The incidence of acute GVHD in these patients was comparable to that seen with conventional allo-SCT and occurred mostly after donor lymphocyte infusion or withdrawal of cyclosporine. [27] The European Group for Blood and Marrow Transplantation recently updated its transplantation registry data on a total of 8,362 multiple myeloma patients. [33-35] In conventional chemotherapy trials, renal failure is a poor prognostic factor. The issue is more complicated for tandem transplants, and even in younger selected patients, only 66% and 75% of those randomized to tandem SCT in the Bologna 96 and IFM 94-02 trials actually received both transplants. Several studies have confirmed the efficacy of high-dose therapy in "elderly" patients with multiple myeloma. On intent-to-treat analysis, a CR was achieved in 6% of patients after VAD chemotherapy, in 12% after cyclophosphamide, in 27% after the first transplant, and in 25% after the second transplant. Reece DE, Filicko J, Flomemberg N, etal: Use of melphalan 280 mg/m. When the cost, duration, and toxicities of therapy are considered, it is clear that tandem auto-SCTs provide minimal benefit to this group of patients. Semin Hematol 38:243-249,2001. [16] Depending on response, those with less than a complete response after the second transplant received a third cycle. Median overall survival was 15 months. Patients were further randomized to receive either bone marrow transplant or peripheral blood stem cells as follows: In the single-SCT arm, group A1 (n = 79) received bone marrow transplant and group A2 (n = 88) received peripheral blood stem cells; in the tandem-SCT arm, group B1 (n = 85) received bone marrow transplant and group B2 (n = 92) received peripheral blood stem cells (Table 2). This trial confirmed the importance of complete response as a prognostic factor for overall survival.[6]. Attal M, Harousseau J, Facon T, et al:Single versus double transplantation in myeloma:A prospective randomized trial of theInter Groupe Francophone du Myelome (IFM)(abstract 2393). [47] Preemptive donor lymphocyte infusions were scheduled on days 21, 42, and 112 to maximize graft-vs-tumor effect and to establish full donor chimerism. [45] The median age was 43 years, and 52% had chemotherapy- sensitive disease at the time of transplant. Smart Grocery Shopping When You Have Diabetes, Surprising Things You Didn't Know About Dogs and Cats, Coronavirus in Context: Interviews With Experts. Br J Haematol 114:600-607, 2001. All rights reserved. Although high-risk patients (defined by cytogenetic abnormalities and high beta-2-microglobulin) can achieve a CR following tandem auto-SCT, most have a short event-free survival of less than 9 months. Jagannath S, Vesole DH, Zhang M, et al:Feasibility and cost-effectiveness of outpatientautotransplants in multiple myeloma. In the early 1990s, Barlogie's group in Little Rock, Arkansas, adopted a "total therapy" program for newly diagnosed multiple myeloma patients. Subsequently, several trials demonstrated high-dose therapy to be superior to conventional chemotherapy in newly diagnosed multiple myeloma patients with response rates of 70% to 90%, complete remission (CR) rates of 25% to 50%, and median overall survivals of 4 to 5 years. N Engl J Med 325:1267,1991. Blood 79:2827-2833, 1992. [48] Seventeen patients had progressive disease, 14 had chemosensitive disease (including 8 with responsive relapse), and 30 had received one (n = 13) or at least two (n = 17) prior auto-SCTs. IntergroupeFrancais du Myelome. Until mature data on nonmyeloablative therapy are available, it is reasonable to offer good-risk patients with chemosensitive disease-and even those good-risk patients with an allogeneic donor available-a planned tandem auto-SCT upfront. Since the early trials of auto-SCT, patient selection has been a crucial issue. Multiple myeloma survival rate after stem cell transplant - Transplantation of microorganisms the basis for Multiple Myeloma, In the transplantation of the microorganisms that are fundamental, patients get a measurement of chemotherapy that high (now and again with radiation to the whole body) to kill cells in the bone marrow (count the myeloma cells). At a median follow-up of 4 years among patients surviving more than 3 years after diagnosis, those who received a tandem auto-SCT (n = 98) had a significantly better overall survival at 5 years than those who received a single transplant (n = 100)-70% vs 85% (P = .01). Desikan R, Barlogie B, Sawyer J, et al:Results of high-dose therapy for 1000 patientswith multiple myeloma: Durable complete remissionsand superior survival in the absenceof chromosome 13 abnormalities. The first is the Bologna 96 trial,[15] which included 192 newly diagnosed myeloma patients from 37 centers who received four cycles of VAD followed by cyclophosphamide at 7 g/m2 and granulocyte colony-stimulating factor (G-CSF [Neupogen]) for stem cell mobilization. Maloney DG, Sahebi F, Stockerl-GoldsteinKE, et al: Combining and allogeneic graftvs-myeloma effect with high-dose autologousstem cell rescue in the treatment of multiplemyeloma (abstract 1822). Siegel DS, Desikan KR, Mehta J, et al:Age is not a prognostic variable with autotransplantsfor multiple myeloma. An additional high-dose chemotherapycourse (with tandem transplants) appears to improve progressionfreesurvival, although the effect is not discernible until 3 to 5 yearsposttransplant. There was no difference in overall outcome between hospitalized and outpatient transplants. WebMD does not provide medical advice, diagnosis or treatment. [ 26] These data show that patients with high-risk features should be considered for novel therapeutic interventions, as tandem auto-SCT does not significantly improve eventfree or overall survival. Blood 96(suppl 1):798a, 2000. Therefore, abnormal renal function per se is not a contraindication to auto-SCT, but a second cycle of high-dose therapy should not be administered in this setting (outside of clinical trials) until its safety has been established. Badros A, Barlogie B, Siegel E, et al:Improved outcome of allogeneic transplantationin high-risk multiple myeloma patients afternonmyeloablative conditioning. The development of allogeneic, nonmyeloablative transplants has allowed the procedure to be performed more often on an outpatient basis and with significant savings. Overall and event-free survivals were 20% and 16%, respectively, at 5 years after allo-SCT. Improvement in renal function has been reported after highdose therapy, but most patients remain dialysis-dependent. September 17, 2020, Medically For example, the European Group for Bone Marrow Transplantation (EBMTR) reported results for 162 patients who underwent allo-SCT for multiple myeloma. This review will focus on the prognostic factors that predict longterm event-free and overall survival following tandem auto-SCT and the potential for cure and benefit associated with tandem "auto/allo" transplantation. Between 40 and 120 days later, they received total-body irradiation (200 cGy), mycophenolate mofetil (CellCept), and cyclosporine plus peripheral blood stem cells from HLA-identical siblings. Blood93:55-65, 1999. Badros A, Barlogie B, Morris C, et al:High response rate in refractory and poor-riskmultiple myeloma after allotransplantation usinga nonmyeloablative conditioning regimenand donor lymphocyte infusions. However, with the introduction of peripheral blood stem cells and growth factors, mortality decreased and overall outcome improved significantly. DeFronzo RA, Cooke CR, Wright JR, etal: Renal function in patients with multiplemyeloma. It is intended for general informational purposes only and does not address individual circumstances. Blood 100(suppl),2002. How does allogeneic stem cell transplant work? [ 32] It must be emphasized, however, that not all patients are eligible for ambulatory therapy. Now, we use a method called mobilization to trick the stem cells to leave the bone marrow and come out into the peripheral blood, where they can be collected more easily. Median overall survival was 56+ months for melphalan and 48 months for chemotherapy (P = .01). © 2020 MJH Life Sciences and Cancer Network. The final reports of the Bologna 96, IFM 94-02, and Mylome-Autogreffe trials may change the standard of care for this disease and provide information on whether multiple myeloma can be "cured" or transformed into a chronic and indolent disease. The median overall survival following auto-SCT was 7.1 years in the tandem group and 5.6 years in the single auto-SCT groups. In the "total therapy" program at the University of Arkansas, 91 of 251 patients received 118 auto-SCTs on an outpatient basis. In all trials, treatment-related mortality has been high, related primarily to the complications of GVHD, infection, and relapse. T-cell depletion was used in 33% of patients. McElwain TJ, Powles RL: High-dose intravenousmelphalan for plasma-cell leukaemiaand myeloma. Blood 88:2787-2793, 1996. Acute grade II-IV GVHD was present in 45%, and 55% developed chronic GVHD. Blood 89:789-793,1997. Conditioning regimens were busulfan and cyclophosphamide (n = 57) or total-body irradiation (n = 23). Good-risk patients (defined by normal cytogeneticsand low beta-2–microglobulin levels), especially those who achievea complete or near-complete response after the first transplant, appearto benefit the most from a second cycle. [21] A total of 70 patients over 70 years old (34 with newly diagnosed multiple myeloma and 36 with refractory disease) with a median age of 72 years received melphalan at 200 mg/m2 (n = 25) or melphalan at 140 mg/m2 (n = 45). These studies vary significantly in design and eligibility criteria, and all are in different stages of maturation, making it difficult to define the benefits of tandem auto-SCT. Björkstrand B, Ljungman P, Bird JM, etal: Double high-dose chemoradiotherapy withautologous stem cell transplantation can inducemolecular remissions in multiple myeloma.Bone Marrow Transplant 15:367-371,1995. The quality of stem cell collection and engraftment were not affected by renal failure. Bensinger WI, Maloney D, Storb R: Allogeneichematopoietic cell transplantation formultiple myeloma. One approach to improving outcome in multiple myeloma patients is to administer additional cycles of high-dose therapy (usually two to three) with "tandem" transplants. Durie BG, Salmon SE: A clinical stagingsystem for multiple myeloma. Similar experience was reported by the investigators from the Fred Hutchinson Cancer Center on 80 patients who underwent allo-SCT for multiple myeloma, most of whom had chemotherapy-refractory disease. Bone marrow stem cells are collected. However, the procedure is still associated with significant GVHD. Administration of a second transplant was biased by patient selection but significantly improved event-free and overall survival (Figure 4). A central issue of tandemtransplants, whether they involve autologous or allogeneic transplants,revolves around defining the subsets of patients who will benefitfrom the procedure. Although the majority of patients relapsed within the first 5 years after auto-SCT, a plateau was noted in event-free and overall survival after 7 to 8 years, thus supporting the possibility of "cure" in a small subset of patients. An additional high-dose chemotherapy course (with tandem transplants) appears to improve progressionfree survival, although the effect is not discernible until 3 to 5 years posttransplant. Other studies using tandem auto-SCT reported similar long-term survival rates. The first review, published in Cancer and authored by Roberto Mina and our co-chair Sagar Lonial, questioned the role of SCT in MM. Effect of Disease Status and Number of Auto-SCTs. Attal M, Harousseau JL, Stoppa AM, etal: A prospective, randomized trial of autologousbone marrow transplantation and chemotherapyin multiple myeloma. Despite theseresults, autologous transplantation has not changed the ultimatelyfatal outcome of the disease, as there is no substantial evidence of“cure” in most published studies. A better understanding and differentiation of the graft-vs-myeloma effect from GVHD may further help optimize use of the tandem autologous and nonmyeloablative approach. 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