71 y/o female diagnosed with high risk smoldering myeloma initially (M protein 2.1 IgG lambda and 50% plasma cells on BMBx). She was treated with Len-Dex for 15 months. She then started to show signs of progression (M protein elevated to 2.7, hemoglobin worsening to 8 with no other cause). She was restaged, repeat BMBx with 25% plasma cells, standard risk cytogenetics trisomy 11, b2 microglobulin 10.2 (H) and normal LDH with 2% plasma cells in peripheral blood. No bone disease or worsening creatinine/calcium. What are thoughts on treatment with Dara-VD considering that she is Len refractory now. She is a poor transplant candidate. After treatment with triplet Dara-VD, what are thoughts on Dara maintenance? Lastly, what would be her best options if she does not respond to Dara-VD ?
I would treat this patient now as multiple myeloma and I suspect her disease was already borderline at the time of her SMM diagnosis based on the degree of plasmacytosis. Daratumumab-Vd is certainly appropriate and you can also consider adding either pomalidomide or cyclophosphamide to her regimen. The latter may particularly be helpful if you think she is developing PCL and you need a faster response. With dose modifications, I have been able to get patients like this through quadruplets (weekly bortezomib, 3mg dose of POM, lower dose cytoxan IV weekly etc). After induction therapy, maintenance therapy should certainly include daratumumab and you can also continue bortezomib twice monthly until we can be sure her disease is under control.
