Immuno-PRISM (PRecision Intervention Smoldering Myeloma): A Randomized Phase II Platform Study of Select Immunotherapies for High-Risk Smoldering Myeloma

Protocol # :
High-risk Smoldering Multiple Myeloma
Smoldering Multiple Myeloma
Multiple Myeloma
Disease Sites
Multiple Myeloma
Principal Investigator
Ghobrial, Irene, M
Site Research Nurses
Barrell, Anna
Davie, Christine, M.
Doherty, Randi
Ricciardi, Caroline
Spillane, Kerry, L.
Tattersall, Alice, Emily
Ward, Mackenna

Trial Description

The purpose of this study is to test the anti-cancer activity of Teclistamab and to
compare it with Lenalidomide + Dexamethasone combination in people with high risk
smoldering multiple myeloma.

People with smoldering multiple myeloma (SMM) usually do not have symptoms but are at
risk for progressing to active multiple myeloma (MM). Multiple Myeloma is a cancer of the
plasma cells, which are an important part of the immune system. Patients with active
multiple myeloma generally require treatment but there are currently no approved
therapies for smoldering multiple myeloma.

The names of the study drugs involved in this study are:

- Teclistamab

- Lenalidomide (also called Revlimid)

- Dexamethasone (also called Decadron)

Eligibility Requirements

Inclusion Criteria:

- Age ≥18 years.


1) High risk SMM defined as having 1 of the following 2 criteria: High risk per
"20-2-20" Criteria defined as presence of any two of the following:

-- Serum M spike ≥ 2 gm/dL, Involved to uninvolved free light chain (FLC) ratio≥ 20,
Bone marrow Plasma Cell (BMPC) % ≥ 20%

- OR total score of 9 using the following scoring system:

- FLC Ratio >10-25 = 2, >25-40 = 3, > 40 = 5

- Serum M-Protein (g/dL) >1.5-3 = 3, >3 = 4

- BMPC% >15-20 = 2, >20-30 = 3, >30-40 = 5, >40 = 6

- Fluorescence In Situ Hybridization (FISH) abnormality (t(4,14), t(14,16), 1q gain,
or del13q = 2


2) Presence of ≥10% BMPC and at least one of the following:

-- Evolving pattern:

- evolving Monoclonal Protein (eMP) (≥10% increase in Monoclonal
Protein/Immunoglobulin (Ig)) within the first 6 months (only if M-protein ≥3
g/dl) and/or ≥25% increase in M/Ig within the first 12 months, with a minimum
required increase of 0.5 g/dl in M-protein and/or 500 mg/dl in Ig.

- Evolving change in hemoglobin (eHb) ≥0.5 g/dl decrease within 12 months of

- Progressive involved light chain increase on two successive evaluation

- Abnormal Plasma Cell immunophenotype (≥ 95% of BMPCs are clonal) and reduction
of ≥1 uninvolved immunoglobulin isotype. (Only IgG; IgA and IgM will be

- High risk cytogenetics defined as presence of t(4;14), t(14;16), t(14;20), 17p
deletion, TP53 mutation, 1q21 gain

- No evidence of CRAB criteria* or new criteria of active MM (SLIM-CRAB) which include
the following:

- Increased calcium levels: Corrected serum calcium >0.25 mmol/L (>1mg/dL) above
the upper limit of normal or >2.75 mmol/L (>11mg/dL);

- Renal insufficiency (attributable to myeloma);

- Anemia (Hgb 2g/dL below the lower limit of normal or <10g/dL);

- Bone lesions (lytic lesions or generalized osteoporosis with compression

- No evidence of the following new criteria for active MM including the

- Bone marrow plasma cells >60%

- Serum involved/uninvolved FLC ratio ≥100

- MRI with more than one focal lesion

- Participants with CRAB criteria that are attributable to conditions other than the
disease under study may be eligible after discussion with the Sponsor Investigator.

- Eastern Cooperative Oncology Group (ECOG) Performance Status (PS) 0, 1, or 2

- The following laboratory values obtained <28 days prior to registration:

- Absolute Neutrophil Count (ANC) >1000/mL

- Platelets Count (PLT) >75,000/mL

- Total bilirubin ≤ 2.0 mg/dL (If total is elevated check direct and if normal
patient is eligible.)

- Aspartates Aminotransferase (AST) <2.5 x institutional upper limit of normal

- Alanine Transaminase (ALT) <2.5 x institutional upper limit of normal (ULN)

- Estimated creatinine clearance (CLcr) ≥60 mL/min (Cockcroft Gault equation).

- Voluntary written informed consent will be obtained 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.

- Females of child-bearing potential* randomized to Lenalidomide must have a negative
serum or urine pregnancy test with a sensitivity of at least 50 mIU/mL within 10 -
14 days and again within 24 hours prior to prescribing lenalidomide for Cycle 1
(prescriptions must be filled within 7 days as required by Revlimid Risk Evaluation
and Mitigation Strategies (REMS®) 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 28 days before she starts taking lenalidomide.

- A female of child-bearing potential is a sexually mature female who: has not
undergone a hysterectomy (the surgical removal of the uterus) or bilateral
oophorectomy (the surgical removal of both ovaries), or has not been naturally
postmenopausal (amenorrhea following cancer therapy does not rule out
childbearing potential) for at least 24 consecutive months (i.e., has had
menses at any time during the preceding 24 consecutive months)

- A woman must be . A Not of childbearing potential, or b. Of childbearing
potential and Practicing true abstinence; or Have a sole partner who is
vasectomized; or Practicing ≥1 highly-effective, user-independent method of
contraception NOTE: Participant must agree to continue the above throughout the
study and for 90 days after the last dose of study treatment.

NOTE: If a woman becomes of childbearing potential after start of the study the woman
must comply with point (b) as described above.

NOTE: An interaction between hormonal contraception and teclistamab has not been formally
studied. Therefore, it is unknown whether teclistamab may reduce the efficacy of the
contraception method.

- A woman must agree not to donate eggs (ova, oocytes) or freeze for future use, for
the purposes of assisted reproduction during the study and for 90 days after
receiving the last dose of study treatment

- A man must wear a condom (with or without spermicidal
foam/gel/film/cream/suppository) when engaging in any activity that allows for
passage of ejaculate to another person during the study and for a minimum of 90 days
after receiving the last dose of study treatment. If a female partner is of
childbearing potential, she must also be practicing a highly effective method of

- If the male participant is vasectomized, he still must wear a condom (with
spermicidal foam/gel/film/cream/suppository), but his female partner is not required
to use contraception.

- A male participant must agree not to donate sperm for the purpose of reproduction
during the study and for a minimum of 90 days after receiving the last dose of study

- Must be willing and able to adhere to the lifestyle restrictions specified in this

- All study participants randomized to lenalidomide must be registered into the
mandatory Revlimid REMS® program and be willing and able to comply with the
requirements of the REMS® program.

- Females of child-bearing potential must adhere to the scheduled pregnancy testing as
required in the Revlimid REMS® program if randomized to lenalidomide

- Men must agree to use a latex condom during sexual contact with a female of
childbearing potential even if they have had a successful vasectomy

- Ability to understand and the willingness to sign a written informed consent.

Exclusion Criteria:

- Prior SMM directed therapy administered within 6 months of beginning treatment on
study. To avoid including primary refractory cases to the lenalidomide arm,
participants who received a prior lenalidomide-based therapy should have had at
least an Minimal Response (MR) to be considered on this trial.

- Symptomatic Multiple Myeloma or any evidence of CRAB criteria, including presence of
myeloma defining events (MDE). Any prior therapy for active Myeloma should also be
excluded. Prior therapy for smoldering myeloma is not an exclusion criterion.
Bisphosphonates are not excluded

- Other concurrent chemotherapy, immunotherapy, radiotherapy, or any ancillary therapy
considered investigational. Prior therapy with bisphosphonate is allowed. Prior
radiation therapy to a solitary plasmacytoma is allowed but had to be at least 6
months prior to enrollment on the trial. Prior clinical trials or therapy for
smoldering MM or Monoclonal Gammopathy of Unknown Significance (MGUS) are allowed
per exclusion criteria described above.

- Serious medical or psychiatric illness likely to interfere with participation in
this clinical study.

- Diagnosed or treated for another malignancy within 2 years of enrollment

- Uncontrolled intercurrent illness including, but not limited to, ongoing or active
infection, symptomatic congestive heart failure, unstable angina pectoris, cardiac
arrhythmia, or psychiatric illness/social situations that would limit compliance
with study requirements.

- Plans to father a child while enrolled in this study or within 90 days after
receiving the last dose of study drug.

- Pregnant or breast-feeding or planning to become pregnant while enrolled in this
study or within 90 days after receiving the last dose of study drug.

- Known seropositive for or active viral infection with human immunodeficiency virus
(HIV), hepatitis B virus (HBV) or hepatitis C virus (HCV) or SARS-CoV-2 (COVID- 19).

- Participants who are seropositive because of hepatitis B virus vaccine are eligible.

- Participants who are positive for SARS-COV-2 antibody, HIV1 and 2 antibody,
hepatitis B core antibody or hepatitis B surface antigen must have a negative
polymerase chain reaction (PCR) result before enrollment. Those who are PCR positive
will be excluded.

- Contraindications or life-threatening allergies, hypersensitivity, or intolerance to
any study drug or its excipients (refer to the teclistamab Investigator's Brochure
and appropriate package inserts).

- Prior or concurrent exposure to any of the following:

- Investigational vaccine within 4 weeks

- Live, attenuated vaccine within 4 weeks before randomization.

- Monoclonal antibody therapy within 21 days

- Cytotoxic therapy within 14 days

- PI therapy within 14 days

- IMiD agent therapy within 14 days

- Radiotherapy within 14 days or focal radiation within 7 days

- A maximum cumulative dose of corticosteroids of ≥140 mg of prednisone or equivalent
within 14-day period before the first dose of study drug (does not include
pretreatment medications)

- Known active Central Nervous System (CNS) involvement or exhibits clinical signs of
meningeal involvement of multiple myeloma. If either is suspected, negative whole
brain MRI and lumbar cytology are required.

- Myelodysplastic syndrome or active malignancies (i.e., progressing or requiring
treatment change in the last 24 months). The only allowed exceptions are: a.
Non-muscle invasive bladder cancer treated within the last 24 months that is
considered completely cured b. Skin cancer (non-melanoma or melanoma) treated within
the last 24 months that is considered completely cured. c. Noninvasive cervical
cancer treated within the last 24 months that is considered completely cured d.
Localized prostate cancer (N0M0): With a Gleason score of ≤6, treated within the
last 24 months, or untreated and under surveillance With a Gleason score of 3+4 that
has been treated >6 months prior to full study screening and considered to have a
very low risk of recurrence, or e. History of localized prostate cancer and
receiving androgen deprivation therapy and considered to have a very low risk of
recurrence. f. Breast cancer: adequately treated lobular carcinoma in situ or ductal
carcinoma in situ, or history of localized breast cancer and receiving antihormonal
agents and considered to have a very low risk of recurrence. g. Other malignancy
that is considered cured with minimal risk of recurrence

- Stroke or seizure within 6 months prior to signing informed consent form

- Presence of the following cardiac conditions:

-- New York Heart Association stage III or IV congestive heart failure, 2)
Myocardial infarction or coronary artery bypass graft ≤6 months prior to
randomization,3) History of clinically significant ventricular arrhythmia or
unexplained syncope, not believed to be vasovagal in nature or due to dehydration,4)
History of severe non-ischemic cardiomyopathy

- Major surgery within 2 weeks prior to the start of administration of study
treatment, or will not have fully recovered from surgery, or has major surgery
planned during the time the participant is expected to be treated in the study or
within 2 weeks after administration of the last dose of study treatment. NOTE:
Participants with planned surgical procedures to be conducted under local anesthesia
may participate. Kyphoplasty or vertebroplasty are not considered major surgery. If
there is a question whether a procedure is considered a major surgery, the
investigator must consult with the appropriate sponsor representative and resolve
any issues before enrolling a participant in the study.

- Concurrent medical or psychiatric condition or disease that is likely to interfere
with study procedures or results, or that in the opinion of the investigator would
constitute a hazard for participating in this study, such as:

- Uncontrolled diabetes defined by Hemoglobin A1C > 8.5, Acute diffuse infiltrative
pulmonary disease, Evidence of active systemic viral, fungal, or bacterial
infection, requiring systemic, antimicrobial therapy, History of autoimmune disease
with the exception of vitiligo, type I diabetes, and, prior autoimmune thyroiditis
that is currently euthyroid based on clinical symptoms and laboratory testing, .
Disabling psychiatric conditions (e.g., alcohol or drug abuse), severe dementia, or
altered mental status, Any other issue that would impair the ability of the
participant to receive or tolerate the planned treatment at the investigational
site, to understand informed consent or any condition for which, in the opinion of
the investigator, participation would not be in the best interest of the participant
(e.g., compromise the wellbeing) or that could prevent, limit, or confound the
protocol-specified assessments, History of non-compliance with recommended medical