Acute Lymphoblastic Leukemia following Lenalidomide Maintenance for Multiple Myeloma: Two Cases with Unexpected Presentation and Good Prognostic Features

Table 1

Characteristics of patients with multiple myeloma who were exposed to IMiDs maintenance and developed acute lymphoblastic leukemia as a second primary malignancy.

Reference number	IMiD type	Time to Dx (mo)	Age (Y)/sex /presentation	Morphologic type	Cytogenetics/FISH	Treatment/outcome
[15]	Len^1	20	62/F/pancytopenia	B cell (CD19, 20, 10, 22, 79a, TdT, IgMc+, and CD34−)	Normal	Death due to septicemia during induction
[16]	Len	2	66/M/fatigue, low WBC	B cell (CD45, 19, 22, 34+, CD79±, TdT+)	Trisomy 4	Death 8 mo with no response to induction with CHOP
	Thal	31
[17]	Len^1	30	59/M/fatigue, pancytopenia	B cell (CD10, 19+, CD79a, Pax5, and TdT±)	Deletion 20q	Linker regimen, alive > 1 y after allo-SCT in CR
[17]	Len	36	34/M/pancytopenia and circulating blasts	B cell (CD10, 19, 22, 34, 79a, 38+)	Chr 14 rearrangement	CALGB 8811, death 1 month after induction due to CVS and septicemia
[17]	Len^1	84	53/M/leukopenia	B cell (CD19, 34, 79a, PAX5, TdT+)	Small population of tetraploid cells by FISH	Linker regimen, >1 y after 2nd ASCT in CR
[18]	Thal^1,2	29	61/F/pancytopenia	B cell (CD19, 38+)	NA	CALGB 9111
[19]	Len^1	4.5	65/F/dizziness	B cell (CD19, 22, 34, 79a+, HLA-DR+)	NA	No treatment, death after 14 mo
	Thal	32.5
[19]	Thal	32	63/M/fatigue, cytopenias	B cell (CD10, 34+, HLA-DR, and CD33 dim)	NA	Lost to follow-up
[19]	Thal^1	73	33/F/cough, fatigue and anemia	B cell (CD10, 34, 19, 22, 33, 79a+, HLA-DR+)	NA	No treatment, lost to follow-up
[20]	Thal	53	56/F/edema and dyspnea, pancytopenia	B cell (CD19, 20, 22, 10+, HLA-DR+)	Normal	Steroids only, DVT/PE, death within 10 days
[21]	Len	24–36	72/M/pancytopenia	B cell (CD10, 19, 20, 79a, and TdT+, CD34, 117, 38, 56−)	NA	Hyper-CVAD, POMP maintenance. CR for 26 mo, then relapse
Our case	Len^1	23	69/F/none	B cell (CD34, 19, 22+)	t(7;19) in one metaphase	Hyper-CVAD, then POMP maintenance, in CR for 3 year
Our case	Len^1	72	53/F/pancytopenia	B cell (CD19, 33, 34, 38, 79a+, PAX5+, TdT+)	+8, +10, +22, −20, and FISH showed MYC and IgH gene locus copy gain	Abbreviated CALGB 8811 due to intolerance, now on POMP maintenance, in CR for 1 year

¹These patients had prior ASCT, while the others did not; ²developed ALL 3 years after stopping Thal maintenance.