Multimodal melphalan delivery: improved safety and outcomes with autologous myeloma transplant in India

BACKGROUND High-dose melphalan–based autologous stem cell transplantation (ASCT) remains a cornerstone of treatment in multiple myeloma but causes severe gastrointestinal toxicity in up to 50% of patients due to mucosal injury. OBJECTIVE To mitigate this, we assessed a multimodal approach of combined oral cryotherapy, extended duration of melphalan infusion (1 h compared to bolus), and upright patient positioning during administration. DESIGN A cohort study using hospital patient records to evaluate the safety and outcomes of this approach at a tertiary hospital in South India, from January 2017 to March 2026. RESULTS Among 47 patients undergoing ASCT, 4% had grade 3 (severe) mucositis, 15% experienced grade 3 diarrhoea, and one patient had severe vomiting. No grade 4 (life threatening) or grade 5 (fatal) gastrointestinal toxicities were observed. Total parenteral nutrition was required in 4% patients. The median duration of stay in the transplant unit was 14 days. There was no post-transplant mortality within 1 year. Relapse-free survival at 1 year was 88%, and relapse was significantly associated with high-risk cytogenetics. CONCLUSION Multimodal melphalan delivery is feasible, with manageable toxicity and low rates of severe adverse events, while maintaining excellent short-term outcomes. Further multicentric evaluation and wider adoption is warranted.