|
Advertisement |
|
|
||
 |
|
|||||
|
|||||
|
 |
||||||
|
||||||
|
||||||
|
Journal of Clinical Oncology, Vol 22, No 15 (August 1), 2004: pp. 3192-3193 © 2004 American Society of Clinical Oncology. DOI: 10.1200/JCO.2004.09.143
Uncommon Manifestations of Common MalignanciesCASE 2. Chronic Lymphocytic Leukemia and Multiple Myeloma in the Same PatientDepartment of Pathology and Medical Oncology, Kidwai Memorial Institute of Oncology, Bangalore, India A 67-year-old man presented to a private hospital with fatigue. Routine investigations showed an absolute lymphocytosis of 29,230/mm3. Bone marrow aspiration showed a hypercellular marrow with 83% mature lymphocytes. Immunophenotyping by flow cytometry showed that the lymphocytes were CD5, CD19, CD23, and HLA-DR positive, and CD3, CD10, CD38, CD103, FMC7, and CD11c negative. Kappa chain was negative, and lambda chain was positive. Serum immunoglobulin levels showed an immunoglobulin G gamma type of monoclonal gammopathy. Immunoglobulin G level was 7,589 mg/dL (normal, 723 to 1,685 mg/dL). There was an M band in the gamma region. Beta-2 microglobulin level was raised to 5.21 mg/L (normal, 0.7 to 2.0 mg/L). A diagnosis of chronic lymphocytic leukemia with monoclonal gammopathy was made, and treatment with chlorambucil was initiated. He responded well to the treatment and was asymptomatic for 6 months. Six months later, he was referred to our oncology center for weakness of both the lower limbs. Mild hepatomegaly was present. Computed tomography scan showed multiple lytic bony lesions in the left femoral neck; left iliac bone; and L3, L4, and D9 vertebral bodies (Fig 1). The peripheral smear showed a lymphocytosis. Bone marrow aspirate showed sheets of mature lymphocytes interspersed with islands of large plasma cells of an intermediate grade of differentiation (Fig 2). The plasma cells showed asynchronous maturation, with the nucleus exhibiting a single nucleolus. With these findings, a diagnosis of chronic lymphocytic leukemia (CLL) with concomitant multiple myeloma (MM) was made, and the patient was started on treatment with cyclophosphamide, vincristine, and prednisolone (COP). He developed septicemia after receiving three cycles of chemotherapy, and died of adult respiratory distress syndrome.
B-cell CLL and MM are chronic B-cell malignancies that represent different stages in B-cell maturation. The occurrence of both malignancies in the same patient is rare. CLL is known to be associated with transformation to various entities, such as prolymphocytic leukemia and large-cell lymphoma (Richter's syndrome). This represents a dedifferentiation, whereas transformation to myeloma represents a change to a more mature form. This raises the question of whether the two diseases arise from the same progenitor cell or are of biclonal derivation. Some authors have attempted to address this issue by studying the immunoglobulin light chains produced by the two types of cells1-3 or by immunoglobulin gene rearrangement analysis.4-6 Clonal chromosomal abnormalities in lymphocytes and plasma cells have been studied by interphase fluorescent in situ hybridization.7 The conclusion by some workers1,5-7 is that the CLL and MM are of biclonal derivation, while others2-4 are of the opinion that the CLL cells have transformed to plasma cells. In most of the cases, the CLL has been diagnosed 1 to 15 years before the onset of the MM. The clinical features reflect the two diseases, with the occurrence of extraosseous plasmacytoma being a noteworthy feature. In our case, there was a gap of 6 months between the diagnosis of CLL and the onset of MM. The onset of paraplegia heralded the discovery of the myeloma. This case illustrates the rare association of these two malignancies in the same patient. Authors' Disclosures of Potential Conflicts of Interest The authors indicated no potential conflicts of interest.
REFERENCES 1. Brouet JC, Fermand JP, Laurent G, et al: The association of chronic lymphocytic leukemia and multiple myeloma: A study of eleven patients. Br J Haematol 59:55-66, 1985[Medline]
2. Fermand JP, James JM, Herait P, et al: Associated chronic lymphocytic leukemia and multiple myeloma: Origin from a single clone. Blood 66:291-293, 1985 3. Pines A, Ben-Bassat I, Selzer G, et al: Transformation of chronic lymphocytic leukemia to plasmacytoma. Cancer 54:1904-1907, 1984[CrossRef][Medline]
4. Saltman DL, Ross JA, Banks RE, et al: Molecular evidence for a single clonal origin in bi phenotypic chronic lymphocytic leukemia and multiple myeloma. Blood 74:2062-2065, 1989 5. Novak PM, Mattson JC, Crisan D, et al: Separate clones in concomitant multiple myeloma and a second cell neoplasm demonstrated by molecular and immunophenotypic analysis. Eur J Haematol 54:254-261, 1995[Medline]
6. Patriarca F, Gaidano G, Capello D, et al: Occurrence of multiple mycloma after fludaribine treatment of a chronic lymphocytic leukemia: Evidence of a biclonal deviation and clinical response to autologous stem cell transplantation. Haematologica 85:982-985, 2000 7. Kaufmann H, Ackermann J, Nosslinger T, et al: Absence of clonal chromosomal relationship between concomitant B-CLL and multiple myeloma: A report on two cases. Ann Hematol 80:474-478, 2001[CrossRef][Medline]
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|
|||||||||||
|
|||||||||||
|
|
Copyright © 2004 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
|
