Daratumumab-bortezomib-dexamethasone (Dara-VCd) vs Bortezomib-Thalidomide-Dexamethasone (VTd), Then Maintenance With Ixazomib (IXA) or IXA-Dara

Prior treatment

• Patient has prior or current systemic therapy or SCT for multiple myeloma, with the exception of an emergency use of a short course (equivalent of dexamethasone 40 mg/day for a maximum 4 days) of corticosteroids before treatment.
• Contraindication to any of the required concomitant drugs or supportive treatments.

Other illness

• Patient with a diagnosis of Waldenström's disease, or other conditions in which immunoglobulin M (IgM) M-protein is present in the absence of a clonal plasma cell infiltration with lytic bone lesions.
• Patient has peripheral neuropathy of grade 2 or higher as defined by National Cancer Institute Common Toxicity Criteria (NCI CTC) 4.0.
• Clinical active infectious hepatitis type A, B, C or HIV.
• Subject has known chronic obstructive pulmonary disease (COPD) (defined as a Forced Expiratory Volume In 1 second (FEV1) \<60% of predicted normal), persistent asthma, or a history of asthma within the last 2 years. Subjects with known or suspected COPD or asthma must have a FEV1 test during screening.
• Evidence of current uncontrolled cardiovascular conditions, including uncontrolled hypertension, uncontrolled cardiac arrhythmias, symptomatic congestive heart failure, unstable angina, or myocardial infarction within the past 6 months.
• Known allergy to any of the study medications, their analogues, or excipients in the various formulations.

Lab values

• Patient with a diagnosis of primary amyloidosis, monoclonal gammopathy of undetermined significance, smoldering MM or Plasma Cell Leukemia (PCL). Monoclonal gammopathy of undetermined significance is defined by presence of serum M-protein \<3 g/dL, clonal bone marrow plasma cells \<10%, and absence of end-organ damage or amyloidosis that can be attributed to the plasma cell proliferative disorder. Smoldering multiple myeloma is defined as serum monoclonal protein ≥ 30 g/L or urinary monoclonal protein ≥ 500 mg per 24 h and/or clonal bone marrow plasma cell 10-60% with absence of related organ or tissue impairment or end-organ damage or amyloidosis. Plasma cell leukemia is defined as presence of circulating plasmacells (PCs) \>2×109/L in peripheral blood or a peripheral blood plasmacytosis \>20%

Other

• Patient is exhibiting clinical signs of meningeal involvement of multiple myeloma.
• Pregnant or lactating females.

• Patient at least 18 years of age and ≤ 65 years.
• Patient eligible for autologous stem cell transplantation (ASCT).
• Left Ventricular Ejection Fraction (LVEF) ≥ 40%. 2-D transthoracic echocardiogram (ECHO) is the preferred method of evaluation. Multigated Acquisition Scan (MUGA) is acceptable if ECHO is not available.
• Newly diagnosed multiple myeloma patient.
• Patient has given voluntary written informed consent before performance of any study related procedure not part of standard medical care, with the understanding that consent may be withdrawn by the patient at any time without prejudice to future medical care.
• Patient with documented multiple myeloma and measurable disease as defined by:
• Monoclonal plasma cells in the bone marrow ≥10% or presence of a biopsy proven plasmacytoma
• Measurable disease as defined by at least one of the following:
  • serum M-protein level ≥1 g/dL or urine M-protein level ≥200 mg/24 hours; or
  • Light chain multiple myeloma: Serum immunoglobulin free light chain ≥10 mg/dL and abnormal serum immunoglobulin kappa lambda free light chain ratio.
• Evidence of end organ damage/presence of biomarkers of malignancies, specifically:
• Hypercalcaemia: serum calcium \>0.25 mmol/L (\>1 mg/dL) higher than the upper limit of normal or \>2.75 mmol/L (\>11 mg/dL)
• Renal insufficiency: creatinine clearance (CLcr)\<40 mL per minute (measured or estimated by validated equations) or serum creatinine \>177 μmol/L (\>2 mg/dL)
• Anaemia: haemoglobin value of \>20 g/L below the lower limit of normal, or haemoglobin value \<100 g/L
• Bone lesions: one or more osteolytic lesions on skeletal radiography, CT, or PET-CT. If bone marrow has \<10% clonal plasma cells, more than one bone lesion is required to distinguish from solitary plasmacytoma with minimal marrow involvement
• Any one or more of the following biomarkers of malignancy:
• Clonal bone marrow plasma cell percentage ≥ 60% (clonality should be established by showing κ/λ-light-chain restriction on flow cytometry, immunohistochemistry, or immunofluorescence. Bone marrow plasma cell percentage should preferably be estimated from a core biopsy specimen; in case of a disparity between the aspirate and core biopsy, the highest value should be used)
• Involved:uninvolved serum free light chain ration ≥ 100 (values based on the serum Free light assay. The involved free light chain must be ≥100 mg/L)
  • -\> 1 focal lesion on MRI (magnetic resonance imaging) studies (each focal lesion must be 5 mm or more in size) Patient is, in the investigator(s) opinion willing and able to comply with the protocol requirements.
• Women of childbearing potential must commit to either abstain continuously from heterosexual intercourse or to use 2 methods of reliable birth control simultaneously. This includes one highly effective form of contraception (tubal ligation, intrauterine device, hormonal \[birth control pills, hormonal patches, vaginal rings or implants\] or partner's vasectomy) and one additional effective contraceptive method (male latex or synthetic condom, diaphragm, or cervical cap). Contraception must begin prior to dosing through 90 days after the last dose of study drug. Reliable contraception is indicated even where there has been a history of infertility, unless due to hysterectomy or bilateral oophorectomy.
• Male patient agrees to use an acceptable method for contraception (i.e., condom or abstinence) during study drug therapy (including dose interruption) and for 90 days after the last dose of study drug.
• Patient with an Eastern Cooperative Oncology Group (ECOG) performance status score of 0, 1, or 2 or Karnofsky performance status ≥ 60%.
• Pretreatment clinical laboratory values within 30 days of enrolment:
• Platelet count ≥75 x 109/L;
• Absolute neutrophil count (ANC) ≥ 1 x 109/L (G-CSF use is permitted);
• Corrected serum calcium \<14 mg/dL (\<3.5 mmol/L);
• Aspartate transaminase (AST) ≤ 2.5 x the upper limit of normal (ULN);
• Alanine transaminase (ALT) ≤ 2.5 x the ULN;
• Total bilirubin ≤ 1.5 x the ULN;
• Calculated or measured creatinine clearance ≥ 30 mL/minute.
• Patient has a life-expectancy \>3 months.