Wow! A lot to digest here...
I will only make a few comments:
1) Joe, there was a HOVON study in which Revlimid was used post-allogeneic stem cell transplant. There was a high rate of acute graft versus host disease and the study was abandoned. The link: http://www.ncbi.nlm.nih.gov/pubmed/21690556. This likely has something to do with its "immunomodulatory" effects. As such, I would ask your physician about this and how their trial differs from the HOVON study. Perhaps the inclusion of sirolimus is to reduce this risk (plus there is evidence to suggest that this agent may have activity against myeloma in and of itself).
2) Allogeneic stem cell transplantation is a potentially curative option but the risks remain considerable. I won't belabor this point as many of you have commented on this previously. But it is not just the increased risk of death associated with the procedure -- the morbidity of graft versus host disease can be quite challenging, and I can tell you it is not easy to treat a patient with relapsed myeloma who is also dealing with this complication. Certainly, this is an area that deserves further study. Moving forward, it will be important to utilize the best therapies we have available to minimize disease burden prior to allogeneic stem cell transplant and to find a way to dissect out the graft versus myeloma effect from the graft versus host effect -- the holy grail of allogeneic stem cell transplantation!
3) Stem cell rescue only rescues you from the bone marrow toxicity of high dose chemotherapy. It has no impact on any of the other side effects. High dose Velcade, for example, would lead to prohibitive neuropathy. Having said that, there are an increasing number of studies looking at incorporating newer agents into the high-dose melphalan backbone. Certainly, transplant regimens deserve further refinement and improvement just as any other aspect of myeloma therapy!
Pete V.
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