Successful salvage therapy using lenalidomide in a patient with relapsed multiple myeloma after allogeneic hematopoietic
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LETTER TO THE EDITOR
Successful salvage therapy using lenalidomide in a patient with relapsed multiple myeloma after allogeneic hematopoietic stem cell transplantation Tomotaka Suzuki • Shigeru Kusumoto • Tatsuya Yoshida Fumiko Mori • Asahi Ito • Masaki Ri • Takashi Ishida • Hirokazu Komatsu • Akio Niimi • Shinsuke Iida
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Received: 31 August 2012 / Revised: 18 February 2013 / Accepted: 19 February 2013 / Published online: 2 March 2013 Ó The Japanese Society of Hematology 2013
A 34-year-old Japanese man was diagnosed in 2008 as having stage III symptomatic multiple myeloma (IgDlambda type) as defined by the Durie Salmon and International staging system. Chromosomal analysis revealed a normal karyotype, although overexpression of Cyclin D1 was detected by reverse-transcription/real-time polymerase chain reaction assay. After three cycles of induction chemotherapy with vincristine, doxorubicin, and dexamethasone, he received high-dose melphalan therapy with adjunct autologous peripheral blood stem cell transplantation (PBSCT). A very good partial response (VGPR) was achieved, although he relapsed at 11 months after PBSCT. Four cycles of bortezomib and dexamethasone therapy were subsequently given, resulting in a second VGPR. In March 2010, he underwent allogeneic bone marrow transplantation (BMT) from an HLA-matched unrelated donor. The conditioning regimen consisted of fludarabine (30 mg/ m2/day on days -8 to -3) and intravenous busulfan (3.2 mg/kg/day on days -6 to -5) and total body irradiation (4 Gy on day -2). Prophylaxis for graft-versus-host disease (GVHD) included tacrolimus and short-term methotrexate. Neutrophil engraftment was observed on day 16 after BMT, and 92 % donor chimerism was confirmed in the bone marrow on day 32. He developed grade 1 skin GVHD on day 31, which resolved with topical corticosteroids. On day 120, as monoclonal IgD levels increased to 502 mg/dl, tacrolimus was reduced in dose to relieve immunosuppression. However, IgD levels continued to
T. Suzuki S. Kusumoto (&) T. Yoshida F. Mori A. Ito M. Ri T. Ishida H. Komatsu A. Niimi S. Iida Department of Medical Oncology and Immunology, Nagoya City University Graduate School of Medical Sciences, 1 Kawasumi, Mizuho-chou, Mizuho-ku, Nagoya 467-8601, Japan e-mail: [email protected]
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increase up to 968 mg/dl 2 weeks later. Lenalidomide (Len) (10 mg/day per-oral [PO] for 21 days of a 28-day cycle) was then given on day 154. No symptoms of GVHD developed, and tacrolimus was discontinued before the second cycle of Len began. The patient’s IgD levels promptly decreased, and after the forth cycle of Len, the monoclonal protein was undetectable on immunofixation electrophoresis of serum and urine, which correlated with resolution of immunoparesis. On day 840, stringent complete remission was confirmed by serum-free light chain assay and bone marrow examination (Fig. 1). As the patient relapsed just 4 months after allogeneic BMT, his myeloma cells were considered refractory to the prior treatment. However, Len alone
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