Cyclophosphamide and Pulse Dexamethasone With Rapamycin or Hydroxychloroquine

Multiple myeloma is a plasma cell neoplasm with median survival of 3 to 5 years. Recent
advances have improved patient outlook, but the disease remains incurable and patients
become refractory to treatments, develop organ dysfunction from myeloma itself, and
encounter severe toxicities from therapies, limiting further treatment options. Subjects
over the age of 18 with relapsed or refractory multiple myeloma who have had at least one
prior therapy, have a life expectancy of at least 4 weeks and an ECOG performance status of
0,1 or 2 will be included. The investigators propose an initial pilot trial to test the
feasibility of giving standard chemotherapy with infusional cyclophosphamide and pulse
dexamethasone (cy/dex) for four days, together with the investigational agents, oral
rapamycin (cohort A), and in a separate parallel arm, oral hydroxychloroquine (HCQ) (cohort
B). The investigators will enroll 3 patients on cohort A and 3 patients on cohort B, both
at the planned 1st dose level for the overall phase I/II trial which will succeed this trial
if feasibility is demonstrated. The 6 patients from this pilot trial will be included in
total number of patients for the overall study which will be completed when further funding
is secured. Feasibility will be defined by the ability to deliver the regimen as planned
and the ability to perform the planned correlative studies. Subjects will receive up to 12
cycles and will be followed for 12 months after the last cycle. Data collected will include
toxicity, response rates, correlative studies to examine the pharmacodynamics of mTOR
inhibition and autophagy and the pharmacokinetics of rapamycin and HCQ.

Inclusion Criteria:

Each subject must meet ALL of the following criteria during screening to be enrolled:

- Histologically confirmed multiple myeloma

- Documented relapse or persistent disease after at least one prior therapy (which may
include autologous and allogeneic bone marrow transplantation)

- Need for further therapy for myeloma, as determined by the patients treating
physician

- Age 18 years

- ECOG PS 0-2

Exclusion Criteria:

History of allergic reactions to compounds of similar chemical or biological composition
to rapamycin or hydroxychloroquine

- Patients may not take any of the following medications while on study (in the
rapamycin arms only), but will be considered eligible if medication is discontinued
72 hrs prior to first dose of Rapamycin:

- Carbamazepine (e.g. Tegretol)

- Rifabutin (e.g. Mycobutin)

- Rifampin (e.g. Rifadin)

- Rifapentine (e.g. Priftin)

- St. Johns Wort Clarithromycin (e.g. Biaxin)

- Cyclosporin e.g. (Neorla or Sandimmune)

- Diltiazem (e.g. Cardizem)

- Erythromycin (e.g. Akne-Mycin, Ery-Tab)

- Itraconazole (e.g. Sporonox)

- Fluconazole (e.g. Diflucan)

- Ketoconazole (e.g. Nizoral)

- Telithromycin (e.g. Ketek)

- Verapamil (e.g. Calan SR, Isoptin, Verelan)

- Voriconazole (e.g. VFEND)Tacrolimus (e.g. Prograf)

- Known macular degeneration or retinopathy (diabetic or otherwise), porphyria, or
psoriasis (well-controlled psoriasis allowed provided under the care of a specialist
who agrees to monitor the patient for exacerbations)

- Patients with the following cytopenias: ANC 1.0 x 109/L; Platelets 50 x 109/L

- Serum Creatinine 2.5 mg/dL; Total or Direct Bilirubin 2.0 mg/dL; Fasting Glucose
200mg/dL

- Other conditions that would require therapy with hydroxychloroquine, including but
not limited to, any of the following:

- Systemic lupus

- Rheumatoid arthritis

- Porphyria cutanea tarda

- Malaria treatment or prophylaxis

- Other active malignancy, except:

- Basal cell or squamous cell carcinoma of the skin

- Treated carcinoma in situ

- Localized prostate adenocarcinoma (stage T1a or T1b) with a stable PSA for a
period of at least 4 months allowed

- Patients with a prior malignancy treated with chemotherapy, biologic agents,
and/or radiation are eligible for this study if they have completed therapy 4
years previously with no evidence of recurrent disease

- Patients with a prior malignancy treated with surgery alone are eligible for
this study if they have completed therapy 2 years previously with no evidence of
recurrent disease

- Uncontrolled intercurrent illness including, but not limited to, any of the
following:

- Uncontrolled ongoing infection

- Symptomatic congestive heart failure

- Unstable angina pectoris

- Uncontrolled cardiac arrhythmia

- Psychiatric illness or social situations that would limit compliance with study
requirements

- Inability to understand or unwillingness to sign the informed consent document

- Concurrent anti-myeloma therapy within:

- 7 days of prior corticosteroids

- 14 days of prior antimyeloma agents, including thalidomide or lenalidomide

- 28 days of a different investigational regimen

- 14 days of any radiation

- Women of child-bearing who are unwilling or unable to use an acceptable method to
avoid pregnancy for the entire study period and for up to 30 days after the last dose
of study drug.

- Women who are pregnant or breastfeeding