A 70-year-old male patient has good performance status and t(4;14) mutation. The individual has been through the following lines of therapy. The first line was lenalidomide/dexamethasone which the patient was on for 2 years until progression (I will abbreviate dexamethasone as dex). Then, the patient moved to bortezomib/dex with cyclophosphamide achieving a VGPR with grade 2 peripheral neuropathy. The response was maintained for almost 2 years with maintenance carfilzomib switching to maintenance ixazomib. Then in the third line Daratumumab/Pomalidomide/dex was given which resulted in progressive disease. Carfilzomib/cyclophosphamide/dex was then given after progression with no response after 2 cycles. Carfilzomib/panobinostat/dex was given for 2 cycles with no response. Belantamab mafodotin was given for 2 doses, but the patient developed keratopathy so treatment was stopped. The patient then was switched to carfilzomib/selinexor/dex. After this treatment, the patient received CAR T therapy achieving a VGPR, but progression occurred after about 1 year with new lesions on PET and increased IgA. Given this treatment history, any suggestions for future therapy for this patient? Patient has good performance status. We are considering teclistamab or clinical trials.
If a marrow hasnt been done recently, suggest a marrow with NGS to evaluate for actionable mutations. were any cells collected? ASCT would be an option. otherwise agree with next line t-cell engager with tec or other clinical trial. if not eligible for trial and tec not available and ASCT not available consider either: stem cell harvest ( DCEP--> SCH) with understanding that this has a significant failure rate. other therapeutic options include bendamustine. if access to Epizyme clinical trial that would be ideal given t(4;14).