What is your preferred maintenance strategy for high risk multiple myeloma?

Ok. First off, what is high risk in the setting of maintenance therapy? I define high risk in this area as R-ISS 3 [incl t(14;20)], ≥ 5% circulating PCs, extramedullary disease [except salivary glands], hypodiploidy, or karyotypic t(8;22). We frequently argue about this definition since there is no prospective data.

Second, what is maintenance? Does this mean after induction in a frail patient where you aren't using autologous transplant (a la GEM2005MAS65 trial) or is this in a 'low risk' CALGB ...

A loaded question for sure. One thing I can say with a fair amount of confidence is that most patients with high risk disease (I like the inclusive definition of high risk used in the SWOG S1211 study) will be undertreated with single agent maintenance alone. For context, the median PFS was 47 months for all-comers who received VRd, ASCT, and one year of lenalidomide maintenance in the IFM-2009 study with an eight-year PFS of 35% and an eight-year OS of 62%

Re: Lenalidomide. A meta-analysis from ...