Outcomes of stem cell boost (SCB) versus supportive care alone for prolonged cytopenias after chimeric antigen receptor T cell therapy (CAR-T) in relapsed/refractory multiple myeloma (RRMM): A muli-center real-world analysis Free

Background: Prolonged cytopenias are a well-recognized complication following CAR-T therapy, leading to increased morbidity and healthcare utilization. Autologous SCB offers a potential strategy to promote hematologic recovery. We conducted a retrospective multi-institutional analysis across 18 centers comparing outcomes of SCB versus supportive care alone in RRMM patients who experienced prolonged cytopenias >30 days after CAR-T infusion.

Methods: Patients were included if they received SCB within 1 year after commercial CAR-T between 6/2021 and 3/2024. To identify matched controls, we reviewed other CAR-T recipients from the same consortium and selected those with an absolute neutrophil count (ANC) of <0.72x10⁹/L and platelet count of <21K at day 30 post-infusion-thresholds representing the 75^th percentile of cytopenia severity in the SCB cohort. These criteria ensured control patients had comparable hematologic toxicity but without SCB. Hematologic recovery in the SCB cohort was assessed using the CIBMTR engraftment criteria. For the non-SCB (nSCB) group, cell counts were analyzed cross-sectionally at day 90 post-CAR-T and compared to the SCB cohort with Kruskal Wallis tests. Progression-free survival (PFS) and overall survival (OS) were evaluated using Kaplan Meier methods.

Results: Of the 590 CAR-T recipients, 91 patients (15.4%) developed prolonged cytopenias; 39 patients received SCB and 52 did not. SCB patients more frequently had ISS stage III disease (23.1% vs. 11.5%), exrtamedullary disease (59% vs. 46.2%) and penta-refractory status (43.6% vs. 34.6%). The median number of prior lines of therapy was 6 in both cohorts. Thirteen patients (33.3%) in the SCB and 11 (21.2%) in the nSCB received high intensity infusional chemotherapy (DCEP/PACE/HyperCVAD). Pre-CAR-T cytopenias tended to be less frequent in the SCB vs. nSCB cohort: ANC <1000 in 5.1% vs. 13.5%, Hgb <8 in 23.1% vs. 21.2%, and platelets <50K in 28.2% vs. 40.4%. Median plasmacytosis in the bone marrow prior to CAR-T in the SCB group was 35% and 47.5% in the nSCB group. In the SCB cohort, 2 patients harbored DNMT3A mutations, one of whom had CCUS. Ide-cel was administered in 64.8% and cilta-cel in 35.2% of all patients. The rates and grades of cytokine release syndrome did not differ between groups. Six patients (15.4%) had HLH in the SCB group vs. none in the control group. All (100%) SCB patients received growth factor support; 58% also received TPO agonists. In the nSCB group, 43 patients (82.7%) received growth factor, and 16 patients (30.8%) received TPO agonists. Out of 24 pre-SCB bone marrow biopsies available, only 1 patient had relapsed MM while the remainder had hypocellular marrows. Median CD34+ cell dose was 2.93 million/kg (range: 1.76-23.55) administered at a median of 53 days post-CAR-T (range 24-265). All but one patient (97.4%) in the SCB group achieved hematologic recovery; median time to recovery was 24 days (range 9-87). No new toxicities attributable to SCB were observed. On day 90 post CAR-T infusion, SCB patients had higher median ANC (2.12 vs. 1.59x10⁹/L, p=0.277), Hgb (10.6 vs. 8.7g/dL, p=0.002), and platelet counts (135 vs. 35K/L (p<0.001). Minimal residual disease negativity was achieved in 82.4% (SCB) vs. 83.3% (nSCB). Infections occured in 53.8% and 48.1% of SCB and nSCB cohorts. All serious infections occurred prior to SCB. There were 12 deaths in the SCB group (7 from disease progression, 2 from infection, 1 from neurotoxicity (NT), and 1 unknown) and 27 in the nSCB group (22 from progression, 3 from infection, 1 from HLH, 1 from NT). After a median follow-up period of 12.6 months in the SCB cohort and 11.6 months in the nSCB arm, the mPFS was 11.0 months and 8.2 months, respectively. The mPFS was 10.6 months (SCB) and 5.8 months (nSCB) (p=0.216), and 11.0 months (SCB) and 10.9 months (nSCB), for ide-cel and cilta-cel treated-patients, respectively. Median OS was not reached vs.12.3 months in the SCB vs. nSCB groups, respectively.

Conclusion: Overall, SCB was safe and effective in promoting rapid hematologic recovery in nearly all patients. Compared to controls, SCB recipeints had significantly higher Hgb and platelet levels by day 90 post-CAR-T infusion. SCB was associated wih a near doubling of PFS in patients who received ide-cel, though interpretation is limited by non-randomized design and small sample size. Further study is needed to optimize paient selection, timing, and integration of SCB into CAR-T care.