Hi All,
My 68 year old mother was diagnosed with Waldenstrom's macroglobulinemia in March 2014. She presented with weight loss, tingling in her fingers, and one episode of severe dizziness (likely due to hyperviscosity). At the time of diagnosis, her bloodwork was as follows:
IgM: 2.8g/dl
WBC: 5.1
HGB: 15.9
HCT:34
PLT: 182K
MPV: 8.4
The bone marrow biopsy revealed an increased proportion of B cell that showed kappa light chain restriction as well as an increased proportion of plasma cells with similar light chain restriction. Lymphoma involvement approached 25-30% in the core biopsy.
Neutrophilis and precursors: 57.4%
Monocytes:1.8%
Eosinophilis: 1.0%
Basophils: 0.4%
Myeloid total: 60.6%
Erythroid precursors: 4%
Myeloid to Erythroid ratio: 15:1
Lymphocytes: 34.6%
Plasma cells: 0.8%
The CT scan showed no masses or involvement in the lymph nodes or organs. The x rays suggested no bone lesions.
My mother was treated for 6 months with dexamethasone, rituximab (Rituxan, MabThera), and cyclophosphamide. Initially, she seemed to be very responsive to treatment, with her IgM falling from 2.8 to 2.1 to 1.7 to 1.5 to 1.1 and then 0.8. However, between month 4 and 6 of treatment, her IgM values stayed relatively constant at about 1.0.
Last week they performed a bone marrow biopsy to see the results of her treatment. Her IgM in blood work was at 1.3 g/dl. They found the B cells were within a normative range but now evidence of plasma cell neoplasm, kappa restricted involving 15-20% of marrow cellularity. They said this may be indicative of multiple myeloma or smoldering (asymptomatic myeloma) and this diagnosis now needs to be ruled out.
The doctor is currently consulting with some of his colleagues to figure out next steps for treatment, although it sounds like he is considering Velcade to target the plasma cells.
I wanted to know if anyone on here is aware of other situations where a patient was treated for Waldenstrom's and, following treatment, the B cells were within a normative range but the plasma cells were now elevated.
Thank you for any information you can provide!
Christine
Forums
3 posts
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Re: IgM multiple myeloma or Waldenstrom's?
It is always a bit difficult to give very direct recommendations as to management of a particular case based on a summary, but these are some of my thoughts ...
IgM myeloma is exceedingly rare. Having an experienced pathology review of the initial bone marrow and the current bone marrow is critical. I would guess that this the same WM now as it was in the beginning, with about half as much remaining disease. Rituximab will result in fewer lymphocytes in the bone marrow (by depleting cells with a marker called CD20 on their surfaces). Thus, with some disease response, it is not unexpected that more of the remaining abnormal cells will not have that marker, and be deemed more plasma-cell like. Regardless, logic would dictate that she does not have two diseases, but rather one disease with features of both plasma cell and lymphocytes -- which is what WM truly is (hence, the other term for WM being 'lymphoplasmacytic lymphoma').
If she has no associated symptoms, observation alone is often best. Velcade can work for WM, and is therefore not unreasonable, but with this disease, one needs always to evaluate whether the burden of treatment outweighs the burden of the illness. As such, asymptomatic patients can often be watched alone.
Hope this helps.
IgM myeloma is exceedingly rare. Having an experienced pathology review of the initial bone marrow and the current bone marrow is critical. I would guess that this the same WM now as it was in the beginning, with about half as much remaining disease. Rituximab will result in fewer lymphocytes in the bone marrow (by depleting cells with a marker called CD20 on their surfaces). Thus, with some disease response, it is not unexpected that more of the remaining abnormal cells will not have that marker, and be deemed more plasma-cell like. Regardless, logic would dictate that she does not have two diseases, but rather one disease with features of both plasma cell and lymphocytes -- which is what WM truly is (hence, the other term for WM being 'lymphoplasmacytic lymphoma').
If she has no associated symptoms, observation alone is often best. Velcade can work for WM, and is therefore not unreasonable, but with this disease, one needs always to evaluate whether the burden of treatment outweighs the burden of the illness. As such, asymptomatic patients can often be watched alone.
Hope this helps.
-
Dr. James Hoffman - Name: James E. Hoffman, M.D.
Beacon Medical Advisor
3 posts
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