Myeloma: Thalidomide as salvage therapy for VAD-refractory multiple myeloma priorto autologous PBSCT

Several trials have shown the activity of thalidomide (THAL) in relapsed multiple myeloma (MM) patients failingPBSCT or conventional chemotherapy. PBSCT is considered standard treatment for most patients requiring therapy for MM; however, patients with VAD-resistant disease may not be able to receive PBSCT due to rapidly advancing disease. We reportfour cases of VAD-refractory MM salvaged with THAL + VAD followed by PBSCT. All patients underwent stem cell mobilization with cyclophosphamide (Cy) (4.5 g/m²) and GMCSF. Melphalan (140-200 mg/m²) was given as conditioning. All patients engrafted within 12-16 days after PBSCT. Day + 100 evaluation showed the following: very good partialresponse (n = 1) and complete response (n = 3). After a median follow-up to 153 days, two patients continue to take THALwith no signs of disease progression. One patient developed CHF and was taken off THAL while another patient has died ofprogressive disease while on THAL (MTD 50 mg). In conclusion, VAD-refractory patients were salvaged with the addition ofTHAL to VAD. They were subsequently able to undergo autologous PBSCT for MM, which will likely improve their overall survival. This suggests that THAL and other related immunomodulatory drugs may prove useful for initial MM therapy in combination with standard chemotherapy followed by PBSCT.