High-dose therapy plus autologous stem-cell transplantation (ASCT) is currently the standard of care for patients with multiple myeloma up to the age of 65 without severe comorbidities. The introduction of novel agents (thalidomide, bortezomib, lenalidomide) has already dramatically improved the ASCT results. Two or three-drug bortezomib-based induction treatments are superior to the classical VAD. Post-ASCT treatment with thalidomide and probably in the near future with lenalidomide further improves the response rate and the progression-free survival. The use of novel agents both before and after ASCT yields unprecedented complete plus very good partial response rates and progression-free survival. These new strategies partially overcome poor prognosis related to t(4;14) and/or del(17p).
At the same time, novel agents without ASCT have also improved the outcome in patients who are not candidates for ASCT and yield complete plus very partial response rates that are comparable to those achieved with high-dose therapy. Therefore the place of ASCT in the treatment of MM (upfront or after progression) should be addressed in future randomized trials
In this context, the role of allogeneic stem-cell transplantation remains limited since it still induces a high incidence of treatment-related morbidity and mortality despite the use of reduced conditioning regimens.