According to international guidelines, upfront therapy for transplant eligible myeloma
patients should include triplet induction containing proteasome inhibitor and
immunomodulatory agent, autologous stem cell transplant, PI+Imid based triplet consolidation
and lenalidomide maintenance. Despite this approach, virtually all MM patients experience
disease relapse, especially those with High Risk disease defined by adverse cytogenetic
abnormalities (i.e. del(17p), or t(14;16) or t(4;14)) detected by FISH and/or SNP arrays.
Indeed, HR myeloma is associated with poorer progression free survival and overall survival
and frontline therapy should therefore be improved for this subset of HR patients. The
primary objective of this prospective multicenter, open label, interventional phase 2 trial
is to evaluate the feasibility of an intensive program including quadruplet induction and
consolidation, tandem autologous stem cell transplantation and maintenance in newly diagnosed
multiple myeloma patients presenting with HR cytogenetic. Quadruplet induction and
consolidation include carfilzomib, lenalidomide, dexamethasone and daratumumab. Maintenance
will include lenalidomide and daratumumab. Secondary objectives will include efficacy
parameters (i.e. response rate, minimal residual disease, safety, progression free survival,
1. Male or female subjects, 18 years of age or older, younger than 66 years (< 66 years)
2. Voluntary written informed consent must be given before performance of any
study-related procedure not part of normal medical care, with the understanding that
the subject may withdraw consent at any time without prejudice to future medical care.
3. Subject must have documented multiple myeloma satisfying the Diagnostic criteria for
symptomatic Myelome Multiple and measurable disease as defined by:
- Monoclonal plasma cells in the bone marrow ≥ 10% or presence of a biopsy proven
plasmacytoma AND any one or more of the following myeloma defining events:
- Hypercalcemia: serum calcium > 0.25 mmol/L higher than ULN or > 2.75 mmol/L
- Renal insufficiency: creatinine clearance < 40mL/min or serum creatinine >
- Anemia: hemoglobin > 2 g/dL below the lower limit of normal or hemoglobin <
- Bone lesions: one or more osteolytic lesions on skeletal radiography, CT or
- Clonal bone marrow plasma cell percentage ≥ 60%
- Involved: uninvolved serum free light chain ratio ≥ 100
- Superior 1 focal lesion on MRI studies
- Measurable disease as defined by the following:
M-component ≥ 5g/l, and/or urine M-component ≥ 200 mg/24h and/or serum Free Light
Chain ≥ 100 mg/l.
4. Newly diagnosed subjects eligible for high dose therapy and autologous stem cell
5. Subject must have high risk disease according to FISH analysis: del(17p), or t(14;16)
or t(4;14). The FISH-positivity cut-off value for defining the presence of del(17p) in
this study is 50%
6. Karnofsky performance status score ≥ 50%
7. Women of childbearing potential must have a negative serum or urine pregnancy test
within 10 to 14 days prior to therapy and repeated within 24 hours before starting
study drug. They must commit to continued abstinence from heterosexual intercourse or
begin 2 acceptable methods of birth control used at the same time, beginning at least
4 weeks before initiation of lenalidomide treatment and continuing for at least 30
days after the last dose of Lenalidomide. Women must also agree to notify pregnancy or
doubt upon pregnancy during the study.
8. Men must agree to not father a child and agree to use a latex condom during therapy
and for 4 weeks after the last dose of study drug, even if they have had a successful
vasectomy, if their partner is of childbearing potential.
9. Subject must have pretreatment clinical laboratory values meeting the following
criteria during the Screening Phase (Lab tests should be repeated if done more than 15
days before C1D1):
1. Hemoglobin ≥ 7.5 g/dL. Prior red blood cell transfusion or recombinant human
erythropoietin use is permitted;
2. Absolute neutrophil count ≥ 1.0 Giga/l (GCSF use is permitted);
3. ASAT ≤ 3 x ULN;
4. ALAT ≤ 3 x ULN;
5. Total bilirubin ≤ 3 x ULN (except in subjects with congenital bilirubinemia, such
as Gilbert syndrome, direct bilirubin ≤ 1.5 x ULN);
6. Calculated creatinine clearance ≥ 40 mL/min/1.73 m² ;
7. Corrected serum calcium ≤ 14 mg/dL; or free ionized calcium ≤6.5 mg/dL;
8. Platelet count ≥ 50 Giga/l for subjects in whom < 50% of bone marrow nucleated
cells are plasma cells; otherwise platelet count > 50 Giga/l (transfusions are
not permitted to achieve this minimum platelet count).
10. Affiliation with French social security system or beneficiary from such system
1. Subjects must not have been treated previously with any systemic therapy for multiple
myeloma. Prior treatment with corticosteroids or radiation therapy does not disqualify
the subject (the maximum dose of corticosteroids should not exceed the equivalent of
160 mg of dexamethasone in a 2-week period). Two weeks must have elapsed since the
date of the last radiotherapy treatment. Enrolment of subjects who require concurrent
radiotherapy (which must be localized in its field size) should be deferred until the
radiotherapy is completed and 2 weeks have elapsed since the last date of therapy
2. Subject has received daratumumab or other anti-CD38 therapies previously
3. Subject has a diagnosis of primary amyloidosis, monoclonal gammopathy of undetermined
significance, smoldering multiple myeloma, or solitary plasmacytoma.
4. Subject has a diagnosis of Waldenström's macroglobulinemia, or other conditions in
which IgM M-protein is present in the absence of a clonal plasma cell infiltration
with lytic bone lesions.
5. Subject has had plasmapheresis within 28 days of C1D1.
6. Subject is exhibiting clinical signs of meningeal involvement of multiple myeloma.
7. Myocardial infarction within 6 months prior to enrolment according to NYHA Class III
or IV heart failure, uncontrolled angina, severe uncontrolled ventricular arrhythmias,
or electrocardiographic evidence of acute ischemia or active conduction system
8. Uncontrolled hypertension
9. Subjects with known chronic obstructive pulmonary disease (COPD) with a Forced
Expiratory Volume (FEV1) in 1 second < 50% of predicted normal. Note that FEV1 testing
is required for patients suspected of having COPD and subjects must be excluded if
FEV1 < 50% of predicted normal.
10. Subjects with a history of moderate or severe persistent asthma within the past 2
years, or with uncontrolled asthma of any classification at the time of screening
(Note that subjects who currently have controlled intermittent asthma or controlled
mild persistent asthma are allowed in the study).
11. Subject has plasma cell leukemia (according to WHO criterion: ≥ 20% of cells in the
peripheral blood with an absolute plasma cell count of more than 2 × 10^9/L) or
polyneuropathy, organomegaly, endocrinopathy, monoclonal protein, and skin changes
12. Systemic treatment with strong inhibitors of CYP1A2 (fluvoxamine, enoxacin), strong
inhibitors of CYP3A (as clarithromycin, telithromycin, itraconazole, voriconazole,
ketoconazole, nefazodone, posaconazole) or strong CYP3A inducers (as rifampin,
rifapentine, rifabutin, carbamazepine, phenytoin, fosphenytoin phenobarbital), or use
of Ginkgo biloba or St. John's wort within 14 days before the first dose of study
13. Known intolerance to steroid therapy
14. History of hypersensitivity to any of the study medications, their analogues, or
excipients in the various formulations, or to study-required co medication
15. Subject has had major surgery within 2 weeks before the first dose of study treatment
or will not have fully recovered from surgery, or has surgery planned during the time
the subject is expected to participate in the study. Kyphoplasty or Vertebroplasty are
not considered major surgery.
16. Clinically relevant active infection or serious co-morbid medical conditions
17. Prior malignancy except adequately treated basal cell or squamous cell skin cancer, in
situ cervical, breast or prostate cancer free of disease since 5 years.
18. Female subject who is pregnant or breast-feeding + male and female refusing birth
19. Serious medical or psychiatric illness likely to interfere with participation in study
20. Uncontrolled diabetes mellitus
21. Known HIV infection; Known active hepatitis B or C viral infection; or other ongoing
22. Incidence of gastrointestinal disease that may significantly after the absorption of
23. Subjects unable or unwilling to undergo antithrombotic prophylactic treatment
24. Person under guardianship, trusteeship or deprived of freedom by a judicial or