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Re: Immune system recovery after transplant?
I also agree with what Nancy Shamanna wrote; I thought it was standard policy to revaccinate transplant patients within a year or so after transplantation. I had never heard of a transplant center not advising revaccination. (I don't doubt what Nancy Stewart wrote, it's just the first time I've heard of a policy like that.)
Re: Immune system recovery after transplant?
Cheryl,
The vaccinations are available, but a patient still has to be deemed healthy enough to take them. I was able to take them since I asked about them, and was approved first. I know that not all patients take vaccines after a transplant, so I feel fortunate that it worked out for me. My doctors were fine with recommending vaccines (my oncologist and my transplant oncologist). It seems to vary from one patient to the next!
The vaccinations are available, but a patient still has to be deemed healthy enough to take them. I was able to take them since I asked about them, and was approved first. I know that not all patients take vaccines after a transplant, so I feel fortunate that it worked out for me. My doctors were fine with recommending vaccines (my oncologist and my transplant oncologist). It seems to vary from one patient to the next!
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Nancy Shamanna - Name: Nancy Shamanna
- Who do you know with myeloma?: Self and others too
- When were you/they diagnosed?: July 2009
Re: Immune system recovery after transplant?
These therapies impact the immune system differently [14], and their application has resulted in the emergence of infections not previously associated with myeloma, such as those caused by cytomegalovirus (CMV) [15], Aspergillus species [53], Fusarium species [54], herpes simplex virus (HSV), and varicella-zoster virus (VZV) [26], the prevalence of the latter 2 significantly increased following treatment with bortezomib
So do people get these infections because the virus is already in their body? Like you had chicken pox as a child, and then it turns into shingles (varicella-zoster virus) when your immune system is compromised? I imagine this is something 'most people' don't get, but there is an unlucky group (less than 10%?) for whom it happens?
Regarding vaccinations, thanks all for your comments on this. One more thing to ask the oncologists about. I've never even had a flu vaccine, since I never get the flu!
RT
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RadiantTiger - Name: Radiant Tiger
- Who do you know with myeloma?: Myself, my deceased uncle
- When were you/they diagnosed?: Feb 2015
- Age at diagnosis: 54
Re: Immune system recovery after transplant?
Hi Cheryl G.,
I hope you are doing well today.
I should have highlighted this part of second paper that I quoted.
It is thought that the immune system can control MGUS prior to the disease progressing.
Source: JB Swann & MJ Smyth, "Immune surveillance of tumors," Journal of Clinical Investigation, May 2007 (full-text PDF at Pubmed Central)
The overall point I was trying to make was that a typical myeloma patient starts with a dysfunctional immune system at diagnosis and it gets worse as they continue to use more therapies and the disease progresses. It certainly is not functioning great at diagnosis and while a patient is on never ending cycles of novel agents and steroids and than can never go back to functioning "normally" because a patient does an auto.
You wrote:
Having 100% donor chimerism does not mean you have a healthy functioning donor immune system. I had 100% donor chimerism at my first BMB after allo and was getting IVIG at the same time. People that need IVIG do not have a healthy functioning immune system. Where I go we check the results of my blood tests for things like numbers/ratios of CD4 and CD8 cells.
Risk of relapse is low for allo recipients after 2-6 years after transplant (depending on the disease) but higher during the first couple of years. Just look at a PFS (progression free survival) curve for patients who do an allo transplant for any blood cancer. That time frame coincides with the donor immune system maturing.
It is common knowledge that an allo from an MRD-negative, first complete response has the best chance to be effective because the donor immune system has the time to reconstitute without the disease interfering with it. Knowing that, I would say effective therapies to achieve a deep response COMBINED with immunotherapy can be curative for a myeloma / blood cancer patient. Who thinks an allo transplant is a "one shot miracle cure" and that a donor immune system is all you need to cure myeloma?
Mark
I hope you are doing well today.
I should have highlighted this part of second paper that I quoted.
Interestingly, this operational cure is not restricted to patients in complete response, since those who revert to having a monoclonal gammopathy of undetermined significance (MGUS)-like profile may also achieve long-term disease control (LTDC), despite persistence of a residual M-component.4 Recent clinical and molecular data suggest that some features may help to identify this group of LTDC-MM patients such as an evolving smoldering pattern, a gene expression profile signature of MGUS and the CD2 molecular subtype.5,6 Collectively, these findings suggest that in addition to antimyeloma therapy, other factors may play a critical role in disease control.
It is thought that the immune system can control MGUS prior to the disease progressing.
"The plasma cell malignancy multiple myeloma (multiple myeloma) might also be a system in which immunoediting can be evaluated in a clinical setting (51). The advantage of studying multiple myeloma is that several stages of disease have been identified, and disease progresses from a premalignant state, known as monoclonal gammopathy of undetermined significance (MGUS), through to terminal disease (52). The ability to detect this premalignant phase of disease allows for immunologic monitoring to assess the contribution of the immune system to preventing and / or inhibiting progression to multiple myeloma (53). Intriguingly, such monitoring has revealed that T cells derived from the bone marrow of patients with MGUS mount strong responses to autologous premalignant cells; these responses are not detected in patients with multiple myeloma (53). These findings are consistent with a T cell response holding pre malignant cells in check (i.e., equilibrium) followed by the eventual failure of this response to control such abnormal plasma cell clones, resulting in the eventual transition to multiple myeloma (i.e., escape)."
Source: JB Swann & MJ Smyth, "Immune surveillance of tumors," Journal of Clinical Investigation, May 2007 (full-text PDF at Pubmed Central)
The overall point I was trying to make was that a typical myeloma patient starts with a dysfunctional immune system at diagnosis and it gets worse as they continue to use more therapies and the disease progresses. It certainly is not functioning great at diagnosis and while a patient is on never ending cycles of novel agents and steroids and than can never go back to functioning "normally" because a patient does an auto.
You wrote:
"If a healthy immune system is all that one needs to overcome myeloma, then why is it that even allo transplant patients who achieve 100 percent chimerism – meaning they now have the immune system of their donor (who doesn't have myeloma) – often relapse?"
Having 100% donor chimerism does not mean you have a healthy functioning donor immune system. I had 100% donor chimerism at my first BMB after allo and was getting IVIG at the same time. People that need IVIG do not have a healthy functioning immune system. Where I go we check the results of my blood tests for things like numbers/ratios of CD4 and CD8 cells.
Risk of relapse is low for allo recipients after 2-6 years after transplant (depending on the disease) but higher during the first couple of years. Just look at a PFS (progression free survival) curve for patients who do an allo transplant for any blood cancer. That time frame coincides with the donor immune system maturing.
It is common knowledge that an allo from an MRD-negative, first complete response has the best chance to be effective because the donor immune system has the time to reconstitute without the disease interfering with it. Knowing that, I would say effective therapies to achieve a deep response COMBINED with immunotherapy can be curative for a myeloma / blood cancer patient. Who thinks an allo transplant is a "one shot miracle cure" and that a donor immune system is all you need to cure myeloma?
Mark
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Mark11
Re: Immune system recovery after transplant?
Hi Radiant Tiger,
You should ask your doctor about taking anti fungal, anti viral meds, etc. For example, I was taking acyclovir (anti viral) for about 3 years. Myeloma patients are more susceptible to infection than someone in the general population - even the patients that never did a transplant!
Mark
You should ask your doctor about taking anti fungal, anti viral meds, etc. For example, I was taking acyclovir (anti viral) for about 3 years. Myeloma patients are more susceptible to infection than someone in the general population - even the patients that never did a transplant!
Mark
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Mark11
Re: Immune system recovery after transplant?
Earlier in this thread, I wrote:
A few weeks after writing this, I got diagnosed with shingles (after 4 cycles of induction therapy). "The unlucky 10% .." Yep, that's me.
I am now on acyclovir, and will be on it for a long time (at least for a year after transplant). Now I am concerned what the virus will do because of the transplant. Can the anti-viral meds keep it at bay, even though your immune system is severely disabled? Oh well
I'm going to stay optimistic that my pre-transplant immune system will mostly regrow itself, even with a few bumps in the road. Getting through this first year for treatment is just a long haul, but there's no way around it. At least I'm responding well to induction treatment. Kappa light chains are down almost 90%!
RT
So do people get these infections because the virus is already in their body? Like you had chicken pox as a child, and then it turns into shingles (varicella-zoster virus) when your immune system is compromised? I imagine this is something 'most people' don't get, but there is an unlucky group (less than 10%?) for whom it happens?
A few weeks after writing this, I got diagnosed with shingles (after 4 cycles of induction therapy). "The unlucky 10% .." Yep, that's me.
I am now on acyclovir, and will be on it for a long time (at least for a year after transplant). Now I am concerned what the virus will do because of the transplant. Can the anti-viral meds keep it at bay, even though your immune system is severely disabled? Oh well
I'm going to stay optimistic that my pre-transplant immune system will mostly regrow itself, even with a few bumps in the road. Getting through this first year for treatment is just a long haul, but there's no way around it. At least I'm responding well to induction treatment. Kappa light chains are down almost 90%!
RT
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RadiantTiger - Name: Radiant Tiger
- Who do you know with myeloma?: Myself, my deceased uncle
- When were you/they diagnosed?: Feb 2015
- Age at diagnosis: 54
Re: Immune system recovery after transplant?
Radiant Tiger,
It seems that your induction therapy consisted of Revlimid, dexamethasone and Velcade. Mine was just Revlimid and dex (Rd) until three months ago, when Velcade was added – a weekly injection for three weeks and one week off. Because Velcade is known to cause shingles in some patients, I was probably more fearful of starting it than most, especially because my father had a shingles experience a few years ago that was pretty awful. It was around his eye and to this day, years later, he still has twinges of pain from time to time.
I discussed this with my specialist on various occasions. She said that acyclovir is what she prescribes for every patient she starts on Velcade. She said it was essential not to miss a single dose and so I have been extremely careful in this regard. She also said under her breath that lots of doctors do not initially prescribe acyclovir initially and she just could not comprehend why they do not.
My dosage is 400 mg in the morning and 400 mg in the evening. So far things, have been going well, but one never knows. I share this with you in the hope that it may have some relevance for you and other posters.
It seems that your induction therapy consisted of Revlimid, dexamethasone and Velcade. Mine was just Revlimid and dex (Rd) until three months ago, when Velcade was added – a weekly injection for three weeks and one week off. Because Velcade is known to cause shingles in some patients, I was probably more fearful of starting it than most, especially because my father had a shingles experience a few years ago that was pretty awful. It was around his eye and to this day, years later, he still has twinges of pain from time to time.
I discussed this with my specialist on various occasions. She said that acyclovir is what she prescribes for every patient she starts on Velcade. She said it was essential not to miss a single dose and so I have been extremely careful in this regard. She also said under her breath that lots of doctors do not initially prescribe acyclovir initially and she just could not comprehend why they do not.
My dosage is 400 mg in the morning and 400 mg in the evening. So far things, have been going well, but one never knows. I share this with you in the hope that it may have some relevance for you and other posters.
Re: Immune system recovery after transplant?
I agree with Mrozdav. I thought it was standard practice to have myeloma patients on prophylactic anti-viral medication, since myeloma patients have compromised immune systems while taking novel agents / steroids, etc.
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Mark11
Re: Immune system recovery after transplant?
Hi Radiant Tiger,
I'm sorry to hear that you got shingles. I had that a decade or more ago, before I'd ever even heard of multiple myeloma. It was no fun then; I can't imagine how bad it must be to have that piled on top of everything else you're dealing with when you have multiple myeloma.
I'm in the same camp with mrozdav and Mark11. I've been on the same dose of acylovir as mrozdav from Day 1 of my induction treatment back in January 2013. I'm still in maintenance treatment BTW.
Best wishes to you for a speedy recovery from shingles.
Mike
I'm sorry to hear that you got shingles. I had that a decade or more ago, before I'd ever even heard of multiple myeloma. It was no fun then; I can't imagine how bad it must be to have that piled on top of everything else you're dealing with when you have multiple myeloma.
I'm in the same camp with mrozdav and Mark11. I've been on the same dose of acylovir as mrozdav from Day 1 of my induction treatment back in January 2013. I'm still in maintenance treatment BTW.
Best wishes to you for a speedy recovery from shingles.
Mike
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mikeb - Name: mikeb
- Who do you know with myeloma?: self
- When were you/they diagnosed?: 2009 (MGUS at that time)
- Age at diagnosis: 55
Re: Immune system recovery after transplant?
I was on an anti-viral for a few weeks post transplant because we are so at risk for developing various problems with our weakened immune systems. I developed shingles about 14 months post transplant on my face and into one of my eyes. I still have some problems with my eye 4 years later. My ophthamologist treated me with acyclovir 800 mg 4 times a day immediately. After I recovered the dose was dropped to 800 mg twice a day which I still take. He said that I would be taking it for the rest of my life.
My oncologist said that about 50% of people who have transplants develop shingles at some point later. There are clinical trials on now with a shingles vaccine that is a dead virus. I haven't heard any results on this trial. And, who knows when, and if, it would be approved.
Nancy in Phila
My oncologist said that about 50% of people who have transplants develop shingles at some point later. There are clinical trials on now with a shingles vaccine that is a dead virus. I haven't heard any results on this trial. And, who knows when, and if, it would be approved.
Nancy in Phila
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NStewart - Name: Nancy Stewart
- Who do you know with myeloma?: self
- When were you/they diagnosed?: 3/08
- Age at diagnosis: 60
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