Hi all,
I was wondering if there was a limit to the number of stem cell transplants a person can have as part of their therapy?
I have had an autologous and recently an allogeneic (donor), and I was wondering if down the line the doctor could use another transplant as part of my therapy?
Thanks,
Grant
Forums
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Grant - Name: Grant
- Who do you know with myeloma?: myself
- When were you/they diagnosed?: April 2014
- Age at diagnosis: 43
Re: Is there a limit to the number of stem cell transplants?
There are two limitations.
The first is the availability of sufficient stem cells for transplant purposes. It may be more difficult to mobilise sufficient self cells for a further transplant when you have already been transplanted twice. On the other hand, you may still have sufficient spare in storage. (Obviously this is not relevant to an allo transplant, though I imagine that more than one allo transplant must be very unusual.)
The second is that each time you are being treated with the same drug - high-dose melphalan. And as with any repeat treatment, there is an increasing risk that the target cells will develop resistance so that each re-treatment is less effective than the previous.
The first is the availability of sufficient stem cells for transplant purposes. It may be more difficult to mobilise sufficient self cells for a further transplant when you have already been transplanted twice. On the other hand, you may still have sufficient spare in storage. (Obviously this is not relevant to an allo transplant, though I imagine that more than one allo transplant must be very unusual.)
The second is that each time you are being treated with the same drug - high-dose melphalan. And as with any repeat treatment, there is an increasing risk that the target cells will develop resistance so that each re-treatment is less effective than the previous.
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Davidg - Name: David
- When were you/they diagnosed?: Feb 2015 - AL Amyloidosis
- Age at diagnosis: 53
Re: Is there a limit to the number of stem cell transplants?
Hello Grant:
You ask a very interesting question. I think that you are getting into the realm of a "case by case basis". For autos, I have heard that a second auto will be routinely considered, but only in the case where the initial auto had a superior result (I am not talking about tandem autos). I have heard a report of an occasional 3rd auto, one in which a woman got her 3rd auto about 15 years after her first. Regarding an auto after an allo, that is something you do not read about very much. What type of response did you get to each of the two transplants?? Best case, if you get a CR after the auto, and do an allo immediately thereafter, while still in CR, then the donor cells have a good chance entirely wiping out the residual multiple myeloma. I understand that if you are in CR 5 years after an allo, that there is a very good chance it will never come back. Did you get a CR after the auto/allo, and did it stick?? Good luck to you.
You ask a very interesting question. I think that you are getting into the realm of a "case by case basis". For autos, I have heard that a second auto will be routinely considered, but only in the case where the initial auto had a superior result (I am not talking about tandem autos). I have heard a report of an occasional 3rd auto, one in which a woman got her 3rd auto about 15 years after her first. Regarding an auto after an allo, that is something you do not read about very much. What type of response did you get to each of the two transplants?? Best case, if you get a CR after the auto, and do an allo immediately thereafter, while still in CR, then the donor cells have a good chance entirely wiping out the residual multiple myeloma. I understand that if you are in CR 5 years after an allo, that there is a very good chance it will never come back. Did you get a CR after the auto/allo, and did it stick?? Good luck to you.
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JPC - Name: JPC
Re: Is there a limit to the number of stem cell transplants?
Hi JPC,
I had a paraprotein concentration of 3 g/L (0.3 g/dL) before my first auto transplant, which happened in January 2015. Coming out of that, I still had a paraprotein level of 3 g/L (0.3 g/dL) and went in for an allo transplant in November 2016. Again, I have come out of that with a paraprotein level of 3 g/L (0.3 g/dL), which got me to wondering if I have now exhausted my options for transplants or if there was a chance of getting another allo at some stage?
The reason I ask is that the only chance of a cure as far as I know is an allo transplant and if this did not work, perhaps another will?
Going in to get results of my 3-month myeloma bloods tomorrow and terrified that they have gone up
Thanks,
Grant
I had a paraprotein concentration of 3 g/L (0.3 g/dL) before my first auto transplant, which happened in January 2015. Coming out of that, I still had a paraprotein level of 3 g/L (0.3 g/dL) and went in for an allo transplant in November 2016. Again, I have come out of that with a paraprotein level of 3 g/L (0.3 g/dL), which got me to wondering if I have now exhausted my options for transplants or if there was a chance of getting another allo at some stage?
The reason I ask is that the only chance of a cure as far as I know is an allo transplant and if this did not work, perhaps another will?
Going in to get results of my 3-month myeloma bloods tomorrow and terrified that they have gone up
Thanks,
Grant
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Grant - Name: Grant
- Who do you know with myeloma?: myself
- When were you/they diagnosed?: April 2014
- Age at diagnosis: 43
Re: Is there a limit to the number of stem cell transplants?
Hi Grant:
Before I start, just wanted to tell you that these are questions and issues way above my league. No way that I can give good guidance as to specifically what is the best thing to do. So just a couple of thoughts and questions for you to think about.
There are "transplant" doctors and "myeloma" doctors. Transplant doctors tend to see the transplant solution in everything. They are, I am fairly well sure good at transplanting, but they do it for all of the conditions (leukemias, lymphomas, and other conditions). So for your myeloma doctor, are you sure you have a myeloma specialist? Secondly, are you at the point of maybe getting a second opinion??
Next, you did not specify your location. You appear to be using the European / Canadian measure of M-spike, which is 10 times higher than the US standard measurement. Your treatment options depend on your location, so letting us know may help some people help you. But at an M-spike of 0.3 (US measurement standard), that in and of itself is not a major concern. Did you have an initial induction before the first auto, and if so, what was your highest M-spike?
When a treatment no longer works, it is called being "refractory" to that treatment. I have read that the melphalan simply does not work for all people, that you may be "refractory" to melphalan. Also, I have read that to get the "cure" from an allo, that it is best to be as near to zero M-spike as possible going in to the allo, and maybe, even though yours was pretty low, it was not low enough, and the new immune system had too high of a burden to wipe out the remaining multiple myeloma cells.
After having had two transplants (one of them an allo!), and not getting the desired result, maybe you should look at some of the newer agents (monoclonal antibodies) when you need them, though they are not yet available all over the world. You could also look at some of the clinical trials that might be available. I have read a lot, but I simply have never come across your question and case regarding a third transplant, after one auto and one allo. I hope your numbers come back stable, and stay there for a long time. Good luck.
Before I start, just wanted to tell you that these are questions and issues way above my league. No way that I can give good guidance as to specifically what is the best thing to do. So just a couple of thoughts and questions for you to think about.
There are "transplant" doctors and "myeloma" doctors. Transplant doctors tend to see the transplant solution in everything. They are, I am fairly well sure good at transplanting, but they do it for all of the conditions (leukemias, lymphomas, and other conditions). So for your myeloma doctor, are you sure you have a myeloma specialist? Secondly, are you at the point of maybe getting a second opinion??
Next, you did not specify your location. You appear to be using the European / Canadian measure of M-spike, which is 10 times higher than the US standard measurement. Your treatment options depend on your location, so letting us know may help some people help you. But at an M-spike of 0.3 (US measurement standard), that in and of itself is not a major concern. Did you have an initial induction before the first auto, and if so, what was your highest M-spike?
When a treatment no longer works, it is called being "refractory" to that treatment. I have read that the melphalan simply does not work for all people, that you may be "refractory" to melphalan. Also, I have read that to get the "cure" from an allo, that it is best to be as near to zero M-spike as possible going in to the allo, and maybe, even though yours was pretty low, it was not low enough, and the new immune system had too high of a burden to wipe out the remaining multiple myeloma cells.
After having had two transplants (one of them an allo!), and not getting the desired result, maybe you should look at some of the newer agents (monoclonal antibodies) when you need them, though they are not yet available all over the world. You could also look at some of the clinical trials that might be available. I have read a lot, but I simply have never come across your question and case regarding a third transplant, after one auto and one allo. I hope your numbers come back stable, and stay there for a long time. Good luck.
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JPC - Name: JPC
Re: Is there a limit to the number of stem cell transplants?
Hi JPC,
Thanks for your advice. I am based in Cape Town, South Africa, and yes I do have a very good hematologist (I think).
To answer you question, I did start out with bone lesions, a tumour, and a paraprotein level of 48 g/l (4.8 g/dl). I had induction therapy (8 months) and radiation for the lesions / tumour before my first auto.
Unfortunately, clinical trials are not really an option here. But I may at some stage travel to the US for a second opinion.
Thanks for your help.
Ta
Grant
Thanks for your advice. I am based in Cape Town, South Africa, and yes I do have a very good hematologist (I think).
To answer you question, I did start out with bone lesions, a tumour, and a paraprotein level of 48 g/l (4.8 g/dl). I had induction therapy (8 months) and radiation for the lesions / tumour before my first auto.
Unfortunately, clinical trials are not really an option here. But I may at some stage travel to the US for a second opinion.
Thanks for your help.
Ta
Grant
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Grant - Name: Grant
- Who do you know with myeloma?: myself
- When were you/they diagnosed?: April 2014
- Age at diagnosis: 43
Re: Is there a limit to the number of stem cell transplants?
Hello again Grant,
You are obviously not deterred by strong treatments. If you are looking for something "aggressive", and down the road are willing to travel, you may want to look at CAR-T cell treatment. Still very early, and not yet ready for prime time, but in theory, it could have the same type of immunotherapeutic activity as an allo.
Good luck to you.
You are obviously not deterred by strong treatments. If you are looking for something "aggressive", and down the road are willing to travel, you may want to look at CAR-T cell treatment. Still very early, and not yet ready for prime time, but in theory, it could have the same type of immunotherapeutic activity as an allo.
Good luck to you.
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JPC - Name: JPC
Re: Is there a limit to the number of stem cell transplants?
Hi Grant,
It is possible to do a second allogeneic transplant. I am in the process of discussing this and making plans for a second allo (in Sweden). I had my first allo in 2012 when my sister, a matched related donor (MRD), donated cells. This time we are discussing a matched unrelated donor (MUD). I was not in complete response before the transplant and not after, so my situation is similar to yours.
I have been on maintenance (Revlimid and dexamethasone) for three years, but lately numbers are rising. Unfortunately, I believe it was due to my attempt to skip the dex that brought the relapse on. When I added the dex again, it didn't work!
I have seen a study where a second allo was done where approximately 25 % were alive after a year. There was no difference if you used the same donor or a new. But this study was done several years ago and I would expect the numbers to be much better now with new drugs available.
Good luck to you.
It is possible to do a second allogeneic transplant. I am in the process of discussing this and making plans for a second allo (in Sweden). I had my first allo in 2012 when my sister, a matched related donor (MRD), donated cells. This time we are discussing a matched unrelated donor (MUD). I was not in complete response before the transplant and not after, so my situation is similar to yours.
I have been on maintenance (Revlimid and dexamethasone) for three years, but lately numbers are rising. Unfortunately, I believe it was due to my attempt to skip the dex that brought the relapse on. When I added the dex again, it didn't work!
I have seen a study where a second allo was done where approximately 25 % were alive after a year. There was no difference if you used the same donor or a new. But this study was done several years ago and I would expect the numbers to be much better now with new drugs available.
Good luck to you.
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asaryden - Name: asaryden
- Who do you know with myeloma?: myself
- When were you/they diagnosed?: August 2010
- Age at diagnosis: 48
Re: Is there a limit to the number of stem cell transplants?
Hi Grant,
I won't comment on the transplant side of things and will leave that to allo experts like Mark11.
But is a 30 g/L M-spike so bad to live with if you can maintain a level somewhere in that range with maintenance drugs? Which then begs the question as to whether you are on any sort of maintenance treatment?
It looks like you did CTD for induction. Out of curiosity, just which multiple myeloma drugs are available to you in South Africa? Do you have access to carfilzomib (Kyprolis), bortezomib (Velcade), lenalidomide (Revlimid) and/or pomalidomide (Pomalyst, Imnovid)?
I won't comment on the transplant side of things and will leave that to allo experts like Mark11.
But is a 30 g/L M-spike so bad to live with if you can maintain a level somewhere in that range with maintenance drugs? Which then begs the question as to whether you are on any sort of maintenance treatment?
It looks like you did CTD for induction. Out of curiosity, just which multiple myeloma drugs are available to you in South Africa? Do you have access to carfilzomib (Kyprolis), bortezomib (Velcade), lenalidomide (Revlimid) and/or pomalidomide (Pomalyst, Imnovid)?
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Multibilly - Name: Multibilly
- Who do you know with myeloma?: Me
- When were you/they diagnosed?: Smoldering, Nov, 2012
Re: Is there a limit to the number of stem cell transplants?
Hi Multibilly,
I have no problem with my current levels but what I am worried about is what I'm lead to believe will be the inevitable rise in these number again. Yesterday's 3 monthly myeloma bloods are now at 4 g/L (0.4 g/dL).
I'm not on any maintenance therapy. My doctor seems to be of the opinion that I should live and enjoy life as much as possible off treatment, and then when the number start climbing we go in for treatment. He said this approach would not compromise my response to treatment when I needed it.
You are quite right about my induction therapy; it was CTD but after about 6 months my numbers had not dropped enough so I was put onto Velcade, which did the job.
As far as I know, we have access to Velcade and Revlimid here, and my doctor has said that my next drug would be Revlimid.
I have no problem with my current levels but what I am worried about is what I'm lead to believe will be the inevitable rise in these number again. Yesterday's 3 monthly myeloma bloods are now at 4 g/L (0.4 g/dL).
I'm not on any maintenance therapy. My doctor seems to be of the opinion that I should live and enjoy life as much as possible off treatment, and then when the number start climbing we go in for treatment. He said this approach would not compromise my response to treatment when I needed it.
You are quite right about my induction therapy; it was CTD but after about 6 months my numbers had not dropped enough so I was put onto Velcade, which did the job.
As far as I know, we have access to Velcade and Revlimid here, and my doctor has said that my next drug would be Revlimid.
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Grant - Name: Grant
- Who do you know with myeloma?: myself
- When were you/they diagnosed?: April 2014
- Age at diagnosis: 43
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