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Kirchberg J, Fischer L, Born P, Brunner F, Morgner C, Fürst D, Heyn S, Bach E, Brueckner M, Jentzsch M, Wang SY, Böttcher S, Franke GN, Schrezenmeier H, Platzbecker U, Merz M, Vučinić V. Impact of Previous Allogeneic Hematopoietic Stem Cell Transplantation on Chimeric Antigen Receptor (CAR) T Cell Treatment for Relapsed/Refractory Multiple Myeloma. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2024:S2152-2650(24)00176-9. [PMID: 38821728 DOI: 10.1016/j.clml.2024.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/18/2024] [Revised: 04/18/2024] [Accepted: 05/01/2024] [Indexed: 06/02/2024]
Abstract
BACKGROUND Anti-BCMA-directed chimeric antigen receptor (CAR) T cells are effective treatment for patients with refractory/relapsed multiple myeloma (RRMM). However, little is known about the impact of previous allogeneic hematopoietic stem cell transplantation (allo-HSCT) on lymphocyte collection for production of CAR T cells and subsequent treatment with CAR T cells. PATIENTS AND METHODS We performed a retrospective analysis of cellular composition of lymphocyte collections, CAR T cell expansion and treatment outcomes of RRMM patients undergoing therapy with idecabtagene vicleucel (ide-cel) with and without history of allo-HSCT. 27 patients (11/27 female) with median age 63 (range 39-75) years were analyzed. Five patients (19%) had the history of allo-HSCT median of 5.5 years before ide-cel. RESULTS Prior to apheresis, the white blood cell, absolute lymphocyte counts, CD3+ cells and monocytes did not differ in patients with and without prior allo-HSCT. We also noticed no differences in the collected CD3+ yields or cellular compositions of lymphocyte collections. One year after ide-cel infusion, the progression-free survival and overall survival of patients with and without previous allo-HSCT did not differ with 60% and 45% respectively (P = .58) and 66.7% and 74% respectively (P = .84). The highest expansion of CAR T was detected between day 7 after infusion and showed no difference regarding previous allo-HSCT (P = .71). No graft-versus-host disease during the follow-up was detected. CONCLUSION Our data confirm that the treatment with ide-cel is feasible for patients with prior allo-HSCT. Furthermore, allo-HSCT did not influence cellular composition of lymphocyte collections, clinical outcome or in vivo expansion of ide-cel.
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Affiliation(s)
- Janine Kirchberg
- Department of Hematology, Cellular Therapy, Hemostaseology and Infectious Diseases, University Leipzig Medical Center, Leipzig, Germany; Comprehensive Cancer Center Central Germany, Leipzig, Jena, Germany
| | - Luise Fischer
- Department of Hematology, Cellular Therapy, Hemostaseology and Infectious Diseases, University Leipzig Medical Center, Leipzig, Germany; Comprehensive Cancer Center Central Germany, Leipzig, Jena, Germany
| | - Patrick Born
- Department of Hematology, Cellular Therapy, Hemostaseology and Infectious Diseases, University Leipzig Medical Center, Leipzig, Germany; Comprehensive Cancer Center Central Germany, Leipzig, Jena, Germany
| | - Franziska Brunner
- Department of Internal Medicine IV, Hematology and Oncology, Martin Luther University Halle-Wittenberg, Halle, Germany
| | - Charlotte Morgner
- Department of Internal Medicine IV, Hematology and Oncology, Martin Luther University Halle-Wittenberg, Halle, Germany
| | - Daniel Fürst
- Institute of Clinical Transfusion Medicine and Immunogenetics Ulm, German Red Cross Blood Transfusion Service, Baden Wuerttemberg-Hessen, University Hospital Ulm, Ulm, Germany; Institute of Transfusion Medicine, University of Ulm, Ulm, Germany
| | - Simone Heyn
- Department of Hematology, Cellular Therapy, Hemostaseology and Infectious Diseases, University Leipzig Medical Center, Leipzig, Germany; Comprehensive Cancer Center Central Germany, Leipzig, Jena, Germany
| | - Enrica Bach
- Department of Hematology, Cellular Therapy, Hemostaseology and Infectious Diseases, University Leipzig Medical Center, Leipzig, Germany; Comprehensive Cancer Center Central Germany, Leipzig, Jena, Germany
| | - Mandy Brueckner
- Department of Hematology, Cellular Therapy, Hemostaseology and Infectious Diseases, University Leipzig Medical Center, Leipzig, Germany; Comprehensive Cancer Center Central Germany, Leipzig, Jena, Germany
| | - Madlen Jentzsch
- Department of Hematology, Cellular Therapy, Hemostaseology and Infectious Diseases, University Leipzig Medical Center, Leipzig, Germany; Comprehensive Cancer Center Central Germany, Leipzig, Jena, Germany
| | - Song-Yau Wang
- Department of Hematology, Cellular Therapy, Hemostaseology and Infectious Diseases, University Leipzig Medical Center, Leipzig, Germany; Comprehensive Cancer Center Central Germany, Leipzig, Jena, Germany
| | - Sebastian Böttcher
- Department of Medicine III Hematology, Oncology and Palliative Care, University Hospital, Rostock, Germany
| | - Georg-Nikolaus Franke
- Department of Hematology, Cellular Therapy, Hemostaseology and Infectious Diseases, University Leipzig Medical Center, Leipzig, Germany; Comprehensive Cancer Center Central Germany, Leipzig, Jena, Germany
| | - Hubert Schrezenmeier
- Institute of Clinical Transfusion Medicine and Immunogenetics Ulm, German Red Cross Blood Transfusion Service, Baden Wuerttemberg-Hessen, University Hospital Ulm, Ulm, Germany; Institute of Transfusion Medicine, University of Ulm, Ulm, Germany
| | - Uwe Platzbecker
- Department of Hematology, Cellular Therapy, Hemostaseology and Infectious Diseases, University Leipzig Medical Center, Leipzig, Germany; Comprehensive Cancer Center Central Germany, Leipzig, Jena, Germany
| | - Maximilian Merz
- Department of Hematology, Cellular Therapy, Hemostaseology and Infectious Diseases, University Leipzig Medical Center, Leipzig, Germany; Comprehensive Cancer Center Central Germany, Leipzig, Jena, Germany
| | - Vladan Vučinić
- Department of Hematology, Cellular Therapy, Hemostaseology and Infectious Diseases, University Leipzig Medical Center, Leipzig, Germany; Comprehensive Cancer Center Central Germany, Leipzig, Jena, Germany.
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Strassl I, Nikoloudis A, Machherndl-Spandl S, Buxhofer-Ausch V, Binder M, Wipplinger D, Stiefel O, Kaynak E, Milanov R, Aichinger C, Nocker S, Bauer T, Kreissl S, Girschikofsky M, Petzer A, Weltermann A, Clausen J. Allogeneic Stem Cell Transplantation in Multiple Myeloma: Risk Factors and Outcomes in the Era of New Therapeutic Options-A Single-Center Experience. Cancers (Basel) 2023; 15:5738. [PMID: 38136284 PMCID: PMC10742138 DOI: 10.3390/cancers15245738] [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: 11/01/2023] [Revised: 12/02/2023] [Accepted: 12/05/2023] [Indexed: 12/24/2023] Open
Abstract
BACKGROUND Despite major treatment advances, multiple myeloma remains incurable. The outcome of patients who are refractory to immunomodulatory agents, proteasome inhibitors, and anti-CD38 monoclonal antibodies is poor, and improved treatment strategies for this difficult-to-treat patient population are an unmet medical need. METHODS This retrospective, unicentric analysis included 38 patients with relapsed/refractory multiple myeloma or plasma cell leukemia who underwent allogeneic stem cell transplantation (allo-HSCT) between 2013 and 2022. Survival outcomes, relapse incidence, and non-relapse mortality were calculated according to remission status, date of allo-HSCT, cytogenetic risk status, timing, and number of previous autologous HSCTs. RESULTS The median PFS was 13.6 months (95% CI, 7.7-30.4) and the median OS was 51.4 months (95% CI, 23.5-NA) in the overall cohort. The cumulative incidence of relapse at 3 years was 57%, and non-relapse mortality was 16%. The median PFS and OS were significantly longer in patients with very good partial remission (VGPR) or better compared to patients with less than VGPR at the time of allo-HSCT (mPFS 29.7 months (95% CI, 13.7-NA) vs. 6.5 months (95% CI, 2.6-17.0); p = 0.009 and mOS not reached vs. 18.6 months (95% CI, 7.0-NA); p = 0.006). CONCLUSION For selected patients, allo-HSCT may result in favorable overall survival, in part by providing an appropriate hemato-immunological basis for subsequent therapies.
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Affiliation(s)
- Irene Strassl
- Division of Hematology with Stem Cell Transplantation, Hemostaseology and Medical Oncology, Department of Internal Medicine I, Ordensklinikum Linz, Fadingerstrasse 1, 4020 Linz, Austria; (A.N.); (S.M.-S.); (V.B.-A.); (D.W.); (O.S.); (E.K.); (R.M.); (C.A.); (S.N.); (T.B.); (S.K.); (M.G.); (A.P.); (A.W.); (J.C.)
- Medical Faculty, Johannes Kepler University Linz, Altenberger Strasse 69, 4040 Linz, Austria
| | - Alexander Nikoloudis
- Division of Hematology with Stem Cell Transplantation, Hemostaseology and Medical Oncology, Department of Internal Medicine I, Ordensklinikum Linz, Fadingerstrasse 1, 4020 Linz, Austria; (A.N.); (S.M.-S.); (V.B.-A.); (D.W.); (O.S.); (E.K.); (R.M.); (C.A.); (S.N.); (T.B.); (S.K.); (M.G.); (A.P.); (A.W.); (J.C.)
- Medical Faculty, Johannes Kepler University Linz, Altenberger Strasse 69, 4040 Linz, Austria
| | - Sigrid Machherndl-Spandl
- Division of Hematology with Stem Cell Transplantation, Hemostaseology and Medical Oncology, Department of Internal Medicine I, Ordensklinikum Linz, Fadingerstrasse 1, 4020 Linz, Austria; (A.N.); (S.M.-S.); (V.B.-A.); (D.W.); (O.S.); (E.K.); (R.M.); (C.A.); (S.N.); (T.B.); (S.K.); (M.G.); (A.P.); (A.W.); (J.C.)
- Medical Faculty, Johannes Kepler University Linz, Altenberger Strasse 69, 4040 Linz, Austria
| | - Veronika Buxhofer-Ausch
- Division of Hematology with Stem Cell Transplantation, Hemostaseology and Medical Oncology, Department of Internal Medicine I, Ordensklinikum Linz, Fadingerstrasse 1, 4020 Linz, Austria; (A.N.); (S.M.-S.); (V.B.-A.); (D.W.); (O.S.); (E.K.); (R.M.); (C.A.); (S.N.); (T.B.); (S.K.); (M.G.); (A.P.); (A.W.); (J.C.)
- Medical Faculty, Johannes Kepler University Linz, Altenberger Strasse 69, 4040 Linz, Austria
| | - Michaela Binder
- Division of Hematology with Stem Cell Transplantation, Hemostaseology and Medical Oncology, Department of Internal Medicine I, Ordensklinikum Linz, Fadingerstrasse 1, 4020 Linz, Austria; (A.N.); (S.M.-S.); (V.B.-A.); (D.W.); (O.S.); (E.K.); (R.M.); (C.A.); (S.N.); (T.B.); (S.K.); (M.G.); (A.P.); (A.W.); (J.C.)
| | - Dagmar Wipplinger
- Division of Hematology with Stem Cell Transplantation, Hemostaseology and Medical Oncology, Department of Internal Medicine I, Ordensklinikum Linz, Fadingerstrasse 1, 4020 Linz, Austria; (A.N.); (S.M.-S.); (V.B.-A.); (D.W.); (O.S.); (E.K.); (R.M.); (C.A.); (S.N.); (T.B.); (S.K.); (M.G.); (A.P.); (A.W.); (J.C.)
| | - Olga Stiefel
- Division of Hematology with Stem Cell Transplantation, Hemostaseology and Medical Oncology, Department of Internal Medicine I, Ordensklinikum Linz, Fadingerstrasse 1, 4020 Linz, Austria; (A.N.); (S.M.-S.); (V.B.-A.); (D.W.); (O.S.); (E.K.); (R.M.); (C.A.); (S.N.); (T.B.); (S.K.); (M.G.); (A.P.); (A.W.); (J.C.)
- Medical Faculty, Johannes Kepler University Linz, Altenberger Strasse 69, 4040 Linz, Austria
| | - Emine Kaynak
- Division of Hematology with Stem Cell Transplantation, Hemostaseology and Medical Oncology, Department of Internal Medicine I, Ordensklinikum Linz, Fadingerstrasse 1, 4020 Linz, Austria; (A.N.); (S.M.-S.); (V.B.-A.); (D.W.); (O.S.); (E.K.); (R.M.); (C.A.); (S.N.); (T.B.); (S.K.); (M.G.); (A.P.); (A.W.); (J.C.)
| | - Robert Milanov
- Division of Hematology with Stem Cell Transplantation, Hemostaseology and Medical Oncology, Department of Internal Medicine I, Ordensklinikum Linz, Fadingerstrasse 1, 4020 Linz, Austria; (A.N.); (S.M.-S.); (V.B.-A.); (D.W.); (O.S.); (E.K.); (R.M.); (C.A.); (S.N.); (T.B.); (S.K.); (M.G.); (A.P.); (A.W.); (J.C.)
| | - Christoph Aichinger
- Division of Hematology with Stem Cell Transplantation, Hemostaseology and Medical Oncology, Department of Internal Medicine I, Ordensklinikum Linz, Fadingerstrasse 1, 4020 Linz, Austria; (A.N.); (S.M.-S.); (V.B.-A.); (D.W.); (O.S.); (E.K.); (R.M.); (C.A.); (S.N.); (T.B.); (S.K.); (M.G.); (A.P.); (A.W.); (J.C.)
| | - Stefanie Nocker
- Division of Hematology with Stem Cell Transplantation, Hemostaseology and Medical Oncology, Department of Internal Medicine I, Ordensklinikum Linz, Fadingerstrasse 1, 4020 Linz, Austria; (A.N.); (S.M.-S.); (V.B.-A.); (D.W.); (O.S.); (E.K.); (R.M.); (C.A.); (S.N.); (T.B.); (S.K.); (M.G.); (A.P.); (A.W.); (J.C.)
- Medical Faculty, Johannes Kepler University Linz, Altenberger Strasse 69, 4040 Linz, Austria
| | - Thomas Bauer
- Division of Hematology with Stem Cell Transplantation, Hemostaseology and Medical Oncology, Department of Internal Medicine I, Ordensklinikum Linz, Fadingerstrasse 1, 4020 Linz, Austria; (A.N.); (S.M.-S.); (V.B.-A.); (D.W.); (O.S.); (E.K.); (R.M.); (C.A.); (S.N.); (T.B.); (S.K.); (M.G.); (A.P.); (A.W.); (J.C.)
- Medical Faculty, Johannes Kepler University Linz, Altenberger Strasse 69, 4040 Linz, Austria
| | - Stefanie Kreissl
- Division of Hematology with Stem Cell Transplantation, Hemostaseology and Medical Oncology, Department of Internal Medicine I, Ordensklinikum Linz, Fadingerstrasse 1, 4020 Linz, Austria; (A.N.); (S.M.-S.); (V.B.-A.); (D.W.); (O.S.); (E.K.); (R.M.); (C.A.); (S.N.); (T.B.); (S.K.); (M.G.); (A.P.); (A.W.); (J.C.)
| | - Michael Girschikofsky
- Division of Hematology with Stem Cell Transplantation, Hemostaseology and Medical Oncology, Department of Internal Medicine I, Ordensklinikum Linz, Fadingerstrasse 1, 4020 Linz, Austria; (A.N.); (S.M.-S.); (V.B.-A.); (D.W.); (O.S.); (E.K.); (R.M.); (C.A.); (S.N.); (T.B.); (S.K.); (M.G.); (A.P.); (A.W.); (J.C.)
| | - Andreas Petzer
- Division of Hematology with Stem Cell Transplantation, Hemostaseology and Medical Oncology, Department of Internal Medicine I, Ordensklinikum Linz, Fadingerstrasse 1, 4020 Linz, Austria; (A.N.); (S.M.-S.); (V.B.-A.); (D.W.); (O.S.); (E.K.); (R.M.); (C.A.); (S.N.); (T.B.); (S.K.); (M.G.); (A.P.); (A.W.); (J.C.)
- Medical Faculty, Johannes Kepler University Linz, Altenberger Strasse 69, 4040 Linz, Austria
| | - Ansgar Weltermann
- Division of Hematology with Stem Cell Transplantation, Hemostaseology and Medical Oncology, Department of Internal Medicine I, Ordensklinikum Linz, Fadingerstrasse 1, 4020 Linz, Austria; (A.N.); (S.M.-S.); (V.B.-A.); (D.W.); (O.S.); (E.K.); (R.M.); (C.A.); (S.N.); (T.B.); (S.K.); (M.G.); (A.P.); (A.W.); (J.C.)
- Medical Faculty, Johannes Kepler University Linz, Altenberger Strasse 69, 4040 Linz, Austria
| | - Johannes Clausen
- Division of Hematology with Stem Cell Transplantation, Hemostaseology and Medical Oncology, Department of Internal Medicine I, Ordensklinikum Linz, Fadingerstrasse 1, 4020 Linz, Austria; (A.N.); (S.M.-S.); (V.B.-A.); (D.W.); (O.S.); (E.K.); (R.M.); (C.A.); (S.N.); (T.B.); (S.K.); (M.G.); (A.P.); (A.W.); (J.C.)
- Medical Faculty, Johannes Kepler University Linz, Altenberger Strasse 69, 4040 Linz, Austria
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John L, Sauer S, Hegenbart U, Dreger P, Hundemer M, Müller-Tidow C, Schmitt A, Schmitt M, Raab MS, Schönland SO. Idecabtagene Vicleucel Is Well Tolerated and Effective in Relapsed/Refractory Myeloma Patients with Prior Allogeneic Stem Cell Transplantation. Transplant Cell Ther 2023; 29:609.e1-609.e6. [PMID: 37348705 DOI: 10.1016/j.jtct.2023.06.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 05/31/2023] [Accepted: 06/17/2023] [Indexed: 06/24/2023]
Abstract
BCMA-specific chimeric-antigen receptor (CAR-) T cell therapy has led to high response rates and durable remissions in patients with relapsed refractory multiple myeloma. However, little data are available for patients after prior allogeneic stem cell transplantation (allo-SCT) in whom T cells are chimeric. In this study, we aimed to assess the safety and efficacy of patient-derived donor CAR-T therapy in myeloma patients with prior allo-SCT, particularly with regard to graft-versus-host disease (GVHD). We report a comprehensive clinical analysis of 3 patients who had previously undergone allo-SCT for high-risk myeloma and were treated with idecabtagene vicleucel (ide-cel) at our institution. Ide-cel was well tolerated, with no clinically relevant immune effector cell-associated neurotoxicity syndrome or cytokine release syndrome observed in any patient. Importantly, no new GVHD was observed, even though all patients had a history of GVHD. All patients responded to treatment with at least a very good partial remission. Two patients relapsed within 6 months, and 1 patient was still in stringent complete remission at the time of this report. Our findings demonstrate that treatment with ide-cel is feasible, very well tolerated, and effective in patients with relapsed/refractory multiple myeloma after prior allo-SCT.
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Affiliation(s)
- Lukas John
- Department of Internal Medicine V, Heidelberg University Hospital, Heidelberg, Germany; Clinical Cooperation Unit Molecular Hematology/Oncology, Department of Internal Medicine V, Heidelberg University Hospital and German Cancer Research Center, Heidelberg, Germany
| | - Sandra Sauer
- Department of Internal Medicine V, Heidelberg University Hospital, Heidelberg, Germany
| | - Ute Hegenbart
- Department of Internal Medicine V, Heidelberg University Hospital, Heidelberg, Germany
| | - Peter Dreger
- Department of Internal Medicine V, Heidelberg University Hospital, Heidelberg, Germany
| | - Michael Hundemer
- Department of Internal Medicine V, Heidelberg University Hospital, Heidelberg, Germany
| | - Carsten Müller-Tidow
- Department of Internal Medicine V, Heidelberg University Hospital, Heidelberg, Germany; National Center for Tumor Diseases, Heidelberg, Germany
| | - Anita Schmitt
- Department of Internal Medicine V, Heidelberg University Hospital, Heidelberg, Germany
| | - Michael Schmitt
- Department of Internal Medicine V, Heidelberg University Hospital, Heidelberg, Germany
| | - Marc S Raab
- Department of Internal Medicine V, Heidelberg University Hospital, Heidelberg, Germany; Clinical Cooperation Unit Molecular Hematology/Oncology, Department of Internal Medicine V, Heidelberg University Hospital and German Cancer Research Center, Heidelberg, Germany
| | - Stefan O Schönland
- Department of Internal Medicine V, Heidelberg University Hospital, Heidelberg, Germany.
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Claveau JS, LeBlanc R, Ahmad I, Delisle JS, Cohen S, Kiss T, Bambace NM, Bernard L, Lachance S, Roy DC, Sauvageau G, Veilleux O, Roy J. Bortezomib Maintenance After Allogeneic Transplantation in Newly Diagnosed Myeloma Patients Results in Decreased Incidence and Severity of Chronic GVHD. Transplant Cell Ther 2023; 29:44.e1-44.e9. [PMID: 36334654 DOI: 10.1016/j.jtct.2022.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 10/11/2022] [Accepted: 10/26/2022] [Indexed: 11/05/2022]
Abstract
Allogeneic hematopoietic cell transplantation (HCT) has curative potential in myeloma but remains hampered by high rates of relapse and chronic graft-versus-host disease (GVHD). We hypothesized that bortezomib (BTZ) as maintenance therapy after allo HCT could not only decrease the incidence of relapse but also the incidence and severity of chronic GVHD. The primary endpoint of this study was to determine whether BTZ maintenance decreases the incidence and severity of chronic GVHD using National Institutes of Health (NIH) criteria. The secondary endpoints were to determine the immunosuppression burden, organ involvement and survival (overall survival, progression-free survival) in patients either receiving or not receiving BTZ. In this retrospective study, we compared the outcome of 46 myeloma patients who received BTZ after upfront tandem auto-allo HCT between 2008 and 2020 to 61 patients without maintenance. We explored the impact of BTZ maintenance on incidence and severity of chronic GVHD using the 2014 NIH criteria. At 2 years, incidences of overall (61.2% versus 83.6%; P = .001), and moderate/severe chronic GVHD (44.5% versus 77.0%; P = .001) were significantly lower in BTZ recipients who had less mouth (43% versus 67%; P = .018) and eyes (9% versus 41%; P = .001) involvement at initial diagnosis. We report a lower use of systemic steroids (45.1% versus 76.4%; P < .001), mycophenolate mofetil (15.5% versus 28.2%; P = .031) and tacrolimus (34.5% versus 70.6%; P < .001) in BTZ recipients. Probability of being alive and off systemic immunosuppressants at 3 years was 77% in BTZ recipients and 56% in controls (P = .046). To date, there is no difference in survival between both groups. In summary, BTZ maintenance improved incidence and severity of chronic GVHD and should be considered as a valid option in myeloma patients receiving upfront tandem auto-allo HCT.
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Affiliation(s)
- Jean-Sébastien Claveau
- Division of Hematology, Oncology and Transplantation, Institut Universitaire d'Hémato-Oncologie et de Thérapie Cellulaire, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, Québec, Canada.
| | - Richard LeBlanc
- Division of Hematology, Oncology and Transplantation, Institut Universitaire d'Hémato-Oncologie et de Thérapie Cellulaire, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, Québec, Canada
| | - Imran Ahmad
- Division of Hematology, Oncology and Transplantation, Institut Universitaire d'Hémato-Oncologie et de Thérapie Cellulaire, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, Québec, Canada
| | - Jean-Sébastien Delisle
- Division of Hematology, Oncology and Transplantation, Institut Universitaire d'Hémato-Oncologie et de Thérapie Cellulaire, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, Québec, Canada
| | - Sandra Cohen
- Division of Hematology, Oncology and Transplantation, Institut Universitaire d'Hémato-Oncologie et de Thérapie Cellulaire, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, Québec, Canada
| | - Thomas Kiss
- Division of Hematology, Oncology and Transplantation, Institut Universitaire d'Hémato-Oncologie et de Thérapie Cellulaire, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, Québec, Canada
| | - Nadia M Bambace
- Division of Hematology, Oncology and Transplantation, Institut Universitaire d'Hémato-Oncologie et de Thérapie Cellulaire, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, Québec, Canada
| | - Léa Bernard
- Division of Hematology, Oncology and Transplantation, Institut Universitaire d'Hémato-Oncologie et de Thérapie Cellulaire, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, Québec, Canada
| | - Silvy Lachance
- Division of Hematology, Oncology and Transplantation, Institut Universitaire d'Hémato-Oncologie et de Thérapie Cellulaire, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, Québec, Canada
| | - Denis Claude Roy
- Division of Hematology, Oncology and Transplantation, Institut Universitaire d'Hémato-Oncologie et de Thérapie Cellulaire, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, Québec, Canada
| | - Guy Sauvageau
- Division of Hematology, Oncology and Transplantation, Institut Universitaire d'Hémato-Oncologie et de Thérapie Cellulaire, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, Québec, Canada
| | - Olivier Veilleux
- Division of Hematology, Oncology and Transplantation, Institut Universitaire d'Hémato-Oncologie et de Thérapie Cellulaire, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, Québec, Canada
| | - Jean Roy
- Division of Hematology, Oncology and Transplantation, Institut Universitaire d'Hémato-Oncologie et de Thérapie Cellulaire, Hôpital Maisonneuve-Rosemont, Université de Montréal, Montréal, Québec, Canada
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Goldsmith SR, Ghobadi A, Dipersio JF, Hill B, Shadman M, Jain T. Chimeric Antigen Receptor T Cell Therapy versus Hematopoietic Stem Cell Transplantation: An Evolving Perspective. Transplant Cell Ther 2022; 28:727-736. [PMID: 35878743 PMCID: PMC10487280 DOI: 10.1016/j.jtct.2022.07.015] [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: 04/29/2022] [Revised: 06/30/2022] [Accepted: 07/16/2022] [Indexed: 11/27/2022]
Abstract
Cellular therapy modalities, including autologous (auto-) hematopoietic cell transplantation (HCT), allogeneic (allo-) HCT, and now chimeric antigen receptor (CAR) T cell therapy, have demonstrated long-term remission in advanced hematologic malignancies. Auto-HCT and allo-HCT, through hematopoietic rescue, have permitted the use of higher doses of chemotherapy. Allo-HCT also introduced a nonspecific immune-mediated targeting of malignancy resulting in protection from relapse, although at the expense of similar targeting of normal host cells. In contrast, CAR T therapy, through genetically engineered immunotherapeutic precision, allows for redirection of autologous immune effector cells against malignancy in an antigen-specific and MHC-independent fashion, with demonstrated efficacy in patients who are refractory to cytotoxic chemotherapy. It too has unique toxicities and challenges, however. Non-Hodgkin lymphoma (including large B cell lymphoma, mantle cell lymphoma, and follicular lymphoma), B cell acute lymphoblastic leukemia, and multiple myeloma are the 3 main diseases associated with the use of fully developed CAR T products with widespread deployment. Recent and ongoing clinical trials have been examining the interface among the 3 cellular therapy modalities (auto-HCT, allo-HCT, and CAR T) to determine whether they should be "complementary" or "competitive" therapies. In this review, we examine the current state of this interface with respect to the most recent data and delve into the controversies and conclusions that may inform clinical decision making.
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Affiliation(s)
- Scott R Goldsmith
- Judy and Bernard Briskin Center for Multiple Myeloma Research, City of Hope Comprehensive Cancer Center, Duarte, California; Division of Oncology, Washington University School of Medicine in St Louis, St Louis, Missouri.
| | - Armin Ghobadi
- Division of Oncology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - John F Dipersio
- Division of Oncology, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Brian Hill
- Taussig Cancer Institute, Cleveland Clinic, Cleveland, Ohio
| | - Mayzar Shadman
- Clinical Research Division, Fred Hutch Cancer Center and Medical Oncology division, University of Washington, Seattle, Washington
| | - Tania Jain
- Division of Hematological Malignancies and Bone Marrow Transplantation, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, Maryland
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6
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Current Role of Allogeneic Stem Cell Transplantation in Multiple Myeloma. Oncol Ther 2022; 10:105-122. [PMID: 35377068 PMCID: PMC9098709 DOI: 10.1007/s40487-022-00195-3] [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: 02/15/2022] [Accepted: 03/10/2022] [Indexed: 11/01/2022] Open
Abstract
Major progress in the treatment of multiple myeloma has been made in the last several years. However, myeloma remains incurable and patients with high-risk cytogenetics or advanced stage disease have an even worsen survival. Only allogeneic transplantation may have curative potential in some patients. However, the high non-relapse mortality and incidence of chronic graft-versus-host disease have raised controversy regarding this procedure. In this review, we will address the role of upfront and delayed allogeneic transplant.
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7
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Blouin AG, Askar M. Chimerism analysis for clinicians: a review of the literature and worldwide practices. Bone Marrow Transplant 2022; 57:347-359. [PMID: 35082369 DOI: 10.1038/s41409-022-01579-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 12/18/2021] [Accepted: 01/12/2022] [Indexed: 11/09/2022]
Abstract
This review highlights literature pertinent to chimerism analysis in the context of hematopoietic cell transplantation (HCT). We also conducted a survey of testing practices of program members of CIBMTR worldwide. Questions included testing methods, time points, specimen type, cell lineage tested and testing indications. Recent literature suggests that detection of low level mixed chimerism has a clinical utility in predicting relapse. There is also increasing recognition of HLA loss relapse to potentially guide rescue decisions in cases of relapse. These developments coincide with wider access to high sensitivity next generation sequencing (NGS) in clinical laboratories. Our survey revealed a heterogeneity in practices as well as in findings and conclusions of published studies. Although the most commonly used method is STR, studies support more sensitive methods such as NGS, especially for predicting relapse. There is no conclusive evidence to support testing chimerism in BM over PB, particularly when using a high sensitivity testing method. Periodic monitoring of chimerism especially in diagnoses with a high risk of relapse is advantageous. Lineage specific chimerism is more sensitive than whole blood in predicting impending relapse. Further studies that critically assess how to utilize chimerism testing results will inform evidence based clinical management decisions.
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Affiliation(s)
- Amanda G Blouin
- Department of Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Medhat Askar
- Department of Laboratory Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA. .,Department of Pathology & Laboratory Medicine, Baylor University Medical Center, Dallas, TX, USA. .,Department of Pathology and Laboratory Medicine, Texas A&M Health Science Center College of Medicine, Bryan, TX, USA. .,National Donor Marrow Program (NMDP)/Be The Match, Minneapolis, MN, USA.
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8
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LeBlanc R, Ahmad I, Terra R, Boudreault JS, Ogez D, Lamore K, Delisle JS, Bambace N, Bernard L, Cohen S, Kiss T, Lachance S, Landais S, Lemieux-Blanchard É, Sauvageau G, Sebag M, Roy DC, Roy J. Outcomes in newly diagnosed young or high-risk myeloma patients receiving tandem autologous/allogeneic transplant followed by bortezomib maintenance: a phase II study. Bone Marrow Transplant 2021; 57:252-260. [PMID: 34845367 DOI: 10.1038/s41409-021-01532-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 10/29/2021] [Accepted: 11/15/2021] [Indexed: 01/14/2023]
Abstract
Despite novel drugs and autologous HCT, MM remains incurable, with short survival in patients with poor biological characteristics. Allo HCT may be curative in some patients but is hampered by high rates of toxicity and relapse. We hypothesized that bortezomib (BTZ), with its anti-myeloma and immunologic properties, could improve PFS and cGVHD after allo HCT in newly diagnosed MM patients. In this prospective phase II study, we included 39 young (≤50 years) and high-risk patients who received a tandem auto-allo HCT followed by BTZ. Patients had prospective minimal residual disease (MRD) evaluations using Next-Generation Flow cytometry prior to allo HCT, prior BTZ and every 3 months for 2 years. With a median follow-up of 48 months, we report PFS and OS at 5 years of 41% and 80%, with a non-relapse mortality of 12%. Incidences of grade II-IV aGVHD at 12 months and moderate/severe cGVHD at 2 years were 26% and 57%. In a multivariate analysis model including cytogenetics, ISS and MRD status, MRD positivity prior to allo HCT (HR 3.75, p = 0.037), prior BTZ (HR 11.3, p = 0.018) and 3 months post-BTZ initiation (HR 9.7, p = 0.001) was highly predictive of progression. Peritransplant MRD assessment thus strongly predicts disease progression.
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Affiliation(s)
- Richard LeBlanc
- Division of Hematology, Oncology and Transplantation, Hôpital Maisonneuve-Rosemont, Department of Medicine/Université de Montréal, Montreal, QC, Canada.
| | - Imran Ahmad
- Division of Hematology, Oncology and Transplantation, Hôpital Maisonneuve-Rosemont, Department of Medicine/Université de Montréal, Montreal, QC, Canada
| | - Rafik Terra
- Division of Hematology, Oncology and Transplantation, Hôpital Maisonneuve-Rosemont, Montreal, QC, Canada
| | - Jean-Samuel Boudreault
- Division of Hematology and Oncology, Hôpital du Sacré-Coeur, Department of Medicine/Université de Montréal, Montreal, QC, Canada
| | - David Ogez
- Chronic Pain Clinic, Hôpital Maisonneuve-Rosemont, Department of Anesthesiology and Pain Medicine/Université de Montréal, Montreal, QC, Canada
| | - Kristopher Lamore
- Laboratoire de psychopathologie et processus de santé, Université de Paris, Paris, Boulogne-Billancourt, France
| | - Jean-Sébastien Delisle
- Division of Hematology, Oncology and Transplantation, Hôpital Maisonneuve-Rosemont, Department of Medicine/Université de Montréal, Montreal, QC, Canada
| | - Nadia Bambace
- Division of Hematology, Oncology and Transplantation, Hôpital Maisonneuve-Rosemont, Department of Medicine/Université de Montréal, Montreal, QC, Canada
| | - Léa Bernard
- Division of Hematology, Oncology and Transplantation, Hôpital Maisonneuve-Rosemont, Department of Medicine/Université de Montréal, Montreal, QC, Canada
| | - Sandra Cohen
- Division of Hematology, Oncology and Transplantation, Hôpital Maisonneuve-Rosemont, Department of Medicine/Université de Montréal, Montreal, QC, Canada
| | - Thomas Kiss
- Division of Hematology, Oncology and Transplantation, Hôpital Maisonneuve-Rosemont, Department of Medicine/Université de Montréal, Montreal, QC, Canada
| | - Silvy Lachance
- Division of Hematology, Oncology and Transplantation, Hôpital Maisonneuve-Rosemont, Department of Medicine/Université de Montréal, Montreal, QC, Canada
| | - Séverine Landais
- Division of Hematology, Oncology and Transplantation, Hôpital Maisonneuve-Rosemont, Montreal, QC, Canada
| | - Émilie Lemieux-Blanchard
- Division of Hematology and Oncology, Centre Hospitalier de l'Université de Montréal, Department of Medicine/Université de Montréal, Montreal, QC, Canada
| | - Guy Sauvageau
- Division of Hematology, Oncology and Transplantation, Hôpital Maisonneuve-Rosemont, Department of Medicine/Université de Montréal, Montreal, QC, Canada
| | - Michael Sebag
- Division of Hematology, McGill University Health Center, Department of Medicine/McGill University, Montreal, QC, Canada
| | - Denis Claude Roy
- Division of Hematology, Oncology and Transplantation, Hôpital Maisonneuve-Rosemont, Department of Medicine/Université de Montréal, Montreal, QC, Canada
| | - Jean Roy
- Division of Hematology, Oncology and Transplantation, Hôpital Maisonneuve-Rosemont, Department of Medicine/Université de Montréal, Montreal, QC, Canada
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9
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Khorochkov A, Prieto J, Singh KB, Nnadozie MC, Shrestha N, Dominic JL, Abdal M, Abe RAM, Masroor A, Mohammed L. The Role of Allogeneic Stem Cell Transplantation in Multiple Myeloma: A Systematic Review of the Literature. Cureus 2021; 13:e18334. [PMID: 34725596 PMCID: PMC8553292 DOI: 10.7759/cureus.18334] [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: 07/06/2021] [Accepted: 09/27/2021] [Indexed: 11/05/2022] Open
Abstract
Multiple myeloma (MM) is an indolent B-cell malignancy, where treatment is aimed at preventing organ dysfunction from light chain accumulation (slowing disease progression) and inducing remission. Allogeneic stem cell transplant (allo-SCT), through graft versus myeloma (GVM) effects, has the potential to induce remission to a potentially curative-like state. In this systematic review, we aimed to understand this relationship to the risks and severity of disease in categorized patients and gain an updated comprehension of the future of allo-SCT in MM treatment. We conducted this review according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and searched the PubMed database to obtain the specified literature with both the use of keywords and Medical Subject Headings (MeSH). A total of 16 relevant articles were included for discussion after the quality appraisal was completed, as appropriate, by either the Cochrane tool or Newcastle-Ottawa checklist. Our review concludes that while allo-SCT may benefit high-risk patients, successful procedures may incorporate a tandem autologous hematopoietic stem cell transplant approach in combination with novel pharmacologic contributions for which there is an observed synergy in the modulation of the immunologic microenvironment. Furthermore, tailored patient selection by evaluating pre-transplant factors including high-risk cytogenetics, age, and pre-salvage International Staging System (ISS) can predict post-transplantation success including non-relapse mortality. Successive research should continue to revise and update treatment options as the evolving therapeutic drug regimens may change over the course of indolent disease.
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Affiliation(s)
- Arseni Khorochkov
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Jose Prieto
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Karan B Singh
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Maduka C Nnadozie
- Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Niki Shrestha
- Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Jerry Lorren Dominic
- General Surgery, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
- General Surgery, Stony Brook Medicine/Southampton Hospital, Southampton, USA
- General Surgery and Orthopaedic Surgery, Cornerstone Regional Hospital/South Texas Health System, Edinburg, USA
- General Surgery, LaSante Health Center, Brooklyn, USA
| | - Muhammad Abdal
- Emergency Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Rose Anne M Abe
- Research, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Anum Masroor
- Psychiatry, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
- Psychiatry, Psychiatric Care Associates, Englewood, USA
- Medicine, Khyber Medical College, Peshawar, PAK
| | - Lubna Mohammed
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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10
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[Chinese guidelines of autologous stem cell transplantation for multiple myeloma (2021)]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2021; 42:353-357. [PMID: 34218575 PMCID: PMC8293008 DOI: 10.3760/cma.j.issn.0253-2727.2021.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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11
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Lopes R, Ferreira BV, Caetano J, Barahona F, Carneiro EA, João C. Boosting Immunity against Multiple Myeloma. Cancers (Basel) 2021; 13:1221. [PMID: 33799565 PMCID: PMC8001641 DOI: 10.3390/cancers13061221] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 02/12/2021] [Accepted: 03/01/2021] [Indexed: 01/10/2023] Open
Abstract
Despite the improvement of patient's outcome obtained by the current use of immunomodulatory drugs, proteasome inhibitors or anti-CD38 monoclonal antibodies, multiple myeloma (MM) remains an incurable disease. More recently, the testing in clinical trials of novel drugs such as anti-BCMA CAR-T cells, antibody-drug conjugates or bispecific antibodies broadened the possibility of improving patients' survival. However, thus far, these treatment strategies have not been able to steadily eliminate all malignant cells, and the aim has been to induce a long-term complete response with minimal residual disease (MRD)-negative status. In this sense, approaches that target not only myeloma cells but also the surrounding microenvironment are promising strategies to achieve a sustained MRD negativity with prolonged survival. This review provides an overview of current and future strategies used for immunomodulation of MM focusing on the impact on bone marrow (BM) immunome.
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Affiliation(s)
- Raquel Lopes
- Lymphoma and Myeloma Research Programme, Champalimaud Centre for the Unknown, 1400-038 Lisbon, Portugal; (R.L.); (B.V.F.); (J.C.); (F.B.); (E.A.C.)
- Faculty of Medicine, University of Lisbon, 1649-028 Lisbon, Portugal
| | - Bruna Velosa Ferreira
- Lymphoma and Myeloma Research Programme, Champalimaud Centre for the Unknown, 1400-038 Lisbon, Portugal; (R.L.); (B.V.F.); (J.C.); (F.B.); (E.A.C.)
- Faculty of Medical Sciences, NOVA Medical School, 1169-056 Lisbon, Portugal
| | - Joana Caetano
- Lymphoma and Myeloma Research Programme, Champalimaud Centre for the Unknown, 1400-038 Lisbon, Portugal; (R.L.); (B.V.F.); (J.C.); (F.B.); (E.A.C.)
- Faculty of Medical Sciences, NOVA Medical School, 1169-056 Lisbon, Portugal
- Hemato-Oncology Department, Champalimaud Centre for the Unknown, 1400-038 Lisbon, Portugal
| | - Filipa Barahona
- Lymphoma and Myeloma Research Programme, Champalimaud Centre for the Unknown, 1400-038 Lisbon, Portugal; (R.L.); (B.V.F.); (J.C.); (F.B.); (E.A.C.)
- Faculty of Medical Sciences, NOVA Medical School, 1169-056 Lisbon, Portugal
| | - Emilie Arnault Carneiro
- Lymphoma and Myeloma Research Programme, Champalimaud Centre for the Unknown, 1400-038 Lisbon, Portugal; (R.L.); (B.V.F.); (J.C.); (F.B.); (E.A.C.)
| | - Cristina João
- Lymphoma and Myeloma Research Programme, Champalimaud Centre for the Unknown, 1400-038 Lisbon, Portugal; (R.L.); (B.V.F.); (J.C.); (F.B.); (E.A.C.)
- Faculty of Medical Sciences, NOVA Medical School, 1169-056 Lisbon, Portugal
- Hemato-Oncology Department, Champalimaud Centre for the Unknown, 1400-038 Lisbon, Portugal
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12
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Afram G, Susek KH, Uttervall K, Wersäll JD, Wagner AK, Luong V, Lund J, Gahrton G, Alici E, Nahi H. Improved survival in multiple Myeloma patients undergoing autologous stem cell transplantation is entirely in the standard cytogenetic risk groups. Eur J Haematol 2021; 106:546-554. [PMID: 33471414 DOI: 10.1111/ejh.13585] [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: 12/26/2020] [Revised: 01/15/2021] [Accepted: 01/18/2021] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Novel drugs and drug combinations have improved outcomes for multiple myeloma patients. However, subgroups of patients still have a poor progression-free survival (PFS) and overall survival (OS). In an attempt to identify how the novel drugs affect the outcome in standard-risk and high-risk patients, respectively, we have investigated 715 multiple myeloma (MM) patients who have undergone high dose treatment followed by autologous stem cell transplantation at our center during 1995 - 2020. Outcomes during three time periods, 1995-1999 (period I), 2000-2009 (period II), and 2010-2020 (period III), were compared separately for standard-risk and high-risk patients. Risk stratification was based on chromosome analysis for periods II and III. RESULTS The whole cohort of patients showed significantly improved OS with time during the three periods being at a median of 5.8, 7.0, and 10.0 years, respectively. There is also a weak tendency for improved PFS, that is, a median of 2.4, 2.6, and 2.9 years, respectively, during the same periods. However, the separate analysis of standard-risk and high-risk patients showed that the overall improvement with time was due to improved standard-risk patients (median OS 8.4 years for the period I and not reached for period II and III). In contrast, no significant improvement was seen in high-risk patients. For patients with del17p, PFS was even worse during period III as compared to period II (median 1.6 vs 3.2 years respectively). CONCLUSION Our results show that the dramatic improvement in outcome for MM patients during the last 20 years only applies for standard-risk patients, while high-risk MM patients still are doing poorly, indicating that the novel drugs developed during this time are preferentially effective in standard-risk patients. New treatment modalities like CAR-T cells, CAR-NK cells, and/or bispecific antibodies should be tried in clinical studies early in the course of the disease, especially in patients with high-risk cytogenetics.
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Affiliation(s)
- Gabriel Afram
- Department of Medicine, Center for Hematology and Regenerative Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden.,Haematology Center, Karolinska University Hospital, Stockholm, Sweden
| | - Katharina Helene Susek
- Department of Medicine, Center for Hematology and Regenerative Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Katarina Uttervall
- Department of Medicine, Center for Hematology and Regenerative Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden.,Haematology Center, Karolinska University Hospital, Stockholm, Sweden
| | - Johanna Dehlsen Wersäll
- Department of Medicine, Center for Hematology and Regenerative Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Arnika Kathleen Wagner
- Department of Medicine, Center for Hematology and Regenerative Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden.,Haematology Center, Karolinska University Hospital, Stockholm, Sweden
| | - Vincent Luong
- Department of Medicine, Center for Hematology and Regenerative Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden.,Haematology Center, Karolinska University Hospital, Stockholm, Sweden
| | - Johan Lund
- Department of Medicine, Center for Hematology and Regenerative Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Gösta Gahrton
- Department of Medicine, Center for Hematology and Regenerative Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden
| | - Evren Alici
- Department of Medicine, Center for Hematology and Regenerative Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden.,Haematology Center, Karolinska University Hospital, Stockholm, Sweden
| | - Hareth Nahi
- Department of Medicine, Center for Hematology and Regenerative Medicine, Huddinge, Karolinska Institutet, Stockholm, Sweden.,Haematology Center, Karolinska University Hospital, Stockholm, Sweden
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