Autologous Stem Cell Transplantation Arm Research Articles

Treatment Outcomes and Prognostic Factors with Lenalidomide, Bortezomib, and Dexamethasone (RVd) Alone Versus Rvd Plus Autologous Stem Cell Transplantation (ASCT) in African American (AA) Patients (Pts) with Newly Diagnosed Multiple Myeloma (NDMM) in the Determination Phase 3 Trial

Background AA pts with NDMM have equal or longer overall survival (OS) vs White pts when treatment access is equal (Fillmore, Blood 2019; Dong, Blood Cancer J 2022). DETERMINATION included one of the largest cohorts of AA pts in prospective NDMM trials (n=132/722, 18.3%). The overall progression-free survival (PFS) difference (RVd-alone vs RVd+ASCT; median 46.2 vs 67.5 months [mos]; hazard ratio [HR] 1.53) was not seen in AA pts (HR 1.07; Richardson, N Engl J Med 2022). Multivariable PFS analyses, overall and by arm, showed that prognostic factors may vary according to treatment received, potentially indicating differences in MM pathobiology; PFS in AA vs White pts was longer with RVd-alone (HR 0.58) but similar with RVd+ASCT (HR 0.95) (Hassoun, EBMT 2023). We build upon this prior work with new analyses to explore outcomes with RVd-alone vs RVd+ASCT in AA and White pts. Methods Pts aged 18-65 y received RVd (3 cycles), stem cell mobilization, then 5 more RVd cycles (RVd-alone: n=357; 66 AA, 268 White) or ASCT and 2 more RVd cycles (RVd+ASCT: n=365; 66 AA, 272 White), and then R maintenance. We analyzed PFS (primary endpoint) by race, with exploration of potentially confounding effects of body mass index (BMI) and sex. Treatment exposure, response, event-free survival (EFS; events: progressive disease [PD], death, non-protocol therapy [NPT]), OS, and safety by race were evaluated. Exploratory genomic analyses in a subset of pts assessed frequency of Duffy-null genotype, a common variant in AA pts associated with lower circulating neutrophil count without increased infection risk that may have a key role in cytokine homeostasis (Jinna, Cells 2022). Results AA pts were younger and more commonly female than White pts, as seen in the GRIFFIN study (Nooka, Blood Cancer J 2022), with higher rates of ECOG PS >0, BMI ≥30, LDH >ULN, and low hemoglobin (panel A). Of 153 samples tested to date, 13 (8.5%) were Duffy-null: 11/17 (64.7%) AA and 2/136 (1.5%) non-AA pts. Median treatment duration from randomization (cycle 2) in AA and White pts, respectively, was 27.5 and 28.7 mos (RVd-alone) vs 36.1 and 36.2 mos (RVd+ASCT); 16% of AA and 13% of White pts discontinued within the first 3 RVd cycles due to adverse events (AEs; 5%/3% of AA/White pts), pt/investigator decision (5%/6%), PD (3%/3%), death (2%/<1%), or other reasons (2%/1%). In the 79%/86% of AA/White pts (RVd+ASCT) who underwent ASCT on study, transplant parameters were similar. 77%/83% of AA/White pts on the RVd-alone arm and 74%/80% on RVd+ASCT started R maintenance; median duration was 43.3/35.8 mos and 45.2/40.4 mos, respectively. In AA/White pts, median % of cycles with mean R dose >10 mg was 78%/88% (RVd-alone) and 83%/58% (RVd+ASCT). At data cut-off, of pts who started maintenance, 35%/25% of AA/White pts on the RVd-alone arm and 35%/29% on the RVd+ASCT arm were ongoing, and 65%/75% and 65%/71% had discontinued (including 37%/57% and 33%/37% due to PD), respectively. AE data are shown in panel B. Odds of achieving ≥CR were greater with RVd-alone vs RVd+ASCT in AA pts and were lower for AA vs White pts on the RVd+ASCT arm (panel B). Median PFS (RVd-alone vs RVd+ASCT) was not reached (NR) vs 61.4 mos (HR 1.07) in AA pts and 44.3 vs 67.2 mos (HR 1.67) in White pts. PFS with RVd-alone vs RVd+ASCT was longer in AA pts with BMI ≥30 (median NR vs 58.6 mos, HR 0.74), but shorter in AA pts with BMI <30 (66.4 mos vs NR, HR 1.86) and White pts with BMI <30 (45.3 vs 82.3 mos, HR 1.78) or ≥30 (41.1 vs 64.4 mos, HR 1.58). The PFS with RVd-alone vs RVd+ASCT was similar in male (HR 1.28) and female (HR 0.90) AA pts but shorter in male (HR 1.47) and female (HR 1.85) White pts. With RVd-alone vs RVd+ASCT, median EFS was 47.7 vs 48.2 mos (HR 0.99) in AA pts and 31.7 vs 46.7 mos (HR 1.30) in White pts; 5-y OS was 83.2% vs 78.7% (HR 0.99) in AA pts and 77.1% vs 80.3% (HR 1.08) in White pts. Among AA/White pts off study treatment, 64%/77% had received NPT; 27%/28% (RVd-alone arm) had received ASCT as NPT. Conclusions Our analyses suggest that PFS, EFS, and OS were similar with RVd-alone and RVd+ASCT in AA pts on this study. Importantly, while outcomes with RVd+ASCT were similar in AA and White pts, exploratory analyses suggest AA pts with high BMI and female AA pts may derive more PFS benefit from RVd-alone. Rates of starting maintenance/NPT use were lower in AA vs White pts, but maintenance duration proved longer in AA pts, with similar rates of grade ≥3 hematologic AEs, including neutropenia; analyses of outcomes by Duffy status are ongoing and will be presented.

CELL‐FREE DNA KINETICS DECIPHER POTENTIAL MECHANISMS OF ACTION OF IBRUTINIB COMBINATION THERAPY IN MANTLE CELL LYMPHOMA (MCL)

Introduction: The European MCL Network trial TRIANGLE (NCT02858258) evaluated the addition of ibrutinib to standard treatment with autologous stem cell transplantation (ASCT) (arm A+I) in comparison to ASCT alone (arm A) and ibrutinib plus chemoimmunotherapy without ASCT (arm I) demonstrating significant and clinically relevant superiority of additional ibrutinib on outcome. Cell-free (cf)DNA captures tumor genetics and can be used to assess disease kinetics and minimal residual disease (MRD). We used capture based targeted sequencing for genotyping and MRD monitoring in cfDNA in the TRIANGLE trial to gain insight into the mechanisms of action of Ibrutinib and to identify patients (pts) with high risk of relapse. Methods: Peripheral blood (PB) and plasma samples from 57 pts with a PB infiltration of ≥10% at baseline (BL) and samples at mid induction (MI, n = 57) and end of induction (EoI, n = 53) were sequenced using the EuroClonality (EC)-NDC assay (Univ8® Genomics UK) to detect immunoglobulin and T-cell receptor (IG/TR) rearrangements, structural- (SV) and single nucleotide variants (SNVs) in 72 genes. Bioinformatics by ARResT/Interrogate with adaptations for cfDNA. Pts were considered MRD+ by detecting ≥1 read of a lymphoma-specific IG, SV or SNV. MRD in PB was analyzed by ASO-qPCR. Results: cfDNA levels were high at BL (mean 93 ng/mL) and MI (124 mg/mL) and decreased at EoI (12 ng/mL). BL cfDNA levels correlated with MIPI scores and identified pts with poor outcome. Genotyping by EC-NDC showed fully concordant IG clonotypes and SVs among 57 paired PB gDNA and cfDNA samples. 126 SNVs were identified (VAF 2.7%–75%, median 30%) in genes described as drivers in MCL, ATM (44%), TP53 (19%), KMT2D (16%), SAMHD1 (8%), CCND1 (8%) and 18 others. On average, 6 MRD markers were identified per patient (range 3-10). Copy number variation analysis revealed deletions in ATM (10%), CDKN2A (16%) and TP53 (5%) pts. TP53 mutations/deletions are a poor prognostic indicator in MCL, but therapy in arms A+I/I (n = 6) overcomes this poor outcome in comparison to arm A (n = 5). At MI, total cfDNA and ctDNA levels were significantly increased in arms A+I/I as compared to arm A (p = 0.049). 20/57 (35%) pts were MRD+ in PB and 35/55 (64%) in cfDNA. ctDNA was detected in 17/21 pts (81%) in Arm A and 18/34 pts (53%) in Arms A+I/I, suggesting effective disease clearance in the lymph nodes by ibrutinib. ctDNA detection at MI predicted outcome only in arm A. At EoI 8/53 (15%) pts were MRD+ in PB and 20/40 (50%) pts were MRD+ in cfDNA. ctDNA was detected in 12/18 pts (66%) in Arm A and 8/22 pts (36%) in Arms A+I/I. Similar to MI, ctDNA at EoI predicted outcome only in arm A. Keywords: combination therapies, liquid biopsy, minimal residual disease Conflicts of interests pertinent to the abstract S. Ferrero Consultant or advisory role: EUSA Pharma, Jannsen Honoraria: Servier Research funding: Gilead, Morphosys, Jannsen V. H. van der Velden Other remuneration: EuroFlow: Patents and Royalties R. García Sanz Honoraria: Janssen, BeiGene, Gilead, Astellas, Amgen, Takeda Research funding: Janssen, Gilead, Astellas, Takeda Educational grants: Janssen M. Dreyling Consultant or advisory role: Novartis, Lilly/Loxo, AstraZeneca, Roche, Janssen, Gilead/Kite, BMS/Celgene, Beigene Honoraria: Novartis, Lilly/Loxo, Amgen, AstraZeneca, Roche, Janssen, Gilead/Kite Research funding: Roche, Janssen, Bayer, AbbVie A. W. Langerak Research funding: Genentech, Roche Other remuneration: Spearkers Bureau: Janssen, Gilead D. Gonzalez de Castro Employment or leadership position: Founder and director of Univ8 Genomics Ltd.

Continuous induction with lenalidomide/dexamethasone versus autologous stem cell transplantation in newly diagnosed multiple myeloma: a case for response-adapted approach

Although upfront autologous stem cell transplantation (ASCT) generally improves progression-free survival (PFS) in newly diagnosed multiple myeloma (NDMM), the overall survival (OS) benefit and optimal timing of ASCT are not well established. Patients with early response may be able to safely continue induction and avoid ASCT without compromised outcomes. We report an extended follow-up analysis of a phase 2 trial that randomized transplant-eligible patients with NDMM who responded to induction (50/65 patients) to continued induction or ASCT; median follow-up was 8.0 years. Patients had similar 8-year PFS (55% vs. 43%), 8-year OS (83% vs. 72%), and rates of at least very good partial response (72% vs. 84%) whether continuing induction of lenalidomide and dexamethasone (Ld arm) or receiving ASCT (Ld + ASCT arm) (p = 0.5). Notably, over 50% of patients receiving continuous Ld had PFS of 5–10 years. These results suggest the need for prospective trials incorporating response-adapted therapeutic approaches to NDMM. STATEMENT OF PRIOR PRESENTATION Presented in abstract form (interim analysis) at the 56th annual meeting of the American Society of Hematology (San Francisco, CA, 6 December 2014) and at the 57th annual meeting of the American Society of Hematology (Orlando, FL, 3 December 2015).

Autologous Stem Cell Transplantation Versus Bortezomib-Melphalan-Prednisone for Newly Diagnosed Multiple Myeloma: Second Interim Analysis of the Phase 3 EMN02/HO95 Study

Autologous Stem Cell Transplantation Versus Bortezomib-Melphalan-Prednisone for Newly Diagnosed Multiple Myeloma: Second Interim Analysis of the Phase 3 EMN02/HO95 Study

The initial management of multiple myeloma in the era of novel agents: 2021 and beyond.

The initial management of multiple myeloma in the era of novel agents: 2021 and beyond.

Impact of Minimal Residual Disease (MRD) By Multiparameter Flow Cytometry (MFC) and Next-Generation Sequencing (NGS) on Outcome: Results of Newly Diagnosed Transplant-Eligible Multiple Myeloma (MM) Patients Enrolled in the Forte Trial

Impact of Minimal Residual Disease (MRD) By Multiparameter Flow Cytometry (MFC) and Next-Generation Sequencing (NGS) on Outcome: Results of Newly Diagnosed Transplant-Eligible Multiple Myeloma (MM) Patients Enrolled in the Forte Trial

Autologous stem cell transplantation for untreated transformed indolent B-cell lymphoma in first remission: An international, multicenter propensity matched study.

8021 Background: Transformation of untreated indolent B-cell lymphoma (Tr-iNHL) is associated with poor outcomes. Current practices are extrapolated from prospective studies of de novo large B-cell lymphoma (DLBCL) or small retrospective studies. High dose chemotherapy (HDC) and autologous stem cell transplantation (ASCT) is used as consolidation in first remission (CR1) in some centers but the evidence-base is weak. Methods: CLL/SLL, MCL as primary diseases and non-DLBCL transformations were excluded. Propensity score analysis (PSM) using the “greedy match” algorithm was used to match the baseline covariates to adjust for potential selection bias. Landmark analysis was performed with time zero at 3 months after completion of front line chemotherapy (FLC). Kaplan-Meier method and the Cox proportional hazards model were was used for time-to-event analysis including progression-free survival (PFS) and overall survival (OS). Results: 319 transplant eligible patients (age <75, LVEF >45%, no severe lung disease, CR by PET or CT >3 months after FLC) who received >/= standard RCHOP intensity FLC were identified across three centers in Australia & US. 283 (89%) patients had follicular lymphoma, 30 (9%) marginal zone lymphoma, 6 (2%) other subtypes. 49 patients underwent HDC and ASCT in CR1, a matched cohort of 98 pts based on age, stage, HGBL-DH and ECOG PS at diagnosis was generated with a 1:2 ratio using PSM. After a median follow-up of 3.6 (min: 0.1, max: 18.3) years, ASCT was associated with significantly superior PFS on multivariable analysis (MVA) (HR 0.51, 0.27-0.98; P=0.043). Univariate analysis demonstrated a trend towards inferior OS in the ASCT cohort (HR 2.36; 0.87-6.42; P=0.092) with more deaths in the ASCT arm due to PD (8% v 4%). Of the 40 patients (41%) with relapsed disease in the non-ASCT cohort–15 patients underwent salvage HDC & ASCT with 7/15 (47%) ongoing CR; 10 patients underwent CAR-T therapy (5 relapse post ASCT, 4 refractory disease, 1 relapse post FLC) with 6/10 (60%) ongoing CR; 3 patients underwent allogeneic SCT (2 relapse post ASCT, 1 relapse post FLC) with 2/3 (67%) ongoing CR. Conclusions: Although ASCT in CR1 may improve initial duration of disease control in de novo Tr-iNHL, the impact on OS is less clear with effective salvage therapies in the CAR-T era.

Regulatory T-cell depletion in the setting of autologous stem cell transplantation for multiple myeloma: pilot study

BackgroundProgression after high-dose melphalan with autologous stem cell transplantation (ASCT) in multiple myeloma (MM) may be due in part to immune dysfunction. Regulatory T (Treg) cells reconstitute rapidly after ASCT...

Pilot Study of Regulatory T-Cell Depletion in the Setting of Autologous Stem Cell Transplantation for Multiple Myeloma

Introduction High dose melphalan with autologous stem cell transplantation (ASCT) is a therapy mainstay in multiple myeloma (MM). However, the median PFS after ASCT is under 5 years even with contemporary agents. This may be due to immune dysfunction after ASCT. Regulatory T cells (Tregs, CD4+CD25+FoxP3+) reconstitute rapidly after ASCT, can inhibit antitumor immune responses, and are a target for non-cross-resistant therapy in the MRD-positive state. Methods We conducted a randomized pilot study to evaluate 2 methods of Treg depletion in MM patients undergoing ASCT. No Treg depletion was performed in the control ASCT arm. An anti-CD25 mAb (basiliximab 20 mg IV) was given day +1 post-ASCT in the in vivo Treg depletion (IVTRD) arm. In the ex vivo Treg depletion (EVTRD) arm, CD4+CD25+ Tregs were depleted from ASC grafts with anti-CD25 microbeads and CliniMACS device (Miltenyi). Primary endpoints were: 1) evaluate efficiency of Treg depletion, 2) measure kinetics of Treg depletion and recovery and 3) determine toxicities with the two methods of Treg depletion. Secondary endpoints were engraftment rates and disease response. Results Fifteen patients were enrolled, 5 in each arm. One patient in the IVTRD arm was removed from study due to mobilization failure. ASC were collected following filgrastim/plerixafor. The conditioning regimen consisted of melphalan 200 mg/m2. All patients engrafted; median times to neutrophil/platelet engraftment were similar between arms. 4/5 patients in the EVTRD arm had neutropenic fever (vs 2/5 in control ASCT arm and 2/4 in IVTRD arm). Engraftment syndrome occurred in 1 patient in the EVTRD arm. Conclusion Median ex vivo depletion of CD4+CD25+ Tregs from 5 ASC grafts was 93% (figure 1). Baseline frequencies of peripheral blood (PB) CD4+FoxP3+ Tregs were similar between all arms (p=NS). A reduction in Treg frequency was seen in the EVTRD arm compared to controls at day +14 (p=0.0001) and +21 (p=0.025, figure 2). The IVTRD arm had lower Treg frequency at day +28 compared to controls (p=0.053). These data suggest that in vivo and ex vivo Treg depletion are feasible and result in significant reduction and delay in Treg recovery post-ASCT for MM. These methods could serve as a platform for using post-transplant immunotherapies to improve post-ASCT outcomes.

The IMWG Frailty Score and Age Can be More Effective Than Clinical Judgement in the Selection of Elderly Patients with Newly Diagnosed Multiple Myeloma Who Can Benefit from an Intensive Treatment Approach with High Dose Melphalan and Autologous Stem Cell Transplantation

The IMWG Frailty Score and Age Can be More Effective Than Clinical Judgement in the Selection of Elderly Patients with Newly Diagnosed Multiple Myeloma Who Can Benefit from an Intensive Treatment Approach with High Dose Melphalan and Autologous Stem Cell Transplantation

Prospective randomization of post-remission therapy comparing autologous peripheral blood stem cell transplantation versus high-dose cytarabine consolidation for acute myelogenous leukemia in first remission

We prospectively compared outcomes of autologous stem cell transplantation (ASCT) versus high-dose cytarabine (HiDAC) consolidation as post-remission therapy for favorable- and intermediate-risk acute myelogenous leukemia (AML) in first complete remission (CR1). Two-hundred-forty patients under 65years with AML-M1, M2, M4, or M5 subtypes were enrolled. After induction, 153 patients did not undergo randomization, while the remaining 87 who achieved CR1 were prospectively randomized to HiDAC (n=45) or ASCT arm (n=42). In the HiDAC arm, 43 patients completed three cycles of HiDAC, whereas in ASCT arm 22 patients completed two cycles of consolidation consisting of intermediate-dose cytarabine plus mitoxantrone or etoposide followed by ASCT. The three-year disease-free survival (DFS) rate was 41% in HiDAC and 55% in ASCT arm (p=0.25). Three-year overall survival (OS) rates were 77 and 68% (p=0.67). Incidence of relapse was 54 and 41% (p=0.22). There was no significant difference in nonrelapse mortality between two arms (p=0.88). Patients in the ASCT arm tended to have higher DFS rates and lower relapse rates than patients in HiDAC; however, there was no significant improvement in OS in patients with favorable- and intermediate-risk AML in CR1. Patients with AML are not benefited by the intensified chemotherapy represented by ASCT.

The role of stem cell transplant for lymphoma in 2017.

The role of stem cell transplant for lymphoma in 2017.

Cost-Effectiveness of Autologous Stem Cell Treatment as Compared to Conventional Chemotherapy for Treatment of Multiple Myeloma in India.

Recent innovations in treatment of multiple myeloma include autologous stem cell transplantation (ASCT) along with high dose chemotherapy (HDC). We undertook this study to estimate incremental cost per quality adjusted life year gained (QALY) with use of ASCT along with HDC as compared to conventional chemotherapy (CC) alone in treatment of multiple myeloma. A combination of decision tree and markov model was used to undertake the analysis. Incremental costs and effects of ASCT were compared against the baseline scenario of CC (based on Melphalan and Prednisolone regimen) in the patients of multiple myeloma. A lifetime study horizon was used and future costs and consequences were discounted at 5%. Consequences were valued in terms of QALYs. Incremental cost per QALY gained using ASCT as against CC for treatment of multiple myeloma was estimated using both a health system and societal perspective. The cost of providing ASCT (with HDC) for multiple myeloma patients was INR 500,631, while the cost of CC alone was INR 159,775. In the long run, cost per patient per year for ASCT and CC arms was estimated to be INR 119,740 and INR 111,565 respectively. The number of QALYs lived per patient in case of ASCT and HDC alone were found to be 4.1 and 3.5years respectively. From a societal perspective, ASCT was found to incur an incremental cost of INR 334,433 per QALY gained. If the ASCT is initiated early to patients, the incremental cost for ASCT was found to be INR 180,434 per QALY gained. With current mix of patients, stem cell treatment for multiple myeloma is not cost effective at a threshold of GDP per capita. It becomes marginally cost-effective at 3-times the GDP per capita threshold. However, accounting for the model uncertainties, the probability of ASCT to be cost effective is 59%. Cost effectiveness of ASCT can be improved with early detection and initiation of treatment.

Autologous Stem Cell Transplantation for Patients with Early Progression of Follicular Lymphoma- Retrospective Analysis of 2 Randomized Trials of the German Low Grade Lymphoma Study Group (GLSG)

Background: Follicular lymphoma (FL) is a highly heterogeneous disease. Patients with early progression of disease (POD) have a remarkably poor outcome. Approximately 20% of patients with symptomatic, advanced stage FL experience POD within 24 months of first-line treatment (POD24) and have a 5-year overall survival (OS) of <50%, compared to >85% for patients without POD24 (Casulo et al, JCO 2015; Jurinovic et al, Blood 2016). The optimal salvage treatment for these high-risk patients is unclear. We aimed to assess the role of autologous stem cell transplantation (ASCT) applied as 2nd-line treatment for patients with POD24 who -in principle- qualified for dose-intensified regimens.Methods: Patients with advanced stage FL from 2 successive randomized trials of the German Low Grade Lymphoma Study Group (GLSG1996 [MCP versus CHOP] and GLSG2000 [CHOP versus R-CHOP], followed by randomization for ASCT consolidation versus interferon maintenance, respectively) were eligible for retrospective analysis of 2nd-line treatment if they had progressive, relapsed or refractory FL (ie, less than a partial response), were <65 years, required treatment according to our established criteria, and had not received prior ASCT. Three patients who received an allogeneic transplant (alloTx) as 2nd-line treatment were excluded from this analysis. POD24 was defined as progressive, relapsed or refractory disease within 24 months after 1st-line treatment. Progression-free survival (PFS) and OS were calculated from initiation of 2nd-line treatment (2nd-line PFS and 2nd line-OS, respectively).Results: The evaluable 162 patients were enriched for POD24 (113/162 [70%]). POD24 patients were more likely to receive ASCT as 2nd-line treatment (52/113 [46%] versus 11/49 [22%], p=0.008), whereas rituximab was more commonly added to 2nd-line regimens in patients without POD24 (48% versus 69%, p=0.018). With a median follow-up of 9.4 years, POD24 patients had a significantly shorter 5-year 2nd-line PFS and OS with 35% versus 53% (p=0.04) and 60% versus 83% (p=0.02), respectively, compared to patients without POD24.Within the POD24 group, 52 patients (46%) received ASCT, 54 (48%) received rituximab-containing regimens, 25 (22%) received both ASCT and rituximab as part of their 2nd-line treatment. Patients in the ASCT arm were younger (median age 47 versus 51 years, p=0.018) and more frequently male (73% versus 51%, p=0.026). The distribution of high-risk FLIPI (39% versus 46%, p=0.60), ECOG performance status >1 (10% versus 21%, p=0.15) and the addition of rituximab (48% versus 48%, p=1.0) was not significantly different between the ASCT and no-ASCT groups.In univariate analysis, ASCT for POD24 patients was associated with significantly higher 5-year 2nd-line PFS and OS rates of 51% versus 19% and 77% versus 46% (CI=[35;60]), respectively (Figure). The hazard ratios (HR) for 2nd-line PFS and OS were 0.36 (CI=[0.22;0.59], p<0.0001) and 0.50 (CI=[0.30;0.83], p=0.006).Multivariate analysis demonstrated that ASCT had a stronger impact on favorable treatment outcome compared to the addition of rituximab: the HRs of ASCT for 2nd-line PFS and 2nd-line OS were 0.37 (CI=[0.21;0.63], p=0.0003) and 0.34 (CI=[0.21;0.56], p<0.0001), whereas the HRs of rituximab were 0.63 (CI=[0.39;1.00], p=0.05) and 0.64 (CI=[0.39;1.08], p=0.09), respectively.Finally, to account for the selection bias associated with retrospective studies, we considered patients as ASCT if there had been an attempt to collect an autograft. This included an additional 13 patients from the no-ASCT group and another patient who ultimately received an alloTx as 2nd-line treatment. In this intention-to-treat-like analysis the benefit of ASCT remained statistically significant with a HR=0.48 for 2nd line PFS (CI=[0.30;0.77], p=0.002) and a HR=0.50 for 2nd-line OS (CI=[0.30;0.83], p=0.006).Conclusion: This retrospective analysis suggests that ASCT is an effective 2nd-line treatment option for patients with high-risk FL as defined by the early progression of disease (POD24) who qualify for dose-intensified protocols, and should be evaluated in prospective clinical trials. It remains to be determined if ASCT is also an effective 1st-line treatment strategy for selected patients identified to be high-risk by pre-treatment risk classifiers, such as the recently established clinicogenetic risk-model m7-FLIPI. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Study: Stem cell transplant should remain preferred therapy for multiple myeloma

Patients with multiple myeloma who underwent autologous stem cell transplantation (ASCT) survived longer without disease progression than those who received only chemotherapy with novel agents, according to early findings from a phase 3 clinical trial. The findings, presented at the annual meeting of the American Society of Clinical Oncology, held June 3–7, 2016, in Chicago, Illinois, were from the largest study to date aimed at comparing ASCT with a bortezomib-based regimen alone in patients younger than 65 years of age. The proteasome inhibitor bortezomib was approved by the US Food and Drug Administration in 2008 for the upfront treatment of multiple myeloma. Since then, it has been incorporated into the standard treatment for patients with newly diagnosed multiple myeloma, whether or not they are able to undergo ASCT. The continued need for ASCT for patients younger than age 65 years has been debated in this era of novel agents such as bortezomib. Lead author Michele Cavo, MD, head of the Seràgnoli Institute of Hematology at the University of Bologna in Italy, notes that although transplant-free treatment with novel agents continues to be an “intriguing prospect,” stem cell transplantation still remains an important and proven approach, with novel agents playing a supporting role. The study included 1266 patients newly diagnosed with multiple myeloma. After induction therapy with bortezomib, cyclophosphamide, and dexamethasone, patients were randomly assigned to receive either bortezomib, melphalan, and prednisone (VMP) or high-dose melphalan followed by a single treatment with ASCT. In the study's second phase, patients in both groups were randomly assigned to either consolidation therapy with bortezomib, lenalidomide, and dexamethasone or no consolidation therapy. All patients received maintenance therapy with lenalidomide until disease progression or intolerable toxicity. The median follow-up after the first treatment randomization was 2 years. Data showed that patients who received stem cell transplants showed slower disease progression than those who received VMP therapy without transplantation. Among patients who had not yet experienced disease progression, those in the ASCT arm had a 24% lower risk of progressing at any future time point in comparison with patients who did not receive the transplant. In a further multivariate analysis, the benefit of transplantation was even greater among certain patients at high risk for early progression. Patients with advanced disease who were randomized to the ASCT arm had a 48% lower chance of having progressed by the next analysis in comparison with those not undergoing transplantation. Furthermore, among patients with certain high-risk genetic factors, ASCT was associated with a 28% lower chance of future progression in comparison with VMP therapy without transplantation. The study is ongoing and will include analyses of overall survival, toxicity, and quality of life.

Interim Analysis of a Randomized Phase II Trial Comparing Continuous Lenalidomide and Dexamethasone to Autologous Stem Cell Transplantation in Multiple Myeloma Patients Responsive to Lenalidomide and Dexamethasone Induction

Background: The aggressive approach to first-line treatment of multiple myeloma (MM) incorporating autologous stem cell transplantation (ASCT) remains widely prevalent, although it is not without controversy in the current era of novel effective agents. Some trials and meta-analysis comparing ASCT to non-myeloabaltive standard therapy or delayed ASCT have failed to show an overall survival (OS) difference between the two arms [Fermand et al. Blood 92:3131-3136 (1998); Koreth et al. BBMT 13:183-196 (2007); Kumar, et al. Cancer 118(6):1585-92 (2012)]. On the other hand, analysis of transplant-eligible patients receiving lenalidomide and dexamethasone induction on the E4A03 trial and then either undergoing ASCT or continuing lenalidomide and dexamethasone showed that ASCT conferred improved OS (Blood 2010;116:38a). This controversy lead us to design a phase II clinical trial comparing continuous lenalidomide and dexamethasone (Ld) versus ASCT followed by lenalidomide maintenance, in patients responding to four cycles of Ld.Methods: Patients with newly diagnosed symptomatic MM as defined by IMWG criteria were enrolled. Patients deemed to be in urgent need of aggressive therapy (e. g. symptomatic bone disease, acute renal failure, hyperviscosity syndrome, etc÷) were not eligible. Patients received induction with lenalidomide (L) 25 mg PO daily on days 1-21, and dexamethasone (d) 40 mg PO daily on days 1,8,15, and 22 of a 28-day cycle with standard prophylaxis. Patients with POD during induction or SD after four cycles of Ld were taken off study. All other patients had stem cells harvested after four cycles of Ld and were randomized to either the continuous (Ld) arm (L at the last tolerated dose during induction, continued indefinitely until progression or toxicity; and d at 20mg weekly for one year) or the ASCT arm (using melphalan conditioning followed by L maintenance started three months post-ASCT at 10mg daily, escalated to 15 mg daily six months post-ASCT and continued indefinitely until progression or toxicity).Results: Fifty seven patients have been registered to the trial. Two patients did not initiate therapy, one because of a concurrent diagnosis of amyloidosis and the other due to aggressive disease mandating alternative therapy according to the treating physician. At this time, four patients are still receiving induction therapy and are not available for response assessments. Among the 51 remaining patients, the response to initial induction therapy includes 12% CR (n=6), 2% uCR (n=1), 4% nCR (n=2), 14% VGPR (n=7), 51% PR (n=26), 6% SD (n= 3), 4% POD (n=2), and 8 % inevaluable (n = 4 who did not receive at least two cycles of Ld). Thirteen patients were removed from the trial prior to randomization due to POD (n=2), SD after four cycles (n=3), toxicity (n=4), physician discretion (n=2), and withdrawal of consent (n=2). Among these 13 patients, one was lost to follow-up, two continued lenalidomide therapy off protocol (one patient refused ASCT, and one patient had inadequate stem cell collection), and 10 proceeded to alternative induction. All 12 patients achieved a response [25 % CR (n=3), 42 % VGPR (n=5), and 33 % PR (n=4)]; 10 patients proceeded to ASCT without event. Thirty-eight patients were randomized, 20 to Ld and 18 to ASCT. Improvement of response by at least one level occurred in 45% and 65% of patients on the Ld and ASCT arms, respectively. The median follow-up for all surviving patients from time of randomization is 38.3 months. The 1- and 3-year PFS in the Ld arm were 100% and 66%, respectively. The 1- and 3-year PFS in the ASCT arm were 89% and 68%, respectively. The 2- and 3-year OS in the Ld arm were 100% and 92%, respectively. The 2- and 3-year OS in the ASCT arm were 100% and 85%, respectively. Considering the entire population of 51 patients, with a median follow-up of 38 months, the median PFS has not been reached.Conclusions: This interim analysis, with relatively short follow-up, suggests that in transplant-eligible patients responsive to Ld during induction, continuous Ld results in similar PFS and OS compared to patients who undergo ASCT followed by L maintenance. Furthermore, this overall approach based on response-adapted treatment results in 100% of patients reaching at least PR at completion of first-line therapy. The trial remains ongoing. [Display omitted] [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Mobilization-Driven Postconsolidation Therapy in Elderly Patients with Acute Myeloid Leukemia: Feasibility and Efficacy of Autologous Stem Cell Transplantation versus Low-Dose Gemtuzumab Ozogamicin

We prospectively evaluated 2 postconsolidation strategies, administered according to the mobilization outcome, in 72 acute myeloid leukemia (AML) fit elderly patients, achieving complete remission after the first high-dose cytarabine-based induction. Autologous stem cell transplantation (ASCT) was performed in patients collecting ≥3 × 106 CD34+/kg and low-dose gemtuzumab ozogamicin (GO) was performed in poor mobilizers (collecting <3 × 106 CD34+/kg). Fifty-five patients (76.3%) underwent peripheral blood stem cell (PBSC) mobilization, after first consolidation, and 24 of 55 (44%) collected >3 × 106 CD34+ cells/kg. Among the 55 patients eligible for PBSC mobilization, 7 did not receive the planned treatment, 23 were allocated for ASCT, and 25 were allocated for GO on an intention-to-treat basis. With a median follow-up of 70 months (range, 24 to 124), 20 of 55 patients are alive, 18 of them in continuous complete remission. The 8-year overall survival (OS) and disease-free survival (DFS) are, respectively, 35.9% (95% confidence interval [CI] 24% to 49.8%) and 31.2% (95% CI, 21% to 43.8%), median OS and DFS were 22 and 16 months, respectively. In multivariate analysis, postconsolidation treatment and hyperleukocytosis (WBC > 50,000/μL) significantly predicted OS and DFS, whereas secondary AML was significantly associated with a higher relapse rate (83.4% versus 54% of de novo AML). Patients with hyperleukocytosis had 0% 3-year OS versus the 46% (at 8 years) in patients without hyperleukocytosis (P = .01); 57% of patients in the GO arm are alive at 8 years, compared with 25.4% of patients in the ASCT arm, who had an overall relative risk (RR) of death of 2.6 (95% CI, 1.2 to 5.8; P = .02). DFS at 8 years was 45.3% in patients receiving GO, compared with 26% in ASCT arm (RR, 2.1; 95% CI, 1 to 4.3; P = .05). Our study outlines low feasibility and efficacy of ASCT in elderly AML patients, whereas postconsolidation with GO appears safe and effective in this unfavorable setting. The study was registered at Umin Clinical Trial Registry (www.umin.ac.jp/ctr), number R000014052.

High-dose therapy with autologous stem cell transplantation versus chemotherapy or immuno-chemotherapy for follicular lymphoma in adults

Follicular lymphoma (FL) is the most common indolent and second most common Non-Hodgkin`s lymphoma (NHL) in the Western world. Standard treatment usually includes rituximab and chemotherapy. High-dose therapy (HDT) followed by autologous stem cell transplantation (ASCT) is an option for patients in advanced stages or for second-line therapy, leading to improved progression-free survival (PFS) rates. However, the impact of HDT and ASCT remains unclear, as there are hints of an increased risk of second cancers. We performed a systematic review with meta-analysis of randomised controlled trials (RCTs) comparing HDT plus ASCT with chemotherapy or immuno-chemotherapy in patients with FL with respect to overall survival (OS), PFS, treatment-related mortality (TRM), adverse events and secondary malignancies. We searched CENTRAL, MEDLINE, and EMBASE as well as conference proceedings from January 1985 to September 2011 for RCTs. Two review authors independently screened search results. Randomised controlled trials comparing chemotherapy or immuno-chemotherapy with HDT followed by ASCT in adults with previously untreated or relapsed FL. We used hazard ratios (HR) as effect measures used for OS and PFS as well as relative risks for response rates. Two review authors independently extracted data and assessed the quality of trials. Our search strategies led to 3046 potentially relevant references. Of these, five RCTs involving 1093 patients were included; four trials in previously untreated patients and one trial in relapsed patients. Overall, the quality of the five trials is judged to be moderate. All trials were reported as randomised and judged to be open-label studies, because usually trials evaluating stem cell transplantation are not blinded. Due to the small number of studies in each analysis (four or less), the quantification of heterogeneity was not reliable and not evaluated in further detail. A potential source of bias are uncertainties in the HR calculation. For OS, the HR had to be calculated for three trials from survival curves, for PFS for two trials.We found a statistically significant increased PFS in previously untreated FL patients in the HDT + ASCT arm (HR = 0.42 (95% confidence interval (CI) 0.33 to 0.54; P < 0.00001). However, this effect is not transferred into a statistically significant OS advantage (HR = 0.97; 95% 0.76 to 1.24; P = 0.81). The subgroup of trials adding rituximab to both intervention arms (one trial) confirms these results and the trial had to be stopped early after an interim analysis due to a statistically significant PFS advantage in the HDT + ASCT arm (PFS: HR = 0.36; 95% CI 0.23 to 0.55; OS: HR = 0.88; 95% CI 0.40 to 1.92). In the four trials in previously untreated patients there are no statistically significant differences between HDT + ASCT and the control-arm in terms of TRM (RR = 1.28; 95% CI 0.25 to 6.61; P = 0.77), secondary acute myeloid leukaemia/myelodysplastic syndromes (RR = 2.87; 95% CI 0.7 to 11.75; P = 0.14) or solid cancers (RR = 1.20; 95% CI 0.25 to 5.77; P = 0.82). Adverse events were rarely reported and were observed more frequently in patients undergoing HDT + ASCT (mostly infections and haematological toxicity).For patients with relapsed FL, there is some evidence (one trial, N = 70) that HDT + ASCT is advantageous in terms of PFS and OS (PFS: HR = 0.30; 95% CI 0.15 to 0.61; OS: HR = 0.40; 95% CI 0.18 to 0.89). For this trial, no results were reported for TRM, adverse events or secondary cancers. In summary, the currently available evidence suggests a strong PFS benefit for HDT + ASCT compared with chemotherapy or immuno-chemotherapy in previously untreated patients with FL. No statistically significant differences in terms of OS, TRM and secondary cancers were detected. These effects are confirmed in a subgroup analysis (one trial) adding rituximab to both treatment arms. Further trials evaluating this approach are needed to determine this effect more precisely in the era of rituximab. Moreover, longer follow-up data are necessary to find out whether the PFS advantage will translate into an OS advantage in previously untreated patients with FL.There is evidence that HDT + ASCT is advantageous in patients with relapsed FL.

Autologous Blood Stem Cell Transplantation Results In Better Relapse-Free Survival Than Consolidation Chemotherapy: Results of a HOVON/SAKK Phase III Trial In 519 AML Patients In First Complete Remission

AbstractAbstract 367Autologous bone marrow transplantation as post remission treatment in patients with acute myeloid leukemia (AML) has been associated with reduced relapse rates as compared to postremission chemotherapy but this advantage was offset by delayed hematopoietic recovery, excess mortality, and frequent premature withdrawals from planned transplantation. Autologous stem cell transplantation (ASCT) following myeloablative chemotherapy has regained interest when peripheral blood stem cells became available because many of the disadvantages of marrow grafts could be circumvented by the use of peripheral blood transplants. However, the clinical benefit of ASCT in comparison to consolidation chemotherapy has not been critically assessed in large prospective cohorts of patients with long term follow up. To define the optimal postremission strategy, AML patients up to 60 yrs in complete remission after two cycles of intensive chemotherapy according to the HOVON 29 or HOVON 42 protocol (NEJM 2003;349:743) and not eligible for allogeneic SCT were randomly assigned to a third cycle of chemotherapy with etoposide (100 mg/m2 days 1–5) and mitoxantrone (10 mg/m2 days 1–5) vs. ASCT with busulfan (4 mg/kg days 1–4) and cyclofosfamide (60 mg/kg days 5–6) as conditioning regimen followed by reinfusion of G-CSF mobilized peripheral blood stem cells. 261 patients were assigned to the third course of consolidation chemotherapy and 258 patients were assigned to ASCT. At least 90% of the patients received the planned treatment arm. The two groups were evenly matched with respect to various factors, including age and cytogenetic risk (intermediate risk group: 82% of chemotherapy arm and 79% of ASCT-arm). Median follow up of patients alive is more than 8 years. A significantly faster recovery of peripheral blood granulocyte and platelet count was seen following ASCT (ANC >0.5 109/l at day +14 and +28 was demonstrated in 42% vs. 1% and 88% vs. 32% of patients in the ASCT vs. chemotherapy arm respectively (p= .000). Comparable results were obtained for platelet recovery. Non-relapse mortality was estimated 4% in the ASCT arm and 1% in the chemotherapy arm. The ASCT treatment arm showed a better relapse free survival (RFS) at five years than the chemotherapy arm (39% vs. 29%, p= 0.055, HR 0.82 (0.66-1.1). In the ASCT arm 151 patients had recurrence of AML, while 186 patients relapsed in the chemotherapy arm, corresponding with actuarial relapse rate of 57% and 70% respectively. Overall survival (OS) was not different between both arms (44% vs. 40% at 5 years, p=0.9) due to a greater number of patients of the chemotherapy arm receiving salvage therapy by allogeneic SCT (25% vs. 17% of relapsed patients in the ASCT arm) or salvage by ASCT (15% vs. 1%). The relapsed patients that were given SCT salvage reached a 5 year survival of 30% against only 3% for the patients without SCT salvage. It resulted in 5 year survival probabilities after relapse of 15% in the chemotherapy arm versus 7% in the ASCT arm. Collectively, the findings from this large and mature randomized study demonstrate an advantage of consolidation by ASCT as compared to chemotherapy for AML patients in first complete remission both in terms of RFS and hematopoietic regeneration. No difference in OS was observed, possibly due to better salvage options in case of relapse after chemotherapy. Disclosures:Ossenkoppele:Bristol-Myers Squibb: Honoraria, Participated in advisory boards; Novartis: Particpated in advisory boards, Research Funding.

Autologous Stem Cell Transplantation (ASCT) Versus Oral Melphalan and High-Dose Dexamethasone In Patients with AL (Primary) Amyloidosis: Long Term Follow-up of the French Multicentric Randomized Trial

AbstractAbstract 1344In September 2007 we published the results of a prospective randomized trial comparing in 100 AL amyloidosis patients, enrolled between January 2000 and January 2005, high dose melphalan with ASCT and the oral regimen M-Dex (melphalan 10 mg per square meter of body-surface area and dexamethasone 40 mg per day, on days 1 to 4). With a median follow-up of 3 years the median survival was better in the M-Dex arm (56.9 months) than in the ASCT arm (22.2) months (p=0.04). The hematological responses were not statistically different between the 2 arms and the higher toxicity of the ASCT arm was responsible for the shorter median survival.This study has been criticised because of the high treatment related mortality (TRM) in the ASCT arm but a landmark analysis of patients who survived for at least 6 months and who received their assigned treatment, did not show any difference in survival. A second frequent criticism was that too severe patients, who were not able to go through the high dose procedure, have been included. A separate analysis done within the 59 good risk patients showed a nonsignificant difference between the two groups in overall survival at 3 years (58% in the group assigned to receive ASCT vs. 80% in the group assigned to receive M-Dex; P = 0.13).A third concern was related to the duration of response, should high dose treatment, giving slightly more complete responses, results in more sustained responses and, with a prolonged follow-up, in a better long term survival ?To answer this question we extended the follow-up of the surviving patients. The new cut off date was August 1st, 2010, more than 5 and a half years after the last inclusion. Only 1 patient has been lost to follow-up. We did again the landmark analysis with the longer follow-up and we looked, in this population of 65 patients with 100% feasibility and 0 % TRM, at survival and remission duration. As the follow-up was very long and the biologic surveillance not planned after 2006 we took unequivocal events as censor points for the event-free survival analysis: deaths and second line treatment.At the first cutoff date, in 2006, 49 patients were alive, 30 in the M-Dex arm and 19 in the HDT arm. At the new cutoff date in 2010, 38 patients are alive, 22 in the M-Dex arm and 16 in the intensive arm, with a median follow-up of 49 months for the entire cohort and 86 months for surviving patients (figure 1). The majority of late deaths were amyloid related, but 3 patients in the M-Dex arm died of unrelated lung and digestive cancer.The median survival in the 2 arms has not been modified (56.9 month in the M-Dex arm and 22.2 month in ASCT arm, p=0.15). For the 65 patients included in the landmark analysis the median survival is not different in the 2 arms (103 month in the M-Dex arm and 97 month in ASCT arm) and the median event free survival is 56 months in the M-Dex arm and 26 months in the intensive arm (p=0.3, figure 2). Eleven surviving patients in the M-Dex arm and 6 in the intensive have not received a second treatment, 9 of these patients in the M-Dex arm and 5 in the ASCT arm have normal free light chain measurement at their last visit. Only 1 patient, assigned to receive ASCT, has been diagnosed with myelodysplasia.With a longer follow-up we did not found any superiority in the intensive arm in survival or remission duration even in the landmark analysis eliminating treatment related mortality. In the area of very efficient new drugs this analysis reinforces our choice to propose conventional treatment to amyloidosis patient avoiding the risk of intensive treatment. [Display omitted] [Display omitted] Disclosures:Leblond:roche: Consultancy, Membership on an entity's Board of Directors or advisory committees; mundipharma: Membership on an entity's Board of Directors or advisory committees, Speakers Bureau; genzyme: Membership on an entity's Board of Directors or advisory committees; celgene: Membership on an entity's Board of Directors or advisory committees; jansen: Membership on an entity's Board of Directors or advisory committees. Leleu:Celgene: Consultancy, Research Funding; Janssen Cilag: Consultancy, Research Funding; Leo Pharma: Consultancy; Amgen: Consultancy; Chugai: Research Funding; Roche: Consultancy, Research Funding; Novartis: Consultancy, Research Funding.