Hematopoietic Stem Cell Transplantation for Multiple Myeloma

Publication Date: March 11, 2015
Last Updated: March 14, 2022


We recommend high-dose chemotherapy (HDC) and auto-HCT as consolidative therapy for patients with multiple myeloma (MM). ( A )

Though prospective evidence is lacking, we recommend consideration of a first auto-HCT for patients with refractory disease. (C)

We recommend that age not be used as a selection factor. (C)
However, an HCT-CI score of >2 or Karnofsky performance status <90 can warrant additional consideration before proceeding with auto-HCT. Though the evidence is mainly retrospective, it is unlikely that prospective randomized data will be forthcoming to truly answer this question.

We recommend serious consideration of a clinical trial for patients with high-risk cytogenetics, particularly del17p or t(4:14). ( C )

We recommend Mel 200 mg/m2 as the standard regimen for MM conditioning, outside of clinical trials. ( A )

Based on the conflicting data from the prospective randomized trials and the above meta-analyses, there is insufficient evidence to support tandem auto-HCT as the standard of care for myeloma patients. However, there are cases when this may be considered, based in the IFM data, in patients with less than a very good partial response after a first auto-HCT or as part of a clinical trial. (D)
It is important to note that in the current era of IMiDs and proteasome inhibitors, the role of up-front tandem transplantation has not yet been decided.

Recommendations for Follow-up after Auto-HCT

In patients with measurable disease, monitoring should start 2 to 3 months after auto-HCT and continue every 3 months thereafter with serum and/or urine M-protein, serial involved free light chain (FLC) assay, and serum FLC ratio. BM biopsy may be required in patients with oligosecretory plasma cell disorder and in patients with no measurable disease. ()
If documentation of response is desired, bone marrow (BM) examination and FLC ratio are required to document CR, near CR, and stringent CR status or to assess cause of persistent cytopenias. ()
IMWG uniform response criteria should be used to determine disease status after auto-HCT. ()
In asymptomatic patients not suspected to have relapse or progression of disease after HCT, serial radiography/magnetic resonance imaging or PET scan is not routinely required. However, these tests may be used to follow response to therapy or evaluate new symptoms. ()
Minimal residual disease (MRD) testing after auto-HCT in MM can reveal patients at risk for poorer outcomes and should be considered for disease evaluation. (B)
If MRD testing is attempted, multiparametric flow cytometry following the European Myeloma Network consensus guidelines should be the method of choice.

Recommendations for Therapy after Auto-HCT

Consolidation after auto-HCT is not routinely recommended but can be considered in the setting of a clinical trial. ()
Maintenance with an immunomodulatory drug (thalidomide or lenalidomide) is recommended unless a contraindication exists. (A)
In most cases, lenalidomide is preferred because of improved survival data in the era of novel agents.
In patients with high-risk disease with renal failure or adverse chromosome changes, post–auto-HCT bortezomib consolidation and maintenance may be considered. (D)

Recommendations on the Role of Salvage Second Auto-HCT

Second auto-HCT is a safe and efficacious treatment modality for relapsed MM and should be considered. (B)
We note that this grade is based on data with superior PFS as an outcome, but think that this is an appropriate endpoint in the relapsed setting.
Patients with longer progression-free interval after first auto-HCT have better outcomes after salvage second auto-HCT. It is recommended that the minimum length of remission be at least 12 months for consideration of second auto-HCT as salvage therapy. (D)
The role of maintenance therapy after salvage second auto-HCT is unclear.

Recommendations on the Role of Allo-HCT

Upfront myeloablative allo-HCT is not routinely recommended. (A)
It may be appropriate for further study in young patients with very high-risk MM, in the context of a clinical trial.
Planned reduced-intensity conditioning (RIC)-allo-HCT after auto-HCT has not been found to be superior in the majority of clinical trials and is, therefore, not recommended over auto-HCT. (A)
Its role in high-risk subgroups requires further study.
Allo-HCT salvage therapy for relapsed MM has not been shown to be superior to salvage auto-HCT and is not routinely recommended outside of a clinical trial. (D)
For younger patients with a good performance status, allo-HCT can be considered, ideally in the context of a clinical trial.
The role and choice maintenance after allo-HCT has not been adequately studied and is not known.

Recommendation Grading




Hematopoietic Stem Cell Transplantation for Multiple Myeloma

Authoring Organization

Publication Month/Year

March 11, 2015

Last Updated Month/Year

June 27, 2023

Document Type


External Publication Status


Country of Publication


Inclusion Criteria

Female, Male, Adolescent, Adult, Child, Infant, Older adult

Health Care Settings

Hospital, Operating and recovery room, Outpatient

Intended Users

Clinical researcher, nurse, nurse practitioner, physician, physician assistant


Management, Treatment

Diseases/Conditions (MeSH)

D018380 - Hematopoietic Stem Cell Transplantation


multiple myeloma, transplantation, Transplantation, utologous hematopoietic stem cell transplantation

Supplemental Methodology Resources

Data Supplement


Number of Source Documents
Literature Search Start Date
June 1, 2002
Literature Search End Date
December 31, 2014