This phase II trial compares standard consolidation with daratumumab, carfilzomib, lenalidomide, and dexamethasone to consolidation with teclistamab following standard induction therapy and autologous hematopoietic stem cell transplant for improving overall survival of patients with plasma cell leukemia. Consolidation therapy is treatment given after initial therapy to kill any cancer cells that may remain in the body. 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. Carfilzomib inhibits protein complexes called proteasomes, which inhibits cancer cell growth and leads to cancer cell death. Lenalidomide may help kill cancer cells and prevents the growth of blood vessels that cancer cells need to survive. 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. Teclistamab is a monoclonal antibody that may interfere with the ability of cancer cells to grow and spread. A monoclonal antibody is a type of protein that can bind to certain targets in the body, such as molecules that cause the body to make an immune response (antigens). Giving teclistamab as consolidation therapy after induction and autologous hematopoietic stem cell transplant may improve survival outcomes in patients with plasma cell leukemia, compared to standard consolidation with daratumumab, carfilzomib, lenalidomide, and dexamethasone.

PRIMARY OBJECTIVE:

I. To determine if quadruplet induction therapy followed by autologous stem cell transplantation, consolidation with teclistamab, a BCMA-targeted, T-cell redirecting bispecific antibody, and doublet maintenance treatment will improve overall survival compared to those receiving standard of care consolidation therapy (i.e. daratumumab, carfilzomib, lenalidomide, and dexamethasone [D-KRd]).

SECONDARY OBJECTIVES:

I. To evaluate the progression free survival of quadruplet induction, autologous stem cell transplantation, consolidation, and doublet maintenance therapy.

II. To evaluate the safety of quadruplet induction, autologous stem cell transplantation, consolidation, and doublet maintenance therapy.

III. To evaluate response rates per International Myeloma Working Group (IMWG) criteria (overall response rate, partial response, very good partial response, complete response, stringent complete response).

EXPLORATORY OBJECTIVE:

I. To evaluate minimal residual disease negativity by next generation sequencing (10^-5 and 10^-6) after induction, autologous stem cell transplant, consolidation, and after 1 and 2 years of maintenance treatment.

OUTLINE:

INDUCTION THERAPY (CYCLES 1-4): Patients receive daratumumab and recombinant human hyaluronidase (daratumumab and hyaluronidase-fihj) subcutaneously (SC) on days 1, 8, 15, and 22 of cycles 1 and 2 and days 1 and 15 of cycles 3 and 4, carfilzomib intravenously (IV) on days 1, 8, and 15 of each cycle, lenalidomide orally (PO) once daily (QD) on days 1-21 of each cycle, and dexamethasone PO on days 1, 8, and 15 of each cycle. Cycles repeat every 28 days in for up to 4 cycles in the absence of disease progression or unacceptable toxicity.

AUTOLOGOUS STEM CELL TRANSPLANT: Within 60 days of completing induction therapy, patients undergo stem cell mobilization using recombinant granulocyte colony-stimulating factor SC and plerixafor SC followed by stem cell collection according to standard of care. Patients then receive melphalan IV followed by autologous hematopoietic stem cell transplant (autoHSCT).

CONSOLIDATION THERAPY (CYCLES 5-12): Patients are randomized to 1 of 2 arms for consolidation therapy, to start within 120 days of autoHSCT.

ARM 1: Patients receive daratumumab and hyaluronidase-fihj SC on days 1 and 15 of cycles 5-6 and on day 1 of cycles 7-12, carfilzomib IV on days 1, 8, and 15 of each cycle, lenalidomide on days 1-21 of each cycle, and dexamethasone PO on days 1, 8, and 15 of each cycle. Cycles repeat every 28 days for up to 8 cycles in the absence of disease progression or unacceptable toxicity.

ARM 2: Patients receive teclistamab SC on days 1, 3, 7, and 15 of cycle 5, once weekly thereafter for cycles 5-6, every 2 weeks in cycles 7-10, and every 4 weeks in cycles 11-12. Cycles repeat every 28 days for up to 8 cycles in the absence of disease progression or unacceptable toxicity.

MAINTENANCE THERAPY (CYCLES 13-36): Within 60 days of completing consolidation therapy, patients receive carfilzomib IV on days 1 and 15 of each cycle and lenalidomide PO QD on days 1-21 of each cycle. Cycles repeat every 28 days for up to 24 cycles in the absence of disease progression or unacceptable toxicity.

Patients also undergo transthoracic echocardiography (TTE) at screening and then as clinically indicated and undergo bone marrow biopsy and aspiration, collection of blood samples, and fludeoxyglucose F-18 (FDG) positron emission tomography (PET)/computed tomography (CT), magnetic resonance imaging (MRI), and/or CT throughout the trial.

After completion of study treatment, patients are followed up every 3 or 6 months for up to 5 years from registration.

Inclusion Criteria:

• Documented diagnosis of primary plasma cell leukemia according to IMWG criteria defined as 5% or greater circulating plasma cells at the time of initial diagnosis

• Measurable disease at the time of initial diagnosis of at least one of the following as defined by IMWG criteria:

  • Serum monoclonal protein ≥ 0.5 g/dL or
  • Urine monoclonal protein ≥ 200 mg/24 hours (h) or
  • Serum free light chain (FLC) assay: Serum free light chain ≥ 100 mg/L and abnormal serum free light chain ratio

• Age 18 - 80 years

• Prior treatment:

  • ≤ 1 cycle of induction treatment based on physician/investigator discretion
  • No history of severe allergic reaction (including erythema nodosum) to lenalidomide or other prior immunomodulatory imide drug (IMiD) therapy
  • No history of clinically significant cardiopulmonary disease resulting from prior proteosome inhibitor therapy

• Eastern Cooperative Oncology Group (ECOG) performance status ≤ 2

• Not pregnant and not nursing, because this study involves an agent that has known genotoxic, mutagenic and teratogenic effects on the developing fetus and newborn, before study entry, the following criteria must be met

  • Female of childbearing potential (FCBP) is a female who: 1) has achieved menarche (first menstrual cycle) at some point, 2) has not undergone a hysterectomy (the surgical removal of the uterus) or bilateral oophorectomy (the surgical removal of both ovaries), or 3) 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). * Female of childbearing potential (FCBP):

    • Must use a contraceptive method that is highly effective (with a failure rate of < 1% per year), preferably with low user dependency during the intervention and agrees to not donate eggs (ova, oocytes) for the purpose of reproduction during this period. The investigator should evaluate the effectiveness of the contraceptive method in relationship to the first dose of study intervention
    • Given the risk of teratogenicity with immunomodulatory drugs (IMiD), females of child-bearing potential (FCBP) must have a negative serum or urine pregnancy test with a sensitivity of at least 25 mIU/mL within 10-14 days prior to, and again within 24 hours of starting lenalidomide, and must either commit to continued abstinence from heterosexual intercourse or being 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. Examples of highly effective methods are intrauterine device, hormonal contraceptives, tubal ligation, or partner's vasectomy. Examples of barrier method are male condom, diaphragm, or cervical cap. FCBP must also agree to ongoing pregnancy testing. Men must agree to use latex condom during sexual contract with a FCBP even if they have had a successful vasectomy. All patients must be counseled at a minimum frequency of 28 days about pregnancy precautions and risk of fetal exposure
    • The investigator is responsible for review of medical history, menstrual history, and recent sexual activity to decrease the risk for inclusion of a woman with a nearly undetected pregnancy

  • Non-childbearing potential is defined as follows (by other than medical reasons):

    • ≥ 45 years of age and has not had menses for > 1 year
    • Patients who have been amenorrhoeic for < 2 years without history of hysterectomy and oophorectomy must have a follicle stimulating hormone value in the postmenopausal range upon screening evaluation
    • Post-hysterectomy, post-bilateral oophorectomy, or post-tubal ligation. Documented hysterectomy or oophorectomy must be confirmed with medical records of the actual procedure or confirmed by an ultrasound. Tubal ligation must be confirmed with medical records of the actual procedure

• Male patients must agree to use an adequate method of contraception for the duration of the study and for 6 months afterwards.

  • Male participants: Contraceptive use should be consistent with local regulations regarding the methods of contraception for those participating in clinical studies. Male participants are eligible to participate if they agree to the following during the intervention period and for 6 months after the last dose of study treatment to allow for clearance of altered sperm:

    • Refrain from donating sperm, PLUS, either:

      • Be abstinent from heterosexual intercourse as their preferred and usual lifestyle (abstinent on a long term and persistent basis) and agree to remain abstinent, OR

      • Must agree to use contraception/barrier as detailed below:

        • Agree to use a male condom, even if they have undergone successful vasectomy, and female partner to use an additional highly effective contraceptive method with a failure rate of < 1% per year as when having sexual intercourse with a woman of childbearing potential (including pregnant females)

• Patients may not have polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes (POEMS) syndrome, Waldenström's macroglobulinemia, or symptomatic amyloidosis. Amyloidosis found in skin or lymph nodes ("non-vital organs"), or incidental observation of amyloidosis on bone marrow biopsy, are permissible

• Clinically significant adverse effects from any prior oncologic treatment (e.g., prior surgery, radiotherapy, or other antineoplastic therapy) must have resolved or have been determined to be clinically stable per the investigator

• Patients with known HIV infection on effective anti-retroviral therapy with undetectable viral load within 6 months prior to registration are eligible for this trial

• For patients with evidence of chronic hepatitis B virus (HBV) infection, the HBV viral load must be undetectable on suppressive therapy, if indicated

• Patients with a history of hepatitis C virus (HCV) infection must have been treated and cured. For patients with HCV infection who are currently on treatment, they are eligible if they have an undetectable HCV viral load

• No patients known to have cardiac risk factors defined by any of the following criteria:

  • Evidence of current clinically significant uncontrolled arrhythmias, including clinically significant electrocardiogram (ECG) abnormalities such as 2nd degree (Mobitz Type II) or 3rd degree atrioventricular (AV) block
  • History of myocardial infarction, acute coronary syndromes (including unstable angina), coronary angioplasty, or stenting or bypass grafting within two (2) months of screening
  • Class III or IV heart failure as defined by the New York Heart Association functional classification system
  • Uncontrolled hypertension, defined as persistently elevated blood pressure (BP) meeting Common Terminology Criteria for Adverse Events (CTCAE) version (v) 6.0 for ≥ grade 3 despite medical intervention
  • Patients with congenital long QT syndrome, Fridericia's formula-corrected QT interval (QTcF) interval QTcF > 480 msec (the QT interval values must be corrected for heart rate by Fridericia's formula [QTcF])
  • Left ventricular ejection fraction < 40%

• No significant neuropathy ≥ grade 3 or grade 2 neuropathy with pain at baseline

• No known allergies, hypersensitivity, or intolerance to daratumumab and hyaluronidase-fihj, carfilzomib, lenalidomide, or dexamethasone

• No known medical condition causing an inability to swallow oral formulations of agents

• No major surgery within < 2 weeks prior to registration or who have not recovered from the side effects of surgery

• Contraindication to any concomitant medication, including antivirals or anticoagulation

• Absolute neutrophil count (ANC) ≥ 1,000/mm^3 (or ≥ 500/mm^3 if due to underlying disease)

• Total bilirubin ≤ 2 x upper limit of normal (ULN)

• Aspartate aminotransferase (AST) (serum glutamic-oxaloacetic transaminase [SGOT])/alanine aminotransferase (ALT) (serum glutamate pyruvate transaminase [SGPT]) ≤ 3 x upper limit of normal (ULN)

• Calculated (calc.) creatinine clearance ≥ 30 mL/min by Modification of Diet in Renal Disease (MDRD)

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