POEMS syndrome (polyradiculoneuropathy, organomegaly, endocrinopathy, monoclonal plasma cell disorder, and skin changes) is a rare plasma cell disorder often associated with papilledema, extravascular volume overload, sclerotic bone lesions, Castleman disease, and high vascular endothelial growth factor (VEGF) levels. High-dose chemotherapy and autologous hematopoietic stem cell transplant (auto-HCT) can be used with good clinical response, but has significant post-transplant morbidity. Here we present our experience in 5 patients with POEMS syndrome who underwent auto-HCT at the MD Anderson Cancer Center (MDACC).
Between January 1999 and October 2010, 5 patients (4 males, 1 female) with POEMS syndrome received auto-HCT at MDACC. Diagnosis of POEMS was based on criteria of Dispenzieri et. al.1 All 5 patients had received systemic therapy prior to auto-HCT as follows: bortezomib+dexamethasone (dex) in 2, lenalidomide+dex in 1, cyclophosphamide+dex in 1, and pulse dex in 1. Two patients also received localized radiation for bone disease. Peripheral blood stem cells were collected with granulocyte colony-stimulating factor (G-CSF) in 4 patients and with cyclophosphamide+G-CSF in 1. The preparative regimen was melphalan 200 mg/m2 in 4 patients, while 1 patient received 180 mg/m2 due to renal insufficiency. We evaluated the response rate, toxicity, transplant-related mortality, progression-free survival (PFS) and overall survival (OS). Hematologic response was defined by the International Myeloma Working Group (IMWG) criteria2.
Median age at auto-HCT was 48 years (range: 39–58) and median time from diagnosis to auto-HCT was 16.6 months (6.4 – 89 months). All 5 patients had osteosclerotic bone lesions and monoclonal gammopathy: IgA lambda in 3, IgG lambda in 1, and IgG kappa in 1. Two patients had biopsy proven Castleman disease. Four patients had debilitating polyneuropathy. Other features were: skin involvement in 3, endocrinopathy in 2, ascites in 1, anasarca in 2, pulmonary hypertension in 1, and papilledema in 1. Median follow up after auto-HCT was 11.6 months (8.6 – 83.5 months). Median Karnofsky performance status was 80% (70–100) at the time of transplant and 90% (80–100) by the one year follow up visit. Two patients (40%) had complete response, 2 (40%) had a very good partial response, and 1 (20%) had a partial response by IMWG criteria. Engraftment syndrome was not seen in any of the 5 patients. Significant post auto-HCT complications were fungal pneumonia in 2 patients and pulmonary embolism in one. Patients fully recovered from these complications. One-year transplant-related mortality was 0%. All 5 patients had complete or significant resolution of their clinical symptoms after auto-HCT. Median PFS and OS have not yet been reached. With a median follow up of 11.6 months, 1-year PFS and OS were 100%. Four patients are alive and in remission, while one patient died 6 years after his auto-HCT secondary to gastrointestinal bleeding unrelated to his underlying disease.
High-dose therapy followed by auto-HCT is safe and effective in selected patients with POEMS syndrome and is associated with durable responses and survival.
No relevant conflicts of interest to declare.
Asterisk with author names denotes non-ASH members.