BEAM Conditioning Protocol
The BEAM conditioning regimen consists of BCNU (carmustine) 300 mg/m², etoposide 800 mg/m², cytarabine (Ara-C) 800 mg/m², and melphalan 140 mg/m², administered over 7 days prior to allogeneic hematopoietic stem cell transplantation for lymphoma patients. 1
Standard BEAM Protocol Dosing Schedule
The Chinese Society of Hematology guidelines provide the specific dosing schedule for BEAM in allogeneic HSCT for lymphoma 1:
- BCNU (Carmustine): 300 mg/m² on Day -6 1
- Etoposide (VP16): 800 mg/m² total dose, divided over Days -5 through -2 (200 mg/m² per day) 1
- Cytarabine (Ara-C): 800 mg/m² total dose, divided over Days -5 through -2 (200 mg/m² per day) 1
- Melphalan: 140 mg/m² on Day -1 1
Note: The guideline specifies Ara-C dosing as "800 mg/kg" in the table, but this appears to be a typographical error and should be interpreted as 800 mg/m² based on standard oncology dosing conventions. 1
Clinical Indications
BEAM is specifically recommended for patients with multiple myeloma or non-Hodgkin lymphoma undergoing allogeneic HSCT. 1 The regimen is part of the standard conditioning protocols for malignant hematological diseases other than leukemia/MDS. 1
For Hodgkin lymphoma patients undergoing autologous stem cell transplantation, BEAM is recommended as the first conditioning regimen, particularly for intermediate-risk patients who are chemosensitive. 1
Alternative Formulations and Modifications
BeEAM Regimen
Bendamustine can replace BCNU in the BEAM protocol (creating "BeEAM") when BCNU availability is limited or pulmonary toxicity is a concern. 2, 3 The BeEAM protocol uses bendamustine 200 mg/m² on days -7 and -6, with the remaining drugs administered as in standard BEAM. 3
BeEAM demonstrates slightly better progression-free survival (pooled OR 0.70,95% CI 0.52-0.94) and lower relapse rates (OR 0.49,95% CI 0.31-0.76) compared to BEAM, but is associated with higher rates of grade 3 mucositis, renal toxicity, and cardiotoxicity. 2
FEAM Regimen
Fotemustine can substitute for BCNU (creating "FEAM") with fotemustine 150 mg/m² on days -7 and -6, showing comparable efficacy with acceptable toxicity profiles. 4
High-Dose Cytarabine MEAM
In Japan, the MEAM regimen (ranimustine, etoposide, cytarabine, melphalan) is used with high-dose cytarabine (2 g/m² for 2 days) to enhance CNS penetration, demonstrating 3-year overall survival of 80.6% and progression-free survival of 65.7%. 5
Expected Toxicities and Engraftment
Median time to neutrophil engraftment (>500 × 10⁹/L) is 11 days, and platelet engraftment (>20,000 × 10⁹/L) is 13-15 days after BEAM conditioning. 4, 3
Common toxicities include:
- Grade 3 mucositis: 19-23% of patients 4
- Grade 3 nausea/vomiting: 15% 4
- Grade 3 diarrhea: 7% 4
- Transplant-related mortality: 1.4-2.8% 4
No severe hepatic, renal, or pulmonary toxicity is typically observed with standard BEAM. 4
Important Clinical Considerations
BEAM is contraindicated in patients with prior dose-limiting radiation exposure; in such cases, BAM (busulfan replacing TBI) should be used for tandem transplantation protocols. 1
For high-risk Hodgkin lymphoma patients requiring tandem transplantation, BEAM is recommended as the first conditioning regimen, followed 45-90 days later by TAM (TBI 12 Gy-cytarabine-melphalan) for previously unirradiated patients. 1
BEAM conditioning is less preferred than BCNU/thiotepa for CNS lymphomas, including Bing-Neel syndrome, where blood-brain barrier penetration is critical. 1
For multiple sclerosis patients undergoing autologous HSCT, BEAM with anti-thymocyte globulin (BEAM-ATG) is the most frequently used intermediate-intensity conditioning regimen, achieving superior disease control compared to continued disease-modifying therapy escalation. 1, 6