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Fenk R, Giagounidis A, Goldschmidt H, Heinsch M, Rummel M, Kroger N, Boquoi A, Lopez D, Gerrlich C, Baier J, Liesenjohann S, Hauck K, Savickaite I, Mai EK, Aul C, Strapatsas J, Dienst A, Kondakci M, Haas R, Kobbe G. Efficacy and Tolerability of High- versus Low-dose Lenalidomide Maintenance Therapy of Multiple Myeloma after Autologous Blood Stem Cell Transplantation. Clin Cancer Res 2020; 26:5879-5886. [PMID: 32817078 DOI: 10.1158/1078-0432.ccr-20-0841] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 05/28/2020] [Accepted: 08/14/2020] [Indexed: 11/16/2022]
Abstract
PURPOSE For multiple myeloma, high-dose chemotherapy and autologous blood stem-cell transplantation (ASCT) followed by lenalidomide maintenance (LenMT) at 10-15 mg/day is considered standard of care. However, dose reductions due to side effects are common and median LenMT doses achieved over time may remain lower. Dose response during LenMT has never been investigated. PATIENTS AND METHODS In a multicenter, randomized, open-label trial, patients with multiple myeloma after ASCT and high-dose lenalidomide consolidation therapy (CT) at 25 mg/day were randomized to receive LenMT at either 25 or 5 mg/day. Primary endpoint was progression-free survival (PFS). RESULTS Ninety-four patients (median age, 58 years) were randomized to either arm, with 22% having International Staging System (ISS) stage 3 and 22% being in complete remission (CR). After median follow-up of 46.7 months, median doses of 14.5 and 5 mg/day were achieved in the two arms; 53% of dose reductions occurring during CT. In the high- and the low-dose arm, median PFS was 44.8 and 33.0 months (HR, 0.65; 95% CI, 0.44-0.97; P = 0.032), 36% and 23% of patients had stringent CR as best response (P = 0.08), and 4-year OS was 79% and 67% (P = 0.16), respectively. Hematologic toxicity, grade ≥3 neutropenia, and infections were initially more common with LenMT 25 mg, but decreased after dose adjustments. SPM incidence and quality-of-life (QoL) scores in both arms were similar. CONCLUSIONS LenMT dose correlated with efficacy and toxicity. High rates of dose reductions during CT argue against a high starting dose. However, continuous up- and down-titration for each patient to the current maximum tolerated dose is prudent.
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Affiliation(s)
- Roland Fenk
- University Hospital Düsseldorf, Düsseldorf, Germany.
| | | | - Hartmut Goldschmidt
- University Hospital Heidelberg and National Center for Tumor Diseases Heidelberg, Heidelberg, Germany
| | | | | | | | | | - David Lopez
- University Hospital Düsseldorf, Düsseldorf, Germany
| | | | - Julia Baier
- University Hospital Düsseldorf, Düsseldorf, Germany
| | | | | | | | - Elias K Mai
- University Hospital Heidelberg and National Center for Tumor Diseases Heidelberg, Heidelberg, Germany
| | - Carlo Aul
- Helios St. Johannis Hospital Duisburg, Duisburg, Germany
| | | | | | | | - Rainer Haas
- University Hospital Düsseldorf, Düsseldorf, Germany
| | - Guido Kobbe
- University Hospital Düsseldorf, Düsseldorf, Germany
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Ciftciler R, Goker H, Buyukasık Y, Aladag E, Demiroglu H. Impact of Pre-transplant and Post-transplant Remission Status of Patients on Survival in Newly Diagnosed Multiple Myeloma. Indian J Hematol Blood Transfus 2019; 35:655-661. [PMID: 31741617 DOI: 10.1007/s12288-019-01108-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Accepted: 02/27/2019] [Indexed: 10/27/2022] Open
Abstract
The overall survival (OS) in patients with multiple myeloma (MM) has increased in the last decade due to the introduction of proteasome inhibitors, immunomodulatory drugs and monoclonal antibodies as well as an extensive combination of autologous stem cell transplantation (ASCT) for suitable patients. The objective of this study was to examine the impact of pre-transplant and post-transplant remission status of patients on survival in newly diagnosed multiple myeloma. Two hundred and four patients with newly diagnosed MM who received an ASCT in our HSC transplant center at Hacettepe University Hospital between the years of 2001 and 2018 were evaluated in a retrospective manner. The median follow-up period was 35.9 months (range 4.2-206.4) for the entire group. The 5-year OS for pre-transplant remission status CR/VGPR patients and pre-transplant remission status PR or less patients were 79% and 68%, respectively (p = 0.09). The 5-year PFS for pre-transplant remission status CR/VGPR patients and pre-transplant remission status PR or less patients were 62% and 45%, respectively (p = 0.23). The 5-year OS for post-transplant remission status CR/VGPR group was 72% and for post-transplant remission status PR or less group was 60% (p = 0.02). The 5-year PFS in post-transplant remission status CR/VGPR patients was 48% and post-transplant remission status PR or less patients was 36% (p = 0.03). This study focuses on determination of survival outcome based on the best response obtained before and after ASCT and particularly highlights the significance of reaching CR and VGPR.
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Affiliation(s)
- Rafiye Ciftciler
- Departments of Hematology, Faculty of Medicine, Hacettepe University, 06100 Ankara, Turkey
| | - Hakan Goker
- Departments of Hematology, Faculty of Medicine, Hacettepe University, 06100 Ankara, Turkey
| | - Yahya Buyukasık
- Departments of Hematology, Faculty of Medicine, Hacettepe University, 06100 Ankara, Turkey
| | - Elifcan Aladag
- Departments of Hematology, Faculty of Medicine, Hacettepe University, 06100 Ankara, Turkey
| | - Haluk Demiroglu
- Departments of Hematology, Faculty of Medicine, Hacettepe University, 06100 Ankara, Turkey
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Torimoto Y, Shindo M, Ikuta K, Kohgo Y. Current therapeutic strategies for multiple myeloma. Int J Clin Oncol 2015; 20:423-30. [DOI: 10.1007/s10147-015-0826-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Accepted: 03/27/2015] [Indexed: 01/24/2023]
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Quach H, Prince HM, Spencer A. Managing multiple myeloma in the elderly: are we making progress? Expert Rev Hematol 2014; 4:301-15. [DOI: 10.1586/ehm.11.18] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Kapoor P, Kumar SK, Dispenzieri A, Lacy MQ, Buadi F, Dingli D, Russell SJ, Hayman SR, Witzig TE, Lust JA, Leung N, Lin Y, Zeldenrust SR, McCurdy A, Greipp PR, Kyle RA, Rajkumar SV, Gertz MA. Importance of achieving stringent complete response after autologous stem-cell transplantation in multiple myeloma. J Clin Oncol 2013; 31:4529-35. [PMID: 24248686 DOI: 10.1200/jco.2013.49.0086] [Citation(s) in RCA: 128] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE To study the impact of achieving stringent complete response (sCR), an increasingly attainable goal, after autologous stem-cell transplantation (ASCT) in patients with multiple myeloma (MM). PATIENTS AND METHODS Maximal response rates were determined in 445 consecutive patients who underwent ASCT within 12 months of diagnosis of MM. The patients achieving varying degrees of complete response (CR) are the focus of our study. RESULTS One hundred and nine patients (25%) achieved sCR after ASCT. The median overall survival (OS) rate from the time of transplantation for patients attaining sCR was not reached (NR), in contrast to those patients achieving conventional complete response (CR; n = 37; OS, 81 months) or near CR (nCR; n = 91; OS, 60 months; P < .001). Five-year OS rates were 80%, 53%, and 47% for sCR, CR, and nCR, respectively. The median time to progression (TTP) from ASCT of patients achieving sCR was significantly longer (50 months) than TTP of patients achieving CR or nCR (20 months and 19 months, respectively). On multivariable analysis, post-ASCT response of sCR was an independent prognostic factor for survival (hazard ratio, 0.44; 95% CI, 0.25 to 0.80; versus CR; P = .008), in addition to proliferation rate, pre-ASCT cytogenetics, and performance status. OS rates of patients attaining sCR continued to remain superior at 2-year landmark (median, NR v 70 months for conventional CR group; P = .007). CONCLUSION Improved long-term outcome is seen after ASCT with achievement of sCR when compared with lesser degrees of responses. Myeloma trials reporting the response rates should identify patients achieving sCR and CR separately, owing to markedly disparate outcomes of the two categories.
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Paiva B, Vídriales MB, Rosiñol L, Martínez-López J, Mateos MV, Ocio EM, Montalbán MÁ, Cordón L, Gutiérrez NC, Corchete L, Oriol A, Terol MJ, Echeveste MA, De Paz R, De Arriba F, Palomera L, de la Rubia J, Díaz-Mediavilla J, Granell M, Gorosquieta A, Alegre A, Orfao A, Lahuerta JJ, Bladé J, Miguel JFS. A multiparameter flow cytometry immunophenotypic algorithm for the identification of newly diagnosed symptomatic myeloma with an MGUS-like signature and long-term disease control. Leukemia 2013; 27:2056-61. [DOI: 10.1038/leu.2013.166] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2013] [Revised: 05/27/2013] [Accepted: 05/30/2013] [Indexed: 12/22/2022]
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Matched-pair analysis to compare the outcomes of a second salvage auto-SCT to systemic chemotherapy alone in patients with multiple myeloma who relapsed after front-line auto-SCT. Bone Marrow Transplant 2012; 48:425-32. [DOI: 10.1038/bmt.2012.164] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Pessoa de Magalhães RJ, Vidriales MB, Paiva B, Fernandez-Gimenez C, García-Sanz R, Mateos MV, Gutierrez NC, Lecrevisse Q, Blanco JF, Hernández J, de las Heras N, Martinez-Lopez J, Roig M, Costa ES, Ocio EM, Perez-Andres M, Maiolino A, Nucci M, De La Rubia J, Lahuerta JJ, San-Miguel JF, Orfao A. Analysis of the immune system of multiple myeloma patients achieving long-term disease control by multidimensional flow cytometry. Haematologica 2012; 98:79-86. [PMID: 22773604 DOI: 10.3324/haematol.2012.067272] [Citation(s) in RCA: 120] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Multiple myeloma remains largely incurable. However, a few patients experience more than 10 years of relapse-free survival and can be considered as operationally cured. Interestingly, long-term disease control in multiple myeloma is not restricted to patients with a complete response, since some patients revert to having a profile of monoclonal gammopathy of undetermined significance. We compared the distribution of multiple compartments of lymphocytes and dendritic cells in the bone marrow and peripheral blood of multiple myeloma patients with long-term disease control (n=28), patients with newly diagnosed monoclonal gammopathy of undetermined significance (n=23), patients with symptomatic multiple myeloma (n=23), and age-matched healthy adults (n=10). Similarly to the patients with monoclonal gammopathy of undetermined significance and symptomatic multiple myeloma, patients with long-term disease control showed an expansion of cytotoxic CD8(+) T cells and natural killer cells. However, the numbers of bone marrow T-regulatory cells were lower in patients with long-term disease control than in those with symptomatic multiple myeloma. It is noteworthy that B cells were depleted in patients with monoclonal gammopathy of undetermined significance and in those with symptomatic multiple myeloma, but recovered in both the bone marrow and peripheral blood of patients with long-term disease control, due to an increase in normal bone marrow B-cell precursors and plasma cells, as well as pre-germinal center peripheral blood B cells. The number of bone marrow dendritic cells and tissue macrophages differed significantly between patients with long-term disease control and those with symptomatic multiple myeloma, with a trend to cell count recovering in the former group of patients towards levels similar to those found in healthy adults. In summary, our results indicate that multiple myeloma patients with long-term disease control have a constellation of unique immune changes favoring both immune cytotoxicity and recovery of B-cell production and homing, suggesting improved immune surveillance.
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Abstract
Abstract
The clinical approach to older patients with myeloma has to be modified to take into account comorbidities and the likelihood of higher treatment-related toxicity. Individualization of management and adequate supportive therapy are important to obtain the best response while minimizing adverse effects. Corticosteroids, novel agents, conventional cytotoxic agents, and high-dose chemotherapy with autotransplantation (modalities used in younger patients) are also used in older patients, although the elderly undergo transplantation less frequently. The sequential use of active agents singly and in different combinations has improved response rates and survival of all patients with myeloma, including the elderly.
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Krejci M, Scudla V, Tothova E, Schutzova M, Koza V, Adam Z, Krivanova A, Pour L, Buchler T, Sandecka V, Kralova D, Zahradova L, Vorlicek J, Mayer J, Hajek R. Long-term outcomes of autologous transplantation in multiple myeloma: significant survival benefit of novel drugs in post-transplantation relapse. ACTA ACUST UNITED AC 2010; 9:436-42. [PMID: 19951883 DOI: 10.3816/clm.2009.n.086] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
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.
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Affiliation(s)
- Marta Krejci
- Department of Internal Medicine - Hematooncology, Masaryk University Hospital, Jihlavska 20, 625 00 Brno, Czech Republic.
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Nakasone H, Kanda Y, Ueda T, Matsumoto K, Shimizu N, Minami J, Sakai R, Hagihara M, Yokota A, Oshima K, Tsukada Y, Tachibana T, Nakaseko C, Fujisawa S, Yano S, Fujita H, Takahashi S, Kanamori H, Okamoto S. Retrospective comparison of mobilization methods for autologous stem cell transplantation in multiple myeloma. Am J Hematol 2009; 84:809-14. [PMID: 19862826 DOI: 10.1002/ajh.21552] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
The combination of cyclophosphamide and granulocyte-colony stimulating factor (G-CSF) has widely been used to mobilize hematopoietic stem cells (HSCs) for autologous stem cell transplantation (ASCT) for multiple myeloma (MM). Recently, however, alternative approaches such as G-CSF alone or etoposide followed by G-CSF have been investigated. We, therefore, retrospectively analyzed the effects of these mobilization methods on collection yield and disease outcome in ASCT for MM. We reviewed 146 MM patients from whom we intended to collect stem cells. For mobilization, 67, 58, and 21 patients received cyclophosphamide and G-CSF, etoposide and G-CSF, and G-CSF alone (including nonmyelosuppressive chemotherapy followed by G-CSF), respectively. Among them, 136 achieved the target number of HSCs (at least 2 x 10(6)/kg). Lower creatinine and higher albumin levels at diagnosis were significantly associated with successful yield. A lower number of infused HSCs, use of the etoposide for mobilization and high ISS were associated with delayed hematopoietic recovery. The mobilization methods did not significantly affect either the successful collection of more than 2 x 10(6) CD34-positive cells/kg or PFS after ASCT. G-CSF alone was sufficient for stem cell mobilization for a single ASCT. The optimal approach to collect HSCs in MM remains to be elucidated.
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Affiliation(s)
- Hideki Nakasone
- Division of Hematology, Saitama Medical Center, Jichi Medical University, 1-847 Amanuma-cho, Saitama, Japan
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Mehta J. Re: Tandem vs single autologous hematopoietic cell transplantation for the treatment of multiple myeloma: a systematic review and meta-analysis. J Natl Cancer Inst 2009; 101:1430-1; author reply 1431-3. [PMID: 19794130 DOI: 10.1093/jnci/djp320] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Burzynski JA, Toro JJ, Patel RC, Lee S, Greene RE, Ochoa-Bayona JL, Frei CR, Freytes CO. Toxicity of a second autologous peripheral blood stem cell transplant in patients with relapsed or recurrent multiple myeloma. Leuk Lymphoma 2009; 50:1442-7. [DOI: 10.1080/10428190903085936] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Buchholz S, Ganser A. [Hematopoietic stem cell transplantation. Indications, foundations and perspective]. Internist (Berl) 2009; 50:572-80. [PMID: 19396412 DOI: 10.1007/s00108-008-2273-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The hematopoietic stem cell transplantation (HSCT) has become a standard therapy for many inherited and acquired disorders of the bone marrow and immune system. Autologous HSCT is mainly done as part of the primary therapy in multiple myeloma and as part of relapse therapy in malignant lymphoma. In contrast, allogeneic HSCT is predominantly performed in patients with acute leukemias. The selection process for allogeneic HSCT takes disease-specific as well as patient-specific factors into account. Risk factors which can predict for poor response to chemotherapy can now be identified in acute myeloid as well as lymphoid leukemia, based on phenotype, cytogenetics, molecular genetics and response to therapy. In these patients allogeneic HSCT can improve overall survival from 0-20% to 30-60%. New conditioning protocols have now raised the upper age limit for transplantation to 70 years. In elderly patients the selection of patients based on absence of comorbidities becomes especially important. The increasing number of long-term survivors requires knowledge of organ-specific late toxicities including secondary malignancies.
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Affiliation(s)
- S Buchholz
- Klinik für Hämatologie, Hämostaseologie, Onkologie und Stammzelltransplantation, Medizinische Hochschule Hannover, Hannover
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Alegre A. Optimal mobilization method and CD34+ dose calculation for autologous PBSC transplant in myeloma patients: two important unresolved questions. Bone Marrow Transplant 2009; 43:593-5. [DOI: 10.1038/bmt.2008.371] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Kim JS, Kim K, Cheong JW, Min YH, Suh C, Kim H, Jo DY, Ryoo HM, Yoon SS, Lee JH. Complete Remission Status before Autologous Stem Cell Transplantation Is an Important Prognostic Factor in Patients with Multiple Myeloma Undergoing Upfront Single Autologous Transplantation. Biol Blood Marrow Transplant 2009; 15:463-70. [DOI: 10.1016/j.bbmt.2008.12.512] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2008] [Accepted: 12/24/2008] [Indexed: 11/16/2022]
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Second auto-SCT is safe and effective salvage therapy for relapsed multiple myeloma. Bone Marrow Transplant 2008; 43:417-22. [PMID: 18850013 DOI: 10.1038/bmt.2008.334] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Therapeutic options for patients with multiple myeloma whose disease has relapsed after a prior auto-SCT include novel biologic therapies, traditional chemotherapy or a second transplant, with no clear standard of care. Few published studies address the safety and efficacy of a second auto-SCT for relapsed disease. We reviewed the Abramson Cancer Center experience with salvage auto-SCT for relapsed multiple myeloma. Forty-one patients had received a salvage auto-SCT at our institution; the median time between transplants was 37 months (range 3-91). The overall response rate in assessable patients was 55%, and treatment-related mortality was 7%. With a median follow-up time of 15 months, the median PFS was 8.5 months and the median overall survival (OS) was 20.7 months. In a multivariate analysis of OS, independent prognostic factors were >or=5 prior lines of therapy and time to progression after initial auto-SCT of <or=12 months. We conclude that in well-selected patients, salvage auto-SCT is safe and effective for relapsed myeloma.
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Actual or ideal body weight to calculate CD34+ cell dose in patients undergoing autologous hematopoietic SCT for myeloma? Bone Marrow Transplant 2008; 43:301-5. [DOI: 10.1038/bmt.2008.322] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Affiliation(s)
- S Vincent Rajkumar
- Division of Hematology, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA.
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Current Awareness in Hematological Oncology. Hematol Oncol 2008. [DOI: 10.1002/hon.832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Current status of autologous hematopoietic stem cell transplantation in myeloma. Bone Marrow Transplant 2008; 42 Suppl 1:S28-S34. [DOI: 10.1038/bmt.2008.109] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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