Lenalidomide and High-Dose Melphalan

The Study Drugs:

Melphalan is designed to damage the DNA (the genetic material of cells) of cells, which may
cause cancer cells to die. High-dose melphalan is considered the standard of care for
multiple myeloma.

Lenalidomide is designed to block a protein that plays a role in cell function and growth,
which may cause cancer cells to die.

Study Dose Levels:

If you agree to take part in this study, you will be assigned to a dose level of
lenalidomide based on when you join this study. Up to 4 dose levels of lenalidomide will be
tested for safety. The first group of participants will receive the lowest dose level.
Each new group will receive a higher dose than the group before it, if no intolerable side
effects were seen.

All participants will receive the same dose level of melphalan.

Once the highest tolerable dose of the combination of melphalan and lenalidomide is found,
the next group of patients will be randomly assigned to 1 of 4 possible groups that will be
determined by the computer, based on the safest and most effective dose level at that
particular point.

Study Drug Administration:

You will take lenalidomide by mouth 1 time a day beginning 8 days before the stem cell
transplant (Day -8). You will take the drug for 7 days (Days -8 through -2). You should
take it with a few sips of water.

On Days -3 and -2, you will receive melphalan by vein over 30 minutes.

On Day 0, after you have received the chemotherapy study drugs, you will receive an infusion
of stem cells, which were previously collected from you. This infusion of stem cells is
given in an effort to help increase blood production and strengthen your immune system. You
will receive antibiotics in an effort to decrease the likelihood that you will develop an
infection.

Hospitalization following transplant usually lasts about 2-4 weeks, but may be longer. Some
participants may be discharged earlier and followed in the outpatient clinic.

Study Visits:

About 1 month, 3 months, and 6 months after the transplant:

- You will have a physical exam and your medical history will be recorded.

- Blood (about 2 tablespoons) and urine will be collected for routine tests and to check
the status of the disease.

- About 3 months after the transplant, you will have a bone marrow biopsy and aspiration
to check the status of the disease. This will be repeated more often, if your doctor
thinks it is needed.

About 1 year after the transplant:

- You will have a physical exam and your medical history will be recorded.

- Blood (about 2 tablespoons) and urine will be collected for routine tests.

- You will have a bone marrow biopsy and aspiration to check the status of the disease.

- You will have x-rays of your bones to check the status of the disease.

Length of Study:

Your participation in this study will be over after the 1 year transplant follow-up visit.

If intolerable side effects from the chemotherapy occur or there is sign of disease after
the transplant, you will be taken off study. If you have intolerable side effects after you
receive melphalan, then you will still have the transplant. However, if intolerable side
effects develop before you take melphalan, you may be taken off study without having the
transplant. If you are taken off study early, you still may need to return for routine
post-transplant follow-up visits, if your transplant physician decides it is necessary.

It may be life-threatening to leave the study early during the conditioning regimen without
following up with the stem cell transplant, because your blood cell counts may be
dangerously low.

This is an investigational study. Lenalidomide and melphalan are commercially available and
FDA approved for the treatment of myeloma. However, the use of lenalidomide with melphalan
before an autologous stem cell transplant is investigational.

Up to 60 patients will take part in this study. All will be enrolled at MD Anderson.

Inclusion Criteria:

1. Patients with multiple myeloma with relapsed or progressive disease after achieving a
partial or complete response to prior conventional therapy or autologous stem cell
transplantation

2. Age 18 to 80 years

3. Performance score of at least 80% by Karnofsky or performance score of 0 or 1 (ECOG)

4. Left ventricular ejection fraction =/> 40%. No uncontrolled arrhythmias or
symptomatic cardiac disease.

5. FEV1, FVC and DLCO=/> 40%. No symptomatic pulmonary disease.

6. Serum bilirubin <2 x upper limit of normal, SGPT <3x upper limit of normal. No
evidence of chronic active hepatitis or cirrhosis. No pleural effusion or ascites > 1
L prior to drainage.

7. Creatinine Clearance =/> 50 ml/min

8. HIV negative

9. Negative beta HCG test in women with child bearing potential, defined as not
post-menopausal for 24 months or no previous sterilization.

10. Patients or guardian able to sign informed consent.

11. All study participants must be registered into the mandatory RevAssist® program, and
be willing and able to comply with the requirements of RevAssist®.

12. Females of childbearing potential (FCBP) must have a negative serum pregnancy test
with a sensitivity of at least 50 mIU/mL within 10 -14 days prior to and again within
24 hours of prescribing lenalidomide (prescriptions must be filled within 7 days) and
must either commit to continued abstinence from heterosexual intercourse or begin TWO
acceptable methods of birth control, one highly effective method and one additional
effective method AT THE SAME TIME, at least 4 weeks before she starts taking
lenalidomide.

13. Contd. FCBP must also agree to ongoing pregnancy testing. Men must agree to use a
latex condom during sexual contact with females of child bearing potential even if
they have had a successful vasectomy. See Appendix F: Risks of Fetal Exposure,
Pregnancy Testing Guidelines and Acceptable Birth Control Methods.

Exclusion Criteria:

1. Fertile men or women unwilling to use contraceptive techniques during and for 12
months following treatment.

2. Patients with uncontrolled hypertension (systolic > 140, diastolic >90 despite
anti-hypertensive therapy.)

3. Patients with uncontrolled bacteria, viral or fungal infections (currently taking
medication and progression of clinical symptoms).

4. Known hypersensitivity or desquamating rash to either thalidomide or lenalidomide.

5. Women who are pregnant (positive ß-HCG) or breastfeeding. (Lactating women must agree
not to breast feed while taking lenalidomide and for 28 days after last dose of
lenalidomide.)

6. New York Heart Association (NYHA) Class III or IV heart failure, uncontrolled angina,
severe uncontrolled ventricular arrhythmia's, or electrocardiographic evidence of
acute ischemia, or a 2nd or 3rd degree AV block or new left bundle branch block on
EKG.