Non-myeloablative conditioning and allogeneic transplantation for multiple myeloma

In multiple myeloma (MM), allogeneic stem cell transplantation (alloHCT) carries a lower relapse risk than autologous transplantation but a greater transplant-related mortality. Nonmyeloablative conditioning for allogeneic transplantation (NST) reduces transplant-related toxicity. Results are encouraging when used during first remission in low-risk patients, but less-so in relapsed or refractory disease. This is a single-center retrospective analysis of 20 previously treated MM patients who underwent NST from matched-related or matched-unrelated donors from 2000-2006. Median age was 52.7 years (37.2-68.0). Twenty-five percent had advanced or high-risk disease. Eleven still had active disease prior to NST. Conditioning was total body irradiation 200 cGy on a single fraction on day 25, followed by antithymocyte globulin (ATG) 1.5 mg/kg/day and fludarabine 30 mg/m²/day on days 24 to 22. All received immunosuppression, most commonly with oral mycofenylate mofetil and cyclosporine beginning on day 25. At day 100, 50% had achieved complete remission. Transplant-related mortality was 25%. Median overall survival (OS) was 21.2 months (0.6-901) and progression-free survival (PFS) 6.6 months (0.6-901). Both OS and PFS were 24% at 3 years. OS was significantly greater for patients with age <52 years (median 27 months vs. 7.9 months, P 5 0.031), and there was a trend toward greater OS for those with β2 microglobulin <2.5 mg/l (median 27 months vs. 7.7 months, P 5 0.08). Donor characteristics and Ig type had no significant effect on survival. These data suggest a benefit of NST in relapsed/refractory MM. Randomized trials must be performed to confirm and further qualify this benefit.