Successful bortezomib/dexamethasone induction therapy with lenalidomide in an elderly patient with primary plasma cell leukemia complicated by renal failure and pulmonary hypertension

Echocardiography-defined pulmonary hypertension is an adverse prognostic factor for newly diagnosed multiple myeloma patients

BACKGROUND

Pulmonary hypertension (PH) is a common but rarely recognized comorbidity of multiple myeloma (MM) patients, while its prognostic significance for MM has been rarely reported.

METHODS

We retrospectively analyzed the clinical characteristics and prognostic value of baseline echocardiography-defined PH in 426 newly diagnosed MM (NDMM) patients.

RESULTS

Echocardiograph-defined PH was found in 12.7% (54/426) of NDMM patients, associated with older age, anemia, and renal insufficiency, as well as severe diastolic dysfunction and higher BNP and NT-pro-BNP levels. Patients with PH presented with a higher prevalence of atrial fibrillation, while with a similar incidence of thrombosis compared with those without PH. Based on similar treatment regimens and autologous stem cell transplantation (ASCT) rates, patients without PH have deeper and better responses than those with PH (p = 0.002). With the remission of MM, 81.5% of PH was reversible, accompanied by improvement of right ventricular dysfunction and normalization of BNP/NT-pro-BNP levels, while could reoccur at MM relapse. Survival analysis revealed that PH was an adverse prognostic factor, associated with reduced progression-free survival (PFS) (21 vs. 50 months, p < 0.001) and overall survival (OS) (45 vs. 90 months, p = 0.014). Multivariate analysis further verified that baseline PH was an independent predictor for shorter PFS and OS.

CONCLUSION

In conclusion, echocardiography-defined PH is an adverse prognostic indicator for MM patients and should be routinely evaluated in MM patients at diagnosis to make a precise prognosis.

Pulmonary Vascular Disease Due to Plasma Cell Dyscrasia

Pulmonary hypertension (PH) has been described in myeloproliferative disorders; monoclonal plasma cell disorder such as polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes syndrome; and plasma cell dyscrasias such as multiple myeloma and amyloidosis. We describe 4 cases of PH likely due to pulmonary vascular involvement and myocardial deposition from light chain deposition disease, amyloidosis, and multiple myeloma. On the basis of our clinical experience and literature review, we propose screening for plasma cell dyscrasia in patients with heart failure with preserved ejection fraction, unexplained PH, and hematological abnormalities. We also recommend inclusion of cardiopulmonary screening in patients with monoclonal gammopathy of undetermined significance.

Severe but reversible pulmonary hypertension in scleromyxedema and multiple myeloma: a case report

BACKGROUND

Scleromyxedema is a progressive, systemic connective tissue disorder characterized by fibro-mucous skin lesions and increased serum monoclonal immunoglobulin levels. Pulmonary involvement occurs in a subset of patients, though the overall prevalence of pulmonary lesions in scleromyxedema is unknown. Since pulmonary hypertension presumably occurs in these patients due to disease progression and development of additional conditions, treatment of the underlying plasma cell dyscrasia and connective tissue disorder may improve pulmonary hypertension symptoms.

CASE PRESENTATION

An elderly patient with scleromyxedema developed pulmonary hypertension refractory to vasodilator and diuretic therapy and subsequently multiple myeloma that responded to a combination therapy of bortezomib, cyclophosphamide, and dexamethasone treatment.

CONCLUSIONS

Treatment of the underlying disease(s) that contributed to pulmonary hypertension development with anti-neoplastic agents like bortezomib may improve cardiopulmonary symptoms secondary to reducing abnormal blood cell counts and paraprotein levels.

Successful Intrathecal Chemotherapy Combined with Radiotherapy Followed by Pomalidomide and Low-Dose Dexamethasone Maintenance Therapy for a Primary Plasma Cell Leukemia Patient

Primary plasma cell leukemia (PPCL) is a rare aggressive variant of plasma cell disorder and frequently presents with extramedullary disease. Central nervous system (CNS) involvement with PPCL has an extremely poor prognosis. We describe a 46-year-old man with PPCL treated with a combination of lenalidomide, bortezomib, and dexamethasone as induction therapy following upfront allogeneic stem cell transplantation (allo-SCT). Despite achieving a very good partial response, the patient suffered from an isolated CNS relapse 12 months after allo-SCT. He was immediately started on concurrent intrathecal chemotherapy (IT) and cranial irradiation (RT). Subsequently, pomalidomide and low-dose dexamethasone (Pd) were given as maintenance therapy. He has been without CNS recurrence for more than 18 months. Our case suggests that concurrent IT and RT followed by Pd maintenance therapy may be an effective option to control CNS relapse of PPCL after allo-SCT.