Acute Flaccid Paralysis Accompanying West Nile Meningitis Ahmed ...

Autologous Hematopoietic Cell Transplantation and Risk of Secondary
Malignancy
Koehn, Zachary, OMS-III
University of New England College of Osteopathic Medicine, Biddeford, ME
Introduction: Multiple myeloma accounts for 1% of all cancers in the US, about 10%
of hematologic malignancies in the US. While the initial therapy for multiple myeloma
is autologous hematopoietic cell transplantation (HCT), the treatment is not without its
own risks. One of the most significant risks is the development of future
malignancies. Our patient presented 7 years after stem cell transplant for multiple
myeloma with 2 weeks of bleeding gums and pancytopenia, and was subsequently
diagnosed with myelodysplastic syndrome.
Case: A 59 year-old Portuguese woman presents to our hospital with bleeding gums
over the last two weeks. She had been diagnosed with multiple myeloma in 2001,
and received autologous stem cell transplants in 2005 with two years of maintenance
thalidomide after that with notable remission. Since then, she has had imaging
studies to evaluate for remission, including PET scans and MRIs as well as blood
work. The patient had been asymptomatic with no bruising or petechiae, and her
labs from August 2012 showed a white blood cell count of 4.5, platelets of 85, and a
hemoglobin of 12. A total body PET-CT done in January 2012 showed no FDG avid
masses or adenopathy. But in the last two weeks, she has observed that she was
having bleeding in her mouth and bruising on her back, arms, and legs, as well as
tiny red spots on her lower legs over the last few days. Vital signs on admission were
temperature 97.2°F, heart rate 74, respiratory rate 16, blood pressure 119/75 mmHg,
and oxygen saturation 98% on room air. Laboratory studies were significant for
pancytopenia: leukocytes 2400/uL, hemoglobin 7.8 g/dL, hematocrit 23.1%, and
platelets 7000/uL. Peripheral blood smear showed no schistocytes, blasts 3-5%,
lymphocytes, and nucleated erythrocytes. A bone marrow biopsy was performed to
determine the etiology of the pancytopenia. The pathology report identified an
increased number of atypical megakaryocytes, consistent with myelodysplastic
syndrome.
Discussion: This patient had a past history of multiple myeloma, which was treated
with three autologous HCTs, who presented with new pancytopenia, which was
diagnosed as myelodysplastic syndrome. HCT carries the risk of developing future
malignancies, such as acute leukemia, myelodysplastic syndrome, and solid tumors
including non-melanoma skin cancer, squamous cell cancer of the oral cavity, and
breast cancer. Cumulative incidences of myelodysplastic syndrome or acute
leukemia were found in one study to be 3.1% at 5 years, 4.5% at 10 years, and 15%
at 15 years. Studies have estimated a cumulative incidence rate of solid tumors
secondary to autologous HCT at 4% at 10 years.