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Arribas I, Maluquer C, Pomares H, Carro I, Baca C, Bosch A, Arévalo CE, Montané C, Ribes-Amorós J, Zamora L, Granada I, Gamundi E, Arnan M, Sureda A. B-cell acute lymphoblastic leukemia after lenalidomide maintenance therapy; a deleterious adverse event that needs further investigation. Report of three cases and review of the literature. Leuk Lymphoma 2023; 64:1701-1705. [PMID: 37455651 DOI: 10.1080/10428194.2023.2234527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 06/30/2023] [Indexed: 07/18/2023]
Affiliation(s)
- I Arribas
- Clinical Hematology Department IDIBELL, Catalan Institute of Oncology, Hospital Duran i Reynals, Hospitalet de Llobregat, Barcelona, Spain
| | - C Maluquer
- Clinical Hematology Department IDIBELL, Catalan Institute of Oncology, Hospital Duran i Reynals, Hospitalet de Llobregat, Barcelona, Spain
| | - H Pomares
- Clinical Hematology Department IDIBELL, Catalan Institute of Oncology, Hospital Duran i Reynals, Hospitalet de Llobregat, Barcelona, Spain
| | - I Carro
- Clinical Hematology Department IDIBELL, Catalan Institute of Oncology, Hospital Duran i Reynals, Hospitalet de Llobregat, Barcelona, Spain
| | - C Baca
- Clinical Hematology Department IDIBELL, Catalan Institute of Oncology, Hospital Duran i Reynals, Hospitalet de Llobregat, Barcelona, Spain
| | - A Bosch
- Clinical Hematology Department IDIBELL, Catalan Institute of Oncology, Hospital Duran i Reynals, Hospitalet de Llobregat, Barcelona, Spain
| | - C E Arévalo
- Clinical Hematology Department IDIBELL, Catalan Institute of Oncology, Hospital Duran i Reynals, Hospitalet de Llobregat, Barcelona, Spain
| | - C Montané
- Clinical Hematology Department IDIBELL, Catalan Institute of Oncology, Hospital Duran i Reynals, Hospitalet de Llobregat, Barcelona, Spain
| | - J Ribes-Amorós
- Clinical Hematology Department IDIBELL, Catalan Institute of Oncology, Hospital Duran i Reynals, Hospitalet de Llobregat, Barcelona, Spain
| | - L Zamora
- Hematology Department, ICO-Hospital Germans Trias i Pujol, José Carreras Leukemia Research Institute, Badalona, Spain
| | - I Granada
- Hematology Department, ICO-Hospital Germans Trias i Pujol, José Carreras Leukemia Research Institute, Badalona, Spain
| | - E Gamundi
- Pathology Department, Bellvitge University Hospital, Barcelona, Spain
| | - M Arnan
- Clinical Hematology Department IDIBELL, Catalan Institute of Oncology, Hospital Duran i Reynals, Hospitalet de Llobregat, Barcelona, Spain
| | - A Sureda
- Clinical Hematology Department IDIBELL, Catalan Institute of Oncology, Hospital Duran i Reynals, Hospitalet de Llobregat, Barcelona, Spain
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2
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Distinct clonal identities of B-ALLs arising after lenolidomide therapy for multiple myeloma. Blood Adv 2022; 7:236-245. [PMID: 36251745 PMCID: PMC9860439 DOI: 10.1182/bloodadvances.2022007496] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 06/27/2022] [Accepted: 06/28/2022] [Indexed: 01/29/2023] Open
Abstract
Patients with multiple myeloma (MM) who are treated with lenalidomide rarely develop a secondary B-cell acute lymphoblastic leukemia (B-ALL). The clonal and biological relationship between these sequential malignancies is not yet clear. We identified 17 patients with MM treated with lenalidomide, who subsequently developed B-ALL. Patient samples were evaluated through sequencing, cytogenetics/fluorescence in situ hybridization (FISH), immunohistochemical (IHC) staining, and immunoglobulin heavy chain (IgH) clonality assessment. Samples were assessed for shared mutations and recurrently mutated genes. Through whole exome sequencing and cytogenetics/FISH analysis of 7 paired samples (MM vs matched B-ALL), no mutational overlap between samples was observed. Unique dominant IgH clonotypes between the tumors were observed in 5 paired MM/B-ALL samples. Across all 17 B-ALL samples, 14 (83%) had a TP53 variant detected. Three MM samples with sufficient sequencing depth (>500×) revealed rare cells (average of 0.6% variant allele frequency, or 1.2% of cells) with the same TP53 variant identified in the subsequent B-ALL sample. A lack of mutational overlap between MM and B-ALL samples shows that B-ALL developed as a second malignancy arising from a founding population of cells that likely represented unrelated clonal hematopoiesis caused by a TP53 mutation. The recurrent variants in TP53 in the B-ALL samples suggest a common path for malignant transformation that may be similar to that of TP53-mutant, treatment-related acute myeloid leukemia. The presence of rare cells containing TP53 variants in bone marrow at the initiation of lenalidomide treatment suggests that cellular populations containing TP53 variants expand in the presence of lenalidomide to increase the likelihood of B-ALL development.
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3
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Puliafito B, Oveisi D, Fanous C, El-Masry M. Secondary B-cell acute lymphoblastic leukaemia in a patient with multiple myeloma. BMJ Case Rep 2022; 15:e249637. [PMID: 35732365 PMCID: PMC9226925 DOI: 10.1136/bcr-2022-249637] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2022] [Indexed: 12/28/2022] Open
Abstract
Although patients with multiple myeloma (MM) have improved survival with current therapies, there remains a long-term risk of treatment-associated second primary malignancies. We present a case of a patient with IgG kappa MM undergoing treatment for relapsed disease who was noted to have progressive pancytopenia. For his MM, he had previously undergone autologous stem cell transplant with high-dose melphalan and had received immunomodulatory (IMiD) agents in induction, maintenance and relapse regimens. A peripheral blood smear showed abnormal lymphoid cells, and a bone marrow biopsy revealed B-cell acute lymphoblastic leukaemia (B-ALL). He underwent intensive induction chemotherapy with plans for possible allogeneic stem cell transplant. Secondary B-ALL is a rare occurrence in patients with MM, with exposure to alkylating and IMiD agents being potential risk factors.
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Affiliation(s)
- Benjamin Puliafito
- Hematology and Oncology, VA West Los Angeles Medical Center, Los Angeles, California, USA
- Hematology and Oncology, University of California Los Angeles, Los Angeles, California, USA
| | - David Oveisi
- Hematology and Oncology, UCLA Medical Center Olive View, Sylmar, California, USA
| | - Christina Fanous
- Medicine, University of Nevada Las Vegas, Las Vegas, Nevada, USA
| | - Monica El-Masry
- Hematology and Oncology, VA West Los Angeles Medical Center, Los Angeles, California, USA
- Hematology and Oncology, University of California Los Angeles, Los Angeles, California, USA
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4
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Sadowska-Klasa A, Abba M, Gajkowska-Kulik J, Zaucha JM. Therapy-related acute lymphoblastic leukemia following treatment for multiple myeloma - diagnostic and therapeutic dilemma. Acta Oncol 2022; 61:1126-1131. [PMID: 35668607 DOI: 10.1080/0284186x.2022.2083921] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Affiliation(s)
- Alicja Sadowska-Klasa
- Department of Hematology and Transplantology, Medical University of Gdańsk, Gdansk, Poland
| | - Mary Abba
- Medical University of Gdańsk, Gdansk, Poland
| | - Justyna Gajkowska-Kulik
- Department of Hematology and Bone Marrow Transplantation, SSM Nicolaus Copernicus, Toruń, Poland
| | - Jan Maciej Zaucha
- Department of Hematology and Transplantology, Medical University of Gdańsk, Gdansk, Poland
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5
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Kallen ME, Koka R, Singh ZN, Ning Y, Kocoglu MH, Badros AZ, Niyongere S, Duong VH, Emadi A, Baer MR. Therapy-related B-lymphoblastic leukemia after multiple myeloma. Leuk Res Rep 2022; 18:100358. [PMID: 36353199 PMCID: PMC9637917 DOI: 10.1016/j.lrr.2022.100358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 09/29/2022] [Accepted: 10/30/2022] [Indexed: 11/07/2022] Open
Abstract
New therapies for multiple myeloma have improved outcomes, but are associated with therapy-related hematologic malignancies. We report eight patients with therapy-related B-lymphoblastic leukemias (t-B-ALL) in the setting of therapy for multiple myeloma, which included lenalidomide maintenance. A subset of patients had pancytopenia and low-level marrow involvement by acute leukemia, an unusual finding in de novo B-ALL. One patient died of chemotherapy complications; the other seven responded. No patient died of B-ALL (median follow up of 1.0 years). Our series suggests that t-B-ALL is clonally unrelated to myeloma, presents with diverse cytogenetic abnormalities, and responds well to B-ALL therapy.
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Affiliation(s)
- Michael E. Kallen
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD, United States
- Corresponding author at: Department of Pathology, University of Maryland School of Medicine, 22 S. Greene St., NBW-54, 21201, Baltimore, MD.
| | - Rima Koka
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Zeba N. Singh
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Yi Ning
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Mehmet H. Kocoglu
- Department of Medicine, Division of Hematology/Oncology, University of Maryland School of Medicine, Baltimore, MD, United States
- University of Maryland Greenebaum Comprehensive Cancer Center, Baltimore, MD, , United States
| | - Ashraf Z. Badros
- Department of Medicine, Division of Hematology/Oncology, University of Maryland School of Medicine, Baltimore, MD, United States
- University of Maryland Greenebaum Comprehensive Cancer Center, Baltimore, MD, , United States
| | - Sandrine Niyongere
- Department of Medicine, Division of Hematology/Oncology, University of Maryland School of Medicine, Baltimore, MD, United States
- University of Maryland Greenebaum Comprehensive Cancer Center, Baltimore, MD, , United States
| | - Vu H. Duong
- Department of Medicine, Division of Hematology/Oncology, University of Maryland School of Medicine, Baltimore, MD, United States
- University of Maryland Greenebaum Comprehensive Cancer Center, Baltimore, MD, , United States
| | - Ashkan Emadi
- Department of Medicine, Division of Hematology/Oncology, University of Maryland School of Medicine, Baltimore, MD, United States
- University of Maryland Greenebaum Comprehensive Cancer Center, Baltimore, MD, , United States
| | - Maria R. Baer
- Department of Medicine, Division of Hematology/Oncology, University of Maryland School of Medicine, Baltimore, MD, United States
- University of Maryland Greenebaum Comprehensive Cancer Center, Baltimore, MD, , United States
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6
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Germans SK, Kulak O, Koduru P, Oliver D, Gagan J, Patel P, Anderson LD, Fuda FS, Chen W, Jaso JM. Lenalidomide-Associated Secondary B-Lymphoblastic Leukemia/Lymphoma-A Unique Entity. Am J Clin Pathol 2020; 154:816-827. [PMID: 32880627 DOI: 10.1093/ajcp/aqaa109] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES Autologous stem cell transplant with lenalidomide maintenance therapy has greatly improved the relapse-free and overall survival rates of patients with multiple myeloma but also has been associated with an increased risk of secondary B-lymphoblastic leukemia/lymphoma (B-ALL). METHODS We report a comprehensive review of the clinicopathologic features of 2 patients with multiple myeloma who developed secondary B-ALL during lenalidomide maintenance. RESULTS Our observations showed that the disease may initially present with subtle clinical, morphologic, and flow-cytometric findings. The flow cytometry findings in such cases may initially mimic an expansion of hematogones with minimal immunophenotypic variation. Both patients achieved complete remission of secondary B-ALL after standard chemotherapy; however, one patient continues to have minimal residual disease, and the other experienced relapse. Next-generation sequencing of the relapse specimen showed numerous, complex abnormalities, suggesting clonal evolution. CONCLUSIONS Our findings suggest the need for increased awareness and further study of this unique form of secondary B-ALL.
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Affiliation(s)
| | - Ozlem Kulak
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas
| | - Prasad Koduru
- Department of Genomics and Molecular Pathology, University of Texas Southwestern Medical Center, Dallas
| | - Dwight Oliver
- Department of Genomics and Molecular Pathology, University of Texas Southwestern Medical Center, Dallas
| | - Jeffery Gagan
- Department of Genomics and Molecular Pathology, University of Texas Southwestern Medical Center, Dallas
| | - Prapti Patel
- Department of Internal Medicine, Hematology and Oncology Division, University of Texas Southwestern Medical Center, Dallas
| | - Larry D Anderson
- Department of Internal Medicine, Hematology and Oncology Division, University of Texas Southwestern Medical Center, Dallas
| | - Franklin S Fuda
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas
| | - Weina Chen
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas
| | - Jesse Manuel Jaso
- Department of Pathology, University of Texas Southwestern Medical Center, Dallas
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7
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Poh C, Keegan T, Rosenberg AS. Second primary malignancies in multiple myeloma: A review. Blood Rev 2020; 46:100757. [PMID: 32972803 DOI: 10.1016/j.blre.2020.100757] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Revised: 07/24/2020] [Accepted: 08/27/2020] [Indexed: 12/16/2022]
Abstract
As survival times of multiple myeloma (MM) patients continue to improve, second primary malignancies (SPM) have become an increasingly relevant long-term risk among MM survivors. Population studies since the 1950s have consistently observed an increased incidence of hematologic SPMs, specifically acute leukemia, among MM survivors. Prolonged treatment with alkylators, especially melphalan, was associated with an increased hematologic SPM risk; likewise, autologous stem cell transplantation appeared to minimally increase SPM risk. Immunomodulatory drugs, specifically lenalidomide, was associated with an increased SPM incidence, although most studies concluded that the benefits of therapy outweighed any risks of SPM. Newer anti-myeloma therapy such as proteasome inhibitors and monoclonal antibodies did not appear to increase SPM risk although robust long-term follow-up is lacking. This review discusses current understanding regarding SPMs among survivors of MM, how different host-, disease- and treatment-related factors contribute to SPM incidence and highlights emerging screening guidelines and prognosis for SPMs.
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Affiliation(s)
- Christina Poh
- University of California, Davis Comprehensive Cancer Center, Sacramento, CA, USA; University of Washington, Department of Medicine, Division of Medical Oncology, Seattle, WA, USA.
| | - Theresa Keegan
- University of California, Davis Comprehensive Cancer Center, Sacramento, CA, USA
| | - Aaron Seth Rosenberg
- University of California, Davis Comprehensive Cancer Center, Sacramento, CA, USA
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8
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Sinit RB, Hwang DG, Vishnu P, Peterson JF, Aboulafia DM. B-cell acute lymphoblastic leukemia in an elderly man with plasma cell myeloma and long-term exposure to thalidomide and lenalidomide: a case report and literature review. BMC Cancer 2019; 19:1147. [PMID: 31775673 PMCID: PMC6882354 DOI: 10.1186/s12885-019-6286-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Accepted: 10/24/2019] [Indexed: 04/04/2023] Open
Abstract
BACKGROUND The advent of the immunomodulatory imide drugs (IMiDs) lenalidomide and thalidomide for the treatment of patients with plasma cell myeloma (PCM), has contributed to more than a doubling of the overall survival of these individuals. As a result, PCM patients join survivors of other malignancies such as breast and prostate cancer with a relatively new clinical problem - second primary malignancies (SPMs) - many of which are a result of the treatment of the initial cancer. PCM patients have a statistically significant increased risk for acute myeloid leukemia (AML) and Kaposi sarcoma. IMiD treatment has also been associated with an increased risk of myelodysplastic syndrome (MDS), AML, and squamous cell carcinoma of the skin. However, within these overlapping groups, acute lymphoblastic leukemia (ALL) is much less common. CASE PRESENTATION Herein, we describe an elderly man with PCM and a 14-year cumulative history of IMiD therapy who developed persistent pancytopenia and was diagnosed with B-cell acute lymphoblastic leukemia (B-ALL). He joins a group of 17 other patients documented in the literature who have followed a similar sequence of events starting with worsening cytopenias while on IMiD maintenance for PCM. These PCM patients were diagnosed with B-ALL after a median time of 36 months after starting IMiD therapy and at a median age of 61.5 years old. CONCLUSIONS PCM patients with subsequent B-ALL have a poorer prognosis than their de novo B-ALL counterparts, however, the very low prevalence rate of subsequent B-ALL and high efficacy of IMiD maintenance therapy in PCM should not alter physicians' current practice. Instead, there should be a low threshold for bone marrow biopsy for unexplained cytopenias.
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Affiliation(s)
- Ryan B. Sinit
- Floyd and Delores Jones Cancer Institute, Virginia Mason Medical Center, 1100 Ninth Avenue (C2-HEM), Seattle, WA 98101 USA
| | - Dick G. Hwang
- Department of Pathology, Virginia Mason Medical Center, Seattle, WA USA
| | - Prakash Vishnu
- Department of Medical Oncology, Mayo Clinic, Jacksonville, FL USA
| | - Jess F. Peterson
- Division of Laboratory Genetics and Genomics, Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN USA
| | - David M. Aboulafia
- Floyd and Delores Jones Cancer Institute, Virginia Mason Medical Center, 1100 Ninth Avenue (C2-HEM), Seattle, WA 98101 USA
- Division of Hematology, University of Washington School of Medicine, Seattle, WA USA
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9
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Acute Lymphoblastic Leukemia following Lenalidomide Maintenance for Multiple Myeloma: Two Cases with Unexpected Presentation and Good Prognostic Features. Case Rep Hematol 2018; 2018:9052314. [PMID: 29785311 PMCID: PMC5896379 DOI: 10.1155/2018/9052314] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2017] [Accepted: 01/22/2018] [Indexed: 01/09/2023] Open
Abstract
Lenalidomide maintenance following autologous stem cell transplant (ASCT) is considered the standard of care for eligible patients with multiple myeloma (MM). A recent meta-analysis has provided additional evidence that lenalidomide maintenance is associated with a higher incidence of second primary malignancies, including both hematologic and solid malignancies. Acute lymphoblastic leukemia (ALL) as a second primary malignancy is rarely described in the literature. Herein, we describe two patients with MM treated with induction therapy, ASCT, and lenalidomide maintenance that experienced cytopenias while on maintenance. ALL was unexpectedly diagnosed on bone marrow biopsy. One patient was diagnosed on routine biopsy performed as part of requirements of the clinical trial. Both patients had B-cell ALL, without known poor risk cytogenetics, and were managed with standard induction therapies resulting in complete remission. We also reviewed the literature for similar cases of secondary ALL (sALL) in MM patients exposed to immunomodulatory drugs (IMiDs). In conclusion, persistent cytopenias in responding MM patients receiving IMiDs maintenance should be an indication for bone marrow biopsy. Patients develop sALL after median of 32.5 months (range, 20–84) from being on lenalidomide or thalidomide maintenance, often presenting with cytopenias, display low tolerance to chemotherapy, but remission can often be achieved.
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10
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Alhuraiji A, Naqvi K, Huh YO, Ho C, Verstovsek S, Bose P. Acute lymphoblastic leukemia secondary to myeloproliferative neoplasms or after lenalidomide exposure. Clin Case Rep 2017; 6:155-161. [PMID: 29375856 PMCID: PMC5771935 DOI: 10.1002/ccr3.1264] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 09/02/2017] [Accepted: 09/29/2017] [Indexed: 11/06/2022] Open
Abstract
Philadelphia‐negative (Ph−) myeloproliferative neoplasms (MPN) do rarely transform to acute lymphoblastic leukemia (ALL). While causality is difficult to establish, a few cases of ALL arising after exposure to lenalidomide for registered indications (multiple myeloma, myelodysplastic syndrome with 5q deletion) have been described in the literature.
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Affiliation(s)
- Ahmad Alhuraiji
- Department of Leukemia University of Texas MD Anderson Cancer Center Houston 77030 Texas
| | - Kiran Naqvi
- Department of Leukemia University of Texas MD Anderson Cancer Center Houston 77030 Texas
| | - Yang O Huh
- Department of Hematopathology University of Texas MD Anderson Cancer Center Houston 77030 Texas
| | - Coty Ho
- Oklahoma Cancer Specialists and Research Institute Tulsa 74133 Oklahoma
| | - Srdan Verstovsek
- Department of Leukemia University of Texas MD Anderson Cancer Center Houston 77030 Texas
| | - Prithviraj Bose
- Department of Leukemia University of Texas MD Anderson Cancer Center Houston 77030 Texas
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11
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Kurant D, Fisher S, Tang W, Aguilera N. B-lymphoblastic leukemia/lymphoma arising in treated plasma cell myeloma: A rare second malignancy. HUMAN PATHOLOGY: CASE REPORTS 2017. [DOI: 10.1016/j.ehpc.2017.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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12
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Tan M, Fong R, Lo M, Young R. Lenalidomide and secondary acute lymphoblastic leukemia: a case series. Hematol Oncol 2015; 35:130-134. [DOI: 10.1002/hon.2248] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Revised: 06/16/2015] [Accepted: 07/04/2015] [Indexed: 11/10/2022]
Affiliation(s)
- Marisela Tan
- University of California; San Francisco School of Pharmacy Department of Clinical Pharmacy; USA
| | - Richard Fong
- University of California; San Francisco School of Pharmacy Department of Clinical Pharmacy; USA
- University of California; San Francisco Medical Center Department of Pharmaceutical Services; USA
| | - Mimi Lo
- University of California; San Francisco School of Pharmacy Department of Clinical Pharmacy; USA
- University of California; San Francisco Medical Center Department of Pharmaceutical Services; USA
| | - Rebecca Young
- University of California; San Francisco School of Pharmacy Department of Clinical Pharmacy; USA
- University of California; San Francisco Medical Center Department of Pharmaceutical Services; USA
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