Challenging Cases in Multiple Myeloma Panel Discussion Robert Z. Orlowski, Ph.D., M.D.

Transplant-eligible, standard-risk patient achieves <PR after 4 cycles of induction therapy. A 52 year old woman with IgA-λ Multiple Myeloma fails to achieve a PR after 4 cycles of Rd induction chemotherapy. What would you recommend for her at this point? 1. Continue Rd for another 3-4 cycles and re-evaluate 2. Go immediately to auto-SCT 3. Collect stem cells and then add bortezomib to Rd and continue treatment 4. Collect stem cells and then add carfilzomib to Rd and continue treatment 5. Change therapy to CyBorD 6. Something else

Transplant-eligible, standard-risk patient achieves CR after induction therapy plus ASCT, but relapses 18 months later A 68 year old man with IgG-λ multiple myeloma receives induction therapy with RVD and achieves a VGPR. He then undergoes a single auto-SCT and improves his response to CR. Unfortunately he experiences symptomatic disease progression only 18 months after his SCT? What would you plan for this man now? 1. Carfilzomib-pomalidomide-dexamethasone (CPd) 2. Cyclophosphamide-bortezomib-dexamethasone (CyBorD) 3. Cyclophosphamide-carfilzomib-dexamethasone 4. Clinical trial with daratumumab plus Len-Dex 5. Clinical trial with bendamustine plus Len-Dex 6. Something else

Transplant-eligible, high-risk patient achieves <VGPR after induction plus ASCT A 61 year old man is diagnosed with symptomatic IgA-kappa multiple myeloma with a t(4;14) translocation. He is treated with six cycles of CyBorD followed by auto-SCT. Following transplant he has achieved less than a VGPR response. What would you now recommend for this gentleman?   1. CRd followed by a second auto-SCT 2. CPd followed by a second auto-SCT 3. RIC allogeneic–SCT 4. Clinical trial with Rd plus or minus ixazomib 5. Clinical trial with Rd plus or minus daratumumab 6. Something else

Transplant-ineligible, standard-risk patient achieves <PR after 4 cycles of frontline therapy. What to do next: continue present regimen for another 2-4 cycles or more, or switch to an alternate regimen? A 74 year old man is diagnosed with symptomatic IgG-kappa Multiple Myeloma with numerous lytic bone lesions. He is treated with VMP, but after 4 cycles he has achieved less than a PR response and remains symptomatic. What would you recommend as further therapy for this older gentleman? 1. Continue VMP for 2-3 additional cycles before re-evaluating his response 2. Switch therapy to Len-dex 3. Switch therapy to carfilzomib plus Len-dex 4. Pomalidomide-Dex 5. Clinical trial

Transplant-eligible patient with 17p deletion A 51 year old otherwise healthy woman is diagnosed with symptomatic Multiple Myeloma. Cytogenetic studies demonstrate the 17p deletion. What would you recommend as induction therapy for this woman?   1. RVD 2. CRD 3. CyBorD 4. Cyclophosphamide-carfilzomib-dexamethasone 5. Cyclophosphamide-carfilzomib-dexamethasone-thalidomide 6. Something else