Allogeneic hematopoietic cell transplantation in multiple myeloma
- S Vincent Rajkumar, MD
S Vincent Rajkumar, MD
- Edward W. and Betty Knight Scripps Professor of Medicine
- Mayo Clinic
Allogeneic hematopoietic cell transplantation (HCT) may be the only treatment for patients with multiple myeloma that has a chance of producing cure. Its use, however, is limited since even ideal candidates who undergo allogeneic HCT have a high rate of treatment-related mortality, and because its efficacy compared with autologous HCT is not fully established. The treatment-related mortality associated with allogeneic HCT is decreasing with the advent of nonmyeloablative preparative regimens. At the same time, new chemotherapeutic agents (eg, bortezomib, thalidomide, lenalidomide) are being incorporated into the initial treatment of multiple myeloma, and survival with chemotherapy alone or with autologous HCT is improving. As such, the role of allogeneic HCT in the treatment of multiple myeloma is not clear.
The use of allogeneic HCT in the management of patients with multiple myeloma will be reviewed here. The process of determining the appropriate initial therapy for patients with multiple myeloma, eligibility guidelines for HCT, and response criteria used to evaluate the treatment of multiple myeloma are discussed separately, as is a comparison of allogeneic HCT to autologous HCT and chemotherapy. (See "Overview of the management of multiple myeloma" and "Selection of initial chemotherapy for symptomatic multiple myeloma" and "Evaluating response to treatment of multiple myeloma".)
The term "hematopoietic cell transplantation" (HCT) will be used throughout this review as a general term to cover transplantation of progenitor (stem) cells from any source (eg, bone marrow, peripheral blood, cord blood). Otherwise, the source of such cells will be specified (eg, autologous peripheral blood progenitor cell transplantation). (See "Sources of hematopoietic stem cells".)
Myeloablative allogeneic HCT requires hematopoietic cells from an HLA-matched donor, which are given after the patient receives high dose chemotherapy and total body radiation. Allogeneic HCT has two advantages over autologous HCT: the graft does not contain tumor cells; and the transplant can produce a graft-versus-myeloma effect [1,2]. Less than 5 to 10 percent of patients with multiple myeloma are candidates for this approach due to its high toxicity. A detailed discussion on eligibility guidelines is presented separately. (See "Overview of the management of multiple myeloma", section on 'Autologous versus allogeneic HCT'.)
In earlier studies, allogeneic HCT for myeloma was associated with an early mortality of at least 20 percent and an overall mortality of 30 to 50 percent, due to fungal infections, interstitial pneumonitis, and graft-versus-host disease [3-8]. This mortality rate limited the use of myeloablative allogeneic HCT . Although there is a suggestion that the mortality rates are lower in more recent years, data are lacking. (See "Overview of the management of multiple myeloma", section on 'Autologous versus allogeneic HCT'.)
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- MYELOABLATIVE HCT
- SYNGENEIC HCT
- T CELL DEPLETED ALLOGENEIC HCT
- NONMYELOABLATIVE ALLOGENEIC HCT
- Autologous followed by nonmyeloablative allogeneic HCT in newly diagnosed myeloma
- Nonmyeloablative allogeneic HCT in relapsed myeloma
- MONITORING REMISSION POST-ALLOGENEIC HCT
- Allo-HCT and minimal residual disease negative state
- TREATMENT OF RELAPSE AFTER HCT
- Donor lymphocyte infusion
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS