Heyll A, Söhngen D, Aul C, Schneider P, Kobbe G, Bauser U, Quenzel E M, Schneider W
Klinik für Hämatologie, Heinrich-Heine-Universität, Düsseldorf.
Praxis (Bern 1994). 1998 Jun 24;87(25-26):879-83.
For patients younger than 60 years with multiple myeloma in a stage requiring chemotherapy high dose chemotherapy followed by autologous blood stem cell transplantation appears to be the best therapeutic option. Conditioning regimens resulting in a high proportion of patients with 90% tumor reduction (very good partial or complete remissions) should be preferred. A good quality of remission is a prerequisite for prolonging the disease free survival. World-wide the tandem high dose melphalan protocol developed by Barlogie and coworkers is deemed the most effective conditioning regimen. A pilot study in our clinic with an intensified high dose regimen combining idarubicin, melphalan and cyclophosphamide showed similar remission rates. The application of peripheral blood stem cells reduces the treatment related mortality to less than 10%. It is expected that more than 50% of patients treated with high dose chemotherapy and autologous peripheral blood stem cell transplantation will survive at least 5 years. Therefore, the prognosis of such patients is significantly improved compared with patients treated with conventional chemotherapy. Treatment related mortality after allogeneic blood stem cell transplantation is about 40%. Therefore, during the first 2 to 3 years after transplantation the prognosis of patients after allogeneic transplantation is inferior to that of patients receiving autologous transplants. Subsequently, patients with allogeneic transplants do better, because the relapse rate after allogeneic transplantation is decreased and some patients may achieve long term remissions or even cures. Therefore, we recommend allogneic blood stem cell transplantation for patients younger than 50 years if an HLA-identical sibling donor is available and there are no contraindications. For patients older than 60 years the Alexanian protocol is still the therapeutic standard. On the other hand, successful application of high dose chemotherapy and autologous blood stem cell transplantation in patients of this age group has been reported. Therefore, clinical trials are required to clarify whether the prognosis of patients older than 60 years can be improved with treatment strategies including high dose chemotherapy.
对于年龄小于60岁、处于需要化疗阶段的多发性骨髓瘤患者，高剂量化疗后进行自体血干细胞移植似乎是最佳治疗选择。应优先选择能使高比例患者肿瘤缩小90%（非常好的部分缓解或完全缓解）的预处理方案。良好的缓解质量是延长无病生存期的前提。在全球范围内，由巴洛吉及其同事研发的串联高剂量美法仑方案被认为是最有效的预处理方案。我们诊所进行的一项试点研究采用了一种强化高剂量方案，联合使用伊达比星、美法仑和环磷酰胺，显示出相似的缓解率。外周血干细胞的应用可将治疗相关死亡率降低至10%以下。预计接受高剂量化疗和自体外周血干细胞移植的患者中，超过50%将至少存活5年。因此，与接受传统化疗的患者相比，此类患者的预后有显著改善。异基因血干细胞移植后的治疗相关死亡率约为40%。因此，在移植后的头2至3年，异基因移植患者的预后不如接受自体移植的患者。随后，异基因移植患者的情况会更好，因为异基因移植后的复发率降低，一些患者可能实现长期缓解甚至治愈。因此，如果有 HLA 配型相同的同胞供者且无禁忌证，我们建议对年龄小于50岁的患者进行异基因血干细胞移植。对于年龄大于60岁的患者，亚历克萨尼安方案仍是治疗标准。另一方面，也有报道称在这个年龄组的患者中成功应用了高剂量化疗和自体血干细胞移植。因此，需要进行临床试验以明确对于年龄大于60岁的患者，采用包括高剂量化疗在内的治疗策略是否能改善其预后。
