SAN FRANCISCOMultiple myeloma patients receiving
intensive chemotherapy following bone marrow transplantation had
"significantly superior" survival, according to a poster presentation
at the American Society of Hematology (ASH) 42nd Annual Meeting. The survival
advantages extended to patients with two or more risk factors for relapse after
As previously identified in large cohort studies, significant
adverse prognostic indicators for patients receiving high-dose therapy for
multiple myeloma are cytogenetic abnormalities, especially deletion of
chromosome 13; elevated B2M (2.5 mg/L or higher) prior to the first transplant;
and more than 12 months of preceding standard therapy. Event-free survival and
overall survival have been shown to decrease as the number of risk factors
rises from 1 to 3.
Ramen Desikan, MD, and his colleagues at the Myeloma and
Transplantation Research Center, University of Arkansas for Medical Sciences,
Little Rock, reported that intensive consolidation therapy prolonged survival
for multiple myeloma patients at high risk of relapse after tandem high-dose
Dr. Desikan added, however, that a randomized trial is needed
to confirm the benefit of maintenance therapy in patients at high risk for
relapse. They also called for a trial of maintenance chemotherapy in patients
at low risk of relapse.
The Post-transplant Regimen
Eligible patients had completed tandem transplants, had no
evidence of disease progression, and had platelet recovery to 100,000,
creatinine of 2.0 g/dL or less, no active infections, and normal
The consolidation therapy used was DCEPdexamethasone 40 mg
orally, along with continuous infusion of cyclophosphamide 300 mg/m2, etoposide
30 mg/m2, and cisplatin 15 mg/m2 daily for 4 days. This regimen has
demonstrated efficacy as salvage treatment for patients relapsing after
Supportive measures included G-CSF (Neupogen) and prophylactic
ciprofloxacin, fluconazole, and acyclovir until granulocyte recovery to 2.0 ×
The first cycle of DCEP began 90 days post-transplant, with
three additional cycles given 3 months apart. Of the 71 patients selected to
receive DCEP, 35 patients had completed all four cycles by the time of the ASH
meeting and 36 had discontinued treatment, 17 because of progressive disease.
When compared with the 142 controls matched for the prognostic
factors cited above (cytogenetics, B2M levels, and duration of prior therapy),
patients receiving DCEP had significantly superior survival rates.
Median event-free survival was 37 months for the DCEP group,
compared with 15 months for controls. Median overall survival was 37+ months,
compared with 31 months for controls. The survival advantage with DCEP cut
across risk groups (see table below).
Lack of DCEP post-transplantation significantly worsened
event-free survival on a multivariate analysis with DCEP as a variable.
Secondary acute myelogenous leukemia (AML) occurred in two
patients receiving DCEP consolidation and in one patient in the control group.