Simultaneous therapy-related acute myeloid leukemia and relapse/refractory multiple myeloma: a therapeutic dilemma

Abstract

We present a case of a 61-year-old woman with relapse/refractory multiple myeloma post-autologous peripheral blood stem cell transplantation who presented with recurrent febrile episodes and infection. Worsening thrombocytopenia during lenalidomide-based therapy for early biochemical relapse warranted further investigations. Even though it was initially attributed to lenalidomide and relapse/refractory multiple myeloma, there was not much improvement in her counts despite adjustment of her medications. Subsequent serial bone marrow results and cytogenetic evolution eventually revealed therapy-related myelodysplastic syndrome progressing to therapy-related acute myeloid leukemia. In view of her age and comorbidities, she was treated with subcutaneous azacytidine with palliative intent which resulted in transient disappearance of blasts in the peripheral blood. She subsequently succumbed to progressive therapy-related acute myeloid leukemia and relapse/refractory multiple myeloma. This case highlights the complexity in diagnosing therapy-related myelodysplastic syndrome earlier as prompt diagnosis is crucial in delaying its progression to therapy-related acute myeloid leukemia. Managing therapy-related acute myeloid leukemia in the setting of relapse/refractory multiple myeloma post-autologous peripheral blood stem cell transplantation is challenging in terms of balancing the treatment toxicity and providing the best possible quality of life.