One potential approach to improve the results of autologous stem cell transplantation (ASCT) in multiple myeloma (MM) involves the use of more potent induction regimens; the achievement of deeper remission pre-ASCT should translate into longer progression-free (PFS) and overall survival (OS). To evaluate this hypothesis, we assessed the influence of the percent reduction in serum monoclonal protein (M protein) pre-ASCT in patients (pts) treated with dexamethasone-based regimens (most often VAD) on the best response, PFS and OS achieved after ASCT. Between 2000–2006, 376 pts with IgG (267) or IgA (109) non-progressive MM underwent ASCT. Median age was 59 (21–73) yrs; 60% were male. The median hemoglobin at diagnosis was 103 g/L, creatinine 98 μmol/L, β2-microglobulin 241 nmol/L and albumin 35 g/L. Maintenance therapy was given to 84 (22%) after ASCT and consisted of corticosteroids in 29, thalidomide in 10, both in 41 and other regimens in 4 pts. Patients were divided into 4 groups based on the per cent reduction in M protein after induction therapy:

  1. group A, ≥ 99%;

  2. group B, 90–98%;

  3. group C, 50–89%;

  4. group D, < 50%.

Post-ASCT responses included complete remission (CR), very good partial remission (VGPR) (≥ 90% reduction in M protein), PR (≥ 50% reduction) and stable disease (SD). Median follow-up from diagnosis is 37.4 mos and from ASCT 24.1 mos. For all pts, the median OS from diagnosis is 90.8 mos (95% CI 73.9–129.1 mos) and from ASCT 63.9 mos (95% CI 50.8–69.4 mos), while the median PFS from ASCT is 21.3 mos (95% CI 19.1–23.3 mos). Maintenance therapy had no significant effect on PFS (p=0.49) or OS (p=0.59). The post-ASCT results in evaluable patients according to the percent reduction in M protein after induction therapy are summarized below. We conclude:

  1. High-grade remissions after dexamethasone-based induction therapy are uncommon, with only 2% achieving ≥ 99% and 13% achieving 90–98% reduction in serum M protein;

  2. post-ASCT CR and VGPR rates were higher in these 2 groups;

  3. there was no significant difference in PFS or OS-based on protein response prior to transplant;

  4. whether newer induction regimens, which incorporate novel agents and which produce more CRs and VGPRs before ASCT, will confer better PFS and OS post-ASCT will be of great interest.

Table 1
GroupNCR (%)1VGPR (%)1PR (%)1SD (%)1Median PFS (mo)2Median OS (mo)3
1p<0.001;2p=0.77;3p=0.79 
A 7 50 50   Not reached Not reached 
B 47 19 64 17  23.3 Not reached 
C 232 14 17 68 1 20.7 59.1 
D 87 11 7 54 28 21.1 69.4 
GroupNCR (%)1VGPR (%)1PR (%)1SD (%)1Median PFS (mo)2Median OS (mo)3
1p<0.001;2p=0.77;3p=0.79 
A 7 50 50   Not reached Not reached 
B 47 19 64 17  23.3 Not reached 
C 232 14 17 68 1 20.7 59.1 
D 87 11 7 54 28 21.1 69.4 
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Topics:
autologous stem cell transplant, immunoglobulin a, immunoglobulin g, monoclonal immunoglobulin, multiple myeloma, neoadjuvant therapy, brachial plexus neuritis, dexamethasone, disease remission, adrenal corticosteroids

Author notes

Disclosure: No relevant conflicts of interest to declare.

2007, The American Society of Hematology
2007
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