. Two large phase III trials have shown significantly improved response rates (RR) of lenalidomide/dexamethasone compared with placebo/dexamethasone in relapsed MM (RMM) patients. These results have led to the approval of lenalidomide for RMM patients and lenalidomide/dexamethasone has since become a widely accepted second-line treatment. Furthermore, in RMM patients consolidation with high-dose chemotherapy plus autologous stem cell transplantation has been shown to significantly increase progression free survival (PFS) as compared to cyclophosphamide in a phase III trial. The randomized prospective ReLApsE trial is designed to evaluate PFS after lenalidomide/dexamethasone induction, high-dose chemotherapy consolidation plus autologous stem cell transplantation and lenalidomide maintenance compared with the well-established lenalidomide/dexamethasone regimen in RMM patients. METHODS/DESIGN ReLApsE is a randomized, open, multicenter phase III trial in a planned study population of 282 RMM patients. All patients receive three lenalidomide/dexamethasone cycles and--in absence of available stem cells from earlier harvesting--undergo peripheral blood stem cell mobilization and harvesting. Subsequently, patients in arm A continue on consecutive lenalidomide/dexamethasone cycles, patients in arm B undergo high dose chemotherapy plus autologous stem cell transplantation followed by lenalidomide maintenance until discontinuation criteria are met. Therapeutic response is evaluated after the 3(rd) (arm A + B) and the 5(th) lenalidomide/dexamethasone cycle (arm A) or 2 months after autologous stem cell transplantation (arm B) and every 3 months thereafter (arm A + B). After finishing the study treatment, patients are followed up for survival and subsequent myeloma therapies. The expected trial duration is 6.25 years from first patient in to last patient out. The primary endpoint is PFS, secondary endpoints include overall survival (OS), RR, time to best response and the influence of early versus late salvage high dose chemotherapy plus autologous stem cell transplantation on OS. DISCUSSION This phase III trial is designed to evaluate whether high dose chemotherapy plus autologous stem cell transplantation and lenalidomide maintenance after lenalidomide/dexamethasone induction improves PFS compared with the well-established continued lenalidomide/dexamethasone regimen in RMM patients. TRIAL REGISTRATION ISRCTN16345835 (date of registration 2010-08-24).
Collapse
Affiliation(s)
- Marc-Andrea Baertsch
- />Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Jana Schlenzka
- />Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Elias K. Mai
- />Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Maximilian Merz
- />Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Jens Hillengaß
- />Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Marc S. Raab
- />Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Dirk Hose
- />Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Patrick Wuchter
- />Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Anthony D. Ho
- />Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
| | - Anna Jauch
- />Institute for Human Genetics, University of Heidelberg, Heidelberg, Germany
| | - Thomas Hielscher
- />Division of Biostatistics, German Cancer Research Center, Heidelberg, Germany
| | - Christina Kunz
- />Division of Biostatistics, German Cancer Research Center, Heidelberg, Germany
| | - Steffen Luntz
- />Coordination Centre for Clinical Trials (KKS), University Hospital Heidelberg, Heidelberg, Germany
| | - Stefan Klein
- />Hematology and Oncology, University Hospital Mannheim, Mannheim, Germany
| | - Ingo G. H. Schmidt-Wolf
- />Center for Integrated Oncology, Med. Klinik und Poliklinik III, University Hospital Bonn, Bonn, Germany
| | - Martin Goerner
- />Hematology, Oncology and Palliative Care, Community Hospital Bielefeld, Bielefeld, Germany
| | | | - Peter Reimer
- />Hematology, Oncology and Stem Cell Transplantation, Evangelisches Krankenhaus Essen-Werden gGmbH, Essen, Germany
| | - Ullrich Graeven
- />Hematology, Oncology and Gastroenterology, Maria-Hilf-Krankenhaus, Mönchengladbach, Germany
| | - Roland Fenk
- />Hematology, Oncology and Clinical Immunology, University of Duesseldorf, Duesseldorf, Germany
| | - Hans Salwender
- />Hematology, Oncology and Palliative Care, Asklepios Klinik Altona, Hamburg, Germany
| | - Christof Scheid
- />Department I of Internal Medicine, University of Cologne, Cologne, Germany
| | - Axel Nogai
- />Internal Medicine III, Charité Campus Benjamin Franklin, Berlin, Germany
| | - Mathias Haenel
- />Hematology, Oncology and Stem Cell Transplantation, Klinikum Chemnitz GmbH, Chemnitz, Germany
| | - Hans W. Lindemann
- />Hematology and Oncology, Kath. Krankenhaus Hagen gem. GmbH - St.-Marien-Hospital, Hagen, Germany
| | - Hans Martin
- />Hematology and Oncology, Goethe University, Frankfurt, Germany
| | | | - Katja Weisel
- />Hematology, Oncology and Immunology, University of Tuebingen, Tuebingen, Germany
| | - Hartmut Goldschmidt
- />Hematology, Oncology and Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
- />National Center for Tumor Diseases, Heidelberg University Hospital, Heidelberg, Germany
| |
Collapse
|