MM-021: Case Report: Successful Management of Hepatic Lesions Secondary to Multiple Myeloma (MM) with Lenalidomide and Dexamethasone

Abstract

A 43-year-old male with severe back pain was diagnosed in 2011 with IgA kappa multiple myeloma associated with multiple lytic bone lesions (costal and pelvic lesions). The bone marrow biopsy was consistent with MM. The immunohistochemistry study showed CD38+ and kappa+. Induction chemotherapy with bortezomib 1.3 mg/m² thalidomide 200 mg, steroids 40 mg and zoledronic acid 4 mg IV was initiated with a very good response. He underwent ASCT after he was maintained on thalidomide, dexamethasone, and zoledronic acid. In September 2018, the patient complained of right lower limb pain. Lumbar MRI demonstrated an isolated bone mass at the L3-L4 level. Bone marrow aspiration and biopsy with protein electrophoresis and immunofixation were performed confirming disease relapse. The level of plasma cells in the bone marrow was <3%. The serum protein electrophoresis was normal. Surgical resection of the lumbar mass was done. The histological report showed a plasma cell neoplasm. Surgery was followed with 30 sessions of radiotherapy. In March 2019, the patient presented with severe right upper quadrant for which an abdominal CT scan showed a hypermetabolic mass in the liver. Lab tests showed CEA 1.68 ng/ml and CA19.9 16.44 U/ml with a suspicion of colon cancer. PET CT scan showed hypermetabolic mass on the segment IV of the liver, and in the left hepatic lobe. MRI of the abdomen March 2019 revealed multiple metastatic hepatic deposits. Biopsy of one of the hepatic lesions showed diffuse infiltrate of atypical plasmacytoid cells with prominent nucleoli and numerous mitoses on macroscopic evaluation while immunohistochemistry demonstrated positive staining for CD138, kappa light chain restriction, scattered small CD3-positive T cells, and CD20-positive B cells, thus confirming a new relapse of his multiple myeloma. Myelogram with flow cytometry in March 2019 with no plasmocytes. After a thorough discussion with the patient, daratumumab was not initiated due to financial reasons, which incited the start of second line treatment with lenalidomide 25 mg, dexamethasone 40 mg, and zoledronic acid 4 mg. A subsequent evaluation of response by PET CT scan performed 4 months after the initiation of therapy showed a complete disappearance of myeloma-related hepatic lesions.