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364 Part V: Therapeutic Principles Chapter 23: Hematopoietic Cell Transplantation 365

From Time of Diagnosis
High-dose melphalan plus lenaidomide maintenance MPR plus lenalidomide maintenance
High-dose melphalan plus no maintenance MPR plus no maintenance
100 100
Probability of Progression-free Survival 25 Probability of 5-Yr Overall Survival 25
75
75
50
50

37.4
54.7
0
0 6 12 18 24 21.8 3036 34.2 48 5460 66 0 0 6 12 18 24 3036 42 48 54 60 66
42
Months Months
No. at Risk
High-dose melphalan plus 100 88 73 64 57 53 49 43 40 19 1 100 97 92 84 79 76 71 68 61 31 3
lenalidomide maintenance
High-dose melphalan plus 100 87 74 60 56 49 41 31 21 9 2 100 93 87 79 74 71 69 62 52 26 4
no maintenance
MPR plus lenalidomide 98 84 71 63 54 48 36 28 24 10 2 98 91 84 82 80 77 73 67 63 23 7
maintenance
MPR plus no maintenance 104 87 77 55 36 26 18 14 7 2 0 104 96 93 87 81 77 72 65 56 23 3
A
From Start of Consolidation High-dose melphalan MPR
100 Hazard ratio for progression 100
Probability of Progression-free Survival 50 0.32–0.61); P<0.001 Probability of 4-Yr Overall Survival 75 Hazard ratio for death with high-dose melphalan,
or death with high-dose
melphalan, 0.44 (95% CI,
75
50
0.55 (95% CI, 0.32–0.93); P=0.02
25
25
43.0
0
30
0 6 12 18 24 22.6 36 42 48 54 60 0 0 6 12 18 24 30 36 42 48 54 60
Months Months
No. at Risk
High-dose melphalan 141 131 114105 92 82 67 49 21 3 141 136 129121 115 111 105 88 42 7
MPR 132 128 98 76 57 41 32 25 7 1 132 131 124 121 117 106 94 82 27 5
B
From Start of Maintenance Lenalidomide maintenance No maintenance
100 maintenance, 0.47 (95% CI, 100
Hazard ratio for progression
Probability of Progression-free Survival 50 0.33–0.65); P<0.001 Probability of 3-Yr Overall Survival 50 Hazard ratio for death with lenalidomide maintenance
or death with lenalidomide
75
75
0.64 (95% CI, 0.36–1.15); P=0.14

25
25
0
0 6 12 18 24 21.6 36 42 41.9 54 60 0 0 6 12 18 24 30 36 42 48 54 60
48
30
Months Months
No. at Risk
Lenalidomide maintenance 126112 100 86 73 6251 15 2 0 126120 115110 103100 83 32 7 2
No maintenance 125 96 7864 51 3720 9 2 1 125117 114109 99 94 71 25 6 2
C
Figure 23–1. Results from a prospective randomized clinical trial comparing upfront autologous hematopoietic cell transplantation to mainte-
nance therapy in myeloma. Panel A shows progression-free survival and 5-year overall survival from the time of diagnosis. Panel B shows progres-
269
sion-free survival and 4-year overall survival from the start of consolidation therapy. Panel C shows progression-free survival and 3-year overall survival
from the start of maintenance or no maintenance. CI, confidence interval; MPR, melphalan,prednisone, and lenalidomide. (Reproduced with permission
from Palumbo A, Cavallo F, Gay F, et al: Autologous transplantation and maintenance therapy in multiple myeloma. N Engl J Med 4;371(10):895–905, 2014.)

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