Study to evaluate the effectiveness of a combination of 3 treatments, followed by transplantation of their own blood cell progenitor cells for patients under 70 years of age with asymptomatic multiple myeloma at high risk of developing into symptomatic myeloma

Prior treatment

• The patient has experienced unstable angina or myocardial infarction in the 6 months prior to recruitment, class III or IV cardiac failure (according to the New York Heart Association criteria) uncontrolled angina, a history of acute coronary artery syndrome, uncontrolled ventricular arrhythmias, sick sinus syndrome or electrocardiographic evidence of acute ischemia or grade 3 conduction system abnormalities, unless the patient has a pacemaker.
• Significant neuropathy (grades 3-4, or grade 2 with pain), in the 14 days prior to recruitment.
• The patient presents a contraindication that prevents the administration of the concomitant or adjunctive treatments, including hydration intolerance due to pre-existing pulmonary or cardiac impairment.
• Presence of an acute active infection that requires treatment (systemic antibiotics, antivirals, or antifungal agents), in the 14 days prior to recruitment.
• The patient has received prior treatment for SMM.
• The patient has undergone major surgery in the 4 weeks prior to inclusion in the study.
• The patient has received an investigational drug of any type in the 4 weeks prior to inclusion in the study.

Other illness

• Any physical or mental health condition that prevents the patient from signing or understanding the informed consent document.
• Uncontrolled hypertension or diabetes.
• Known history of allergies to captisol (a derivative of cyclodextrin that is used to dissolve carfilzomib).
• Pulmonary hypertension.
• The patient has lytic lesions, anemia, renal failure or hypercalcemia.
• The patient has active HIV, hepatitis B or hepatitis C infection.

Lab values

• LVEF < 40
• Any of the following abnormal laboratory values: o Absolute neutrophil count (ANC) < 1,000/mm3. o Platelet count < 75,000/mm3. o Serum GOT or GPT > 3 times the upper limit of normal. o Total serum bilirubin > 2 times the upper limit of normal.

Age

• History of neoplasms other than multiple myeloma (except in the case of basal cell skin cancers, squamous cell cancers or carcinoma in situ of the cervix or breast unless the patient has been disease-free for >5 years.

Other

• The patient is pregnant or breastfeeding.

• The patient must, in the investigator’s opinion, be able to fulfill all of the clinical trial requirements.
• The patient must voluntarily sign the informed consent document before any study procedures that are not part of standard clinical care are carried out. The patient must be made aware that they can withdraw from the study at any time without this affecting their future medical care.
• The patient must be aged between 18 and 70 years, and eligible to receive high-dose therapy and autologous peripheral blood stem cell transplant.
• The patient must have been diagnosed with SMM with high risk of progression to symptomatic MM, or ultra-high risk of progression to symptomatic disease in the five years prior to inclusion in the study. It should be emphasized that we are referring to a diagnosis of high-risk SMM during this time period, not to monoclonal gammopathy, or intermediate or low-risk smoldering myeloma. In other words: o SMM with high risk of progression to symptomatic disease: 1. ≥ 10% BM clonal PC and presence of a monoclonal protein, IgG >3 g/dl or IgA >2 g/dl or Bence Jones proteinuria of >1 g/24h and absence of lytic lesions, hypercalcemia, renal failure (creatinine < 2 mg/dl) and anemia (hemoglobin > 10 g/dl, or not 2 g/dl below the lower limit of normal.) 2. ≥ 10% BM clonal PC or IgG >3 g/dl or IgA >2 g/dl, or Bence Jones proteinuria > 1 g/24 h (but not both at the same time), always in the absence of lytic lesions, hypercalcemia, renal failure and anemia. These patients can be included in the study if they fulfill the following additional criteria: - Presence of a percentage of phenotypically abnormal PC in the in plasma cell compartment of the BM (aPC/PC) ≥ 95% and immunoparesis, defined as a reduction in the concentration of 1 or 2 immunoglobulins (lgs) by more the 25%, compared with the normal values of the corresponding lg. o SMM with ultra-high risk of progression to symptomatic disease: 1. Appearance of more than 1 focal lesion on MRI (ideally whole-body MRI) 2. Clonal PC in BM ≥ 60%. 3. Ratio of involved /uninvolved sFLC greater than 100 together with involved free light chain levels great than 100 mg/L.
• The patient must present an ECOG performance status of < 2.
• The patient must be able to attend scheduled visits.
• Women with gestational capacity must have a negative pregnancy test (serum or urine) which will be taken in the 14 days prior to initiation of treatment with the study drug. Sexually active women must also agree to use two methods of contraception [hormonal contraceptives (oral, injectable, or implants)], tubal ligation, intrauterine device, barrier methods with spermicide, or her partner has had a vasectomy) while receiving the study drug. Women with gestational capacity must agree to have a pregnancy test every 4 weeks (urine or serum) while receiving the study drug (or every 14 days if they have irregular menstrual cycles), and 4 weeks after receiving the last dose of the study drug.