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Medizinischen Universitätsklinik und Poliklinik V
University of Heidelberg
by Lynne Lederman, PhD
High dose therapy followed by single ASCT has been the standard of care for “younger” patients (less than 60 years but up to 75 years of age in some centers). This has led to improved response rates, increased EFS, improved OS, particularly for patients with VGPR or CR, and low (15 to 5%) treatment-related mortality. Double ASCT after high dose therapy has become standard in some centers, resulting in further improvements in CR, VGPR, and PR rates, and improved EFS. Prolonged OS has been shown only in two trials. Critical factors include the type of high dose therapy, whether total body irradiation is used, the time between transplants, the therapies used in induction, and the use of maintenance therapy. In the GMMGHD2 trial, comparing VID vs. VAD and single vs. double transplant, there were no significant differences in CR, EFS, or OS between arms. There is a need to identify patients who do not have CR who will benefit from double transplant. Classification based on cytogenetics and gene expression profiling (GEP) may be used to identify such patients. Those with t(4;14) and altered cyclin and FGFR gene expression may have a worse prognosis after ASCT. Dr. Goldschmidt suggested that outside of clinical trials, a second ASCT should be performed only if there is no VGPR or CR after the first ASCT.