scholarly journals Lower Performance Status and Higher Hematopoietic Cell Transplantation Specific Co-Morbidity Index are Associated with Increased Unplanned Admission Rates for Patients with Multiple Myeloma Undergoing Outpatient Autologous Stem Cell Transplantation

2017 ◽  
Vol 23 (3) ◽  
pp. S135
Author(s):  
Cynthia Obiozor ◽  
Dipti Subramaniam ◽  
G. John Chen ◽  
Clint L. Divine ◽  
Leyla Shune ◽  
...  
Keyword(s):  
Multiple Myeloma ◽  
Stem Cell ◽  
Stem Cell Transplantation ◽  
Cell Transplantation ◽  
Hematopoietic Cell Transplantation ◽  
Performance Status ◽  
Unplanned Admission ◽  
Admission Rates ◽  
Co Morbidity ◽  
Morbidity Index

Feasibility of Outpatient Autologous Stem Cell Transplantation in Multiple Myeloma and Risk Factors Predicting Hospital Admission

Blood ◽  
2020 ◽  
Vol 136 (Supplement 1) ◽  
pp. 44-44
Author(s):  
Kristin Larsen ◽  
Meera Mohan ◽  
Clyde Bailey ◽  
Kerri Hill ◽  
Horace Spencer ◽  
...  
Keyword(s):  
Multiple Myeloma ◽  
Stem Cell ◽  
Stem Cell Transplantation ◽  
Hospital Admission ◽  
Cell Transplantation ◽  
Performance Status ◽  
Outpatient Setting ◽  
Advanced Age ◽  
Ambulatory Setting ◽  
High Dose

Introduction- High dose chemotherapy followed by autologous hematopoietic stem cell transplantation (ASCT) remains the standard treatment for multiple myeloma (MM) for eligible patients. While ASCT in most centers is performed on an inpatient basis, we and others have shown its feasibility in an outpatient setting. Due to improved supportive care, enhanced patient and caregiver education and preference, the majority of MM patients at our center will initiate outpatient ASCT. However, a part of these patients will require hospital admission pre-emptively due to co-morbid conditions or related to therapy-associated toxicity. To elucidate clinical characteristics and markers predicting for hospital admission in an ambulatory setting, we investigated a total of 1446 MM patients receiving ASCT at UAMS from 2015-2019. Methods- Of the 1446 MM patients, 550 initiated their ASCT as inpatients, 280 started as outpatients but required subsequent hospital admission and 616 completed ASCT in an ambulatory setting. The decision to initiate ASCT as in- or outpatient was based on clinical and social factors. In most cases, Pptients received high dose Melphalan conditioning (74%) followed by dose-reduced Melphalan in combination with Cisplatin, Adriamycin, Cyclophosphamide and Etoposide (PACE, 15%) and BEAM conditioning (9.2%). For comparison between the transplant groups, we used analysis of variance (for continuous-like variables) and Pearson's chi-squared test (for categorical variables). Multivariable logistic regression model was used to examine the combined effects of various clinical variables on the probability of hospitalization after receiving an outpatient autologous transplant. Results- 62% (896/1446) of all patients initiated ASCT on an outpatient basis. Of those, 31% (280/896) required hospital admission within 15 days post-transplant. Main reasons for hospital admission were neutropenic fever (45%), intractable nausea/diarrhea/poor oral intake (29%, n=81/280) followed by more uncommon events such as cardiac problems (6%) and MM related pain (4%, n=12/280) and 16% other reasons (45/280). Median day of admission was D+7 after ASCT (range: D+1 to D+15) with a median length of stay of 8 days (range: 2-49 days). Median age of patients who completed outpatient ASCT (60.4 years) was significantly lower (p<0.001) than of those who required admission (62.9 years) or initiated ASCT as inpatients (61.6 years). Patients initiating ASCT as inpatients had significantly lower Karnosfsky score, albumin and DLCO but higher b2-microglobulin and creatinine compared to those who completed ASCT as outpatients and those requiring admission (all p<0.001). There was no significant difference in day of ANC nadir or engraftment, number of previous ASCTs, body mass index or conditioning regimen between these groups. To predict the need for admission in patients who initiated ASCT in an ambulatory setting, we investigated various clinical markers, including performance status, age, creatinine, b2-microglobulin and lung function tests, and showed that in a multivariant model only advanced age (p=0.02) and reduced albumin (p<0.01) were significant prognostic factors for hospital admission. Thirty day mortality was low in all transplant groups, yet patients who completed their ASCT on an ambulatory setting had significant less 30 day mortality (0.1%, n=1/616) compared to those that underwent inpatient ASCT (1.6%, n=9/550) and those that required admission after ASCT initiation in an outpatient setting (1.4%), p=0.03. Conclusion- Outpatient stem cell transplantation can be safely performed in the large majority of patients with good performance status and organ function. Advanced age and reduced albumin levels predict for a significantly higher likelihood of inpatient admission. These factors could help guiding physicians to better identify patients at high risk for admission during outpatient ASCT. Disclosures van Rhee: Takeda: Consultancy; Adaptive Biotech: Consultancy; CDCN: Consultancy; EUSA: Consultancy; Karyopharm: Consultancy.

Poor Mobilization of CD34+ Stem Cells Predicts Inferior Relapse and Survival Outcomes After Autologous Stem Cell Transplantation for Multiple Myeloma

Blood ◽  
2011 ◽  
Vol 118 (21) ◽  
pp. 3000-3000 ◽  
Author(s):  
Aleksandr Lazaryan ◽  
Hien Duong ◽  
Lisa Rybicki ◽  
Frederic J. Reu ◽  
Robert Dean ◽  
...  
Keyword(s):  
Stem Cells ◽  
Multiple Myeloma ◽  
Stem Cell ◽  
Stem Cell Transplantation ◽  
Cell Transplantation ◽  
Autologous Stem Cell Transplantation ◽  
Conflicts Of Interest ◽  
Statistical Significance ◽  
Performance Status ◽  
Hematopoietic Stem

Abstract Abstract 3000 Autologous stem cell transplantation (ASCT) remains the standard upfront therapy of younger patients with multiple myeloma (MM). Identifying a prognostic threshold amount of mobilized CD34+ hematopoietic stem cells (SC) may become an important modifiable parameter in the era of novel stem cell mobilization strategies. While poor mobilization of CD34+ cells has been shown to cause delays in hematopoietic recovery, the data on long-term clinical outcomes of patients with inferior CD34+ SC collection (‘under mobilizers’) are limited. We analyzed prospectively collected data on 239 adult patients with MM who underwent ASCT at our institution from 01/1996 to 12/2009. Fifty-one patients (21.3%) who collected less than 4 × 106/kg CD34+ SC were classified as ‘under mobilizers’ and were compared to the rest of the study population (n=188) who collected ≥ 4 × 106/kg CD34+ SC. Even though under mobilizers were slightly older (median 59 vs. 54 years, p =0.01), had longer time from diagnosis to ASCT (11 vs. 8 months, p =0.05), and required more days of leukapheresis (5 vs. 3 days, p <0.001), they did not differ from the other group according to the number of prior treatment regimens, mobilization method (only 2 patients received plerixafor), performance status, or disease remission status at transplant (all p >0.2). Median time-to-recovery for both neutrophils (11 vs. 10 days, p <0.001) and platelets (13 vs. 12 days, p <0.001) was delayed among under mobilizers. Under mobilizers had worse relapse-free survival (RFS) (hazard ratio [HR]=1.49, 95% CI, 1.03–2.16, p =0.03) and non-relapse mortality (NRM) (HR=3.59, 95% CI, 1.51–8.56, p <0.01) in multivariable Cox proportional hazards analysis. Even though the association between poor CD34+ SC collection and inferior overall survival did not reach statistical significance (HR=1.42, 95% CI, 0.94–2.16, p =0.1), under mobilizers were found to have significantly higher rates of 100-day post-transplant mortality (p =0.02). We conclude that in the context of ASCT for MM, failure to collect ≥ 4 × 106/kg CD34+ SC is independently associated with worse RFS and NRM. Disclosures: No relevant conflicts of interest to declare.

Practice Patterns in Newly Diagnosed Multiple Myeloma in the Prospective Observational Commpass Trial

Blood ◽  
2016 ◽  
Vol 128 (22) ◽  
pp. 4502-4502 ◽  
Author(s):  
Joshua Necamp ◽  
Sulsal Haque ◽  
Saulius K Girnius
Keyword(s):  
Multiple Myeloma ◽  
Stem Cell ◽  
High Risk ◽  
Stem Cell Transplantation ◽  
Cell Transplantation ◽  
Autologous Stem Cell Transplantation ◽  
Practice Patterns ◽  
Performance Status ◽  
High Risk Disease ◽  
To Receive

Abstract Introduction:The management of multiple myeloma has become increasingly complex, given late age of onset, underlying co-morbidities, plethora of drugs, and variable clinical presentation and natural history. Practice patterns likely vary based on practice type, physician experience, and geographic distributions. The Multiple Myeloma Research Foundation's (MMRF) CoMMpass Trial (Relating Clinical Outcomes in Multiple Myeloma to Personal Assessment of Genetic Profile) is a prospective, longitudinal, observation trial in NDMM with the primary goal of correlating patient data and response with molecular profiles. Here, we evaluate practice patterns in NDMM the CoMMpass Trial based on staging, high-risk features, and demographics. Methods: Clinical data were derived from MMRF's CoMMpass IA8, accessed in late July 2016 on https://research.themmrf.org/rp/explore. Independent categorical variables analyzed include International Staging System (ISS), Revised-ISS (R-ISS), LDH (normal vs. above upper limit of normal), Fluorescence-In-Situ Hybridization (FISH) (standard vs. high risk (t(4;14), t(14;16), t(14:20), del17p)), race, performance status (PS) (0-1, 2, 3-4), age (>65, 65-75, 76-80, >80 years), and gender. Dependent variables include use of doublets vs. triplets, the use of triplets using combined immunomodulatory/proteosome inhibition (IMID/PI), receiving or not receiving an autologous stem cell transplantation (ASCT), and timing of transplant (<10 vs. >10 months). For high-risk MM, defined as ISS 3, R-ISS 3, elevated LDH, or high risk FISH, patients receiving doublet therapy without an autologous stem cell transplantation were further analyzed for performance status and age. Descriptive statistics were used. Chi-square testing was used to compare variables, using STATA v14.1. Results: Data on 921 patients has been released and was reviewed. Although men and women had similar upfront therapy, including the use of triplet (57% vs. 61%, p=0.483) and IMID/PI combinations (56% vs. 62%, p=0.181), women were more likely to have an ASCT (44% vs. 34%, p=0.002). When compared to European Americans (EA), African-Americans (AA) were less likely to receive triplets (47% vs. 61%, p=0.004), IMID/PI combination (55% vs. 59%, p=0.001), and ASCT (30% vs. 40%, p=0.034). Patients with high-risk disease were not more likely to be treated more aggressively. Patients with ISS Stage 3 disease were less likely to receive triplets (50% vs. 64%, p=0.002), IMID/PI combinations (51% vs. 66%, p=0.001), or an ASCT (26% vs. 48%, p=<10-3). When comparing standard-risk MM, as defined by LDH or FISH, high-risk patients were not more likely to receive triplet therapy or ASCT. Performance status did not correlate triplet use, but lower rates of IMID/PI combinations and ASCT were noted in those with worse PS. We subsequently reviewed patients with high-risk features who were treated with doublet therapy and without ASCT, specifically looking performance status and age. Of those with elevated LDH, 12 (46%) were younger than 65 years and 12 (46%) had PS<1. Of those with high risk FISH, 20 (49%) were younger than 65 years and 37 (76%) had PS<1. Of those with ISS 3, 24 (26%) were younger than 65 years and 49 (56%) had PS<1. Of those with R-ISS 3, 12 (44%) were younger than 65 years and 17 (63%) had PS<1. Conclusions: The MMRF CoMMpass trial allowed assessment of practice patterns in the United States both inside and outside of academic medical centers. AA appear to be treated less aggressively, possibly explaining shorter survival despite more favorable cytogenetics. Second, high-risk disease does not appear to be treated more aggressively, even in younger patients with excellent performance status. This presented data must be interpreted with caution since this trial does not capture the treating physician's decision-making, nor survival data. Disclosures Girnius: Takeda: Consultancy, Membership on an entity's Board of Directors or advisory committees; Celgene: Speakers Bureau.

scholarly journals Real-world Experience of Improvement in the Survival of Lymphoma and Myeloma Patients with Autologous Stem Cell Transplantation over a 25-year Period

2021 ◽  
Vol 96 (6) ◽  
pp. 501-511
Author(s):  
Hyungwoo Cho ◽  
Shin Kim ◽  
Kyoungmin Lee ◽  
Jung Sun Park ◽  
Cheolwon Suh
Keyword(s):  
Multiple Myeloma ◽  
Overall Survival ◽  
Stem Cell ◽  
Stem Cell Transplantation ◽  
Hodgkin Lymphoma ◽  
Cell Transplantation ◽  
Real World ◽  
Survival Data ◽  
Hematopoietic Cell Transplantation ◽  
Lymphoid Malignancy

Background/Aims: The first autologous peripheral blood stem cell transplantation (ASCT) in Korea was performed for a small-cell lung cancer patient at Asan Medical Center (AMC) in 1993. Recently, lymphoma and myeloma have been the main indications; there has been progress in the treatments for these lymphoid malignancies. We explored the real-world experience of ASCT for lymphoma and myeloma at AMC over a 25-year period.Methods: We used the AMC ASCT registry, which has collected ASCT data prospectively since January 1993. Data for Hodgkin lymphoma, non-Hodgkin lymphoma, and multiple myeloma patients were analyzed. Patients transplanted up to December 2018 were included to assess adequate survival data. The ASCT time period was divided arbitrarily into 1994-1999, 2000-2009, and 2010-2018. In cases of multiple myeloma, we analyzed the 1st ASCT data only.Results: Survival of these lymphoid malignancy patients after ASCT has progressively improved. The increase in survival may be related to advances in various medical skills supporting ASCT. However, overall survival has improved much more than progression-free survival. This suggests that better salvage therapies after ASCT failure have mainly affected the improvement in overall survival. The hematopoietic cell transplantation-specific comorbidity index could not be used as a survival indicator in this analysis.Conclusions: This real-world experience study showed that the survival of lymphoid malignancy patients treated with ASCT has improved over the past 25 years.

Significance of Salvage Autologous Stem Cell Transplantation for Relapsed Multiple Myeloma: A Nationwide Retrospective Study in Japan

2018 ◽  
Vol 139 (1) ◽  
pp. 35-44 ◽  
Author(s):  
Tsuyoshi Muta ◽  
Toshihiro Miyamoto ◽  
Tomohiko Kamimura ◽  
Yoshinobu Kanda ◽  
Masaharu Nohgawa ◽  
...  
Keyword(s):  
Multiple Myeloma ◽  
Stem Cell ◽  
Retrospective Study ◽  
Stem Cell Transplantation ◽  
Cell Transplantation ◽  
Autologous Stem Cell Transplantation ◽  
Performance Status ◽  
Staging System ◽  
Early Relapse ◽  
Time To Relapse

Autologous stem cell transplantation (ASCT) has been employed for patients with relapsed multiple myeloma (MM) after up-front ASCT. The present retrospective study aimed to examine the survival benefit from salvage ASCT. Among 446 patients with relapsed MM after up-front single ASCT, 70 patients received salvage ASCT, the employment of which reduced the risk of mortality after relapse (p = 0.041). Using the parameters before initial ASCT, the advantage of salvage ASCT compared to standard therapy was confirmed in the subgroup with an international staging system stage of I or II (p = 0.040), good performance status (PS; p = 0.043), or no/mild renal comorbidity (p = 0.029). The advantage of salvage ASCT was also confirmed in the subgroup excluding those with early relapse within 7 months after initial ASCT (p = 0.026). Among patients who received salvage ASCT, a favorable prognosis is apparent for those with a time to relapse after initial ASCT of longer than 24 months. The overall survival after salvage ASCT was favorable excluding patients with the following factors: early relapse, poor PS, moderate/severe renal comorbidity, and progressive disease (p < 0.001). In conclusion, our results reinforced the evidence for encouraging salvage ASCT for eligible patients.

Melphalan (M), Prednisone (P) and Lenalidomide (R) Combination (MPR) for Newly Diagnosed Multiple Myeloma Patients Who Are Not Candidates for Stem Cell Transplantation.

Blood ◽  
2006 ◽  
Vol 108 (11) ◽  
pp. 3558-3558 ◽  
Author(s):  
Vivek Roy ◽  
Bergsagel P. Leif ◽  
Allred Jacob ◽  
Greipp R. Philip
Keyword(s):  
Multiple Myeloma ◽  
Stem Cell ◽  
Stem Cell Transplantation ◽  
Cell Transplantation ◽  
Dose Level ◽  
Performance Status ◽  
Hematologic Toxicity ◽  
Antibacterial Prophylaxis ◽  
Newly Diagnosed ◽  
Level 1

Abstract Lenalidomide is an orally active immunomodulatory drug effective in the treatment of multiple myeloma. We evaluated the toxicity and efficacy of MPR combination in a phase I/II study. Patients with newly diagnosed symptomatic multiple myeloma who were not candidates or refused stem cell transplantation were eligible. Treatment consisted of M and P on days 1 – 4 and R on days 1 – 21 in a 28 day cycle. All patients received aspirin 325 mg a day. Routine antibacterial prophylaxis was not used. Patients were accrued in cohorts of 3 at dose level 0 (M 5mg/m 2/d P 60 mg/m2/d R 10 mg/d) and level 1 (M 8mg/m2/d P 60 mg/m2/d R 10 mg/d). Patients were followed for at least 2 cycles to assess Dose Limiting Toxicity (DLT). G/GM-CSF use was not allowed in the first 2 cycles unless DLT had occurred. DLT was defined as occurrence of at least grade (G) 4 hematologic toxicity, G3 febrile neutropenia, or G 3 non-hematologic toxicity in the first two cycles. Failure to start the next cycle within 7 days of day 1 due to toxicity also constituted DLT. Results: 7 patients have been accrued (4 at dose level 0 {one patient had to be replaced} and 3 at dose level 1). 4 were males. ECOG performance status was 0 or1 (2 and 4 patients). Median age was 74 yrs, range 72 – 85. Between 3 and 10 cycles (median 4) have been administered at the time of this reporting. The following G3 or higher toxicities were encountered and considered at least possibly related to treatment: 2 patients at level 0 had G3 neutropenia. Of the three patients at dose level 1, there was 1 G4 neutropenia, 1 G4 thrombocytopenia, 1 G3 hyperglycemia and 1 G4 vascular access device related thrombosis. Responses were defined by EBMT/IBMTR criteria. 1 had a complete remission (after 3 cycles), 4 had partial remission (at least 50% reduction in monoclonal protein) and 1 had minimal response (after 3 cycles). Due to 3 DLT’s in dose level 1, dose level 0 was chosen for phase II of the study. Conclusion: M 5 mg/m2, P 60 mg/m2 and R 10 mg combination is well tolerated and appears effective in patients with multiple myeloma. These results are similar to the experience reported by Palumbo et al (Blood2005, 106(11):abst 785) although a stricter definition of DLT was used in our study. Escalation of R dose in combination with M 5 mg/m2, P 60 mg/m2 may be possible and improve responses. Updated data will be presented.

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