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Dr. Sagar Lonial’s thoughts about stem cell transplants

Posted on July 13 2014 by Pat Killingsworth | 750 views

Here’s an excerpt from an interesting and comprehensive article from the July edition of Clinical Oncology News,  How I Manage: Evolving Role of Autologous Transplantation in Multiple Myeloma.   It features the views of myeloma specialist, Sagar Lonial, with the Winship Cancer Institute at Emory University in Atlanta:

Dr. LThere is some discussion that, perhaps, patients with high-risk MM do not benefit as much from auto-HCT; however, there are data from European groups suggesting that high-risk patients actually may gain additional benefit from tandem auto-HCT.1 These conflicting data sets confuse the management of patients on a moment-to-moment basis. Our group recently published on a series of high-risk patients who were induced with RVD, followed by auto-HCT, and then placed on RVD maintenance for 3 years.2,3 These patients were all high-risk, with more than one-fourth having del 17p. In our analysis, the median progression-free survival and OS were far superior to what is reported in many other large clinical trials, suggesting that for the high-risk cohort, aggressive maintenance is needed to maintain remission. The Spanish Myeloma Group has shown that high-risk patients may achieve conventional complete remission (CR) at a rate similar to standard-risk patients, yet they fail to achieve minimal residual disease (MRD) negativity.4 This lack of MRD negativity may contribute to early and rapid relapse, especially when no maintenance therapy is planned.

Currently, which group of MM patients derives the most benefit from front-line auto-HCT?

This question also is awaiting data from randomized trials. However, careful review of older data sets may help to answer this question. For instance, data from European groups suggest that many centers have a 10% to 15% tail on the OS curve, suggesting that some patients may be cured simply with the use of alkylating agents. An update from the PETHEMA group suggests the presence of a tail on the OS curve,6 as does a series of patients from the Arkansas group, where there are more than 15% of patients from total therapy 1 (induction with vincristine, doxorubicin, dexamethasone , tandem auto-HCT with melphalan 200 mg/m2 and interferon maintenance) who are in continuous CR more than 10 years after completion of therapy.7 Based on these long-term follow-up reports and others from large cooperative groups, it appears there is a group of standard-risk patients who could be potentially cured with front-line auto-HCT. Although this may not be a large cohort of patients, the recent and soon-to-be-available new agents may serve to increase the number of patients in this cure group, and it is possible that the use of early auto-HCT may render these patients MRD-negative, thereby increasing their chances of achieving a cure…

The article delves into detail in areas not normally covered in media interviews.  It’s definitely worth a look.  And I’d be interested in our thoughts; some of his conclusions are a bit controversial.

Here’s the link:

http://www.clinicaloncology.com/ViewArticle.aspx?d=Hematologic%2BMalignancies&d_id=149&i=July+2014&i_id=1082&a_id=27750

Feel good and keep smiling!  Pat

7 Comments For This Post

  1. suzierose Says:

    I agree with Lonial.

    The data is showing that HR-MM has to have maintenance to sustain the MRD negative response.

    The data is also showing that standard-risk patients who achieved CR with tandems are having a decade or more remission and that benchmark (10years without relapse) is being considered a cure.

    What is evident in both of these scenarios is the achievement of MRD negative. Once that is obtained patients can have a remission that is long and enduring if standard risk and sustained remission in HR-MM with maintenance.

    Maintenance is the key for sustained remission and for achieving MRD for those patients who may not be MRD negative following HDT but maintenance then drives a deeper response for them.

  2. nil desperandum Says:

    When I read the Emory group’s original HRMM paper (Leukemia, leu.2013.335) last fall, the results seemed astounding – 93% OS at 3 years.

    Just a few years earlier the stats quoted to me were closer to 50% OS at 3 yrs (for 17p).

    Thankfully, my MM specialist had presciently prescribed a very similar protocol at that time, including HDT and continuous RVD maintenance.

  3. Pat Killingsworth Says:

    Thanks for weighing in, suzierose and Nil! Helpful!

  4. Susan Says:

    I have a general comment regarding Dr. L….
    Dr. L was a guest speaker at the IMF Patient & Family Seminar in Atlanta that my husband I attended in May. I have to say he was probably the best speaker there, not necessarily content-wise (though he was excellent regarding content) but just as a speaker overall. He was clear, understandable, and kept my attention. Just an observation =)

  5. Pat Killingsworth Says:

    :)

  6. Gary Petersen Says:

    Pat great post, I tweeted it. The data for high risk patients that Nil mentioned is exceptional. I mentioned your blog and Nil’s comment in the attached blog post.

    http://www.myelomasurvival.com/myeloma-blog.html

  7. Pat Killingsworth Says:

    Thanks, Gary!

1 Trackbacks For This Post

  1. High Risk Multiple Myeloma - Finally There Is a Hopeful Prognosis!!! | The Myeloma CrowdThe Myeloma Crowd Says:

    […] recent post on Pat Killingworth’s site discussed Dr. Sagar Lonial’s views (of Emory University) on stem cell transplant. However, […]

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