This has become the standard treatment for younger myeloma patients in otherwise good health. Many centers are using this treatment for patients up to age 70. Several studies have shown that this treatment increases survival compared to standard chemotherapy.

The first step is to treat the myeloma to reduce the amount of myeloma in a patient's body. The drugs can be either thalidomide or chemotherapy with vincristine and doxorubicin (Adriamycin). Dexamethasone is also used in either case. One disadvantage of the VAD regimen is that it requires a special IV (intravenous) catheter that must be placed in the large veins leading to the heart.

After the chemotherapy, often the drug cyclophosphamide and a white blood cell stimulating drug are given. Then, blood-forming stem cells are removed from the patient's or a donor's blood by a process called leukapheresis. In this process, blood is removed from the patient or donor, the stem cells separated, and the blood returned. In some cases, bone marrow is used.

These blood-forming cells, called stem cells, are preserved by being frozen while the patient receives high-dose chemotherapy. The usual drug is melphalan, which is given intravenously. The high doses of chemotherapy destroy almost all the cells in the patient's bone marrow. This includes the blood-forming stem cells as well as plasma cells. Although this would normally be fatal, it can be avoided by giving the frozen stem cells to the patient after chemotherapy. These are given IV into the blood from where they travel to, and begin to grow in, the bone marrow.

During the period after the chemotherapy, patients often have high fevers, usually due to infections. These are treated with IV antibiotics. Another common problem is mouth sores. These can be very painful. Morphine may be given to reduce the pain. The chemotherapy also kills cells in the intestinal tract leading to cramps and diarrhea. Finally, because the bone marrow is unable to make blood cells, it will be necessary to give a transfusion of red blood cells. Transfusions of platelets, a kind of cell that stops bleeding, will also be necessary.

Autologous transplants. This procedure uses the patient's own blood-forming stem cells. These transplants are fairly safe and have a low risk of serious complications. Because of this, they can be used in elderly patients. Unfortunately, because it is difficult to kill all the myeloma cells with high-dose chemotherapy, patients who undergo this procedure eventually have their myeloma return. Although a few of these patients will be free of myeloma for quite a long time, it is not possible to say that this procedure is curative. But it is clearly becoming the preferred treatment for eligible patients. Around 4,000 were performed in North America in 2002.

Some doctors are recommending that this procedure be repeated within 6 to 12 months after the first autologous transplant. This is called a tandem transplant. Recent studies show that it may prolong patients' survival longer than a single transplant, but of course, it causes more side effects. One study found that the major benefit in the second transplant was found in patients who did not have a good response to the first procedure. This is a rapidly evolving area as the results of new studies become available.

Still, it is not possible to say with certainty that autologous transplants prolong life. Although it is clear that patients will have less myeloma for a while, study results are not in agreement about whether this will extend their life.

Allogeneic transplants. This is used much less often than autologous transplants. This procedure uses blood-forming stem cells from donors (usually close relatives or, less often, unrelated donors whose tissue type is closely matched to the patient). Allogeneic transplants carry a higher risk of serious complications, even death, but may produce more long-lasting remissions because the transplanted (donor) immune system cells may actually help to destroy the myeloma cells. This procedure is not used often in myeloma patients because they must be relatively young and healthy to withstand the side effects of transplantation (most myeloma patients are elderly) and a donor's tissue type must be compatible with the patient's. Fewer than 500 of these procedures were performed in myeloma patients in 2002.

In some allogeneic transplants low doses of certain kinds of chemotherapy drugs are used, usually a drug called fludarabine, to allow the transplanted stem cells to "take" without all the toxicity of high doses. This is called a nonmyeloblative transplant. This type of transplant allows the treatment to be done on older patients. Although the myeloma hasn't been destroyed by the low-dose chemotherapy, the transplanted blood-forming stem cells are expected to react against the myeloma cells and destroy them. Last Revised: 08/04/2006