Bortezomib, Melphalan, and Total-Body Irradiation Before Stem Cell Transplant in Treating Patients With Multiple Myeloma

PRIMARY OBJECTIVES:

I. To determine the maximum tolerated dose (MTD) of bortezomib that can be added to high dose
melphalan and low dose total body irradiation as part of conditioning chemotherapy for
myeloma. (Phase I) II. To determine the efficacy of the bortezomib added to high dose
melphalan and low dose total-body irradiation (TBI) in patients with myeloma undergoing stem
cell transplantation, as defined by achievement of complete response (CR). (Phase II)

SECONDARY OBJECTIVES:

I. To examine the toxicities associated with addition of bortezomib to high dose melphalan
and TBI in patients with multiple myeloma (MM).

II. To determine the progression free rate at 1 and 2 years.

TERTIARY OBJECTIVES:

I. To determine the proportion of patients achieving a minimal residual disease (MRD)
negative status.

II. To assess the HevyLite assay prior to and during treatment.

OUTLINE: This is a phase I, dose-escalation study of bortezomib followed by a phase II study.

CONDITIONING REGIMEN: Patients receive bortezomib intravenously (IV) on days -5 and -2, TBI
twice daily (BID) on days -5 and -2, and melphalan IV over 1 hour on days -4 and -3.

TRANSPLANT: Patients undergo autologous bone marrow or peripheral blood stem cell transplant
on day 0.

After completion of study treatment, patients are followed up at 100 days and then every 90
days for up to 3 years.

Inclusion Criteria:

- Serum creatinine =< 2 mg/dL

- Serum total bilirubin =< 1.5 X upper limit of normal (ULN)

- Platelet count >= 30,000/μL

- Hemoglobin >= 8.0 g/dL

- Diagnosis of myeloma for which autologous stem cell transplant is being considered

- Measurable disease of multiple myeloma at the time of baseline values for disease
assessment as defined by at least one of the following:

- Serum monoclonal protein >= 1.0 g/dL

- >= 200 mg of monoclonal protein in the urine on 24 hour electrophoresis

- Serum immunoglobulin free light chain >= 10 mg/dL AND abnormal serum
immunoglobulin kappa to lambda free light chain ratio

- Bone marrow plasma cells >= 30%

- NOTE:

- For patients with no relapse prior to transplant, measurable disease at the time
of diagnosis

- For patients who have had a disease relapse prior to transplant, measurable
disease at the time of the most recent relapse immediately prior to transplant.

- If the patient had treatment for the relapsed disease prior to transplant, the
patient must have measurable disease at the time of relapse prior to this therapy

- Patient is considered for autologous stem cell transplantation with full dose
melphalan (200 mg/m^2)

- Eastern Cooperative Oncology Group (ECOG) performance status (PS) 0, 1 or 2

- Recovered from non-hematological toxicity of previous chemotherapy (excludes grade 1
neurotoxicity)

- Voluntary written informed consent before performance of any study-related procedure
not part of normal medical care, with the understanding that consent may be withdrawn
by the subject at any time without prejudice to future medical care

- Ejection fraction >= 45%

- Corrected pulmonary diffusion capacity of greater than or equal to 50%

- Forced expiratory volume in one second (FEV1) >= 50%

- Forced vital capacity (FVC) >= 50%

- Negative pregnancy test performed =< 14 days prior to registration, for women of
childbearing potential only

- Willing to return to Mayo Clinic Rochester, for treatment and follow-up

- Note: During the Active Monitoring Phase of a study (i.e., active treatment and
observation), participants must be willing to return to the consenting
institution for follow-up

- Willing to provide blood and bone marrow samples for correlative research purposes

Exclusion Criteria:

- Prior autologous or allogeneic bone marrow/peripheral blood stem cell transplant

- More than two prior regimens for therapy of MM

- Myocardial infarction within 6 months prior to enrollment, or has New York Heart
Association (NYHA) class III or IV heart failure, uncontrolled angina, severe
uncontrolled ventricular arrhythmias, or electrocardiographic evidence of acute
ischemia or active conduction system abnormalities; NOTE: prior to study entry, any
electrocardiogram (ECG) abnormality at screening has to be documented by the
investigator as not medically relevant

- Seroreactivity for human immunodeficiency virus (HIV), human T-cell lymphotrophic
virus (HTLV) I or II, hepatitis B virus (HBV), hepatitis C virus (HCV)

- Other active malignancy < 2 years prior to registration; EXCEPTIONS: non-melanotic
skin cancer or carcinoma-in-situ of the cervix or low-risk prostate cancer after
curative therapy

- NOTE: If there is a history of prior malignancy, they must not be receiving other
specific treatment for their cancer

- Any of the following:

- Pregnant women or women of reproductive capability who are unwilling to use
effective contraception (2 effective methods of contraception, at the same time)
from the time of signing the informed consent through 30 days after the last dose
of study treatment, OR unwilling to agree to completely abstain from heterosexual
intercourse

- Nursing women

- Men who are unwilling to use a condom (even if they have undergone a prior
vasectomy) while having intercourse with any woman, while taking the drug and for
30 days after stopping treatment

- Unwilling to agree to completely abstain from heterosexual intercourse

- Other co-morbidity, which would interfere with patient's ability to participate in the
trial, e.g. uncontrolled infection, uncompensated lung disease or psychiatric illness

- Concurrent chemotherapy, radiotherapy, or any ancillary therapy considered
investigational; NOTE: bisphosphonates are considered to be supportive care rather
than therapy, and are thus allowed while on protocol treatment

- Known allergies to any of the components of the investigational treatment regimen or
required ancillary treatments

- Patient has >= grade 2 peripheral neuropathy

- Participation in clinical trials with other investigational agents not included in
this trial, within 14 days of the start of this trial and throughout the duration of
this trial