What percent of plasma cells do they want the bone marrow to have before they will proceed with a stem cell transplant?
Thanks
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dogmom - Who do you know with myeloma?: husband
- When were you/they diagnosed?: December 2015
- Age at diagnosis: 58
Re: Target bone marrow plasma cell percentage for SCT?
Hello, Dogmom:
Although it has been one year since my wife's autologous stem cell transplant at Memorial Sloan-Kettering in New York, I remember the issue really well. The target is to get the plasma cell percentage below 10% and ideally below 5%. If, after induction, it is higher than 10%, they will give Cytoxan for mobilization in an effort to get the plasma cell percentage to the desirable range. My wife's biopsy report called it 5% to 10%, which the doctor took to mean just a little more than 5%, and Cytoxan was not used for mobilization.
At the end of 2014, when my wife went through induction, the standard of care for transplant-eligible patients was 4 rounds of Revlimid, Velcade, and dexamethasone (RVD). Since my wife did not appear to plateau, they gave her a 5th round, when we called it a plateau at that point, and proceeded to transplant in VGPR, at an M-spike of 0.4 g/dL.
Since about the middle of last year, I understand that Kyprolis, Revlimid, and dexamethasone (KRD) has come to be used for initial induction at Memorial Sloan-Kettering, if insurance approved. Very roughly, I understand insurance is approving KRD at this time in about half the cases for initial induction. Although the data is early, I think that KRD generally has a noticeably deeper response than RVD or CyBorD (if, of course, you can tolerate it), and you would have better chance of reaching the target after 4 or 5 rounds.
Hope this is helpful. Regards,
Although it has been one year since my wife's autologous stem cell transplant at Memorial Sloan-Kettering in New York, I remember the issue really well. The target is to get the plasma cell percentage below 10% and ideally below 5%. If, after induction, it is higher than 10%, they will give Cytoxan for mobilization in an effort to get the plasma cell percentage to the desirable range. My wife's biopsy report called it 5% to 10%, which the doctor took to mean just a little more than 5%, and Cytoxan was not used for mobilization.
At the end of 2014, when my wife went through induction, the standard of care for transplant-eligible patients was 4 rounds of Revlimid, Velcade, and dexamethasone (RVD). Since my wife did not appear to plateau, they gave her a 5th round, when we called it a plateau at that point, and proceeded to transplant in VGPR, at an M-spike of 0.4 g/dL.
Since about the middle of last year, I understand that Kyprolis, Revlimid, and dexamethasone (KRD) has come to be used for initial induction at Memorial Sloan-Kettering, if insurance approved. Very roughly, I understand insurance is approving KRD at this time in about half the cases for initial induction. Although the data is early, I think that KRD generally has a noticeably deeper response than RVD or CyBorD (if, of course, you can tolerate it), and you would have better chance of reaching the target after 4 or 5 rounds.
Hope this is helpful. Regards,
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JPC - Name: JPC
Re: Target bone marrow plasma cell percentage for SCT?
Hi Dogmom,
I may be mistaken, but I do not believe there are any universally accepted guidelines on what the bone marrow plasma cell percentage should be prior to a stem cell transplant. It's a matter of physician (or treatment center) practice, and I think that really has to be kept in mind.
I know of at least one very well known myeloma specialist at a top myeloma treatment center who will give his patients a fixed number of cycles of treatment prior to transplantation, and then have the patient go on to transplant almost regardless of the response the patient has had prior to the transplant. His approach may be extreme, but I think it points out that targeting a specific plasma cell percentage is not necessarily universal.
What is your husband's myeloma specialist's target for the plasma cell percentage?
I also find it unfortunate that there are postings regularly here in the forum suggesting that it is better to give treatment regimen "A" first instead of treatment regimen "B". Myeloma specialists are still struggling to prove that intensive treatment with three or more drugs always provides longer OVERALL survival than less intensive treatment. They are a LONG WAY away from knowing that sequencing treatments in one specific way provides longer overall survival than sequencing them some other way.
The most important thing, in my opinion, is that myeloma patients ensure that they fully exploit every possible myeloma treatment they can be treated with. Don't hop to another treatment, or treatment regimen, unless you know for sure your current treatment isn't working. Yes, there are a lot of "cool" new treatments out there, but treating myeloma should be viewed as a marathon, not as a sprint to the latest, greatest new treatment.
I may be mistaken, but I do not believe there are any universally accepted guidelines on what the bone marrow plasma cell percentage should be prior to a stem cell transplant. It's a matter of physician (or treatment center) practice, and I think that really has to be kept in mind.
I know of at least one very well known myeloma specialist at a top myeloma treatment center who will give his patients a fixed number of cycles of treatment prior to transplantation, and then have the patient go on to transplant almost regardless of the response the patient has had prior to the transplant. His approach may be extreme, but I think it points out that targeting a specific plasma cell percentage is not necessarily universal.
What is your husband's myeloma specialist's target for the plasma cell percentage?
I also find it unfortunate that there are postings regularly here in the forum suggesting that it is better to give treatment regimen "A" first instead of treatment regimen "B". Myeloma specialists are still struggling to prove that intensive treatment with three or more drugs always provides longer OVERALL survival than less intensive treatment. They are a LONG WAY away from knowing that sequencing treatments in one specific way provides longer overall survival than sequencing them some other way.
The most important thing, in my opinion, is that myeloma patients ensure that they fully exploit every possible myeloma treatment they can be treated with. Don't hop to another treatment, or treatment regimen, unless you know for sure your current treatment isn't working. Yes, there are a lot of "cool" new treatments out there, but treating myeloma should be viewed as a marathon, not as a sprint to the latest, greatest new treatment.
Re: Target bone marrow plasma cell percentage for SCT?
Hi Dogmom, and Cheryl:
Further to Cheryl's point that it differs from treatment center to treatment center, I think that's absolutely correct. For example, posters report that some centers will give Cytoxan, regardless, in all situations. So my data was intended to be a "typical", and certainly not the final answer. Generally, however, lower is better. Also, on that part of the test, I think the lowest they will measure is less than 5% anyway. Also, I understand that in some cases, the response is such that its poor (say 20%), and there is nothing they can do to get it better, in that case they will go to ASCT at whatever level it is. Regards,
Further to Cheryl's point that it differs from treatment center to treatment center, I think that's absolutely correct. For example, posters report that some centers will give Cytoxan, regardless, in all situations. So my data was intended to be a "typical", and certainly not the final answer. Generally, however, lower is better. Also, on that part of the test, I think the lowest they will measure is less than 5% anyway. Also, I understand that in some cases, the response is such that its poor (say 20%), and there is nothing they can do to get it better, in that case they will go to ASCT at whatever level it is. Regards,
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JPC - Name: JPC
Re: Target bone marrow plasma cell percentage for SCT?
I had 70% plasma cells in an October bone marrow biopsy and it dropped to 40% in a biopsy a month ago. I started round 6 of RVD Tuesday this week and they are hopeful after round 7 the figure will be in the 5 to 10% range, allowing the stem cell transplant at UNC-Chapel Hill. All of my other numbers look pretty good.
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wyatwe - Name: Wes
- Who do you know with myeloma?: myself
- When were you/they diagnosed?: October 2015
- Age at diagnosis: 59
Re: Target bone marrow plasma cell percentage for SCT?
Thanks everyone, my husband had severely compromised kidney function upon diagnosis due to the myeloma. His myeloma specialist at Sarah Cannon in Nashville, Tennessee originally was to give Revlimid, Velcade, and dexamethasone (RVD) as induction, but due to kidney issues switched to cyclophosphamide, Velcade, and dexamethasone (CyBorD). He said Revlimid can be hard on the kidneys and with my husband's kidney issue he switched to Cytoxan.
He has kappa IgA myeloma. His IgA was 1804 when diagnosed and after 4 rounds of treatment has dropped to 394, which is within the normal range. We hope the induction treatment will give him good results and a low plasma cell percentage so a stem cell transplant will have it's best possible chance for a long-term remission.
I have not asked our MD what his target percentage is, but I will next time we meet. Unless there is an issue, we only see him after each cycle of treatment, and we have just started the second cycle.
He has kappa IgA myeloma. His IgA was 1804 when diagnosed and after 4 rounds of treatment has dropped to 394, which is within the normal range. We hope the induction treatment will give him good results and a low plasma cell percentage so a stem cell transplant will have it's best possible chance for a long-term remission.
I have not asked our MD what his target percentage is, but I will next time we meet. Unless there is an issue, we only see him after each cycle of treatment, and we have just started the second cycle.
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dogmom - Who do you know with myeloma?: husband
- When were you/they diagnosed?: December 2015
- Age at diagnosis: 58
Re: Target bone marrow plasma cell percentage for SCT?
Thank you for the update Dogmom (Cathy), and I hope that the good news keeps rolling in. Rgds, JPC
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JPC - Name: JPC
Re: Target bone marrow plasma cell percentage for SCT?
Please excuse my ignorance, but are they doing another bone marrow biopsy to get the percentages?
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wekebu - Name: Wendy
- Who do you know with myeloma?: Hubby
- When were you/they diagnosed?: Jan 2016
- Age at diagnosis: 55
Re: Target bone marrow plasma cell percentage for SCT?
Wekebu, they will do one after his four-cycle induction therapy is finished and before the stem cell transplant.
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dogmom - Who do you know with myeloma?: husband
- When were you/they diagnosed?: December 2015
- Age at diagnosis: 58
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