OnCo

Sign in to keep your watchlist

Your watched pages live in this browser. Sign in with an email link and OnCo keeps the same list on every device you use. Only your email address and your watchlist are stored.

Living with cancer·Standard of care

Plasma cell leukaemia: the decisions you may face

Cancer page →Second-opinion finder →

3 treatment settings, 3 with more than one named option. Each section lays out the options the standard of care names, what each is for, the trials behind them with their recorded results, the side effects and cautions on record, and questions to ask. Built from the cancer page's standard-of-care rows; nothing here is advice for your case.

Advanced, first line

Primary plasma cell leukaemia, induction

6 optionsCompare side by side →

Bortezomib-based quadruplet (daratumumab with bortezomib, lenalidomide or cyclophosphamide, and dexamethasone), or VTD-PACE-type multi-agent chemotherapy for rapid control, with tumour lysis and renal precautions.

Guideline
NCCN Guidelines: Multiple Myeloma
The options, in plain words
BortezomibApprovedProteasome inhibitor

Bortezomib was the first proteasome inhibitor: it jams the cell's protein-recycling machine, which antibody-factory plasma cells cannot tolerate.

DaratumumabApprovedMonoclonal antibody (anti-CD38)

The CD38 antibody that turned triplets into quadruplets: adding it to standard induction roughly halves the risk of myeloma progressing.

LenalidomideApprovedImmunomodulatory drug (cereblon E3 ligase modulator)

Lenalidomide is a thalidomide descendant that glues the proteins IKZF1 and IKZF3 to cereblon so the cell destroys them, killing plasma cells and rousing T cells. It is the backbone of myeloma treatment and maintenance, also used in mantle cell and follicular lymphoma, and generic since 2022.

CyclophosphamideApprovedAlkylating agent (oxazaphosphorine prodrug)

Cyclophosphamide is an alkylating chemotherapy that damages DNA in dividing cells. It is part of CHOP for lymphoma, AC for breast cancer and VAC for childhood sarcomas, clears lymphocytes before CAR-T and prevents graft-versus-host disease after transplant; bladder bleeding, infertility and secondary leukaemia are its harms.

DexamethasoneApprovedGlucocorticoid

Dexamethasone is a long-acting glucocorticoid steroid that kills lymphoid cancer cells directly, which is why it sits in nearly every myeloma regimen and in childhood leukaemia and lymphoma protocols. It is also the standard drug for preventing chemotherapy sickness and for brain swelling and spinal cord compression; high blood sugar, insomnia, muscle wasting and infection follow prolonged use.

CarfilzomibApprovedProteasome inhibitor (irreversible)

Carfilzomib is a second-generation proteasome inhibitor with less nerve damage but more heart and blood-pressure effects.

Also referenced:Tumour lysis syndrome (TLS)
The evidence behind it

No trial record is attached to this row yet. The trials tab lists what is recruiting and the landmark trials for this cancer.

The main trade-offs on record
Bortezomiball recorded rates →
  • Start at 0.7 mg/m² in moderate or severe impairment.
Lenalidomideall recorded rates →
  • Dose by creatinine clearance: 10 mg daily for CrCl 30-60, 15 mg every other day below 30, 5 mg daily on dialysis.
Questions to ask about this decision
  1. Between Bortezomib, Daratumumab, Lenalidomide and the other options, which do you recommend for me, and what about my case would make you choose differently?
    Why: Guidelines list several reasonable options; the choice turns on details of your tumour, your health and your priorities.
  2. What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?
    Why: The aim shapes how much side effect and disruption is worth accepting.
  3. What happens if I delay, or decline this step for now? Is the decision reversible?
    Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
  4. Does your recommendation follow the current guideline (NCCN Guidelines: Multiple Myeloma), and if it departs from it, why?
    Why: Departures from guidelines are sometimes right for an individual; they should be explained.
  5. For my situation (primary plasma cell leukaemia, induction), which of the standard options do you recommend and why?
    Why: Guideline options include: Bortezomib-based quadruplet (daratumumab with bortezomib, lenalidomide or cyclophosphamide, and dexamethasone), or VTD-PACE-type multi-agent chemotherapy for rapid control, with tumour lysis and renal precautions.
  6. Am I a candidate for Bortezomib, Daratumumab, Lenalidomide or related drugs, and what side effects should I expect?
    Why: Knowing the expected toxicities helps you plan work, family, and supportive care.

Add these to your appointment list, or take the full question set for this cancer.

Other settings

Consolidation

4 optionsCompare side by side →

Autologous stem cell transplant for all fit patients; tandem autologous or reduced-intensity allogeneic transplant considered in young patients; continuous maintenance after transplant.

Guideline
NCCN Guidelines: Multiple Myeloma
The options, in plain words
Autologous stem cell transplant (high-dose therapy)Standard of care

Autologous stem cell transplant collects the patient's own blood-forming stem cells, gives melphalan or another chemotherapy at a dose that would otherwise destroy the marrow, then returns the cells to rebuild it. It is standard consolidation in myeloma and for relapsed lymphoma, though CAR-T has displaced it in early-relapsing large B-cell lymphoma.

  • Permits dose intensity impossible otherwise
  • Decades of outcome data
  • Widely available
Allogeneic stem cell transplantationStandard of care

Allogeneic stem cell transplantation replaces a patient's blood system with a donor's after conditioning chemotherapy, so donor immune cells hunt down leukaemia left behind. It remains the only cure for adverse-risk acute myeloid leukaemia, high-risk acute lymphoblastic leukaemia and Richter transformation, at the price of graft-versus-host disease.

  • Curative for otherwise incurable leukaemia
  • Graft-versus-leukaemia is an antigen-agnostic immune therapy
Melphalan (including hepatic delivery system)ApprovedAlkylating agent (nitrogen mustard)

The myeloma chemotherapy that is also the standard high-dose conditioning before autologous transplant, and, delivered directly into the liver's blood supply or the eye, treats uveal melanoma metastases and retinoblastoma.

LenalidomideApprovedImmunomodulatory drug (cereblon E3 ligase modulator)

Lenalidomide is a thalidomide descendant that glues the proteins IKZF1 and IKZF3 to cereblon so the cell destroys them, killing plasma cells and rousing T cells. It is the backbone of myeloma treatment and maintenance, also used in mantle cell and follicular lymphoma, and generic since 2022.

Also referenced:Maintenance therapy
The evidence behind it

No trial record is attached to this row yet. The trials tab lists what is recruiting and the landmark trials for this cancer.

The main trade-offs on record
Autologous stem cell transplant (high-dose therapy)
  • Treatment-related mortality ~1-2% (myeloma) to higher in children
  • Infertility, second malignancies, prolonged cytopenias
  • Being challenged by CAR-T and MRD-guided deferral
Allogeneic stem cell transplantation
  • Treatment-related mortality 10-20%
  • Chronic GVHD
  • Relapse remains the main cause of failure
Lenalidomideall recorded rates →
  • Dose by creatinine clearance: 10 mg daily for CrCl 30-60, 15 mg every other day below 30, 5 mg daily on dialysis.
Questions to ask about this decision
  1. Between Autologous stem cell transplant (high-dose therapy), Allogeneic stem cell transplantation, Melphalan (including hepatic delivery system) and the other options, which do you recommend for me, and what about my case would make you choose differently?
    Why: Guidelines list several reasonable options; the choice turns on details of your tumour, your health and your priorities.
  2. What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?
    Why: The aim shapes how much side effect and disruption is worth accepting.
  3. What happens if I delay, or decline this step for now? Is the decision reversible?
    Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
  4. Does your recommendation follow the current guideline (NCCN Guidelines: Multiple Myeloma), and if it departs from it, why?
    Why: Departures from guidelines are sometimes right for an individual; they should be explained.
  5. For my situation (consolidation), which of the standard options do you recommend and why?
    Why: Guideline options include: Autologous stem cell transplant for all fit patients; tandem autologous or reduced-intensity allogeneic transplant considered in young patients; continuous maintenance after transplant.
  6. Am I a candidate for Melphalan (including hepatic delivery system), Lenalidomide, and what side effects should I expect?
    Why: Knowing the expected toxicities helps you plan work, family, and supportive care.

Add these to your appointment list, or take the full question set for this cancer.

Second line

Secondary plasma cell leukaemia or relapse

5 optionsCompare side by side →

Treated as heavily relapsed myeloma: BCMA or GPRC5D bispecific antibodies, CAR-T where feasible, selinexor or pomalidomide combinations; palliative care early.

Guideline
NCCN Guidelines: Multiple Myeloma
The options, in plain words
TeclistamabApprovedBispecific T-cell engager (BCMA×CD3)

Teclistamab was the first off-the-shelf bispecific for multiple myeloma, and is now approved after just one prior line of therapy.

TalquetamabApprovedBispecific T-cell engager (GPRC5D×CD3)

Talquetamab is the first drug against GPRC5D, a second myeloma target used after BCMA therapies stop working; taste and skin side effects are its signature.

Ciltacabtagene autoleucelApprovedCAR-T (BCMA)

Ciltacabtagene autoleucel is a one-time BCMA CAR-T for myeloma that, in CARTITUDE-4, cut the risk of death by about 45% compared with standard regimens.

SelinexorApprovedSmall-molecule XPO1 (nuclear export) inhibitor

Selinexor is a first-in-class pill that traps tumour-suppressor proteins inside the nucleus; approved in myeloma, it failed its endometrial cancer test in 2026.

PomalidomideApprovedOral cereblon E3 ligase modulator (IMiD)

The third-generation thalidomide analogue for myeloma that has failed lenalidomide, and since 2020 the first new drug for Kaposi sarcoma in two decades.

The evidence behind it

No trial record is attached to this row yet. The trials tab lists what is recruiting and the landmark trials for this cancer.

The main trade-offs on record
Teclistamaball recorded rates →
Side effectAny gradeGrade 3+
Neutrophils decreased · MajesTEC-188%70%
Pneumonia · MajesTEC-124%15%
Neurologic toxicity · ICANS 6%60%6%
Musculoskeletal pain · MajesTEC-144%4.2%

Rates from the label or pivotal trial as recorded on the product page; each grade 3+ figure links to its source.

Ciltacabtagene autoleucelall recorded rates →
Side effectAny gradeGrade 3+
Neutropenia (grade 3+) · CARTITUDE-4, n=188-95%
Infections (grade 3+) · CARTITUDE-4, n=188-24%
Hypogammaglobulinaemia · CARTITUDE-4, n=18894%9%
Cytokine release syndrome · CARTITUDE-4, n=18878%3%

Rates from the label or pivotal trial as recorded on the product page; each grade 3+ figure links to its source.

Selinexorall recorded rates →
  • Nausea and anorexia are near-universal: prophylactic 5-HT3 antagonist plus olanzapine or dexamethasone.
Pomalidomideall recorded rates →
  • Smoking induces CYP1A2 and lowers exposure by about a third.
Questions to ask about this decision
  1. Between Teclistamab, Talquetamab, Ciltacabtagene autoleucel and the other options, which do you recommend for me, and what about my case would make you choose differently?
    Why: Guidelines list several reasonable options; the choice turns on details of your tumour, your health and your priorities.
  2. What is each option trying to achieve: cure, long control, or relief of symptoms, and over what time?
    Why: The aim shapes how much side effect and disruption is worth accepting.
  3. Which side effects of Teclistamab or Ciltacabtagene autoleucel are most likely for me, which are reversible, and which would make us stop?
    Why: The recorded rates below come from labels and trials; your own risk depends on dose, other medicines and your health.
  4. What happens if I delay, or decline this step for now? Is the decision reversible?
    Why: Some decisions can wait for a second opinion or a trial slot; others cannot. Knowing which is part of the choice.
  5. Does your recommendation follow the current guideline (NCCN Guidelines: Multiple Myeloma), and if it departs from it, why?
    Why: Departures from guidelines are sometimes right for an individual; they should be explained.
  6. For my situation (secondary plasma cell leukaemia or relapse), which of the standard options do you recommend and why?
    Why: Guideline options include: Treated as heavily relapsed myeloma: BCMA or GPRC5D bispecific antibodies, CAR-T where feasible, selinexor or pomalidomide combinations; palliative care early.
  7. Am I a candidate for Teclistamab, Talquetamab, Ciltacabtagene autoleucel or related drugs, and what side effects should I expect?
    Why: Knowing the expected toxicities helps you plan work, family, and supportive care.

Add these to your appointment list, or take the full question set for this cancer.

How to read this page. Options and results come from OnCo records with their sources; the settings are the standard-of-care rows on the cancer page, and the lines of therapy are on the sequencing grid. Where a setting names one path, the choice is usually about timing, trials and where to be treated: see expert centres. OnCo is orientation, not medical advice.