This phase II trial compares the combination of selinexor, daratumumab and hyaluronidase-fihj (daratumumab), velcade (bortezomib), and dexamethasone (Dara-SVD) to the usual treatment of daratumumab, lenalidomide, bortezomib, and dexamethasone (Dara-RVD) in treating patients with high-risk newly diagnosed multiple myeloma. Selinexor is in a class of medications called selective inhibitors of nuclear export (SINE). It works by blocking a protein called CRM1, which may keep cancer cells from growing and may kill them. Daratumumab is in a class of medications called monoclonal antibodies. It binds to a protein called CD38, which is found on some types of immune cells and cancer cells, including myeloma cells. Daratumumab may block CD38 and help the immune system kill cancer cells. Bortezomib blocks several molecular pathways in a cell and may cause cancer cells to die. It is a type of proteasome inhibitor and a type of dipeptidyl boronic acid. Dexamethasone is in a class of medications called corticosteroids. It is used to reduce inflammation and lower the body's immune response to help lessen the side effects of chemotherapy drugs. Lenalidomide is in a class of medications called immunomodulatory agents. It works by helping the bone marrow to produce normal blood cells and by killing abnormal cells in the bone marrow. The drugs daratumumab, lenalidomide, bortezomib, dexamethasone and selinexor are already approved by the Food and Drug Administration for use in myeloma. But selinexor is not used until myeloma comes back (relapses) after initial treatment. Giving selinexor in the initial treatment may be a superior type of treatment for patients with high-risk newly diagnosed multiple myeloma.
PRIMARY OBJECTIVE: I. To compare deep response (complete response \[CR\] + stringent CR \[sCR\]) by the end of induction cycle 4 in newly diagnosed high-risk multiple myeloma patients (HR NDxMM), in both study arms. SECONDARY OBJECTIVES: I. To assess the minimal residual disease (MRD)-negativity (10\^-5). II. To assess overall response rate (ORR), very good partial response (VGPR), and partial response (PR). III. To assess progression-free survival (PFS) and duration of response (DOR). CORRELATIVE OBJECTIVE: I. To identify differential gene expression signature that predicts response to selinexor through ribonucleic acid sequencing (RNAseq) and cell-free deoxyribonucleic acid (cfDNA) studies. EXPLORATORY THROMBOEMBOLISM RISK OBJECTIVES: I. To estimate cumulative incidence of venous and arterial thromboembolic events. II. To calculate IMPEDE and SAVED risk scores at baseline and at time of venous thromboembolic event. III. To describe thromboprophylaxis strategies on treatment and venous and arterial thromboembolic events. IV. To estimate incidence of clinically significant (major) bleeding events and assess association with thromboprophylaxis strategy. V. To assess the association of venous and arterial thromboembolic events with PFS and all-cause mortality. OUTLINE: Patients are randomized to 1 of 2 arms. ARM I (Dara-SVD): Patients receive daratumumab and hyaluronidase-fihj subcutaneously (SC) on days 1, 8, 15, \& 22 for cycles 1-2, then days 1 \& 15 for cycles 3-4, and selinexor orally (PO), bortezomib SC, and dexamethasone PO on days 1, 8, 15, \& 22 of each cycle. Treatment repeats every 28 days for up to 4 cycles in the absence of disease progression or unacceptable toxicity. Patients also undergo positron emission tomography (PET), magnetic resonance imaging (MRI), or computed tomography (CT), and bone marrow aspiration and biopsy, and collection of blood and urine samples throughout the study. ARM II (Dara-RVD): Patients receive daratumumab and hyaluronidase-fihj SC on days 1, 8, 15, \& 22 for cycles 1-2, then days 1 \& 15 for cycles 3-4, lenalidomide PO once daily (QD) on days 1-21 of each cycle, and bortezomib SC and dexamethasone PO on days 1, 8, 15, \& 22 of each cycle. Treatment repeats every 28 days for up to 4 cycles in the absence of disease progression or unacceptable toxicity. Treatment repeats every 28 days for up to 4 cycles in the absence of disease progression or unacceptable toxicity. Patients also undergo PET, MRI, or CT, and bone marrow aspiration and biopsy, and collection of blood and urine samples throughout the study. After completion of study treatment, patients are followed up at 6 months and 1 and 2 years.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
Purpose
TREATMENT
Masking
NONE
Enrollment
70
Undergo collection of blood and urine samples
Undergo bone marrow aspiration
Undergo bone marrow biopsy
Given SC
Undergo CT
Given SC
Given PO
Given PO
Undergo MRI
Undergo PET
Given PO
UCI Health - Chao Family Comprehensive Cancer Center and Ambulatory Care
Irvine, California, United States
UCI Health Laguna Hills
Laguna Hills, California, United States
UC Irvine Health/Chao Family Comprehensive Cancer Center
Orange, California, United States
University of California Davis Comprehensive Cancer Center
Sacramento, California, United States
Smilow Cancer Hospital-Derby Care Center
Derby, Connecticut, United States
Deep clinical response
Defined as complete response (CR) + stringent CR.
Time frame: Up to the end of cycle 4 (each cycle = 28 days)
Minimal residual disease-negativity (10^-5)
Will be assessed by next generation flow cytometry.
Time frame: Up to end of cycle 4 (each cycle = 28 days)
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