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work images in hematology

Walking on myeloma
Bart Barlogie and Joshua Richter, Icahn School of Medicine at Mount Sinai

A B

A 60-year-old man who had had immunoglobulin G k multiple
myeloma since 2008 underwent 2 melphalan 200 mg/m2–
based autologous transplantations. Initial genomic analysis
revealed translocation (4;14). He had received 12 lines of therapy,
including all US Food and Drug Administration–approved
therapies and checkpoint inhibitors, with numerous relapses.
The most recent genomic evaluation confirmed IGH-FGFR3 and
IGH-MMSET fusions, loss of BIRC3 and CDKN2C, and a splice
site within NFKB1A. Although he has never had osteolytic
bone disease, a biopsy shows confluent sheets of atypical plasma
cells infiltrating skeletal muscle (panels A and B; hema-
toxylin and eosin stain, original magnification 3100 [A] and
3400 [B]), and immunohistochemical labeling for ki67/mib1
shows a proliferation index of 60% to 70% (panel C; original
magnification 3400). With positron emission tomography/
computed tomography–confirmed focally progressive disease in
the calves and plantar aspects of his feet bilaterally, he is
“walking on myeloma” (arrows indicate active myeloma).
Oligosecretory status and absence of bone marrow in-
volvement with minimal residual disease negativity require
frequent imaging studies, making him ineligible for clinical
trials. He maintains otherwise excellent clinical performance
status and is responding to 28-day metronomically scheduled
therapy: doxorubicin and cisplatin both at 1.0 mg/m2 per day
by continuous infusion; flat-dose vincristine 0.07 mg per day
plus bortezomib 1.0 mg/m2 on days 1, 4, 7, 10, 13, 16, 19, 22,
25, and 28; dexamethasone 12 mg on days 1 to 4, 7 to 10, 13
to 16, 19 to 22, and 25 to 28; daratumumab 16 mg/kg weekly
for 4 weeks; and proteasome inhibitor–synergizing nelfinavir
1250 mg twice daily, complemented by radiation therapy to
both legs.

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DOI 10.1182/blood-2018-07-861096 © 2018 by The American Society of Hematology

1724 blood® 18 OCTOBER 2018 | VOLUME 132, NUMBER 16

 From www.bloodjournal.org by guest on September 19, 2019. For personal use only.

2018 132: 1724

doi:10.1182/blood-2018-07-861096

Walking on myeloma
Bart Barlogie and Joshua Richter

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