Hello MrPotatohead,
I wonder if you might want to consider speaking to another transplant centre about your transplant eligibility. Perhaps your kidney function is not so bad, and a different centre would be less conservative.
As an alternative, perhaps you could work with your doctors to include oral melphalan into the new regimen you will be starting. For example, you could do alternative cycles of Kyprolis, Pomalyst, and dex (KPD) and melphalan and prednisone (MP) – KPD for a cycle, MP for a cycle, and so on.
It would seem a shame to miss out on the efficacy of melphalan simply because you cannot undergo high-dose melphalan therapy as part of the transplant process.
Of course, you also could consider adding melphalan to the KPD regimen, for something like "KPMD", but that may be too intense a regimen for you.
Cheers!
Forums
Re: Relapse on Kyprolis, cyclophosphamide, and dexamethasone
Hi Ian,
Thanks very much for your suggestions. It had occurred to me to consult with another transplant center. My creatinine fluctuates between 1.1 and 1.5 mg/dL, and I hadn't thought that was so bad.
As far as the melphalan is concerned, doesn't that knock out your stem cells? That I think is why they extract your stem cells prior to the chemo phase in an autologous stem cell transplant (ASCT).
So I think I would certainly consider melphalan (as well as some of the other legacy chemo agents) if and when I was no longer entertaining an ASCT.
Your ideas are all good and thanks again for sharing them, Ian.
Thanks very much for your suggestions. It had occurred to me to consult with another transplant center. My creatinine fluctuates between 1.1 and 1.5 mg/dL, and I hadn't thought that was so bad.
As far as the melphalan is concerned, doesn't that knock out your stem cells? That I think is why they extract your stem cells prior to the chemo phase in an autologous stem cell transplant (ASCT).
So I think I would certainly consider melphalan (as well as some of the other legacy chemo agents) if and when I was no longer entertaining an ASCT.
Your ideas are all good and thanks again for sharing them, Ian.
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MrPotatohead - Name: MrPotatohead
- Who do you know with myeloma?: Me
- When were you/they diagnosed?: March, 2015
- Age at diagnosis: 65
Re: Relapse on Kyprolis, cyclophosphamide, and dexamethasone
Hello MrPotatohead,
I suggested alternating Kyprolis, Pomalyst, and dexamethasone (KPD) and melphalan and prednisone (MP) based on the assumption that you would not be doing a stem cell transplant. I was trying to come up with a way to get melphalan into your new regimen because you would not be getting the benefit of the high-dose melphalan given as part of the transplant process.
Perhaps there is a misunderstanding about the purpose of the high-dose melphalan when it is given during the autologous stem cell transplant process. The purpose is to kill off as much of the myeloma as possible. It is intended to be an anti-myeloma therapy. Melphalan is such a powerful chemotherapeutic drug, however, that using it at very high doses also kills off most of the blood-cell producing cells in the bone marrow. That's why you need the reinfusion of your own stem cells after the high-dose melphalan therapy.
When a patient is not able to undergo a transplant, doctors often will often use induction therapy that includes melphalan to ensure the patient still gets some of the benefit of melphalan therapy. A common choice has been Velcade, melphalan, and prednisone (VMP). This strategy has been pursued, in particular, outside the States, where off-label use of Revlimid for induction therapy has not been possible.
Again, melphalan is an anti-myeloma drug. In fact, a case could be made that, as a single agent, it is the most powerful anti-myeloma therapy. So, if you can't use it as part of the stem cell transplant process, there are good reasons for figuring out how to use it in some other way, and at some point in time (not necessarily upfront), to treat a patient's myeloma.
Cheers!
I suggested alternating Kyprolis, Pomalyst, and dexamethasone (KPD) and melphalan and prednisone (MP) based on the assumption that you would not be doing a stem cell transplant. I was trying to come up with a way to get melphalan into your new regimen because you would not be getting the benefit of the high-dose melphalan given as part of the transplant process.
Perhaps there is a misunderstanding about the purpose of the high-dose melphalan when it is given during the autologous stem cell transplant process. The purpose is to kill off as much of the myeloma as possible. It is intended to be an anti-myeloma therapy. Melphalan is such a powerful chemotherapeutic drug, however, that using it at very high doses also kills off most of the blood-cell producing cells in the bone marrow. That's why you need the reinfusion of your own stem cells after the high-dose melphalan therapy.
When a patient is not able to undergo a transplant, doctors often will often use induction therapy that includes melphalan to ensure the patient still gets some of the benefit of melphalan therapy. A common choice has been Velcade, melphalan, and prednisone (VMP). This strategy has been pursued, in particular, outside the States, where off-label use of Revlimid for induction therapy has not been possible.
Again, melphalan is an anti-myeloma drug. In fact, a case could be made that, as a single agent, it is the most powerful anti-myeloma therapy. So, if you can't use it as part of the stem cell transplant process, there are good reasons for figuring out how to use it in some other way, and at some point in time (not necessarily upfront), to treat a patient's myeloma.
Cheers!
Re: Relapse on Kyprolis, cyclophosphamide, and dexamethasone
You are quite right, Ian, I did misunderstand you. Not with respect to the purpose of melphalen when used in an ASCT. I know that its role is to kill off the myeloma, and that one extracts stem cells before using it because it can and will kill those as well. I also know that it is one of the most powerful anti-myeloma agents that there is.
I didn't know that you were advocating its use only when an ASCT had been ruled out for me. And yes, in that case, I would consider it. Before the novel agents came on the scene, melphalen and prednisone were a mainstay of myeloma treatment, and that continues to this day in some cases.
I haven't given up on the stem cell transplant yet, but I am weary of being rejected (this was the second time I was turned down). Also, as I think I mentioned, I recently read that if you have aggressive disease in the sense that your response to novel agent therapy is not long-lasting (my complete response to Kyprolis lasted only about half as long as expected), you are likely to have the same short-lived response to an ASCT.
Decisions, decisions!
Thanks, Ian.
I didn't know that you were advocating its use only when an ASCT had been ruled out for me. And yes, in that case, I would consider it. Before the novel agents came on the scene, melphalen and prednisone were a mainstay of myeloma treatment, and that continues to this day in some cases.
I haven't given up on the stem cell transplant yet, but I am weary of being rejected (this was the second time I was turned down). Also, as I think I mentioned, I recently read that if you have aggressive disease in the sense that your response to novel agent therapy is not long-lasting (my complete response to Kyprolis lasted only about half as long as expected), you are likely to have the same short-lived response to an ASCT.
Decisions, decisions!
Thanks, Ian.
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MrPotatohead - Name: MrPotatohead
- Who do you know with myeloma?: Me
- When were you/they diagnosed?: March, 2015
- Age at diagnosis: 65
Re: Relapse on Kyprolis, cyclophosphamide, and dexamethasone
Hi Mr Potatohead,
If you don't mind me asking, how long has your complete response lasted before your myeloma started to show it's ugly head?
Regards,
Dean
If you don't mind me asking, how long has your complete response lasted before your myeloma started to show it's ugly head?
Regards,
Dean
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Dean UK - Name: Dean
- Who do you know with myeloma?: Myself
- When were you/they diagnosed?: April 2016
- Age at diagnosis: 41
Re: Relapse on Kyprolis, cyclophosphamide, and dexamethasone
Hi Dean
I started Kyprolis (carfilzomib) in October, 2015, and my kappa free light chains began dropping immediately. I reached a complete response in March, 2016, when the free light chain (FLC) assay showed my kappa free light chains to be within the normal reference range of 0.3300-1.94 mg/dL. They stayed within that range until September, 2016, when they reached 4.07 mg/dL. However, they began slowly increasing in April, 2016.
So, even though I remained within the technical definition of complete response for about five months, as defined by the FLC serum assay (I have kappa light chain myeloma), my light chains were dropping for about five months before reaching a normal level.
In addition to Kyprolis, my regimen included six cycles of cyclophosphamide (Cytoxan) and dexamethasone. The cyclophosphamide was discontinued last March and I went on maintenance consisting only of two infusions of Kyprolis and dex every other week. It was a month after this point that the kappa free light chains began rising again.
I started Kyprolis (carfilzomib) in October, 2015, and my kappa free light chains began dropping immediately. I reached a complete response in March, 2016, when the free light chain (FLC) assay showed my kappa free light chains to be within the normal reference range of 0.3300-1.94 mg/dL. They stayed within that range until September, 2016, when they reached 4.07 mg/dL. However, they began slowly increasing in April, 2016.
So, even though I remained within the technical definition of complete response for about five months, as defined by the FLC serum assay (I have kappa light chain myeloma), my light chains were dropping for about five months before reaching a normal level.
In addition to Kyprolis, my regimen included six cycles of cyclophosphamide (Cytoxan) and dexamethasone. The cyclophosphamide was discontinued last March and I went on maintenance consisting only of two infusions of Kyprolis and dex every other week. It was a month after this point that the kappa free light chains began rising again.
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MrPotatohead - Name: MrPotatohead
- Who do you know with myeloma?: Me
- When were you/they diagnosed?: March, 2015
- Age at diagnosis: 65
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