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Liberatore C, Fioritoni F, Di Ianni M. Allogeneic stem cell transplantation in multiple myeloma: is there still a place? Front Oncol 2024; 14:1402106. [PMID: 38894872 PMCID: PMC11183778 DOI: 10.3389/fonc.2024.1402106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Accepted: 05/14/2024] [Indexed: 06/21/2024] Open
Abstract
The introduction of novel agents dramatically improved response and outcomes of multiple myeloma (MM) and led to a sharp decline in the use of allogeneic hematopoietic stem-cell transplantation (allo-HSCT). Thus, recent guidelines do not recommend anymore allo-HSCT as consolidation in the first-line treatment of newly diagnosed MM, even in high-risk patients. In a relapsed/refractory setting, allo-HSCT is not routinely recommended but should only be performed within clinical trials in young and high-risk patients. Nonetheless, allo-HSCT still represents a potential curative approach that has been used for decades in the treatment of MM and plasma cell neoplasms with favorable results and may still represent a treatment option for carefully selected patients. Despite that promising results were obtained with CAR T-cell therapies and bispecific antibodies in triple- and penta-exposed/refractory MM, these patients will inevitably relapse. To date, less is known about outcomes of allo-HSCT in patients exposed to novel immunotherapeutic drugs. Therefore, allo-HSCT could represent a reasonable treatment choice for younger and high-risk patients who have relapsed after CAR T-cell therapies and bispecific antibodies as well as an alternative for patients not eligible to these treatments and in those countries where immunotherapies are not yet available. In the choice of conditioning, reduced intensity conditioning regimens are currently recommended for the lower toxicity and mortality. Moreover, the use of alternative donors, particularly haploidentical, has progressively increased in last years with results comparable to full matched donors. Finally, post-transplantation maintenance strategies are encouraged whenever feasible.
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Affiliation(s)
- Carmine Liberatore
- Hematology Unit, Department of Oncology and Hematology, Ospedale Santo Spirito, Pescara, Italy
| | - Francesca Fioritoni
- Hematology Unit, Department of Oncology and Hematology, Ospedale Santo Spirito, Pescara, Italy
| | - Mauro Di Ianni
- Hematology Unit, Department of Oncology and Hematology, Ospedale Santo Spirito, Pescara, Italy
- Department of Medicine and Sciences of Aging, University of Chieti-Pescara, Chieti, Italy
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Claveau JS, LeBlanc R, Ahmad I, Delisle JS, Cohen S, Kiss T, Bambace NM, Bernard L, Lachance S, Roy DC, Sauvageau G, Veilleux O, Roy J. Bortezomib Maintenance After Allogeneic Transplantation in Newly Diagnosed Myeloma Patients Results in Decreased Incidence and Severity of Chronic GVHD. Transplant Cell Ther 2023; 29:44.e1-44.e9. [PMID: 36334654 DOI: 10.1016/j.jtct.2022.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 10/11/2022] [Accepted: 10/26/2022] [Indexed: 11/05/2022]
Abstract
Allogeneic hematopoietic cell transplantation (HCT) has curative potential in myeloma but remains hampered by high rates of relapse and chronic graft-versus-host disease (GVHD). We hypothesized that bortezomib (BTZ) as maintenance therapy after allo HCT could not only decrease the incidence of relapse but also the incidence and severity of chronic GVHD. The primary endpoint of this study was to determine whether BTZ maintenance decreases the incidence and severity of chronic GVHD using National Institutes of Health (NIH) criteria. The secondary endpoints were to determine the immunosuppression burden, organ involvement and survival (overall survival, progression-free survival) in patients either receiving or not receiving BTZ. In this retrospective study, we compared the outcome of 46 myeloma patients who received BTZ after upfront tandem auto-allo HCT between 2008 and 2020 to 61 patients without maintenance. We explored the impact of BTZ maintenance on incidence and severity of chronic GVHD using the 2014 NIH criteria. At 2 years, incidences of overall (61.2% versus 83.6%; P = .001), and moderate/severe chronic GVHD (44.5% versus 77.0%; P = .001) were significantly lower in BTZ recipients who had less mouth (43% versus 67%; P = .018) and eyes (9% versus 41%; P = .001) involvement at initial diagnosis. We report a lower use of systemic steroids (45.1% versus 76.4%; P < .001), mycophenolate mofetil (15.5% versus 28.2%; P = .031) and tacrolimus (34.5% versus 70.6%; P < .001) in BTZ recipients. Probability of being alive and off systemic immunosuppressants at 3 years was 77% in BTZ recipients and 56% in controls (P = .046). To date, there is no difference in survival between both groups. In summary, BTZ maintenance improved incidence and severity of chronic GVHD and should be considered as a valid option in myeloma patients receiving upfront tandem auto-allo HCT.
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Affiliation(s)
- Jean-Sébastien Claveau
- Division of Hematology, Oncology and Transplantation, Institut Universitaire d'Hémato-Oncologie et de Thérapie Cellulaire, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, Québec, Canada.
| | - Richard LeBlanc
- Division of Hematology, Oncology and Transplantation, Institut Universitaire d'Hémato-Oncologie et de Thérapie Cellulaire, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, Québec, Canada
| | - Imran Ahmad
- Division of Hematology, Oncology and Transplantation, Institut Universitaire d'Hémato-Oncologie et de Thérapie Cellulaire, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, Québec, Canada
| | - Jean-Sébastien Delisle
- Division of Hematology, Oncology and Transplantation, Institut Universitaire d'Hémato-Oncologie et de Thérapie Cellulaire, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, Québec, Canada
| | - Sandra Cohen
- Division of Hematology, Oncology and Transplantation, Institut Universitaire d'Hémato-Oncologie et de Thérapie Cellulaire, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, Québec, Canada
| | - Thomas Kiss
- Division of Hematology, Oncology and Transplantation, Institut Universitaire d'Hémato-Oncologie et de Thérapie Cellulaire, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, Québec, Canada
| | - Nadia M Bambace
- Division of Hematology, Oncology and Transplantation, Institut Universitaire d'Hémato-Oncologie et de Thérapie Cellulaire, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, Québec, Canada
| | - Léa Bernard
- Division of Hematology, Oncology and Transplantation, Institut Universitaire d'Hémato-Oncologie et de Thérapie Cellulaire, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, Québec, Canada
| | - Silvy Lachance
- Division of Hematology, Oncology and Transplantation, Institut Universitaire d'Hémato-Oncologie et de Thérapie Cellulaire, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, Québec, Canada
| | - Denis Claude Roy
- Division of Hematology, Oncology and Transplantation, Institut Universitaire d'Hémato-Oncologie et de Thérapie Cellulaire, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, Québec, Canada
| | - Guy Sauvageau
- Division of Hematology, Oncology and Transplantation, Institut Universitaire d'Hémato-Oncologie et de Thérapie Cellulaire, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, Québec, Canada
| | - Olivier Veilleux
- Division of Hematology, Oncology and Transplantation, Institut Universitaire d'Hémato-Oncologie et de Thérapie Cellulaire, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, Québec, Canada
| | - Jean Roy
- Division of Hematology, Oncology and Transplantation, Institut Universitaire d'Hémato-Oncologie et de Thérapie Cellulaire, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, Québec, Canada
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3
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LeBlanc R, Ahmad I, Terra R, Boudreault JS, Ogez D, Lamore K, Delisle JS, Bambace N, Bernard L, Cohen S, Kiss T, Lachance S, Landais S, Lemieux-Blanchard É, Sauvageau G, Sebag M, Roy DC, Roy J. Outcomes in newly diagnosed young or high-risk myeloma patients receiving tandem autologous/allogeneic transplant followed by bortezomib maintenance: a phase II study. Bone Marrow Transplant 2021; 57:252-260. [PMID: 34845367 DOI: 10.1038/s41409-021-01532-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 10/29/2021] [Accepted: 11/15/2021] [Indexed: 01/14/2023]
Abstract
Despite novel drugs and autologous HCT, MM remains incurable, with short survival in patients with poor biological characteristics. Allo HCT may be curative in some patients but is hampered by high rates of toxicity and relapse. We hypothesized that bortezomib (BTZ), with its anti-myeloma and immunologic properties, could improve PFS and cGVHD after allo HCT in newly diagnosed MM patients. In this prospective phase II study, we included 39 young (≤50 years) and high-risk patients who received a tandem auto-allo HCT followed by BTZ. Patients had prospective minimal residual disease (MRD) evaluations using Next-Generation Flow cytometry prior to allo HCT, prior BTZ and every 3 months for 2 years. With a median follow-up of 48 months, we report PFS and OS at 5 years of 41% and 80%, with a non-relapse mortality of 12%. Incidences of grade II-IV aGVHD at 12 months and moderate/severe cGVHD at 2 years were 26% and 57%. In a multivariate analysis model including cytogenetics, ISS and MRD status, MRD positivity prior to allo HCT (HR 3.75, p = 0.037), prior BTZ (HR 11.3, p = 0.018) and 3 months post-BTZ initiation (HR 9.7, p = 0.001) was highly predictive of progression. Peritransplant MRD assessment thus strongly predicts disease progression.
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Affiliation(s)
- Richard LeBlanc
- Division of Hematology, Oncology and Transplantation, Hôpital Maisonneuve-Rosemont, Department of Medicine/Université de Montréal, Montreal, QC, Canada.
| | - Imran Ahmad
- Division of Hematology, Oncology and Transplantation, Hôpital Maisonneuve-Rosemont, Department of Medicine/Université de Montréal, Montreal, QC, Canada
| | - Rafik Terra
- Division of Hematology, Oncology and Transplantation, Hôpital Maisonneuve-Rosemont, Montreal, QC, Canada
| | - Jean-Samuel Boudreault
- Division of Hematology and Oncology, Hôpital du Sacré-Coeur, Department of Medicine/Université de Montréal, Montreal, QC, Canada
| | - David Ogez
- Chronic Pain Clinic, Hôpital Maisonneuve-Rosemont, Department of Anesthesiology and Pain Medicine/Université de Montréal, Montreal, QC, Canada
| | - Kristopher Lamore
- Laboratoire de psychopathologie et processus de santé, Université de Paris, Paris, Boulogne-Billancourt, France
| | - Jean-Sébastien Delisle
- Division of Hematology, Oncology and Transplantation, Hôpital Maisonneuve-Rosemont, Department of Medicine/Université de Montréal, Montreal, QC, Canada
| | - Nadia Bambace
- Division of Hematology, Oncology and Transplantation, Hôpital Maisonneuve-Rosemont, Department of Medicine/Université de Montréal, Montreal, QC, Canada
| | - Léa Bernard
- Division of Hematology, Oncology and Transplantation, Hôpital Maisonneuve-Rosemont, Department of Medicine/Université de Montréal, Montreal, QC, Canada
| | - Sandra Cohen
- Division of Hematology, Oncology and Transplantation, Hôpital Maisonneuve-Rosemont, Department of Medicine/Université de Montréal, Montreal, QC, Canada
| | - Thomas Kiss
- Division of Hematology, Oncology and Transplantation, Hôpital Maisonneuve-Rosemont, Department of Medicine/Université de Montréal, Montreal, QC, Canada
| | - Silvy Lachance
- Division of Hematology, Oncology and Transplantation, Hôpital Maisonneuve-Rosemont, Department of Medicine/Université de Montréal, Montreal, QC, Canada
| | - Séverine Landais
- Division of Hematology, Oncology and Transplantation, Hôpital Maisonneuve-Rosemont, Montreal, QC, Canada
| | - Émilie Lemieux-Blanchard
- Division of Hematology and Oncology, Centre Hospitalier de l'Université de Montréal, Department of Medicine/Université de Montréal, Montreal, QC, Canada
| | - Guy Sauvageau
- Division of Hematology, Oncology and Transplantation, Hôpital Maisonneuve-Rosemont, Department of Medicine/Université de Montréal, Montreal, QC, Canada
| | - Michael Sebag
- Division of Hematology, McGill University Health Center, Department of Medicine/McGill University, Montreal, QC, Canada
| | - Denis Claude Roy
- Division of Hematology, Oncology and Transplantation, Hôpital Maisonneuve-Rosemont, Department of Medicine/Université de Montréal, Montreal, QC, Canada
| | - Jean Roy
- Division of Hematology, Oncology and Transplantation, Hôpital Maisonneuve-Rosemont, Department of Medicine/Université de Montréal, Montreal, QC, Canada
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Goldman‐Mazur S, Kumar SK. Current approaches to management of high-risk multiple myeloma. Am J Hematol 2021; 96:854-871. [PMID: 33725367 DOI: 10.1002/ajh.26161] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 03/11/2021] [Accepted: 03/12/2021] [Indexed: 12/15/2022]
Abstract
The median overall survival in multiple myeloma is rapidly approaching 10 years; however, in nearly a fifth of patients the prognosis remains poor. Therefore, the modern-day management of myeloma patients should be individualized, with a more intense and continuous approach in these high-risk patients. This includes first-line treatment based on multi-drug combinations employing the most effective drug combinations, upfront autologous stem cell transplantation (in eligible patients with tandem transplantation being a consideration), and maintenance based on proteasome inhibitor-based combinations. This paper reviews the results of recent retrospective analyses and clinical trials, but also gives a glance into the future by presenting the ongoing trials.
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Affiliation(s)
| | - Shaji K. Kumar
- Division of Hematology Mayo Clinic Rochester Minnesota USA
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5
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Allogeneic Stem Cell Transplantation in Patients with High-Risk Multiple Myeloma: Utopia or Continuous Challenge in Aiming for Cure? Curr Treat Options Oncol 2021; 22:65. [PMID: 34110512 DOI: 10.1007/s11864-021-00864-x] [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] [Accepted: 04/30/2021] [Indexed: 10/21/2022]
Abstract
OPINION STATEMENT Nowadays, several novel agents have been introduced in the treatment of multiple myeloma, not only resulting in high response rates and prolonged survival but also offering good quality of life. However, the potential of cure, especially for patients with advanced or unfavorable disease features, remains elusive. Allogeneic hematopoietic stem cell transplantation, based mainly on the graft vs. myeloma effect, can offer prolonged disease control and probability of cure but unfortunately at the cost of considerable transplant-related toxicity rates. Therefore, the role of allogeneic hematopoietic stem cell transplantation in the treatment of multiple myeloma has been called into question. Recently, several studies, particularly those with long-term follow-up, demonstrated a trend of survival superiority for allografted patients with high-risk disease. These data fuel again the interest in allogeneic stem cell transplantation for selected patients with high-risk multiple myeloma, especially if the high remission rates which can be achieved with the currently used treatment protocols could be long-life sustained through the additional exploitation of the long-lasting anti-multiple myeloma effect, originating from the allograft.
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6
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Long-term outcome after allogeneic stem cell transplantation in multiple myeloma. Ann Hematol 2021; 100:1553-1567. [PMID: 33866396 PMCID: PMC8116307 DOI: 10.1007/s00277-021-04514-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 04/05/2021] [Indexed: 12/13/2022]
Abstract
The role of allogeneic hematopoietic stem cell transplantation (allo-SCT) in multiple myeloma is controversial. We analyzed the results of 205 patients transplanted in one center during 2000–2017. Transplantation was performed on 75 patients without a previous autologous SCT (upfront-allo), on 74 as tandem transplant (auto-allo), and on 56 patients after relapse. Median overall survival (OS) was 9.9 years for upfront-allo, 11.2 years for auto-allo, and 3.9 years for the relapse group (p = 0.015). Progression-free survival (PFS) was 2.4, 2.4, and 0.9 years, respectively (p < 0.001). Non-relapse mortality at 5 years was 8% overall, with no significant difference between the groups. Post-relapse survival was 4.1 years for upfront-allo and auto-allo, and 2.6 years for the relapse group (p = 0.066). Survival of high-risk patients was reduced. In multivariate analysis, the auto-allo group had improved OS and chronic graft-versus-host disease was advantageous in terms of PFS, OS, and relapse incidence. Late relapses occurred in all groups. Allo-SCT resulted in long-term survival in a small subgroup of patients. Our results indicate that auto-allo-SCT is feasible and could be considered for younger patients in the upfront setting.
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Devarakonda S, Efebera Y, Sharma N. Role of Stem Cell Transplantation in Multiple Myeloma. Cancers (Basel) 2021; 13:863. [PMID: 33670709 PMCID: PMC7922596 DOI: 10.3390/cancers13040863] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 02/09/2021] [Accepted: 02/12/2021] [Indexed: 12/11/2022] Open
Abstract
Autologous stem cell transplantation (auto-SCT) has been the standard of care in eligible newly diagnosed multiple myeloma (MM) patients. Outcomes of patients with MM have improved significantly due to the advent of several novel drugs. Upfront use of these drugs in induction therapy has significantly increased the rate and depth of responses that have translated into longer remission and survival. This has now raised a debate regarding the role and relevance of auto-SCT in the management of myeloma. However, clinical trials have confirmed the utility of auto-SCT even in the era of novel drugs. Tandem auto-SCT followed by maintenance has shown a progression-free survival (PFS) benefit in high-risk MM, and hence can be considered in young and fit patients with high-risk disease. Auto-SCT has the advantages of resetting the bone marrow microenvironment, short-lived toxicity compared to the long-term physical and financial toxicities of continued chemotherapy in the absence of SCT, very low transplant-related mortality (TRM) in high volume centers, and providing longer disease-free survival when followed by maintenance therapy. Allogeneic SCT is one potentially curative option for MM, albeit with an increased risk of death due to high TRM. Strategies to modulate the graft-versus-host disease (GVHD) while maintaining or improving the graft-versus-myeloma (GVM) effect could place allogeneic SCT back in the treatment armamentarium of MM.
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Affiliation(s)
| | - Yvonne Efebera
- Division of Hematology, Department of Internal Medicine, The Ohio State University Comprehensive Cancer Center Columbus, Columbus, OH 43210, USA; (S.D.); (N.S.)
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Martino M, Paviglianiti A, Gentile M, Martinelli G, Cerchione C. Allogenic stem cell transplantation in multiple myeloma: dead or alive and kicking? Panminerva Med 2020; 62:234-243. [PMID: 32955185 DOI: 10.23736/s0031-0808.20.04142-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Multiple myeloma (MM) accounts for about 1.8% of all cancers and slightly over 17% of hematologic malignancies. Despite improvements in outcomes in recent years, currently, there is still no cure for this disease. Although allogeneic stem cell transplantation (Allo-SCT) is a potentially curative treatment, given the armamentarium of highly effective therapeutic options and a pipeline of novel agents, many opinion leaders sustain that there is no longer a role for this approach. Of note, several studies that did not include novel agents reported long-term molecular remissions, and possibly a cure, in a subset of patients after reduced-intensity conditioning/nonmyeloablative (RIC/NM) Allo-SCT. However, there are no current data supporting upfront Allo-SCT. Prospective trials combining the so-called "graft-versus-myeloma" effect and new drugs are an unmet medical need in high-risk patients. Early relapse after first-line treatment, which identifies patients with poor prognosis independently of other prognostic factors, could become a clinical indication.
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Affiliation(s)
- Massimo Martino
- Unit of Stem Cell Transplantation and Cellular Therapies, Bianchi-Melacrino-Morelli Hospital, Reggio Calabria, Italy
| | - Annalisa Paviglianiti
- Unit of Stem Cell Transplantation and Cellular Therapies, Bianchi-Melacrino-Morelli Hospital, Reggio Calabria, Italy
| | | | - Giovanni Martinelli
- IRCCS Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST), Meldola, Forlì-Cesena, Italy
| | - Claudio Cerchione
- Unit of Hematology, IRCCS Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST), Meldola, Forlì-Cesena, Italy -
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9
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90Y-labeled anti-CD45 antibody allogeneic hematopoietic cell transplantation for high-risk multiple myeloma. Bone Marrow Transplant 2020; 56:202-209. [PMID: 32710011 DOI: 10.1038/s41409-020-01000-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 06/12/2020] [Accepted: 07/14/2020] [Indexed: 01/11/2023]
Abstract
To improve disease control without increasing the toxicity of a reduced-intensity allogeneic hematopoietic cell transplantation (HCT) in multiple myeloma (MM), a phase I trial was performed using an antibody-radionuclide conjugate targeting CD45 (90Y-DOTA-BC8) as conditioning. 90Y-DOTA-BC8 was combined with fludarabine and low-dose TBI followed by allogeneic HCT in patients with MM and ≥1 adverse risk characteristic at diagnosis, relapse after autologous transplant, or plasma cell leukemia (PCL). The primary objective was to estimate the maximum tolerated radiation absorbed dose. Fourteen patients were treated (one with PCL, nine failed prior autologous HCT, and nine with ≥1 adverse cytogenetics). Absorbed doses up to 32 Gy to liver were delivered. No dose-limiting toxicities occurred. Non-hematologic toxicities were manageable and included primarily gastrointestinal (43%) and metabolic/electrolyte disturbances (36%). Treatment-related mortality at 100 days was 0%. At a median follow-up of 5 years, the overall survival was 71% (median not reached) and the progression-free survival was 41% (median 40.9 months). The incorporation of CD45-targeted radioimmunotherapy (RIT) into a reduced-intensity allogeneic HCT is well-tolerated and may induce long-term remissions among patients with poor-risk MM, supporting further development of RIT-augmented conditioning regimens for HCT.
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Holstein SA, Suman VJ, Owzar K, Santo K, Benson DM, Shea TC, Martin T, Silverman M, Isola L, Vij R, Cheson BD, Linker C, Anderson KC, Richardson PG, McCarthy PL. Long-Term Follow-up of CALGB (Alliance) 100001: Autologous Followed by Nonmyeloablative Allogeneic Transplant for Multiple Myeloma. Biol Blood Marrow Transplant 2020; 26:1414-1424. [PMID: 32325171 DOI: 10.1016/j.bbmt.2020.03.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Revised: 03/25/2020] [Accepted: 03/31/2020] [Indexed: 11/18/2022]
Abstract
CALGB (Alliance) 100001 was a phase II study evaluating autologous stem cell transplant (ASCT) followed by nonmyeloablative allogeneic stem cell transplant (alloSCT) in patients with multiple myeloma who had received no more than 18 months of prior therapy and had experienced no more than 1 prior progression event. Conditioning for ASCT was with high-dose melphalan (200 mg/m2). The alloSCT reduced-intensity conditioning (RIC) regimen consisted of fludarabine (30 mg/m2/d i.v. on days -7 through -3) and cyclophosphamide (1 g/m2/d i.v. on days -4 through -3). The primary objective was to determine the 6-month post-alloSCT treatment-related mortality (TRM) rate. Additional objectives included determining the proportion of patients who could complete this tandem ASCT-alloSCT approach in a cooperative group setting, overall response rates, rates of donor chimerism, rates of graft-versus-host disease (GVHD), disease-free survival, and overall survival (OS). Sixty patients were enrolled, of whom 57 (95%) completed ASCT and 49 (82%) completed tandem ASCT-alloSCT. The TRM rate was 2% (1/49; 90% confidence interval, 0.10% to 9.3%). Moderate to severe (grades 2 to 3) acute GVHD was observed in 13 of 49 alloSCT patients (27%). One patient died due to GVHD within 9 months of alloSCT. Twenty-seven of the 49 patients (55%) who underwent alloSCT reported chronic GVHD as either limited (15/49; 31%) or extensive (12/49; 24%) in the first year post-alloSCT and prior to the start of nonprotocol therapy for progressive disease. With a median follow-up for survival of 11 years, the median OS time is 6.6 years and the median time to disease progression is 3.6 years. Similar to other studies, this study confirmed that tandem ASCT/alloSCT is associated with durable disease control in a subset of patients. This study demonstrated the feasibility of performing tandem ASCT/alloSCT in a cooperative group setting and determined that a fludarabine/cyclophosphamide RIC regimen is associated with a very low TRM rate.
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Affiliation(s)
| | - Vera J Suman
- Alliance Statistics and Data Center, Mayo Clinic, Rochester, Minnesota
| | - Kouros Owzar
- Biostatistics and Bioinformatics, Duke Cancer Institute, Duke University, Durham, North Carolina
| | - Katelyn Santo
- Alliance Statistics and Data Center, Mayo Clinic, Rochester, Minnesota
| | - Don M Benson
- The Ohio State University Comprehensive Cancer Center, Columbus, Ohio
| | - Thomas C Shea
- UNC Lineberger Cancer Center, University of North Carolina, Chapel Hill, North Carolina
| | - Thomas Martin
- University of California at San Francisco, San Francisco, California
| | | | - Luis Isola
- Mount Sinai School of Medicine, New York, New York
| | - Ravi Vij
- Washington University School of Medicine, St. Louis, Missouri
| | | | - Charles Linker
- University of California at San Francisco, San Francisco, California
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11
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Comparison of outcomes after human leukocyte antigen-matched and haploidentical hematopoietic stem-cell transplantation for multiple myeloma. Chin Med J (Engl) 2020; 132:1765-1772. [PMID: 31306219 PMCID: PMC6759131 DOI: 10.1097/cm9.0000000000000341] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Background: Allogeneic stem-cell transplantation (SCT) is a well-established immunotherapeutic strategy for multiple myeloma (MM) with a potent and often sustained graft-vs.-myeloma effect. This multicenter investigation aimed to analyze the complications and survival of haploidentical SCT in patients with MM, and compare the main outcomes with matched-related donors (MRDs). Methods: Haploidentical and MRD SCT was identified from a cohort of 97 patients with MM who received a myeloablative transplantation in 13 hospitals from May 2001 to December 2017. A matched-pair analysis was designed. For each haplo recipient, the recipients were randomly selected from the MRD group and were matched according to the following criteria: year of the hematopoietic SCT (±2 years), disease status at transplantation, and the length of follow-up. Results: Seventy cases received MRD and 27 received haploidentical transplantation. The two groups showed no significant differences regarding age, gender, cytogenetic risk, and diagnostic stage. The cumulative incidences of non-relapse mortality (NRM) at 1 and 3 years based on donor type were 20.5% (95% confidence interval [CI], 10.90–30.10%) and 24.2% (95% CI, 13.81–34.59%) for the MRD group and 16.80% (95% CI, 1.71–31.89%) and 28.70% (95% CI, 8.71–48.69%) for the haplo group, respectively. Cumulative incidence of NRM did not differ significantly between the two groups (χ2 = 0.031, P = 0.861). The cumulative incidences of progression-free survival (PFS) and 1 year and 3 years by type of donors were 59.8% (95% CI, 48.24–71.36%) and 45.4% (95% CI, 33.44–57.36%), and 65.6% (95% CI, 47.18–84.02%) and 26.8% (95% CI, 7.59–46. 01%) for MRD and haploidentical donor, respectively. Cumulative incidence of PFS did not differ significantly between the two groups (χ2 = 0.182, P = 0.670). In multivariate analyses, no statistically significant differences were observed between haploidentical and MRD for relapse, NRM, PFS, and overall survival. There were no statistically differences on main outcomes after haploidentical and MRD. Conclusion: Haploidentical SCT could be performed safely and feasibly for patients with MM in need.
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Paul S, Tsai HL, Lowery P, Fuchs EJ, Luznik L, Bolaños-Meade J, Swinnen LJ, Shanbhag S, Wagner-Johnston N, Varadhan R, Ambinder RF, Jones RJ, Gladstone DE. Allogeneic Haploidentical Blood or Marrow Transplantation with Post-Transplantation Cyclophosphamide in Chronic Lymphocytic Leukemia. Biol Blood Marrow Transplant 2019; 26:502-508. [PMID: 31730920 DOI: 10.1016/j.bbmt.2019.11.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 10/28/2019] [Accepted: 11/06/2019] [Indexed: 11/28/2022]
Abstract
Allogeneic blood or marrow transplantation (allo-BMT) remains the only treatment for chronic lymphocytic leukemia (CLL) with curative potential. Although post-transplantation cyclophosphamide (PTCy) reduces allo-BMT toxicity by decreasing the risk of graft-versus-host disease (GVHD), its effect on CLL allo-BMT outcomes is unknown. We studied 64 consecutive patients with CLL who underwent nonmyeloablative (NMA) haploidentical allo-BMT at Johns Hopkins Sidney Kimmel Comprehensive Cancer Center. In this cohort, the 4-year overall survival was 52% (95% confidence interval [CI], 40% to 68%), and progression-free survival was 37% (95% CI, 26% to 54%). Six patients experienced engraftment failure. PTCy prophylaxis was associated with a modest cumulative incidence of 1-year grade II-IV acute GVHD (27%; %95% CI, 15% to 38%) and %%%2-year chronic GVHD (17%; 95% CI, 7% to 26%). We demonstrate that NMA haploidentical allo-BMT with PTCy is a safe and effective treatment option.
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Affiliation(s)
- Suman Paul
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Hua-Ling Tsai
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Patrick Lowery
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ephraim J Fuchs
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Leo Luznik
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Javier Bolaños-Meade
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Lode J Swinnen
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Satish Shanbhag
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Nina Wagner-Johnston
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ravi Varadhan
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Richard F Ambinder
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Richard J Jones
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Douglas E Gladstone
- Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins University School of Medicine, Baltimore, Maryland.
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13
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Gagelmann N, Eikema DJ, Koster L, Caillot D, Pioltelli P, Lleonart JB, Reményi P, Blaise D, Schaap N, Trneny M, Passweg J, Porras RP, Cahn JY, Musso M, Poiré X, Fenk R, Itälä-Remes M, Pavone V, Fouillard L, Maertens J, Bron D, Pouli A, Schroyens W, Schönland S, Garderet L, Yakoub-Agha I, Kröger N. Tandem Autologous Stem Cell Transplantation Improves Outcomes in Newly Diagnosed Multiple Myeloma with Extramedullary Disease and High-Risk Cytogenetics: A Study from the Chronic Malignancies Working Party of the European Society for Blood and Marrow Transplantation. Biol Blood Marrow Transplant 2019; 25:2134-2142. [PMID: 31288095 DOI: 10.1016/j.bbmt.2019.07.004] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 07/02/2019] [Accepted: 07/03/2019] [Indexed: 01/01/2023]
Abstract
Although high-dose therapy and autologous stem cell transplant combined with novel agents continues to be the hallmark of first-line treatment in newly diagnosed transplant-eligible multiple myeloma patients, the impact of tandem autologous or autologous/reduced-intensity allogeneic transplant for patients with extramedullary disease (EMD) and high-risk cytogenetics is not yet defined. Here, we analyzed clinical and cytogenetic data from 488 adult myeloma patients with EMD undergoing single autologous (n = 373), tandem autologous (n = 84), or autologous-allogeneic transplant (n = 31) between 2003 and 2015. At least 1 high-risk abnormality was present in 41% (n = 202), with del(17p) (40%) and t(4;14) (45%) the most frequent. More than 1 high-risk abnormality was found in 54%. High-risk cytogenetics showed worse 4-year overall survival (OS) and progression-free survival (PFS) of 54% and 29%, respectively, versus 78% and 49% for standard-risk cytogenetics (P < .001). Co-segregation of high-risk abnormalities did not seem to affect outcome. Regarding transplant regimen, OS and PFS were 70% and 43% for single autologous versus 83% and 52% for tandem autologous and 88% and 58% for autologous-allogeneic (P = .06 and P = .30). In multivariate analysis high-risk cytogenetics were associated with worse survival (hazard ratio [HR], 2.00; P = .003), whereas tandem autologous significantly improved outcome versus single autologous transplant (HRs, .46 and .64; P = .02 and P = .03). Autologous-allogeneic transplant did not significantly differ in outcome but appeared to improve survival, but results were limited because of small population (HR, .31). In conclusion, high-risk cytogenetics is frequently observed in newly diagnosed myeloma with EMD and significantly worsens outcome after single autologous, whereas a tandem autologous transplant strategy may overcome onset poor prognosis.
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Affiliation(s)
- Nico Gagelmann
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | | | | | | | | | - Péter Reményi
- St. István and St. Laszlo Hospital, Budapest, Hungary
| | | | - Nicolaas Schaap
- Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Marek Trneny
- Charles University Hospital, Prague, Czech Republic
| | | | | | | | | | - Xavier Poiré
- Cliniques Universitaires St. Luc, Brussels, Belgium
| | - Roland Fenk
- Heinrich Heine University, Düsseldorf, Germany
| | | | | | | | | | | | | | | | - Stefan Schönland
- Medizinische Klinik V, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | | | | | - Nicolaus Kröger
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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Paul B, Lipe B, Ocio EM, Usmani SZ. Induction Therapy for Newly Diagnosed Multiple Myeloma. Am Soc Clin Oncol Educ Book 2019; 39:e176-e186. [PMID: 31099624 DOI: 10.1200/edbk_238527] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The frontline therapy for newly diagnosed multiple myeloma (MM) has continued to evolve over the last 10 years. There has been a growing emphasis on achieving the best depth of response in the context of minimal residual disease negativity, given its prognostic correlation with superior overall survival. Another important area of emphasis has been to improve prognostication and staging by including information on disease biology. There also a growing appreciation of global differences in drug access and patterns of care. The current review explores each of these areas and how best to incorporate the emerging induction regimens in to schema of MM therapy.
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Affiliation(s)
| | - Brea Lipe
- 2 Wilmont Cancer Institute, University of Rochester Medical Center, Rochester, NY
| | - Enrique M Ocio
- 3 University Hospital Marqués de Valdecilla (IDIVAL), University of Cantabria, Santander, Spain
| | - Saad Z Usmani
- 4 Plasma Cell Disorders Division, Department of Hematologic Oncology & Blood Disorders, Levine Cancer Institute/Atrium Health, Charlotte, NC
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15
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Mina R, Lonial S. Is there still a role for stem cell transplantation in multiple myeloma? Cancer 2019; 125:2534-2543. [PMID: 30985927 DOI: 10.1002/cncr.32060] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 07/16/2018] [Accepted: 07/23/2018] [Indexed: 12/16/2022]
Abstract
High-dose chemotherapy and autologous stem cell transplantation (ASCT) are a standard of care for transplant-eligible patients with newly diagnosed multiple myeloma (MM). The introduction of novel agents, which range from immunomodulatory drugs and proteasome inhibitors to monoclonal antibodies and have now been integrated into both induction and salvage regimens, has dramatically revolutionized the treatment landscape of MM and challenged the role of high-dose chemotherapy and ASCT in treating MM. These advances have led to a number of provocative questions. First, what is the current role of stem cell transplantation (SCT) in comparison with standard-dose therapy incorporating novel agents? Second, should ASCT be performed upfront ("early") or later ("delayed") in the course of the disease? Third, should single or double ASCT be performed? Fourth, is allogeneic SCT still an option for patients with MM? This article provides an overview of available data and evidence-based responses regarding the role of SCT in MM.
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Affiliation(s)
- Roberto Mina
- Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
| | - Sagar Lonial
- Hematology and Medical Oncology, Winship Cancer Institute, Emory University, Atlanta, Georgia
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16
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Maymani H, Lin P, Saliba RM, Popat U, Bashir Q, Shah N, Patel K, Parmar S, Kebriaei P, Hosing C, Ciurea S, Andersson B, Shpall E, Champlin R, Srour SA, Qazilbash MH. Comparison of Outcomes of Allogeneic Hematopoietic Cell Transplantation for Multiple Myeloma Using Three Different Conditioning Regimens. Biol Blood Marrow Transplant 2019; 25:1039-1044. [PMID: 30639822 DOI: 10.1016/j.bbmt.2019.01.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 01/07/2019] [Indexed: 11/27/2022]
Abstract
Allogeneic hematopoietic cell transplantation (allo-HCT) is a potentially curative therapy for patients with multiple myeloma, as it provides a graft-versus-myeloma effect alongside a myeloma-free graft. Although reduced-intensity conditioning regimens decrease nonrelapse mortality (NRM), there is a paucity of data with regard to the ideal conditioning regimen in myeloma. We conducted a retrospective comparison of 3 different preparative regimens used for allo-HCT for multiple myeloma at our institution in recent clinical trials: busulfan/fludarabine (BuFlu), fludarabine/melphalan 100 mg/m2 (FM100), and fludarabine/melphalan 140 mg/m2 (FM140). NRM, progression-free survival (PFS) at 3 years, and overall survival (OS) at 3 years were the primary endpoints. Secondary endpoints included time to engraftment, and the incidence of grades II through IV acute graft-versus-host disease and chronic graft-versus-host disease. A total of 73 patients received allo-HCT with these regimens. NRM at 3 years was seen in 3 (21%), 5 (28%), and 6 (24%) patients in the BuFlu, FM100, and FM140 groups, respectively. Three-year PFS in the BuFlu, FM100, and FM140 groups was 16% (hazard ratio [HR], 1.2; 95% confidence interval [CI], 0.6 to 2.1), 26% (HR, 0.6; 95% CI, 0.3 to 1.2), and 11% (reference), respectively. Three-year OS in the BuFlu, FM100, and FM140 groups was 39% (HR, 1.1; 95% CI, 0.5 to 2.2), 43% (HR, 0.7; 95% CI, 0.3 to 1.4), and 32% (reference), respectively. High-risk cytogenetics and relapsed disease prior to allo-HCT were found to be independent predictors of inferior OS on multivariate analysis, with a HR of 2.1 (P = .02) and 2.6 (P = .004), respectively. In contrast, the preparative regimen did not emerge as a predictor of PFS or OS. Durable clinical remission can be achieved in 11% to 25% of patients with multiple myeloma with the use of allo-HCT without any significant difference in the safety or efficacy of the conditioning regimen. High-risk cytogenetics and relapsed disease prior to transplant were associated with inferior PFS and OS.
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Affiliation(s)
- Hossein Maymani
- Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Paul Lin
- Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Rima M Saliba
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Uday Popat
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Qaiser Bashir
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Nina Shah
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Krina Patel
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Simrit Parmar
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Partow Kebriaei
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Chitra Hosing
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Stefan Ciurea
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Borje Andersson
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Elizabeth Shpall
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Richard Champlin
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Samer A Srour
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas
| | - Muzaffar H Qazilbash
- Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas MD Anderson Cancer Center, Houston, Texas.
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17
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Maffini E, Storer BE, Sandmaier BM, Bruno B, Sahebi F, Shizuru JA, Chauncey TR, Hari P, Lange T, Pulsipher MA, McSweeney PA, Holmberg L, Becker PS, Green DJ, Mielcarek M, Maloney DG, Storb R. Long-term follow up of tandem autologous-allogeneic hematopoietic cell transplantation for multiple myeloma. Haematologica 2018; 104:380-391. [PMID: 30262560 PMCID: PMC6355483 DOI: 10.3324/haematol.2018.200253] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Accepted: 09/24/2018] [Indexed: 12/22/2022] Open
Abstract
We previously reported initial results in 102 multiple myeloma (MM) patients treated with sequential high-dose melphalan and autologous hematopoietic cell transplantation followed by 200 cGy total body irradiation with or without fludarabine 90 mg/m2 and allogeneic hematopoietic cell transplantation. Here we present long-term clinical outcomes among the 102 initial patients and among 142 additional patients, with a median follow up of 8.3 (range 1.0-18.1) years. Donors included human leukocyte antigen identical siblings (n=179) and HLA-matched unrelated donors (n=65). A total of 209 patients (86%) received tandem autologous-allogeneic upfront, while thirty-five patients (14%) had failed a previous autologous hematopoietic cell transplantation before the planned autologous-allogeneic transplantation. Thirty-one patients received maintenance treatment at a median of 86 days (range, 61-150) after allogeneic transplantation. Five-year rates of overall survival (OS) and progression-free survival (PFS) were 54% and 31%, respectively. Ten-year OS and PFS were 41% and 19%, respectively. Overall non-relapse mortality was 2% at 100 days and 14% at five years. Patients with induction-refractory disease and those with high-risk biological features experienced shorter OS and PFS. A total of 152 patients experienced disease relapse and 117 of those received salvage treatment. Eighty-three of the 117 patients achieved a clinical response, and for those, the median duration of survival after relapse was 7.8 years. Moreover, a subset of patients who became negative for minimal residual disease (MRD) by flow cytometry experienced a significantly lower relapse rate as compared with MRD-positive patients (P=0.03). Our study showed that the graft-versus-myeloma effect after non-myeloablative allografting allowed long-term disease control in standard and high-risk patient subsets. Ultra-high-risk patients did not appear to benefit from tandem autologous/allogeneic hematopoietic cell transplantation because of early disease relapse. Incorporation of newer anti-MM agents into the initial induction treatments before tandem hematopoietic cell transplantation and during maintenance might improve outcomes of ultra-high-risk patients. Clinical trials included in this study are registered at: clinicaltrials.gov identifiers: 00075478, 00005799, 01251575, 00078858, 00105001, 00027820, 00089011, 00003196, 00006251, 00793572, 00054353, 00014235, 00003954.
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Affiliation(s)
- Enrico Maffini
- Fred Hutchinson Cancer Research Center, Clinical Research Division, Seattle, WA, USA
| | - Barry E Storer
- Fred Hutchinson Cancer Research Center, Clinical Research Division, Seattle, WA, USA.,University of Washington School of Public Health, Seattle, WA, USA
| | - Brenda M Sandmaier
- Fred Hutchinson Cancer Research Center, Clinical Research Division, Seattle, WA, USA.,Department of Medicine, Seattle, WA, USA
| | - Benedetto Bruno
- University of Turin, Department of Molecular Biotechnology and Health Sciences, Turin, Italy
| | - Firoozeh Sahebi
- City of Hope National Medical Center/Southern California Kaiser Permanente Medical Group, Duarte, CA, USA
| | | | - Thomas R Chauncey
- Fred Hutchinson Cancer Research Center, Clinical Research Division, Seattle, WA, USA.,Department of Medicine, Seattle, WA, USA.,VA Puget Sound Medical Health Care System, Seattle, WA, USA
| | | | | | | | | | - Leona Holmberg
- Fred Hutchinson Cancer Research Center, Clinical Research Division, Seattle, WA, USA.,University of Washington School of Public Health, Seattle, WA, USA
| | - Pamela S Becker
- Fred Hutchinson Cancer Research Center, Clinical Research Division, Seattle, WA, USA.,Department of Medicine, Seattle, WA, USA
| | - Damian J Green
- Fred Hutchinson Cancer Research Center, Clinical Research Division, Seattle, WA, USA.,Department of Medicine, Seattle, WA, USA
| | - Marco Mielcarek
- Fred Hutchinson Cancer Research Center, Clinical Research Division, Seattle, WA, USA.,Department of Medicine, Seattle, WA, USA
| | - David G Maloney
- Fred Hutchinson Cancer Research Center, Clinical Research Division, Seattle, WA, USA.,Department of Medicine, Seattle, WA, USA
| | - Rainer Storb
- Fred Hutchinson Cancer Research Center, Clinical Research Division, Seattle, WA, USA .,Department of Medicine, Seattle, WA, USA
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18
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Yin X, Tang L, Fan F, Jiang Q, Sun C, Hu Y. Allogeneic stem-cell transplantation for multiple myeloma: a systematic review and meta-analysis from 2007 to 2017. Cancer Cell Int 2018; 18:62. [PMID: 29713245 PMCID: PMC5913895 DOI: 10.1186/s12935-018-0553-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 04/03/2018] [Indexed: 11/10/2022] Open
Abstract
Background Despite recent advances, multiple myeloma (MM) remains incurable. However, the appearance of allogeneic stem cell transplantation (allo-SCT) through graft-versus-myeloma effect provides a potential way to cure MM to some degree. This systematic review aimed to evaluate the outcome of patients receiving allo-SCT and identified a series of prognostic factors that may affect the outcome of allo-SCT. Patients/methods We systematically searched PubMed, Embase, and the Cochrane Library from 2007.01.01 to 2017.05.03 using the keywords ‘allogeneic’ and ‘myeloma’. Results A total of 61 clinical trials involving 8698 adult patients were included. The pooled estimates (95% CI) for overall survival (OS) at 1, 2, 3 and 5 years were 70 (95% CI 56–84%), 62 (95% CI 53–71%), 52 (95% CI 44–61%), and 46 (95% CI 40–52%), respectively; for progression-free survival were 51 (95% CI 38–64%), 40 (95% CI 32–48%), 34 (95% CI 27–41%), and 27 (95% CI 23–31%), respectively; and for treatment-related mortality (TRM) were 18 (95% CI 14–21%), 21 (95% CI 17–25%), 20 (95% CI 13–26%), and 27 (95% CI 21–33%), respectively. Additionally, the pooled 100-day TRM was 12 (95% CI 5–18%). The incidences of grades II–IV acute graft-versus-host disease (GVHD) and chronic GVHD were 34 (95% CI 30–37%) and 51 (95% CI 46–56%), respectively. The incidences of relapse rate (RR) and death rate were 50 (95% CI 45–55%) and 51 (95% CI 45–57%), respectively. Importantly, disease progression was the most major cause of death (48%), followed by TRM (44%). The results failed to show an apparent benefit of allo-SCT for standard risk patients, compared with tandem auto-SCT. In contrast, all 14 trials in our study showed that patients with high cytogenetic risk after allo-SCT had similar OS and PFS compared to those with standard risk, suggesting that allo-SCT may overcome the adverse prognosis of high cytogenetic risk. Conclusion Due to the lack of consistent survival benefit, allo-SCT should not be considered as a standard of care for newly diagnosed and relapsed standard-risk MM patients. However, for patients with high-risk MM who have a poor long-term prognosis, allo-SCT may be a strong consideration in their initial course of therapy or in first relapse after chemotherapy, when the risk of disease progression may outweigh the transplant-related risks. A large number of prospective randomized controlled trials were needed to prove the benefits of these therapeutic options. Electronic supplementary material The online version of this article (10.1186/s12935-018-0553-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Xuejiao Yin
- 1Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Dadao, Wuhan, 430022 China
| | - Liang Tang
- 1Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Dadao, Wuhan, 430022 China
| | - Fengjuan Fan
- 1Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Dadao, Wuhan, 430022 China
| | - Qinyue Jiang
- 2Collaborative Innovation Center of Hematology, Huazhong University of Science and Technology, Jiefang Dadao, Wuhan, 430022 China
| | - Chunyan Sun
- 1Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Dadao, Wuhan, 430022 China.,2Collaborative Innovation Center of Hematology, Huazhong University of Science and Technology, Jiefang Dadao, Wuhan, 430022 China
| | - Yu Hu
- 1Institute of Hematology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Jiefang Dadao, Wuhan, 430022 China.,2Collaborative Innovation Center of Hematology, Huazhong University of Science and Technology, Jiefang Dadao, Wuhan, 430022 China
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19
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Gay F, Engelhardt M, Terpos E, Wäsch R, Giaccone L, Auner HW, Caers J, Gramatzki M, van de Donk N, Oliva S, Zamagni E, Garderet L, Straka C, Hajek R, Ludwig H, Einsele H, Dimopoulos M, Boccadoro M, Kröger N, Cavo M, Goldschmidt H, Bruno B, Sonneveld P. From transplant to novel cellular therapies in multiple myeloma: European Myeloma Network guidelines and future perspectives. Haematologica 2018; 103:197-211. [PMID: 29217780 PMCID: PMC5792264 DOI: 10.3324/haematol.2017.174573] [Citation(s) in RCA: 91] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 12/05/2017] [Indexed: 12/20/2022] Open
Abstract
Survival of myeloma patients has greatly improved with the use of autologous stem cell transplantation and novel agents, such as proteasome inhibitors, immunomodulatory drugs and monoclonal antibodies. Compared to bortezomib- and lenalidomide-based regimens alone, the addition of high-dose melphalan followed by autologous transplantation significantly improves progression-free survival, although an overall survival benefit was not observed in all trials. Moreover, follow up of recent trials is still too short to show any difference in survival. In the light of these findings, novel agent-based induction followed by autologous transplantation is considered the standard upfront treatment for eligible patients (level of evidence: 1A). Post-transplant consolidation and maintenance treatment can further improve patient outcome (1A). The availability of several novel agents has led to the development of multiple combination regimens such as salvage treatment options. In this context, the role of salvage autologous transplantation and allotransplant has not been extensively evaluated. In the case of prolonged remission after upfront autologous transplantation, another autologous transplantation at relapse can be considered (2B). Patients who experience early relapse and/or have high-risk features have a poor prognosis and may be considered as candidates for clinical trials that, in young and fit patients, may also include an allograft in combination with novel agents (2B). Ongoing studies are evaluating the role of novel cellular therapies, such as inclusion of antibody-based triplets and quadruplets, and chimeric antigen receptor-T cells. Despite encouraging preliminary results, longer follow up and larger patient numbers are needed before the clinical use of these novel therapies can be widely recommended.
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Affiliation(s)
- Francesca Gay
- Myeloma Unit, Division of Hematology, University of Torino, Azienda-Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Italy
| | - Monika Engelhardt
- Universitätsklinikum Freiburg, Medical Department, Hematology, Oncology & Stem Cell Transplantation, Freiburg, Germany
| | - Evangelos Terpos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Greece
| | - Ralph Wäsch
- Universitätsklinikum Freiburg, Medical Department, Hematology, Oncology & Stem Cell Transplantation, Freiburg, Germany
| | - Luisa Giaccone
- Department of Oncology, A.O.U Città della Salute e della Scienza di Torino, and Department of Molecular Biotechnology and Health Sciences, University of Torino, Italy
| | - Holger W Auner
- Centre for Haematology, Department of Medicine, Imperial College London, UK
| | - Jo Caers
- Department of Clinical Hematology, Centre Hospitalier Universitaire de Liège, Domaine Universitaire du Sart Tilman, Liège, Belgium
| | - Martin Gramatzki
- Division of Stem Cell Transplantation and Immunotherapy, 2 Medical Department, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Niels van de Donk
- Department of Hematology, VU University Medical Center, Amsterdam, the Netherlands
| | - Stefania Oliva
- Myeloma Unit, Division of Hematology, University of Torino, Azienda-Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Italy
| | - Elena Zamagni
- Seragnoli Institute of Hematology, Bologna University School of Medicine, Italy
| | - Laurent Garderet
- INSERM, UMR_S 938, Proliferation and Differentiation of Stem Cells, Paris, AP-HP, Hôpital Saint Antoine, Département d'Hématologie et de Thérapie Cellulaire; Sorbonne Universités, UPMC Univ Paris 06, France
| | | | - Roman Hajek
- Department of Hematooncology, University Hospital Ostrava, Czech Republic and Faculty of Medicine University of Ostrava, Czech Republic
| | - Heinz Ludwig
- Wilhelminen Cancer Research Institute, c/o Department of Medicine I, Center of Oncology, Hematology and Palliative Care, Vienna, Austria
| | - Herman Einsele
- Department of Internal Medicine II, University Hospital Würzburg, Germany
| | - Meletios Dimopoulos
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, School of Medicine, Greece
| | - Mario Boccadoro
- Myeloma Unit, Division of Hematology, University of Torino, Azienda-Ospedaliero Universitaria Città della Salute e della Scienza di Torino, Italy
| | - Nicolaus Kröger
- Department of Stem cell Transplantation, University Medical Center Hamburg-Eppendorf, Germany
| | - Michele Cavo
- Seragnoli Institute of Hematology, Bologna University School of Medicine, Italy
| | - Hartmut Goldschmidt
- Medizinische Klinik, Abteilung Innere Medizin V, Universitätsklinikum Heidelberg und National Centrum für Tumorerkrankungen (NCT), Heidelberg, Germany
| | - Benedetto Bruno
- Department of Oncology, A.O.U Città della Salute e della Scienza di Torino, and Department of Molecular Biotechnology and Health Sciences, University of Torino, Italy
| | - Pieter Sonneveld
- Department of Hematology, Erasmus Medical Center, Rotterdam, the Netherlands
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20
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Malek E, El-Jurdi N, Kröger N, de Lima M. Allograft for Myeloma: Examining Pieces of the Jigsaw Puzzle. Front Oncol 2017; 7:287. [PMID: 29322027 PMCID: PMC5732220 DOI: 10.3389/fonc.2017.00287] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 11/13/2017] [Indexed: 12/15/2022] Open
Abstract
Multiple myeloma (MM) cure remains elusive despite the availability of newer anti-myeloma agents. Patients with high-risk disease often suffer from early relapse and short survival. Allogeneic hematopoietic cell transplantation (allo-HCT) is an “immune-based” therapy that has the potential to offer long-term remission in a subgroup of patients, at the expense of high rates of transplant-related morbidity and mortality. Donor lymphocyte infusion (DLI) upon disease relapse after allo-HCT is able to generate an anti-myeloma response suggestive of a graft-versus-myeloma effect. Allo-HCT provides a robust platform for additional immune-based therapy upon relapse including DLI and, maintenance with immunomodulatory drugs and immunosuppressive therapy. There have been conflicting findings from randomized prospective trials questioning the role of allo-HCT. However, to this date, allo-HCT remains the only potential curable treatment for MM and its therapeutic role needs to be better defined especially for patients with high-risk disease. This review examines different aspects of this treatment and summarizes ongoing attempts at improving its therapeutic index.
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Affiliation(s)
- Ehsan Malek
- Stem Cell Transplant Program, University Hospitals Seidman Cancer Center, Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH, United States
| | - Najla El-Jurdi
- Stem Cell Transplant Program, University Hospitals Seidman Cancer Center, Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH, United States
| | - Nicolaus Kröger
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marcos de Lima
- Stem Cell Transplant Program, University Hospitals Seidman Cancer Center, Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH, United States
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21
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Allogeneic Hematopoietic Cell Transplantation for Myeloma: When and in Whom Does It Work. Curr Hematol Malig Rep 2017; 12:126-135. [PMID: 28285435 DOI: 10.1007/s11899-017-0374-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
The growing list of available therapies for patients with multiple myeloma has resulted in tremendously high response rates and prolonged survival. However, the cure remains elusive. A continued effort at developing strategies to utilize all available treatment modalities in the most effective manner is needed. Allogeneic hematopoietic cell transplantation (allo-HCT) is a robust platform, associated with high response rates, and provides a unique foundation on which immune therapies and novel agents can be employed to improve clinical outcomes. Patients with high-risk myeloma and those relapsing after novel agent-based therapies or early after an autologous HCT should be considered for allo-HCT, ideally in a clinical trial setting. Results from several ongoing studies are expected to provide important information that will help determine the place of allo-HCT in the myeloma treatment algorithm.
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Impact of New Drugs on the Long-Term Follow-Up of Upfront Tandem Autograft-Allograft in Multiple Myeloma. Biol Blood Marrow Transplant 2017; 24:189-193. [PMID: 28987930 DOI: 10.1016/j.bbmt.2017.09.017] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 09/20/2017] [Indexed: 11/24/2022]
Abstract
Before the introduction of "new drugs," we designed a trial in which 162 newly diagnosed myeloma patients were biologically randomized to receive either an autologous stem cell transplant (auto-SCT) followed by a nonmyeloablative allogeneic stem cell transplant (allo-SCT) or a double auto-SCT. Fifty-eight patients in the allo-SCT arm and 46 in the double auto-SCT arm completed the assigned treatment. At a median follow-up of 12.3 years from allo-SCT and 12.1 years from second auto-SCT, median overall survival (OS) was 11.4 in the allo-SCT arm and 3.9 years in the auto-SCT -arm (P = .007), whereas event-free survival was 3.6 and 1.5 years (P < .001), respectively. A subset of allo-SCT patients showed persistent molecular remission. Two-year cumulative incidence of chronic graft-versus-host disease was 67.2%. At 5 years, 39% of these patients were alive, disease-free, and off immunosuppression; 36.6% had relapsed and 12.2% were still on immunosuppression. Thirty-three of 58 patients (allo-SCT arm) and 39 of 46 (auto-SCT arm) relapsed at least once and were rescued with new drugs. In the allo-SCT arm, 2 patients in biochemical relapse did not reach clinical criteria for treatment. Overall 28 (90%) were treated with new drugs and 14 (45%) received donor lymphocyte infusions (DLIs). In 28 of 31 patients (90%) DLIs were given with new drugs. Median OS from first relapse was 7.5 years in the allo-SCT arm and 2 years in the auto-SCT arm (P = .01). Patients who received DLI showed significantly longer OS (hazard ratio, .38; P = .042) as compared with auto-SCT patients. This difference was slightly lower when only allo-SCT patients who did not receive DLIs were considered (hazard ratio, .56; P = .154). In summary, long-term disease-free survival and survival outcomes after treating relapse with new drugs with or without DLIs were better in allo-SCT patients.
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23
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Ghosh N, Ye X, Tsai HL, Bolaños-Meade J, Fuchs EJ, Luznik L, Swinnen LJ, Gladstone DE, Ambinder RF, Varadhan R, Shanbhag S, Brodsky RA, Borrello IM, Jones RJ, Matsui W, Huff CA. Allogeneic Blood or Marrow Transplantation with Post-Transplantation Cyclophosphamide as Graft-versus-Host Disease Prophylaxis in Multiple Myeloma. Biol Blood Marrow Transplant 2017; 23:1903-1909. [PMID: 28711728 DOI: 10.1016/j.bbmt.2017.07.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 07/02/2017] [Indexed: 02/07/2023]
Abstract
Allogeneic blood or marrow transplantation (alloBMT) may lead to long-term disease control in patients with multiple myeloma (MM). However, historically, the use of alloBMT in MM has been limited by its high nonrelapse mortality (NRM) rates, primarily from graft-versus-host disease (GVHD). We previously demonstrated that post-transplantation cyclophosphamide (PTCy) decreases the toxicities of both acute and chronic GVHD after alloBMT. Here, we examine the impact of PTCy in patients with MM undergoing alloBMT at Johns Hopkins Hospital. From 2003 to 2011, 39 patients with MM underwent bone marrow or peripheral blood alloBMT from HLA-matched related/unrelated or haploidentical related donors after either myeloablative or nonmyeloablative conditioning. Post-transplantation GVHD prophylaxis consisted of cyclophosphamide (50 mg/kg) on days +3 and +4 with or without mycophenolate mofetil and tacrolimus. Engraftment was detected in 95% of patients, with neutrophil and platelet recovery at a median of 15 and 16 days, respectively. The cumulative incidences of acute grades 2 to 4 and grades 3 and 4 GVHD were .41 and .08, respectively, and no cases of grade 4 acute GVHD were observed. The cumulative incidence of chronic GVHD was .13. One patient succumbed to NRM. All cases of chronic GVHD involved extensive disease and 60% of these patients received systemic therapy with complete resolution. After alloBMT, the overall response rate was 62% with complete, very good partial, and partial response rates of 26%, 21%, and 15%, respectively. The median progression-free survival was 12 months and was associated with the depth of response but not cytogenetic risk. The estimated cumulative incidence of relapse was .46 (95% confidence interval [CI], .3 to .62) at 1 year and .56 (95% CI, .41 to .72) at 2 years. At last follow-up, 23% of patients remain without evidence of disease at a median follow-up of 10.3 years after alloBMT. The median overall survival was 4.4 years and the 5-year and 10-year overall survival probabilities were 49% (95% CI, 35% to 67%) and 43% (95% CI, 29% to 62%), respectively. The use of PTCy after alloBMT for MM is feasible and results in low NRM and GVHD rates. The safety of this approach may allow the development of novel post-transplantation maintenance strategies to improve long-term disease control.
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Affiliation(s)
- Nilanjan Ghosh
- School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Xiaobu Ye
- School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Hua-Ling Tsai
- School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | | | - Ephraim J Fuchs
- School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Leo Luznik
- School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Lode J Swinnen
- School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | | | | | - Ravi Varadhan
- School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Satish Shanbhag
- School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Robert A Brodsky
- School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Ivan M Borrello
- School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Richard J Jones
- School of Medicine, Johns Hopkins University, Baltimore, Maryland
| | - William Matsui
- School of Medicine, Johns Hopkins University, Baltimore, Maryland.
| | - Carol Ann Huff
- School of Medicine, Johns Hopkins University, Baltimore, Maryland
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24
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Adverse impact of high donor CD3+ cell dose on outcome following tandem auto-NMA allogeneic transplantation for high-risk myeloma. Bone Marrow Transplant 2017; 52:839-845. [DOI: 10.1038/bmt.2017.37] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Revised: 01/10/2017] [Accepted: 01/19/2017] [Indexed: 11/08/2022]
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25
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Dispenzieri A. Myeloma: management of the newly diagnosed high-risk patient. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2016; 2016:485-494. [PMID: 27913520 PMCID: PMC6142458 DOI: 10.1182/asheducation-2016.1.485] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Although there have been many definitions for high-risk (HR) myeloma, most recent consensus for classifying risk in patients with newly diagnosed multiple myeloma (NMM) comes from the International Myeloma Working Group. This recently published revised International Staging System includes del(17p) or t(4;14) by fluorescence in situ hybridization, β-2 microglobulin, albumin, and lactate dehydrogenase. These elements should be captured in all NMM patients. The optimal treatments for HR myeloma have not been fully worked out; therefore, these patients should be considered for clinical trials. Outside of the trial setting for those patients who are not eligible for autologous stem cell transplantation (ASCT), a regimen with bortezomib, but not thalidomide, should be considered, with a duration of therapy of at least 1 year. The regimen with the best results to date is bortezomib, melphalan, and predisone. A nonthalidomide maintenance could also be considered. In patients who are eligible for ASCT, an induction regimen with bortezomib and an immunomodulatory drug should be administered for 3 to 6 months followed by 2 ASCTs. Finally, a consolidation/maintenance regimen containing at least 1 year of bortezomib should be administered followed by maintenance thereafter. For patient convenience, an oral agent that is not thalidomide could be prescribed as maintenance. Finally, in patients with HR myeloma, allogeneic SCT may be associated with reasonable outcomes, but this too will require further research.
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Affiliation(s)
- Angela Dispenzieri
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN
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26
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Muchtar E, Magen H, Gertz MA. High-risk multiple myeloma: a multifaceted entity, multiple therapeutic challenges. Leuk Lymphoma 2016; 58:1283-1296. [PMID: 27734720 DOI: 10.1080/10428194.2016.1233540] [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] [Indexed: 12/22/2022]
Abstract
The term high-risk multiple myeloma is aimed to identify a heterogeneous group of patients who are more likely to progress and die early of their disease. Therefore, recognition of these patients is crucial. With the increase in the number of treatment options, the outcome for high-risk patients has probably improved, although the true extent of this improvement remains unknown, due to both the heterogeneous components of high-risk disease and its under-representation in clinical trials. In this article, we review the definitions of high-risk disease, emphasizing the fact that no single definition can represent the entire high-risk population. In the second part, we review the treatment options available for the management of high-risk myeloma as well as our general approach for high-risk disease. In light of the poor prognosis associated with high-risk myeloma, even in the current era, new approaches for the management of this subset of patients are needed.
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Affiliation(s)
- Eli Muchtar
- a Division of Hematology , Mayo Clinic , Rochester , MN , USA
| | - Hila Magen
- b Institute of Hematology, Davidoff Cancer Center, Beilinson Hospital, Rabin Medical Center , Petah-Tikva , Israel
| | - Morie A Gertz
- a Division of Hematology , Mayo Clinic , Rochester , MN , USA
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27
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Paviglianiti A, Xavier E, Ruggeri A, Ceballos P, Deconinck E, Cornelissen JJ, Nguyen-Quoc S, Maillard N, Sanz G, Rohrlich PS, Garderet L, Volt F, Rocha V, Kroeger N, Gluckman E, Fegueux N, Mohty M. Outcomes of unrelated cord blood transplantation in patients with multiple myeloma: a survey on behalf of Eurocord, the Cord Blood Committee of Cellular Therapy and Immunobiology Working Party, and the Chronic Leukemia Working Party of the EBMT. Haematologica 2016; 101:1120-7. [PMID: 27229716 DOI: 10.3324/haematol.2015.138917] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Accepted: 05/24/2016] [Indexed: 12/11/2022] Open
Abstract
Although allogeneic stem cell transplantation is not a standard therapy for multiple myeloma, some patients can benefit from this intense therapy. There are few reports on outcomes after umbilical cord blood transplantation in multiple myeloma, and investigation of this procedure is warranted. We retrospectively analyzed 95 patients, 85 with multiple myeloma and 10 with plasma cell leukemia, receiving single or double umbilical cord blood transplantation from 2001 to 2013. Median follow up was 41 months. The majority of patients received a reduced intensity conditioning. The cumulative incidence of neutrophil engraftment was 97%±3% at 60 days, and that of 100-day acute graft-versus-host disease grade II-IV was 41%±5%. Chronic graft-versus-host disease at two years was 22%±4%. Relapse and non-relapse mortality was 47%±5% and 29%±5% at three years, respectively. Three-year progression-free survival and overall survival were 24%±5% and 40%±5%, respectively. Anti-thymocyte globulin was associated with decreased incidence of acute graft-versus-host disease, higher non-relapse mortality, decreased overall and progression-free survival. Patients with high cytogenetic risk had higher relapse, and worse overall and progression-free survival. In conclusion, umbilical cord blood transplantation is feasible for multiple myeloma patients.
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Affiliation(s)
- Annalisa Paviglianiti
- Eurocord, APHP, University Paris Diderot, Hôpital Saint Louis, Paris, France Monacord, Centre Scientifique de Monaco, France
| | - Erick Xavier
- Eurocord, APHP, University Paris Diderot, Hôpital Saint Louis, Paris, France Monacord, Centre Scientifique de Monaco, France
| | - Annalisa Ruggeri
- Eurocord, APHP, University Paris Diderot, Hôpital Saint Louis, Paris, France Monacord, Centre Scientifique de Monaco, France Service d'Hématologie et Thérapie Cellulaire, Hôpital Saint Antoine, AP-HP, Paris, France
| | - Patrice Ceballos
- Département d'Hématologie Clinique, CHU Lapeyronie, Montpellier, France
| | | | - Jan J Cornelissen
- Department of Hematology, Erasmus MC-Daniel den Hoed Cancer Centre, Rotterdam, the Netherlands
| | - Stephanie Nguyen-Quoc
- Department Hematology, University Paris IV, Hôpital la Pitié-Salpêtrière, Paris, France
| | - Natacha Maillard
- Bone Marrow Transplant Unit Clinical Hematology, Hôpital La Miletrie, Poitiers, France
| | - Guillermo Sanz
- Servicio de Hematologia, Hospital Universitario y Politecnico La Fe, Valencia, Spain
| | | | - Laurent Garderet
- Service d'Hématologie et Thérapie Cellulaire, Hôpital Saint Antoine, AP-HP, Paris, France
| | - Fernanda Volt
- Eurocord, APHP, University Paris Diderot, Hôpital Saint Louis, Paris, France Monacord, Centre Scientifique de Monaco, France
| | - Vanderson Rocha
- Eurocord, APHP, University Paris Diderot, Hôpital Saint Louis, Paris, France Monacord, Centre Scientifique de Monaco, France Department Hematology, Churchill Hospital, Oxford, UK
| | - Nicolaus Kroeger
- Dept. Stem Cell Transplantation, University Hospital of Hamburg, Germany
| | - Eliane Gluckman
- Eurocord, APHP, University Paris Diderot, Hôpital Saint Louis, Paris, France Monacord, Centre Scientifique de Monaco, France
| | - Nathalie Fegueux
- Département d'Hématologie Clinique, CHU Lapeyronie, Montpellier, France
| | - Mohamad Mohty
- Service d'Hématologie et Thérapie Cellulaire, Hôpital Saint Antoine, AP-HP, Paris, France INSERM, UMRs 938, Paris, France
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28
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Treatment of multiple myeloma with high-risk cytogenetics: a consensus of the International Myeloma Working Group. Blood 2016; 127:2955-62. [PMID: 27002115 DOI: 10.1182/blood-2016-01-631200] [Citation(s) in RCA: 624] [Impact Index Per Article: 78.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Accepted: 03/08/2016] [Indexed: 02/07/2023] Open
Abstract
The International Myeloma Working Group consensus updates the definition for high-risk (HR) multiple myeloma based on cytogenetics Several cytogenetic abnormalities such as t(4;14), del(17/17p), t(14;16), t(14;20), nonhyperdiploidy, and gain(1q) were identified that confer poor prognosis. The prognosis of patients showing these abnormalities may vary with the choice of therapy. Treatment strategies have shown promise for HR cytogenetic diseases, such as proteasome inhibition in combination with lenalidomide/pomalidomide, double autologous stem cell transplant plus bortezomib, or combination of immunotherapy with lenalidomide or pomalidomide. Careful analysis of cytogenetic subgroups in trials comparing different treatments remains an important goal. Cross-trial comparisons may provide insight into the effect of new drugs in patients with cytogenetic abnormalities. However, to achieve this, consensus on definitions of analytical techniques, proportion of abnormal cells, and treatment regimens is needed. Based on data available today, bortezomib and carfilzomib treatment appear to improve complete response, progression-free survival, and overall survival in t(4;14) and del(17/17p), whereas lenalidomide may be associated with improved progression-free survival in t(4;14) and del(17/17p). Patients with multiple adverse cytogenetic abnormalities do not benefit from these agents. FISH data are implemented in the revised International Staging System for risk stratification.
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29
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Favorable long-term outcome of patients with multiple myeloma using a frontline tandem approach with autologous and non-myeloablative allogeneic transplantation. Bone Marrow Transplant 2015; 51:529-35. [PMID: 26691426 DOI: 10.1038/bmt.2015.319] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Revised: 10/15/2015] [Accepted: 10/19/2015] [Indexed: 11/08/2022]
Abstract
Despite survival improvement with novel agents and use of autologous hematopoietic stem cell transplantation (HSCT), cure of patients with multiple myeloma (MM) remains anecdotal. Initial observations suggested that chronic GvHD was accompanied by an anti-myeloma effect after myeloablative HSCT, but unfortunately this procedure was hampered by high non-relapse mortality (NRM). To maximize the anti-myeloma effect and minimize NRM, we developed a non-myeloablative (NMA) regimen associated with a high incidence of chronic GvHD and tested its efficacy on patient survival and disease eradication. From 2001 to 2010, 92 patients aged ⩽ 65 years with a compatible sibling donor received autologous HSCT followed by an outpatient NMA allogeneic HSCT using a conditioning of fludarabine and cyclophosphamide. Patient median age was 52 years and 97% presented Durie-Salmon stages II-III disease. After a median follow-up of 8.8 years, probability of 10-year progression free and overall survival were 41% and 62%, respectively. Although the cumulative incidence of extensive chronic GvHD was high (at 79%), the majority of long-term survivors were off immunosuppressive drugs by year 5 and NRM was low (at 10%). Together, our results suggest that potential MM cure can be achieved with NMA transplantation regimens that maximize graft-versus-myeloma effect and minimize NRM.
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Lokhorst HM, van der Holt B, Cornelissen JJ, Kersten MJ, van Oers M, Raymakers R, Minnema MC, Zweegman S, Bos G, Schaap N, Wittebol S, de Weerdt O, Ammerlaan R, Sonneveld P. Reduced relapse rate in upfront tandem autologous/reduced-intensity allogeneic transplantation in multiple myeloma only results in borderline non-significant prolongation of progression-free but not overall survival. Haematologica 2015; 100:e508-10. [PMID: 26341740 DOI: 10.3324/haematol.2015.128728] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
- Henk M Lokhorst
- Department of Hematology, VU University Medical Center Amsterdam, The Netherlands
| | - Bronno van der Holt
- HOVON Data Center, Erasmus MC Cancer Center - Clinical Trial Center, Rotterdam, The Netherlands
| | - Jan J Cornelissen
- Department of Hematology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Marie José Kersten
- Department of Hematology, Academic Medical Center, Amsterdam, The Netherlands
| | - Marinus van Oers
- Department of Hematology, Academic Medical Center, Amsterdam, The Netherlands
| | - Reinier Raymakers
- Department of Hematology, University Medical Center Utrecht, The Netherlands
| | - Monique C Minnema
- Department of Hematology, University Medical Center Utrecht, The Netherlands
| | - Sonja Zweegman
- Department of Hematology, VU University Medical Center Amsterdam, The Netherlands
| | - Gerard Bos
- Department of Hematology, Academic Hospital Maastricht, The Netherlands
| | - Nicolaas Schaap
- Radboud University Nijmegen Hospital, Nijmegen, The Netherlands
| | | | | | - Rianne Ammerlaan
- HOVON Data Center, Erasmus MC Cancer Center - Clinical Trial Center, Rotterdam, The Netherlands
| | - Pieter Sonneveld
- Department of Hematology, Erasmus Medical Center, Rotterdam, The Netherlands
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31
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Defining and treating high-risk multiple myeloma. Leukemia 2015; 29:2119-25. [PMID: 26265183 DOI: 10.1038/leu.2015.209] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Revised: 04/20/2015] [Accepted: 05/07/2015] [Indexed: 12/18/2022]
Abstract
Multiple myeloma (MM) is more recently being recognized as a heterogeneous group of disease with variability in outcomes based on specific clinical and biologic predictors. MM patients can be broadly categorized into standard, intermediate and high risk for disease relapse, morbidity and mortality. The high-risk features include patient-specific factors such as old age, poor performance status and comorbidities; clinical features such as primary plasma cell leukemia and extramedullary disease; disease-specific biologic features such as deletion 17p, t(4;14) and high-risk gene expression profiling signatures. The current paper reviews the available data on best therapeutic approaches for high-risk MM.
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32
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Efficacy and Outcome of Allogeneic Transplantation in IgD and Nonsecretory Myeloma. A Report on Behalf of the Myeloma Subcommittee of the Chronic Malignancies Working Party of the European Group for Blood and Marrow Transplantation. Biol Blood Marrow Transplant 2015; 21:1054-8. [DOI: 10.1016/j.bbmt.2015.02.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2014] [Accepted: 02/14/2015] [Indexed: 01/01/2023]
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33
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Trends and Outcomes in Allogeneic Hematopoietic Stem Cell Transplant for Multiple Myeloma at Mayo Clinic. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2015; 15:349-357.e2. [DOI: 10.1016/j.clml.2015.03.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Revised: 03/23/2015] [Accepted: 03/26/2015] [Indexed: 11/23/2022]
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34
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van de Donk NWCJ, Sonneveld P. Diagnosis and risk stratification in multiple myeloma. Hematol Oncol Clin North Am 2014; 28:791-813. [PMID: 25212883 DOI: 10.1016/j.hoc.2014.06.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Multiple myeloma (MM) is a tumor of monoclonal plasma cells, which produce a monoclonal antibody and expand predominantly in the bone marrow. Patients present with hypercalcemia, renal impairment, anemia, and/or bone disease. Only patients with symptomatic MM require therapy, whereas asymptomatic patients receive regular follow-up. Survival of patients with MM is very heterogeneous. The variety in outcome is explained by host factors as well as tumor-related characteristics reflecting biology of the MM clone and tumor burden. The identification of cytogenetic abnormalities by fluorescence in situ hybridization is currently the most important and widely available prognostic factor in MM.
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Affiliation(s)
- Niels W C J van de Donk
- Department of Hematology, University Medical Center Utrecht, Heidelberglaan 100, Utrecht 3584CX, The Netherlands
| | - Pieter Sonneveld
- Department of Hematology, Erasmus MC Cancer Institute, 's Gravendijkwal 230, Rotterdam 3015CE, The Netherlands.
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Allogeneic Stem Cell Transplantation and Targeted Immunotherapy for Multiple Myeloma. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2013; 13 Suppl 2:S330-48. [DOI: 10.1016/j.clml.2013.05.021] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Accepted: 05/06/2013] [Indexed: 11/17/2022]
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Auner HW, Szydlo R, van Biezen A, Iacobelli S, Gahrton G, Milpied N, Volin L, Janssen J, Nguyen Quoc S, Michallet M, Schoemans H, El Cheikh J, Petersen E, Guilhot F, Schönland S, Ahlberg L, Morris C, Garderet L, de Witte T, Kröger N. Reduced intensity-conditioned allogeneic stem cell transplantation for multiple myeloma relapsing or progressing after autologous transplantation: a study by the European Group for Blood and Marrow Transplantation. Bone Marrow Transplant 2013; 48:1395-400. [PMID: 23708704 DOI: 10.1038/bmt.2013.73] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2013] [Revised: 03/24/2013] [Accepted: 04/16/2013] [Indexed: 11/12/2022]
Abstract
Outcomes and prognostic factors of reduced intensity-conditioned allo-SCT (RIC allo-SCT) for multiple myeloma (MM) relapsing or progressing after prior autologous (auto)-SCT are not well defined. We performed an analysis of 413 MM patients who received a related or unrelated RIC allo-SCT for the treatment of relapse/progression after prior auto-SCT. Median age at RIC allo-SCT was 54.1 years, and 44.6% of patients had undergone two or more prior auto-SCTs. Median OS and PFS from the time of RIC allo-SCT for the entire population were 24.7 and 9.6 months, respectively. Cumulative non-relapse mortality (NRM) at 1 year was 21.5%. In multivariate analysis, CMV seronegativity of both patient and donor was associated with significantly better PFS, OS and NRM. Patient-donor gender mismatch was associated with better PFS, fewer than two prior auto-SCT was associated with better OS, and shorter time from the first auto-SCT to the RIC allo-SCT was associated with lower NRM. The results of this study identify patient and donor CMV seronegativity as the key prognostic factor for outcome after RIC allo-SCT for MM relapsing or progressing after prior auto-SCT.
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Affiliation(s)
- H W Auner
- Department of Medicine, Centre for Haematology, Hammersmith Hospital Campus, Imperial College London, London, UK
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37
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Aoki T, Kasai M, Harada Y, Matsubara E, Morishita T, Suzuki T, Tsujita M, Goto N, Katayama A, Watarai Y, Uchida K, Ito M, Saji H, Tsuzuki T, Uchida T, Ogura M. Stable renal engraftment in a patient following successful tandem autologous/reduced-intensity conditioning allogeneic transplantation for treatment of multiple myeloma with del(17p) that developed as a post-transplantation lymphoproliferative disease following renal transplantation. Int J Hematol 2013; 98:129-34. [DOI: 10.1007/s12185-013-1355-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2013] [Revised: 04/30/2013] [Accepted: 05/01/2013] [Indexed: 01/20/2023]
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Wirk B, Byrne M, Dai Y, Moreb JS. Outcomes of salvage autologous versus allogeneic hematopoietic cell transplantation for relapsed multiple myeloma after initial autologous hematopoietic cell transplantation. J Clin Med Res 2013; 5:174-84. [PMID: 23671543 PMCID: PMC3651068 DOI: 10.4021/jocmr1274w] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2013] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Standard therapy for multiple myeloma (MM) includes initial autologous hematopoietic cell transplantation (autoHCT1) but this is not curative and most patients will relapse. Role of salvage autoHCT2 or allogeneic HCT (alloHCT2) is undefined. METHODS MM patients who relapsed after autoHCT1 and had salvage autoHCT2 (N = 27) or alloHCT2 (N = 19) between 1995 - 2011 at our institution were studied retrospectively. RESULTS Complete and very good partial remission (CR/VGPR) improved from 7% to 56% after autoHCT2 and from 26% to 37% after alloHCT2. Nonrelapse mortality (NRM) at 3 years was 3.7% for autoHCT2 and 5.3% for alloHCT2 (P = 0.901). Median progression free survival (PFS) and overall survival (OS) for autoHCT2 (19 months, 23 months) and alloHCT2 (6 months, 19 months) were not significantly different. On multivariate analysis, time from autoHCT1 to relapse ≥ 1year (HR 24.81, 95% CI 2.4 - 249.9) and maintenance therapy after autoHCT2 (HR 12.19, 95% CI 2.5 - 249.9) impacted OS after autoHCT2. Time from autoHCT1 to relapse < 1 year vs. ≥ 1 year (HR 18.55, 95% CI 2.28 - 150.57) impacted PFS after autoHCT2. For alloHCT2, no factors impacted NRM, PFS or OS. For those with relapse from autoHCT1 < 1 year vs. ≥ 1 year undergoing autoHCT2, median OS was 15 months (range, 1 - 53) vs. not yet reached at 143 months and median PFS was 5 months (range, 1 - 49) vs. not yet reached at 88 months. CONCLUSIONS Salvage autoHCT2 and alloHCT2 are both feasible for post autoHCT1 MM relapse. Relapse ≥ 1 year from autoHCT1 predicts for better PFS and OS after autoHCT2. Maintenance therapy after autoHCT2 is beneficial.
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Affiliation(s)
- Baldeep Wirk
- Division of Hematology-Oncology, University of Florida, USA
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39
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Passera R, Pollichieni S, Brunello L, Patriarca F, Bonifazi F, Montefusco V, Falda M, Montanari M, Guidi S, Giaccone L, Mordini N, Carella AM, Bavaro P, Milone G, Benedetti F, Ciceri F, Scimè R, Benedetti E, Castagna L, Festuccia M, Rambaldi A, Bacigalupo A, Corradini P, Bosi A, Boccadoro M, Bandini G, Fanin R, Bruno B. Allogeneic hematopoietic cell transplantation from unrelated donors in multiple myeloma: study from the Italian Bone Marrow Donor Registry. Biol Blood Marrow Transplant 2013; 19:940-8. [PMID: 23538113 DOI: 10.1016/j.bbmt.2013.03.012] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2012] [Accepted: 03/21/2013] [Indexed: 11/12/2022]
Abstract
To evaluate trends in allografting from unrelated donors, we conducted a study on 196 consecutive myeloma patients transplanted between 2000 and 2009 in Italy. Twenty-eight percent, 37%, and 35%, respectively, received myeloablative, reduced-intensity, and nonmyeloablative conditioning. In these 3 cohorts, 1-year and 5-year transplantation-related mortalities were 28.8% and 37.0%, 20.3% and 31.3%, and 25.0% and 30.3%, respectively (P = .745). Median overall survival (OS) and event-free survival from transplantation for the 3 cohorts were 29 and 10 months, 11 and 6 months, and 32 and 13 months, respectively (P = .039 and P = .049). Overall cumulative incidences of acute and chronic graft-versus-host-disease (GVHD) were 46.1% and 51.1%. By Cox multivariate analyses, chronic GVHD was significantly associated with longer OS (hazard ratio [HR], .51; P = .009), whereas the use of peripheral blood stem cells was borderline significant (HR, .55; P = .051). Better response posttransplantation was associated with longer event-free survival (HR, 2.13 to 4.25; P < .001). Acute GVHD was associated with poorer OS (HR, 2.53; P = .001). This analysis showed a strong association of acute and chronic GVHD and depth of response posttransplantation with clinical outcomes. Long-term disease control remains challenging regardless of the conditioning. In the light of these results, prospective trials may be designed to better define the role of allografting from unrelated donors in myeloma.
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Affiliation(s)
- Roberto Passera
- Divison of Nuclear Medicine 2, Azienda Ospedaliera Città della Salute e della Scienza di Torino, Torino, Italy
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Autologous/reduced-intensity allogeneic stem cell transplantation vs autologous transplantation in multiple myeloma: long-term results of the EBMT-NMAM2000 study. Blood 2013; 121:5055-63. [PMID: 23482933 DOI: 10.1182/blood-2012-11-469452] [Citation(s) in RCA: 157] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Long-term follow-up of prospective studies comparing allogeneic transplantation to autologous transplantation in multiple myeloma is few and controversial. This is an update at a median follow-up of 96 months of the European Group for Blood and Marrow Transplantation Non-Myeloablative Allogeneic stem cell transplantation in Multiple Myeloma (NMAM)2000 study that prospectively compares tandem autologous/reduced intensity conditioning allogeneic transplantation (auto/RICallo) to autologous transplantation alone (auto). There are 357 myeloma patients up to age 69 years enrolled. Patients with an HLA-identical sibling were allocated to auto/RICallo (n = 108) and those without to auto alone (n = 249). At 96 months progression-free survival (PFS) and overall survival (OS) were 22% and 49% vs 12% (P = .027) and 36% (P = .030) with auto/RICallo and auto respectively. The corresponding relapse/progression rate (RL) was 60% vs 82% (P = .0002). Non-relapse mortality at 36 months was 13% vs 3% (P = .0004). In patients with the del(13) abnormality corresponding PFS and OS were 21% and 47% vs 5% (P = .026), and 31% (P = .154). Long-term outcome in patients with multiple myeloma was better with auto/RICallo as compared with auto only and the auto/RICallo approach seemed to overcome the poor prognostic impact of del(13) observed after autologous transplantation. Follow up longer than 5 years is necessary for correct interpretation of the value of auto/RICallo in multiple myeloma.
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Kröger N, Badbaran A, Zabelina T, Ayuk F, Wolschke C, Alchalby H, Klyuchnikov E, Atanackovic D, Schilling G, Hansen T, Schwarz S, Heinzelmann M, Zeschke S, Bacher U, Stübig T, Fehse B, Zander AR. Impact of high-risk cytogenetics and achievement of molecular remission on long-term freedom from disease after autologous-allogeneic tandem transplantation in patients with multiple myeloma. Biol Blood Marrow Transplant 2012; 19:398-404. [PMID: 23078786 DOI: 10.1016/j.bbmt.2012.10.008] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2012] [Accepted: 10/11/2012] [Indexed: 10/27/2022]
Abstract
Within a prospective protocol, the incidence and impact of achievement of molecular remission (mCR) and high-risk cytogenetics was investigated in 73 patients with multiple myeloma (MM) after autologous (auto)-allogeneic (allo) tandem stem cell transplantation (SCT). After induction chemotherapy, patients received melphalan 200 mg/m(2) before undergoing auto-SCT, followed 3 months later by melphalan 140 mg/m(2) and fludarabine 180 mg/m(2) before allo-SCT. Sixteen patients had high-risk cytogenetic features, defined by positive FISH for del(17p13) and/or t(4;14). Overall, 66% of the patients achieved CR or near-CR, and 41% achieved mCR, which was sustained negative (at least 4 consecutive samples negative) in 15 patients (21%), with no significant difference in incidence between the patients with high-risk cytogenetics and others (P = .70). After a median follow-up of 6 years, overall 5-year progression-free survival was 29%, with no significant difference between del 17p13/t(4;14)-harboring patients and others (24% versus 30%; P = .70). The 5-year progression-free survival differed substantially according to the achieved remission: 17% for partial remission, 41% for CR, 57% for mCR, and 85% for sustained mCR. These results suggest that auto-allo tandem SCT may overcome the negative prognostic effect of del(17p13) and/or t(4;14) and that achievement of molecular remission resulted in long-term freedom from disease.
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Affiliation(s)
- Nicolaus Kröger
- Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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Fett-Conte AC, Carvalho-Salles AB, Vendrame CB, Pedrassa P, Freitas PC, Varella-Garcia M. New complex chromosome abnormalities in multiple myeloma associated with a poor prognosis: A case report. Leuk Res 2012; 36:e140-2. [DOI: 10.1016/j.leukres.2012.02.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2012] [Revised: 02/27/2012] [Accepted: 02/28/2012] [Indexed: 11/28/2022]
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Donor versus no-donor comparison of newly diagnosed myeloma patients included in the HOVON-50 multiple myeloma study. Blood 2012; 119:6219-25; quiz 6399. [PMID: 22442350 DOI: 10.1182/blood-2011-11-393801] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
To prospectively evaluate allogeneic stem cell transplantation (allo-SCT) for myeloma as part of first-line therapy, a donor versus no-donor analysis was performed of patients treated in the HOVON-50 study, a study that was originally designed to examine thalidomide combined with intensive therapy. Two hundred sixty patients having received an autologous-SCT fulfilled the criteria to be included, 138 patients without an HLA-identical sibling donor and 122 patients with a donor. After a median follow-up of 77 months, complete remission, progression-free survival (PFS), and overall survival were not significantly different between the 2 groups. PFS at 6 years was 28% for patients with a donor versus 22% for patients without a donor (P = .19) and overall survival at 6 years from high-dose melphalan was 55%, irrespective of having a donor (P = .68). Cumulative incidence of nonrelapse mortality at 6 years after autologous-SCT was 16% in the donor group versus 3% in the no-donor group (P < .001). However, PFS was significantly prolonged in the 99 patients who actually proceeded to allo-SCT compared with the 115 patients who continued maintenance or received a second high-dose melphalan, but the difference did not translate into a prolonged survival benefit. These results do not support a general application of allo-SCT in all myeloma patients as part of first-line therapy.
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