Health Professionals  /  Multiple myeloma

Multiple myeloma

Autologous transplant

66-69 years

• It is no longer recommended to perform autologous transplant as first line therapy. All patients should receive melphalan, prednisone and thalidomide as initial treatment.

≤ 65 years

Inclusions

• Stages II and III, as well as stage I patients requiring chemotherapy for myeloma control.

Exclusion criteria

• Stage I patients who do not require treatment for myeloma control.
• Significant co-morbidity.
• Refractory disease is not an exclusion criteria. However, if the patient’s overall condition is poor due to disease progression, it is recommended to attempt 2nd line therapy before performing autologous transplant.
• Renal insufficiency is not an exclusion criteria. However, it is suggested to stabilize the patient with second line therapy in presence of rapidly progressive renal insufficiency before proceeding to autologous transplant.

Treatment after autologous tranplant # 1

• In presence of a 6/6 HLA compatible sibling donor and a patient ≤ 65 years, the option of nonmyeloablative allogeneic transplant will be discussed with the patient.
• In patients ≤ 50 years old and without a sibling donor, the option of an unrelated donor nonmyeloablative transplant will be discussed with the patient and presented at the transplant tumor board.
• If there is no allogeneic transplant, a second autologous transplant will be offered if the patient has not achieved a very good partial response (↓ ≥90% of initial paraprotein level).
• Two months after autologous transplant, thalidomide will be started in patients who have not achieved a very good partial response (↓ ≥90% of initial paraprotein level) and who don’t present a del 13. The initial recommended dose of thalidomide is 50-100 mg po HS.

Autologous transplant followed by sibling allogeneic nonmyeloablative transplant

≤ 65 years

• In presence of a compatible sibling donor, a nonmyeloablative allogeneic transplant is offered within 3 months after autologous transplant. It is important to mention to the patient and family that this approach remains experimental and associated with significant morbidity and mortality.
• Results of nonmyeloablative sibling transplant are disappointing when performed in patients with relapse/progressive disease. This treatment will therefore be offered as sequential therapy only in absence of progressive disease.
• A creatinine clairance ≥ 50 mL/min is required.
• Conditioning regimen: Cyclophosphamide-Fludarabine.

Autologous transplant followed by unrelated donor allogeneic nonmyeloablative transplant

≤ 50 years

• When an 8/8 molecular matched unrelated donor is available, a nonmyeloablative transplant will be offered if the patient understands this approach is experimental. The case will need to be discussed at the transplant tumor board.
• Results of nonmyeloablative unrelated donor transplant are disappointing when performed in patients with relapse/progressive disease. This treatment will therefore be offered as sequential therapy only in absence of progressive disease.
• A creatinine clairance ≥ 50 mL/min is required.

Renal insufficiency

• Renal insufficiency is not an exclusion criteria for autologous transplant.
• If creatinine clearance (CC) is ≤ 30 mL/min, the dose of melphalan should be decreased to 140 mg/m2.
• Sibling transplant: CC ≥ 50 ml/min is required.
• Unrelated transplant: CC ≥ 60 mL/min is required.

Biphosphonates

• Lytic lesion visible on plain X-rays: pamidronate monthly.
• Osteoporosis or osteopenia on plain X-rays or osteodensitometry: pamidronate monthly.
• Indolent myeloma: not indicated.
• Biphosphonate therapy duration: 2 years, then discontinue if disease is stable and patient not receiving any myeloma treatment; if patient requires anti-myeloma therapy, continue biphosphonates every 3 months.
• Dental evaluation:
  • Before initiation of biphosphonates.
  • Perform invasive dental procedures before starting biphosphonates.
  • Yearly evaluation afterwards.
  • Avoid dental extraction unless absolutely necessary.
  • Consult maxillary surgeon if extraction is required.
  • Discontinue biphosphonates > 1 month before any invasive dental procedure and resume only after complete healing.

Autologous stem cells mobilization

Patients will bet mobilized with cyclophosphamide 1.5g/m2. Patients who have not achieved partial response before transplant will be mobilized with cyclophosphamide 3g/m2 if physically fit.