title: VTD-melphalan is well tolerated and results in very high rates of stringent CR and MRD-negative status in multiple myeloma.
abstract: The addition of cytotoxic drugs to high-dose melphalan as a preparative regimen for autologous stem cell transplantation in multiple myeloma has not resulted in superior activity. Although novel agents have significantly improved outcome in multiple myeloma, their role in preparative regimens remains largely unknown. We have evaluated the toxicity and efficacy of combining bortezomib, thalidomide, and dexamethasone with high-dose melphalan. An institutional review board-approved retrospective analysis was performed on 100 consecutive patients receiving 153 transplants; 53 had tandem transplants; 64 patients received early transplants; and 36 had salvage transplantation. Endpoints were treatment-related toxicity and mortality, and quality of response post-transplantation with assessment of stringent complete remission (sCR) and minimal residual disease (MRD) status. Median age was 61 years, and median follow-up was 16.2 months. At 6 months, sCR was attained in 56% of patients and CR in 20%. An MRD status, assessed by sensitive (10-4) multiparameter flow cytometry, was achieved in 85%. The 100-day mortality rate was 2.6% (4/153); 1.8% for early transplants and 4.5% for salvage transplants. Grade 3-5 non-hematologic toxicities were mainly related to metabolism/nutrition; gastrointestinal and infectious problems. Median time to absolute neutrophil count of >500/µL was 12 days for both early and salvage transplantations. No significant differences in quality of response were observed between early and salvage transplantation or between single and tandem autologous stem cell transplantation. Since both sCR and MRD are excellent early surrogate markers for progression-free and overall survival, this regimen will likely be superior to melphalan alone, but it needs to be formally assessed in a randomized study.
authors.affiliation: Division of Hematology/Oncology; Holden Comprehensive Cancer Center.
authors.forename: Kalyan
authors.initials: K
authors.lastname: Nadiminti
authors.affiliation: Holden Comprehensive Cancer Center; Department of Internal Medicine, Blood and Marrow Transplantation, University of Iowa Hospitals and Clinics, Iowa City, IA, USA.
authors.forename: Kamal Kant
authors.initials: KK
authors.lastname: Singh Abbi
authors.affiliation: Holden Comprehensive Cancer Center.
authors.forename: Sarah L
authors.initials: SL
authors.lastname: Mott
authors.affiliation: Holden Comprehensive Cancer Center.
authors.forename: Lindsay
authors.initials: L
authors.lastname: Dozeman
authors.affiliation: Holden Comprehensive Cancer Center.
authors.forename: Annick
authors.initials: A
authors.lastname: Tricot
authors.affiliation: Holden Comprehensive Cancer Center.
authors.forename: Allyson
authors.initials: A
authors.lastname: Schultz
authors.affiliation: Holden Comprehensive Cancer Center; Department of Internal Medicine, Blood and Marrow Transplantation, University of Iowa Hospitals and Clinics, Iowa City, IA, USA.
authors.forename: Sonya
authors.initials: S
authors.lastname: Behrends
authors.affiliation: Holden Comprehensive Cancer Center; Department of Internal Medicine, Blood and Marrow Transplantation, University of Iowa Hospitals and Clinics, Iowa City, IA, USA.
authors.forename: Fenghuang
authors.initials: F
authors.lastname: Zhan
authors.affiliation: Holden Comprehensive Cancer Center; Department of Internal Medicine, Blood and Marrow Transplantation, University of Iowa Hospitals and Clinics, Iowa City, IA, USA.
authors.forename: Guido
authors.initials: G
authors.lastname: Tricot
keywords: autologous transplantation; minimal residual disease; mortality; multiple myeloma; response; toxicity