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10 slides generated from the cancer page, with a quiz from the open benchmark and speaker notes that cite the sources. Arrow keys move between slides; Print gives one slide per page.
Fit patients with newly diagnosed myeloma receive four drugs at once, then their own stem cells are collected, they are given high-dose chemotherapy, the cells are returned and they continue on maintenance. Adding the CD38 antibody daratumumab to the three-drug backbone, tested in PERSEUS and CASSIOPEIA, means most patients now reach a state where no myeloma can be detected.
Eligibility for autologous transplant rests on age, organ function and frailty rather than a fixed cut-off; most centres transplant to around 70 to 75. The sequence is three to six cycles of induction, stem cell mobilisation and collection, high-dose melphalan with autologous stem cell rescue, consolidation and then lenalidomide maintenance until progression. Two randomised trials settled the place of the transplant in the era of modern induction: IFM 2009 and DETERMINATION both showed a longer remission with early transplant after bortezomib-lenalidomide-dexamethasone (median progression-free survival 67.5 versus 46.2 months in DETERMINATION) but no survival difference, so delayed transplant at first relapse is an accepted choice.
Induction moved from triplets to quadruplets on the strength of CD38 antibodies. CASSIOPEIA (2019) added daratumumab to bortezomib-thalidomide-dexamethasone and raised stringent complete responses after consolidation from 20 to 29 percent while cutting progression or death by about half. PERSEUS (2024) added daratumumab to bortezomib-lenalidomide-dexamethasone around transplant with daratumumab-lenalidomide maintenance: progression-free survival at four years 84.3 percent versus 67.7 percent (hazard ratio 0.42), with three in four patients reaching MRD negativity at 10^-5, and daratumumab-VRd became the standard induction with regulatory approval in 2024. Isatuximab quadruplets (IsKia, GMMG-HD7) show the same pattern.
| Setting | Approach | Guideline |
|---|---|---|
| Induction | Daratumumab plus bortezomib, lenalidomide and dexamethasone (PERSEUS) for four to six cycles; isatuximab-VRd or daratumumab-VTd (CASSIOPEIA) are alternatives. | not mapped |
| Consolidation | High-dose melphalan with autologous stem cell transplant, early or deferred to first relapse after stem cell collection; tandem transplant considered in high-risk disease. | not mapped |
| Maintenance | Lenalidomide until progression; daratumumab added after daratumumab-based induction (PERSEUS); bortezomib-containing maintenance in high-risk disease; MRD-guided stopping in trials. | not mapped |
| Response assessment | M-protein and free light chains every cycle, MRD by sequencing or flow cytometry after transplant and during maintenance, imaging for residual focal lesions. | not mapped |