Carfilzomib in Treatment Patients Under 65 Years With High Risk Smoldering Multiple Myeloma

Prior treatment

• Previous treatment for smoldering multiple myeloma.
• Prior history of neoplasm other than multiple myeloma (except for basal cell or squamous cell carcinoma of the skin or carcinoma in situ of the cervix or breast) unless the patient has been disease-free for \> 5 years.
• Major surgery within 4 weeks before inclusion in the study.
• Any investigational drug within 30 days before inclusion in the study.
• Acute active infection requiring treatment (systemic antibiotics, antivirals, or antifungals) within 14 days prior to enrolment.
• Unstable angina or myocardial infarction within 6 months prior to enrollment, New York Heart Association (NYHA) Class III or IV heart failure, uncontrolled angina, history of severe coronary artery disease, severe uncontrolled ventricular arrhythmias, sick sinus syndrome, or electrocardiographic evidence of acute ischemia or Grade 3 conduction system abnormalities unless subject has a pacemaker.
• Significant neuropathy (Grades 3?4, or Grade 2 with pain) within 14 days prior to enrollment.
• Contraindication to any of the required concomitant drugs or supportive treatments, including intolerance to hydration due to pre-existing pulmonary or cardiac impairment.

Other illness

• Any physical condition or psychiatric disorder that would prevent the patient from signing or understanding the informed consent form.
• Presence of lytic lesions, anemia, renal failure or hypercalcemia.
• Known active infection by human acquired immunodeficiency virus, B or C hepatitis virus.
• Uncontrolled hypertension or uncontrolled diabetes.
• Known history of allergy to Captisol (a cyclodextrin derivative used to solubilize carfilzomib).
• Pulmonary hypertension

Lab values

• Any of the following laboratory abnormalities:
  • Absolute neutrophil count (ANC) less than 1,000/mm3
  • Platelet count less than 75,000/mm3.
  • Serum GOT or glutamic pyruvic transaminase (GPT) greater than 3 x upper limit of normal
  • Serum total bilirubin greater than 2 x upper limit of normal
• Left ventricular ejection fraction (LVEF) less than 40

Other

• Pregnancy or breastfeeding.

• In the investigator's opinion, the patient must be able to fulfill all the clinical trial requirements.
• The patient must voluntarily sign the informed consent before any study procedure that is not part of the standard of care for these patients is performed, with the patient's knowledge that he/she may withdraw from the study at any time, without prejudice to his/her future 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 be diagnosed with smoldering multiple myeloma at high risk of progressing to symptomatic multiple myeloma, or at ultra high risk of progression to symptomatic disease, defined by:
• smoldering multiple myeloma at high risk of progression to symptomatic disease:
  • Bone marrow infiltration with plasma cells (PCs) greater than or equal 10% and presence of a monoclonal component, immunoglobulin G (IgG) greater than3 g/dL or IgA greater than 2 g/dL or Bence Jones proteinuria greater than 1 g/24h and absence of lytic lesions, hypercalcemia, renal failure (creatinine less than 2 mg/dL) and anemia (hemoglobin greater than 10 gr/dL or not 2 gr/dL below the lower limit of normal).
  • Bone marrow infiltration with PCs greater than or equal 10% OR IgG greater than 3 g/dL or immunoglobulin A (IgA) greater than 2 g/dL or Bence Jones proteinuria greater than 1g/24h (but not both together) and always in the absence of lytic lesions, hypercalcemia, renal failure and anemia. These patients may be included in the study if they meet the following additional criteria: A percentage of phenotypically aberrant plasma cells (PCs) within the bone marrow (BM) PC compartment (aPC/ BM PC) greater than or equal 95% and immunoapheresis, defined as a reduction in the levels of 1 or 2 immunoglobulin (Igs) of more than 25% compared with the normal values of the corresponding Ig.
  • \- smoldering multiple myeloma at ultra high risk of progression to symptomatic disease:
  • Presence of more than 1 focal lesion in MRI (ideally whole body MRI).
  • Infiltration in the BM equal or higher than 60%.
  • Ratio of involved/uninvolved serum Friend leukemia cell (FLC) higher than 100.
• The patient must have an Eastern Cooperative Oncology Group (ECOG) performance status less than 2.
• The patient must be able to attend the scheduled visits.
• Women of childbearing potential must have a negative pregnancy test (serum or urine) within the 14 days before the starting the study drug. In addition, sexually active women must agree to use contraceptive methods (hormone contraceptives \[oral, injectable or implanted\], tubal ligation, intrauterine device, barrier contraceptives with spermicide or have a vasectomised partner) while receiving the study drug. Women of childbearing potential must agree to undergo pregnancy tests every 4 weeks while receiving the study drug (every 14 days for women with irregular menstrual cycles) and 4 weeks after the last dose of study drug.