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Zhukovsky S, White J, Chakraborty R, Costa LJ, Van Oekelen O, Sborov DW, Cliff ERS, Mohyuddin GR. Multiple myeloma clinical trials exclude patients with the highest-risk disease: a systematic review of trial exclusion criteria. Leuk Lymphoma 2024:1-10. [PMID: 39314111 DOI: 10.1080/10428194.2024.2395440] [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: 08/07/2024] [Accepted: 08/16/2024] [Indexed: 09/25/2024]
Abstract
Patients with certain subsets of multiple myeloma continue to have poor outcomes and are in need of novel treatment approaches. Strict eligibility criteria for randomized controlled trials (RCTs) limit access to clinical trials and limit the external validity of trial results for these patients. We systematically reviewed RCTs in newly diagnosed myeloma from 2006 to 2023 to ascertain the prevalence of 12 key exclusion criteria and trends over time. 80 RCTs were included. Exclusion criteria included: age in 43 (51%) trials; projected life expectancy in 20 (24%); performance status in 74 (87%); non-secretory and/or oligosecretory disease in 47 (55%), hepatic function in 64 (79%), renal function in 63 (74%), hematological thresholds in 50 (59%), prior malignancy in 68 (80%), and neuropathy in 50 (59%). For 53 trials which had detailed exclusion criteria available, plasma cell leukemia was excluded in 21 (40%), extramedullary disease in 5 (9%) and CNS disease in 13 (25%). The percentage of studies invoking each of these exclusion criteria did not significantly improve over time on univariate regression analysis, and exclusion criteria relating to neuropathy have worsened. The restrictive eligibility criteria of most myeloma RCTs perpetuate a cycle where limited data exists to treat challenging myeloma subtypes.
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Affiliation(s)
- Sara Zhukovsky
- Division of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Joshua White
- Division of Internal Medicine, University of Utah, Salt Lake City, UT, USA
| | - Rajshekhar Chakraborty
- Herbert Irving Comprehensive Cancer Center, Columbia University Irving Medical Center, New York, NY, USA
| | - Luciano J Costa
- Division of Hematology and Oncology, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
- O'Neal Comprehensive Cancer Center, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Oliver Van Oekelen
- Department of Medicine, Mount Sinai Beth Israel, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Douglas W Sborov
- Division of Hematology and Hematological Malignancies, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Edward R Scheffer Cliff
- Program on Regulation, Therapeutics and Law, Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Ghulam Rehman Mohyuddin
- Division of Hematology and Hematological Malignancies, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
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2
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Brown Z, Scott C, Zhang LF, Sadek R, Clarke A, Jillella A, Keruakous AR, Clemmons AB. Assessing Outcomes in Patients With Multiple Myeloma Postautologous Stem Cell Transplantation: Contrasting the Effects of Melphalan Dosages at 200 mg/m 2 versus 140 mg/m 2. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2024; 24:642-647. [PMID: 38845275 DOI: 10.1016/j.clml.2024.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 04/26/2024] [Accepted: 05/01/2024] [Indexed: 08/27/2024]
Abstract
BACKGROUND No standard criteria for dose reduction exists for high-dose melphalan for autologous stem cell transplantation (ASCT) for multiple myeloma (MM) due to limited and conflicting evidence. OBJECTIVE To evaluate efficacy and safety of standard dose (200 mg/m2 = Mel200) versus reduced dose 140 mg/m2 = Mel140) of melphalan in patients with MM undergoing ASCT. DESIGN A single-center retrospective review of adults with MM for their first ASCT between January 1, 2010, and November 1, 2022, who received Mel200 or Mel140 as conditioning. Primary endpoint was progression-free survival (PFS). Secondary safety and efficacy endpoints included overall survival (OS), incidence of febrile neutropenia and acute kidney injury, and time to engraftment. Subgroup analyses were performed based on patient age and renal function. RESULTS A total of 322 patients were included in the study, 240 in the Mel200 group and 82 in the Mel140 group. Baseline demographics were similar except patients receiving Mel140 were on average older and had worse kidney function. PFS at 2 years was not different between groups (P = .2335). No difference existed in 2 year PFS or OS for patients < 65 years of age versus ≥ 65 years of age or for patients with CrCl 30-59 mL/min versus CrCl ≥ 60 mL/min within either Mel200 group or Mel140 group (all P > .05). No differences existed between groups across all secondary outcomes. CONCLUSION Reduced doses melphalan showed no differences in safety or efficacy outcomes versus standard dose even when analyzed based on age and renal function. Larger randomized controlled trials need to be performed to validate these findings.
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Affiliation(s)
- Zachary Brown
- PGY1 Pharmacy Resident, Wellstar-MCG Health and University of Georgia College of Pharmacy
| | - Campbell Scott
- PGY2 Oncology Resident, Wellstar-MCG Health and University of Georgia College of Pharmacy
| | - Li Fang Zhang
- Department of Biostatics, Data Science, and Epidemiology, Medical College of Georgia
| | - Ramses Sadek
- Department of Medicine, Georgia Cancer Center Medical College of Georgia
| | - Andrea Clarke
- Hematologic Malignancy/BMT Clinical Pharmacist, Wellstar-MCG Health
| | - Anand Jillella
- Department of Medicine: Hematology and Oncology, Wellstar-MCG Health, Georgia Cancer Center
| | - Amany R Keruakous
- Department of Medicine: Hematology and Oncology, Wellstar-MCG Health, Georgia Cancer Center
| | - Amber B Clemmons
- Clinical Professor, University of Georgia College of Pharmacy, BMT Clinical Pharmacist, Wellstar-MCG Health.
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3
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Garderet L, Gras L, Koster L, Baaij L, Hamad N, Dsouza A, Estrada-Merly N, Hari P, Saber W, Cowan AJ, Iida M, Okamoto S, Takamatsu H, Mizuno S, Kawamura K, Kodera Y, Ko BS, Liam C, Ho KW, Goh AS, Tan SK, Elhaddad AM, Bazarbachi A, Chaudhry QUN, Alfar R, Bekadja MA, Benakli M, Ortiz CAF, Riva E, Galeano S, Bass F, Mian HS, McCurdy A, Wang FR, Meng L, Neumann D, Koh M, Snowden JA, Schönland S, McLornan DP, Hayden PJ, Sureda A, Greinix HT, Aljurf M, Atsuta Y, Niederwieser D. Global characteristics and outcomes of autologous hematopoietic stem cell transplantation for newly diagnosed multiple myeloma: A study of the worldwide network for blood and marrow transplantation (WBMT). Am J Hematol 2024. [PMID: 39158218 DOI: 10.1002/ajh.27451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2024] [Revised: 07/01/2024] [Accepted: 07/21/2024] [Indexed: 08/20/2024]
Abstract
Autologous hematopoietic cell transplantation (AHCT) is a commonly used treatment in multiple myeloma (MM). However, real-world global demographic and outcome data are scarce. We collected data on baseline characteristics and outcomes from 61 725 patients with newly diagnosed MM who underwent upfront AHCT between 2013 and 2017 from nine national/international registries. The primary endpoint was overall survival (OS), and the secondary endpoints were progression-free survival (PFS), relapse incidence (RI) and non-relapse mortality (NRM). Median OS amounted to 90.2 months (95% CI 88.2-93.6) and median PFS 36.5 months (95% CI 36.1-37.0). At 24 months, cumulative RI was 33% (95% CI 32.5%-33.4%) and NRM was 2.5% (95% CI 2.3%-2.6%). In the multivariate analysis, superior outcomes were associated with younger age, IgG subtype, complete hematological response at auto-HCT, Karnofsky score of 100%, international staging scoring (ISS) stage 1, HCT-comorbidity index (CI) 0, standard cytogenetic risk, auto-HCT in recent years, and use of lenalidomide maintenance. There were differences in the baseline characteristics and outcomes between registries. While the NRM was 1%-3% at 12 months worldwide, the OS at 36 months was 69%-84%, RI at 12 months was 12%-24% and PFS at 36 months was 43%-63%. The variability in these outcomes is attributable to differences in patient and disease characteristics as well as the use of maintenance and macroeconomic factors. In conclusion, worldwide data indicate that AHCT in MM is a safe and effective therapy with an NRM of 1%-3% with considerable regional differences in OS, PFS, RI, and patient characteristics. Maintenance treatment post-AHCT had a beneficial effect on OS.
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Affiliation(s)
- Laurent Garderet
- Service d'Hématologie, Sorbonne Université, Hopital Pitié Salpêtière APHP, Paris, France
| | - Luuk Gras
- EBMT Statistical Unit, Leiden, Netherlands
| | | | | | - Nada Hamad
- Department of Haematology, School of Medicine, St Vincent's Hospital Sydney, St Vincent's Clinical School, University of New South Wales, University of Notre Dame Australia, Sydney, New South Wales, Australia
| | - Anita Dsouza
- Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Noel Estrada-Merly
- CIBMTR® (Center for International Blood and Marrow Transplant Research), Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Parameswaran Hari
- Department of Hematology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Wael Saber
- Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Andrew J Cowan
- Clinical Research Division, Fred Hutchinson Cancer Center, Seattle, Washington, USA
| | - Minako Iida
- School of Medicine, Aichi Medical University, Aichi, Japan
| | | | - Hiroyuki Takamatsu
- School of Entrepreneurial and Innovation Studies, Kanazawa University, Kanazawa, Japan
| | - Shohei Mizuno
- Department of Hematology, School of Medicine, Aichi Medical University, Nagakute, Japan
| | - Koji Kawamura
- Division of Hematology, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Yoshihisa Kodera
- Department of Promotion for Blood and Marrow Transplantation, School of Medicine, Aichi Medical University, Nagoya, Japan
| | - Bor-Sheng Ko
- Department of Hematology, National Taiwan University Hospital, Taipei, Taiwan
| | | | - Kim Wah Ho
- Department of Hematology, Ampang Hospital, Ampang Jaya, Malaysia
| | - A Sim Goh
- Penang General hospital, Penang, Malaysia
| | - S Keat Tan
- Penang General hospital, Penang, Malaysia
| | - Alaa M Elhaddad
- Department of Pediatric Oncology and Stem Cell Transplantation Unit, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Ali Bazarbachi
- Bone Marrow Transplantation Program, Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
| | | | | | - Mohamed-Amine Bekadja
- Department of Hematology and Cell Therapy, EHU 1st Novembre 1954 Bir el Djir Usto, University Ahmed Benbella 1, Oran, Algeria
| | - Malek Benakli
- Centre Pierre et Marie Curie (CPMC), Algiers, Algeria
| | | | - Eloisa Riva
- Facultad de Medicina, Cátedra de Hematología, Hospital de Clínicas, Montevideo, Uruguay
| | | | | | - Hira S Mian
- Department of Oncology, McMaster University, Hamilton, Canada
| | - Arleigh McCurdy
- Department of Medicine, Division of Hematology, The Ottawa Hospital, Ottawa, Canada
| | - Feng Rong Wang
- Department of Hematology, Peking University, Beijing, China
| | - Ly Meng
- Department of Hematology, Peking University, Beijing, China
| | | | - Mickey Koh
- Infection and Immunity Clinical Academic Group St George's, University of London, London, UK
| | - John A Snowden
- BSBMTCT, Department of Haematology, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
| | - Stefan Schönland
- Department of Internal Medicine V, Amyloidosis Center, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Patrick John Hayden
- Department of Haematology, Trinity College Dublin, St. James's Hospital, Dublin, Ireland
| | - Anna Sureda
- Institut Català d'Oncologia, Hospital Duran i Reynals, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Universitat de Barcelona, L'Hospitalet de Llobregat, Spain
| | - Hildegard T Greinix
- Division of Hematology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Mahmoud Aljurf
- Oncology Center, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Yoshiko Atsuta
- Japanese Data Center for Hematopoietic Cell Transplantation, Department of Registry Science for Transplant and Cellular Therapy, School of Medicine, Aichi Medical University, Nagakute, Japan
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4
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Shinde S, Guntiboina VA, Nag A, Podder D, Chattopadhyay D, Kumar J, Bhave S, Mishra DK, Chandy M, Nair R. Melphalan-associated encephalopathy following autologous stem cell transplant: a transplanter's nightmare! BLOOD CELL THERAPY 2024; 7:33-36. [PMID: 38854402 PMCID: PMC11153210 DOI: 10.31547/bct-2023-025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 11/25/2023] [Indexed: 06/11/2024]
Abstract
Melphalan-induced encephalopathy is a rare complication observed in patients undergoing autologous stem cell transplantation (ASCT) and is characterized by symptoms ranging from drowsiness to seizures. Previous reports have described similar cases, including a review of a large cohort of patients in whom melphalan-associated encephalopathy was identified in 2% of the patients undergoing ASCT. We describe the case of a 63-year-old male with Multiple Myeloma and underlying chronic kidney disease (CKD) who underwent ASCT with a reduced dose of melphalan due to renal dysfunction in complete remission following induction therapy and subsequent neurological deterioration, which necessitated an extensive evaluation of several neurological and infective etiologies. In this report, we highlight that melphalan-associated encephalopathy is a distinct entity complicating ASCT in patients with myeloma, especially in those with preexisting renal insufficiency, and consider its management.
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Affiliation(s)
- Suchita Shinde
- Department of Clinical Haematology and Cellular Therapies, Tata Medical Center, Kolkata, India
| | - Vinay Anand Guntiboina
- Department of Clinical Haematology and Cellular Therapies, Tata Medical Center, Kolkata, India
| | - Arijit Nag
- Department of Clinical Haematology and Cellular Therapies, Tata Medical Center, Kolkata, India
| | - Dibakar Podder
- Department of Clinical Haematology and Cellular Therapies, Tata Medical Center, Kolkata, India
| | | | - Jeevan Kumar
- Department of Clinical Haematology and Cellular Therapies, Tata Medical Center, Kolkata, India
| | - Saurabh Bhave
- Department of Clinical Haematology and Cellular Therapies, Tata Medical Center, Kolkata, India
| | | | - Mammen Chandy
- Department of Clinical Haematology and Cellular Therapies, Tata Medical Center, Kolkata, India
| | - Reena Nair
- Department of Clinical Haematology and Cellular Therapies, Tata Medical Center, Kolkata, India
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5
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Cohen I, Vaxman I, Gertz MA. Historical Perspective of High-Dose Therapy Followed by Autologous Stem Cell Transplantation in Multiple Myeloma. Acta Haematol 2024:1-10. [PMID: 38710160 DOI: 10.1159/000539225] [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: 02/27/2024] [Accepted: 05/03/2024] [Indexed: 05/08/2024]
Abstract
BACKGROUND High-dose therapy (HDT) followed by autologous stem cell transplantation (ASCT) has become part of standard of care (SOC) in newly diagnosed multiple myeloma. In this review, we provide a historical perspective on ASCT since its introduction in the 1990s. SUMMARY Overall survival (OS) benefit for HDT followed by ASCT was demonstrated in studies comparing HDT with ASCT to standard-dose therapy (SDT) before the era of novel agents. Conditioning is done with melphalan 200 mg/m2. Lower doses (MEL140, MEL150) for older patients with comorbidities are safe and have comparable results. The addition of busulfan to melphalan improves progression-free survival (PFS) but not OS. HDT with ASCT after induction with novel agents prolongs PFS but not OS compared to SDT alone. The benefit is more evident in patients with high-risk cytogenetics. Mobilization can be achieved with granulocyte colony-stimulating factor alone, but is improved with the addition of chemotherapy. Plerixafor reduces mobilization failure and enables sufficient stem cell collection after induction with novel agents. ASCT is safe with a low rate of mortality (1%), and selected patients can be managed as outpatients. KEY MESSAGES HDT followed by ASCT remains part of SOC due to its PFS benefit and relatively low toxicity.
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Affiliation(s)
- Inbar Cohen
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel,
- Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel,
| | - Iuliana Vaxman
- Institute of Hematology, Davidoff Cancer Center, Rabin Medical Center, Petah Tikva, Israel
- Faculty of Medical and Health Sciences, Tel Aviv University, Tel Aviv, Israel
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
| | - Morie A Gertz
- Division of Hematology, Mayo Clinic, Rochester, Minnesota, USA
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6
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Neuendorff NR, Khan A, Ullrich F, Yates S, Devarakonda S, Lin RJ, von Tresckow B, Cordoba R, Artz A, Rosko AE. Cellular therapies in older adults with hematological malignancies: A case-based, state-of-the-art review. J Geriatr Oncol 2024; 15:101734. [PMID: 38430810 DOI: 10.1016/j.jgo.2024.101734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 11/05/2023] [Accepted: 02/19/2024] [Indexed: 03/05/2024]
Abstract
Cellular therapies, including autologous stem cell transplant (ASCT), allogeneic hematopoietic cell transplantation (alloHCT), and chimeric antigen receptor- (CAR-) T cell therapies are essential treatment modalities for many hematological malignancies. Although their use in older adults has substantially increased within the past decades, cellular therapies represent intensive treatment approaches that exclude a large percentage of older adults due to comorbidities and frailty. Under- and overtreatment in older adults with hematologic malignancy is a challenge and many treatment decisions are influenced by chronologic age. The advent of efficient and well-tolerated newer treatment approaches for multiple myeloma has challenged the role of ASCT. In the modern era, there are no randomized clinical trials of transplant versus non-transplant strategies for patients ≥65 years. Nonetheless, ASCT is feasible for selected older patients and does not result in long-term compromise in quality of life. AlloHCT is the only curative approach for acute myeloid leukemia of intermediate and unfavourable risk but carries a significant risk for non-relapse mortality depending on comorbidities, general fitness, and transplant-specific characteristics, such as intensity of conditioning and donor choice. However, alloHCT is feasible in appropriately-selected older adults. Early referral for evaluation is strongly encouraged as this is the most obvious barrier. CAR-T cell therapies have shown unprecedented clinical efficacy and durability in relapsed and refractory diffuse large B cell lymphoma. Its use is well tolerated in older adults, although evidence comes from limited case numbers. Whether patients who are deemed unfit for ASCT qualify for CAR-T cell therapy remains elusive, but the tolerability and efficacy of CAR-T cell therapy appears promising, especially for older patients. The evidence from randomized trials is strong in favor of using a comprehensive geriatric assessment (CGA) to reduce treatment-related toxicities and guide treatment intensity in the care for solid tumors; its use for evaluation of cellular therapies is less evidence-based. However, CGA can provide useful information on patients' fitness, resilient mechanisms, and reveal potential optimization strategies for compensating for vulnerabilities. In this narrative review, we will discuss key questions on cellular therapies in older adults based on illustrative patient cases.
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Affiliation(s)
- Nina Rosa Neuendorff
- Department of Hematology and Stem Cell Transplantation, University Hospital Essen, University Duisburg-Essen, Hufelandstrasse 55, D-45147 Essen, Germany.
| | - Abdullah Khan
- Department of Hematology, The Ohio State University, James Comprehensive Cancer Center, Columbus, OH, United States of America
| | - Fabian Ullrich
- Department of Hematology and Stem Cell Transplantation, University Hospital Essen, University Duisburg-Essen, Hufelandstrasse 55, D-45147 Essen, Germany
| | - Samuel Yates
- Department of Internal Medicine, Section of Hematology and Oncology, University of Chicago, Chicago, IL, United States of America
| | - Srinivas Devarakonda
- Department of Hematology, The Ohio State University, James Comprehensive Cancer Center, Columbus, OH, United States of America
| | - Richard J Lin
- Adult Bone Marrow Transplantation (BMT) Service, Cellular Therapy Service, Division of Hematologic Malignancies, Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
| | - Bastian von Tresckow
- Department of Hematology and Stem Cell Transplantation, University Hospital Essen, University Duisburg-Essen, Hufelandstrasse 55, D-45147 Essen, Germany
| | - Raul Cordoba
- Lymphoma Unit, Department of Hematology, Health Research Institute IIS-FJD, Fundacion Jimenez Diaz University Hospital, Madrid, Spain
| | - Andrew Artz
- Division of Leukemia, Department of Hematology & Hematopoietic Cell Transplantation, City of Hope, Duarte, CA, USA
| | - Ashley E Rosko
- Department of Hematology, The Ohio State University, James Comprehensive Cancer Center, Columbus, OH, United States of America
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7
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Beksac M, Eikema DJ, Koster L, Hulin C, Poiré X, Hamladji RM, Gromek T, Bazarbachi A, Ozkurt ZN, Pabst T, Ben Othman T, Finke J, Pirogova O, Wu D, Hayat A, Hilgendorf I, Tholouli E, de Wreede LC, Schönland S, Garderet L, Drozd-Sokolowska J, Raj K, Hayden PJ, Yakoub-Agha I, McLornan DP. In the era of Bortezomib-based Induction, intensification of Melphalan-based conditioning with Bortezomib does not improve Survival Outcomes in newly diagnosed Multiple Myeloma: a study from the Chronic Malignancies Working Party of the EBMT. Bone Marrow Transplant 2024; 59:526-533. [PMID: 38297040 PMCID: PMC10994834 DOI: 10.1038/s41409-023-02160-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 11/03/2023] [Accepted: 11/21/2023] [Indexed: 02/02/2024]
Abstract
Bortezomib (Vel)- Melphalan 200 mg/m2 (Mel200) (Vel-Mel) has been utilised to intensify conditioning in autologous hematopoietic stem cell transplantation (AHCT) for multiple myeloma (MM). This EBMT registry-based study compared Vel-Mel with Mel200 during upfront AHCT. Between 2010 and 2017, MM patients who received Vel-Mel (n = 292) conditioning were compared with 4,096 Mel200 patients in the same 58 centres. Pre-AHCT, compared to Mel200 patients, Vel-Mel patients had similar International Staging System (ISS) scores and cytogenetic risk profiles; a similar proportion had received bortezomib-based induction (85% and 87.3%, respectively) though they were younger with a better performance status. Vel-Mel patients were more likely to achieve CR post-induction (40.6% vs 20.3%, p < 0.001) and by day 100 of AHCT (CR/VGPR: 70.2 % vs. 57.2%, p < 0.001). There was no difference in 3-year PFS (49% vs 46%, p = 0.06) or early post-AHCT mortality. In multivariable analysis, Vel-Mel associated with inferior PFS (HR: 1.69 (1.27-2.25, p < 0.001) and OS (HR:1.46 (1.14-1.86,p = 0.002), similar to negative effects on PFS of advanced ISS (HR:1.56 (1.33-1.83, p < 0.001), high-risk cytogenetics (HR:1.43(1.18-1.74, p < 0.001) and poor post-induction response(<=PR)(HR: 1.43(1.25-1.62, p < 0.001) Overall, despite superior pre- and post-AHCT responses, there was no improvement in PFS or OS following Vel-Mel. This data supports the findings of the smaller prospective IFM study.
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Affiliation(s)
- Meral Beksac
- Istinye University Ankara Liv Hospital Hematology and Stem Cell Transplantation Unit, Ankara, 06880, Turkey.
| | | | | | | | - Xavier Poiré
- Cliniques Universitaires St. Luc, Brussels, Belgium
| | | | | | - Ali Bazarbachi
- Bone Marrow Transplantation Program, American University of Beirut Medical Center, Beiruit, Lebanon
| | | | | | | | | | - Olga Pirogova
- RM Gorbacheva Research Institute, Pavlov University, St. Petersburg, Russian Federation
| | - Depei Wu
- First Affiliated Hospital of Soochow University, Suzhou, China
| | - Amjad Hayat
- The Blood and Tissue Establishment, Galway University Hospital, Galway, Ireland
| | | | | | - Liesbeth C de Wreede
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | - Stefan Schönland
- Medizinische Klinik u. Poliklinik V, University of Heidelberg, Heidelberg, Germany
| | | | | | - Kavita Raj
- Department of Stem Cell Transplantation, University College London Hospitals, London, UK
| | - Patrick J Hayden
- Department of Haematology, Trinity College Dublin, St. James's Hospital, Dublin, Ireland
| | | | - Donal P McLornan
- Department of Stem Cell Transplantation, University College London Hospitals, London, UK
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8
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Shah G, Giralt S, Dahi P. Optimizing high dose melphalan. Blood Rev 2024; 64:101162. [PMID: 38097487 DOI: 10.1016/j.blre.2023.101162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 11/13/2023] [Accepted: 12/05/2023] [Indexed: 03/12/2024]
Abstract
Melphalan, has been a major component of myeloma therapy since the 1950s. In the context of hematopoietic cell transplantation (HCT), high dose melphalan (HDM) is the most common conditioning regimen used due to its potent anti-myeloma effects and manageable toxicities. Common toxicities associated with HDM include myelosuppression, gastrointestinal issues, and mucositis. Established approaches to reduce these toxicities encompass dose modification, nausea prophylaxis with 5HT3 receptor antagonists, cryotherapy, amifostine use, and growth factors. Optimization of melphalan exposure through personalized dosing and its combination with other agents like busulfan, or bendamustine show promise. Propylene glycol-free melphalan (Evomela) represents a novel formulation aiming to enhance drug stability and reduce adverse effects. This review explores strategies to enhance the efficacy and mitigate the toxicity of HDM in multiple myeloma. Future directions involve exploring these strategies in clinical trials to improve the safety and efficacy of HDM, thereby enhancing outcomes for multiple myeloma patients undergoing autologous HCT.
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Affiliation(s)
- Gunjan Shah
- Adult BMT Service Memorial Sloan Kettering Cancer Center, 530 East 74th Street, New York, NY 10021, United States of America.
| | - Sergio Giralt
- Adult BMT Service Memorial Sloan Kettering Cancer Center, 530 East 74th Street, New York, NY 10021, United States of America.
| | - Parastoo Dahi
- Adult BMT Service Memorial Sloan Kettering Cancer Center, 530 East 74th Street, New York, NY 10021, United States of America.
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9
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Bostankolu Değirmenci B, Yegin ZA, Akdemir ÜÖ, Dede A, Gündem GG, Özkurt ZN, Atay LÖ, Yağcı M. Clinical factors associated with autologous stem cell transplantation outcomes in multiple myeloma: upfront transplant with MEL200 remains the standard of care. Ann Hematol 2024; 103:269-283. [PMID: 37880484 DOI: 10.1007/s00277-023-05511-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 10/12/2023] [Indexed: 10/27/2023]
Abstract
Autologous stem cell transplantation (ASCT) remains the mainstay of the treatment in newly diagnosed transplant-eligible multiple myeloma (MM) patients. This retrospective study was performed to investigate the potential prognostic markers which may modify transplant course in a total of 256 ASCT recipients [median age: 58 (30-74) years; male/female: 138/118], including pretransplant (PET0) and day + 60 (PET2) PET/CT assessments and comparative analysis of melphalan (Mel) dose. Better responses with significantly higher complete response/very good partial response rates were achieved in patients who proceeded to transplant within 301 days from diagnosis (p < 0.001). Patients who had received < 1.5 lines of treatment prior to transplant had significantly higher probability of overall survival (OS) (p = 0.004) and progression-free survival (PFS) (p < 0.001). The probability of OS was significantly higher in patients with low Eastern Cooperative Oncology Group (ECOG) performance score (PS = 0-1) (p = 0.003) and HCT-Comorbidity Index (HCT-CI = 0) (p = 0.011). The number of involved areas (p = 0.028) and maximum standardized uptake value (SUVmax) (p = 0.021) in PET0 represented significant impact on OS. The probabilities of OS (p < 0.001) and PFS (p = 0.01) were significantly better with Mel200 mg/m2 conditioning compared to Mel140 mg/m2. Conditioning with Mel200 mg/m2, early and upfront ASCT and low pretransplant treatment burden were found to be significantly associated with ASCT outcome in MM patients. Despite its predictor impact on survival and prognosis, further studies are warranted to standardize PET/CT-based response assessments before being used as a guide for treatment decisions in clinical practice.
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Affiliation(s)
| | - Zeynep Arzu Yegin
- Department of Hematology, Gazi University Faculty of Medicine, Ankara, Turkey.
| | - Ümit Özgür Akdemir
- Department of Nuclear Medicine, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Ali Dede
- Department of Internal Medicine, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Gonca Gül Gündem
- Department of Internal Medicine, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Zübeyde Nur Özkurt
- Department of Hematology, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Lütfiye Özlem Atay
- Department of Nuclear Medicine, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Münci Yağcı
- Department of Hematology, Gazi University Faculty of Medicine, Ankara, Turkey
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10
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Ursu SG, Maples S, Williams KJ, Patrus G, Samhouri Y, Fazal S, Mewawalla P, Sadashiv S. The Impact of Renal Impairment in Multiple Myeloma Patients Undergoing Autologous Stem Cell Transplantation With Melphalan Conditioning. J Hematol 2023; 12:201-207. [PMID: 37936977 PMCID: PMC10627361 DOI: 10.14740/jh1148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 09/13/2023] [Indexed: 11/09/2023] Open
Abstract
Background There are no standard renal dose adjustments for melphalan conditioning for autologous stem cell transplantation (ASCT) in multiple myeloma (MM) patients. The objective of this study was to evaluate the effect of melphalan dosing and chronic kidney disease (CKD) on transplant-related outcomes, progression-free survival (PFS), and overall survival (OS). Methods A retrospective chart review was performed, and MM patients who underwent ASCT between February 2016 and September 2021 were included. Melphalan 200 mg/m2 (Mel200) or 140 mg/m2 (Mel140) was administered. The cohort was divided based on renal function: creatinine clearance (CrCl) ≥ 60 mL/min (no-CKD) and CrCl < 60 mL/min (CKD). Outcomes measured include PFS, OS, treatment-related mortality (TRM), incidence of adverse events, hospitalization duration, and hospital readmission within 30 days. Statistical analysis included Chi-square test, t-test, and Kaplan-Meier method. Logistic regression model was used to account for melphalan dose adjustment. Results A total of 124 patients were included (n = 108 no-CKD, and n = 16 CKD). Median age was 62 years, majority (62%) were male, and 97% had at least a partial response at time of ASCT. Of the 124 patients, nine (7%) received Mel140. Five of these patients had CKD (CrCl range: 26 - 58 mL/min), with one on hemodialysis. Median time to neutrophil engraftment was 13.6 vs. 14.9 days and median time to platelet engraftment was 18.3 vs. 18.5 days in the CKD group vs. no-CKD group, respectively (P = 0.03 and P = 0.8). When adjusting for melphalan dose reduction, the median time to neutrophil engraftment was not statistically significant (P = 0.11). At a median follow-up of 28.7 months, the median PFS for the CKD vs. no-CKD group was 60 vs. 46 months (P = 0.3). One-year OS was 93.8% in the CKD group vs. 97% in the no-CKD group. There was a higher incidence of grade 3 or 4 mucositis in the CKD group vs. no-CKD group (P = 0.013). Conclusions There is no significant difference in engraftment, PFS, or OS for MM patients with CKD vs. no-CKD receiving melphalan conditioning for ASCT. Severe mucositis was significantly more common in the CKD group, including when accounting for melphalan dose reduction.
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Affiliation(s)
- Sorana G. Ursu
- Division of Hematology/Cellular Therapy, Allegheny Health Network Cancer Institute, Pittsburgh, PA 15224, USA
| | - Samantha Maples
- Division of Hematology/Cellular Therapy, Allegheny Health Network Cancer Institute, Pittsburgh, PA 15224, USA
| | - Kiersten J. Williams
- Division of Hematology/Cellular Therapy, Allegheny Health Network Cancer Institute, Pittsburgh, PA 15224, USA
| | - Gina Patrus
- Division of Hematology/Cellular Therapy, Allegheny Health Network Cancer Institute, Pittsburgh, PA 15224, USA
| | - Yazan Samhouri
- Division of Hematology/Cellular Therapy, Allegheny Health Network Cancer Institute, Pittsburgh, PA 15224, USA
| | - Salman Fazal
- Division of Hematology/Cellular Therapy, Allegheny Health Network Cancer Institute, Pittsburgh, PA 15224, USA
| | - Prerna Mewawalla
- Division of Hematology/Cellular Therapy, Allegheny Health Network Cancer Institute, Pittsburgh, PA 15224, USA
| | - Santhosh Sadashiv
- Division of Hematology/Cellular Therapy, Allegheny Health Network Cancer Institute, Pittsburgh, PA 15224, USA
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11
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Seehaus CM, Schutz N, Brulc E, Ferini G, Arbelbide J, Fantl D, Basquiera AL. Autologous stem cell transplantation in patients older than 65 years with multiple myeloma: a real-world study. Hematol Transfus Cell Ther 2023:S2531-1379(23)00169-4. [PMID: 37739860 DOI: 10.1016/j.htct.2023.07.012] [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: 03/20/2022] [Revised: 06/20/2023] [Accepted: 07/24/2023] [Indexed: 09/24/2023] Open
Abstract
INTRODUCTION The treatment of elderly multiple myeloma (MM) patients with autologous stem cell transplantation (ASCT) is a controversial procedure. Most clinical trials evaluating the safety and efficacy of ASCT have primarily included patients younger than 65 years. DESIGN AND METHODS This was a retrospective analysis of patients with MM who underwent ASCT between 2008 and 2018. Patients at or over 65 years were compared with patients under 65 years. We analyzed treatment-related mortality (TRM), response rate, progression-free survival (PFS) and overall survival (OS). RESULTS Two hundred and twenty-one patients were included: 50 patients at or over 65 years, (median age 68 years), including 7 patients over 70 years and 151 patients under 65 years, (median age 57 years). No differences were found in the neutrophil and platelet engraftment, median days of hospitalization and life support requirement during the hospitalization period for the ASCT. No statistically significant differences were found in the incidence of TRM between both groups at 100 days post-transplant (2% vs. 2.9%, p = 0.322). The ASCT improved complete response and stringent complete response rates (44% vs. 37%, p < 0.001). Survival was not modified by age: after a median follow-up of 53 months, the estimated PFS rates at three years were 63% and 60% (p = 0.88) and the OS rates at five years were 75% and 74% (p = 0.72), respectively. CONCLUSIONS Our data suggest that the ASCT is feasible in selected elderly patients with MM over 65 years of age, achieving response and survival rates similar to those of younger patients.
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Affiliation(s)
| | - Natalia Schutz
- Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Erika Brulc
- Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Gonzalo Ferini
- Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | | | - Dorotea Fantl
- Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
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12
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Beksac M, Iacobelli S, Koster L, Cornelissen J, Griskevicius L, Rabin NK, Stoppa AM, Meijer E, Mear JB, Zeerleder S, Mayer J, Fenk R, Fegueux N, Chevallier P, Konirova E, Snowden JA, Engelhardt M, Orchard K, Hulin C, Schaap N, Sossa C, Elmaagacli A, McLornan DP, Hayden PJ, Schönland S, Yakoub-Agha I. An early post-transplant relapse prediction score in multiple myeloma: a large cohort study from the chronic malignancies working party of EBMT. Bone Marrow Transplant 2023; 58:916-923. [PMID: 37160942 DOI: 10.1038/s41409-023-01999-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 04/17/2023] [Accepted: 04/21/2023] [Indexed: 05/11/2023]
Abstract
Early relapse (ER) following Autologous Hematopoietic Cell Transplantation (AHCT) confers a poor prognosis. We therefore developed a novel scoring system to predict ER. A total of 14,367 AHCT-1 patients were transplanted between 2014 and 2019, and were conditioned with Melphalan 200 mg/m2 (Mel200) (n = 7228; 2014-2017) (training cohort); Mel200 (n = 5616; 2018-2019) or Mel140 (n = 1523; 2018-2019) (validation cohorts). PFS-12 and the Cumulative Incidence of Relapse at 12 months were 84.1% and 14.7% (training Mel200), 87.2% and 11.6% (validation Mel200), and 80.3% and 16.9% (validation Mel140), respectively. The points in the risk score were: 0, 1,2 for ISS stages I, II, and III; Disease status: 0 (CR/VGPR); 1 (PR); 2 (SD/MR); 4 (Relapse/Progression); and 1 for Karnofsky ≤ 70. The distribution of scores: 0 (24%), 1 (33.9%), 2 (29.6 %), 3 (9.5%), and ≥4 (2.7%). The score separated PFS-12, with the lowest risk group (n = 1752) having a PFS-12 of 91.7% and the highest risk group (n = 195) 57.1%. This also applied in cytogenetically high-risk patients. If the pre-score baseline risks are 15% (standard risk) and 25% (high-risk), a score of ≥4 confers calculated risks of 38% and 54%, respectively. This novel EBMT ER score, therefore, allows for the identification of five discrete prognostic groups.
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Affiliation(s)
| | | | - Linda Koster
- European Society for Blood and Marrow Transplantation Leiden Study Unit, Leiden, the Netherlands
| | - Jan Cornelissen
- Erasmus University Medical Center-Daniel Den Hoed, Rotterdam, the Netherlands
| | | | - Neil K Rabin
- University College London Hospitals NHS Foundation Trust, London, UK
| | | | - Ellen Meijer
- VU University Medical Center, Amsterdam, the Netherlands
| | | | | | - Jiri Mayer
- University Hospital Brno, Brno, Czech Republic
| | - Roland Fenk
- University Hospital Duesseldorf, Dusseldorf, Germany
| | | | | | | | | | | | - Kim Orchard
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | | | - Nicolaas Schaap
- Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands
| | - Claudia Sossa
- Clinica FOSCAL, Floridablanca, Santander, Colombia
- Universidad Autónoma de Bucaramanga - UNAB, Bucaramanga, Santander, Colombia
| | | | | | - Patrick J Hayden
- Department of Haematology, School of Medicine, Trinity College Dublin, Dublin, Ireland
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13
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Sharma N, Benson E, Zhao Q, Nunnelee J, Cottini F, Elder P, Rosko A, Bumma N, Khan A, Umyarova E, Devarakonda S, Efebera YA, Benson DM. Survival outcomes following autologous stem cell transplant with melphalan 140mg/m 2 versus 200mg/m 2 preparative regimens in patients with multiple myeloma. Leuk Lymphoma 2023; 64:1315-1321. [PMID: 37199099 DOI: 10.1080/10428194.2023.2213366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 04/24/2023] [Accepted: 05/04/2023] [Indexed: 05/19/2023]
Abstract
The standard preparative regimen for autologous stem cell transplant (ASCT) in multiple myeloma (MM) is 200 mg/m2 of intravenous melphalan; however, a dose of 140 mg/m2 is often used when concerns exist related to patient age, performance status, organ function, and other factors. It is unclear whether a lower dose of melphalan impacts post-transplant survival outcomes. We performed a retrospective review of 930 patients with MM who underwent ASCT with 200 mg/m2 versus 140 mg/m2 melphalan. On univariable analysis, no difference in progression-free survival (PFS) was observed, however, an overall survival (OS) benefit was observed in patients receiving 200 mg/m2 melphalan (p = 0.04). Multivariable analyses showed patients receiving 140 mg/m2 faired no worse than those receiving 200 mg/m2. While a subset of younger patients with normal renal function may achieve superior OS with a standard dose of 200 mg/m2 melphalan, these findings suggest an opportunity to individualize the ASCT preparative regimen to optimize outcomes.
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Affiliation(s)
- Nidhi Sharma
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH, USA
| | - Evan Benson
- Pre-Medical Program, University of Dayton, Dayton, OH, USA
| | - Qiuhong Zhao
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH, USA
| | - Jordan Nunnelee
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH, USA
- The Ohio State University College of Medicine, Columbus, OH, USA
| | - Francesca Cottini
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH, USA
| | - Patrick Elder
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH, USA
| | - Ashley Rosko
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH, USA
| | - Naresh Bumma
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH, USA
| | - Abdullah Khan
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH, USA
| | - Elvira Umyarova
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH, USA
| | - Srinivas Devarakonda
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH, USA
| | - Yvonne A Efebera
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH, USA
- Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Don M Benson
- Division of Hematology, Department of Internal Medicine, The Ohio State University, Columbus, OH, USA
- Bone Marrow Transplantation & Cellular Therapy, OhioHealth, Columbus, OH, USA
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14
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Costa BA, Mouhieddine TH, Ortiz RJ, Richter J. Revisiting the Role of Alkylating Agents in Multiple Myeloma: Up-to-Date Evidence and Future Perspectives. Crit Rev Oncol Hematol 2023; 187:104040. [PMID: 37244325 DOI: 10.1016/j.critrevonc.2023.104040] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 05/15/2023] [Accepted: 05/23/2023] [Indexed: 05/29/2023] Open
Abstract
From the 1960s to the early 2000s, alkylating agents (e.g., melphalan, cyclophosphamide, and bendamustine) remained a key component of standard therapy for newly-diagnosed or relapsed/refractory multiple myeloma (MM). Later on, their associated toxicities (including second primary malignancies) and the unprecedented efficacy of novel therapies have led clinicians to increasingly consider alkylator-free approaches. Meanwhile, new alkylating agents (e.g., melflufen) and new applications of old alkylators (e.g., lymphodepletion before chimeric antigen receptor T-cell [CAR-T] therapy) have emerged in recent years. Given the expanding use of antigen-directed modalities (e.g., monoclonal antibodies, bispecific antibodies, and CAR-T therapy), this review explores the current and future role of alkylating agents in different treatment settings (e.g., induction, consolidation, stem cell mobilization, pre-transplant conditioning, salvage, bridging, and lymphodepleting chemotherapy) to ellucidate the role of alkylator-based regimens in modern-day MM management.
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Affiliation(s)
- Bruno Almeida Costa
- Department of Medicine, Mount Sinai Morningside and West, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Tarek H Mouhieddine
- Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ricardo J Ortiz
- Department of Medicine, Mount Sinai Morningside and West, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Joshua Richter
- Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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15
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Banday SZ, Guru F, Ayub M, Ahmed SN, Banday AZ, Mir MH, Nisar R, Hussain S, Bhat GM, Aziz SA. Long-Term Outcomes of Autologous Hematopoietic Stem Cell Transplant (HSCT) for Multiple Myeloma: While New Horizons Emerge, It Is Still Only a Silver Lining for Resource-Constrained Settings. Cureus 2023; 15:e36642. [PMID: 37155458 PMCID: PMC10122934 DOI: 10.7759/cureus.36642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2023] [Indexed: 05/10/2023] Open
Abstract
Background Significant hurdles impede the optimal implementation of hematopoietic stem cell transplantation (HSCT) in low-middle income countries (LMICs). Herein, we highlight the challenges faced in LMICs while performing HSCT and report the long-term outcomes of patients with newly diagnosed multiple myeloma (MM) who underwent autologous HSCT (AHSCT) at our center. Besides, we provide a comprehensive review of studies reporting long-term outcomes of AHSCT in MM from the Indian subcontinent. Methodology This study was conducted at the State Cancer Institute, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, India. Case records of all patients with MM who received AHSCT from December 2010 to July 2018 were reviewed retrospectively. A non-systematic literature search was performed using PubMed and Google Scholar databases. Data regarding clinicopathological parameters and long-term follow-up were extracted from relevant studies and for patients included in our study. Results At our center, 47 patients (median age 52.0 years) with MM underwent AHSCT. Majority of patients had stage III disease (ISS) and median time to transplant was 11.5 months. The five-year progression free survival (PFS) and overall survival (OS) were 59.1% and 81.2%, respectively. Studies from the Indian subcontinent have observed a five-year OS of ~50% to ~85%. However, a greater variability in the five-year PFS has been reported, ranging from ~20% to ~75%. The median time to transplant has ranged from seven to 17 months (indicating time delays) with median CD34 cell counts of 2.7-6.3×106 cells/kg (lower than developed countries). Conclusions Despite significant resource limitations in LMICs, AHSCT is increasingly been performed in MM with encouraging long-term outcomes.
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Affiliation(s)
- Saquib Z Banday
- Department of Medical Oncology, State Cancer Institute, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, IND
| | - Faisal Guru
- Department of Medical Oncology, Pediatrics Unit, State Cancer Institute, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, IND
| | - Maniza Ayub
- Department of Pathology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, IND
| | - Syed N Ahmed
- Department of Medical Oncology, State Cancer Institute, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, IND
| | - Aaqib Z Banday
- Department of Pediatrics, Government Medical College, Srinagar, IND
| | - Mohmad H Mir
- Department of Medical Oncology, State Cancer Institute, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, IND
| | - Rahila Nisar
- Department of Microbiology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, IND
| | - Saleem Hussain
- Department of Laboratory Hematology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, IND
| | - Gull M Bhat
- Department of Medical Oncology, State Cancer Institute, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, IND
| | - Sheikh A Aziz
- Department of Medical Oncology, State Cancer Institute, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, IND
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16
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Kumar L, Sahoo RK, Kumar S, Baa AK, Tansir G, Pathak N, Malik PS, Sharma OD, Mathew A, Jha A, Gupta R, Sharma A, Biswas A, Kumar R, Thulkar S, Malik S, Dutt A. Autologous stem cell transplant for multiple myeloma: Impact of melphalan dose on the transplant outcome. Leuk Lymphoma 2023; 64:378-387. [PMID: 36416679 DOI: 10.1080/10428194.2022.2148214] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
We evaluated impact of melphalan dose on transplant outcomes for multiple myeloma. Between 1995 and 2019 459 consecutive patients received a transplant; 69(15%) received melphalan ≤150 mg/m2 (Mel 150 cohort) and 390 (85%) melphalan 200 mg/m2 (MEL 200 cohort). The primary outcome was overall survival (OS) from the date of transplant. Progression-free survival (PFS), engraftment, transplant response, and cumulative relapse at 2 years were secondary outcome measures. Patients in Mel 150 cohort had adverse clinical and laboratory parameters at base line. Transplant response was better for Mel 200 cohort (p < 0.024). Median OS at a median follow-up of 88 months was similar in the two cohorts; 100 Vs 102 months (Mel 200), p = 0.817. Median PFS (60.0 Vs 53 months, p = 0.746), relapse at two years (32.4% Vs 30.9%, p = 0.745) and grade 3-4 mucositis (p = 0.823) were similar. Initial treatment prepares patients better for subsequent similar transplant outcomes despite differences in baseline characteristics.
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Affiliation(s)
- Lalit Kumar
- Department of Medical Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Ranjit Kumar Sahoo
- Department of Medical Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Sudhir Kumar
- Department of Medical Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Annie K Baa
- Department of Medical Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Ghazal Tansir
- Department of Medical Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Neha Pathak
- Department of Medical Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Prabhat S Malik
- Department of Medical Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Om Dutt Sharma
- Department of Medical Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Anisha Mathew
- Department of Medical Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Ankit Jha
- Department of Medical Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Ritu Gupta
- Department of Medical Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Atul Sharma
- Department of Medical Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Ahitagni Biswas
- Department of Radiation Oncology, All India Institute of Medical Sciences, New Delhi, India
| | - Rakesh Kumar
- Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Sanjay Thulkar
- Department of Radio-diagnosis, All India Institute of Medical Sciences, New Delhi, India
| | - Soumyaranjan Malik
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - Ashish Dutt
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
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17
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Chaireti R, Uttervall K, Luong V, Lund J, Kashif M, Gahrton G, Alici E, Nahi H, Afram G. Response to Caravita di Toritto and Rago. Eur J Haematol Suppl 2023; 110:224-225. [PMID: 36300846 DOI: 10.1111/ejh.13887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 10/24/2022] [Indexed: 01/19/2023]
Affiliation(s)
- Roza Chaireti
- Department of Hematology, Karolinska University Hospital, Stockholm, Sweden.,Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Katarina Uttervall
- Department of Hematology, Karolinska University Hospital, Stockholm, Sweden.,Center for Hematology and Regenerative Medicine, Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Vincent Luong
- Department of Hematology, Karolinska University Hospital, Stockholm, Sweden.,Center for Hematology and Regenerative Medicine, Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Johan Lund
- Department of Hematology, Karolinska University Hospital, Stockholm, Sweden
| | - Muhammad Kashif
- Center for Hematology and Regenerative Medicine, Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Gösta Gahrton
- Center for Hematology and Regenerative Medicine, Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Evren Alici
- Department of Hematology, Karolinska University Hospital, Stockholm, Sweden.,Center for Hematology and Regenerative Medicine, Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Hareth Nahi
- Center for Hematology and Regenerative Medicine, Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Gabriel Afram
- Department of Hematology, Karolinska University Hospital, Stockholm, Sweden.,Center for Hematology and Regenerative Medicine, Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden.,Pfizer AB, Sollentuna, Sweden
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18
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Safety and efficacy of autologous stem cell transplantation in dialysis-dependent myeloma patients-The DIADEM study from the chronic malignancies working party of the EBMT. Bone Marrow Transplant 2023; 58:424-429. [PMID: 36681775 DOI: 10.1038/s41409-023-01915-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 12/27/2022] [Accepted: 01/10/2023] [Indexed: 01/22/2023]
Abstract
The role of high-dose chemotherapy followed by autologous stem cell transplantation (ASCT) in the treatment of myeloma (MM) patients with severe and/or dialysis-dependent renal impairment remains uncertain. We report on the outcomes of 110 patients (median age 57 years) who had become dialysis-dependent pre-ASCT and who underwent a first ASCT between 1997 and 2017. Sixty-three (57%) patients had light chain MM. All patients required dialysis (94% hemodialysis and 6% peritoneal). Forty-four of 71 (62%) patients received bortezomib-based induction regimens and 42 (39%) patients had achieved at least a very good partial response (VGPR) pre-ASCT. Melphalan dosing was as follows: ≤140 mg/m2 (82%), and >140 mg/m2 (18%). The median PFS after ASCT was 35 months (95% CI: 21.5-42.2) and the median OS 102 months (95% CI: 70.4-129.1). At 1, 2, and 5 years after ASCT, 8% (95% CI 3-14%), 13% (6-20%), and 20% (12-29%) of patients, respectively, had achieved dialysis independence. In multivariate analyses of OS and PFS including age at ASCT, response at ASCT, and year of ASCT, younger age at ASCT and better response at ASCT (CR/VGPR/PR vs. MR/SD/progression) were significantly associated with better OS and PFS.
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19
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Pawlyn C, Khan AM, Freeman CL. Fitness and frailty in myeloma. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2022; 2022:337-348. [PMID: 36485137 PMCID: PMC9820647 DOI: 10.1182/hematology.2022000346] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
As the aging population grows, so too does the number of well-tolerated antimyeloma therapies. Physicians will see an increasing volume of patients for subsequent lines of therapy, which could now extend this relationship for over a decade. For younger patients, treatment choices are infrequently impacted by concerns of fitness, but instead about effecting the deepest, most durable response. Older adults, in contrast, are more likely to experience under- than overtreatment, and therefore more objective (and ideally straightforward) ways to evaluate their fitness and ability to tolerate therapy will increasingly assist in decision-making. Post hoc analyses categorizing the fitness of trial patients in the modern treatment era globally demonstrate that even in highly selected populations, those that are recategorized as less fit or frail are consistently at higher risk of inferior outcomes and increased toxicities. Real-world data are comparatively lacking but do demonstrate that most patients with myeloma are not representative of those enrolled on clinical trials, generally more heavily burdened by comorbidities and more likely to be categorized as "less than fit." Simultaneously, the number of therapeutic options open to patients in the relapsed setting continues to grow, now including T-cell engagers and cellular therapies, with their unique toxicity profiles. The aim of this review is to summarize the available data, highlight some of the approaches possible to easily assess fitness and how results might inform treatment selection, and illustrate ways that patients' condition can be optimized rather than lead to exclusion from the more complex therapies newly available.
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Affiliation(s)
- Charlotte Pawlyn
- The Institute of Cancer Research, London, UK
- The Royal Marsden NHS Foundation Trust, London, UK
| | - Abdullah M Khan
- The Ohio State University Comprehensive Cancer Center, Columbus, OH
| | - Ciara L Freeman
- H. Lee Moffitt Cancer Centre & Research Institute, Morsani College of Medicine, University of South Florida, Tampa, FL
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20
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Afram G, Chaireti R, Uttervall K, Luong V, Lund J, Kashif M, Gahrton G, Alici E, Nahi H. Conditioning with melphalan 200 mg/m 2 and subsequent ASCT improves progression-free and overall survival in elderly myeloma patients compared to standard of care. Eur J Haematol 2022; 109:749-754. [PMID: 36066204 PMCID: PMC9826071 DOI: 10.1111/ejh.13861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 08/30/2022] [Accepted: 09/01/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVES Despite the effectiveness of newer drugs for the treatment of multiple myeloma (MM), the outcomes are further improved by subsequent autologous stem cell transplantation (ASCT). Data on effectiveness in older patients are limited. We compared outcomes in patients aged 65-75 years depending on whether they were treated with ASCT or not and compared those to outcomes in patients <65 years. METHODS This was a retrospective, single-center study. We compared progression-free survival (PFS) and overall survival (OS) for all MM patients below and above the age of 65 years treated ± ASCT at the Karolinska University Hospital between 2010 and 2020. PFS and OS were calculated by the Kaplan-Meier method. Variables affecting PFS and OS were evaluated using Cox regression model. RESULTS Both PFS and OS were improved in the group 65-75 years treated +ASCT compared to those treated pharmacologically (p = 0.008 and p < 0.001, respectively). There were no significant differences between patients <65 years and those 65-75 years treated with ASCT. CONCLUSION The findings indicate that even patients >65 years should be evaluated as candidates for ASCT. An individualized approach supported by a frailty/geriatric assessment score could assist clinicians to select the appropriate treatment for each patient.
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Affiliation(s)
- Gabriel Afram
- Center for Hematology and Regenerative Medicine, Department of MedicineHuddinge, Karolinska InstitutetStockholmSweden,Department of HematologyKarolinska University HospitalStockholmSweden,Pfizer ABSollentunaSweden
| | - Roza Chaireti
- Department of HematologyKarolinska University HospitalStockholmSweden,Department of Molecular Medicine and SurgeryKarolinska InstitutetStockholmSweden
| | - Katarina Uttervall
- Center for Hematology and Regenerative Medicine, Department of MedicineHuddinge, Karolinska InstitutetStockholmSweden,Department of HematologyKarolinska University HospitalStockholmSweden
| | - Vincent Luong
- Center for Hematology and Regenerative Medicine, Department of MedicineHuddinge, Karolinska InstitutetStockholmSweden,Department of HematologyKarolinska University HospitalStockholmSweden
| | - Johan Lund
- Center for Hematology and Regenerative Medicine, Department of MedicineHuddinge, Karolinska InstitutetStockholmSweden
| | - Muhammad Kashif
- Center for Hematology and Regenerative Medicine, Department of MedicineHuddinge, Karolinska InstitutetStockholmSweden
| | - Gösta Gahrton
- Center for Hematology and Regenerative Medicine, Department of MedicineHuddinge, Karolinska InstitutetStockholmSweden
| | - Evren Alici
- Center for Hematology and Regenerative Medicine, Department of MedicineHuddinge, Karolinska InstitutetStockholmSweden,Department of HematologyKarolinska University HospitalStockholmSweden
| | - Hareth Nahi
- Center for Hematology and Regenerative Medicine, Department of MedicineHuddinge, Karolinska InstitutetStockholmSweden
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21
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Song GY, Jung SH, Kim JS, Eom HS, Moon JH, Yhim HY, Kim K, Min CK, Lee JJ. Busulfan and thiotepa as a conditioning regimen for autologous stem cell transplantation in patients with multiple myeloma: A study of the Korean Multiple Myeloma Working Party (KMMWP-1801 study). Front Oncol 2022; 12:959949. [PMID: 36110935 PMCID: PMC9468269 DOI: 10.3389/fonc.2022.959949] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 07/29/2022] [Indexed: 12/04/2022] Open
Abstract
Background Autologous stem cell transplantation (ASCT) remains the standard of care for patients with newly diagnosed multiple myeloma (MM). Several attempts to improve the efficacy of conditioning regimens have been conducted in MM, but no more effective regimen than conventional high-dose melphalan has been introduced. Objective In this study, the efficacy and toxicity of busulfan and thiotepa (BuTT) and those of high-dose melphalan (HD-MEL) were compared retrospectively as a conditioning regimen for ASCT in patients with MM. Study design Included in the analysis were 114 patients who received BuTT and 114 patients who received HD-MEL treatment between March 2008 and May 2020. The BuTT regimen consisted of intravenous thiotepa 5 mg/kg once a day from days 7 to 6, followed by intravenous busulfan 3.2 mg/kg once a day from days 5 to 3. The HD-MEL conditioning regimen consisted of melphalan 100 mg/m2 once a day from days 3 to 2. Results The overall response rate after ASCT did not differ between BuTT and HD-MEL (94.7% in BuTT vs. 97.4% in HD-MEL, p = 0.333). After a median follow-up of 47.6 months, progression-free survival (PFS) tended to be longer in the BuTT group (median PFS, 41.5 months vs. 30.3 months; hazard ratio (HR), 0.706; 95% confidence interval (CI), 0.497–1.004, p = 0.053). In the subgroup analysis of patients who did not proceed to maintenance or consolidation treatment after ASCT, the difference in PFS became more significant (median PFS, 41.5 months vs. 24.4 months; HR, 0.621; 95% CI, 0.388–0.993; p = 0.047). Additionally, the BuTT group had fewer adverse events, such as grade 3 or 4 stomatitis and diarrhea, than the HD-MEL group (stomatitis, 10.5% vs. 23.7%, p = 0.013; diarrhea, 10.5% vs. 25.4%, p = 0.005). There was no difference in the occurrence of venous-occlusive disease (2.6% in BuTT vs. 0.9% in HD-MEL, p = 0.622). Conclusion Our study results suggest that BuTT is an effective alternative conditioning regimen with reduced toxicity in patients with newly diagnosed MM.
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Affiliation(s)
- Ga-Young Song
- Department of Hematology-Oncology Chonnam National University Hwasun Hospital and Chonnam National University Medical School, Hwasun, South Korea
| | - Sung-Hoon Jung
- Department of Hematology-Oncology Chonnam National University Hwasun Hospital and Chonnam National University Medical School, Hwasun, South Korea
| | - Jin Seok Kim
- Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | | | - Joon Ho Moon
- Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, South Korea
| | - Ho-Young Yhim
- Division of Hematology/Oncology Chonbuk National University Medical School, Jeonju, South Korea
| | - Kihyun Kim
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Chang-Ki Min
- Seoul St. Mary's Hematology Hospital, Catholic University of Korea, Seoul, South Korea
| | - Je-Jung Lee
- Department of Hematology-Oncology Chonnam National University Hwasun Hospital and Chonnam National University Medical School, Hwasun, South Korea
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22
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Waszczuk-Gajda A, Penack O, Sbianchi G, Koster L, Blaise D, Reményi P, Russell N, Ljungman P, Trneny M, Mayer J, Iacobelli S, Kobbe G, Scheid C, Apperley J, Touzeau C, Lenhoff S, Jantunen E, Anagnostopoulos A, Paris L, Browne P, Thieblemont C, Schaap N, Sierra J, Yakoub-Agha I, Garderet L, Styczynski J, Schoemans H, Moiseev I, Duarte RF, Peric Z, Montoto S, van Biezen A, Mikulska M, Aljurf M, Ruutu T, Kröger N, Morris C, Koenecke C, Schoenland S, Basak GW. Complications of Autologous Stem Cell Transplantation in Multiple Myeloma: Results from the CALM Study. J Clin Med 2022; 11:jcm11123541. [PMID: 35743620 PMCID: PMC9225651 DOI: 10.3390/jcm11123541] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 06/12/2022] [Accepted: 06/16/2022] [Indexed: 01/27/2023] Open
Abstract
Background: The main goal of this post hoc analysis of the Collaboration to Collect Autologous Transplant Outcomes in Lymphoma and Myeloma (CALM) study was to evaluate the rate of short- and long-term infectious and non-infectious complications occurring after ASCT in patients with multiple myeloma (MM). Methods: The analysis included all patients with MM from the CALM study who underwent ≥1 ASCT. The primary endpoint of the analysis was to determine the rate of infectious and non-infectious complications after ASCT and to compare them in three time periods: 0−100 days, 101 days−1 year, and >1 year after the first transplant. Results: The analysis included a total of 3552 patients followed up for a median of 56.7 months (range 0.4−108.1). Complication rates decreased with the time from ASCT with 24.85 cases per 100 patient-years from day 0 to 100 days after the transplant, and <2.31 cases per 100 patient-years from the 101st day. At 100 days after ASC T, 45.7% of patients had complications, with infectious events being twice as frequent as non-infectious complications. Bacterial infections (6.5 cases per 100 patient-years, 95% CI: 6.1−7.0) and gastrointestinal complications (4.7 cases per 100 patient-years, 95% CI: 4.3−5.1) were the most common early events. The pattern of complications changed with time from ASCT. The presence of complications after ASCT was not associated with overall survival. Conclusions: Our data provide a solid basis for comparing ASCT-related complications to those caused by emerging treatments in multiple myeloma, such as CAR T-cell therapy and other immunotherapies.
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Affiliation(s)
- Anna Waszczuk-Gajda
- Department of Hematology, Transplantation and Internal Medicine, University Clinical Centre—The Medical University of Warsaw, 02-097 Warsaw, Poland;
- Correspondence:
| | - Olaf Penack
- Charité Universitätsmedizin Berlin, 10771 Berlin, Germany;
| | | | - Linda Koster
- EBMT Data Office Leiden, 2333 AA Leiden, The Netherlands; (L.K.); (A.v.B.)
| | | | | | | | - Per Ljungman
- Department of Cellular Therapy and Allogeneic Stem Cell Transplantation, Karolinska Comprehensive Cancer Center, Karolinska University Hospital Huddinge, 17177 Stockholm, Sweden;
- Division of Hematology, Department of Medicine Huddinge, Karolinska Institute, 171 77 Stockholm, Sweden
| | - Marek Trneny
- University Hospital, 12808 Prague, Czech Republic;
| | - Jiri Mayer
- University Hospital Brno, 62500 Brno, Czech Republic;
| | | | - Guido Kobbe
- Heinrich Heine Universitaet, 40225 Duesseldorf, Germany;
| | | | | | | | | | - Esa Jantunen
- Department of Medicine, University of Eastern Finland and Hospital District of North Carelia, Kuopio University Hospital, 70211 Kuopio, Finland;
| | | | - Laura Paris
- Division of Hematology, SST Papa Giovanni XXIII, 24127 Bergamo, Italy;
| | | | | | - Nicolaas Schaap
- Radboud University Medical Centre, Department of Hematology, 6525 GA Nijmegen, The Netherlands;
| | - Jorge Sierra
- Hospital Santa Creu i Sant Pau, 08001 Barcelona, Spain;
| | | | - Laurent Garderet
- Centre de Recherche Saint-Antoine, Sorbonne Université-INSERM, UMR_S 938, 75013 Paris, France;
- Département d’Hématologie et de Thérapie Cellulaire, Assistance Publique-Hôpitaux de Paris, Hôpital Pitié Salpetrière, 75012 Paris, France
| | - Jan Styczynski
- Department of Pediatric Hematology and Oncology, Collegium Medicum UMK, 85-067 Bydgoszcz, Poland;
| | - Helene Schoemans
- Department of Hematology, University Hospitals Leuven, 3000 Leuven, Belgium;
- Department of Public Health and Primary Care, ACCENT VV, KU Leuven—University of Leuven, 3000 Leuven, Belgium
| | - Ivan Moiseev
- R.M. Gorbacheva Memorial Institute of Hematology, Oncology and Transplantation, Pavlov University, 197022 Saint-Petersburg, Russia;
| | - Rafael F. Duarte
- Hospital Universitario Puerta de Hierro Majadahonda—Universidad Autónoma de Madrid, 28222 Madrid, Spain;
| | - Zinaida Peric
- Department of Internal Medicine, School of Medicine, University of Zagreb, 10000 Zagreb, Croatia;
| | - Silvia Montoto
- Department of Haemato-Oncology, St Bartholomew’s Hospital, Barts Health NHS Trust, London EC1A 7BE, UK;
| | - Anja van Biezen
- EBMT Data Office Leiden, 2333 AA Leiden, The Netherlands; (L.K.); (A.v.B.)
| | - Malgorzata Mikulska
- Division of Infectious Diseases, Department of Health Sciences (DISSAL), University of Genoa, 16121 Genoa, Italy;
- Division of Infectious Diseases, IRC CS Ospedale Policlinico San Martino, 16132 Genoa, Italy
| | - Mahmoud Aljurf
- Section of Adult Haematolgy/BMT, King Faisal Specialist Hospital & Research Centre Oncology, Riyadh 11564, Saudi Arabia;
| | - Tapani Ruutu
- Comprehensive Cancer Center, Department of Hematology, Helsinki University Hospital and University of Helsinki, 00290 Helsinki, Finland;
- Clinical Research Institute, Helsinki University Hospital and University of Helsinki, 00280 Helsinki, Finland
| | | | | | - Christian Koenecke
- Department of Hematology, Hemostasis, Oncology and Stem Cell Transplantation, Hannover Medical School, 30625 Hannover, Germany;
| | - Stefan Schoenland
- Department of Internal Medicine V, Division of Hematology/Oncology, Heidelberg University Hospital, 69120 Heidelberg, Germany;
| | - Grzegorz W. Basak
- Department of Hematology, Transplantation and Internal Medicine, University Clinical Centre—The Medical University of Warsaw, 02-097 Warsaw, Poland;
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23
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Rago A, Annibali O, Tomarchio V, Coppetelli U, Fazio F, Cupelli L, Fiorini A, Piciocchi A, Tafuri A, Caravita di Toritto T. Autologous stem cell transplantation in multiple myeloma patients over 70 years: A GIMEMA Lazio Working Group experience in a retrospective case-control study. Eur J Haematol Suppl 2022; 109:250-256. [PMID: 35617025 DOI: 10.1111/ejh.13804] [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: 03/31/2022] [Revised: 05/20/2022] [Accepted: 05/23/2022] [Indexed: 11/27/2022]
Abstract
High-dose chemotherapy followed by autologous stem cell transplantation (auto-SCT) is the standard treatment for young patient ≤65 years with multiple myeloma (MM). The role of auto-SCT in elderly patients older than 70 years remains controversial in the era of novel agents and especially since the recent introduction of monoclonal antibodies (AbMo). In this study, we evaluated 12 patients with MM over 70 years old undergoing auto-SCT (elderly graft cohort) in seven centers of GIMEMA Working Group Lazio. We compared the baseline characteristics, treatment and outcome with 97 MM elderly patients who did not receive auto-SCT (nontransplant patients) from the same registry who were ≥ 70 years old, but did not undergo auto-SCT. The median progression free survival (PFS) for graft versus no-graft cohort was 56.4 versus 26.1 months, respectively. There was a trend for better PFS among graft compared to nontransplant patient (p = .1). On the other hand, the median overall survival for transplant versus nontransplant cohort was 107.6 versus 49.5 months (p = .02). Despite the small number of patients aged ≥70 years and ≤74 years, it seems that auto-SCT is well tolerated, safe and effective. Therefore, we propose that it should be considered an important treatment option in the era of new drugs in elderly fit patients with MM.
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Affiliation(s)
| | - Ombretta Annibali
- Area di Ematologia, Trapianto di Cellule Staminali, Fondazione Policlinico Campus Bio Medico, Roma, Italy
| | - Valeria Tomarchio
- Area di Ematologia, Trapianto di Cellule Staminali, Fondazione Policlinico Campus Bio Medico, Roma, Italy
| | | | - Francesca Fazio
- Dipartimento di Medicina Traslazionale e di Precisione - Ematologia, Università Sapienza di Roma, Roma, Italy
| | - Luca Cupelli
- Ospedale Sant'Eugenio, UOC Ematologia, Rome, Italy
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24
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Hari P, Chhabra S. A Review of Propylene Glycol-free Melphalan Conditioning for Hematopoietic Cell Transplantation for Multiple Myeloma and Light Chain Amyloidosis. Transplant Cell Ther 2022; 28:242-247. [PMID: 35196581 DOI: 10.1016/j.jtct.2022.02.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 01/04/2022] [Accepted: 02/12/2022] [Indexed: 01/05/2023]
Abstract
Autologous hematopoietic cell transplantation (AHCT) remains a standard therapeutic option for patients with multiple myeloma (MM). Outcomes have improved for this patient group after first AHCT, with the use of novel agents in induction, as well as post-transplantation maintenance. High-dose melphalan remains the gold standard as the conditioning regimen for MM. Traditional melphalan is a lyophilized formulation that after reconstitution has insufficient chemical stability and water solubility, thus requiring the addition of propylene glycol to act as a cosolvent to improve these characteristics. After the reconstitution of melphalan with propylene glycol-containing solution, impurities can develop within 30 minutes, and if further dilution occurs, the potency of melphalan diminishes. Propylene glycol is associated with a spectrum of toxicities that can be dose limiting. Evomela is a propylene glycol-free melphalan (PGF-Mel) that at a high dose of 200 mg/2 (100 mg/m2/d for 2 days) is approved for conditioning before AHCT in MM patients. Once reconstituted by directly dissolving in saline solution, PGF-Mel solution can be stored in the vial for up to 1 hour at room temperature or for up to 24 hours at refrigerated temperature (2° to 8°C) with no significant degradation. The demonstrated stability, up to 24 hours at room temperature, results in reduced handling requirements and increased convenience and flexibility of administration. Since its approval, Evomela has been the subject of several retrospective and investigator-initiated studies. This review summarizes the prospective and real-world evidence on practical aspects of PGF-Mel and critically appraises the available data and its clinical implications.
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Affiliation(s)
- Parameswaran Hari
- Division of Hematology Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Saurabh Chhabra
- Division of Hematology Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin.
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25
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Drozd-Sokołowska J, Gras L, Zinger N, Snowden JA, Arat M, Basak G, Pouli A, Crawley C, Wilson KMO, Tilly H, Byrne J, Bulabois CE, Passweg J, Ozkurt ZN, Schroyens W, Lioure B, Colorado Araujo M, Poiré X, Van Gorkom G, Gurman G, de Wreede LC, Hayden PJ, Beksac M, Schönland SO, Yakoub-Agha I. Autologous hematopoietic cell transplantation for relapsed multiple myeloma performed with cells procured after previous transplantation-study on behalf of CMWP of the EBMT. Bone Marrow Transplant 2022; 57:633-640. [PMID: 35169284 PMCID: PMC8993690 DOI: 10.1038/s41409-022-01592-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Revised: 12/23/2021] [Accepted: 01/19/2022] [Indexed: 11/27/2022]
Abstract
Autologous hematopoietic cell transplantation (auto-HCT) may be performed in multiple myeloma (MM) patients relapsing after a previous auto-HCT. For those without an adequate dose of stored stem cells, remobilization is necessary. This retrospective study included patients who, following disease relapse after the first auto-HCT(s), underwent stem cell remobilization and auto-HCT performed using these cells. There were 305 patients, 68% male, median age at salvage auto-HCT was 59 years. The median time to relapse after the first-line penultimate auto-HCT(s) was 30.6 months, the median follow-up after salvage auto-HCT 31 months. The 2- and 4-year non-relapse mortality (NRM) after the salvage auto-HCT was 5 and 9%, the relapse incidence 56 and 76%, respectively. Overall survival (OS) after 2 and 4 years was 76 and 52%, progression-free survival (PFS) 39 and 15%. In multivariable analysis an increasing interval between the penultimate auto-HCT and relapse was associated with better OS and PFS, later calendar year of salvage auto-HCT with better OS. In conclusion, salvage auto-HCT performed with cells remobilized after a previous auto-HCT was associated with acceptable NRM. The leading cause of failure was disease progression of MM, which correlated with a shorter interval from the penultimate auto-HCT to the first relapse.
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Affiliation(s)
| | - Luuk Gras
- EBMT Statistical Unit Data Office, Leiden, the Netherlands
| | | | - John A Snowden
- Department of Haematology, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
| | - Mutlu Arat
- Florence Nightingale Sisli Hospital, Istanbul, Turkey
| | - Grzegorz Basak
- Central Clinical Hospital, The Medical University of Warsaw, Warsaw, Poland
| | - Anastasia Pouli
- Haematology Department, "St Savvas" Oncology Hospital, Athens, Greece
| | | | | | | | | | | | | | | | | | - Bruno Lioure
- Techniciens d'Etude Clinique suivi de patients greffes, Strasbourg, France
| | | | - Xavier Poiré
- Cliniques Universitaires St. Luc, Brussels, Belgium
| | | | - Gunhan Gurman
- Ankara University Faculty of Medicine, Ankara, Turkey
| | - Liesbeth C de Wreede
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands
| | - Patrick J Hayden
- Department of Haematology, Trinity College Dublin, St. James's Hospital, Dublin, Ireland
| | - Meral Beksac
- Ankara University Faculty of Medicine, Ankara, Turkey
| | - Stefan O Schönland
- Medizinische Klinik u. Poliklinik V, University of Heidelberg, Heidelberg, Germany.
| | - Ibrahim Yakoub-Agha
- CHU de Lille, Univ Lille, INSERM U1286, Infinite, 59000 Lille, Lille, France
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26
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Swan D, Hayden PJ, Eikema DJ, Koster L, Sauer S, Blaise D, Nicholson E, Rabin N, Touzeau C, Byrne J, Huynh A, Cornelissen JJ, Potter V, Forcade E, Parrish C, Gribben J, Chretien ML, Mielke S, Gedde-Dahl T, Reményi P, Tsirigotis P, Garcia Guiñón A, Beksac M, Schönland S, Yakoub-Agha I. Trends in autologous stem cell transplantation for newly diagnosed multiple myeloma: Changing demographics and outcomes in European Society for Blood and Marrow Transplantation centres from 1995 to 2019. Br J Haematol 2022; 197:82-96. [PMID: 35166376 DOI: 10.1111/bjh.18025] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 11/26/2021] [Accepted: 12/15/2021] [Indexed: 11/29/2022]
Abstract
Multiple myeloma (MM) accounts for 10% of haematological malignancies. Overall survival (OS) has improved in recent years due to increased use of autologous stem cell transplantation (ASCT) in the treatment of newly diagnosed MM and the advent of novel agents, including proteasome inhibitors, immunomodulatory drugs and monoclonal antibodies. To assess trends in ASCT including patient selection, choice of induction regimen, depth of response and survival, we performed a retrospective analysis of all patients undergoing first ASCT for MM in European Society for Blood and Marrow Transplantation centres between 1995 and 2019. A total of 117 711 patients across 575 centres were included. The number of transplants performed increased sevenfold across the study period. The median age increased from 55 to 61 years, and the percentage of patients aged >65 years rose from 7% to 30%. Use of chemotherapy-based induction fell significantly, being largely replaced by bortezomib-based regimens. The two-year complete response rate increased from 22% to 42%. The five-year progression-free survival and OS rates increased from 28% to 31% and from 52% to 69%, respectively. Transplant mortality fell from 5.9% to 1.5%. Ongoing advances in MM treatment may challenge the future role of ASCT. However, at the current time, ASCT remains central to the MM treatment paradigm.
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Affiliation(s)
- Dawn Swan
- Department of Haematology, St James's Hospital, Dublin, Ireland
| | | | - Dirk-Jan Eikema
- European Society for Blood and Marrow Transplantation (EBMT) Statistical Unit, Leiden, the Netherlands
| | | | | | - Didier Blaise
- Programme de Transplantation and Therapie Cellulaire, Marseille, France
| | | | - Neil Rabin
- University College London Hospital, London, UK
| | | | | | - Anne Huynh
- CHU - Institut Universitaire du Cancer Toulouse, Toulouse, France
| | | | | | | | | | - John Gribben
- St Bartholomew's and The Royal London NHS Trust, London, UK
| | | | | | | | | | | | | | - Meral Beksac
- Ankara University Faculty of Medicine, Ankara, Turkey
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[Efficacy and safety of autologous hematopoietic stem cell transplantation in elderly multiple myeloma patients: a single center retrospective study]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2022; 43:141-145. [PMID: 35381675 PMCID: PMC8980643 DOI: 10.3760/cma.j.issn.0253-2727.2022.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Objective: To evaluate the efficacy and safety of autologous hematopoietic stem cell transplantation (auto-HSCT) in elderly patients (≥65 years old) with multiple myeloma (MM) . Methods: From June 1, 2006 to July 31, 2020, 22 MM patients (≥65 years old) who were diagnosed in the First Affiliated Hospital, Sun Yat-sen University and received novel drug induction followed by auto-HSCT were analyzed retrospectively. These patients were evaluated for important organ functions before transplantation, and the International Myeloma Working Group frail score was used in 2016 to screen out transplant-eligible patients. Results: The median (interquartile range, IQR) age at the time of transplantation of the 22 patients was 66.75 (IQR 4.50) years. A total of 20 patients received stem cell mobilization. The median number of mononuclear cells collected was 4.53×10(8)/kg, that of CD34(+) cells was 3.37×10(6)/kg, and the median number of apheresis procedures performed was 2. After stem cell transfusion, the median time of neutrophil implantation was 11 days, that of platelet implantation was 13 days, and the treatment-related mortality was 0 at 100 days after transplantation. The median follow-up was 48.7 months. The median time to progression time was not reached, and the median overall survival time was 111.8 months. Conclusion: Auto-HSCT is a safe and effective treatment for selected elderly patients of 65 years or older with MM.
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28
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Pawlyn C, Cairns D, Menzies T, Jones J, Jenner M, Cook G, Boyd K, Drayson M, Kaiser M, Owen R, Gregory W, Morgan G, Jackson G, Davies F. Autologous stem cell transplantation is safe and effective for fit older myeloma patients: exploratory results from the Myeloma XI trial. Haematologica 2022; 107:231-242. [PMID: 33297668 PMCID: PMC8719065 DOI: 10.3324/haematol.2020.262360] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 11/25/2020] [Indexed: 12/03/2022] Open
Abstract
Autologous stem cell transplant (ASCT) remains standard of care for consolidation after induction therapy for eligible newly diagnosed myeloma patients. In recent clinical trials comparing ASCT to delayed ASCT, patients aged over 65 were excluded. In real-world practice stem cell transplants are not restricted to those aged under 65 and clinicians decide on transplant eligibility based on patient fitness rather than a strict age cut off. Data from the UK NCRI Myeloma XI trial, a large phase III randomised controlled trial with pathways for transplant-eligible (TE) and ineligible (TNE) patients, was used in an exploratory analysis to examine the efficacy and toxicity of ASCT in older patients including analysis using an agematched population to compare outcomes for patients receiving similar induction therapy with or without ASCT. Older patients within the TE pathway were less likely to undergo stem cell harvest at the end of induction than younger patients and of those patients undergoing ASCT there was a reduction in PFS associated with increasing age. ASCT in older patients was well tolerated with no difference in morbidity or mortality between patients aged.
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Affiliation(s)
- Charlotte Pawlyn
- The Institute of Cancer Research, London, UK; The Royal Marsden Hospital, London.
| | - David Cairns
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds
| | - Tom Menzies
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds
| | - John Jones
- Kings Hospital NHS Foundation Trust, London
| | - Matthew Jenner
- University Hospital Southampton NHS Foundation Trust, Southampton
| | - Gordon Cook
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK; Leeds Cancer Centre, Leeds Teaching Hospitals Trust, Leeds
| | | | - Mark Drayson
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham
| | - Martin Kaiser
- The Institute of Cancer Research, London, UK; The Royal Marsden Hospital, London
| | - Roger Owen
- HMDS, Leeds Cancer Centre, Leeds Teaching Hospitals Trust, Leeds
| | - Walter Gregory
- Clinical Trials Research Unit, Leeds Institute of Clinical Trials Research, University of Leeds, Leeds
| | | | - Graham Jackson
- Department of Haematology, Newcastle University, Newcastle
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Wang X, Ren J, Liang X, He P. Efficacy and cost of G-CSF derivatives for prophylaxis of febrile neutropenia in lymphoma and multiple myeloma patients underwent autologous hematopoietic stem cell transplantation. Hematology 2021; 26:950-955. [PMID: 34904529 DOI: 10.1080/16078454.2021.2003071] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
OBJECTIVES To compare the efficacies and costs between pegfilgrastim and filgrastim prophylaxis for FN post-ASCT for lymphoma and multiple myeloma patients. METHODS 43 patients who received pegfilgrastim (6 mg) were compared to a retrospective cohort of 129 patients that had received filgrastim post-ASCT. Hematopoietic recovery time, FN incidence and treatment costs were assessed and compared. RESULTS The mean time to absolute neutrophil count engraftment was 8.72 ± 2.38 days for the prospective pegfilgrastim group and 9.87 ± 3.13 days for the retrospective filgrastim group (P = 0.027). The incidence of FN was 18.60% and 50.39% in prospective pegfilgrastim and retrospective filgrastim groups, respectively (P = 0.000). The mean cost of filgrastim was $617.22 ± 37.87, compared with $525.78 for pegfilgrastim (P = 0.032). DISCUSSION Convenience, effectiveness, and safety of prophylaxis for FN in the prospective pegfilgrastim group were significantly improved compared to the retrospective filgrastim group in ASCT patients. CONCLUSION Pegfilgrastim prophylaxis was more effective and convenient than filgrastim for FN prophylaxis in patients post-ASCT, especially for MM patients.
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Affiliation(s)
- Xiaoning Wang
- Department of Hematology, The First Affiliated Hospital of Xi'an Jiaotong University, Xian, People's Republic of China
| | - Juan Ren
- Department of Hematology, The First Affiliated Hospital of Xi'an Jiaotong University, Xian, People's Republic of China
| | - Xiao Liang
- Department of Lymphoma, The Affiliated Tumor Hospital of Xinjiang Medical University, Urumqi, People's Republic of China
| | - Pengcheng He
- Department of Hematology, The First Affiliated Hospital of Xi'an Jiaotong University, Xian, People's Republic of China
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30
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Ice-cream used as cryotherapy during high-dose melphalan conditioning reduces oral mucositis after autologous hematopoietic stem cell transplantation. Sci Rep 2021; 11:22507. [PMID: 34795377 PMCID: PMC8602377 DOI: 10.1038/s41598-021-02002-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Accepted: 11/08/2021] [Indexed: 11/23/2022] Open
Abstract
Oral mucositis (OM) is one of the most frequent adverse events of high-dose conditioning chemotherapy with melphalan prior to autologous hematopoietic stem cell transplantation (AHSCT). It significantly reduces the patients’ quality of life. One of the preventive strategies for OM is cryotherapy. We retrospectively analyzed whether commercially available ice-cream could prevent OM during the melphalan infusion. We retrospectively analyzed 74 patients after AHSCT to see whether there is any correlation between OM and cryotherapy (ice-cream), melphalan dose (140 mg/m2 or 200 mg/m2). The incidence of OM in our study inversely correlated with cryotherapy in the form of ice-cream. Out of 74 patients receiving conditioning chemotherapy with high-dose melphalan, 52 received cryotherapy. Fifteen patients in the cryotherapy group (28.84%) developed OM, whereas 13 patients (59.09%) developed it in the group without cryotherapy. In a multiple linear regression test cryotherapy remained a significant protective factor against OM (p = 0.02) We have also seen the relationship between melphalan dose with OM (p < 0.005). Cryotherapy in the form of ice-cream is associated with a lower rate of OM and, therefore, could potentially be used as a cost-effective, less burdensome, and easy to implement method in prevention of oral mucositis.
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Duque-Afonso J, Ewald S, Ihorst G, Waterhouse M, Struessmann T, Zeiser R, Wäsch R, Bertz H, Müller-Quernheim J, Duyster J, Finke J, Marks R, Engelhardt M. The impact of pulmonary function in patients undergoing autologous stem cell transplantation. Blood Adv 2021; 5:4327-4337. [PMID: 34610094 PMCID: PMC8579263 DOI: 10.1182/bloodadvances.2021004863] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 08/09/2021] [Indexed: 02/07/2023] Open
Abstract
High-dose chemotherapy, followed by autologous hematopoietic stem cell transplantation (auto-HSCT), is an established therapy for patients with hematological malignancies. The age of patients undergoing auto-HSCT and, therefore, the comorbidities, has increased over the last decades. However, the assessment of organ dysfunction prior to auto-HSCT has not been well studied. Therefore, we retrospectively analyzed the association of clinical factors and lung and cardiac function with outcome and complications after conditioning with BEAM (BCNU/carmustine, etoposide, cytarabine, melphalan) or high-dose melphalan in patients undergoing auto-HSCT. This study included 629 patients treated at our institution between 2007 and 2017; 334 and 295 were conditioned with BEAM or high-dose melphalan, respectively. The median follow-up was 52 months (range, 0.2-152) and 50 months (range, 0.5-149), respectively. In the multivariate analysis, we identified that progressive disease, CO-diffusion capacity corrected for hemoglobin (DLCOcSB) ≤ 60% of predicted, Karnofsky Performance Status (KPS) ≤ 80%, Hematopoietic Cell Transplantation Comorbidity Index (HCT-CI) score ≥ 4, and age > 70 years were associated with decreased overall survival (OS) in patients treated with BEAM. Similarly, DLCOcSB ≤ 60% of predicted, HCT-CI score ≥ 4, and age > 60 years were identified in patients treated with high-dose melphalan. Abnormalities in DLCOcSB ≤ 60% of predicted were associated with chemotherapy with lung-toxic substances, mediastinal radiotherapy, KPS ≤ 80%, current/previous smoking, and treatment in the intensive care unit. More often, patients with DLCOcSB ≤ 60% of predicted experienced nonrelapse mortality, including pulmonary causes of death. In summary, we identified DLCOcSB ≤ 60% of predicted as an independent risk factor for decreased OS in patients conditioned with BEAM or high-dose melphalan prior to auto-HSCT.
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Affiliation(s)
| | - Sophie Ewald
- Department of Hematology/Oncology/Stem Cell Transplantation
| | | | | | | | - Robert Zeiser
- Department of Hematology/Oncology/Stem Cell Transplantation
| | - Ralph Wäsch
- Department of Hematology/Oncology/Stem Cell Transplantation
| | - Hartmut Bertz
- Department of Hematology/Oncology/Stem Cell Transplantation
| | - Joachim Müller-Quernheim
- Department of Pneumology, Faculty of Medicine and Medical Center - University of Freiburg, Freiburg, Germany
| | - Justus Duyster
- Department of Hematology/Oncology/Stem Cell Transplantation
| | - Jürgen Finke
- Department of Hematology/Oncology/Stem Cell Transplantation
| | - Reinhard Marks
- Department of Hematology/Oncology/Stem Cell Transplantation
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32
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Straka C, Salwender H, Knop S, Vogel M, Müller J, Metzner B, Langer C, Sayer H, Jung W, Dürk HA, Bassermann F, Gramatzki M, Rösler W, Wolf HH, Brugger W, Engelhardt M, Fischer T, Liebisch P, Einsele H. Full or intensity-reduced high-dose melphalan and single or double autologous stem cell transplant with or without bortezomib consolidation in patients with newly diagnosed multiple myeloma. Eur J Haematol 2021; 107:529-542. [PMID: 34270825 DOI: 10.1111/ejh.13690] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 07/13/2021] [Accepted: 07/15/2021] [Indexed: 01/18/2023]
Abstract
OBJECTIVE A post hoc subgroup analysis of two phase III trials (NCT00416273, NCT00416208) was carried out to investigate the influence of 100/140 and 200 mg/m² melphalan as well as single/double autologous stem cell transplantation (ASCT) on progression-free survival (PFS). Additionally, the effect of bortezomib consolidation on PFS was analyzed. METHODS Following induction therapy and high-dose melphalan with subsequent ASCT, patients with newly diagnosed multiple myeloma (NDMM) were randomized 1:1 to either four 35-day cycles of bortezomib consolidation (1.6 mg/m² IV on days 1, 8, 15, 22) or observation. RESULTS Of the 340 patients included in this analysis, 13.5% received 1 × MEL100/140, 22.9% 2 × MEL100/140, 31.2% 1 × MEL200, and 32.4% 2 × MEL200. With higher cumulative melphalan dose, PFS improved (P = .0085). PFS curves of patients treated with 2 × MEL100/140 and 1 × MEL200 were very similar. The superior dose effect of MEL200 over MEL100/140 was non-existent in the bortezomib consolidation arm but pronounced in the observation arm (P = .0015). Similarly, double ASCT was only beneficial in patients without bortezomib consolidation (P = .0569). CONCLUSIONS Full dose melphalan and double transplantation seem advantageous only as long as patients are not receiving bortezomib consolidation afterwards.
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Affiliation(s)
| | - Hans Salwender
- Asklepios Tumorzentrum, AK Altona und AK St. Georg, Hamburg, Germany
| | - Stefan Knop
- Universitätsklinikum Würzburg, Medizinische Klinik und Poliklinik II, Würzburg, Germany
| | | | | | - Bernd Metzner
- Universitätsklinik für Innere Medizin II, Oldenburg, Germany
| | - Christian Langer
- Universitätsklinikum Ulm, Klinik für Innere Medizin II, Ulm, Germany
| | - Herbert Sayer
- Universitätsklinikum Jena, Klinik für Innere Medizin II, Jena, Germany
| | - Wolfram Jung
- Universitätsmedizin Göttingen, Göttingen, Germany
| | | | - Florian Bassermann
- Klinikum rechts der Isar der Technischen Universität München, Munich, Germany
| | | | - Wolf Rösler
- Universitätsklinikum Erlangen, Erlangen, Germany
| | | | | | | | | | - Peter Liebisch
- Universitätsklinikum Ulm, Klinik für Innere Medizin II, Ulm, Germany
| | - Hermann Einsele
- Universitätsklinikum Würzburg, Medizinische Klinik und Poliklinik II, Würzburg, Germany
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33
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Lemieux C, Muffly LS, Iberri DJ, Craig JK, Johnston LJ, Lowsky R, Shiraz P, Rezvani AR, Frank MJ, Weng WK, Meyer E, Shizuru JA, Arai S, Liedtke M, Negrin RS, Miklos DB, Sidana S. Outcomes after delayed and second autologous stem cell transplant in patients with relapsed multiple myeloma. Bone Marrow Transplant 2021; 56:2664-2671. [PMID: 34163014 DOI: 10.1038/s41409-021-01371-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 05/17/2021] [Accepted: 05/27/2021] [Indexed: 12/22/2022]
Abstract
We evaluated the outcomes of 168 patients undergoing delayed or second autologous stem cell transplant (ASCT) for relapsed multiple myeloma (MM) from 2010 to 2019. Overall, 21% (n = 35) patients had received a prior transplant and 69% (n = 116) underwent transplant at first relapse. Overall, 27% patients had high-risk cytogenetics and 15% had ISS stage III disease. Stem cell collection was performed after relapse in 72% and 35% of patients received maintenance therapy. Median PFS from salvage treatment and transplant were 28 and 19 months, respectively. Median OS from salvage treatment and transplant was 69 and 55 months. Multivariate analysis revealed that ASCT in first relapse was associated with superior PFS (HR 0.63, p = 0.03) and OS (HR 0.59, p = 0.04) compared to later lines of therapy. In addition, PFS of ≥36 months with prior therapy was associated with improved PFS (HR 0.62, p = 0.04) and OS (HR 0.41, p = 0.01). Ninety-five patients underwent delayed transplant at first relapse, median PFS and OS from start of therapy was 30 and 69 months, and median OS from diagnosis was 106 months. These data may serve as a guide when counseling patients undergoing ASCT for relapsed MM and provide a benchmark in designing clinical trials of transplantation/comparative treatments for relapsed MM.
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Affiliation(s)
- Christopher Lemieux
- Department of Medicine, Stanford University, Stanford, CA, USA.,Division of Hematology and Medical Oncology, Department of Medicine, Université Laval, Québec, QC, Canada
| | - Lori S Muffly
- Department of Medicine, Stanford University, Stanford, CA, USA
| | - David J Iberri
- Department of Medicine, Stanford University, Stanford, CA, USA
| | - Juliana K Craig
- Department of Medicine, Stanford University, Stanford, CA, USA
| | | | - Robert Lowsky
- Department of Medicine, Stanford University, Stanford, CA, USA
| | - Parveen Shiraz
- Department of Medicine, Stanford University, Stanford, CA, USA
| | | | - Matthew J Frank
- Department of Medicine, Stanford University, Stanford, CA, USA
| | - Wen-Kai Weng
- Department of Medicine, Stanford University, Stanford, CA, USA
| | - Everett Meyer
- Department of Medicine, Stanford University, Stanford, CA, USA
| | | | - Sally Arai
- Department of Medicine, Stanford University, Stanford, CA, USA
| | | | - Robert S Negrin
- Department of Medicine, Stanford University, Stanford, CA, USA
| | - David B Miklos
- Department of Medicine, Stanford University, Stanford, CA, USA
| | - Surbhi Sidana
- Department of Medicine, Stanford University, Stanford, CA, USA.
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Scheubeck S, Ihorst G, Schoeller K, Holler M, Möller MD, Reinhardt H, Wäsch R, Engelhardt M. Comparison of the prognostic significance of 5 comorbidity scores and 12 functional tests in a prospective multiple myeloma patient cohort. Cancer 2021; 127:3422-3436. [PMID: 34061991 DOI: 10.1002/cncr.33658] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 04/13/2021] [Accepted: 04/16/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Because of the various therapeutic options available for multiple myeloma (MM), remarkable interest exists today in individualized therapeutic concepts based on patients' fitness. The main objectives of this study were to compare different comorbidity scores and functional tests with respect to their impact on survival (overall survival [OS] and progression-free survival [PFS]); develop a time-efficient, MM-specific functional assessment (FA); and evaluate changes in patients' FA during treatment. METHODS The authors performed a prospective FA in 266 consecutive patients with MM at their initial diagnosis. This included 5 comorbidity scores and 12 commonly used geriatric functional tests. To evaluate changes in the course of treatment, the authors reassessed these 17 tests after ≥6 months. The entire analysis included 7327 FA tests. RESULTS On the basis of univariate and multivariate Cox regression analyses, the authors identified 4 of the 17 evaluated scores and functional tests as most relevant: the Revised Myeloma Comorbidity Index (R-MCI), Activity of Daily Living (ADL), the Mini-Mental State Examination (MMSE), and the quality-of-life 12-Item Short Form Health Survey Physical Composite Scale (SF-12 PCS). These showed precise group differences for fit, (intermediate-fit), and frail patients in OS and PFS: the 3-year OS rates were 90%, 74%, and 43% via the R-MCI for fit, intermediate-fit, and frail patients, respectively (P = .0006); 80% and 66% via the ADL for fit and frail patients, respectively (P = .0159); 78% and 48% via the MMSE for fit and frail patients, respectively (P = .0001); and 86% and 66% via the SF-12 PCS for fit and frail patients, respectively (P = .0091). In follow-up analyses, 16 of 17 FA tests improved, mostly in younger patients (<70 years old) and responding patients (partial remission or better). CONCLUSIONS Patients may recover from functional and physical limitations under applied MM therapy. The newly established MM-specific FA (via the R-MCI, ADL, MMSE, and SF-12 PCS) allows a precise evaluation of the prognosis and risk status in MM. Its use may improve treatment tolerability and should be validated to individualize MM treatment decisions in the future. LAY SUMMARY The authors performed a prospective functional assessment (FA) in 266 consecutive patients with multiple myeloma at their initial diagnosis. On the basis of univariate and multivariate Cox regression analyses, the authors identified 4 of 17 initially evaluated scores and functional tests as most relevant: the Revised Myeloma Comorbidity Index, Activity of Daily Living, the Mini-Mental State Examination, and the quality-of-life 12-Item Short Form Health Survey Physical Composite Scale. The authors checked the stability of the final model by applying forward and stepwise selection. To evaluate changes in the course of treatment, they reassessed these 17 tests in 165 patients after ≥6 months: 16 of the 17 FA tests improved, mostly in younger patients (<70 years old) and responding patients (partial remission or better).
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Affiliation(s)
- Sophia Scheubeck
- Department of Medicine I: Hematology and Oncology, Medical Center/Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Comprehensive Cancer Center Freiburg, Medical Center/Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Gabriele Ihorst
- Clinical Trials Unit, Medical Center/Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Katja Schoeller
- Department of Medicine I: Hematology and Oncology, Medical Center/Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Comprehensive Cancer Center Freiburg, Medical Center/Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Maximilian Holler
- Department of Medicine I: Hematology and Oncology, Medical Center/Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Comprehensive Cancer Center Freiburg, Medical Center/Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Mandy-Deborah Möller
- Department of Medicine I: Hematology and Oncology, Medical Center/Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Comprehensive Cancer Center Freiburg, Medical Center/Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Heike Reinhardt
- Department of Medicine I: Hematology and Oncology, Medical Center/Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Comprehensive Cancer Center Freiburg, Medical Center/Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ralph Wäsch
- Department of Medicine I: Hematology and Oncology, Medical Center/Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Comprehensive Cancer Center Freiburg, Medical Center/Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Monika Engelhardt
- Department of Medicine I: Hematology and Oncology, Medical Center/Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Comprehensive Cancer Center Freiburg, Medical Center/Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Treatment of Multiple Myeloma and the Role of Melphalan in the Era of Modern Therapies-Current Research and Clinical Approaches. J Clin Med 2021; 10:jcm10091841. [PMID: 33922721 PMCID: PMC8123041 DOI: 10.3390/jcm10091841] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 04/01/2021] [Accepted: 04/16/2021] [Indexed: 12/18/2022] Open
Abstract
Multiple myeloma (MM) accounts for 10% of all hematological malignancies, and it is the second most common hematological neoplasm for which chemotherapy is an important pharmacological treatment. High dose melphalan followed by autologous stem cell transplantation remains the standard of treatment for transplant-eligible patients with MM. In this review, we describe aspects of the pharmacokinetics and pharmacodynamics of melphalan therapy and related compounds. In addition, we describe the use of melphalan in innovative therapies for the treatment of MM, including the development of drug carriers to reduce systemic toxicity, combination therapy to improve the effectiveness of cancer therapy, and the chemical modification of the melphalan molecule to improve antitumor activity.
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36
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Salivary Osteopontin as a Potential Biomarker for Oral Mucositis. Metabolites 2021; 11:metabo11040208. [PMID: 33808230 PMCID: PMC8066152 DOI: 10.3390/metabo11040208] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 03/25/2021] [Accepted: 03/26/2021] [Indexed: 12/12/2022] Open
Abstract
Osteopontin (OPN), a multifunctional phosphoglycoprotein also presents in saliva, plays a crucial role in tumour progression, inflammation and mucosal protection. Mucosal barrier injury due to high-dose conditioning regimen administered during autologous and allogeneic peripheral stem cell transplantation (APSCT) has neither efficient therapy nor established biomarkers. Our aim was to assess the biomarker role of OPN during APSCT, with primary focus on oral mucositis (OM). Serum and salivary OPN levels were determined by ELISA in 10 patients during APSCT at four stages of transplantation (day -3/-7, 0, +7, +14), and in 23 respective healthy controls. Results: There was a negative correlation between both salivary and serum OPN levels and grade of OM severity during APSCT (r = -0.791, p = 0.019; r = -0.973, p = 0.001). Salivary OPN increased at days +7 (p = 0.011) and +14 (p = 0.034) compared to controls. Among patients, it was higher at day +14 compared to the time of admission (day -3/-7) (p = 0.039) and transplantation (day 0) (p = 0.011). Serum OPN remained elevated at all four stages of transplantation compared to controls (p = 0.013, p = 0.02, p = 0.011, p = 0.028). During APSCT elevated salivary OPN is a potential non-invasive biomarker of oral mucositis whereas the importance of high serum OPN warrants further studies.
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37
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UNCU ULU B, BAKIRTAŞ M, YİĞENOĞLU TN, BAŞCI S, YILDIZ J, ŞAHİN D, DARÇIN T, MERDİN A, BATGİ H, İSKENDER D, BAYSAL NA, DAL S, KIZIL ÇAKIR M, ALTUNTAŞ F. Efficacy of reduced dose melphalan conditioning for multiple myeloma patients undergoing autologous stem cell transplantation: in the era of combined induction with novel agents. JOURNAL OF HEALTH SCIENCES AND MEDICINE 2021. [DOI: 10.32322/jhsm.868279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
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38
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Giebel S, Sobczyk-Kruszelnicka M, Blamek S, Saduś-Wojciechowska M, Najda J, Czerw T, Mendrek W, Woźniak G, Jochymek B, Radwan M, Leszczyński W, Dolla Ł, D'Amico A, Ślosarek K, Hołowiecki J, Miszczyk L. Tandem autologous hematopoietic cell transplantation with sequential use of total marrow irradiation and high-dose melphalan in multiple myeloma. Bone Marrow Transplant 2020; 56:1297-1304. [PMID: 33339899 DOI: 10.1038/s41409-020-01181-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 10/27/2020] [Accepted: 11/27/2020] [Indexed: 01/02/2023]
Abstract
The goal of this phase II trial was to evaluate safety and efficacy of a tandem autologous hematopoietic cell transplantation (auto-HCT) using sequentially total marrow irradiation (TMI) at the dose of 12 Gy (4 Gy on days -3, -2, and -1) and melphalan 200 mg/m2 for patients with multiple myeloma (MM). TMI was performed using helical tomotherapy. Additional "boosts" (total 24 Gy) were applied for patients with active lesions as revealed by PET-FDG. Fifty patients with median age 58 years (41-64 years) were included and received tandem auto-HCT. TMI resulted in absolute neutropenia in all patients. Grade 3 infections were reported in 30% patients. Other toxicities were rare. Proportion of patients who achieved at least very good partial response increased from 46% before the first auto-HCT to 82% after tandem transplantation. Complete remission rates changed from 10% to 42%, respectively. The probabilities of overall and progression-free survival at 5 years were 74% and 55%, respectively. No patient died without progression. We conclude that conditioning with TMI ± PET-guided "boosts" represents personalized treatment approach in MM and is characterized by very good toxicity profile. Tandem auto-HCT using TMI in sequence with high-dose melphalan appears safe with encouraging early efficacy.
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Affiliation(s)
- Sebastian Giebel
- Department of Bone Marrow Transplantation and Onco-Hematology, Maria Skłodowska-Curie National Research Institute of Oncology, Gliwice Branch, Gliwice, Poland.
| | - Małgorzata Sobczyk-Kruszelnicka
- Department of Bone Marrow Transplantation and Onco-Hematology, Maria Skłodowska-Curie National Research Institute of Oncology, Gliwice Branch, Gliwice, Poland
| | - Sławomir Blamek
- Department of Radiotherapy, Maria Sklodowska-Curie National Research Institute of Oncology, Gliwice Branch, Gliwice, Poland
| | - Maria Saduś-Wojciechowska
- Department of Bone Marrow Transplantation and Onco-Hematology, Maria Skłodowska-Curie National Research Institute of Oncology, Gliwice Branch, Gliwice, Poland
| | - Jacek Najda
- Department of Bone Marrow Transplantation and Onco-Hematology, Maria Skłodowska-Curie National Research Institute of Oncology, Gliwice Branch, Gliwice, Poland
| | - Tomasz Czerw
- Department of Bone Marrow Transplantation and Onco-Hematology, Maria Skłodowska-Curie National Research Institute of Oncology, Gliwice Branch, Gliwice, Poland
| | - Włodzimierz Mendrek
- Department of Bone Marrow Transplantation and Onco-Hematology, Maria Skłodowska-Curie National Research Institute of Oncology, Gliwice Branch, Gliwice, Poland
| | - Grzegorz Woźniak
- Department of Radiotherapy, Maria Sklodowska-Curie National Research Institute of Oncology, Gliwice Branch, Gliwice, Poland
| | - Bożena Jochymek
- Department of Radiotherapy, Maria Sklodowska-Curie National Research Institute of Oncology, Gliwice Branch, Gliwice, Poland
| | - Michał Radwan
- Department of Radiotherapy Planning, Maria Sklodowska-Curie National Research Institute of Oncology, Gliwice Branch, Gliwice, Poland
| | - Wojciech Leszczyński
- Department of Radiotherapy Planning, Maria Sklodowska-Curie National Research Institute of Oncology, Gliwice Branch, Gliwice, Poland
| | - Łukasz Dolla
- Department of Radiotherapy Planning, Maria Sklodowska-Curie National Research Institute of Oncology, Gliwice Branch, Gliwice, Poland
| | - Andrea D'Amico
- Department of PET Diagnostics, Maria Sklodowska-Curie National Research Institute of Oncology, Gliwice Branch, Gliwice, Poland
| | - Krzysztof Ślosarek
- Department of Radiotherapy Planning, Maria Sklodowska-Curie National Research Institute of Oncology, Gliwice Branch, Gliwice, Poland
| | - Jerzy Hołowiecki
- Department of Bone Marrow Transplantation and Onco-Hematology, Maria Skłodowska-Curie National Research Institute of Oncology, Gliwice Branch, Gliwice, Poland
| | - Leszek Miszczyk
- Department of Radiotherapy, Maria Sklodowska-Curie National Research Institute of Oncology, Gliwice Branch, Gliwice, Poland
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Brioli A, Vom Hofe F, Rucci P, Ernst T, Yomade O, Hilgendorf I, Scholl S, Sayer H, Mügge LO, Hochhaus A, von Lilienfeld-Toal M. Melphalan 200 mg/m 2 does not increase toxicity and improves survival in comparison to reduced doses of melphalan in multiple myeloma patients. Bone Marrow Transplant 2020; 56:1209-1212. [PMID: 33299059 DOI: 10.1038/s41409-020-01170-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 11/09/2020] [Accepted: 11/20/2020] [Indexed: 11/09/2022]
Abstract
Autologous stem cell transplantation (ASCT) conditioned with melphalan 200 mg/m2 (Mel200) is standard of care for young multiple myeloma (MM) patients. Lower doses of melphalan (MelRed) have been used to reduce toxicity, although data regarding their efficacy are not concordant. We retrospectively evaluated 313 MM patients receiving ASCT at Jena University Hospital between 2003 and 2017. Patients receiving MelRed were on average older (p < 0.001), had a worse renal function (p < 0.001) and more comorbidities (p < 0.001). No differences were seen in treatment response before ASCT between the two groups, whilst after ASCT the rate of at least very good partial responses (VGPR) was significantly higher for patients receiving Mel200 (93% vs. 76%, p < 0.001). PFS (39 vs. 20 months, p < 0.001) and OS (103 vs. 59 months, p = 0.001) were longer with Mel200. Toxicities were comparable in the two groups. After adjusting for age and clinical characteristics using the propensity score, for VGPR before and after ASCT and for double ASCT strategy in a Cox regression analysis, Mel200 was still associated with a lower risk of disease progression (HR = 0.40, 95% CI = 0.40-0.96) and of death (HR = 0.61, 95% CI = 0.35-1.07). Our results confirm that Mel200 is still the standard of care for ASCT eligible myeloma patients.
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Affiliation(s)
- Annamaria Brioli
- Universitätsklinikum Jena, Klinik für Innere Medizin II, Abt. Hämatologie und Internistische Onkologie, Jena, Germany. .,Research Programm, Else Kröner-Forschungskolleg AntiAge, Universitätsklinikum Jena, Jena, Germany.
| | - Felix Vom Hofe
- Universitätsklinikum Jena, Klinik für Innere Medizin II, Abt. Hämatologie und Internistische Onkologie, Jena, Germany
| | - Paola Rucci
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Thomas Ernst
- Universitätsklinikum Jena, Klinik für Innere Medizin II, Abt. Hämatologie und Internistische Onkologie, Jena, Germany
| | - Olaposi Yomade
- Universitätsklinikum Jena, Klinik für Innere Medizin II, Abt. Hämatologie und Internistische Onkologie, Jena, Germany
| | - Inken Hilgendorf
- Universitätsklinikum Jena, Klinik für Innere Medizin II, Abt. Hämatologie und Internistische Onkologie, Jena, Germany
| | - Sebastian Scholl
- Universitätsklinikum Jena, Klinik für Innere Medizin II, Abt. Hämatologie und Internistische Onkologie, Jena, Germany
| | - Herbert Sayer
- HELIOS Klinikum, 4. Medizinische Klinik-Hämatologie und internistische Onkologie, Hämostaseologie, Erfurt, Germany
| | - Lars-Olof Mügge
- Heinrich-Braun-Klinikum, Klinik für Innere Medizin III (Hämatologie, Onkologie und Palliativmedizin), Zwickau, Germany
| | - Andreas Hochhaus
- Universitätsklinikum Jena, Klinik für Innere Medizin II, Abt. Hämatologie und Internistische Onkologie, Jena, Germany
| | - Marie von Lilienfeld-Toal
- Universitätsklinikum Jena, Klinik für Innere Medizin II, Abt. Hämatologie und Internistische Onkologie, Jena, Germany.,Leibniz Institut für Infektionsbiologie und Naturstoff-Forschung, Hans-Knöll Institut, Jena, Germany
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Gebri E, Kiss A, Tóth F, Hortobágyi T. Female sex as an independent prognostic factor in the development of oral mucositis during autologous peripheral stem cell transplantation. Sci Rep 2020; 10:15898. [PMID: 32985512 PMCID: PMC7522228 DOI: 10.1038/s41598-020-72592-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 08/28/2020] [Indexed: 11/11/2022] Open
Abstract
Oral mucositis (OM) is a frequent complication of stem cell transplantation-associated toxicity in haematological malignancies, contributing to mortality. Therapy still remains mainly supportive. We assessed risk factors in retrospective analysis of 192 autologous peripheral stem cell transplantation patients with lymphoma and multiple myeloma (MM), respectively. Futhermore, we examined the hormone levels both in serum and saliva during transplantation in 7 postmenopausal female patients with lymphoma compared to healthy controls using electrochemiluminescence immunoassay (ECLIA). Multivariable analysis revealed neutrophil engraftment (p < 0.001; p = 0.021) and female sex (p = 0.023; p = 0.038) as independent predictive factors in the combined patient group and in the lymphoma group, and neutrophil engraftment (p = 0.008) in the MM group. Of the 85 female participants 19 were pre- and 66 postmenopausal. Fifteen of the pre-, and 49 of the postmenopausal women developed ulcerative mucositis (p = 0.769), more often with lymphoma than MM (p = 0.009). Serum estrogen decreased significantly both in postmenopausal controls and transplantated patients compared to premenopausals, with no difference in saliva. Serum progesterone level was significantly (p = 0.026) elevated at day + 7 of transplantation, while salivary progesterone increased at day + 7 and + 14. Our results indicate a predominantly negative effect of female sex hormones on oral immunity with role in the aetiopathogenesis of OM.
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Affiliation(s)
- Enikő Gebri
- Department of Dentoalveolar Surgery and Dental Outpatient Care, Faculty of Dentistry, University of Debrecen, Debrecen, Hungary
| | - Attila Kiss
- Department of Haematopoietic Transplantation Centre, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Ferenc Tóth
- Department of Biomaterials and Prosthetic Dentistry, Faculty of Dentistry, University of Debrecen, Debrecen, Hungary
| | - Tibor Hortobágyi
- MTA-DE Cerebrovascular and Neurodegenerative Research Group, Department of Neurology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary.
- Faculty of Medicine, Institute of Pathology, University of Szeged, Állomás utca 2, Szeged, 6725, Hungary.
- Department of Old Age Psychiatry, Institute of Psychiatry Psychology and Neuroscience, King's College London, London, UK.
- Centre for Age-Related Medicine, SESAM, Stavanger University Hospital, Stavanger, Norway.
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Outcomes with autologous stem cell transplant vs. non-transplant therapy in patients 70 years and older with multiple myeloma. Bone Marrow Transplant 2020; 56:368-375. [PMID: 32782351 DOI: 10.1038/s41409-020-01026-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 07/27/2020] [Accepted: 07/30/2020] [Indexed: 11/08/2022]
Abstract
We evaluated 79 patients with multiple myeloma (MM) ≥70 years referred to our blood and marrow transplant clinic, within 1 year of diagnosis from 2010 to 2019, for consideration of autologous stem cell transplant (ASCT). Thirty-eight (48%) of 79 patients underwent ASCT. ASCT was not pursued in 41 (52%) patients due to: patient or physician preference in 80% (n = 33) or ineligibility in 20% (n = 8). Baseline characteristics of patients in the two groups were similar. Median PFS from treatment start amongst patients undergoing ASCT (n = 38) vs. not (n = 41) was 41 months vs. 33 months, p = 0.03. There was no difference in OS, with estimated 5-year OS of 73% vs. 83%, respectively (p = 0.86). Day +100 transplant-related mortality (TRM) was 0%. ASCT was an independent favorable prognostic factor for PFS in multivariate analysis, after accounting for HCT-CI score, performance status, hematologic response, and maintenance. Finally, patients ≥70 years undergoing ASCT had similar PFS compared to a contemporaneous institutional cohort of patients <70 years (n = 631) (median PFS from transplant: 36 vs. 47 months, p = 0.25). In this retrospective analysis, ASCT was associated with low TRM and better PFS in fit older adults with MM compared to non-transplant therapy, with comparable benefits as seen in younger patients.
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Fotiou D, Ntanasis-Stathopoulos I, Gavriatopoulou M, Dimopoulos MA. Multiple myeloma: Current and future management in the aging population. Maturitas 2020; 138:8-13. [DOI: 10.1016/j.maturitas.2020.04.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Revised: 04/20/2020] [Accepted: 04/24/2020] [Indexed: 12/11/2022]
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Garderet L, Morris C, Beksac M, Gahrton G, Schönland S, Yakoub-Agha I, Hayden PJ. Are Autologous Stem Cell Transplants Still Required to Treat Myeloma in the Era of Novel Therapies? A Review from the Chronic Malignancies Working Party of the EBMT. Biol Blood Marrow Transplant 2020; 26:1559-1566. [PMID: 32417491 DOI: 10.1016/j.bbmt.2020.04.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 04/06/2020] [Accepted: 04/07/2020] [Indexed: 12/27/2022]
Abstract
Melphalan at a myeloablative dose followed by autologous stem cell transplantation (ASCT) remains the standard of care for transplant-eligible patients with myeloma. However, therapies such as new immunomodulatory drugs and proteasome inhibitors and, more recently, monoclonal antibodies and chimeric antigen receptor T cells are challenging the traditional role of ASCT. Which patients benefit from ASCT? Can its use be delayed until first relapse? The field is moving rapidly as novel agents lead to new patient care strategies. The place of ASCT in this changing landscape will be reviewed and reassessed.
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Affiliation(s)
- Laurent Garderet
- Sorbonne Université, INSERM, UMR_S 938, Centre de Recherche Saint-Antoine-Team Proliferation and Differentiation of Stem Cells, Assistance Publique-Hôpitaux de Paris, Hôpital Pitié Salpêtrière, Service d'Hématologie, Paris, France.
| | - Curly Morris
- Haematology, Queen's University Belfast Faculty of Medicine Health and Life Sciences, Belfast, United Kingdom
| | | | - Gösta Gahrton
- Department of Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Stefan Schönland
- Amyloidosis Center, Division of Stem Cell Transplantation, Department Internal Medicine V, Hematology, Oncology, Rheumatology, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Patrick J Hayden
- Department of Haematology, Trinity College Dublin, St. James's Hospital, Dublin, Ireland
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Wiebach H, Gezer D, Brummendorf TH, Crysandt M, Wilop S. Tolerability of high dose chemotherapy and autologous stem cell transplantation in elderly patients with multiple myeloma: A single-center retrospective analysis. Curr Res Transl Med 2020; 68:139-144. [PMID: 32381471 DOI: 10.1016/j.retram.2020.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 03/28/2020] [Accepted: 04/09/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE OF THE STUDY In the past years, high dose chemotherapy (HDT) with autologous stem cell transplantation (ASCT)has more extensively been performed in elderly patients with multiple myeloma (MM). Several studies found a similar survival benefit compared to younger patients. The objective of our retrospective study is to analyse the tolerability of HDT + ASCT in elderly patients. PATIENTS AND METHODS We compared 26 ASCT performed in MM patients ≥65 years to 127 ASCT in patients <65 years by evaluating treatment-tolerability, length of hospital stay and number of transfusions. RESULTS There was no significant difference in the duration of hospitalisation (16 days (range 14-47) in the elderly vs. 17 days (range 14-71) days, P = 0.0903), median time of cytopenia (neutrophils<500/μl: 5 days (range 4-24) vs. 6 days (range 3-28) days, P = 0.1091; platelets<30 000/μl: 6 days (range 3-36) vs. 7 days (range 0-53) days, P = 0.274) or incidence of, or degree of complications between the two age-groups. Immediate and day 100 treatment related mortality (TRM) was comparable in both groups (3.85% vs. 1.58%, P = 0.4304). CONCLUSION our findings support the concept that HDT + ASCT can be safely administered as first-line option for well-selected patients≥65 years.
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Affiliation(s)
- H Wiebach
- Department of Hematology, Oncology, Hemostaseology, and Stem Cell Transplantation, Medical Faculty, RWTH Aachen University, Aachen, Germany.
| | - D Gezer
- Department of Hematology, Oncology, Hemostaseology, and Stem Cell Transplantation, Medical Faculty, RWTH Aachen University, Aachen, Germany.
| | - T H Brummendorf
- Department of Hematology, Oncology, Hemostaseology, and Stem Cell Transplantation, Medical Faculty, RWTH Aachen University, Aachen, Germany.
| | - M Crysandt
- Department of Hematology, Oncology, Hemostaseology, and Stem Cell Transplantation, Medical Faculty, RWTH Aachen University, Aachen, Germany.
| | - S Wilop
- Department of Hematology, Oncology, Hemostaseology, and Stem Cell Transplantation, Medical Faculty, RWTH Aachen University, Aachen, Germany; MVZ West GmbH Wuerselen, Hematology - Oncology, Wuerselen, Germany.
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45
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Delivering intensive therapies to older adults with hematologic malignancies: strategies to personalize care. Blood 2020; 134:2013-2021. [PMID: 31805199 DOI: 10.1182/blood.2019001300] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 07/30/2019] [Indexed: 12/23/2022] Open
Abstract
Intensive therapies are often medically indicated for older adults with hematologic malignancies. These may include induction chemotherapy for acute myeloid leukemia (AML), as well as autologous hematopoietic cell transplant (autoHCT) and allogeneic hematopoietic cell transplant (alloHCT). However, it is not always clear how to best deliver these therapies, in terms of determining treatment eligibility, as well as adjusting or adding supportive measures to the treatment plan to maximize successful outcomes. Beyond performance status and presence of comorbidities, comprehensive geriatric assessment and individual geriatric metrics have increasingly been used to prognosticate in these settings and may offer the best approach to personalizing therapy. In the setting of AML induction, evidence supports the use of measures of physical function as independent predictors of survival. For patients undergoing alloHCT, functional status, as measured by instrumental activities of daily living (IADL) and gait speed, may be an important pretransplant assessment. IADL has also been associated with post-autoHCT morbidity and mortality. Current best practice includes assessment of relevant geriatric metrics prior to intensive therapy, and work is ongoing to develop complementary interventions.
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Olin RL. Delivering intensive therapies to older adults with hematologic malignancies: strategies to personalize care. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2019; 2019:63-70. [PMID: 31808886 PMCID: PMC6913447 DOI: 10.1182/hematology.2019001300] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Intensive therapies are often medically indicated for older adults with hematologic malignancies. These may include induction chemotherapy for acute myeloid leukemia (AML), as well as autologous hematopoietic cell transplant (autoHCT) and allogeneic hematopoietic cell transplant (alloHCT). However, it is not always clear how to best deliver these therapies, in terms of determining treatment eligibility, as well as adjusting or adding supportive measures to the treatment plan to maximize successful outcomes. Beyond performance status and presence of comorbidities, comprehensive geriatric assessment and individual geriatric metrics have increasingly been used to prognosticate in these settings and may offer the best approach to personalizing therapy. In the setting of AML induction, evidence supports the use of measures of physical function as independent predictors of survival. For patients undergoing alloHCT, functional status, as measured by instrumental activities of daily living (IADL) and gait speed, may be an important pretransplant assessment. IADL has also been associated with post-autoHCT morbidity and mortality. Current best practice includes assessment of relevant geriatric metrics prior to intensive therapy, and work is ongoing to develop complementary interventions.
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Affiliation(s)
- Rebecca L Olin
- Helen Diller Family Comprehensive Cancer Center, University of California San Francisco, San Francisco, CA
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47
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Soekojo CY, Kumar SK. Stem-cell transplantation in multiple myeloma: how far have we come? Ther Adv Hematol 2019; 10:2040620719888111. [PMID: 31798820 PMCID: PMC6859676 DOI: 10.1177/2040620719888111] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 10/16/2019] [Indexed: 12/22/2022] Open
Abstract
High-dose therapy (HDT) and autologous stem-cell transplantation (ASCT) has historically been an essential part of multiple myeloma (MM) management since early studies demonstrated its efficacy in relapsed disease, and subsequent phase III trials demonstrated better responses and improved survival with this modality compared with standard chemotherapy. With further advances in the MM treatment landscape, including the development of potent novel agents, there has been an increasing debate around various aspects of ASCT, including the optimal timing, role of single versus tandem ASCT, and the practice of consolidation and maintenance therapy post-ASCT. Routine incorporation of the novel agents at each of the treatment phases, induction, consolidation when used, and maintenance has led to better responses as reflected by increasing rates of minimal residual disease (MRD) negativity, longer progression-free survival (PFS) with improvement in overall survival (OS) and in some of the trials. The phase III trials over the last decade have provided significant clarity on the current approach, and have raised important questions regarding the applicability of this modality in all patients. This review aims to summarize the latest literature in the field and discusses how these findings impact the practice of ASCT today.
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Affiliation(s)
- Cinnie Y. Soekojo
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Shaji K. Kumar
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA
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Choufi B, Alsuliman T. Autologous hematopoietic stem-cell transplant in small-sized and peripheral centers: a 10-year experiment. Ther Adv Hematol 2019; 10:2040620719879587. [PMID: 31632621 PMCID: PMC6778989 DOI: 10.1177/2040620719879587] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Accepted: 09/04/2019] [Indexed: 11/17/2022] Open
Abstract
Background Along with continuing changes in therapeutic modalities, indications of autologous hematopoietic stem-cell transplantation (ASCT) have been emerging and changing considerably, especially in the era of targeted therapy and small molecule inhibitors. Patients treated with novel agents tend to have a longer survival period, thus eventually reaching higher ages at ASCT. Herein, and to address the question of ASCT outcomes in small, community-based, peripheral French centers, we report the 10-year follow-up results of 136 patients who received ASCT in our eight-bed ASCT unit, situated in an urban area. Methods We retrospectively analyzed a cohort of 136 patients treated between 2008 and 2017 at the Duchenne Hospital Center. Of these 136 patients, 75 underwent ASCT for myeloma, while 61 underwent ASCT for lymphoma, amongst which 57 patients were treated for B-cell lymphoma. The median age was 65 years (range, 27-72) for myeloma patients, and 62 years (range, 27-71) for patients with lymphoma. Results The cohort median follow up was estimated at 33 months; 10-year overall survival (OS) and progression-free survival (PFS) were 71% and 64% for B-cell non-Hodgkin lymphoma, and 75% and 45% for myeloma, respectively. No statistically significant differences were found for OS or 1-year PFS between patients who received ASCT from 2008 to 2012, and those who received it from 2013 to 2017. Conclusions In the absence of randomized trials studying the role of center size, experience, and standardization procedure for ASCT outcome, these results may suggest that ASCT in peripheral accredited small-sized centers could be a viable option to facilitate follow up and enable access to this treatment, especially for elderly patients, in comparison with referring the patient to central large hospitals to undergo ASCT.
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Affiliation(s)
- Bachra Choufi
- Service d'Hématologie, Centre Hospitalier de Boulogne-sur-Mer, Boulogne-sur-Mer, 147 Current adress: allée des lauriers roses la mitre, Toulon 83000, France
| | - Tamim Alsuliman
- Service d'Hématologie, Centre Hospitalier de Boulogne-sur-Mer, Boulogne-sur-Mer, France
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Abstract
PURPOSE OF REVIEW Autologous stem cell transplantation has been the standard of care in myeloma treatment for many years, but the availability of newer antimyeloma drugs and the emerging data from chimeric antigen receptor (CAR) T-cell clinical studies make us question the relevance of it. The purpose of this review is to go over recent data and to reassess the current status of autologous stem cell transplantation as a standard of care. RECENT FINDINGS Autologous stem cell transplantation can be safely performed for elderly patients and there is no absolute age limit. Recent data on BEAM (Carmustine, Etoposide, Cytarabine, and Melphalan), Busulfan/Melphalan, and Carmustine/Melphalan conditioning when compared with Melphalan showed favorable survival outcomes with manageable toxicities although we need to see data from randomized, multicenter studies. Posttransplant maintenance and consolidation can maximize the benefit of transplant by prolonging progression-free survival. Current B-cell maturation antigen CAR T-cell therapy showed remarkably high response rates, but didn't seem to provide durable response yet. SUMMARY Recent advances in myeloma therapy and autologous stem cell transplantation are described. Although we've seen many new developments including CAR T-cell therapies, autologous stem cell transplantation remains as the standard of care. However, it may be replaced by or combined with newer therapies in the future.
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50
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Nampoothiri RV, Kasudhan KS, Patil AN, Malhotra P, Khadwal A, Prakash G, Jain A, Malhotra S, Verma Attri S, Varma N, Varma S, Lad DP. Impact of frailty, melphalan pharmacokinetics, and pharmacogenetics on outcomes post autologous hematopoietic cell transplantation for multiple myeloma. Bone Marrow Transplant 2019; 54:2088-2095. [DOI: 10.1038/s41409-019-0631-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 06/22/2019] [Accepted: 07/13/2019] [Indexed: 12/27/2022]
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