LWBK1006-34 LWW-Govindan-Review November 24, 2011 11:25
Chapter 34•Plasma Cell Neoplasms 471compared to subcutaneous bortezomib and was found to be equally effi-
cacious but with significantly decreased toxicity including a much lower
incidence of peripheral neuropathy. Since the patient is already symp-
tomatic with painful neuropathy, not altering the current regimen is likely
to make the neuropathy worse and would not be appropriate.Answer 34.6. The answer is C.
Thalidomide has been shown to improve survival postautologous trans-
plant (Attal et al. Blood. 2006 Nov 15;108(10):3289–3294 and Spencer
et al. J Clin Oncol. 2009 Apr 10;27(11):1788–1793). Two randomized
clinical trials IFM 2005-02 (Attal et al. Blood. Nov 2010;116:310) and
CALGB 100104 (McCarthy et al. Blood. Nov 2010;116:37.) have stud-
ied lenalidomide maintenance after autologous stem cell transplantation.
Both trials have shown a progression-free survival advantage for lenalido-
mide versus observation following autologous stem cell transplanta-
tion with the CALGB trial also showing superior survival for patients
receiving lenalidomide maintenance. In the HOVON-65/GMMG-HD4
randomized phase III trial comparing bortezomib, doxorubicin, dex-
amethasone (PAD) versus VAD followed by high-dose melphalan and
maintenance with bortezomib or thalidomide in patients with newly
diagnosed multiple myeloma patients who received bortezomib main-
tenance achieved a superior survival that indirectly provides evidence
supporting bortezomib maintenance following autologous transplanta-
tion (Sonnoveld et al. Blood. Nov 2010;116:40). Pomalidomide, a third-
generation immunomodulatory drug, is being studied in patients with
relapsed/refractory myeloma. There is currently no evidence to support
pomalidomide maintenance after autologous stem cell transplantation.Answer 34.7. The answer is D.
At this time, there is no data to suggest that allogeneic transplantation
improves outcomes in patients with multiple myeloma with high-risk
chromosomal features. Three randomized trials have shown no bene-
fit to tandem autologous allogeneic transplantation: the PATHEMA trial
(Rosinol et al. Blood. 2008 Nov 1;112(9):3591–3593), the French IFM99-
03 trial (Garbon et al. Blood. 2006;107(9):3474–3480), and the BMT
CTN 0102 trial (Krishnan et al. Blood. Nov 2010;116:41). These stud-
ies that compared tandem autologous transplantation with autologous
transplantation followed by reduced intensity allogeneic stem cell trans-
plantation showed no difference in survival between the two groups. Only
Bruno et al. (NEJM, 15;356(11):1110-20.2007) demonstrated superior
survival with allogeneic stem cell transplantation compared to autolo-
gous stem cell transplantation in newly diagnosed patients with mul-
tiple myeloma less than 65 years old. High-risk patients have similar
response rates following autologous and allogeneic stem cell transplan-
tation but shorter progression-free survival compared to patients with
standard-risk cytogenetics. There is emerging evidence supporting the use
of maintenance therapy following autologous transplantation. Mainte-
nance therapy trials with bortezomib and lenalidomide suggest that this
benefit is apparent even for patients with high-risk cytogenetic features