[LauraScot]

Autologous transplant after allogeneic transplant?

by LauraScot on Thu Apr 17, 2014 10:45 am

Hi,

I'm about to have a reduced intensity conditioning (RIC) allogeneic (donor) transplant following a recent autologous SCT. I was only able to harvest enough stem cells for 1 auto, so I have none left stored. Before doing the donor transplant, is there any reason I should ask my doctors if my stem cells could be harvested again.

I'm wondering if the allo transplant fails and a subsequent DLI [donor lymphocyte infusion] fails, would going back to my own stem cells be an option? If I have bad GvHD and the donor transplant is not helping with multiple myeloma, wouldn't this be desirable?

Or would harvesting stem cells from my new/donor bone marrow and doing a full myeloablative transplant using them be an option.

I don't want to close off any options by not having stem cells stored pre-allo transplant.

Thanks
Laura

[Mark]

Re: Autologous transplant after allogeneic transplant?

by Mark on Thu Apr 17, 2014 11:28 am

Hi Laura,

First of all best of luck with your transplant. I did a tandem auto-myeloablative allo back in 2011 and I am doing great. My quality of life is back to "pre-myeloma" levels other than the bone damage done by the myeloma prior to being diagnosed. I would ask your doctors if they are planning to use ATG or something to lessen the chance of having extensive chronic GVHD. It worked great for me, as I currently have no GVHD symptoms.

I collected enough stem cells for 2 transplants prior to my auto. I think they like some cells left over in the highly unlikely situation that the donor cells do not engraft. I did read a story once about a patient who did an auto after an allo to get rid of GVHD, so I guess that is an option. I am not too sure if an insurance company would pay for harvest for storage after the allo, though. Same with doing an auto after an allo.

One advantage of doing an allo is that Revlimid [lenalidomide] works very well after an allo.

"The comparison between Auto and Allo patients has shown a benefit in terms of PFS and OS in favor of Len administered after AlloHSCT. This observation supports the hypothesis that Len is synergistic with the GVM effect. Since Len has a potent immunomodulatory effect, this can raise concerns about its use after AlloHSCT. A Dutch prospective study showed that the early administration of Len 10 mg daily after non-myeloablative Allo-HSCT induces late onset acute GVHD in a substantial proportion of patients, causing the premature discontinuation of the study. On the contrary, our retrospective study has shown that a later administration is feasible and safe, without an excess of GVHD, suggesting that a more mature immune system can better tolerate Len. Moreover, since in all cases dexamethasone was given in combination with Len, its immunosuppressive effect may have harnessed the Len-induced immune activation. In conclusion our study suggests that Len is particularly active after AlloHSCT, still retaining a favorable toxicity profile."
https://ash.confex.com/ash/2011/webprogram/Paper43648.html

Bortezomib [Velcade] can also work well after allo.

"Despite a remarkable efficacy, the use of bortezomib after allo-SCT was not associated with GVHD reactivation, in contrast to results obtained with, for example, thalidomide.17 Indeed, in vitro results demonstrated that bortezomib may be of benefit in the management of GVHD."
http://www.haematologica.org/content/93/3/455.full.pdf

Fortunately I have not needed any therapy since my allo, but it is good to know how well the myeloma drugs work after the transplant in case I ever need them. I have read of cases in which patients have a related donor do another allo with an unrelated donor if the related donor immune system does not give enough immunotherapy. That was discussed with me prior to knowing that my brother was not a match.

I had an unrelated female donor and the pair of female donor to male patient is the least likely to relapse, so it is unlikely another allo would help me.

Your post reminds me that I have not emailed / called my donor for a few months. That is too long to not thank the incredible person that did so much for me!

Mark

[LauraScot]

Re: Autologous transplant after allogeneic transplant?

by LauraScot on Thu Apr 17, 2014 1:47 pm

Hi Mark,

Thank you for your reply. I have read your posts in the past about allo and I've found them very useful, informative and encouraging.

I'm in the UK, so it's whether or not I can get NHS to harvest stem cells again. I suspect not, but I don't want to remove any future options if possible.

I'm doing mini allo as part of clinical trial (UK LenaRIC), which is testing the benefit of using lenalidomide [Revlimid] as maintenance for 12 months starting 21 days post transplant. It's hoped that the lenalidomide will reduce relapse rates. Trial started by using 10mg, but has been recently drop to 5mg. It looks like a good trial to me, and results so far have been good that I know of. And it does use ATG depletion, I'm happy with that.

My donor is my sister, is interesting about future option maybe using MUD.

I've thought long and hard about doing this allo. I was diagnosed last year, had first autoSCT in December which went well, and recovery has been good. It's not been an easy decision to go ahead with the allo, but I've decided to take the risk and do it early rather than wait until first relapse. I want to give allo the best chance of working by doing it now.

Cheers, all the best
Laura