Is it possible to stay, in multiple myeloma, at the autogreffe of hematopoietic stem cells (CSH) in patients who have been eligible for it? This is the question asked in the phase 3 Midas test carried out in 70 centers in France and Belgium. Measurement of residual disease could help guide management. The results are published in The New England Journal of Medicine.
Currently, first -line treatment for patients with multiple myeloma combines therapeutic induction treatment composed of four drugs, followed by intensive chemotherapy with stem cell autogreffe, then maintenance treatment.
“This protocol, which applies according to the age, the general condition of the patient and any comorbidities, ultimately concerns 35 to 40 % of patients whose median age is 70 yearsmeasures Professor Aurore Perrot, hematologist at the Toulouse University Hospital at Oncopole and first author of the study. The objective of our clinical trial was to assess the response to these treatments, to validate the hypothesis of a possible change in practice and better personalization of treatments. »»
In eighteen months, 791 patients were included in the Midas academic study carried by the French-speaking myelome intergroup with two national coordinators, Professor Aurore Perrot at the Toulouse CHU and Professor Cyrille Touzeau at the Nantes University Hospital.
In this context, all patients have received the induction phase of four drugs —Isatuximab, Carfilzomib, Lénalinomide and Dexamethasone (Isakrd). “With this optimized combination both on the balance of efficiency and on the toxicity balance, we noticed a residual disease (MRD for Measurable Residual Disease, editor’s note) after six months in 63 % of patients”specifies the Toulouse hematologist.
Lack of profit at a double autogreffe in poor responders
Patients good answers were then randomized in two groups. The first was treated by the classic protocol. The second did not undergo an autogreffe and was treated with six months of additional induction with this same combination. “The hypothesis was whether the autogreffe still allows you to do better, and we found that the difference is minimal in the right answers, points the doctor. No difference was observed between those who have received an autogreffe and those who pursued Isakrd without autogreffe (84 % versus 86 % of MRD negative after consolidation). »»
The least good answers, in which traces of the disease remain after six months, were randomized in a single transplant group and a group two transplants. “With them, only one autogreffe seems as effective as a double autogreffe (40 % versus 32 % of negative MRD), with even a trend in favor of simple transplant”, continues the doctor.
These results could lead to the abandonment of the autogreffe in certain “good responders” patients and limit themselves to a single autogreffe in “less good answers”. “” It’s a good signal, estimates the Toulouse expert, Because the transplant accompanied by heavy chemotherapy is toxic and weighs on the quality of life of patients. Many of them ask us for solutions that would escape it. Nevertheless at this stage, the study gives indications only on short -term survival. Longer -term data will be necessary to confirm these results. »»
A. Perrot et al., The New Eng J Med, 2025. DOI: 10.1056/NEJMoa2505133
