Intra-cerebral relapse following prolonged remission after autologous stem cell transplantation for multiple myeloma

Multiple myeloma with isolated central nervous system relapse after autologous stem cell transplantation: A case report and review of the literature

Patients with multiple myeloma (MM) rarely present with central nervous system (CNS) involvement as a manifestation of extramedullary disease (EMD), a condition that is associated with poor prognosis. CNS relapse without evidence of systemic involvement is even rarer, and there is no standardized treatment because there are only few case reports. We present a 47-year-old female who was diagnosed with nonsecretory multiple myeloma (NSMM) 9 years previously. She had a complete remission after receiving aggressive therapies, including high-dose chemotherapy and autologous stem cell transplantation (ASCT). However, after 7 years of progression-free survival, she had CNS relapse without evidence of systemic involvement. We switched to a salvage regimen consisting of high-dose methotrexate with lenalidomide. She achieved rapid clinical improvement, with a reduction in cerebrospinal fluid plasmacytosis of more than 80%, and no notable side effects. Our description of this unique case of a patient with MM and isolated CNS relapse after ASCT provides a reference for physicians to provide more appropriate management of these patients. We also reviewed previously reported cases and summarized the outcomes of isolated CNS relapse after ASCT, and discuss the pathogenesis and possible treatment strategies for MM with isolated CNS relapse.

Isolated central nervous system relapse of multiple myeloma post autologous stem cell transplant- A rare presentation

•CNS relapse in multiple myeloma after ASCT without medullary relapse is uncommon.•Isolated CNS relapse is extremely rare with only 7 cases reported in literature.•Prognosis is poor with very short median survival after detection of CNS relapse.•Management is based on IMiD's and intrathecal therapy with radiation.

56-year-old male with left-sided weakness

A 56-year-old male with a 3-year history of multiple myeloma that was treated with tandem autologous stem cell transplantations. He presented in July 2006 with a left partial hemiparesis and ataxia. MRI of the brain revealed an enhancing large right frontoparietal lesion with heterogeneously hyperintense nodular septations on T2WI, with no significant surrounding edema. The differential diagnosis of this lesion placed a high-grade glioma at the top of the list. The patient underwent surgical resection of the lesion. Pathology confirmed the diagnosis of a relapse of his multiple myeloma. The specimen demonstrated a monomorphic neoplasm arranged in sheets and trabeculae floating in a background of a proteinaceous substance. Immunohistochemistry showed the neoplastic cell was a CD138 positive plasma cell. The nature of the background substance is still undetermined and is a very unusual appearance for multiple myeloma. Flow cytometry revealed a monoclonal plasma cell population with an immunophenotype identical to the initial diagnostic bone marrow aspirate. A completely intraparenchymal manifestation of multiple myeloma is rare in itself but the unusual radiographic and histological appearance of this case is extraordinary.