[dianaiad]

Second autologous stem cell transplant at relapse

by dianaiad on Fri Oct 02, 2015 11:23 am

This is a weird thing.

I had an autologous transplant almost exactly two years ago. Yesterday I saw my transplant doc, and was told, first, that in his experience people with 'high risk" (17p deletion) multiple myeloma generally relapse within three years of diagnosis, and have a tough time. However, I'm still in 'complete remission," as in ... absolutely no sign of high proteins anywhere. My only problems are related to the cure! Some of those side effects are annoying.

One thing he did mention was interesting: a second autologous transplant when I finally do relapse (I have enough cells stored for one more), because 'the first one worked so well." He also talked about other things, like pomalidomide (Pomalyst, Imnovid) and other new 'novel' agents.

This is the first time he has mentioned that possibility to me; he's been a bit on the negative side regarding a second transplant, partly because of my age; if things go as they are going, I might well be over seventy before I would need one. . However, he brought it up to me yesterday.

What is the current medical opinion of second transplants?

I got the impression that the field is trending against FIRST ones, what with the new treatments coming available. Does someone know what's going on with this? Any studies I can look at?

After all, he was right; the first one worked REALLY well for me, so if a second would work equally, or even half, as well, I'll do it in spite of the fact that the first one wasn't exactly a vacation in the Bahamas.

[Dr. Luciano Costa]

Re: Second autologous stem cell transplant at relapse

by Dr. Luciano Costa on Fri Oct 02, 2015 12:52 pm

This is a very interesting topic. I agree with your doctor that a second transplant becomes a more attractive option if you have a prolonged remission from first transplant.

So far, there has been only one randomized trial, performed in Europe, that compared second transplant with conventional therapy for patients relapsing after one autologous transplant, and in that trial second transplant was superior (reference [1] below). Retrospective data from North America also shows that duration of remission after first transplant is the best predictor of benefit from a second transplant [2].

Speaking from experience, the second transplant is not necessarily "harder" than the first trans­plant, and many patients have a better experience – perhaps in part by knowing what to expect.

References:

[1] G Cook et al, "High-dose chemotherapy plus autologous stem-cell transplantation as consolidation therapy in patients with relapsed multiple myeloma after previous autologous stem-cell transplantation (NCRI Myeloma X Relapse [Intensive trial]): a randomised, open-label, phase 3 trial," The Lancet Oncology, July, 2014 (abstract)

[2] LC Michaelis et al, "Salvage Second Hematopoietic Cell Transplantation in Myeloma," Biology of Blood and Marrow Transplantation, May 2013 (full text of article)

Additional References:

[3] KKS Abbi, ""Second autologous stem cell transplant: an effective therapy for relapsed multiple myeloma," Biology of Blood and Marrow Transplantation, March 2015 (abstract).

[4] WI Gonsalves et al, "Second auto-SCT for treatment of relapsed multiple myeloma, " Bone Marrow Transplantation, April 2013 (full text of article)

[mikeb]

Re: Second autologous stem cell transplant at relapse

by mikeb on Sat Oct 03, 2015 1:46 pm

Hi Dianaiad,
We are in the same boat. And it's not a vacation cruise in the Bahamas. (Loved your comment about your SCT.)

My doctor mentioned to me a few months ago that he might recommend a 2nd SCT for me when I relapse, if my remission is a "long" one. He didn't get into specifics of how long is long. Maybe because he saw the not-so-thrilled expression on my face.

His comment was especially surprising to me because I had been thinking that my SCT was not successful because I ended up with the same 0.4 m-spike 90 days after the SCT as immediately before it. However, my doctor said that was not a good way to judge the success of the SCT, as it might have had a delayed impact in my case.

Through consolidation therapy and maintenance therapy, my m-spike slowly went down until it was not detectable 10 months after the SCT. I had assumed that it was the RVD consolidation and Rev maintenance that helped me over that time, not the SCT. But my doctor apparently thought the SCT might be helping during that time too. I didn't realize the SCT could have such a delayed effect.

Thanks for your comment, Dr. Costa. Your references confirm my doctor's thinking that a second SCT might be in order if my remission holds for awhile.

I learn something new about this weird disease everyday.

Mike

[dianaiad]

Re: Second autologous stem cell transplant at relapse

by dianaiad on Sun Oct 04, 2015 9:46 pm

As did I.

I had been given the impression that because I am sixty six, that a second autologous transplant would not be considered. Then Dr. C comes up with this one, 'out of the blue,' so to speak.

It's certainly interesting, as if the length of my remission will mean more than my age at the time of the relapse. It will be an interesting conversation, come the day ...

[rumnting]

Re: Second autologous stem cell transplant at relapse

by rumnting on Mon Oct 05, 2015 8:30 am

My husband is also deletion 17p. He had his first ASCT exactly 4 years ago. Since that time his M-spike has slowly continued to rise. He never really had any "symptoms", but by this summer had become transfusion dependent.

During these 4 years, he was treated (was only off treatment a few months after transplant) with different combinations of all the novel agents. He does have stem cells on ice, but his Mayo doc does not advise another transplant at this time (he's 59) because he doesn't really have any maintenance drug options.

He has just finished a round of D-PACE, which he tolerated well, and which knocked the M-spike way down. They are going to repeat this treatment one more time, and then hope to get him in an expanded access trial of daratumumab.

[Mike F]

Re: Second autologous stem cell transplant at relapse

by Mike F on Mon Oct 05, 2015 12:13 pm

Just noticed an article that went onto PubMed today on this topic. Here's the abstract and reference:

Abstract:

In contrast to the upfront setting in which the role of high dose therapy with autologous hematopoietic cell transplantation (HCT) as consolidation of a 1st remission in patients with multiple myeloma (M​M) is well established, the role of high dose therapy with autologous or allogeneic HCT has not been extensively studied in M​M patients relapsing after primary therapy. The International Myeloma Working Group together with the Blood and Marrow Transplant Clinical Trials Network (BMT-CTN), the American Society of Blood and Marrow Transplantation (ASBMT), and the European Society of Blood and Marrow Transplantation (EBMT) convened a meeting of multiple myeloma experts to:

1. Summarize current knowledge regarding the role of autologous or allogeneic HCT in M​M patients progressing after primary therapy;
2. Propose guidelines for the use of salvage HCT in M​M;
3. Identify knowledge gaps;
4. Propose a research agenda and
5. Develop a collaborative initiative to move the research agenda forward.

After reviewing the available data, the expert committee came to the following consensus statement for salvage autologous HCT:

1. In transplant eligible patients relapsing after primary therapy that did NOT include an autologous HCT, high dose therapy with HCT as part of salvage therapy should be considered standard;
2. High dose therapy and autologous HCT should be considered appropriate therapy for any patients relapsing after primary therapy that includes an autologous HCT with initial remission duration of more than 18 months;
3. High dose therapy and autologous HCT can be used as a bridging strategy to allogeneic HCT;
4. The role of post salvage HCT maintenance needs to be explored in the context of well designed prospective trials that should include new agents such as monoclonal antibodies, immune-modulating agents and oral proteasome inhibitors;
5. Autologous HCT consolidation should be explored as a strategy to develop novel conditioning regimens or post HCT strategies in patients with short (less than 18 months remissions) after primary therapy;
6. Prospective randomized trials need to be performed to define the role of salvage autologous HCT in patients with M​M relapsing after primary therapy comparing to "best non HCT" therapy.

The expert committee also underscored the importance of collecting enough hematopoietic stem cells to perform two transplants early in the course of the disease.

In regards to allogeneic HCT the expert committee agreed on the following consensus statements:

1. Allogeneic HCT should be considered appropriate therapy for any eligible patient with early relapse (less than 24 months) after primary therapy that included an autologous HCT and/or high risk features (i.e cytogenetics, extramedullary disease, plasma cell leukemia or high LDH);
2. Allogeneic HCT should be performed in the context of a clinical trial if possible;
3. The role of post allogeneic HCT maintenance therapy needs to be explored in the context of well designed prospective trials;
4. Prospective randomized trials need to be performed to define the role salvage allogeneic HCT in patients with M​M relapsing after primary therapy.

Reference:

S Giralt et al, "American Society of Blood and Marrow Transplant, European Society of Blood and Marrow Transplantation, Blood and Marrow Transplant Clinical Trials Network and International Myeloma Working Group Consensus Conference on Salvage Hematopoietic Cell Transplantation in Patients with Relapsed Multiple Myeloma." Biology of Blood and Marrow Transplantatation, Sep 28 2015 (link to abstract)

[dianaiad]

Re: Second autologous stem cell transplant at relapse

by dianaiad on Tue Oct 06, 2015 8:22 pm

Thank you, all.

Dr. Cai called me today with the results of my latest tests. I am, according to him, still in com­plete remission, as in there is absolutely no sign of multiple myeloma anywhere in any of my tests. He was pretty giddy.

I'm extremely happy, too, given that my SCT was almost precisely two years ago, to the day. I have that pesky 17p deletion, but no bone involvement, my kidneys are fine, and so is my liver and everything else. My only problems are side effects from the Revlimid that I'm taking for maintenance. I'll admit that those are getting to be a bit more than annoying, but given every­thing, I'll deal with them.

Dr. Cai is the one who brought up how a second SCT would be the best treatment option for me if and when (and the 'when' looks like it's going to be awhile ... woo hoo!), even if I"m 75 or so when I need it.

After close to three years of reading about this, it was a bit of a surprise; I honestly thought that a second SCT would have been out of the question for me because of my age, but because of the length and strength of my remission, it's a very different ball game for me.

I'm not certain what to think at the moment. It's odd. I'm not cured, and I feel wonderful and thankful and as excited as Dr. Cai was (and yes, he was close to dancing on the phone! He's a neat guy) ... and guilty.

And a bit like a ten year stay of execution.

No, I don't quite know what to think or feel right now.

[mikeb]

Re: Second autologous stem cell transplant at relapse

by mikeb on Sat Oct 10, 2015 10:53 pm

Hi again Dianaiad,

Congratulations on the excellent news! I'm very happy for you!

I understand your comment about feeling a little guilty and not being sure how to feel. With so many other folks on the Forum having so many serious problems, I will admit that I do feel some degree of guilt, perhaps something like survivor's guilt, when I think about my own very fortunate situation. And, because of that, I am reluctant to complain about the mostly minor side effects of Revlimid that I deal with.

I don't think of being MRD negative as receiving a 10-year stay of execution, though. Things can change pretty quickly, as you know. It's an X-year stay of execution, but we don't know what X equals.

That said, congratulations again! Definitely news to be happy about. Keep it going!

Mike

[allenbonslett]

Re: Second autologous stem cell transplant at relapse

by allenbonslett on Tue Oct 13, 2015 11:31 pm

After diagnosis in 2003, I had my first auto transplant at Stanford in 2004 and was in CR on thalidomide maintenance until late 2008 when I relapsed. Switched to Revlimid, and under­went a second auto transplant at Stanford with my leftover frozen cells in 2009. Stayed on Revlimid maintenance until this spring as i began to relapse again.

Now on Velcade, my onc had me go talk to Stanford about transplant options but they essen­tially said no, biggest reason being the accumulation of toxicity.

Allen B

[dianaiad]

Re: Second autologous stem cell transplant at relapse

by dianaiad on Tue Jun 27, 2017 10:04 am

So this topic is relevant for me again.

X-rays and CT scans have found plasmacytomas in my skull. Small ones. Two, I think (perhaps three).

My blood work still shows me as in remission. I have an almost imperceptible M spike, and my last bone marrow biopsy showed less than 5% plasma cell involvement. My light chains are dead normal (but then, they were when I was diagnosed in 2013, as well). In fact, if we go only by my blood work and bone marrow biopsy, I'm in really good shape; no 'systemic' disease.

However, because of the plasmacytomas, my doc wants me to have a second autologous trans­plant sooner rather than later. I'm currently on Kyprolis and dexamethasone, and 'they' are adding Pomalyst with my next cycle. The plan, sorta, is to do two more cycles of this, then put me on 'maintenance' Kyprolis (an infusion every other week) until I can check in for the transplant.

I asked about radiation and was told that if those plasmacytomas had been anywhere else, like in my ribs or back, that radiation would have been the 'go to' choice. However, they aren't 'anywhere else.'

Here's the thing: I only have enough cells for one more transplant, and frankly?

A transplant right now is, well, been there, done that, lost the hair and got C. diff. It was not a walk in the park. Well, neither is the Kyprolis and dex I'm doing now, and frankly? I don't know what to do.

My sister, who was my caregiver last time, is going to have her first grandchild in September (about the time I would be going in), and my daughter just might be handing me a grandson, as well. She and her husband are attempting to adopt a baby who is currently in the NICU. He's going to have some major problems.

So I have 'caregiver' issues, timing issues, my own parents need MY help (89 and 92, living with me)

So I'm wondering if a second transplant will actually make sense for me.

Anyone care to share their thoughts or advice?