Dr. David Vesole, Co-Chief, Multiple Myeloma at John Theurer Cancer Center at HackensackUMC presentation at the MMRF Clinical Insights program in April 2012.

1. Management of Multiple
Myeloma:
Stem Cell Transplant
David
H.
Vesole,
MD,
PhD
Co-­‐Director,
Myeloma
Division
Director,
Myeloma
Research
John
Theurer
Cancer
Center
Hackensack
University
Medical
Center
Multiple Myeloma
Research Foundation
1 Powerful thinking advances the cure

2. Multiple Myeloma
Research Foundation
2 Powerful thinking advances the cure

3. Stem Cell Transplantation
• Myeloma and normal cells are killed by high-dose
chemotherapy (eg, melphalan)
• Stem cells are bone marrow-like cells harvested
from the peripheral blood
• Sources of stem cells:
– Autologous—cells collected from the patient
– Allogeneic—cells collected from a donor
• Related or unrelated donors: blood stem cells
or bone marrow
• Umbilical cord
3 Multiple Myeloma
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4. Rationale for Stem Cell Transplant in the
Treatment of MM
• HDC is more effective than conventional dose
chemotherapy against myeloma
– More is better
• Autologous or allogeneic (donor) stem cells can
restore (eg, rescue ) marrow function in
patients after high dose chemotherapy
• Allogeneic BM or PBSC can provide an
additional immune graft vs. myeloma effect
and eliminates graft contamination by myeloma
cells
• Offers opportunity for durable remissions
4 Multiple Myeloma
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5. Autologous Stem Cell Transplant
• Considered standard therapy worldwide
• Patients must have acceptable liver, renal, pulmonary,
and cardiac function to be eligible for ASCT
• High response rate (results confirmed the value of CR,
nCR, and VGPR on survival)
• No overt age limitation
• Low mortality (< 1%) (higher mortality in patients > 70
yrs; ~3%)
• No donor limitation
• Documented survival benefit
• Still not curative for most patients
• Double transplants are beneficial for some patients
5 Multiple Myeloma
Research Foundation
CR = complete response; nCR = near complete response; VGPR = very good partial response. Powerful thinking advances the cure
Bensinger, 2009; Kumar, 2009; NCCN, 2010.

6. Autologous Stem Cell Transplant
Mobilization
and Autologous High Autologous
Leukapheresis Stem Dose Stem
of Patient Cells Chemotherapy Cells
Stem Cells
Autologous
Cryopreservation Stem Thawing and
of Patient Stem Cells infusion of patient
Cells -190oC Freezer stem cells
6 Multiple Myeloma
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7. Multiple Myeloma
Research Foundation
7 Powerful thinking advances the cure

8. Stem Cell Collection
• Harvesting sufficient stem cells is necessary for engraftment
• Most centers collect sufficient cells for two transplants
• Stem cell mobilization options
– Growth factors
• Neupogen® (G-CSF), Neulasta®
• Mozobil®
– Chemotherapy
• Cytoxan (cyclophosphamide)
• Combination chemotherapy (DCEP, VDT-PACE, CDE)
• Bone marrow RARELY collected (except for donor transplant)
8 Multiple Myeloma
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9. Randomized Trial of Stem Cell Purging by
CD34 Selection of PBSC for Myeloma
9 Multiple Myeloma
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Stewart et al, 2001.

10. Autologous Stem Cell Transplant: Conventional
Chemotherapy vs High-Dose + ASCT
• Two large trials
• IFM 90: 200 patients
• MRC VII: 400 patients
• Both reported:
– Higher response rates, longer remission
duration, improved overall survival by 1-2 yrs
• Current trials show approximately 30% of
patients in continuous remission beyond 10 years
10 Multiple Myeloma
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11. Progression-Free and Overall Survival with novel
induction followed by transplant
Regimen PFS OS
Bort/Dex 55% 3y 81% 3y
VAD 45% 3y 77% 3y
Bort/Thal/Dex 70% 3y 86% 3y##
Thal/Dex 55% 3y 84% 3y##
Len/Dex -> Transplant 92% 3y nr
Len/Dex No Transplant* 79% 3y nr
11
## Tandem Tx + consolidation nr not randomized Multiple Myeloma
Research Foundation
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12. Impact of Response on Outcome:
OS After 1 or 2 Transplants
1.00
p = .0002 CR
VGPR
0.75
PR
0.50
< PR
0.25
Median FU
N = 849
0.00
0 1 2 3 4 5 6 7 8
12 Multiple Myeloma
Research Foundation
PR = partial response; FU = follow-up. Powerful thinking advances the cure
Harousseau et al, 2006.

13. 13 Multiple Myeloma
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14. Single Vs. Double Autografts for MM
• Attainment of a CR/nCR is important for
survival benefit
• Patients in CR/VGPR after 1 autograft do not
benefit from second autograft
– Confirmed in 2 trials
– Large US trial (BMT CTN 0702) re-
addressing one versus two transplants
• Only patients with PR/SD currently receiving a
14
second transplant (outside of a clinical trial)
SD = stable disease; CTN = Clinical Trials Network.
Multiple Myeloma
Research Foundation
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Bensinger, 2009.

15. First Randomized Trial in MM: 1962
• A controlled trial of
urethane treatment in
multiple myeloma.
• Randomized 83 patients
with treated or untreated
multiple myeloma to receive
urethane or a placebo
consisting of a cherry- and
cola-flavoured syrup.
• No difference was seen in
objective improvement or in
survival in the two
treatment groups. In fact,
the urethane-treated
15
patients died1966; 27: 328-342
Blood earlier Multiple Myeloma
Research Foundation
Blood. 1966;27:328-42 Powerful thinking advances the cure

16. 16 Multiple Myeloma
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17. 17 Multiple Myeloma
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18. Lenalidomide + Low- or High-Dose Dex
ECOG E4A03
Lenalidomide
High-Dose SCT or
Dexamethasone Continue
Newly 1:1
Off Study
1:1
(LD)
Diagnosed
Multiple
Myeloma Lenalidomide
N = 445 Low-Dose Continue On
Dexamethasone Study
(Ld)
Primary Endpoint
Lenalidomide:
25
mg
daily,
days
1-­‐21
in
a
28-­‐day
cycle
Response at 4 months
High-­‐dose
Dex:
40
mg,
d1-­‐4,
9-­‐12,
17-­‐20
(total
480
mg)
Low-­‐dose
Dex:
40
mg,
d1,
8,
15,
22
(total
160
mg)
Aspirin:
325
mg
18
Rajkumar SV, et al. Lancet Oncology, 11: 29 - 37, 2010 Multiple Myeloma
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19. Landmark Analysis
431 patients alive!
at 4 cycles!
Off therapy ! Primary therapy !
at 4 cycles! beyond 4 cycles!
N = 183! N = 248!
! !
No transplant! Transplant ! Rd! RD!
N = 93 ! N = 90 ! N = 140! N = 108!
(median age: 69)! (median age: 57)! (median age: 66)! (median age: 65)!
! !
19 Multiple Myeloma
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Rajkumar et al, 2010.

20. E4A03: OS According to Transplant or
No Further Treatment at 4 Cycles
E4A03: Primary Therapy Beyond 4 Cycles ASCT after 4 cycles LD or Ld
100 Ld 100 LD
Ld
Survival Probability
80 80
Survival Probability
LD
60 60
79% 92%
40 3-yr OS rate 40 3-yr OS rate
20 20
P=NS P=NS
0 0
0 6 12 18 24 30 36 0 6 12 18 24 30 36
Time (mo) Time (mo)
Response
≥ PR, % 91
CR (IF-, serum/urine), % 22
20 Multiple Myeloma
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CR + VGPR, % 56 Powerful thinking advances the cure

21. Outcomes in pts Age <65
Progression Free Survival Overall Survival
21 Multiple Myeloma
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22. Survival: ASCT vs Ld/LD
1-yr mortality
No Early SCT: Early SCT
Overall 0.94 (0.91, 0.96) 0.99 (0.97, 1.00)
Age <65 0.94 (0.90, 0.98) 0.99 (0.96, 1.00)
65≤ Age <70 0.96 (0.91, 1.00) 0.94 (0.83, 1.00)
Age ≥70 0.92 (0.88, 0.97) 1.00 (1.00, 1.00)
22 Multiple Myeloma
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Siegel et al Blood 2010 Powerful thinking advances the cure

23. Response, n (%) All pts (N=66) Phase II (N=35)
CR 19 (29) 13(37)
nCR 7 (11) 7 (20)
VGPR 18 (27) 6 (17)
PR 22 (33) 9 (26)
CR+nCR 26 (39) 20 (57)
(90% CI) (29, 50) (42, 71)
CR+nCR+VGPR 44 (67) 26 (74)
(90% CI) (56, 76) (59, 86)
At least PR 66 (100) 35 (100)
(90% CI) (96, 100) (92, 100)
• Response improvement seen in 42/56 pts (75%) from C4–8 and 20/38 pts (53%) beyond C8
• Median (range time to best overall response) was 2.1(0.6,20) mo
• 31 pts (47%) have proceeded to ASCT
23 Multiple Myeloma
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24. 24 Multiple Myeloma
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25. Upfront Regimens for Multiple Myeloma
Regimen
ORR
VGPR
CR
Reference
Len/Dex
91
56
22
Rajkumar
VRD
100
74
44
Richardson
VCD
91
60
39
Reeder
VTD
90
62
19
Cavo
VCRD
96
39
32
Kumar
Note:
some
of
these
are
a-er
induc3on
followed
by
transplant
and
others
maximal
response.
ORR=overall
response
rate.
VCD=bortezomib/cyclophosphamide/dexamethasone.
VGPR=very
good
par3al
response.
VTD=bortezomib/thalidomide/dexamethasone.
CR=complete
response.
VCRD=bortezomib/cyclophosphamide/lenalidomide/
25 VRD=bortezomib/lenalidomide/dexamethasone. dexamethasone.
Multiple Myeloma
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26. C:UsersDavidPicturesMy Pictures
London 2011IMG_1279.JPG
26 Multiple Myeloma
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27. BMT
CTN
0702
MEL
200
MEL 200 Lenalidomide
MEL
200
VRD x 4 Lenalidomide
MEL
200
Lenalidomide
27 Multiple Myeloma
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28. IFM/DFCI 2009 Study
Newly Diagnosed MM Pts (SCT candidates)
Randomize, stratification ISS & FISH
VRDx3 Induction VRDx3
CY (3g/m2)
MOBILIZATION CY (3g/m2)
Goal: 5 x106 cells/kg Collection MOBILIZATION
Goal: 5 x106 cells/kg
Melphalan
200mg/m2* +
VRD x 5
ASCT
Consolidation
VRD x 2
Lenalidomide 12 mos Maintenance Lenalidomide 12 mos
SCT at relapse
28
MEL 200 mg/m2 if <65 yrs , Multiple Myeloma
Research Foundation
>65 yrs 140mg/m2
Powerful thinking advances the cure

29. Role of ASCT in the Era of Novel
Therapies
• Up-front ASCT has been the treatment
of choice for eligible patients
• Addition of novel agents has improved
outcomes with ASCT
• Best CR/VGPR and PFS rates are
obtained with novel agents before and/
or after ASCT
29 Multiple Myeloma
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30. 30 Multiple Myeloma
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31. MAINTENANCE AFTER
TRANSPLANT THERAPY
31 Multiple Myeloma
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32. Why Maintenance Therapy?
• Can maintenance therapy:
– prevent or delay disease progression?
– convert partial responses to complete
responses?
– improve overall survival?
32 Multiple Myeloma
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33. Thalidomide as Post-transplantation Maintenance Therapy
• Thalidomide is effective as maintenance therapy
– Longer progression-free survival (PFS)
– Significant benefits only in patients with
– < 90% response at randomization
– No Chr 13 deletion
– Either β2M > 3 mg/L or < 3 mg/L
No Pamidronate
Response Pamidronate P Value
Maintenance + Thalidomide
CR or VGPR, % 55 57 67 0.001
3-year EFS, % 36 37 52 0.009
OS at 4-year, % 77 74 87 <0.04
Bone events, % 24 21 18 0.4
33 Multiple Myeloma
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Attal et al. Blood. 108:3289,

34. 34 Multiple Myeloma
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35. !
Lenalidomide Maintenance after Autologous Transplantation for Myeloma:!
Final analysis of a prospective randomized study of the Intergroupe
Francophone du Myélome!
(IFM 2005-02 trial) !
!
!
!
!
Michel Attal, Valerie Cances Lauwers , Gerald Marit, Denis Caillot, Thierry Facon, Cyrille Hulin, Philippe Moreau, ,
Claire Mathiot, Murielle Roussel, Catherine Payen, Hervé Avet-Loiseau, and Jean-Luc Harousseau for the IFM.!
A Phase III Randomized, Double-Blind Study of Maintenance Therapy With
Lenalidomide (CC 5013) or Placebo Following Autologous Stem Cell
Transplantation for Multiple Myeloma
CALGB 100104
35 Multiple Myeloma
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McCarthy et al Powerful thinking advances the cure

36. 36 Multiple Myeloma
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37. 37 Multiple Myeloma
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38. Efficacy Data from Newly Diagnosed
Multiple Myeloma Studies
Median PFS/TTP Disease
Lenalidomide Arm vs Progression
Control Risk Reduction
IFM 2005/021 42 vs 24 months 50%
(p<0.00000001)
CALGB 1001042 42 vs 22 months 61% (p<0.0001)
1. Attal et al. ASH 2010
2. McCarthy et al. ASH 2010
38 Multiple Myeloma
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39. ASH Data on Second Malignancies
IFM1 CALGB2
Revlimid Placebo Revlimid Placebo
N 307 307 231 229
Solid 6(2.0%) 1(0.3%) 10(4.3%) 5(2.2%)
Hematological 11(3.5%) 2(0.7%) 5(2.2%) 1(0.4%)
Total 17(5.5%) 3(1.0%) 15(6.5%) 6(2.6%)
• Among 845 ndMM patients treated with Revlimid there were 45 second
malignancies (5.4%), which is within the expected background incidence
• Among 689 ndMM patients treated with placebo there were 11 second
malignancies (1.6%), which is below the expected background incidence
1. Attal et al. ASH 2010
39
2. McCarthy et al. ASH 2010 Multiple Myeloma
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40. Maintenance and consolidation studies with bortezomib
in combination with thalidomide or prednisone
Median
Maintenance
Improvement
Induc3on
age,
y
(no.
dose,
dura3on
in
quality
of
EFS
or
PFS*
OS*
Tolerance
therapy
of
pa3ents)
of
treatment
response
(A)
CR/nCR
G3
and
G4
3-­‐y
PFS
3-­‐y
OS
50%
PNP
HOVON/ Bortezomib
1.3
GMMG:
mg/m2,
57
(N
=
Sonneveld
PAD
biweekly,
for
2
613)
et
al46
y;
thalidomide
≥
VGPR
65%
(A)
48%
(A)
78%
(A)
16%
(2010)
50
mg/d
for
2
y
(B)
CR/nCR
VAD
(B)
42%
(B)
71%
(B)
7%
38%
≥
VGPR
61%
P
=
.047
P
=
.048
40 Multiple Myeloma
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41. Summary of benefits and limitations of maintenance
therapy with novel drugs for clinical decision making
Impact
on
Level
of
evidence/
Dura3on
of
Quality
of
Drug
Dose/regimen
PFS
OS
Risk
groups
Tolerance
rade
of
Comments
therapy
response
recommenda3on
No
benefit
In
Poor
tolerance
FISH
defined
in
some
high-­‐risk
Yes,
(par3cularly
Up
to
1
y,†
no
pa3ents§
PNP,
fa3gue
and
preferen3ally
if
elderly)
correla3on
Possible
benefit
other
limi3ng
not
part
of
the
pa3ents;
not
Thalidomide
50*
(100)
mg/d
between
Yes
Yes
in
pa3ents
with
dose
and
I/A
induc3on
recommended
dura3on
and
abnormal
dura3on
of
regimen;
yes,
in
for
pa3ents
outcome‡
metaphase
therapy
meta-­‐analysis
with
FISH
cytogene3cs
and
defined
high-­‐
GEP-­‐defined
high
risk
profile
risk
Unprecedente
d
extension
of
Does
not
PFS,
increase
in
10‖
(5-­‐15)
mg/d
overcome
OS
in
1
of
3
Presently
shown
Few
con3nuously
or
Un3l
PD
or
nega3ve
impact
studies;
usually
Lenalidomide
Yes
Yes
in
one-­‐third
of
discon3nua3ons
I/A
days
1-­‐21,
every
intolerance
of
FISH-­‐defined
well
tolerated,
studies
because
of
AEs
28
d
unfavorable
increased
risk
cytogene3cs
for
secondary
primary
malignancies
Only
comparison
Ac3ve
in
pa3ents
PNP
grades
3
or
between
PAD-­‐
2
y
or
un3l
PD
or
with
renal
failure
4:
16%
(based
on
ASCT
Bortezomib‖
1.3
mg
biweekly
Yes¶
Yes¶
Yes¶
Not
applicable
intolerance
and
cytogene3c
intravenous
bortezomib
41 Multiple Myeloma
risk
groups
administra3on)
with
VAD-­‐
Research Foundation
ASCTthalidoava
Powerful thinking advances the cure
ilable

42. IMWG consensus on maintenance
therapy in multiple myeloma
Whether lenalidomide maintenance therapy
should be routinely offered to patients is
controversial among experts. Some consider the
marked gain in PFS and the survival advantage
observed in one of the 2 studies in younger
patients as a strong argument for therapy,
whereas others weigh the increased incidence of
SPMs as an important risk and so prefer to wait
for more mature survival data before making
specific recommendations.
42 Multiple Myeloma
Research Foundation
Ludwig et al Blood. 2012;119:3003-3015. Powerful thinking advances the cure

43. 43 Multiple Myeloma
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44. Allogeneic Stem Cell Transplantation
• High response rate
• Graft-versus-myeloma immune effect
• High mortality
– 10-20% with non-myeloablative transplants
– 20-40% with ablative transplants
• Age limitation (Medicare does not pay for
alloTx)
• Donor limitation
• Documented long-term survival-20% ? CURE
• Limited number of allogeneic SCTs still
44
performed in US Multiple Myeloma
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45. 45 Multiple Myeloma
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46. Tandem Autologous or Autologous è
Non-Ablative Allograft for MM
Intent to Treat
N = 80
N = 82
46 Multiple Myeloma
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Bruno et al, 2007.

47. BMT CTN 0102 Study Schema
1st Autologous
Transplant
N=710
No Sibling Donor Sibling Donor
Auto-Auto Auto-Allo
N=484 N=226
High Standard Standard High
Risk Risk Risk Risk
N=48 N=436 N=189 N=37
Main groups compared
47 Multiple Myeloma
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48. Survival Outcomes after the First Transplant:
Auto-Auto vs. Auto-Allo:
Intent-to-treat analysis
100
Progression-free Survival Overall Survival 100
Auto/Auto, 80% @ 3yr
90 Auto/Auto, 46% @ 3yr 90
80 80
Auto/Allo, 77% @ 3yr
70 70
Probability, %
60 60
50 50
Auto/Allo, 43% @ 3yr
40 40
30 30
20 20
10 10
p-value = 0.67 p-value = 0.19
0 0
Months 0 6 12 18 24 30 36 42 0 6 12 18 24 30 36 42 48
48
# at risk:
48 436 424 406 395 370 348 305 107 79
Multiple Myeloma
Research Foundation
Auto/Auto 436 395 348 292 242 213 178 54 189 183 167 160 156 143 124 43 27
Powerful thinking advances the cure
42 Mp10_5.ppt

49. mSMART 2.0: Classification of Multiple Myeloma
High
Risk
Intermediate Risk
Standard
Risk*‡
FISH
FISH
All
others
• Del
17p
• t
(4;14)†
including
• t
(14;16)
• Hyperdiploidy
• t
(14;20)
Cytogen3c
• t
(11;14)§
dele3on
13
or
• t
(6;14)
GEP
hypodiploidy
• High
risk
signature
PCLI
≥3%
mSMART=Stra3fica3on
for
Myeloma
And
Risk-­‐adapted
Therapy.
FISH=Fluorescence
in
situ
hybridiza3on.
GEP=gene
expression
profiling.
PCLI=Plasma
cell
labeling
index.
*Note
that
a
subset
of
pa3ents
with
these
factors
will
be
classified
as
high
risk
by
GEP.
†Prognosis
is
worse
when
associated
with
high
beta-­‐2
M
and
anemia.
‡LDH
>ULN
and
beta-­‐2
M
>5.5
may
indicate
worse
prognosis.
49 §t
(11;
14)
may
be
associated
with
plasma
cell
leukemia.
Multiple Myeloma
Research Foundation
Powerful thinking advances the cure
Kumar
SK,
et
al.
Mayo
Clin
Proc.
2009;84:1095-­‐1110
(revised
and
updated,
June
2010).

50. 50 Multiple Myeloma
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51. Bortezomib Administration: Impact on del
(17p13) on PFS and OS.
For all patients with del(17p13), the median PFS times (A) and 3-
year OS rates (B) in the bortezomib-based treatment arm B were
better compared with the standard arm A.
51 Multiple Myeloma
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Neben K et al. Blood 2012;119:940-948

52. Clinical Trials of Interest in US involving SCT
with or without maintenance
Phase Sponsor Regimen
Single Autologous Transplant With or Without Consolidation Therapy Versus Tandem
3 CTN0702
Autologous Transplant With Revlimid Maintenance
Revlimid as Maintenance Therapy Post Allogeneic Hematopoietic Cell Transplantation
2 CTN
for High-risk Multiple Myeloma
Velcade Revlimid, Dexamethasone induction, consolidation, with or without autologous
3 DFCI IFM
transplant followed by Revlimid maintenance
Autologous Peripheral Blood Progenitor Cell Transplantation With Velcade
2 UCLA
Maintenance as Treatment for Intermediate- and Advanced-Stage Multiple Myeloma
Revlimid Plus Low-dose Dexamethasone (Rd x 4 Cycles) Then Stem Cell Collection
3 MSK Followed by Randomization to Continued Rd or Stem Cell Transplantation (SCT) Plus
Maintenance Revlimid
Tandem High-Dose Therapy With Melphalan and Total Marrow Irradiation (TMI) With
2 COH
Peripheral Blood Progenitor Cell Support and Revlimid Maintenance
Tandem Autologous HCT / Nonmyeloablative Allogeneic HCT From HLA-Matched
2 FHCRC Related and Unrelated Donors Followed by Velcade Maintenance Therapy for Patients
With High-Risk Multiple Myeloma
52 Multiple Myeloma
2 FHCRC Velcade and Zolinza as Maintenance Therapy After Autologous Stem Cell Transplant
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53. Conclusions
• Autologous transplant remains a standard of care
(maintenance may be beneficial)
• New drug combinations for frontline therapy are under
evaluation
– Bortezomib, lenalidomide, steroids, liposomal
doxorubicin, cyclophosphamide
• Improved EFS with transplant
• Effect on OS with or without transplant are
unknown
• Allogeneic transplants are still investigational but may
be a reasonable option for high-risk or relapsed young
patients
53 Multiple Myeloma
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EFS = event-free survival.

54. 54 Multiple Myeloma
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