Multiple Myeloma (MM) patients refractory to bortezomib and one or more immunomodulatory drugs have a poor clinical outcome. Alkylating agents are often avoided in the initial management of MM in part due to concerns for impairment of HSC mobilization. High doses of cyclophosphamide (HiCy) administered without HSC support may be an effective treatment to rescue MM patients refractory to novel biological agents. We performed a retrospective single institution analysis of 17 consecutive MM patients receiving high dose cyclophosphamide (HiCy, 3000 mg/m 2 ) after failure of bortezomib and, in most cases, at least one immunomodulatory agent (IMiD). Despite the prevalence of high-risk features in this cohort we found HiCy to be an effective salvage therapy for high-risk MM patients refractory to new biological agents.Multiple Myeloma (MM) is a malignant plasma cell disorder with no standard curative therapy [1] affecting 4.3 per 100,000 individuals yearly in the united states, accounting for about 1% of all cancers and 10% of all hematological malignancies [2]. Patients who receive conventional chemotherapy or autologous stem cell transplantation have a mean overall survival of 3.7 years [1], although survival is likely increasing with the assimilation of new biological agents into the management of MM [3][4][5][6][7].For decades, melphalan and prednisone were the cornerstones of MM management. Complete responses under this regimen are rare, and the median time for progression is not higher than 15 months [5,8]. The immunomodulatory (IMiD) drugs thalidomide and lenalidomide [6,7] along with the first proteasome inhibitor bortezomib have shown efficacy in managing relapsed and refractory MM [4,9,10]. These biological agents have been quickly incorporated in the upfront management of MM so that regimens containing one or more biological agents have produced the highest response rates ever reported for previously untreated MM patients [3,[11][12][13][14][15][16][17][18][19].Despite these advances, patients refractory to, or progressing after, treatment with one or more biological agents have a very poor prognosis and no satisfactory therapeutic option [12,20]. A recent study from the International Myeloma Working Group reported the outcomes of 270 patients relapsing on or refractory to bortezomib and one IMiD. Only 30% of the patients had an objective response to the next line of therapy. The median overall survival and event free survival time were dismal eight months and five month, respectively [12].With the enthusiasm generated by autologous hematopoietic stem cell transplantation (HSCT) and the new biological agents, alkylating agents are often excluded from the initial therapy of MM and patients failing new biological agents are often alkylating-naïve. High-dose, single agent cyclophosphamide can be an attractive alternative in this setting since it does not require stem cell support and is compatible with poor renal function. In this report we present a retrospective analysis of consecutive patients with bortezom...