A 64-year-old man with a history of multiple myeloma presents with new back pain. He has a history of International Staging System stage 1, IgG kappa multiple myeloma with normal cytogenetics that was diagnosed 4 years ago when he presented with a pathological fracture of the left humerus. He was initially managed with mechanical stabilization and four cycles of bortezomib-dexamethasone, as well as 2 years of bisphosphanates. Following induction therapy, he achieved a very good partial response. He subsequently received high-dose melphalan and autologous stem-cell transplantation (auto-SCT) and achieved a complete response post-transplant. He did not receive maintenance therapy and had been lost-to follow-up for about a year. He now presents 5 years after initial diagnosis with back pain and is noted to have a new lytic lesion with a compression fracture at T8. A serum protein electrophoresis demonstrates reappearance of his original monoclonal protein. After appropriate stabilization, he comes to you to discuss additional treatment options.

Treatment of relapsed multiple myeloma depends upon a number of different patient- and disease-related factors. These include duration of first response, exposure to treatment options, age, performance status, and toxicity associated with previous treatments. More recently, the emergence of novel agent-based therapies has significantly changed the clinical outcome for patients with myeloma at all phases of the disease. It is estimated that the use of agents such as thalidomide, lenalidomide, and bortezomib have improved the overall median overall survival by 50%.1  While these agents and auto-SCT have clearly improved response rates, their use in the induction therapy setting has created a new set of challenges: how to best manage patients who relapse after having already been exposed to two or three of these agents during their initial therapy. In this review, we discuss an evidence-based strategy for treatment of patients with relapsed or refractory myeloma who have already been treated with novel agents and auto-SCT.

We performed three separate literature searches for this review. In studying auto-HCT as a salvage therapy, we queried the PubMed database for all combinations of the terms “transplant” (or “transplantation”), “myeloma,” “second,” “salvage,” and “relapsed,” limited to studies published in English. This search yielded eight results, and two additional studies were found in the reference sections of the aforementioned eight articles. Of these, four studies were excluded because they were performed before the era of novel therapeutics. For Table 1 we searched the PubMed database using the terms “myeloma” and “relapsed,” with the limitation of “clinical trial,” “human” and “English.” This yielded 127 hits, of which 34 studies did not included adequate number of patients with previous exposure to novel agents, 15 studies had equivocal results, 36 studies were not relevant for our clinical question, 10 studies were not relevant to our patient population, and four studies were updates. This yielded 43 results. In studying early-phase novel therapeutics (Table 2), we performed a search of the most recent oral presentations at the annual American Society of Hematology and American Society of Oncology meetings. We then cross-referenced the cited agents in a search with “myeloma” and “relapsed” in PubMed. This yielded 11 results.

Table 1.

Overview of combination regimens in relapsed/refractory myelooma patients with previous exposure to novel agents with or without auto-SCT

Overview of combination regimens in relapsed/refractory myelooma patients with previous exposure to novel agents with or without auto-SCT
Overview of combination regimens in relapsed/refractory myelooma patients with previous exposure to novel agents with or without auto-SCT

*Overall response rate = complete response + very good partial response + partial response unless otherwise noted.

Table 2.

Early trial results of novel agents in relapsed/ refractory myeloma

Early trial results of novel agents in relapsed/ refractory myeloma
Early trial results of novel agents in relapsed/ refractory myeloma

*Overall response rate = complete response + very good partial response + partial response; MR, minimal response.

In the patient who achieved a complete response after auto-SCT and maintained a disease-free interval of approximately 3 years, one could consider another auto-SCT. Available data on second autologous transplants for relapsed patients suggests that these procedures are relatively well-tolerated, with a 100-d mortality of 2% to 8%.2–5  The more recent studies of second, salvage transplants include a sizeable proportion of patients who have received thalidomide, lenalidomide, or bortezomib in the induction setting. The overall response rates in studies done in the past 5 years range from 55% to 69%.2,3,5,6  Because of the limited number of patients in each of these studies, it has been difficult to determine the most important factors in selecting ideal candidates for a salvage auto-SCT. However, one small study suggests that a relapse-free survival of more than 18 months after the first auto-SCT is the most reliable predictor of clinical outcome after a second auto-SCT.7  Although there are no official guidelines, the general consensus is that a salvage transplant with the intent of inducing long-term remission should be offered only to those patients who had a durable response for at least 18 to 24 months after their first auto-SCT.

The role of allogeneic SCT (allo-SCT) in relapsed disease is thus far limited. Patients undergoing allo-SCT as a salvage treatment demonstrate a long-term disease-free survival of 10% to 20%, with a significant portion of patients experiencing treatment-related morbidities, including chronic graft-versus-host disease.8,9  In addition, patients with high-risk disease do not appear to benefit from this treatment, even in the up-front setting.10  Finally, the prospective data for salvage allo-SCT in the era of novel therapeutics is scant. Therefore, the use of allo-SCT for patients with relapsed myeloma is not recommended as a standard salvage approach.

When deciding which agents to use in the relapsed/refractory setting, exposure to previous therapy is an important consideration. Among patients who received bortezomib-based induction, the use of immunomodulatory-based therapy in early relapse makes logical sense; the reverse is true for a patient who received an immunomodulatory-based induction.11–16  In addition, updated analyses from the MM-009 and MM-010 studies (lenalidomide-dexamethasone vs. dexamethasone) suggest that the benefit of lenalidomide was maintained despite prior exposure to auto-SCT or thalidomide.17,18  Similarly, a subgroup analysis from the APEX trial (bortezomib vs. dexamethasone) confirmed that bortezomib was better than dexamethasone regardless of prior treatment with thalidomide or auto-SCT.19 

In addition to the activity of novel agents delivered either alone or in combination with steroids, there is emerging data suggesting that combinations of novel agents—either with each other or with cytotoxic chemotherapy—may offer the best chance of response in relapsed/refractory patients. Examples of successful combinations include bortezomib-lenalidomide,20  bortezomib-thalidomide,21  bortezomib or lenalidomide with pegylated liposomal doxorubicin,22–24  bortezomib or lenalidomide with cyclophosphamide,25–28  and bortezomib or lenalidomide with melphalan.29–33  In particular, dedicated subgroup analyses performed in the DOXIL-MMY-3001 study (bortezomib-pegylated liposomal doxorubicin vs. bortezomib) showed a benefit in the combination arm regardless of prior auto-SCT34  or prior immunomodulatory exposure.23  As detailed in Table 1, each of the above combinations has yielded promising results in the relapsed/refractory patient population. These studies are notable because they include patients who, like our patient, had been previously treated with both a novel agent (thalidomide, lenalidomide, or bortezomib) and auto-SCT.

In addition to combinations of established anti-myeloma agents, a host of novel agents have recently been studied in the relapsed/refractory setting. Among the most promising are histone deacetylase inhibitors, carfilzomib, pomalidomide, and elotuzumab (Table 2). Although the data for most of these drugs are from phase I or II clinical trials, many of the included patients are similar to our patient, with a prior exposure to thalidomide, lenalidomide, or bortezomib and/or auto-SCT. The importance of these agents (and their necessary clinical trials) cannot be underscored enough; many of us are utilizing our current “novel” agents much earlier and in combination with each other. As patients live longer, we will have greater opportunity and need for the incorporation of these newer agents in the post-transplant setting.

Based on available phase III data, our recommendation for the patient described above would be salvage treatment with lenalidomide-dexamethasone (Grade 1B). Both the MM-009 and MM-010 trials included patients who had previously been treated with bortezomib.12,13  Additionally, given the long duration of response following bortezomib and auto-SCT, it would be reasonable to use bortezomib with or without dexamethasone as salvage therapy (Grade 2B).53  If the patient could achieve a partial response and had a good performance status, he would be considered for a second, salvage auto-SCT. He would most likely receive lenalidomide maintenance therapy post-transplant, although this would depend on his clinical course and his post-transplant response. If at all possible, a clinical trial should be considered at each of these steps (salvage treatment, salvage transplant conditioning regimen, and post-transplant maintenance), because phase III data are still lacking for most of the combinations detailed above.

Conflict-of-interest disclosure: SL has been a consultant to Millennium, Celgene, and Novartis, and has received research funding from the same sources.

Off-label drug use: Use of experimental agents in the treatment of relapsed myeloma.

Nina Shah, MD, Department of Stem Cell Transplantation and Cellular Therapy, The University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Blvd., Unit 0423, Houston, TX 77030; Phone: (713) 794-5745; Fax: (713) 794-4902; e-mail: nshah@mdanderson.org

1
Kumar
SK
Rajkumar
SV
Dispenzieri
A
et al
Improved survival in multiple myeloma and the impact of novel therapies
Blood
2008
111
2516
2520
2
Burzynski
JA
Toro
JJ
Patel
RC
et al
Toxicity of a second autologous peripheral blood stem cell transplant in patients with relapsed or recurrent multiple myeloma
Leuk Lymphoma
2009
50
1442
1447
3
Elice
F
Raimondi
R
Tosetto
A
et al
Prolonged overall survival with second on-demand autologous transplant in multiple myeloma
Am J Hematol
2006
81
426
431
4
Krivanova
A
Hajek
R
Krejci
M
et al
Second autologous transplantation for multiple myeloma patients relapsing after the first autograft – a pilot study for the evaluation of experimental maintenance therapies. Report of the prospective non-randomized pilot study of the Czech Myeloma Group
Onkologie
2004
27
275
279
5
Olin
RL
Vogl
DT
Porter
DL
et al
Second auto-SCT is safe and effective salvage therapy for relapsed multiple myeloma
Bone Marrow Transplant
2009
43
417
422
6
Qazilbash
MH
Saliba
R
De Lima
M
et al
Second autologous or allogeneic transplantation after the failure of first autograft in patients with multiple myeloma
Cancer
2006
106
1084
1089
7
Alvares
CL
Davies
FE
Horton
C
Patel
G
Powles
R
Morgan
GJ
The role of second autografts in the management of myeloma at first relapse
Haematologica
2006
91
141
142
8
Gahrton
G
Tura
S
Ljungman
P
et al
Prognostic factors in allogeneic bone marrow transplantation for multiple myeloma
J Clin Oncol
1995
13
1312
1322
9
Kroger
N
Perez-Simon
JA
Myint
H
et al
Relapse to prior autograft and chronic graft-versus-host disease are the strongest prognostic factors for outcome of melphalan/fludarabine-based dose-reduced allogeneic stem cell transplantation in patients with multiple myeloma
Biol Blood Marrow Transplant
2004
10
698
708
10
Garban
F
Attal
M
Michallet
M
et al
Prospective comparison of autologous stem cell transplantation followed by dose-reduced allograft (IFM99–03 trial) with tandem autologous stem cell transplantation (IFM99–04 trial) in high-risk de novo multiple myeloma
Blood
2006
107
3474
3480
11
Richardson
PG
Blood
E
Mitsiades
CS
et al
A randomized phase 2 study of lenalidomide therapy for patients with relapsed or relapsed and refractory multiple myeloma
Blood
2006
108
3458
3464
12
Weber
DM
Chen
C
Niesvizky
R
et al
Lenalidomide plus dexamethasone for relapsed multiple myeloma in North America
N Engl J Med
2007
357
2133
2142
13
Dimopoulos
M
Spencer
A
Attal
M
et al
Lenalidomide plus dexamethasone for relapsed or refractory multiple myeloma
N Engl J Med
2007
357
2123
2132
14
Richardson
PG
Barlogie
B
Berenson
J
et al
A phase 2 study of bortezomib in relapsed, refractory myeloma
N Engl J Med
2003
348
2609
2617
15
Mikhael
JR
Belch
AR
Prince
HM
et al
High response rate to bortezomib with or without dexamethasone in patients with relapsed or refractory multiple myeloma: results of a global phase 3b expanded access program
Br J Haematol
2009
144
169
175
16
Jagannath
S
Barlogie
B
Berenson
J
et al
A phase 2 study of two doses of bortezomib in relapsed or refractory myeloma
Br J Haematol
2004
127
165
172
17
Weber
D
Knight
R
Chen
C
et al
Prolonged overall survival with lenalidomide plus dexamethasone compared with dexamethasone alone in patients with relapsed or refractory multiple myeloma [Abstract]
Blood
2007
110
412
18
Wang
M
Dimopoulos
MA
Chen
C
et al
Lenalidomide plus dexamethasone is more effective than dexamethasone alone in patients with relapsed or refractory multiple myeloma regardless of prior thalidomide exposure
Blood
2008
112
4445
4451
19
Vogl
DT
Stadtmauer
EA
Richardson
PG
et al
Impact of prior therapies on the relative efficacy of bortezomib compared with dexamethasone in patients with relapsed/refractory multiple myeloma
Br J Haematol
2009
11
147
4
531
534
20
Richardson
PG
Weller
E
Jagannath
S
et al
Multicenter, phase I, dose-escalation trial of lenalidomide plus bortezomib for relapsed and relapsed/refractory multiple myeloma
J Clin Oncol
2009
12
1
27
34
5713
5719
21
Ciolli
S
Leoni
F
Gigli
F
Rigacci
L
Bosi
A
Low dose Velcade, thalidomide and dexamethasone (LD-VTD): an effective regimen for relapsed and refractory multiple myeloma patients
Leuk Lymphoma
2006
47
171
173
22
Orlowski
RZ
Nagler
A
Sonneveld
P
et al
Randomized phase III study of pegylated liposomal doxorubicin plus bortezomib compared with bortezomib alone in relapsed or refractory multiple myeloma: combination therapy improves time to progression
J Clin Oncol
2007
25
3892
3901
23
Sonneveld
P
Hajek
R
Nagler
A
et al
Combined pegylated liposomal doxorubicin and bortezomib is highly effective in patients with recurrent or refractory multiple myeloma who received prior thalidomide/lenalidomide therapy
Cancer
2008
112
1529
1537
24
Baz
R
Walker
E
Karam
MA
et al
Lenalidomide and pegylated liposomal doxorubicin-based chemotherapy for relapsed or refractory multiple myeloma: safety and efficacy
Ann Oncol
2006
17
1766
1771
25
Kim
YK
Sohn
SK
Lee
JH
et al
Clinical efficacy of a bortezomib, cyclophosphamide, thalidomide, and dexamethasone (Vel-CTD) regimen in patients with relapsed or refractory multiple myeloma: a phase II study
Ann Hematol
2010
5
89
5
475
482
26
Schey
SA
Morgan
GJ
Ramasamy
K
et al
The addition of cyclophosphamide to lenalidomide and dexamethasone in multiply relapsed/refractory myeloma patients; a phase I/II study
Br J Haematol
2010
8
150
3
326
333
27
Reece
DE
Rodriguez
GP
Chen
C
et al
Phase I-II trial of bortezomib plus oral cyclophosphamide and prednisone in relapsed and refractory multiple myeloma
J Clin Oncol
2008
26
4777
4783
28
Kropff
M
Bisping
G
Schuck
E
et al
Bortezomib in combination with intermediate-dose dexamethasone and continuous low-dose oral cyclophosphamide for relapsed multiple myeloma
Br J Haematol
2007
138
330
337
29
Popat
R
Oakervee
H
Williams
C
et al
Bortezomib, low-dose intravenous melphalan, and dexamethasone for patients with relapsed multiple myeloma
Br J Haematol
2009
144
887
894
30
Palumbo
A
Larocca
A
Falco
P
et al
Lenalidomide, melphalan, prednisone and thalidomide (RMPT) for relapsed/refractory multiple myeloma
Leukemia
2010
5
24
5
1037
1042
31
Terpos
E
Kastritis
E
Roussou
M
et al
The combination of bortezomib, melphalan, dexamethasone and intermittent thalidomide is an effective regimen for relapsed/refractory myeloma and is associated with improvement of abnormal bone metabolism and angiogenesis
Leukemia
2008
22
2247
2256
32
Berenson
JR
Yang
HH
Vescio
RA
et al
Safety and efficacy of bortezomib and melphalan combination in patients with relapsed or refractory multiple myeloma: updated results of a phase 1/2 study after longer follow-up
Ann Hematol
2008
87
623
631
33
Palumbo
A
Ambrosini
MT
Benevolo
G
et al
Bortezomib, melphalan, prednisone, and thalidomide for relapsed multiple myeloma
Blood
2007
109
2767
2772
34
Nagler
A
Hajek
R
Sonneveld
P
et al
Doxil + velcade in previously treated myeloma with prior SCT [Abstract]
Haematologica
2007
92
Suppl 2
PO-625
35
Gozzetti
A
Fabbri
A
Oliva
S
et al
Weekly bortezomib, pegylated liposomal doxorubicin, and dexamethasone is a safe and effective therapy for elderly patients with relapsed/refractory multiple myeloma
Clin Lymphoma Myeloma Leuk
2010
2
10
1
68
72
36
Chanan-Khan
A
Miller
KC
Musial
L
et al
Bortezomib in combination with pegylated liposomal doxorubicin and thalidomide is an effective steroid independent salvage regimen for patients with relapsed or refractory multiple myeloma: results of a phase II clinical trial
Leuk Lymphoma
2009
50
1096
1101
37
Ciolli
S
Leoni
F
Casini
C
Breschi
C
Santini
V
Bosi
A
The addition of liposomal doxorubicin to bortezomib, thalidomide and dexamethasone significantly improves clinical outcome of advanced multiple myeloma
Br J Haematol
2008
141
814
819
38
Mele
G
Giannotta
A
Pinna
S
et al
Frail elderly patients with relapsed-refractory multiple myeloma: efficacy and toxicity profile of the combination of bortezomib, high-dose dexamethasone, and low-dose oral cyclophosphamide
Leuk Lymphoma
2010
5
51
5
937
940
39
Knop
S
Gerecke
C
Liebisch
P
et al
Lenalidomide, adriamycin, and dexamethasone (RAD) in patients with relapsed and refractory multiple myeloma: a report from the German Myeloma Study Group DSMM (Deutsche Studiengruppe Multiples Myelom)
Blood
2009
113
4137
4143
40
Palumbo
A
Gay
F
Bringhen
S
et al
Bortezomib, doxorubicin and dexamethasone in advanced multiple myeloma
Ann Oncol
2008
19
1160
1165
41
Lee
SS
Suh
C
Kim
BS
et al
Bortezomib, doxorubicin, and dexamethasone combination therapy followed by thalidomide and dexamethasone consolidation as a salvage treatment for relapsed or refractory multiple myeloma: analysis of efficacy and safety
Ann Hematol
2010
9
89
9
905
912
42
Badros
A
Burger
AM
Philip
S
et al
Phase I study of vorinostat in combination with bortezomib for relapsed and refractory multiple myeloma
Clin Cancer Res
2009
15
5250
5257
43
Mazumder
A
Vesole
DH
Jagannath
S
Vorinostat plus bortezomib for the treatment of relapsed/refractory multiple myeloma: a case series illustrating utility in clinical practice
Clin Lymphoma Myeloma Leuk
2010
4
1
10
2
149
151
44
Richardson
P
Mitsiades
C
Colson
K
et al
Phase I trial of oral vorinostat (suberoylanilide hydroxamic acid, SAHA) in patients with advanced multiple myeloma
Leuk Lymphoma
2008
49
502
507
45
Richardson
P
Weber
D
Mitsiades
C
et al
Phase I study of combined vorinostat (V), lenalidomide (L), and dexamethasone (D) in patients (pts) with relapsed or refractory multiple myeloma (MM) [Abstract]
Presented at the American Society of Clinical Oncology (ASCO) Annual Meeting
June 4–10, 2010
Chicago, Illinois, USA
46
San-Miguel
J
Sezer
O
Siegel
D
et al
Phase Ib study of oral panobinostat (LBH589) plus intravenous bortezomib in patients (Pts) with relapsed (Rel) or Rel and refractory (Ref) multiple myeloma (MM) [Abstract]
Presented at the American Society of Clinical Oncology (ASCO) Annual Meeting
June 4–10, 2010
Chicago, Illinois, USA
47
Mateos
M
Spencer
A
Taylor
K
et al
Phase Ib study of oral panobinostat (LBH589) plus lenalidomide (LEN) plus dexamethasone (DEX) in patients (Pts) with relapsed (Rel) or Rel and refractory (Ref) multiple myeloma (MM) [Abstract]
Presented at the American Society of Clinical Oncology (ASCO) Annual Meeting
June 4–10, 2010
Chicago, Illinois, USA
48
Vij
R
Siegel
D
Kaufman
J
et al
Results of an ongoing open-label, phase II study of carfilzomib in patients with relapsed and/or refractory multiple myeloma (R/R MM) [Abstract]
Presented at the American Society of Clinical Oncology (ASCO) Annual Meeting
June 4–10, 2010
Chicago, Illinois, USA
49
Lacy
MQ
Hayman
SR
Gertz
MA
et al
Pomalidomide (CC4047) plus low-dose dexamethasone as therapy for relapsed multiple myeloma
J Clin Oncol
2009
27
5008
5014
50
Lacy
M
Gertz
M
Hayman
S
et al
Activity of pomalidomide plus dexamethasone (Pom/dex) in dual lenalidomide/bortezomib refractory multiple myeloma (MM) [Abstract]
Presented at the American Society of Clinical Oncology (ASCO) Annual Meeting
June 4–10, 2010
Chicago, Illinois, USA
51
Jakubowiak
A
Benson
D
Jr.
Bensinger
W
et al
Elotuzumab in combination with bortezomib in patients with relapsed/refractory multiple myeloma: A phase I study [Abstract]
Presented at the American Society of Clinical Oncology (ASCO) Annual Meeting
June 4–10, 2010
Chicago, Illinois, USA
52
Lonial
S
Vij
R
Harousseau
J
et al
Elotuzumab in combination with lenalidomide and low-dose dexamethasone in relapsed or refractory multiple myeloma: A phase I/II study [Abstract]
Presented at the American Society of Clinical Oncology (ASCO) Annual Meeting
June 4–10, 2010
Chicago, Illinois, USA
53
Sood
R
Carloss
H
Kerr
R
et al
Retreatment with bortezomib alone or in combination for patients with multiple myeloma following an initial response to bortezomib
Am J Hematol
2009
84
657
660