Radioimmunotherapy (111Indium/225Actinium-DOTA-daratumumab) for the Treatment of Relapsed/Refractory Multiple Myeloma

Inclusion Criteria

• Documented informed consent of the participant and/or legally authorized representative * Assent, when appropriate, will be obtained per institutional guidelines
• Age >= 18 years
• Karnofsky performance status (KPS) >= 60%
• Multiple myeloma according to International Myeloma Working Group (IMWG) criteria with measurable disease defined as one of the following: * Serum monoclonal protein >= 0.5 g/dL * 24 hour urine monoclonal protein >= 200 mg/24 hour * Serum free light chain (FLC) of > 10 mg/dL and an abnormal kappa:lambda ratio
• Previously received treatment with all of the following: a proteasome inhibitor, an immunomodulatory drug, and an anti-CD38 monoclonal antibody. Refractory (defined per IMWG Consensus Criteria) to daratumumab
• Fully recovered from the acute toxic effects (except alopecia) to =< grade 1 to prior anti-cancer therapy
• Prior antitumor therapy must have been completed prior to enrollment as follows: * >= 21 days for investigational agents, cytotoxic chemotherapy * >= 21 days for radiation therapy. Note: Patients must have measurable disease that has been untreated/unaffected by local radiation therapy * >= 3 months for prior anti-CD38-targeted therapy, adoptive cell therapy * >= 3 weeks for bispecific antibodies and T-cell redirecting therapies other than chimeric antigen receptor (CAR) T cells * >=14 days for proteasome inhibitor therapy * >= 7 days for immunomodulatory agents
• Absolute neutrophil count (ANC) >= 1,000/mm^3 (within 28 days prior to day 1 of protocol therapy) * NOTE: Growth factor is not permitted within 7 days of ANC assessment unless cytopenia is secondary to disease involvement
• Platelets >= 75,000/mm^3 (>= 50,000/mm^3 if >= 50% marrow involvement) (within 28 days prior to day 1 of protocol therapy) * NOTE: Platelet transfusions are not permitted within 14 days of platelet assessment unless cytopenia is secondary to disease involvement
• Total bilirubin =< 1.5 x upper limit of normal (ULN) (unless has Gilbert's disease) (within 28 days prior to day 1 of protocol therapy)
• Aspartate aminotransferase (AST) =< 3 x ULN (within 28 days prior to day 1 of protocol therapy)
• Alanine aminotransferase (ALT) =< 3 x ULN (within 28 days prior to day 1 of protocol therapy)
• Creatinine clearance of >= 40 mL/min per 24 hour urine test or the Cockcroft-Gault formula (within 28 days prior to day 1 of protocol therapy)
• Women of childbearing potential (WOCBP): negative urine or serum pregnancy test * If the urine test is positive or cannot be confirmed as negative, a serum pregnancy test will be required (within 14 days prior to day 1 of protocol therapy)
• Woman of childbearing potential must be practicing a highly effective method of birth control consistent with local regulations regarding the use of birth control methods for subjects participating in clinical studies: e.g., established use of oral, injected or implanted hormonal methods of contraception; placement of an intrauterine device or intrauterine system; barrier methods; condom with spermicidal foam/gel/film/cream/suppository or occlusive cap (diaphragm or cervical/vault caps) with spermicidal foam/gel/film/cream/suppository; male partner sterilization; true abstinence (when this is in line with the preferred and usual lifestyle of the subject) during and after the study (6 months after the last dose of 225Ac-DOTA-Daratumumab for women). A man who is sexually active with a woman of childbearing potential and has not had a vasectomy must agree to use a barrier method of birth control, e.g., either condom with spermicidal foam/gel/film/cream/suppository or partner with occlusive cap (diaphragm or cervical/vault caps) with spermicidal foam/gel/film/cream/suppository, and all men must also not donate sperm during the study and for 6 months after receiving the last dose of study drug * Childbearing potential defined as not being surgically sterilized (men and women) or have not been free from menses for > 1 year (women only)

Exclusion Criteria

• Daratumumab or other anti CD38 antibody treatment < 3 months prior to study enrollment
• Prior radiopharmaceutical therapy
• Detectable antibodies directed against daratumumab
• Subject has received previous radiation to > 25% of their bone marrow
• Female patients who are lactating or have a positive pregnancy test during the screening period
• Major surgery within 14 days prior to start of study treatment
• Subject is receiving concurrent chemotherapy, radiation, or biologic for cancer treatment. Subject is receiving bone marrow stimulatory factors (e.g., granulocyte-macrophage colony-stimulating factor [GM-CSF]). Note: Hormonal therapy for someone with a history of cancer treated with curative intent is permitted if subject has been on hormonal therapy > 1 year
• Vaccination with live attenuated vaccines within 4 weeks of study agent administration
• A diagnosis of primary amyloidosis, plasma cell leukemia, Waldenstrom macroglobulinemia, or POEMS
• Severe persistent asthma (forced expiratory volume in 1 second [FEV1] < 60% and/or daily symptoms) or severe chronic obstructive pulmonary disease (COPD) defined clinically or by historical pulmonary function tests with an FEV1 < 50% predicted
• Subject has known allergies, hypersensitivity, or intolerance to monoclonal antibodies or human proteins, or their excipients (refer to respective package inserts or investigator’s brochure). Patients with a history of infusion reactions to daratumumab with prior treatment that resolved with supportive measures and in whom daratumumab therapy was not previously discontinued because of infusion reactions are permitted
• Subject has uncontrolled human immunodeficiency virus (HIV-1), chronic or active hepatitis B, or active hepatitis A or C * Patients with HIV are eligible unless their CD4+ T-cell counts are < 350 cells/mcL or they have a history of acquired immunodeficiency syndrome (AIDS)-defining opportunistic infection within the 12 months prior to registration. Concurrent treatment with effective antiretroviral therapy (ART) according to Department of Health and Human Services (DHHS) treatment guidelines is recommended
• Ongoing or active infection
• Subject has any one of the following: * Clinically significant abnormal electrocardiogram (ECG) finding at screening * Congestive heart failure (New York Heart Association class III or IV) * Myocardial infarction within 12 months prior to starting study treatment * Unstable or poorly controlled angina pectoris, including Prinzmetal variant angina pectoris
• Subject has presence of other active malignancy [see exceptions below] (However, research participants with history of prior malignancy treated with curative intent and in complete remission are eligible). The following malignancies are exceptions to the active malignancy statement: * Basal cell carcinoma of the skin * Squamous cell carcinoma of the skin * Non-muscle invasive bladder cancer * Carcinoma in situ of the cervix * Carcinoma in situ of the breast * Incidental histologic finding of prostate cancer (T1a or T1b using the TNM clinical staging system) or prostate cancer that is curative
• Patients with recurrent or progressive brain or leptomeningeal involvement with cancer. Patients that have had previous therapies for brain metastasis or leptomeningeal disease with demonstrated response or stable disease at least four weeks after therapy will be eligible for the trial
• Any other condition that would, in the investigator’s judgment, contraindicate the patient’s participation in the clinical study due to safety concerns with clinical study procedures
• Prospective participants who, in the opinion of the investigator, may not be able to comply with all study procedures (including compliance issues related to feasibility/logistics)