Total Therapy 2

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Multiple Myeloma

Induction

  • Cycle 1, VAD Vincristine (0.5 mg/d x 4 d) CI; Adriamycin (10 mg/m2/d x 4 d) CI; Dexamethasone 40 mg PO d 1-4, 9-12, 17-20
  • Cycle 2, DCEP Cyclophosphamide (400 mg/m2/day x 4 d) CI; Etoposide (40 mg/m2/day x 4 d) CI; cis-Platin (10 mg/m2/day x 4 d) CI; Dexamethasone (40 mg/d) PO days 1-4

8 Cycle 3, CAD Cyclophosphamide (750 mg/m2/day x 4 d) CI; Adriamycin (15 mg/m2/d x 4 d) CI; G-CSF 10 µg/kg SQ twice daily -> PBSC collection

  • Cycle 4, DCEP Cyclophosphamide (400 mg/m2/day x 4 d) CI; Etoposide (40 mg/m2/day x 4 d) CI; cis-Platin (10 mg/m2/day x 4 d) CI; Dexamethasone (40 mg/d) PO days 1-4

Transplantation

  • First transplantation Melphalan 200 mg/m2 d -1 (reduce to 140 mg/m2 for age >70 years or creatinine >3 mg/dL)
  • Second transplantation Melphalan 200 mg/m2 d -1 (reduced to 140 mg/m2 for age >70 years or creatinine >3 mg/dL) < PR: BCNU 300 mg/m2 d -5; Etoposide 200 mg/m2; Arabinosyl cytosine 400 mg/m2 d -5 through -2; Melphalan 140 mg/m2 d -2

Consolidation

  • Randomized arm A: DCEP Dexamethasone 40 mg/d PO d 1-4; cyclophosphamide (300 mg/m2/d x 4 d) CI; etoposide (30 mg/m2/d x 4 d) CI; cis-platin (7.5 mg/m2/d x 4 d) CI every 3 months for 4 cycles
  • Randomized arm B
    • DCEP* Dexamethasone 40 mg/d PO d 1-4; cyclophosphamide (300 mg/m2/d x 4 d) CI; etoposide (30 mg/m2/d x 4 d) CI; cis-platin (75 mg/m2/d x 4 d)
    • CAD* Cyclophosphamide (400 mg/m2/d x 4 d) CI; adriamycin (10 mg/m2/d x 4 d) CI; dexamethasone 40 mg/d PO d 1-4
    • DPACE Dexamethasone 40 mg/d PO d 1-4; cis-platin (75 mg/m2/d x 4 d) CI; adriamycin (10 mg/m2/d x 4 d) CI; cyclophosphamide (300 mg/m2/d x 4 d) CI; etoposide (30 mg/m2/d x 4 d) CI; every 3 months for 4 cycles.
    • DEX In case of failure to recover platelets to at least 100 000/µL or failure to achieve >25% M-protein reduction with first cycle of DCEP in induction: DEX 40 mg d 1-4 every 28 d for 1 year.

Maintenance

  • Interferon 3 million U/m2 SQ 3 x wk plus first year of maintenance: Dexamethasone 40 mg every 3 months on d 1-4, 9-12, 17-20
  • Second year onward; interferon alone

References

Barlogie et al. Total therapy 2 without thalidomide in comparison with total therapy 1: role of intensified induction and posttransplantation consolidation therapies Blood, 1 April 2006, Vol. 107, No. 7, pp. 2633-2638.