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Impact of High-Risk Cytogenetics and Achievement of

Molecular Remission on Long-Term Freedom from Disease

after Autologous

e

Allogeneic Tandem Transplantation in

Patients with Multiple Myeloma

Nicolaus Kröger

1,

*

, Anita Badbaran

1

, Tatjana Zabelina

1

, Francis Ayuk

1

,

Christine Wolschke

1

, Haefaa Alchalby

1

, Evgeny Klyuchnikov

1

,

Djordje Atanackovic

2

, Georgia Schilling

2

, Timon Hansen

2

, Sabine Schwarz

1

,

Marion Heinzelmann

1

, Silke Zeschke

1

, Ulrike Bacher

1

, Thomas Stübig

1

,

Boris Fehse

1

, Axel R. Zander

1

1Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany 2Department of Hematology/Oncology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany

Article history: Received 1 August 2012 Accepted 11 October 2012 Key Words: Unrelated donor Graft-versus-host disease ASO primer

Plasma cell chimerism

a b s t r a c t

Within a prospective protocol, the incidence and impact of achievement of molecular remission (mCR) and high-risk cytogenetics was investigated in 73 patients with multiple myeloma (MM) after autologous (auto) eallogeneic (allo) tandem stem cell transplantation (SCT). After induction chemotherapy, patients received melphalan 200 mg/m2before undergoing auto-SCT, followed 3 months later by melphalan 140 mg/m2and fludarabine 180 mg/m2 before allo-SCT. Sixteen patients had high-risk cytogenetic features, defined by positive FISH for del(17p13) and/or t(4;14). Overall, 66% of the patients achieved CR or near-CR, and 41% achieved mCR, which was sustained negative (at least 4 consecutive samples negative) in 15 patients (21%), with no significant difference in incidence between the patients with high-risk cytogenetics and others (P¼.70). After a median follow-up of 6 years, overall 5-year progression-free survival was 29%, with no significant difference between del 17p13/t(4;14)-harboring patients and others (24% versus 30%;P¼.70). The 5-year progression-free survival differed substantially according to the achieved remission: 17% for partial remission, 41% for CR, 57% for mCR, and 85% for sustained mCR. These results suggest that autoeallo tandem SCT may overcome the negative prognostic effect of del(17p13) and/or t(4;14) and that achievement of molecular remission resulted in long-term freedom from disease.

Ó2013 Published by Elsevier Inc. on behalf of American Society for Blood and Marrow Transplantation.

INTRODUCTION

Multiple myeloma (MM) is considered an incurable

disease, but in some patients long-term survival can be

achieved after high-dose chemotherapy followed by

autolo-gous (auto) or allogeneic (allo) stem cell transplantation

(SCT). Several previous studies have suggested longer

survival in those patients who achieve complete remission

(CR),

especially

after

high-dose

chemotherapy

[1,2].

Compared with other treatment modalities for MM, allo-SCT

induces a high rate of clinical complete response.

Approxi-mately 50% of patients with CR also achieve CR at the

molecular level (mCR)

[3,4]. Only those patients who achieve

mCR have a high probability of long-term freedom from

disease and cure

[5].

Standard myeloablative conditioning has been associated

with high treatment-related morbidity and mortality. The

advent of reduced-intensity conditioning (RIC) and the use of

auto

e

allo tandem SCT approaches has broadened the use of

allo-SCT in patients with MM; however, the results of

prospective trials are controversial

[6-13]. Patients harboring

del(17p) or t(4;14) are considered to have worse prognoses

[14-17]. In the present study, we investigated within

a prospective protocol the incidence and impact of mCR and

of high-risk cytogenetic features, de

ned as detection of

del(17p13) and t(4;14) by FISH, on long-term outcomes after

auto

e

allo tandem SCT in patients with MM.

PATIENTS AND METHODS Patients

Between April 2000 and October 10, 2008, 73 patients with advanced stage II/III MM were included in the study. The major inclusion criteria were MM stage II/III and age 18-65 years. Induction therapy was not part of the protocol and consisted of idarubicin/dexamethason or vincristine/ adriamycin and dexamethasone and, in more recent years, bortezomib/ dexamethason. Stem cell mobilization was performed with granulocyte colony-stimulating factor (10mg/kg) from the steady state. Before auto-grafting, 3% of the patients were in CR, 59% were in partial remission (PR), 19% had minor response or no change, and 19% had progressive disease. A minimum dose of 2.0106/kg CD34þcells was required for auto-SCT. The

conditioning regimen for auto-SCT consisted of melphalan 200 mg/m2in

divided doses given over 2 days. After an interval of 2-3 months, the patients received an RIC regimen consisting of melphalan 140 mg/m2,fludarabine 180 mg/m2, and antithymocyte globulin (ATG-Fresenius; Fresenius, Grä-felfing, Germany) at a dose of 10 mg/kg for recipients of related donor grafts and 20 mg/kg for recipients of unrelated donor grafts on days -3, -2, and -1, followed by allo-SCT. Twenty-three patients received a graft from an HLA-identical sibling, and 25 patients each received a graft from a matched or mismatched unrelated donor.

Graft-versus-host disease (GVHD) prophylaxis consisted of cyclosporine A and a short course of methotrexate. Additional donor lymphocyte infu-sions (DLIs) were allowed in cases of incomplete chimerism or persistent disease by day 120 after discontinuation of immunosuppressive therapy. FISH analysis was performed in 63 patients and revealed del 13q14 in 43 patients, t4;14 in 8 patients, and del 17q13 in 8 patients. Patient

American Society for Blood

ASBMT

and Marrow Transplantation

This trial was registered inClinicalTrials.gov(registration NCT 00781170).

Financial disclosure:See Acknowledgments on page 403.

*Correspondence and reprint requests: Prof Dr Med Nicolaus Kröger, Department of Stem Cell Transplantation, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, D-20246 Hamburg, Germany.

E-mail address:nkroeger@uke.uni-hamburg.de(N. Kröger).

1083-8791/$esee front matterÓ2013 Published by Elsevier Inc. on behalf of American Society for Blood and Marrow Transplantation.

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characteristics are summarized inTable 1. The median patient age was 49 years (range, 28-64 years). One patient who experienced severe side effects from melphalan after auto-SCT received treosulfan (310 mg/m2) instead of melphalan before allo-SCT. The median time from auto-SCT to allo-SCT was 110 days (range, 39-228 days). Fifteen patients received DLI according to the protocol due to mixed chimerism or residual disease after discon-tinuation of immunosuppressive therapy. Preliminary results of this study have been reported previously[6], and those patients are included in the present cohort with longer follow-up.

All patients provided informed consent, and the study was approved by the local Ethics Committee and health authorities. The study has been registered inClinicalTrials.gov(NCT 00781170).

Response Criteria

The criteria for remission were based on modified European Group for Blood and Marrow Transplant (EBMT) criteria[18]. CR was defined as the absence of detectable monoclonal immunoglobulin in serum and urine, negative immunofixation, and<5% plasma cells in marrow aspirate. PR was defined as at least a 75% reduction in monoclonal immunoglobulin in serum or 90% light chains in 24-hour urine. Near-CR was defined as absence of visible monoclonal paraprotein in electrophoresis but positive immunofi x-ation in serum or urine. mCR was defined as at least 2 negative PCR results with ASO primer or at least 2findings of 99.9% donor chimerism of CD138-selected plasma cells by sensitive PCR from bone marrow samples, as described below.

Sustained minimal residual disease (MRD) negativity was defined by at least 4 consecutive negative molecular results by either ASO primer or plasma cell chimerism. Mixed molecular remission was defined as detection of negative molecular markers on at least 2 occasions, but with intermittent positivity as determined by ASO primer or plasma cell chimerism. Positive MRD was defined as never or only once negativity for ASO primer or plasma cell chimerism. Bone marrow samples for detection of MRD were obtained from patients with CR or near CR (defined as normal electrophoresis but positive immunofixation) in 3- to 6-month intervals during thefirst 3 years after therapy, usually starting between dayþ100 and dayþ180 after allo-SCT.

Molecular Remission Testing

In 37 of 48 patients with CR or near-CR, MRD could be monitored by patient-specific primers (n ¼ 15) or by highly sensitive plasma cell

chimerism (n¼22). In 5 patients, only 1 MRD measurement was available, and those patients were excluded from the MRD subanalysis. Myeloma-specific primers were generated as described elsewhere[19]. In brief, after enrichment of CD138þcells (MACS, Miltenyi, Bergisch Gladbach, Germany), RNA of plasma cells was isolated and transcripted into cDNA. DNA was prepared after a preliminary lysis of erythrocytes and centrifugation from approximately 1-5105bone marrow cells using the QIAampDNA DNA

Blood Mini Kit (Qiagen, Hilden, Germany). Four sets of VH consensus forward primers and one common reverse JH primer were used for IgH sequence identification. Amplification products were electrophoresed on 2% agarose gels with ethidium bromide and visualized. Clonal PCR products were excised and purified with a DNA gel extraction kit (Qiagen). Purified PCR fragments were sequenced directly using a Big Dye Terminator Kit and an ABI Prism Model 377 sequencer (Life Technologies, Carlsbad, CA). The relevant VH family and JH consensus primers were used as sequencing primers. Vh, Dh, and Jh regions; N nucleotides; and other individual features of IgH gene were identified using the IMGT database (http://www.imgt. cines.fr/) and IgBLAST (http://www.ncbi.nlm.nih.gov/igblast/).

Tumor-specific primers for nested PCR and as forward and reverse primers for TaqMan were designed using Primer Express (Life Technologies). Nested PCR was performed in 2 rounds of amplification, with PCR "enrich-ment" with relevant VH family and JH consensus primers followed by the second round with a pair of tumor-specific primers. Parallel analysis of the

HCKgene was performed for amplification control.

Determination of plasma cell chimerism was performed as described previously[20]. In brief, plasma cells were obtained using CD138 microbe-ads and MiniMACS columns (Miltenyi Biotec), according to the manufac-turer’s instructions. The genetic markers were selected following Alizadeh et al.[21], including S01A, S01B, S07A, S07B, S08A, S08B, S11A, and, in cases of a male recipient and female donor, theDFFRYgene from the Y chromo-some, as described by Fehse et al.[22]. The reported sensitivity of this method is 1:1000 cells, 1:100,000 cells for chromosome-specific PCR. Quantitative PCR was performed using TaqMan technology on an ABI Prism 7700 sequencer (Life Technologies). Sensitivity of plasma cell chimerism was assessed by experiments using bone marrow samples from healthy male donors and dilution experiments using healthy female donor cells. These experiments revealed a sensitivity of 104using real-time PCR and

single nucleotide polymorphisms, 105using Y-chromosome PCR, and 105

using nested PCR with patient-specific primers.

To determine the relative specificity threshold of donor plasma cell chimerism for identifying MRD after allo-SCT, the percentage of donor plasma cell chimerism was compared with immunofixation and in some cases with nested PCR of patient-specific primers. For this study, plasma cell chimerism was used in those patients in whom generation of specific primers was not feasible. In some patients, both methods were available and showed good correlation of results, but patient-specific primers were used for thefinal analysis in these patients.

Statistical Methods

Study endpoints were overall survival (OS), progression-free survival (PFS), transplantation-related mortality (TRM), and incidence of relapse.

Table 1 Patient Characteristics (n¼73) Characteristic Value Sex, n Female 29 Male 44 Donor, n HLA-identical sibling 23 Unrelated 50 Matched 25 Mismatched 25

Disease status before allo-SCT, n

CR 4 PR 57 mCR 5 Stable disease 3 Progressive disease 4 Del 13q14, n Positive 43 Negative 20 Unknown 10 t(4;14), n 8 Del 17p13, n 8

Age, years, median (range) 49 (28-64) Stem cell source, n

Peripheral blood 70

Bone marrow 3

Follow-up, years, median (range) 72 (30-131) Interval between auto-SCT and allo-SCT, days,

median (range)

110 (39-228) Remission status after induction therapy, n (%)

CR 2 (3) PR 43 (59) mCR 12 (16) No change 2 (3) Progressive disease 14 (19) Table 2 Results Parameter Value

Primary graft failure, n 1 Time to ANC>1.0109/L, days, median (range) 15 (11-27)

Time to platelets>20109/L, days, median (range) 17 (9-122)

Acute GVHD, n (%) None 31 (43) Grade I 12 (17) Grade II 20 (27) Grade III 9 (12) Grade IV 1 (1) Response CR/near-CR, n (%) 48 (66) mCR, n 30 Sustained negative 15 Mixed 15 PR, n (%) 15 (21) Progressive disease, n (%) 2 (3) Not evaluated, n (%) 8 (11) 5-year PFS, % 29 (17-41) 5-year OS, % 54 (42-66) Cumulative incidence of relapse at 5 years, % 42 (30-54) Cumulative incidence of TRM at 1 year, % 23 (13-33)

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Patient characteristics are expressed as median and range for continuous variables and as frequency for categorical variables. Categorical data were compared using thec2test or the Fisher exact test. Survival curves were estimated by the Kaplan-Meier method. The log-rank test was used to estimate the incidence of TRM and relapse, to account for competing risks. For TRM, relapse was the competing event and for relapse, TRM was the competing event. Gray’s test was used to compare cumulative incidence curves. Calculations were performed with SPSS version 15 (SPSS, Inc., Chi-cago, IL), and the competing-risk analyses were done using ACCorD (V. Gebski, National Health and Medical Research Council Clinical Trials Centre, Camperdown, Australia).

RESULTS

Engraftment

One graft failure was observed. The median time to

leukocyte and platelet engraftment was 15 days (range, 11-27

days) and 17 days (range, 9-122 days), respectively (Table 2).

TRM

The cumulative incidence of 1-year TRM was 23% (95% CI,

13%-33%). This incidence was identical in HLA-identical

sibling graft recipients (22%) and matched unrelated donor

graft recipients (20%) and slightly, but not signi

cantly,

higher in mismatched unrelated donor graft recipients (32%;

P

¼

.40).

Response

A total of 44 patients (60%) achieved CR according to

EBMT criteria with negative immuno

xation, 6% achieved

near-CR, and 21% achieved PR. In addition, 3% had

progres-sive disease, and 11% were not evaluable for determination of

remission. mCR was observed in 30 patients; in 15 of these

patients, the molecular markers were sustained negative,

and in the other 15 patients, the molecular markers were

only mixed negative as described above, resulting in an

overall mCR rate of 41% and a sustained mCR rate of 21%. The

mCR rate was 50% in patients with del 17p/t(4;14) and 40% in

those without del 17p/t(4;14) (P

¼

.50). Sustained mCR was

seen in 6 patients with del 17p and/or t(4;14) and in 9

patients without del 17p/t(4;14) (P

¼

.70) (Table 3).

Table 3

Results According to CR or mCR

CR versus PR PValue mCR versus Others PValue Sustained mCR versus Mixed mCR PValue 5-year PFS 41% (95% CI, 25-57) versus

17% (95% CI, 0-34) (4 years) .008 57% (95% CI, 37-77) versus 26% (95% CI, 10-42) (3 years) <.001 85% (95% CI, 65-100) versus 31% (95% CI, 7-55) .003 5-year OS 74% (95% CI, 60-88) versus

38% (95% CI, 15-61) .03 89% (95% CI, 77-100) versus 39% (95% CI, 19-59) <.001 91% (95% CI, 73-100) versus 87% (95% CI, 69-100) .06 5-year relapse 45% (95% CI, 29-61) versus

56% (95% CI, 31-81) (4 years) .44 36% (95% CI, 18-54) versus 55% (95% CI, 34-76) .06 7% (95% CI, 0-21) versus 63% (95% CI, 35-91) .002 Included patients n=73 nCR/CR after allografting n=48 Molecular markers available n=37 [ASO n=15 PCC n=22] Sustained molecular remission n=10*

Molecular remission after allograft

n=22

No molecular remission n=15

Sustained molecular remission after DLI

n=5 Molecular remission after DLI n=8 <nCR after allografting n=25 No molecular markers available n=11 DLI n=15

Figure 1.mCR after AutoeAllo Tandem SCT in MM. ASO indicates allele-specific oligonucleotide; PCC, plasma cell chimerism.*Five patients with high-risk

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The study protocol allowed DLI in patients with persistent

disease after discontinuation of immunosuppressive therapy.

A total of 15 patients received DLI, 8 of whom achieved mCR

(mixed in 3 and sustained in 5). In 3 of these responding

patients, mCR was associated with the development of GVHD

(Table 3

and

Figure 1).

Figure 2

shows the occurrence of mCR,

along with the dates of DLI and relapse.

PFS

At a median follow-up of 6 years, overall 5-year PFS was

29% (95% CI, 17%-41%). PFS at 5 years did not differ between

patients with del 17p/t(4;14) and those without del 17p/

t(4;14) (24% versus 30%;

P

¼

.70). Patients who achieved CR

after transplantation had a better 5-year PFS compared with

patients with only PR (41% versus 17%;

P

¼

.008). Within

the group that achieved CR according to EBMT criteria, 3-year

PFS was signi

cantly better in the patients who achieved

mCR compared with those who did not (57% versus 26%:

P

.001). However, in the group of patients who achieved mCR,

those with sustained negative mCR had a 5-year PFS of 85%,

versus 31% for those with mixed mCR (P

¼

.003) (Table 3).

The 5-year OS for the entire study population was 54%

(95% CI, 42%-66%). Donor source, HLA mismatch, or

remis-sion before transplantation did not in

uence OS. Patients

who achieved CR according to EBMT criteria had an

improved 5-year OS compared with those who achieved only

PR (74% versus 38%;

P

¼

.03). Patients who achieved mCR

had a better 5-year OS than those who did not (89% versus

39%;

P

<

.001). There was also a trend toward improved OS

in patients with sustained mCR versus those with mixed

mCR (91% versus 87%;

P

¼

.06). The 5-year OS did not differ

among recipients of grafts from HLA-identical siblings,

matched donors, or mismatched donors (65% versus 40%

versus 51%, respectively;

P

¼

.30) (Figure 3A and B).

Relapse

The cumulative incidence of relapse at 5 years was 42%

(95% CI, 30%-54%) and was not in

uenced by the presence of

del 17p or t(4;14) (40% versus 52%;

P

¼

.10). Patients with

mCR exhibited a trend toward a lower incidence of relapse

(36% versus 55%;

P

¼

.06). Patients with sustained mCR had

a relapse incidence of only 7% (95% CI, 0-21%) at 5 years,

Figure 2.Achievement of mCR after autoeallo tandem SCT. Patients 1-15 achieved a mixed mCR; patients 15-30, a sustained mCR. REZ, relapse;B, MRD-negative;
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compared with 63% in those with mixed mCR (P

¼

.005)

(Figures 1

and

4).

DISCUSSION

The achievement of CR is now considered a major factor

for prolonged event-free survival and OS in patients with

MM who receive standard chemotherapy or high-dose

chemotherapy followed by auto-SCT or allo-SCT

[23].

Furthermore, duration of CR in the sense of sustained CR is

a major factor for long-term survival after auto-SCT

[24].

mCR is rarely observed after auto-SCT

[3,4], but can be

ach-ieved in some patients by posttransplantation consolidation

or maintenance therapy

[25]. After standard myeloablative

conditioning followed by allo-SCT, approximately 50% of the

patients who achieve CR will also achieve mCR

[3,4], but this

treatment approach is associated with high

treatment-related morbidity and TRM

[26,27]. The introduction of RIC

has broadened the application of allografting in MM, owing

to the reduced treatment-related morbidity and TRM. Some

randomized studies using an auto

e

allo tandem SCT

approach have suggested a bene

t for OS

[9-13,28].

The incidence and outcome of mCR after RIC have not

been previously studied in a large cohort of patients

[29].

Here we report that 66% of patients achieved CR and 41%

achieved mCR according to EBMT criteria with RIC auto

e

allo

tandem SCT. Sustained mCR, de

ned as 4 consecutive

MRD-negative bone marrow samples, was achieved in 21% of

patients. Those with sustained mCR had a signi

cantly better

5-year PFS than those who achieved only mixed mCR or no

mCR (85% versus 31% versus 17%, respectively), supporting

previously published results on mCR after standard

mye-loablative conditioning

[5]. Our 21% rate of sustained mCR

after RIC is somewhat lower than the reported 50% after

myeloablative conditioning

[3,4], possibly related to

meth-odological differences and the stringent de

nition of

sus-tained

mCR in our study. Of note, PFS increased according to

the depth of remission, from 41% for CR to 57% in mCR and

85% in sustained mCR. Furthermore, only those patients with

sustained mCR, de

ned as 4 consecutive negative samples,

are at very low risk of relapse at 5 years (7%), whereas those

with mixed mCR have only a delayed onset of relapse, but

identical cumulative incidence at 5 years (Figure 2).

The International Myeloma Working Group recently

introduced a stringent de

nition of CR

[30], but comparative

studies have shown no further bene

t from adding the free

light chain ratio to the standard EBMT de

nition of CR

[31,32]. The most sensitive methods are molecular methods,

especially the use allelic-speci

c primers based on IgH

rearrangement, with a sensitivity up to 10

6

[3,4,5,25].

Shortcomings of this approach include the time-consuming

procedure,

generation

of

individual

patient-speci

c

primers, and a success rate of

<

75%. Owing to

pretreat-ment with induction chemotherapy, we were able to

generate patient-speci

c primers in only 45% of our patients.

To overcome this limitation, we used a highly sensitive

plasma cell chimerism with a sensitivity of 10

5

, which has

the advantage of being less time-consuming

[20]. Among the

disadvantages of this approach are the low speci

city and its

applicability only after allo-SCT. Whereas complete donor

plasma cell chimerism is closely correlated with speci

city of

patient-speci

c primers, in cases of mixed plasma cell

chimerism, this method does not allow differentiation

between residual healthy and malignant plasma cells. Other

investigators have used multicolor

ow cytometry to detect

MRD, which is readily applicable but has a lower sensitivity,

w

10

4

, compared with molecular methods

[32,33].

No clear characteristics were identi

ed in those patients

who achieved sustained mCR. Interestingly, long-lasting

mCR was seen in patients harboring del 17p13 or t(4;14)

Figure 3.OS (A) and PFS (B) after autoeallo tandem SCT according to

achievement of mCR.

Figure 4.Cumulative incidence of relapse after autoeallo tandem SCT according to achievement of mCR.

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and in patients who were refractory at time of

trans-plantation (Table 4).

Patients with del 17p and/or t(4;14) and those without

these high-risk cytogenetic features had similar rates of mCR

and relapse, as well as similar PFS, suggesting that these

negative prognostic factors may be overcome by an upfront

auto

e

allo tandem SCT approach. Previous studies in patients

with more advanced disease have shown a negative impact

of del 17p, but not of t(4;14), after allo-SCT

[34,35]. More

recently, the Société Française de Greffe de Moelle et de

Thérapie Cellulaire reported no difference in outcomes

between patients with or without del 17p and/or t(4;14) after

allo-SCT

[36]. Interestingly, no difference in outcomes was

seen between recipients of HLA-identical sibling grafts and

recipients of unrelated donor grafts, which is important

because unrelated SCT as part of an auto

e

allo tandem

approach has been reported only rarely

[37].

Of note, 5 of 15 patients who received DLI because of

persistent disease achieved sustained mCR. This

nding

supports strategies to target mCR by posttransplantation

therapies for those who did not achieve mCR from the

transplantation

itself.

To

improve

results,

post-transplantation strategies including, for instance, DLI or

novel immunomodulating drugs, such as thalidomide,

lena-lidomide, and bortezomib, can be used to upgrade CR to

mCR, as reported recently

[38,39]. The present study

underscores the importance of the depth of remission and

demonstrates that achievement of mCR is associated with

long-term freedom from disease and potential cure of MM

and, even more important, that this can be achieved in

patients with high-risk cytogenetics, de

ned by del 17p and/

or t(4;14).

ACKNOWLEDGMENTS

Financial disclosure:

The authors have nothing to disclose.

Authorship statement:

Nicolaus Kröger designed the study,

analyzed data, and wrote the manuscript. Anita Badbaran,

Sabine Schwarz and Silke Zeschke performed ASO primer

and plasma cell chimerism analyses. Tatjana Zabelina

per-formed statistical analysis. Francis Ayuk, Christine Wolschke,

Haefaa Alchalby, Evgeny Klyuchnikov, Djordje Atanackovic,

Thomas Stübig, Marion Heinzelmann, Ulrike Bacher, and

Axel R. Zander included patients into the study, evaluated

results, and wrote the manuscript. Georgia Schilling and

Timon Hansen performed FISH analyses. Boris Fehse

super-vised ASO primer and plasma cell chimerism analyses.

REFERENCES

1. Lahuerta JJ, Martinez-Lopez J, Serna JD, et al. Remission status defined by immunofixation vs. electrophoresis after autologous transplantation has a major impact on the outcome of multiple myeloma patients.Br J Haematol. 2000;109:438-446.

2. Martinez-Lopez J, Blade J, de la Rubia J, et al. Prognostic impact of posttransplantation complete remission in multiple myeloma:final results of a prospective study in a series of homogenously treated patients.Haematologica. 2007;92. abstract 42.

3. Corradini P, Voena C, Tarella C, et al. Molecular and clinical remissions in multiple myeloma: role of autologous and allogeneic transplantation of hematopoietic cells.J Clin Oncol. 1999;17:208-215.

4. Martinelli G, Terragna C, Zamagni E, et al. Molecular remission after allogeneic or autologous transplantation of hematopoietic stem cells for multiple myeloma.J Clin Oncol. 2000;18:2273-2281.

5. Corradini P, Cavo M, Lokhorst H, et al., Chronic Leukemia Working Party of the European Group for Blood and Marrow Transplantation (EBMT). Molecular remission after myeloablative allogeneic stem cell transplantation predicts a better relapse-free survival in patients with multiple myeloma.Blood. 2003;102:1927-1929.

6. Kröger N, Schwerdtfeger R, Kiehl M, et al. Autologous stem cell trans-plantation followed by dose-reduced allograft induces high complete remission rate in multiple myeloma.Blood. 2002;100:755-760. 7. Maloney DG, Molina AJ, Sahebi F, et al. Allografting with

non-myeloablative conditioning following cytoreductive autografts for the treatment of patients with multiple myeloma. Blood. 2003;102: 3447-3454.

8. Garban F, Attal M, Michallet M, et al. Prospective comparison of autologous stem cell transplantation followed by dose-reduced allo-graft (IFM99-03 trial) with tandem autologous stem cell trans-plantation (IFM99-04 trial) in high-risk de novo multiple myeloma.

Blood. 2006;107:3474-3480.

9. Bruno B, Rotta M, Patriarca F, et al. A comparison of allografting with autografting for newly diagnosed myeloma.N Engl J Med. 2007;356: 1110-1120.

10. Rosinol L, Perez-Simon JA, Sureda A, et al. A prospective PETHEMA study of tandem autologous transplantation versus autograft followed by reduced-intensity conditioning allogeneic transplantation in newly diagnosed multiple myeloma.Blood. 2008;112:3591-3593.

11. Gahrton G, Bjorkstrand B, Iacobelli S, et al. Tandem autologous (ASCT)/ allogeneic reduced-intensity conditioning transplantation (RIC) with identical sibling donor versus ASCT in previously untreated multiple

Table 4

Characteristics of Patients Who Achieved Sustained mCR

Type Sex Donor Cytogenetics (by FISH) Status after Induction

Status before Allo-SCT

GVHD after SCT DLI for MRD

Status at Follow-up IgG kappa Male MUD del 13q14, t(4;14) CR CR Ø Yes Relapse after 7 years; alive

9 yearsþ

Light chain/plasma cell leukemia

Female MUD del 13q14, t(14;16) PR PD Ø No Alive, mCR, 8 yearsþ

IgA kappa Male MUD del 13q14; del 17p13, t(4;14)

PR PR Chronic GVHD No Dead, chronic GVHD, 5 years in mCR

IgA lambda Female MUD t(4;14), del 13q14 PR PR Ø Yes Alive, mCR, 7 yearsþ

IgG kappa Male MUD del 13q14 PR PR Ø No Alive, mCR, 6.5 yearsþ

IgA lambdaþ

extramedullary

Male Related Not done PR PR Ø No Alive, mCR, 6.5 yearsþ

Light chain kappa Male MUD Normal PR PR Chronic GVHD No Alive, mCR 6 yearsþ

IgA lambda Female Related del17p13/ del 13q14 PR CR ChronicGVHD No Relapse after 3.5 years; alive 4.5 yearsþ

IgG lambdaþ

extramedullary

Male MUD Not done PR PR Ø Yes Alive, mCR, 9.5 yearsþ

IgG kappa Female MUD del 13q14 PR PR Ø No Alive, mCR, 4.5 yearsþ

IgG kappa Male Related Unknown PR PR Ø No Alive, mCR, 11.5 yearsþ

IgG kappa Male Related Normal PR PR Ø Yes Alive, mCR, 10.5 yearsþ

IgG kappa Male MUD Not done PR PR Chronic GVHD Yes Alive, mCR, 11yearsþ

IgG kappa Male Related del17p13 PR PR Acute GVHD grade II

No Alive, mCR, 4.5 yearsþ

Light chain kappa Male MUD del 13q14, del 17p13 PD PR Ø No Alive, mCR, 4.5 yearsþ

(7)

myeloma (MM): long-term follow-up of a prospective controlled trial by the EBMT.Blood. 2009;114. abstract 52.

12. Krishnan A, Pasquini MC, Ewell M, et al. Tandem autologous hemato-poietic stem cell transplants (AuHCT) with or without maintenance therapy (auto-auto) versus single AuHCT followed by HLA-matched sibling non-myeloablative allogeneic HCT (auto-allo) for patients with standard risk (SR) multiple myeloma (MM): results from the Blood and Marrow Transplant Clinical Trials Network (BMT CTN) 0102 Trial.Blood. 2010;116. abstract 41.

13. Björkstrand B, Iacobelli S, Hegenbart U, et al. Tandem autologous/ reduced-intensity conditioning allogeneic stem-cell transplantation versus autologous transplantation in myeloma: long-term follow-up.

J Clin Oncol. 2011;29:3016-3022.

14. Avet-Loiseau H, Leleu X, Roussel M, et al. Bortezomib plus dexameth-asone induction improves outcome of patients with t(4;14) myeloma but not outcome of patients with del(17p). J Clin Oncol. 2010;28: 4630-4634.

15. Avet-Loiseau H, Attal M, Campion L, et al. Long-term analysis of the IFM 99 trials for myeloma: cytogenetic abnormalities [t(4;14), del(17p), 1q gains] play a major role in defining long-term survival.J Clin Oncol. 2012;30:1949-1952.

16. Munshi NC, Anderson KC, Bergsagel PL, et al. Consensus recommen-dations for risk stratification in multiple myeloma: report of the International Myeloma Workshop Consensus Panel 2.Blood. 2011;117: 4696-4700.

17. Neben K, Lokhorst HM, Jauch A, et al. Administration of bortezomib before and after autologous stem cell transplantation improves outcome in multiple myeloma patients with deletion 17p.Blood. 2012; 119:940-948.

18. Bladé J, Samson D, Reece D, et al. Myeloma Subcommittee of the European Group for Blood and Marrow Transplant. Criteria for evalu-ating disease response and progression in patients with multiple myeloma treated by high-dose therapy and haemopoietic stem cell transplantation.Br J Haematol. 1998;102:1115-1123.

19. Tögel F, Kröger N, Korioth F, et al. Molecular methods for detection and quantification of myeloma cells after bone marrow transplantation: comparison between real-time quantitative and nested PCR.

J Hematother. 2002;11:971-976.

20. Kröger N, Zagrivnaja M, Schwartz S, et al. Kinetics of plasma-cell chimerism after allogeneic stem cell transplantation by highly sensi-tive real-time PCR based on sequence polymorphism and its value to quantify minimal residual disease in patients with multiple myeloma.

Exp Hematol. 2006;34:688-693.

21. Alizadeh M, Bernard M, Danic B, et al. Quantitative assessment of hematopoietic chimerism after bone marrow transplantation by real-time quantitative polymerase chain reaction. Blood. 2002;99: 4618-4625.

22. Fehse B, Chukhlovin A, Kühlcke K, et al. Real-time quantitative Y chromosome-specific PCR (QYCS-PCR) for monitoring hematopoietic chimerism after sex-mismatched allogeneic stem cell transplantation.

J Hematother Stem Cell Res. 2001;10:419-425.

23. Harousseau JL, Attal M, Avet-Loiseau H. The role of complete remission in multiple myeloma.Blood. 2009;114:3139-3146.

24. Hoering A, Crowley J, Shaughnessy JD Jr, et al. Complete remission in multiple myeloma examined as time-dependent variable in terms of both onset and duration in Total Therapy protocols.Blood. 2009;114: 1299-1305.

25. Ladetto M, Pagliano G, Ferrero S, et al. Major tumor shrinking and persistent molecular remissions after consolidation with bortezomib, thalidomide, and dexamethasone in patients with autografted myeloma.J Clin Oncol. 2010;28:2077-2084.

26. Gahrton G, Tura S, Ljungman P, et al. Allogeneic bone marrow transplantation in multiple myeloma. N Engl J Med. 1991;325: 1267-1273.

27. Gahrton G, Svenssin H, Cavo M, et al. Progress in allogeneic bone marrow and peripheral blood stem cell transplantation for multiple myeloma: a comparison between transplants performed in 1983-93 and 1994-98 at European Group for Blood and Marrow Transplantation centres.Br J Haematol. 2001;113:209-216.

28. Moreau P, Garban F, Attal M, et al. Long-term follow-up results of IFM99-03 and IFM99-04 trials comparing nonmyeloablative allo-transplantation with autologous allo-transplantation in high-risk de novo multiple myeloma.Blood. 2008;112:3914-3915.

29. Galimberti S, Benedetti E, Morabito F, et al. Prognostic role of minimal residual disease in multiple myeloma patients after non-myeloablative allogeneic transplantation.Leuk Res. 2005;29:961-966.

30. Durie BG, Harousseau JL, Miguel JS, et al. International uniform response criteria for multiple myeloma.Leukemia. 2006;20:1467-1473. 31. Kröger N, Asenova S, Gerritzen A, et al. Questionable role of free light chain assay ratio to determine stringent complete remission in multiple myeloma patients.Blood. 2010;115:3413-3414.

32. Pavia B, Martinez-Lopez J, Vidirales MB, et al. Comparison of immu-nofixation, serum free light chain, and immunophenotyping for response evaluation and prognostication in multiple myeloma.J Clin Oncol. 2011;29:1627-1633.

33. Lioznov M, Badbaran A, Fehse B, et al. Monitoring of minimal residual disease in multiple myeloma after allo-SCT:flow cytometry vs. PCR-based techniques.Bone Marrow Transplant. 2008;41:913-916. 34. Schilling G, Hansen T, Shimoni A, et al. Impact of genetic abnormalities

on survival after allogeneic hematopoietic stem cell transplantation in multiple myeloma.Leukemia. 2008;22:1250-1255.

35. Kröger N, Schilling G, Einsele H, et al. Deletion of chromosome band 13q14 as detected by fluorescence in situ hybridization is a prognostic factor in patients with multiple myeloma who are receiving allogeneic dose-reduced stem cell transplantation. Blood. 2004;103:4056-4061.

36. Roos-Weil D, Moreau P, Avet-Loiseau H, et al. Impact of genetic abnormalities after allogeneic stem cell transplantation in multiple myeloma: a report of the Société Française de Greffe de Moelle et de Thérapie Cellulaire.Haematologica. 2011;96:1504-1511.

37. Kröger N, Sayer HG, Schwerdtfeger R, et al. Unrelated stem cell transplantation in multiple myeloma after reduced-intensity condi-tioning with pre-transplantation antithymocyte globulin is highly effective with low transplantation-related mortality.Blood. 2002;100: 3919-3924.

38. Kröger N, Badbaran A, Lioznov M, et al. Post-transplant immuno-therapy with donor-lymphocyte infusions and novel agents to upgrade partial into complete and molecular remission in allografted patients with multiple myeloma.Exp Hematol. 2009;37: 791-798.

39. Kröger N, Shimoni A, Zagrivnaja M, et al. Low-dose thalidomide and donor lymphocyte infusion as adoptive immunotherapy after alloge-neic stem cell transplantation in patients with multiple myeloma.

ClinicalTrials.gov http://dx.doi.org/10.1016/j.bbmt.2012.10.008Biol Blood Marrow Transplant 19 (2013) 398 (http://www.imgt. (http://www.ncbi.nlm.nih.gov/igblast/

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