Initial management of high-risk myeloma remains a treatment challenge. Risk is defined by a combination of clinical and biological features, with fluorescence in situ hybridization detection of specific cytogenetic abnormalities driving categorization. High-risk abnormalities include t(4;14), t(14;16), t(14;20), del(17p), and +1q. Clinical features such as plasma cell leukemia, presence of 5% to 20% circulating plasma cells, and extramedullary disease all are factors in high-risk presentations. The driving principle of treatment of the high-risk patient is the use of a regimen with the greatest likelihood of a deep and prolonged remission, as defined by minimal residual disease negativity. I will describe prior and current treatment approaches, including induction, the role of autologous transplantation, and posttransplantation consolidation and maintenance therapy selection using the best available data to provide a rationale for these decisions. This case-based roundtable walks through treatment of a patient with newly diagnosed high-risk myeloma.