World Trade Center Survivor with Post Solid-Organ Transplant Plasma Cell Neoplasm.

Abstract

Plasma cell neoplasms (PCNs) in post solid organ transplant is a rare occurrence. To date, there is no standardized protocol for treatment. Management is further complicated in World Trade Center (WTC) survivors who present with post- solid organ transplant PCNs. This poses a challenge in management in order to reconcile the use of necessary immunosuppressive therapy (IST) with chemotherapy or immunotherapy and the potential toxic side effects. We report a case of a 59 year old WTC survivor with a history of orthotopic liver transplant (2015) for NASH cirrhosis on IST who was diagnosed with IgG lambda multiple myeloma (MM) in June 2019. The induction regimen of cyclophosphamide, bortezomib and dexamethasone (CyBorD) was initiated. Labs and clinical evaluation showed a very good partial response (VGPR). In January 2020, the patient presented with transaminitis and hyperbilirubinemia. CT abdomen and pelvis indicated multiple low-attenuation hepatic lesions. Ultrasound-guided core liver biopsy revealed malignant plasma cell neoplasm. The patient underwent endoscopic retrograde cholaniopancreatography (ERCP) with intraductal biliary stent placement in an attempt to alleviate the extrinsic obstruction from the hepatic lesions. The procedure was unsuccessful and the patient subsequently developed overt jaundice and progressive ascites. He was started on modified dexamethasone, cyclophosphamide, etoposide and cisplatin (DCEP). Unfortunately, liver failure progressed with enlarging liver lesions, at which point the patient elected hospice and died. This case highlights the fulminant course of PCNs post solid organ transplant. This is an area of unmet need for standardized treatment regimen in these poor prognostic cases. In addition, the case illustrates the complexity involved with management of such patients. A multidisciplinary medical team is needed to manage such patients’ complicated disease course.

Keywords

• Immunosuppressive
• Plasmacytoma
• Liver
• Multi-disciplinary
• Chemo-immunotherapy