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Afram G, Chaireti R, Uttervall K, Luong V, Lund J, Kashif M, Gahrton G, Alici E, Nahi H. Conditioning with melphalan 200 mg/m 2 and subsequent ASCT improves progression-free and overall survival in elderly myeloma patients compared to standard of care. Eur J Haematol 2022; 109:749-754. [PMID: 36066204 PMCID: PMC9826071 DOI: 10.1111/ejh.13861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 08/30/2022] [Accepted: 09/01/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVES Despite the effectiveness of newer drugs for the treatment of multiple myeloma (MM), the outcomes are further improved by subsequent autologous stem cell transplantation (ASCT). Data on effectiveness in older patients are limited. We compared outcomes in patients aged 65-75 years depending on whether they were treated with ASCT or not and compared those to outcomes in patients <65 years. METHODS This was a retrospective, single-center study. We compared progression-free survival (PFS) and overall survival (OS) for all MM patients below and above the age of 65 years treated ± ASCT at the Karolinska University Hospital between 2010 and 2020. PFS and OS were calculated by the Kaplan-Meier method. Variables affecting PFS and OS were evaluated using Cox regression model. RESULTS Both PFS and OS were improved in the group 65-75 years treated +ASCT compared to those treated pharmacologically (p = 0.008 and p < 0.001, respectively). There were no significant differences between patients <65 years and those 65-75 years treated with ASCT. CONCLUSION The findings indicate that even patients >65 years should be evaluated as candidates for ASCT. An individualized approach supported by a frailty/geriatric assessment score could assist clinicians to select the appropriate treatment for each patient.
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Affiliation(s)
- Gabriel Afram
- Center for Hematology and Regenerative Medicine, Department of MedicineHuddinge, Karolinska InstitutetStockholmSweden,Department of HematologyKarolinska University HospitalStockholmSweden,Pfizer ABSollentunaSweden
| | - Roza Chaireti
- Department of HematologyKarolinska University HospitalStockholmSweden,Department of Molecular Medicine and SurgeryKarolinska InstitutetStockholmSweden
| | - Katarina Uttervall
- Center for Hematology and Regenerative Medicine, Department of MedicineHuddinge, Karolinska InstitutetStockholmSweden,Department of HematologyKarolinska University HospitalStockholmSweden
| | - Vincent Luong
- Center for Hematology and Regenerative Medicine, Department of MedicineHuddinge, Karolinska InstitutetStockholmSweden,Department of HematologyKarolinska University HospitalStockholmSweden
| | - Johan Lund
- Center for Hematology and Regenerative Medicine, Department of MedicineHuddinge, Karolinska InstitutetStockholmSweden
| | - Muhammad Kashif
- Center for Hematology and Regenerative Medicine, Department of MedicineHuddinge, Karolinska InstitutetStockholmSweden
| | - Gösta Gahrton
- Center for Hematology and Regenerative Medicine, Department of MedicineHuddinge, Karolinska InstitutetStockholmSweden
| | - Evren Alici
- Center for Hematology and Regenerative Medicine, Department of MedicineHuddinge, Karolinska InstitutetStockholmSweden,Department of HematologyKarolinska University HospitalStockholmSweden
| | - Hareth Nahi
- Center for Hematology and Regenerative Medicine, Department of MedicineHuddinge, Karolinska InstitutetStockholmSweden
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Camilleri M, Bekris G, Sidhu G, Buck C, Elsden E, McCourt O, Horder J, Newrick F, Lecat C, Sive J, Papanikolaou X, Popat R, Lee L, Xu K, Kyriakou C, Rabin N, Yong K, Fisher A. The impact of COVID-19 on autologous stem cell transplantation in multiple myeloma: A single-centre, qualitative evaluation study. Support Care Cancer 2022; 30:7469-7479. [PMID: 35657402 PMCID: PMC9163289 DOI: 10.1007/s00520-022-07173-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 05/24/2022] [Indexed: 11/29/2022]
Abstract
Autologous stem cell transplantation (ASCT) is standard of care in biologically fit, newly diagnosed multiple myeloma (MM) patients, offering better therapeutic outcomes and improved quality of life (QoL). However, with the UK's 1st national lockdown on 23/03/2020, several guidelines recommended deferring ASCT due to risks of infection, with resource limitations forcing some units to suspend ASCT entirely. Such changes to patients' treatment plans inevitably altered their lived experience during these uncertain times with expected impact on QoL. We conducted a qualitative study using semi-structured interviews to gain insight into MM patients' understanding of their disease, initial therapy and ASCT, and their response to therapy changes. A clinical snapshot of how COVID-19 affected the MM ASCT service in a single UK institution is also provided, including changes to chemotherapy treatment plans, timing, and prioritisation of ASCT. Framework analysis identified 6 overarching themes: (1) beliefs about ASCT, (2) perceptions of information provided about MM and ASCT, (3) high levels of fear and anxiety due to COVID-19, (4) feelings about ASCT disruption or delay due to COVID-19, (5) perceptions of care, and (6) importance of social support. Example subthemes were beliefs that ASCT would provide a long-remission/best chance of normality including freedom from chemotherapy and associated side-effects, disappointment, and devastation at COVID-related treatment delays (despite high anxiety about infection) and exceptionally high levels of trust in the transplant team. Such insights will help us adjust our service and counselling approaches to be more in tune with patients' priorities and expectations.
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Affiliation(s)
- Marquita Camilleri
- University College Hospital Cancer Institute, Paul O'Gorman Building, 72 Huntley Street, London, WC1E 6DD, UK.
- Haematology Department, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.
| | - Georgios Bekris
- Department of Behavioural Science and Health, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK
| | - Govundeep Sidhu
- Department of Behavioural Science and Health, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK
| | - Caroline Buck
- Department of Behavioural Science and Health, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK
| | - Esma Elsden
- Department of Behavioural Science and Health, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK
| | - Orla McCourt
- University College Hospital Cancer Institute, Paul O'Gorman Building, 72 Huntley Street, London, WC1E 6DD, UK
- Therapies & Rehabilitation, University College London Hospitals NHS Foundation Trust, London, UK
| | - Jackie Horder
- Haematology Department, University College London Hospital, University College London Hospitals NHS Foundation Trust, London, UK
| | - Fiona Newrick
- Haematology Department, University College London Hospital, University College London Hospitals NHS Foundation Trust, London, UK
| | - Catherine Lecat
- University College Hospital Cancer Institute, Paul O'Gorman Building, 72 Huntley Street, London, WC1E 6DD, UK
- Haematology Department, University College London Hospital, University College London Hospitals NHS Foundation Trust, London, UK
| | - Jonathan Sive
- Haematology Department, University College London Hospital, University College London Hospitals NHS Foundation Trust, London, UK
| | - Xenofon Papanikolaou
- Haematology Department, University College London Hospital, University College London Hospitals NHS Foundation Trust, London, UK
| | - Rakesh Popat
- Haematology Department, University College London Hospital, University College London Hospitals NHS Foundation Trust, London, UK
| | - Lydia Lee
- Haematology Department, University College London Hospital, University College London Hospitals NHS Foundation Trust, London, UK
| | - Ke Xu
- Haematology Department, University College London Hospital, University College London Hospitals NHS Foundation Trust, London, UK
| | - Charalampia Kyriakou
- Haematology Department, University College London Hospital, University College London Hospitals NHS Foundation Trust, London, UK
| | - Neil Rabin
- Haematology Department, University College London Hospital, University College London Hospitals NHS Foundation Trust, London, UK
| | - Kwee Yong
- University College Hospital Cancer Institute, Paul O'Gorman Building, 72 Huntley Street, London, WC1E 6DD, UK
- Haematology Department, University College London Hospital, University College London Hospitals NHS Foundation Trust, London, UK
| | - Abigail Fisher
- Department of Behavioural Science and Health, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK
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Straka C, Salwender H, Knop S, Vogel M, Müller J, Metzner B, Langer C, Sayer H, Jung W, Dürk HA, Bassermann F, Gramatzki M, Rösler W, Wolf HH, Brugger W, Engelhardt M, Fischer T, Liebisch P, Einsele H. Full or intensity-reduced high-dose melphalan and single or double autologous stem cell transplant with or without bortezomib consolidation in patients with newly diagnosed multiple myeloma. Eur J Haematol 2021; 107:529-542. [PMID: 34270825 DOI: 10.1111/ejh.13690] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 07/13/2021] [Accepted: 07/15/2021] [Indexed: 01/18/2023]
Abstract
OBJECTIVE A post hoc subgroup analysis of two phase III trials (NCT00416273, NCT00416208) was carried out to investigate the influence of 100/140 and 200 mg/m² melphalan as well as single/double autologous stem cell transplantation (ASCT) on progression-free survival (PFS). Additionally, the effect of bortezomib consolidation on PFS was analyzed. METHODS Following induction therapy and high-dose melphalan with subsequent ASCT, patients with newly diagnosed multiple myeloma (NDMM) were randomized 1:1 to either four 35-day cycles of bortezomib consolidation (1.6 mg/m² IV on days 1, 8, 15, 22) or observation. RESULTS Of the 340 patients included in this analysis, 13.5% received 1 × MEL100/140, 22.9% 2 × MEL100/140, 31.2% 1 × MEL200, and 32.4% 2 × MEL200. With higher cumulative melphalan dose, PFS improved (P = .0085). PFS curves of patients treated with 2 × MEL100/140 and 1 × MEL200 were very similar. The superior dose effect of MEL200 over MEL100/140 was non-existent in the bortezomib consolidation arm but pronounced in the observation arm (P = .0015). Similarly, double ASCT was only beneficial in patients without bortezomib consolidation (P = .0569). CONCLUSIONS Full dose melphalan and double transplantation seem advantageous only as long as patients are not receiving bortezomib consolidation afterwards.
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Affiliation(s)
| | - Hans Salwender
- Asklepios Tumorzentrum, AK Altona und AK St. Georg, Hamburg, Germany
| | - Stefan Knop
- Universitätsklinikum Würzburg, Medizinische Klinik und Poliklinik II, Würzburg, Germany
| | | | | | - Bernd Metzner
- Universitätsklinik für Innere Medizin II, Oldenburg, Germany
| | - Christian Langer
- Universitätsklinikum Ulm, Klinik für Innere Medizin II, Ulm, Germany
| | - Herbert Sayer
- Universitätsklinikum Jena, Klinik für Innere Medizin II, Jena, Germany
| | - Wolfram Jung
- Universitätsmedizin Göttingen, Göttingen, Germany
| | | | - Florian Bassermann
- Klinikum rechts der Isar der Technischen Universität München, Munich, Germany
| | | | - Wolf Rösler
- Universitätsklinikum Erlangen, Erlangen, Germany
| | | | | | | | | | - Peter Liebisch
- Universitätsklinikum Ulm, Klinik für Innere Medizin II, Ulm, Germany
| | - Hermann Einsele
- Universitätsklinikum Würzburg, Medizinische Klinik und Poliklinik II, Würzburg, Germany
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Al Hamed R, Bazarbachi AH, Malard F, Harousseau JL, Mohty M. Current status of autologous stem cell transplantation for multiple myeloma. Blood Cancer J 2019; 9:44. [PMID: 30962422 PMCID: PMC6453900 DOI: 10.1038/s41408-019-0205-9] [Citation(s) in RCA: 142] [Impact Index Per Article: 28.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Revised: 03/05/2019] [Accepted: 03/12/2019] [Indexed: 12/22/2022] Open
Abstract
More than 30 years after its introduction, autologous stem cell transplantation (ASCT) remains the standard of care for young patients with newly diagnosed multiple myeloma. Not only did the arrival of novel agents such as immunomodulatory drugs (IMiDs), proteasome inhibitors (PI) and monoclonal antibodies not replace ASCT, instead they solidified its central role as standard of care. Novel agent use is now inarguably essential in induction, maintenance, and possibly consolidation. In light of these new advancements, new challenges arise in deciding on optimal practice. Who is most suited to undergo ASCT? Is there an age threshold that should not be surpassed? Should transplantation be embarked on early or is it reasonable to delay it? What are the optimal induction, consolidation, and maintenance therapies? What is the role of tandem transplantation in the era of novel agents and where do patient-specific cytogenetics come into the equation when deciding on treatment? These are some of the questions addressed in this review which we will attempt to answer with the latest currently available data.
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Affiliation(s)
- Rama Al Hamed
- Service d'hématologie clinique et thérapie cellulaire, Hôpital Saint-Antoine, INSERM UMRs 938 and université Sorbonne, Paris, France
| | - Abdul Hamid Bazarbachi
- Service d'hématologie clinique et thérapie cellulaire, Hôpital Saint-Antoine, INSERM UMRs 938 and université Sorbonne, Paris, France
| | - Florent Malard
- Service d'hématologie clinique et thérapie cellulaire, Hôpital Saint-Antoine, INSERM UMRs 938 and université Sorbonne, Paris, France
| | - Jean-Luc Harousseau
- Institut de Cancerologie de l'Ouest, Centre René Gauducheau, Nantes-St Herblain, France
| | - Mohamad Mohty
- Service d'hématologie clinique et thérapie cellulaire, Hôpital Saint-Antoine, INSERM UMRs 938 and université Sorbonne, Paris, France.
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Stadtmauer EA, Pasquini MC, Blackwell B, Hari P, Bashey A, Devine S, Efebera Y, Ganguly S, Gasparetto C, Geller N, Horowitz MM, Koreth J, Knust K, Landau H, Brunstein C, McCarthy P, Nelson C, Qazilbash MH, Shah N, Vesole DH, Vij R, Vogl DT, Giralt S, Somlo G, Krishnan A. Autologous Transplantation, Consolidation, and Maintenance Therapy in Multiple Myeloma: Results of the BMT CTN 0702 Trial. J Clin Oncol 2019; 37:589-597. [PMID: 30653422 PMCID: PMC6553842 DOI: 10.1200/jco.18.00685] [Citation(s) in RCA: 167] [Impact Index Per Article: 33.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
PURPOSE Single-cycle melphalan 200 mg/m2 and autologous hematopoietic cell transplantation (AHCT) followed by lenalidomide (len) maintenance have improved progression-free survival (PFS) and overall survival (OS) for transplantation-eligible patients with multiple myeloma (MM). We designed a prospective, randomized, phase III study to test additional interventions to improve PFS by comparing AHCT, tandem AHCT (AHCT/AHCT), and AHCT and four subsequent cycles of len, bortezomib, and dexamethasone (RVD; AHCT + RVD), all followed by len until disease progression. PATIENTS AND METHODS Patients with symptomatic MM within 12 months from starting therapy and without progression who were age 70 years or younger were randomly assigned to AHCT/AHCT + len (n = 247), AHCT + RVD + len (n = 254), or AHCT + len (n = 257). The primary end point was 38-month PFS. RESULTS The study population had a median age of 56 years (range, 20 to 70 years); 24% of patients had high-risk MM, 73% had a triple-drug regimen as initial therapy, and 18% were in complete response at enrollment. The 38-month PFS rate was 58.5% (95% CI, 51.7% to 64.6%) for AHCT/AHCT + len, 57.8% (95% CI, 51.4% to 63.7%) for AHCT + RVD + len, and 53.9% (95% CI, 47.4% to 60%) for AHCT + len. For AHCT/AHCT + len, AHCT + RVD + len, and AHCT + len, the OS rates were 81.8% (95% CI, 76.2% to 86.2%), 85.4% (95% CI, 80.4% to 89.3%), and 83.7% (95% CI, 78.4% to 87.8%), respectively, and the complete response rates at 1 year were 50.5% (n = 192), 58.4% (n = 209), and 47.1% (n = 208), respectively. Toxicity profiles and development of second primary malignancies were similar across treatment arms. CONCLUSION Second AHCT or RVD consolidation as post-AHCT interventions for the up-front treatment of transplantation-eligible patients with MM did not improve PFS or OS. Single AHCT and len should remain as the standard approach for this population.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Nancy Geller
- 8 National Heart, Lung, and Blood Institute, Rockville, MD
| | | | | | | | | | | | | | | | | | - Nina Shah
- 14 University of California, San Francisco, San Francisco, CA
| | | | - Ravi Vij
- 16 Washington University, St Louis, MO
| | - Dan T Vogl
- 1 University of Pennsylvania, Philadelphia, PA
| | - Sergio Giralt
- 10 Memorial Sloan Kettering Cancer Center, New York, NY
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Efficacy and safety of autologous hematopoietic cell transplantation in elderly patients with multiple myeloma: a retrospective national multi-site cohort study. Ann Hematol 2016; 96:271-278. [PMID: 28039512 DOI: 10.1007/s00277-016-2882-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 11/14/2016] [Indexed: 10/20/2022]
Abstract
We aimed to test the efficacy and toxicity of autologous hematopoietic cell transplant (HCT) in Multiple Myeloma (MM) patients aged ≥65 years compared to patients aged 60-64. Two hundred twenty consecutive patients (age ≥65, n = 87) with MM aged 60 and above, who underwent HCT as part of an upfront MM treatment, at four Israeli centers between 2000 and 2014 were included. A melphalan dose of 200 mg/m2 was more frequent in the 60-64 age group vs. the ≥65 age group (77 vs. 57%, p = 0.002). There were no differences between groups in median day of neutrophil engraftment, incidence of infections, grades 3-4 mucositis, cardiovascular events, or non-relapse mortality at 100 days post HCT (4.7, vs. 5%, p = 0.9). A similar rate of improvement in response level was observed (36, vs. 35%, p = 0.87). At 3 years post HCT progression-free survival (PFS) was higher in the 60-64 age group (42 vs. 29%, p = 0.04); however, it was no longer so after adjustment for disease status prior to HCT (p = 0.49). In a Multivariate analysis, melphalan doses and age did not predict PFS. There was no difference in overall survival (OS) between age groups (p = 0.2). We conclude that toxicity profile, response, PFS, and OS of HCT in aged ≥65 patients with myeloma is similar to patients aged 60-64.
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8
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Remenyi P, Varga G, Mikala G, Reti M, Gopcsa L, Batai A, Csukly Z, Lengyel L, Torbagyi E, Barta A, Fabian J, Levai D, Szombath G, Andrikovics H, Masszi T. Early Versus Delayed Autologous Stem Cell Transplantation and Interferon Maintenance in Multiple Myeloma: Single-Center Experience of 18 Years. Transplant Proc 2016; 48:177-84. [PMID: 26915865 DOI: 10.1016/j.transproceed.2015.12.031] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Revised: 12/14/2015] [Accepted: 12/30/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND Autologous stem cell transplantation (ASCT) has become the mainstay of 1st-line treatment in younger patients with multiple myeloma (MM), but statistical confirmation of its superiority over other therapies, especially in the era of novel agents, is still lacking. METHODS We reviewed the results of all 548 myeloma ASCTs performed in our institute over the past 18 years. RESULTS More than one-half of the patients had access to novel agents before their transplantations. Although the age of the transplanted patients increased significantly over the years, treatment-related mortality (TRM) was remarkably low, especially in 1st-line transplanted patients (100-day TRM, 0.3%). The median overall survival (OS) of the entire cohort was 98.4 months. Patients transplanted within 12 months from the start of their therapy had significantly better responses than those having delayed ASCT (complete response rate, 58.1% vs 46.8%; P = .016) and significant post-ASCT progression-free survival (PFS) benefit (30.2 [26.1-34.3] mo vs 23.3 [16.8-29.8] mo; P = .036), but we found no significant overall survival difference. The results were similar in patients treated with or without novel agents before ASCT. During a period of time, interferon maintenance was our standard approach to post-ASCT maintenance. Our analysis showed not only a significant PFS advantage with interferon, but also a highly significant overall survival benefit (150.4 [105.1-195.8] mo vs 86.1 [72.5-99.7] mo; P = .003). CONCLUSIONS Our findings demonstrate that delayed ASCT can be feasible in selected patients.
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Affiliation(s)
- P Remenyi
- Department of Hematology and Stem Cell Transplantation, St Istvan and St Laszlo Hospital, Budapest, Hungary
| | - G Varga
- 3rd Department of Internal Medicine, Semmelweis University, Budapest, Hungary.
| | - G Mikala
- Department of Hematology and Stem Cell Transplantation, St Istvan and St Laszlo Hospital, Budapest, Hungary
| | - M Reti
- Department of Hematology and Stem Cell Transplantation, St Istvan and St Laszlo Hospital, Budapest, Hungary
| | - L Gopcsa
- Department of Hematology and Stem Cell Transplantation, St Istvan and St Laszlo Hospital, Budapest, Hungary
| | - A Batai
- Department of Hematology and Stem Cell Transplantation, St Istvan and St Laszlo Hospital, Budapest, Hungary
| | - Z Csukly
- Department of Hematology and Stem Cell Transplantation, St Istvan and St Laszlo Hospital, Budapest, Hungary
| | - L Lengyel
- Department of Hematology and Stem Cell Transplantation, St Istvan and St Laszlo Hospital, Budapest, Hungary
| | - E Torbagyi
- Department of Hematology and Stem Cell Transplantation, St Istvan and St Laszlo Hospital, Budapest, Hungary
| | - A Barta
- Department of Hematology and Stem Cell Transplantation, St Istvan and St Laszlo Hospital, Budapest, Hungary
| | - J Fabian
- Department of Hematology and Stem Cell Transplantation, St Istvan and St Laszlo Hospital, Budapest, Hungary
| | - D Levai
- 3rd Department of Internal Medicine, Semmelweis University, Budapest, Hungary
| | - G Szombath
- 3rd Department of Internal Medicine, Semmelweis University, Budapest, Hungary
| | - H Andrikovics
- Laboratory of Molecular Diagnostics, Hungarian National Blood Transfusion Service, Budapest, Hungary; Institute of Pathophysiology, Semmelweis University, Budapest, Hungary
| | - T Masszi
- 3rd Department of Internal Medicine, Semmelweis University, Budapest, Hungary; Department of Hematology and Stem Cell Transplantation, St Istvan and St Laszlo Hospital, Budapest, Hungary
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Stettler J, Novak U, Baerlocher GM, Seipel K, Mansouri Taleghani B, Pabst T. Autologous stem cell transplantation in elderly patients with multiple myeloma: evaluation of its safety and efficacy. Leuk Lymphoma 2016; 58:1076-1083. [DOI: 10.1080/10428194.2016.1233542] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Jasmin Stettler
- Department of Medical Oncology, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Urban Novak
- Department of Medical Oncology, Inselspital, University Hospital Bern, Bern, Switzerland
| | | | - Katja Seipel
- Department of Clinical Research, University of Bern, Bern, Switzerland
| | | | - Thomas Pabst
- Department of Medical Oncology, Inselspital, University Hospital Bern, Bern, Switzerland
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Italian consensus conference for the outpatient autologous stem cell transplantation management in multiple myeloma. Bone Marrow Transplant 2016; 51:1032-40. [PMID: 27042841 DOI: 10.1038/bmt.2016.79] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Revised: 02/07/2016] [Accepted: 02/19/2016] [Indexed: 01/28/2023]
Abstract
Multiple myeloma (MM) is the leading indication for autologous stem cell transplantation (ASCT) worldwide. The safety and efficacy of reducing hospital stay for MM patients undergoing ASCT have been widely explored, and different outpatient models have been proposed. However, there is no agreement on the criteria for selecting patients eligible for this strategy as well as the standards for their clinical management. On the basis of this rationale, the Italian Group for Stem Cell Transplantation (GITMO) endorsed a project to develop guidelines for the management of outpatient ASCT in MM, using evidence-based knowledge and consensus-formation techniques. An expert panel convened to discuss the currently available data on the practice of outpatient ASCT management and formulated recommendations according to the supporting evidence. Evidence gaps were filled with consensus-based statements. Three main topics were addressed: (1) the identification of criteria for selecting MM patients eligible for outpatient ASCT management; (2) the definition of standard procedures for performing outpatient ASCT (model, supportive care and monitoring during the aplastic phase); (3) the definition of the standard criteria and procedures for re-hospitalization during the aplastic phase at home. Herein, we report the summary and the results of the discussion and the consensus.
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Garcia IN. Role of Hematopoietic Stem Cell Transplantation in Multiple Myeloma. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2015; 15:86-91. [DOI: 10.1016/j.clml.2014.07.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Accepted: 07/08/2014] [Indexed: 10/25/2022]
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Sharma M, Zhang MJ, Zhong X, Abidi MH, Akpek G, Bacher U, Callander NS, Dispenzieri A, Freytes CO, Fung HC, Gale RP, Gasparetto C, Gibson J, Holmberg LA, Kindwall-Keller TL, Klumpp TR, Krishnan AY, Landau HJ, Lazarus HM, Lonial S, Maiolino A, Marks DI, Mehta P, Mikhael Med JR, Nishihori T, Olsson R, Ramanathan M, Roy V, Savani BN, Schouten HC, Scott E, Tay J, To LB, Vesole DH, Vogl DT, Hari P. Older patients with myeloma derive similar benefit from autologous transplantation. Biol Blood Marrow Transplant 2014; 20:1796-803. [PMID: 25046833 PMCID: PMC4194262 DOI: 10.1016/j.bbmt.2014.07.013] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Accepted: 07/11/2014] [Indexed: 10/25/2022]
Abstract
Autologous hematopoietic cell transplantation (AHCT) for plasma cell myeloma is performed less often in people >70 years old than in people ≤70 years old. We analyzed 11,430 AHCT recipients for plasma cell myeloma prospectively reported to the Center for International Blood and Marrow Transplant Research between 2008 and 2011, representing the majority of US AHCT activity during this period. Survival (OS) was compared in 3 cohorts: ages 18 to 59 years (n = 5818), 60 to 69 years (n = 4666), and >70 years (n = 946). Median OS was not reached for any cohort. In multivariate analysis, increasing age was associated with mortality (P = .0006). Myeloma-specific mortality was similar among cohorts at 12%, indicating an age-related effect on nonmyeloma mortality. Analyses were performed in a representative subgroup comparing relapse rate, progression-free survival (PFS), and nonrelapse mortality (NRM). One-year NRM was 0% for age >70 years and 2% for other ages (P = not significant). The three-year relapse rate was 56% in age 18 to 59 years, 61% in age 60 to 69 years, and 63% age >70 (P = not significant). Three-year PFS was similar at 42% in age 18 to 59 years, 38% in age 60 to 69 years, and 33% in age >70 years (P = not significant). Postrelapse survival was significantly worse for the older cohort (P = .03). Older subjects selected for AHCT derived similar antimyeloma benefit without worse NRM, relapse rate, or PFS.
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Affiliation(s)
- Manish Sharma
- Department of Medical Oncology, Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Mei-Jie Zhang
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin; Division of Biostatistics, Institute for Health and Society, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Xiaobo Zhong
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Muneer H Abidi
- Department of Medicine, Karmanos Cancer Institute, Wayne State University, Detroit, Michigan
| | - Görgün Akpek
- Banner MD Anderson Cancer Center, Gilbert, Arizona
| | - Ulrike Bacher
- Department of Stem Cell Transplantation, University of Hamburg, Hamburg, Germany; MLL Munich Leukemia Laboratory, Munich, Germany
| | - Natalie S Callander
- Bone Marrow Transplant Program, University of Wisconsin Hospital and Clinics, Madison, Wisconsin
| | | | - César O Freytes
- Department of Medicine, South Texas Veterans Health Care System and University of Texas Health Science Center San Antonio, San Antonio, Texas
| | - Henry C Fung
- Department of Medical Oncology, Fox Chase Cancer Center, Temple Health, Philadelphia, Pennsylvania
| | - Robert Peter Gale
- Hematology Research Centre, Division of Experimental Medicine, Department of Medicine, Imperial College London, London, United Kingdom
| | - Cristina Gasparetto
- Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - John Gibson
- Institute of Haematology, Royal Prince Alfred Hospital, Camperdown, Australia
| | - Leona A Holmberg
- Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington
| | | | - Thomas R Klumpp
- Department of Medicine, Temple Bone Marrow Transplant Program, Philadelphia, Pennsylvania
| | - Amrita Y Krishnan
- Department of Hematology/Oncology, City of Hope National Medical Center, Duarte, California
| | - Heather J Landau
- Department of Medicine, Bone Marrow Transplant Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Hillard M Lazarus
- Department of Medicine, Seidman Cancer Center, University Hospitals Case Medical Center, Cleveland, Ohio
| | - Sagar Lonial
- Department of Medicine, Emory University Hospital, Atlanta, Georgia
| | - Angelo Maiolino
- Hospital Universitario Clementino Fraga Filho, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - David I Marks
- University Hospitals Bristol NHS Trust, Bristol, United Kingdom
| | - Paulette Mehta
- Central Arkansas Veterans Healthcare System, Little Rock, Arkansas; Department of Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Joseph R Mikhael Med
- Department of Hematology/Oncology, Mayo Clinic Arizona and Phoenix Children's Hospital, Phoenix, Arizona
| | - Taiga Nishihori
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida
| | - Richard Olsson
- Division of Therapeutic Immunology, Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden; Centre for Clinical Research Sörmland, Uppsala University, Uppsala, Sweden
| | - Muthalagu Ramanathan
- Department of Hematologic Malignancies Bone Marrow Transplant, UMass Memorial Medical Center, Worcester, Massachusetts
| | - Vivek Roy
- Department of Medicine, Blood and Marrow Transplant Program, Mayo Clinic, Jacksonville, Florida
| | - Bipin N Savani
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Emma Scott
- Department of Medicine, Oregon Health and Science University, Portland, Oregon
| | - Jason Tay
- University of Ottawa, Ottawa, Canada
| | - Luen Bik To
- Royal Adelaide Hospital, Adelaide, Australia
| | - David H Vesole
- Hackensack University Medical Center, Hackensack, New Jersey
| | - Dan T Vogl
- Department of Medicine, Abramson Cancer Center, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania
| | - Parameswaran Hari
- Center for International Blood and Marrow Transplant Research, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin.
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Autologous stem cell transplantation in elderly patients with multiple myeloma: past, present, and future. BIOMED RESEARCH INTERNATIONAL 2014; 2014:394792. [PMID: 24719860 PMCID: PMC3956410 DOI: 10.1155/2014/394792] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Accepted: 01/14/2014] [Indexed: 12/22/2022]
Abstract
High-dose melphalan (200 mg/m2) as conditioning regimen followed by autologous stem cell transplantation (ASCT) rescue has been established as a standard treatment for patients with multiple myeloma (MM) younger than 65 years of age. However, the role of ASCT in elderly patients older than 65 years remains controversial in the era of novel agents such as thalidomide, bortezomib, and lenalidomide. The efficacy and feasibility of ASCT have been shown in elderly patients by reducing the dose of melphalan to 100–140 mg/m2. Although the clinical benefit of reduced-intensity ASCT in elderly patients has not been clearly established in comparison with that of novel agent-based induction therapy, recent studies have demonstrated that sequential strategies of novel agent-based induction therapy and reduced-intensity ASCT followed by consolidation/maintenance with novel agents translate into better outcome in the management of elderly patients. Thus, ASCT could also be a mainstay in the initial treatment of elderly MM patients, and its indication should be evaluated based on performance status and the presence of complications and/or comorbidities of each elderly patient with MM.
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14
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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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15
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Merz M, Neben K, Raab M, Sauer S, Egerer G, Hundemer M, Hose D, Kunz C, Heiß C, Ho A, Goldschmidt H, Hillengass J. Autologous stem cell transplantation for elderly patients with newly diagnosed multiple myeloma in the era of novel agents. Ann Oncol 2014; 25:189-95. [DOI: 10.1093/annonc/mdt509] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
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16
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Sanchorawala V, Hoering A, Seldin DC, Finn KT, Fennessey SA, Sexton R, Mattar B, Safah HF, Holmberg LA, Dean RM, Orlowski RZ, Barlogie B. Modified high-dose melphalan and autologous SCT for AL amyloidosis or high-risk myeloma: analysis of SWOG trial S0115. Bone Marrow Transplant 2013; 48:1537-42. [PMID: 23852321 PMCID: PMC3855173 DOI: 10.1038/bmt.2013.98] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Revised: 06/04/2013] [Accepted: 06/12/2013] [Indexed: 12/22/2022]
Abstract
We designed a trial using two sequential cycles of modified high-dose melphalan at 100 mg/m(2) and autologous SCT (mHDM/SCT) in AL amyloidosis (light-chain amyloidosis, AL), AL with myeloma (ALM) and host-based high-risk myeloma (hM) patients through SWOG-0115. The primary objective was to evaluate OS. From 2004 to 2010, 93 eligible patients were enrolled at 17 centers in the United States (59 with AL, 9 with ALM and 25 with hM). The median OS for patients with AL and ALM was 68 months and 47 months, respectively, and has not been reached for patients with hM. The median PFS for patients with AL and ALM was 38 months and 16 months, respectively, and has not been reached for patients with hM. The treatment-related mortality (TRM) was 12% (11/93) and was observed only in patients with AL after SCT. Grade 3 and higher non-hematologic adverse events were experienced by 81%, 67% and 57% of patients with AL, ALM and hM, respectively, during the first and second HDM/SCT. This experience demonstrates that with careful selection of patients and use of mHDM for SCT in patients with AL, ALM and hM, even in the setting of a multicenter study, OS can be improved with acceptable TRM and morbidity.
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Affiliation(s)
| | - A Hoering
- SWOG Statistical Center, Seattle, WA, USA
| | - DC Seldin
- Boston Medical Center, Boston, MA, USA
| | - KT Finn
- Boston Medical Center, Boston, MA, USA
| | | | - R Sexton
- SWOG Statistical Center, Seattle, WA, USA
| | | | - HF Safah
- Tulane University Health Science Center, New Orleans, LA, USA
| | - LA Holmberg
- Puget Sound Oncology Consortium, Seattle, WA, USA
| | - RM Dean
- Cleveland Clinic, Cleveland, OH, USA
| | - RZ Orlowski
- MD Anderson Cancer Center/University of Texas, Houston, TX, USA
| | - B Barlogie
- University of Arkansas, Little Rock, AR, USA
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Bortezomib induction, reduced-intensity transplantation, and lenalidomide consolidation-maintenance for myeloma: updated results. Blood 2013; 122:1376-83. [DOI: 10.1182/blood-2013-02-483073] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Key Points
Bortezomib-induction/Mel100-ASCT/lenalidomide consolidation-maintenance is effective in elderly patients with excellent performance status. Deaths related to AEs were higher in patients ≥70 years, suggesting the need of a more careful patient selection.
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Martino M, Olivieri A, Offidani M, Vigna E, Moscato T, Fedele R, Montanari M, Console G, Gentile M, Messina G, Irrera G, Morabito F. Addressing the questions of tomorrow: melphalan and new combinations as conditioning regimens before autologous hematopoietic progenitor cell transplantation in multiple myeloma. Expert Opin Investig Drugs 2013; 22:619-34. [DOI: 10.1517/13543784.2013.788643] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Massimo Martino
- Oncology Department, Haematology and Bone Marrow Transplant Unit, Viale Europa, Reggio Calabria, 89100, Italy
| | - Attilio Olivieri
- Clinica di Ematologia, Azienda Ospedaliero-Universitaria Ospedali Riuniti, Ancona, Italy
| | - Massimo Offidani
- Clinica di Ematologia, Azienda Ospedaliero-Universitaria Ospedali Riuniti, Ancona, Italy
| | - Ernesto Vigna
- Divisione di Ematologia, Dipartimento Oncoematologico, Azienda Ospedaliera, Cosenza, Italy
| | - Tiziana Moscato
- Oncology Department, Haematology and Bone Marrow Transplant Unit, Viale Europa, Reggio Calabria, 89100, Italy
| | - Roberta Fedele
- Oncology Department, Haematology and Bone Marrow Transplant Unit, Viale Europa, Reggio Calabria, 89100, Italy
| | - Mauro Montanari
- Clinica di Ematologia, Azienda Ospedaliero-Universitaria Ospedali Riuniti, Ancona, Italy
| | - Giuseppe Console
- Oncology Department, Haematology and Bone Marrow Transplant Unit, Viale Europa, Reggio Calabria, 89100, Italy
| | - Massimo Gentile
- Divisione di Ematologia, Dipartimento Oncoematologico, Azienda Ospedaliera, Cosenza, Italy
| | - Giuseppe Messina
- Oncology Department, Haematology and Bone Marrow Transplant Unit, Viale Europa, Reggio Calabria, 89100, Italy
| | - Giuseppe Irrera
- Oncology Department, Haematology and Bone Marrow Transplant Unit, Viale Europa, Reggio Calabria, 89100, Italy
| | - Fortunato Morabito
- Divisione di Ematologia, Dipartimento Oncoematologico, Azienda Ospedaliera, Cosenza, Italy
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Bashir Q, Shah N, Parmar S, Wei W, Rondon G, Weber DM, Wang M, Orlowski RZ, Thomas SK, Shah J, Qureshi SR, Dinh YT, Popat U, Anderlini P, Hosing C, Giralt S, Champlin RE, Qazilbash MH. Feasibility of autologous hematopoietic stem cell transplant in patients aged ≥70 years with multiple myeloma. Leuk Lymphoma 2012; 53:118-22. [PMID: 21780997 DOI: 10.3109/10428194.2011.606942] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Abstract We retrospectively analyzed the outcomes of all consecutive patients with myeloma (n = 84) aged ≥70 years who had received autologous hematopoietic stem cell transplant (auto HCT) between July 1999 and June 2010 at our institution. The median age at auto HCT was 72 years, the median number of prior therapies was 2.5 and the median time from diagnosis to auto HCT was 10.2 months. The conditioning regimen consisted of melphalan at 140 mg/m(2) in 10%, 180 mg/m(2) in 25% and 200 mg/m(2) in 65% of patients. The day-100 non-relapse mortality was 3%. The overall response rate at day 100 was 85% (complete response 18%, very good partial response 12%, partial response 55%). After a median follow-up of 25 months among surviving patients, the estimated progression-free survival and overall survival at 5 years were 27% and 67%, respectively. The incidence of grade II-IV toxicity, response rate and survival were similar across three melphalan dose levels. These results indicate that high-dose melphalan plus auto HCT is safe and feasible for patients with multiple myeloma aged ≥70 years and age alone should not be an exclusion criterion for auto HCT.
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Affiliation(s)
- Qaiser Bashir
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas M D Anderson Cancer Center, Houston, TX 77030, USA.
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20
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Blimark C, Veskovski L, Westin J, Rödjer S, Brune M, Hjorth M, Holmberg E, Andersson PO, Mellqvist UH. Melphalan 100 mg/m2 with stem cell support as first relapse treatment is safe and effective for myeloma patients with long remission after autologous stem cell transplantation. Eur J Haematol 2011; 87:117-22. [DOI: 10.1111/j.1600-0609.2011.01634.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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21
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Madan S, Kumar S. Current treatment options for elderly patients with multiple myeloma: clinical impact of novel agents. ACTA ACUST UNITED AC 2011. [DOI: 10.2217/thy.11.39] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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22
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Abstract
Outcomes for patients with multiple myeloma have dramatically improved during the past 20 years as a result of improved therapeutic options and a better understanding of malignant plasma cell biology. Until the past 10 years, the major limitations on improving outcomes were related to the minimal efficacy of existing agents and balancing the toxicity of therapy in an older patient population. However, despite these limitations, there have been advances that have resulted in improvements in progression-free survival and overall survival (OS). High-dose therapy and autologous transplant were the first among therapies to demonstrate an improvement in OS; but more recent analyses have demonstrated that there can be improvement in OS, which is also associated with improvement in the complete response (CR) rate, even among nontransplant patients as well. Thus, achieving CR has been associated with improved OS and has become a therapeutic goal. In the current era of new agents, such as thalidomide, bortezomib, and lenalidomide, the fraction of patients who achieve a CR is now greater than before, and the data regarding the importance of achieving this benchmark of response have never been more benefit.
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23
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Barlogie B, Attal M, Crowley J, Rhee FV, Szymonifka J, Moreau P, Durie BG, Harousseau JL. Reply to J.C. Regelink et al. J Clin Oncol 2010. [DOI: 10.1200/jco.2010.31.6927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Bart Barlogie
- University of Arkansas for Medical Sciences, Little Rock, AR
| | | | | | - Frits van Rhee
- University of Arkansas for Medical Sciences, Little Rock, AR
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Novitzky N, Thomson J, Thomas V, du Toit C, Mohamed Z, McDonald A. Combined Submyeloablative and Myeloablative Dose Intense Melphalan Results in Satisfactory Responses with Acceptable Toxicity in Patients with Multiple Myeloma. Biol Blood Marrow Transplant 2010; 16:1402-10. [DOI: 10.1016/j.bbmt.2010.04.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2009] [Accepted: 04/02/2010] [Indexed: 11/29/2022]
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Lee SR, Kim SJ, Park Y, Sung HJ, Choi CW, Kim BS. Bortezomib and melphalan as a conditioning regimen for autologous stem cell transplantation in multiple myeloma. THE KOREAN JOURNAL OF HEMATOLOGY 2010; 45:183-7. [PMID: 21120207 PMCID: PMC2983035 DOI: 10.5045/kjh.2010.45.3.183] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2010] [Revised: 07/23/2010] [Accepted: 09/02/2010] [Indexed: 11/28/2022]
Abstract
BACKGROUND High-dose melphalan (200 mg/m(2)) with autologous stem cell transplantation (ASCT) is the standard treatment for young patients with multiple myeloma (MM). However, the response rates after ASCT are often unsatisfactory. We performed a pilot study by using bortezomib-melphalan as conditioning regimen for ASCT in Korean patients with MM. METHODS The conditioning regimen consisted of administration of intravenous infusion of bortezomib 1.0 mg/m(2) on days -4 and -1 and melphalan 50 mg/m(2) (day -4) and 150 mg/m(2) (day -1). In this study, we enrolled 6 newly diagnosed patients and 2 patients with relapse. RESULTS The disease status of the 6 newly diagnosed patients at ASCT was as follows: 1 complete remission (CR), 1 very good partial remission (VGPR), and 4 partial remissions (PRs). The disease status of the 2 relapsed patients at ASCT was PR. All patients except 1 showed adequate hematologic recovery after ASCT. The median time for the absolute neutrophil counts to increase over 500/mm(3) was 13 days (range, 10-19 days). Six patients with VGPR or PR at the time of transplantation showed an improvement in response to CR after ASCT. The patients were followed up without any maintenance treatment after ASCT except 1 patient who died during ASCT. During the follow-up period, CR was maintained in 3 newly diagnosed patients, but the other 4 patients, including 2 newly diagnosed patients, relapsed. CONCLUSION Conditioning regimen consisting of bortezomib and melphalan may be effective for ASCT in MM; however, the feasibility of this regimen should be further evaluated in large study populations.
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Affiliation(s)
- Se Ryeon Lee
- Department of Internal Medicine, Korea University Medical Center, Seoul, Korea
| | - Seok Jin Kim
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yong Park
- Department of Internal Medicine, Korea University Medical Center, Seoul, Korea
| | - Hwa Jung Sung
- Department of Internal Medicine, Korea University Medical Center, Seoul, Korea
| | - Chul Won Choi
- Department of Internal Medicine, Korea University Medical Center, Seoul, Korea
| | - Byung Soo Kim
- Department of Internal Medicine, Korea University Medical Center, Seoul, Korea
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Ludwig H, Beksac M, Bladé J, Boccadoro M, Cavenagh J, Cavo M, Dimopoulos M, Drach J, Einsele H, Facon T, Goldschmidt H, Harousseau JL, Hess U, Ketterer N, Kropff M, Mendeleeva L, Morgan G, Palumbo A, Plesner T, San Miguel J, Shpilberg O, Sondergeld P, Sonneveld P, Zweegman S. Current multiple myeloma treatment strategies with novel agents: a European perspective. Oncologist 2010; 15:6-25. [PMID: 20086168 PMCID: PMC3227886 DOI: 10.1634/theoncologist.2009-0203] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
The treatment of multiple myeloma (MM) has undergone significant developments in recent years. The availability of the novel agents thalidomide, bortezomib, and lenalidomide has expanded treatment options and has improved the outcome of patients with MM. Following the introduction of these agents in the relapsed/refractory setting, they are also undergoing investigation in the initial treatment of MM. A number of phase III trials have demonstrated the efficacy of novel agent combinations in the transplant and nontransplant settings, and based on these results standard induction regimens are being challenged and replaced. In the transplant setting, a number of newer induction regimens are now available that have been shown to be superior to the vincristine, doxorubicin, and dexamethasone regimen. Similarly, in the front-line treatment of patients not eligible for transplantation, regimens incorporating novel agents have been found to be superior to the traditional melphalan plus prednisone regimen. Importantly, some of the novel agents appear to be active in patients with high-risk disease, such as adverse cytogenetic features, and certain comorbidities, such as renal impairment. This review presents an overview of the most recent data with these novel agents and summarizes European treatment practices incorporating the novel agents.
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Affiliation(s)
- Heinz Ludwig
- Department of Medicine, Wilhelminenspital, Montleartstr. 37, 1160 Vienna, Austria.
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Berz D, Colvin GA, McCormack EM, Winer ES, Karwan P, Colvin L, Rathore R, Lum LG, Elfenbein GJ, Quesenberry PJ. Triple MEL100 therapy in multiple myeloma. Transplant Proc 2009; 41:3863-7. [PMID: 19917402 DOI: 10.1016/j.transproceed.2009.06.196] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2009] [Accepted: 06/03/2009] [Indexed: 11/18/2022]
Abstract
BACKGROUND Tandem high-dose melphalan therapy with autologous peripheral stem cell support has emerged as the standard of care for patients without prohibitive comorbidities. Mucositis and gastrointestinal side effects are the most common extrahematologic side effects. Two previously published studies presented a triple transplant with a conditioning regimen of melphalan 100 mg/m(2) (MEL100) with peripheral stem cell support every 2 to 5 months for patients with prohibitive comorbidities for high-dose tandem transplantation. We present a novel approach that investigates the triple melphalan 100/m(2) approach on a dose-dense, every-3-weeks schedule in a patient population without significant comorbidities. PATIENTS AND METHODS Thirteen standard or high-risk patients with stage III multiple myeloma were prospectively treated. This population contained eight patients with immunoglobin G clonality, three immunoglobin A, one nonsecretory, and one light chain isotype. The induction regimens of the 13 patients were heterogenous and included five VAD, three DCIE, two Thal/Dex, two CIE, and one pulse decadron. Patients underwent peripheral blood leukopheresis, and these cells were divided into three equal sets and frozen. The patients were scheduled to receive melphalan at 100 mg/m(2) on days 1, 20, and 41, and then the autologous infusions occurred at days 0, 21, and 42. RESULTS All patients were able to receive all three cycles of the MEL100 regimen. Seven patients (54%) received the treatments on the every-3-weeks schedule; three treatments (23%) during the second cycle and six treatments (46%) of the third cycle had to be delayed a median of 6 and 4 days, respectively. Three patients were managed completely in the outpatient setting, and the average total hospital stay for the three transplants was 18 days. Median progression-free survival was 854 days (range 73 to 1571), and the overall survival of this cohort has yet to be reached. No patient had worse than grade II mucositis, and no serious adverse events were recorded. CONCLUSION Our regimen of three consecutive autologous peripheral stem cell transplants with a reduced dose of melphalan at 100 mg/m(2) given every 3 weeks was very well tolerated. The progression-free survival and overall survival are similar and can be compared favorably with the standard tandem myeloma regimens. Our data is intriguing, and further studies with larger numbers need to be performed to confirm these results.
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Affiliation(s)
- D Berz
- Brown University, Providence, Rhode Island, USA.
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Harousseau JL, Avet-Loiseau H, Attal M, Charbonnel C, Garban F, Hulin C, Michallet M, Facon T, Garderet L, Marit G, Ketterer N, Lamy T, Voillat L, Guilhot F, Doyen C, Mathiot C, Moreau P. Achievement of at least very good partial response is a simple and robust prognostic factor in patients with multiple myeloma treated with high-dose therapy: long-term analysis of the IFM 99-02 and 99-04 Trials. J Clin Oncol 2009; 27:5720-6. [PMID: 19826130 DOI: 10.1200/jco.2008.21.1060] [Citation(s) in RCA: 125] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE The prognostic impact of complete response (CR) achievement in multiple myeloma (MM) has been shown mostly in the context of autologous stem-cell transplantation. Other levels of response have been defined because, even with high-dose therapy, CR is a relatively rare event. The purpose of this study was to analyze the prognostic impact of very good partial response (VGPR) in patients treated with high-dose therapy. PATIENTS AND METHODS All patients were included in the Intergroupe Francophone du Myelome 99-02 and 99-04 trials and treated with vincristine, doxorubicin, and dexamethasone (VAD) induction therapy followed by double autologous stem-cell transplantation (ASCT). Best post-ASCT response assessment was available for 802 patients. RESULTS With a median follow-up of 67 months, median event-free survival (EFS) and 5-year EFS were 42 months and 34%, respectively, for 405 patients who achieved at least VGPR after ASCT versus 32 months and 26% in 288 patients who achieved only partial remission (P = .005). Five-year overall survival (OS) was significantly superior in patients achieving at least VGPR (74% v 61% P = .0017). In multivariate analysis, achievement of less than VGPR was an independent factor predicting shorter EFS and OS. Response to VAD had no impact on EFS and OS. The impact of VGPR achievement on EFS and OS was significant in patients with International Staging System stages 2 to 3 and for patients with poor-risk cytogenetics t(4;14) or del(17p). CONCLUSION In the context of ASCT, achievement of at least VGPR is a simple prognostic factor that has importance in intermediate and high-risk MM and can be informative in more patients than CR.
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Abstract
AbstractIn multiple myeloma (MM), the impact of complete response (CR) could be shown only after introduction of high-dose therapy plus autologous stem cell transplantation (ASCT). In the context of ASCT, achieving CR (negative immunofixation and normal bone marrow) or at least very good partial response is associated with longer progression-free survival and in most studies longer survival. With novel agents, high CR rates are achieved and this prognostic impact of CR is being shown as well, both in relapsed and in newly diagnosed MM. However the benefit of CR achievement depends on the type of treatment and is not identical for all patients. In elderly patients, treatments inducing more CR may be more toxic. Although CR achievement is necessary in patients with poor-risk disease, it might not be as critical for long survival in more indolent MM. CR achievement is not the only objective of treatment because it is possible to further improve the depth of response and the outcome by continuing treatment after CR achievement. Finally, there are several levels of CR and in the future it will be necessary to confirm the prognostic impact of immunophenotypic or molecular CR or of CR defined by imaging procedures.
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Attal M, Harousseau JL. The role of high-dose therapy with autologous stem cell support in the era of novel agents. Semin Hematol 2009; 46:127-32. [PMID: 19389496 DOI: 10.1053/j.seminhematol.2009.02.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
This review discusses the initial studies concerning the role of high-dose therapy (HDT) in multiple myeloma (MM) and gives the major conclusions drawn from this "historical period." Later, current studies using new drugs for HDT (induction, conditioning regimen, consolidation, and maintenance) are described and the promising results of this strategy reported. Finally, the issue of HDT in the era of new drug regimens is discussed, as well as the necessity of designing future trials comparing HDT and new drug regimens.
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Ataergin SA, Kindwall-Keller T, Berger NA, Lazarus HM. New generation pharmacotherapy in elderly multiple myeloma patients. Expert Opin Pharmacother 2009; 10:81-98. [PMID: 19236183 DOI: 10.1517/14656560802611808] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Observational databases have demonstrated that the overall prognosis of multiple myeloma patients has markedly improved over the past decade, yet the greatest strides have been attained in younger rather than older patients. OBJECTIVE To review recent clinical trials that include new generation agents (thalidomide, lenalidomide and bortezomib) and autologous stem cell transplantation in older multiple myeloma patients. RESULTS Conventional regimens such as melphalan plus prednisone can be improved with the addition of thalidomide or bortezomib: more patients attain complete and near-complete remission, and progression-free survival rates are nearly doubled. In addition, autologous hematopoietic stem cell transplantation studies show that this treatment approach can be used successfully in selected older myeloma patients in whom the toxicity profile of autotransplant and resulting overall survival may be similar to that obtained in the younger patient group. CONCLUSIONS In the advanced-age population, implementation of new therapies results in significant benefits in older as well as younger patients.
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Affiliation(s)
- Selmin A Ataergin
- Gulhane (GATA) Faculty of Medicine Department of Medical Oncology and Bone Marrow Transplantation Unit, 06018, Etlik, Ankara, Turkey
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Siddiqui M, Gertz M. The role of high-dose chemotherapy followed by peripheral blood stem cell transplantation for the treatment of multiple myeloma. Leuk Lymphoma 2008; 49:1436-51. [PMID: 18608872 DOI: 10.1080/10428190802084972] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
The management of multiple myeloma has changed significantly over the past 10 years. The results obtained with conventional chemotherapy were disappointing; however the use of high dose therapy (HDT) and stem cell transplantation has significantly improved survival. Autologous, allogeneic and tandem transplantation, along with different conditioning regimens, have been studied in an attempt to optimise and further improve outcomes. This review summarises the role of stem cell transplantation in multiple myeloma. The advent of novel therapies such as thalidomide, lenalidomide and bortezomib have started to redefine the role of peripheral stem cell transplantation, however, further study is needed to better understand how to most effectively use these agents in multiple myeloma in conjunction with HDT.
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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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Kumar SK, Dingli D, Lacy MQ, Dispenzieri A, Hayman SR, Buadi FK, Rajkumar SV, Litzow MR, Gertz MA. Autologous stem cell transplantation in patients of 70 years and older with multiple myeloma: Results from a matched pair analysis. Am J Hematol 2008; 83:614-7. [PMID: 18429054 DOI: 10.1002/ajh.21191] [Citation(s) in RCA: 113] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
High-dose therapy and autologous stem cell transplant (HDT) have been shown to prolong survival in multiple myeloma (MM) in randomized trials, but only included patients of 65 years or younger. Given the median age at diagnosis of 66 years, it is important to have a better understanding of the outcome of transplantation in the older patients. We identified 33 patients with MM, who were > or =70 years at the time of their HDT. We matched them to a group of 60 patients, 65 years or younger, (two controls for each patient), based on time to transplant, disease status at transplant, Durie-Salmon stage, labeling index, presence of cytogenetic abnormalities, and presence of circulating plasma cells. The median age of the two groups were 55.6 (range, 37.3-64.9) and 71.7 (range 70-75.8) years at transplant. Although more of the older patients received dose reduced melphalan, the overall response rate was similar (97% vs. 98%) as was the median time to progression (28.5 months vs. 17.8 months, P = 0.7) for the elderly group compared to the younger patients. The median overall survival from transplant was not reached for the elderly patient group compared to 53.2 months for the younger patients, P = 0.7. HDT is feasible in selected patients with multiple myeloma over 70 years. The toxicity of transplant as well as the outcome appears comparable to younger patients. Patients with MM should not be excluded from HDT solely on the basis of their chronological age.
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Affiliation(s)
- Shaji K Kumar
- Department of Internal Medicine, Division of Hematology, Mayo Clinic, Rochester, Minnesota 55905, USA.
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37
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Görner M, Späth-Schwalbe E. Modern treatment options for elderly patients with multiple myeloma. ONKOLOGIE 2008; 31:335-42. [PMID: 18547977 DOI: 10.1159/000127403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Multiple myeloma, an incurable malignancy of plasma cells, is a disease of the elderly. In younger patients, significant therapeutic progress has been achieved, but survival outcomes remain unacceptably low in older adults with multiple myeloma. Diverse factors, including comorbidity, performance status, decreased physiologic reserve, and potential undertreatment, contribute to these poor outcomes. Unfortunately, many clinical trials are designed to exclude elderly patients with coexisting diseases, so only limited data are available and no guidelines exist on how to treat this challenging and growing myeloma population. A broader range of therapeutic options has become available within the last few years, including chemotherapy with either established or newly available drugs, immunomodulators, and high-dose treatment with stem cell support (autologous as well as allogeneic). In this review, we discuss the data available from clinical trials investigating antineoplastic treatment of elderly multiple myeloma patients.
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Affiliation(s)
- Martin Görner
- Klinik für Hamatologie und Onkologie, Städtische Kliniken Bielefeld gGmbH, Bielefeld,Germany.
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Abstract
Hematopoietic stem cell transplantation (SCT) was introduced in the treatment of multiple myeloma in the 1980s. In the autologous setting, the use of peripheral blood stem cells instead of bone marrow has markedly improved feasibility. In fit patients who have normal renal function and are younger than 65 years of age, randomized studies have shown the superiority of autologous stem cell transplantation (ASCT) compared with conventional chemotherapy. ASCT is now considered the standard of care in this population of patients. It is currently challenged, however, by the introduction of novel agents, such as thalidomide, bortezomib, and lenalidomide. The role of allogenic SCT remains controversial, even with reduced intensity conditionings. Prospective studies still are needed to evaluate the impact of both autologous and allogeneic SCT in this new era.
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Affiliation(s)
- Jean-Luc Harousseau
- Centre Hospitalier Universitaire Hôtel-Dieu, Place Alexis Ricordeau, 44093 Nantes Cedex 01, France.
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Attal M, Harousseau JL. Role of autologous stem-cell transplantation in multiple myeloma. Best Pract Res Clin Haematol 2007; 20:747-59. [DOI: 10.1016/j.beha.2007.09.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Facon T, Mary JY, Hulin C, Benboubker L, Attal M, Pegourie B, Renaud M, Harousseau JL, Guillerm G, Chaleteix C, Dib M, Voillat L, Maisonneuve H, Troncy J, Dorvaux V, Monconduit M, Martin C, Casassus P, Jaubert J, Jardel H, Doyen C, Kolb B, Anglaret B, Grosbois B, Yakoub-Agha I, Mathiot C, Avet-Loiseau H. Melphalan and prednisone plus thalidomide versus melphalan and prednisone alone or reduced-intensity autologous stem cell transplantation in elderly patients with multiple myeloma (IFM 99-06): a randomised trial. Lancet 2007; 370:1209-18. [PMID: 17920916 DOI: 10.1016/s0140-6736(07)61537-2] [Citation(s) in RCA: 634] [Impact Index Per Article: 37.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND In multiple myeloma, combination chemotherapy with melphalan plus prednisone is still regarded as the standard of care in elderly patients. We assessed whether the addition of thalidomide to this combination, or reduced-intensity stem cell transplantation, would improve survival. METHODS Between May 22, 2000, and Aug 8, 2005, 447 previously untreated patients with multiple myeloma, who were aged between 65 and 75 years, were randomly assigned to receive either melphalan and prednisone (MP; n=196), melphalan and prednisone plus thalidomide (MPT; n=125), or reduced-intensity stem cell transplantation using melphalan 100 mg/m2 (MEL100; n=126). The primary endpoint was overall survival. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00367185. FINDINGS After a median follow-up of 51.5 months (IQR 34.4-63.2), median overall survival times were 33.2 months (13.8-54.8) for MP, 51.6 months (26.6-not reached) for MPT, and 38.3 months (13.0-61.6) for MEL100. The MPT regimen was associated with a significantly better overall survival than was the MP regimen (hazard ratio 0.59, 95% CI 0.46-0.81, p=0.0006) or MEL100 regimen (0.69, 0.49-0.96, p=0.027). No difference was seen for MEL100 versus MP (0.86, 0.65-1.15, p=0.32). INTERPRETATION The results of our trial provide strong evidence to indicate that the use of thalidomide in combination with melphalan and prednisone should, at present, be the reference treatment for previously untreated elderly patients with multiple myeloma.
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Affiliation(s)
- Thierry Facon
- Service d'Hématologie, Centre Hospitalier Universitaire, Lille, France.
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Brenner H, Gondos A, Pulte D. Recent major improvement in long-term survival of younger patients with multiple myeloma. Blood 2007; 111:2521-6. [PMID: 17901246 DOI: 10.1182/blood-2007-08-104984] [Citation(s) in RCA: 417] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
In the past, most patients with multiple myeloma (MM) died within 5 to 10 years after diagnosis. Within the past decade, several new therapeutic interventions have been introduced, including autologous stem-cell transplantation, thalidomide, lenalidomide, and bortezomib. We estimated trends in age-specific 5- and 10-year relative survival of patients with MM in the United States from 1990-1992 to 2002-2004 from the 1973-2004 database of the Surveillance, Epidemiology, and End Results (SEER) Program. Techniques of period analysis were used to show most recent developments. Overall, 5-year relative survival increased from 28.8% to 34.7% (P < .001), and 10-year relative survival increased from 11.1% to 17.4% (P < .001) between 1990-1992 and 2002-2004. Much stronger increases were seen in the age group younger than 50 years, leading to 5- and 10-year relative survival of 56.7% and 41.3% in 2002-2004, and in the age group 50 to 59 years, leading to 5- and 10-year relative survival of 48.2% and 28.6% in 200-2004. By contrast, only moderate improvement was seen in the age group 60 to 69 years, and essentially no improvement was achieved among older patients. Our period analysis discloses a major increase in long-term survival of younger patients with MM in recent years, which most likely reflects the effect of recent advances in therapy and their dissemination in clinical practice.
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Affiliation(s)
- Hermann Brenner
- Division of Clinical Epidemiology and Aging Research, German Cancer Research Center, Bergheimer Strasse 20, Heidelberg, Germany.
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Musto P, D'Auria F. Melphalan: old and new uses of a still master drug for multiple myeloma. Expert Opin Investig Drugs 2007; 16:1467-87. [PMID: 17714032 DOI: 10.1517/13543784.16.9.1467] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The treatment of multiple myeloma has seen significant changes from the initial use of melphalan to the introduction of stem cell transplantation and, most recently, to the era of novel targeted agents. Melphalan still remains as a reference drug for combination regimens, including emerging newer therapeutic options, either used at a standard dose for initial or salvage treatments in patients who are not eligible for more intensive therapies, or in conjunction with new molecules within high-dose chemotherapy programs. In this review, the authors analyze old and novel regimens, including melphalan for the treatment of newly diagnosed or relapsed/resistant patients with multiple myeloma in the clinical settings of standard chemotherapy, as well as autologous or allogeneic stem cell transplantation.
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Affiliation(s)
- Pellegrino Musto
- Unit of Hematology and Stem Cell Transplantation, CROB, Centro di Riferimento Oncologico di Basilicata, Strada Provinciale, Rionero in Vulture (Pz), Italy.
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Przepiorka D, Buadi F, McClune B, Franz G, Walsh W, White F. Myelodysplastic syndrome after autologous peripheral blood stem cell transplantation for multiple myeloma. Bone Marrow Transplant 2007; 40:759-64. [PMID: 17680015 DOI: 10.1038/sj.bmt.1705814] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Long-term survivors after autologous peripheral blood stem cell transplantation (APBSCT) for lymphoma or Hodgkin's disease are known to have a high risk of developing myelodysplastic syndrome (MDS), but the risk of MDS is not clear for patients transplanted for myeloma. We reviewed the outcomes for 82 myeloma patients who underwent APBSCT at our center. The group included 47 men and 35 women of median age 56 years (range: 37-74 years). Median time from diagnosis to APBSCT was 8.2 months (range: 2.6-86.1 months). Before coming to transplantation, 28% had received oral melphalan (MEL), 98% received other chemotherapy and 34% received radiation. A single APBSCT was provided for 68, and 32% underwent APBSCT more than once. High-dose MEL alone was used as the preparative regimen for 83%, and the remainder received at least one APBSCT with a more intensive preparative regimen. Ten patients (12%) developed MDS. The 5-year cumulative incidence is 18% (95% confidence interval, 9-30%). There were no demographic factors associated with an increased risk of developing MDS. Median survival after the diagnosis of MDS was 18 months. There is a relatively high risk of MDS after APBSCT for myeloma, and optimal therapy has not been established for these patients.
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Affiliation(s)
- D Przepiorka
- University of Tennessee Blood and Marrow Transplant Center, Memphis, TN 38104, USA.
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Kumar SK, Hayman SR, Kyle RA. Autologous stem cell transplantation in the elderly including pre- and post-treatment options. Bone Marrow Transplant 2007; 40:1115-21. [PMID: 17680019 DOI: 10.1038/sj.bmt.1705800] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Multiple myeloma (MM) is a disease of the elderly with a median age at diagnosis of 67 years in a referral population. High-dose chemotherapy (HDT) and autologous stem cell transplantation has been shown to improve survival in patients with MM in randomized trials and remains the preferred option for eligible patients. However, the randomized clinical trials demonstrating an advantage for HDT included only patients younger than 65 years and evidence supporting its role for the elderly patients has been based on retrospective reviews. The introduction of thalidomide, lenalidomide and bortezomib has changed the paradigm for treatment of myeloma and improved the outcome for these patients. Several ongoing clinical trials are evaluating the role of these novel agents in this population, specifically comparing these to HDT-based approaches. Other trials are examining the role of maintenance therapy post-HDT with these novel drugs with or without steroids. The role of HDT will be further redefined in the coming years with improvements in other therapies.
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Affiliation(s)
- S K Kumar
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN 55905, USA
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45
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Cavallo F, Ambrosini MT, Rus C, Boccadoro M, Palumbo A. The treatment of the elderly multiple myeloma patients. Leuk Lymphoma 2007; 48:469-80. [PMID: 17454586 DOI: 10.1080/10428190601059852] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Multiple myeloma (MM) is an incurable malignancy of the plasma cells. Most patients are diagnosed when they are older than 65 years. Therapeutic options include chemotherapy, using either established (e.g. melphalan) or newly available (e.g. thalidomide) drugs and high-dose treatment with stem-cell support (autologous as well as allogeneic). Recent research has focused on defining the target population for the different therapeutic approaches, taking into account pre-treatment characteristics of patients, particularly age, and aims to balance treatment benefit with potential adverse events. In this review we present the data available on the most recent trials dealing with the treatment of elderly MM patients.
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Affiliation(s)
- Federica Cavallo
- Divisione di Ematologia dell'Universita' di Torino, Azienda Ospedaliera San Giovanni Battista, Torino, Italy
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46
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Koreth J, Cutler CS, Djulbegovic B, Behl R, Schlossman RL, Munshi NC, Richardson PG, Anderson KC, Soiffer RJ, Alyea EP. High-dose therapy with single autologous transplantation versus chemotherapy for newly diagnosed multiple myeloma: A systematic review and meta-analysis of randomized controlled trials. Biol Blood Marrow Transplant 2007; 13:183-96. [PMID: 17241924 DOI: 10.1016/j.bbmt.2006.09.010] [Citation(s) in RCA: 157] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2006] [Accepted: 09/20/2006] [Indexed: 01/28/2023]
Abstract
Myeloablative high-dose therapy and single autologous stem cell transplantation (HDT) is frequently performed early in the course of multiple myeloma, supported by some randomized controlled trials (RCTs) indicating overall survival (OS) and progression-free survival (PFS) benefit compared with nonmyeloablative standard-dose therapy (SDT). Other RCTs, however, suggest variable benefit. We therefore undertook a systematic review and meta-analysis of all RCTs evaluating upfront HDT versus SDT in myeloma. The primary objective was to quantify OS benefit with HDT, with PFS benefit a secondary objective. Anticipating heterogeneity, sensitivity and subgroup analyses were undertaken to assess robustness of results. Assessment of harms (treatment-related mortality) was also undertaken. We searched the PubMed, Embase, and Cochrane Collection of Controlled Trials databases using the terms myeloma combined with autologous or transplant or myeloablative or stem cell. In total, 3407 articles were accessed, and 10 RCTs prospectively comparing upfront HDT with SDT, with > or =2-year follow-up, and reporting OS benefit on an intent-to-treat basis were identified. Two reviewers independently extracted study characteristics, interventions, and outcomes. Hazard ratios (with 95% confidence interval) were determined. Nine studies comprising 2411 patients were fully analyzed. Significant heterogeneity was present. The combined hazard of death with HDT was 0.92 (95% confidence interval, 0.74-1.13). The combined hazard of progression with HDT was 0.75 (95% confidence interval, 0.59-0.96). The totality of the randomized data indicates PFS benefit but not OS benefit for HDT with single autologous transplantation performed early in multiple myeloma. Sensitivity and subgroup analyses supported the findings and indicated that, contrary to current reimbursement criteria, PFS benefit with upfront HDT is not restricted to chemoresponsive myeloma. However, the overall risk of developing treatment-related mortality with HDT was increased significantly (odds ratio, 3.01; 95% confidence interval, 1.64-5.50). Hence, evaluating alternative therapeutic options upfront may also be reasonable.
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Affiliation(s)
- John Koreth
- Division of Hematologic Malignancies, Dana Farber Cancer Institute, Boston, Massachusetts 02115, USA.
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Qazilbash MH, Saliba RM, Hosing C, Mendoza F, Qureshi SR, Weber DM, Wang M, Flosser T, Couriel DR, De Lima M, Kebriaei P, Popat U, Alousi AM, Champlin RE, Giralt SA. Autologous stem cell transplantation is safe and feasible in elderly patients with multiple myeloma. Bone Marrow Transplant 2007; 39:279-83. [PMID: 17262062 DOI: 10.1038/sj.bmt.1705580] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Several clinical trials have shown the superiority of autologous stem cell transplantation over conventional dose therapy for patients with multiple myeloma. This treatment, however, is limited to younger patients (<65 years) owing to concerns about toxicity and treatment-related mortality (TRM) in older patients. We treated 26 elderly myeloma patients (>70 years), who received a preparative regimen of melphalan 200 mg/m2 (19 patients), melphalan 180 mg/m2 (six patients) or melphalan 140 mg/m2 (one patient). Twenty-two of the 26 patients were alive after a median follow-up of 25 months (range=8-74). Responses (complete+partial response) were seen in 20 patients (77%), five (19%) of which were complete responses. Median PFS was 24 months, whereas median OS has not been reached. Cumulative incidence of 100-day TRM was 0%. Three-year PFS and OS were 39% (range=16-61) and 65% (range=35-83), respectively. A low serum albumin (<3.5 g/dl) was associated with a shorter PFS (P=0.02). Patients with relapsed disease at transplant, and an interval of >12 months between diagnosis and autotransplant, had a shorter OS (P=0.0004 and 0.04). HDT and autologous transplant is safe and feasible in elderly myeloma patients.
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Affiliation(s)
- M H Qazilbash
- Department of Blood and Marrow Transplantation, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA.
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Abstract
Multiple myeloma (MM), a plasma cell malignancy, is a disorder of the elderly with an increasing prevalence as the average life expectancy increases. Survival remains unacceptably low in elderly patients with MM, in whom the gold standard of treatment has been, until recently, oral melphalan and prednisolone, which induces a response rate of approximately 50% and overall survival of <3 years. In the last 15 years, traditional treatment paradigms for elderly patients with MM have been challenged not only as a result of the change in what we define as 'elderly' but also as a result of the reduced morbidity and treatment-related mortality associated with high-dose chemoradiotherapy (HDT) and autologous stem cell transplantation (ASCT), and the emergence of novel therapies including thalidomide, its immunomodulator drug derivative lenalidomide and the first-in-class proteasome inhibitor, bortezomib. In this review, we examine currently available data regarding the treatment of MM in the elderly population. Recent years have seen a paradigm shift in the standard of care of elderly patients with MM from oral melphalan and prednisolone to approaches including HDT with ASCT using intermediate-dose melphalan in selected elderly patients, and the evaluation of and incorporation of drugs such as thalidomide, bortezomib and lenalidomide. Importantly, we now have been able to change the traditional goal of palliation in the elderly group of patients to a more ambitious objective of achieving a complete response or a near complete response, in the hope that this will translate into improved progression-free survival, overall survival and quality of life.
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Affiliation(s)
- Hang Quach
- Peter MacCallum Cancer Centre and University of Melbourne, Melbourne, Victoria, Australia
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49
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Nozza A, Siracusano L, Armando S. Bortezomib-dexamethasone combination in a patient with refractory multiple myeloma and impaired renal function. Clin Ther 2006; 28:953-9. [PMID: 16860177 DOI: 10.1016/j.clinthera.2006.06.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2006] [Indexed: 11/23/2022]
Abstract
BACKGROUND Multiple myeloma (MM) is a hematologic neoplasia characterized by the monoclonal proliferation of bone marrow plasma cells. Renal failure occurs in 20% to 30% of MM patients at diagnosis and in >50% with an advanced form of the disease. For those with advanced MM, often a high-risk group of patients with poor prognosis, salvage treatment for renal failure needs to avoid nephrotoxic drugs. CASE SUMMARY We report a case of a 78-year-old white male (weight, 90 kg) presented to the Department of Medical Oncology and Hematology, Istituto Clinico Humanitas, Rozzano, Milan, Italy, with refractory MM immunoglobulin G kappa (IgGkappa), Durie-Salmon Stage IIA, with progressive renal failure after an oral melphalan, prednisone, and thalidomide regimen (4 mg/m2.d, 40 mg/m2.d for 7 days every 6 weeks, and 100 mg/d, respectively). The patient had documented increments of serum monoclonal component (M-protein), anemia, and renal failure with Bence Jones proteinuria (serum creatinine, 2.9 mg/dL; creatinine clearance, 30 mL/min; hemoglobin, 10.9 g/dL; serum IgGkappa M-protein, 3.9 g/dL; proteinuria 3.5 g/d;light-chain level in urine, 1.2 g/L). After 2 cycles with bortezomib at a reduced dose (1.0 mg/m2 twice weekly for 2 weeks followed by a 10-day rest period) to evaluate tolerability and renal toxicity, the patient completed another 3 cycles at the standard dose (1.3 mg/m2) in combination with dexamethasone (20 mg on the day of bortezomib administration and the day after). This led to an improvement of the renal function with a reduction of serum and urinary M-protein (serum creatinine 1.4 mg/dL; serum IgGkappa M-protein, 2.9 g/dL; proteinuria, 2 g/d; kappa light-chain level in urine, 0.7 g/L). The patient developed thrombocytopenia but did not suffer from some of the more severe adverse events associated with bortezomib, such as infection or peripheral neuropathy, even at full dose. CONCLUSION We report an elderly patient with refractory MM and progression with renal failure who responded to bortezomib treatment. Bortezomib was well tolerated in this patient.
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Affiliation(s)
- Andrea Nozza
- Department of Medical Oncology and Hematology, Istituto Clinico Humanitas, Milan, Italy
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Abstract
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.
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Affiliation(s)
- E Jantunen
- Department of Medicine, Kuopio University Hospital, Kuopio, Finland.
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