An elective single autograft with high-dose melphalan: single-center study of 451 patients

Impact of timing of stem cell return following high dose melphalan in multiple myeloma patients with renal impairment: a single center experience

High dose melphalan (HDM) followed by autologous stem cell transplantation (ASCT) remains the standard consolidation in transplant eligible multiple myeloma (MM) patients. The timing between HDM administration and hematopoietic stem cell return (HSCR) varies among institutions, with a 'rest period' of 48 hours (h) employed by some for patients with renal impairment (RI). We investigated the differences in hematopoietic recovery and HDM toxicity between MM patients with RI who had HSCR after 24 vs 48 h from HDM. Fifty MM patients with RI (48 h group; n = 31 and 24 h group; n = 19) were included. No statistically significant differences were noted in surrogates for hematopoietic recovery and HDM toxicity between both groups. Only one death occurred in the 24 h group. No patients required renal replacement therapy. Therefore, a 24 h period between HDM and AHSC infusion appears safe for MM patients with RI.

The effects of cold atmospheric plasma on cell adhesion, differentiation, migration, apoptosis and drug sensitivity of multiple myeloma

Cold atmospheric plasma was shown to induce cell apoptosis in numerous tumor cells. Recently, some other biological effects, such as induction of membrane permeation and suppression of migration, were discovered by plasma treatment in some types of tumor cells. In this study, we investigated the biological effects of plasma treatment on multiple myeloma cells. We detected the detachment of adherent myeloma cells by plasma, and the detachment area was correlated with higher density of hydroxyl radical in the gas phase of the plasma. Meanwhile, plasma could promote myeloma differentiation by up-regulating Blimp-1 and XBP-1 expression. The migration ability was suppressed by plasma treatment through decreasing of MMP-2 and MMP-9 secretion. In addition, plasma could increase bortezomib sensitivity and induce myeloma cell apoptosis. Taking together, combination with plasma treatment may enhance current chemotherapy and probably improve the outcomes.

Intravenous busulfan and melphalan as a conditioning regimen for autologous stem cell transplantation in patients with newly diagnosed multiple myeloma: a matched comparison to a melphalan-only approach

Melphalan 200 mg/m(2) (MEL200) is the standard conditioning regimen administered to newly diagnosed patients with multiple myeloma (MM) undergoing autologous stem cell transplantation (ASCT). Few alternatives have been explored in order to improve the antimyeloma activity of this conditioning. We compare i.v. busulfan (BU) 9.6 mg/kg and MEL 140 mg/m(2) (MEL140) versus MEL200 mg/m(2) as a conditioning regimen before ASCT for newly diagnosed patients with MM. For this purpose, 51 patients receiving i.v. BU plus MEL were compared to 102 patients receiving MEL200 mg/m(2) in a 1:2 matched control analysis. Matching criteria included age, clinical stage at diagnosis, and response to induction therapy. No differences in the overall and complete response (CR) rates were observed after ASCT between both groups. After a median follow-up of 63 and 50 months in control and BU plus MEL groups, progression-free survival (PFS) was 24 and 33 months, respectively (P = .10). Most frequent toxicities included mucositis and febrile neutropenia in both groups. No case of sinusoidal obstruction syndrome was observed. Transplant-related mortality was 4% and 2% in BU plus MEL and control groups, respectively. ASCT conditioned with i.v. BU plus MEL may be considered an effective and well-tolerated alternative to a MEL-only approach as a conditioning regimen for patients with MM who are candidates for ASCT.

Transfer of influenza vaccine-primed costimulated autologous T cells after stem cell transplantation for multiple myeloma leads to reconstitution of influenza immunity: results of a randomized clinical trial

Severe immune deficiency follows autologous stem cell transplantation for multiple myeloma and is associated with significant infectious morbidity. This study was designed to evaluate the utility of a pretransplantation vaccine and infusion of a primed autologous T-cell product in stimulating specific immunity to influenza. Twenty-one patients with multiple myeloma were enrolled from 2007 to 2009. Patients were randomly assigned to receive an influenza-primed autologous T-cell product or a nonspecifically primed autologous T-cell product. The study endpoint was the development of hemagglutination inhibition titers to the strain-specific serotypes in the influenza vaccine. Enzyme-linked immunospot assays were performed to confirm the development of influenza-specific B-cell and T-cell immunity. Patients who received the influenza-primed autologous T-cell product were significantly more likely to seroconvert in response to the influenza vaccine (P = .001). Seroconversion was accompanied by a significant B-cell response. No differences were observed in the global quantitative recovery of T-cell and B-cell subsets or in global T-cell and B-cell function. The provision of a primed autologous T-cell product significantly improved subsequent influenza vaccine responses. This trial was registered at www.clinicaltrials.gov as #NCT00499577.

Long-term outcomes of autologous transplantation in multiple myeloma: significant survival benefit of novel drugs in post-transplantation relapse

BACKGROUND

Autologous stem cell transplantation (autoSCT) has an important role in the treatment of patients with symptomatic multiple myeloma (MM). Treatment options for myeloma have expanded in the past decade, and it seems that patients who are treated with novel drugs such as thalidomide and bortezomib for relapse after autoSCT have longer overall survival (OS).

PATIENTS AND METHODS

Herein, we describe the long-term outcome of a cohort of 185 patients with newly diagnosed MM treated with autoSCT. We have analyzed factors that might predict for long-term survival.

RESULTS

Following autoSCT, the overall response rate was 94% (173 of 185 patients); 29% (53 of 185 patients) were in complete remission (CR). Median time to progression (TTP) and OS from start of therapy were 39.8 months and 77.9 months, respectively. The median follow-up was 103.8 months (range, 60.8-144.8 months); 23% of the patients are alive and disease free, 21% of the patients are alive with relapse, and 56% of the patients have died. On multivariate analysis, factors associated with significantly better OS were International Staging System (ISS) disease stage < III (hazard ratio [HR], 2.6; P < .001), achievement of CR after autoSCT (HR, 2.8; P < .001) and use of thalidomide (HR, 4.3; P < .001) and/or bortezomib (HR, 7.3; P < .001) in posttransplantation relapse treatment. The patients' age, renal impairment, disease status before autoSCT and maintenance therapy with interferon-alpha (IFN-alpha) or IFN-alpha and dexamethasone did not significantly affect TTP and OS after transplantation.

CONCLUSION

According to our results, the achievement of CR after transplantation, ISS stage other than III, and administration of thalidomide or bortezomib in posttransplantation relapse were significant parameters favoring long-term posttransplantation survival.

Stiff-person syndrome associated with multiple myeloma following autologous bone marrow transplantation

Stiff-person syndrome (SPS) is an immunologically mediated central nervous system disorder that is infrequently associated with malignancy. We report a 31-year-old woman who developed SPS after autologous bone marrow transplantation and subsequent interferon treatment for multiple myeloma. Anti-glutamic acid decarboxylase (anti-GAD) antibody serology was positive. The myeloma remains in remission 10 years posttransplant. SPS has been described in association with lung cancer and breast cancer, thymoma, and Hodgkin lymphoma. This is the second report of SPS in a patient with myeloma and the first description of SPS following autologous transplantation. Aberrant immune reconstitution is known to occur following hematopoietic progenitor cell transplantation. Interferon is also known to augment the immune response posttransplant. We speculate that an aberrant posttransplant immune response may have caused both the SPS and an autologous graft-versus-myeloma effect, resulting in prolonged remission posttransplant.

Future challenges

Treatment for patients with myeloma has changed unrecognisably over the last two decades and now includes a sequence of treatments including chemotherapy, biological targeted therapy with or without consideration for high-dose therapy (autologous and allogeneic stem cell transplantation for younger and fit patients). As patients can now expect a doubling of median survival and a 20-30% chance of surviving longer than 10 years, the focus of treatment is shifting to long-term quality of life. This article focuses on future challenges facing clinicians treating myeloma and how best we may optimize our resources.

The evolving background for high-dose treatment for myeloma

In the constantly evolving field of myeloma, this special issue is slanted towards how the newer targeted treatments fit in with various transplantation strategies. High-dose treatment for myeloma with autologous stem cell transplantation started 25 years ago, with the consequence of producing complete remissions and a doubling of survival. Since then, its role has been refined and it has been accepted as standard treatment. The current challenge is to optimize its use into a background of the development, availability and regulatory approval of newer targeted therapies such as Thalidomide, Revlimid (Lenalidomide) and Velcade (Bortezomib). This special issue addresses these problems, and gives particular emphasis on the attainment of very long-term survival, with normal quality of life for patients with myeloma who do not necessarily need to be cured of their molecular disease, that is, they are 'operationally cured.' It is hoped that the reader will find the information in this issue useful in the day-to-day management of patients and we hope that this will also inspire new research directions designed to improve the outcome of patients with myeloma.

High-dose chemotherapy and autologous hematopoietic stem cell transplantation in myeloma patients under the age of 65 years

One or two cycles of high-dose chemotherapy with autologous hematopoietic stem cell transplantation have been shown to improve response rates and survival in myeloma. While this observation has largely been made in patients under the age of 65 years, there is evidence to suggest that the conclusions can be extrapolated to older individuals as well. In contrast to other hematologic malignancies treated with high-dose therapy, autografted myeloma patients continue to relapse several years after transplantation, and few patients are cured with this modality. However, up to a third of patients may be alive beyond a decade; some with excellent quality of life giving rise to the concept of 'operational cure'. Relapsing disease can be treated with novel agents or repeat high-dose chemotherapy and transplantation. The pressing questions to which answers are not obvious at the moment are whether tandem transplantation should be offered to all patients, and whether novel agents should be used before transplantation or reserved for relapse. Despite their excellent activity, there is no evidence so far that novel agents such as thalidomide, bortezomib and lenalidomide can replace high-dose chemotherapy and stem cell transplantation.

An open, randomized, controlled, phase II, single centre, two-period cross-over study to compare the quality of life and toxicity experienced on PEG interferon with interferon-α2b in patients with multiple myeloma maintained on a steady dose of interferon-α2b

PURPOSE

To compare the effects of pegylated interferon-alpha2b (P-IFN) and interferon-alpha2b (IFN) on quality of life (QoL) and toxicity in patients with multiple myeloma maintained on a steady dose of IFN.

PATIENTS AND METHODS

Consenting, eligible myeloma patients on IFN maintenance therapy for at least 6 weeks were randomly (1:1) allocated to receive P-IFN for 3 months followed by IFN for 3 months, or to continue with IFN for 3 months followed by P-IFN for 3 months (cross-over design). Patients were assessed for toxicity and QoL. Dose of P-IFN was equivalent to IFN.

RESULTS

The study enrolled 60 patients. At enrollment, 35 patients were in complete remission, 20 in partial remission and 5 were minimal responders. P-IFN was associated with significantly better global QoL score (mean difference 8.4; P = 0.0002). There was a significant improvement in functional scales--physical (P = 0.03), emotional (P = 0.04), social (P = 0.0008) with P-IFN. Fatigue (P = 0.0003), pain (P = 0.02) and appetite loss (P = 0.003) symptom scales were less in patients while on P-IFN. There were no statistically significant differences between treatment arms in QoL as measured by QLQ-MY24.

CONCLUSION

These data suggest that patients on P-IFN have a better QoL. Dose escalation studies are warranted to investigate potential impact on survival.

Autologous stem cell transplantation beyond 60 years of age

Along with improved supportive care and thus reduced treatment-related mortality, an increasing number of elderly patients (> 60 years) with haematological malignancies are now considered for high-dose therapy (HDT) supported by autologous stem cell transplantation (ASCT). ASCT is feasible in selected elderly patients with multiple myeloma and those with non-Hodgkin's lymphoma. As elderly patients have generally been excluded from randomized studies evaluating efficacy of ASCT in comparison with non-transplant approaches, limited data are available on the efficacy of ASCT in this patient population. Recent developments in supportive care including amifostine and palifermin may increase feasibility of ASCT in elderly patients. Prospective studies are needed to evaluate feasibility and efficacy of ASCT in patients over 60 years of age. Also, further studies are needed in order to decrease toxicity of high-dose regimens in this patient group where co-morbid conditions may modify the toxicity of HDT in a clinically significant manner.

The clinical outcome and toxicity of high-dose chemotherapy and autologous stem cell transplantation in patients with myeloma or amyloid and severe renal impairment: a British society of blood and marrow transplantation study

The outcome of high-dose chemotherapy (HDT) was evaluated retrospectively in 27 patients with myeloma and four patients with AL amyloidosis with severe renal impairment. Twenty-three patients were receiving dialysis and the rest had a creatinine clearance of <20 ml/min. The median melphalan dose was 140 mg/m2 (range: 60-200 mg/m2), but 10 patients (37%) received 200 mg/m2. Myeloid and platelet engraftment were similar to that seen in patients without renal failure. Five of 27 patients died of transplant-related toxicity before the day 100. Twenty of 27 patients had a response (70%). The median time to disease progression was 32 months (range: 6-54 months) and the median time to best response was 6.5 months. Four of 17 evaluable patients (24%) became dialysis-independent at a median of 5 months post-HDT/stem cell transplantation. At a median follow-up of 70 months, 7/23 patients with myeloma were alive but three of these seven patients had progressive disease. Two of the four patients with amyloidosis have survived. HDT is feasible in these patients and results in 5-year survival in about one-third of patients.

Epidemiology and outcomes research for MGUS, myeloma and amyloidosis

The epidemiology of plasma cell dyscrasias clearly links to a complicated multi-factorial pathogenic pathway that at the individual patient level gives no clear indication of why the malignant process has occurred but factors in the environment and within the genome give clues and are discussed. MGUS is a pre-malignant disorder characterised by monoclonal plasma cell proliferation in the bone marrow and no end-organ damage; the patients are asymptomatic. Primary amyloidosis is a rare disorder that is characterised by deposition of amyloid fibrils composed of immunoglobulin light chain fragments; symptoms relate to the affected organ. Multiple myeloma is a malignant disease of plasma cells and with improvements in treatment, patients can now expect a doubling of median survival to 5 years, a 20% chance of surviving >10 years and a 50% chance of complete remission (CR), morphological and biochemical. The challenge is now to determine exactly what this means to the individual myeloma patient in terms of benefit, and to society as a whole and this is the basis of 'outcomes research' which is discussed in this review.

High-dose melphalan (200 mg/m2) supported by autologous stem cell transplantation is safe and effective in elderly (>or=65 years) myeloma patients: comparison with younger patients treated on the same protocol

Limited information is available on the feasibility and efficacy of autologous stem cell transplantation (ASCT) in multiple myeloma (MM) patients >65 years of age. In 1995-2005, 22 myeloma patients >or=65 years (median 68, eight >or=70) and 79 patients <65 years (median 57) were included in an identical treatment protocol. The first progenitor cell mobilization with cyclophosphamide plus granulocyte-colony stimulating factor (G-CSF) was successful in 95 and 96% of the patients, respectively. To date, 92 patients have received MEL (melphalan) 200 mg/m2 supported by ASCT. No early treatment-related deaths were observed among 22 elderly patients, whereas one younger patient died early. Engraftment and the need for supportive care were comparable between groups. The elderly patients tended to have more WHO grade 3-4 oral or gastrointestinal toxicity when compared to the younger patients (45 vs 23%, P=0.06). After ASCT, a complete response was observed in 44% of the elderly patients and 36% of the younger patients, respectively. No difference was observed between these age groups in progression-free survival (23 vs 21 months) or overall survival (57 vs 66 months) after ASCT. We conclude that MEL200 is a safe and efficacious treatment in selected elderly myeloma patients.