title: Pre-transplantation novel agent induction predicts progression-free survival for patients with immunoglobulin light-chain amyloidosis undergoing high-dose melphalan and autologous stem cell transplantation.
abstract: BACKGROUND
  High-dose melphalan and autologous stem cell transplantation (HDM/SCT) is an effective treatment modality for immunoglobulin light-chain (AL) amyloidosis; however, its application remains restricted to patients with good performance status and limited organ involvement. In recent years, the paradigm for AL amyloidosis has changed with the introduction of novel agents such as immunomodulatory drugs (IMiDs) and proteasome inhibitors (PIs). We hypothesized that use of novel agent induction regimens has improved outcomes for patients with AL amyloidosis undergoing HDM/SCT at our center.
  
  
  METHODS
  All patients with AL amyloidosis, age ≥18 years who underwent HDM/SCT between 2001 and 2014 at the Fred Hutchinson Cancer Research Center and University of Washington Medical Center were included in this study. Any regimen administered within 6 months prior to HDM/SCT including an IMiD or a PI was considered a novel induction regimen. Use of induction regimen was evaluated in a Cox proportional hazard model for association with progression-free survival (PFS) and overall survival (OS).
  
  
  RESULTS
  Forty-five patients with AL amyloidosis underwent HDM/SCT. The median age was 57.2 years (range 39-74.4), 15 (33.3%) were women. The median number of organs involved was 2 (range 1-5), with 20 patients having only 1 (44.4%), 10 patients having 2 (22.2%), and 15 patients (33.3%) having ≥ 3 organs involved. Novel agent induction regimens were used prior to HDM/SCT in 21 patients (46.7%); these comprised PI in 13/21 (57.1%), IMiD alone in 6/21 (28.6%), PI and cyclophosphamide (CyBorD) in 3/21 (14.3%), and IMiD and PI in 3/21 (14.3%). Use of a novel agent induction regimen was associated with improved, but not OS. The 3-year PFS for patients who received a novel agent induction was 79%, while for those who did not was 53% (hazard ratio [HR] = 0.317, p = 0.048). The 3-year OS for patients who received novel agent induction regimens was 95%, while for those who did not was 71% (HR = 0.454, p = 0.247).
  
  
  CONCLUSIONS
  Our data suggest that use of a novel agent induction regimen including an IMiD or PI prior to HDM/SCT for patients with AL amyloidosis could improve outcomes, with improvement in PFS. Although these results are limited by sample size and lack of randomization, these results support possible further investigation of novel agent induction regimens in the context of a prospective clinical trial.
authors.affiliation: a Division of Medical Oncology , University of Washington , Seattle , WA , USA.|b Clinical Research Division, Fred Hutchinson Cancer Research Center , Seattle , WA , USA.
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: Cowan
authors.affiliation: c Hematology/Oncology, Amgen Inc. , Thousand Oaks , CA , USA.
authors.forename: Zandra K
authors.initials: ZK
authors.lastname: Klippel
authors.affiliation: b Clinical Research Division, Fred Hutchinson Cancer Research Center , Seattle , WA , USA.
authors.forename: Philip A
authors.initials: PA
authors.lastname: Stevenson
authors.affiliation: b Clinical Research Division, Fred Hutchinson Cancer Research Center , Seattle , WA , USA.|d Department of Pathology , University of Washington , Seattle , WA , USA , and.
authors.forename: Teresa S
authors.initials: TS
authors.lastname: Hyun
authors.affiliation: a Division of Medical Oncology , University of Washington , Seattle , WA , USA.|b Clinical Research Division, Fred Hutchinson Cancer Research Center , Seattle , WA , USA.
authors.forename: Sherilyn
authors.initials: S
authors.lastname: Tuazon
authors.affiliation: b Clinical Research Division, Fred Hutchinson Cancer Research Center , Seattle , WA , USA.|e Division of Hematology , Department of Medicine, University of Washington , Seattle , WA , USA.
authors.forename: Pamela S
authors.initials: PS
authors.lastname: Becker
authors.affiliation: a Division of Medical Oncology , University of Washington , Seattle , WA , USA.|b Clinical Research Division, Fred Hutchinson Cancer Research Center , Seattle , WA , USA.
authors.forename: Damian J
authors.initials: DJ
authors.lastname: Green
authors.affiliation: a Division of Medical Oncology , University of Washington , Seattle , WA , USA.|b Clinical Research Division, Fred Hutchinson Cancer Research Center , Seattle , WA , USA.
authors.forename: Leona A
authors.initials: LA
authors.lastname: Holmberg
authors.affiliation: a Division of Medical Oncology , University of Washington , Seattle , WA , USA.|b Clinical Research Division, Fred Hutchinson Cancer Research Center , Seattle , WA , USA.
authors.forename: David G
authors.initials: DG
authors.lastname: Coffey
authors.affiliation: a Division of Medical Oncology , University of Washington , Seattle , WA , USA.|b Clinical Research Division, Fred Hutchinson Cancer Research Center , Seattle , WA , USA.
authors.forename: Ajay K
authors.initials: AK
authors.lastname: Gopal
authors.affiliation: a Division of Medical Oncology , University of Washington , Seattle , WA , USA.|b Clinical Research Division, Fred Hutchinson Cancer Research Center , Seattle , WA , USA.
authors.forename: Edward N
authors.initials: EN
authors.lastname: Libby
mesh_terms: D000328:Adult; D000368:Aged; D000686:Amyloidosis / Q000097:blood / Q000175:diagnosis* / Q000401:mortality / Q000473:pathology; D018906:Antineoplastic Agents, Alkylating / Q000627:therapeutic use*; D003520:Cyclophosphamide / Q000627:therapeutic use; D018572:Disease-Free Survival; D004359:Drug Therapy, Combination; D005260:Female; D015870:Gene Expression; D018380:Hematopoietic Stem Cell Transplantation; D006801:Humans; D007147:Immunoglobulin Light Chains / Q000097:blood* / Q000235:genetics; D007155:Immunologic Factors / Q000627:therapeutic use; D060828:Induction Chemotherapy / Q000379:methods*; D008297:Male; D008558:Melphalan / Q000627:therapeutic use*; D008875:Middle Aged; D011379:Prognosis; D061988:Proteasome Inhibitors / Q000627:therapeutic use; D014182:Transplantation, Autologous
chemical_list: D018906:Antineoplastic Agents, Alkylating; D007147:Immunoglobulin Light Chains; D007155:Immunologic Factors; D061988:Proteasome Inhibitors; D003520:Cyclophosphamide; D008558:Melphalan
keywords: Amyloidosis; autologous transplant; bortezomib; induction therapy; lenalidomide