Greffer ou ne pas greffer dans le myélome multiple
Résumé
Le myélome multiple (MM) est le deuxième cancer hématologique le plus fréquent. Il se manifeste par une prolifération et une accumulation de plasmocytes anormaux (cellules myélomateuses), et se niche de préférence, dans la moelle osseuse. Il induit une morbidité importante, y compris des lésions lytiques osseuses, de l’insuffisance rénale, de l’anémie et des infections, pour n’en nommer que quelques-unes. Bien que le MM demeure en grande partie incurable, il s’agit d’une maladie sensible à la chimiothérapie. L’utilisation de melphalan intraveineux à haute dose (100-140 mg /m2) dans le traitement du MM, a été étudiée pour la première fois, il y a près de 4 décennies. Par la suite, la dose de melphalan a été augmentée et a été combinée une greffe autologue de cellules souches hématopoïétiques afin de diminuer la toxicité associée à l’aplasie. Les résultats d’études de phase 3, comparant la chimiothérapie seule à la chimiothérapie, suivie de melphalan à haute dose et d’une greffe autologue de cellules souches, sont apparus au milieu des années 90, avec la publication de l’étude IFM-90. Les résultats ont démontré des avantages cliniques significatifs sur le taux de réponse, sur la survie sans événement, et même, sur la survie globale, dans une cohorte de deux cents patients de moins de 65 ans, non traités auparavant. De cette étude marquante, ont découlé des études de confirmation au début des années 2000. Au cours des 20 dernières années, quoique le traitement des patients admissibles à la greffe s’est amélioré, principalement en raison de meilleurs régimes d’induction et par l’ajout de traitement d’entretien, la greffe autologue de cellules souches demeure la pierre angulaire du traitement des patients atteints de MM. En effet, malgré des traitements novateurs et plus efficaces pour le MM, la greffe autologue de cellules souches continue de démontrer des avantages cliniques (Tableau 1). De plus, la greffe autologue en tandem a démontré des avantages en termes de survie sans progression et de survie globale, pour certains patients présentant une cytogénétique de faible risque.
En 2022, avec une meilleure connaissance du MM, une prise de conscience des conséquences potentielles du melphalan à haute dose et avec des modalités de traitement nouvelles et plus efficaces, le rôle de la greffe autologue de cellules souches devient certainement une question à débattre. Le but de cet article est de présenter les avantages et les inconvénients de la greffe autologue de cellules souches, dans notre réalité canadienne (Figure 1). Cet article vise à mieux évaluer son rôle en tant qu’option thérapeutique, compte tenu des ressources limitées de notre système de santé, dans lequel, de nombreux nouveaux médicaments ne seront pas disponibles ou accessibles au Canada avant plusieurs années.
Références
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