54 yo female with clinically aggressive myeloma diagnosed in 2021 (FISH at diagnosis with gain 1q) s/p Dara-VRD, KCyPomd, VD-PACE, and Abecma (pre-CAR T FISH unable to perform due to insufficient cells) but relapsed at 6 months post CART with purely extramedullary disease (soft tissue plasmacytomas in extremities, abdomen, and pelvis), then started on Teclistamab, however, she further progressed, ended up receiving a cycle of DPACE. No organ failure so far and relatively OK performance status. What would you consider as the next therapeutic steps?
Tough case. The first answer would be clinical trial if available. Not sure if your site/ nearby site has access to trials. In general the next therapy would be a non-BCMA targeted bispecific.: Ie Talquetamab or cevostamab. Talquetamb is pending FDA approval and likely to receive this at any time now. So if trial is not available one option is to contact Janssen for compassionate use talquetamab. Other non trial option is selinexor based therapy. Would probably give selinexor-velcade-dex (boston regimen). Alternatively you could give isatuximab-selinexor-dex. This is not FDA approved, but the patient has been off of CD38 for a while and Isa has some enhanced efficacy in 1q gain patients. One question. Does she have any stem cells collected and has she ever had stem cell transplant? I dont see high-dose melphalan given and if you have cells and that hasnt been given consider that.
