[asaryden]

Conditioning regimen for allogenic transplant?

by asaryden on Thu Aug 09, 2012 9:14 am

Hi everybody,
I´m scheduled for an allogenic transplant in September due to high risk multiple myeloma. My sister is a full HLA match.
Those of you that have done a full allogenic transplant, what conditioning regimen did you use? Do you know about the pros and cons of different regimens?
I´m also curious about ATG; did you use it? As I understand it it isn´t always used with a related donor but my feeling is that it´s becoming more and more common to use it also when the donator is related since it can lower the incidence of GVHD. Any opinions on that?
I´m grateful for any comments!

[Mark]

Re: Conditioning regimen for allogenic transplant?

by Mark on Fri Aug 10, 2012 10:40 am

Asaryden,

Good luck with the allo. I did an allo with myeloablative conditioning back in Spring 2011. I used Melphalan-Fludarabine, no radiation. I am doing very well. I do not have a problem with GVHD. I did use ATG. For the others reading, ATG is an antibody used in allogeneic transplants to prevent GVHD. It is especially effective in preventing extensive chronic GVHD. I used a matched unrelated female donor for my transplant.

I would not have done my transplant without ATG. Male recipients from female donors are at higher risk for GVHD. On the plus side, relapse risk is lowest for this pair. Here is an example of how well ATG can work in preventing extensive chronic GVHD:

"There was an even stronger effect on chronic GVHD, resulting in 23% in those who received ATG but as much as 65% in those who did not. Extensive chronic GVHD was seen in 37% of patients who did not have ATG in the regimen but only in 3% in those who had. "
http://onlinelibrary.wiley.com/doi/10.1111/j.1600-0609.2010.01495.x/full

Here is a link to a paper discussing ATG. Note it has direct cytotoxicity against the myeloma cells as well.

"We and others have recently shown in vitro anti-myeloma cytotoxicity of two commercially available ATG preparations, namely ATG-Fresenius® and Thymoglobulin®.16,17 These findings are further supported by the results of a xenograft model.18 The anti-myeloma effect of ATG is due to complement-mediated cytotoxicity as well as caspase-dependent apoptosis.16,17 ATG therefore not only targets a variety of epitopes, but may also induce several pathways for cell death."
http://www.haematologica.org/content/93/9/1343.full

Extensive chronic GVHD leads to a poor quality of life. No use having long term PFS if you are limited by extensive chronic GVHD. Since ATG can prevent it, I think it is well worth using it since you are using a female donor. If you need more Graft vs Myeloma later, you can use DLI's. I think use of ATG is increasing because DLI's combine well with Velcade, Revlimid and Thalomid. Revlimid is a very effective post allo drug. Myeloma patients have good post allo transplant strategies in 2012.
https://ash.confex.com/ash/2011/webprogram/Paper43648.html
http://www.exphem.org/article/S0301-472X(09)00116-7/abstract
https://ash.confex.com/ash/2011/webprogram/Paper41511.html
https://ash.confex.com/ash/2011/webprogram/Paper40336.html

Mark

[asaryden]

Re: Conditioning regimen for allogenic transplant?

by asaryden on Tue Aug 14, 2012 9:12 am

Thank you Mark for all this information.
As usual doctor´s have different opionions on what to use. One transplant doctor recommended ATG and another one was hesitant. I´m a bit confused. It seems I won´t reach CR before the allo so maybe I need all the effect I can get from the allo and ATG could compromise that? I think, however, I read in some study that no such effect was seen in that particular study.
Anyway I will think of you as an encouraging example of "someone who sailed right through it" (Yes I think I´ve read all your posts!)
Good luck also to you.