High dose melphalan or intermediate dose melphalan can be well tolerated and result in good response rates in selected elderly patients with myeloma

We have used two strategies for treating myeloma patients aged 65–75 years. Those fit enough underwent Cyclophosphamide mobilisation and PBSCT using melphalan 200 mg/m2 (HDM) (n = 15, median 67 years). Those less fit were mobilised with G-CSF and received melphalan 70 mg/m2 (IDM) (n = 15, median 69 years). Where possible sufficient PBSC were collected so that patients not in CR after their first IDM, underwent a second IDM procedure (n = 6). The treatment was well tolerated with zero day + 100 TRM. Median cell dose was 4.85 × 106 CD34+ cells/kg and 2.7 × 106 in the HDM and IDM groups, respectively. Neutrophil engraftment was faster in the HDM group but despite this there was a trend to earlier discharge in the IDM group (13 days versus 15 days) and lower antibiotic and anti-fungal usage, suggesting better tolerability. Response rates were similar with CRs achieved in 7/15 patients receiving HDM and 9/15 receiving IDM (6 after the first and 3 after the second procedure). Three patients did not undergo a second IDM due to insufficient cells. In the IDM group 11/15 remain alive at a median follow up of 14 months with 5 in CR, whilst in the HDM group 12/15 are alive with 5 in CR at a median follow up of 15.5 m. We conclude both approaches have comparable efficacy but that IDM may be better tolerated in an older age group.