Jamal: Plasma cell leukemia: An overview

Introduction

Plasma cell leukaemia (PCL) is a rare haematological malignancy which is classified into primary (pPCL) and secondary PCL (sPCL). The rising incidence of sPCL is attributed to improved survival in multiple myeloma. Kyle’s criteria define pPCL as 20% or more plasma cells and at least 2×109 /L plasma cells in the peripheral blood but the International Myeloma Working Group (IMWG) suggests that either one is sufficient for a diagnosis of PCL.1, 2

pPCL demonstrates an aggressive course and progresses rapidly without therapy. The prognosis is often poor with mortality within the first month as high as 15%.3

Elevated lactate dehydrogenase, anaemia, increased serum beta-2 microglobulin, hypercalcaemia, hypoalbuminaemia and renal impairment are commonly seen in pPCL. Osteolytic lesions are less commonly seen in pPCL as compared with multiple myeloma. Untreated multiple myeloma may lead to sPCL within 20–22 months.4, 5

The diagnosis of pPCL is based on peripheral blood smear, bone marrow morphology, flow cytometry, cytogenetic studies, serum and urine protein electrophoresis.6

The differential diagnoses need to be considered are amyloidosis, multiple myeloma, B-cell chronic lymphocytic leukaemia, hairy cell leukaemia, marginal zone lymphoma and reactive polyclonal plasmacytosis. Amyloidosis is often diagnosed on a positive Congo-red stain biopsy sample taken from the subcutaneous abdominal fat or involved organ system. In this case, the Congo-red stain of the bone marrow trephine biopsy was negative for amyloid deposition.7

Multiple myeloma without transformation to sPCL would not fulfil the diagnostic criteria of 20% or more clonal plasma cells on the peripheral blood film. Reactive polyclonal plasmacytosis is usually associated with infection or autoimmune disorders. Absence of kappa or lambda light-chain restriction excludes reactive polyclonal plasmacytosis.

Treatment

Newer treatment options include cycles of subcutaneous bortezomib oral thalidomide and dexamethasone.

Discussion

The median age of diagnosis for pPCL is 55 years which is a decade younger in comparison with multiple myeloma (MM).

The most common subtype is IgG followed by light-chain-only PCL. Extramedullary involvement is common in pPCL with the IMWG suggesting a baseline 18-fluorodeoxyglucose positron emission tomography computed tomography to be performed in all newly diagnosed PCL.5

Flow cytometry is crucial in assessing plasma cell clonality. Polyclonal plasmacytosis can be attributed to infection which is commonly seen in pPCL as they have moderate to severe immunoparesis. Plasma cells in pPCL express CD20, CD38 and CD138 with CD56 positivity more frequently seen in MM.6 The genetic biology in pPCL differs in comparison with MM. Increased incidence of hypodiploidy, 17p deletion, TP53 and DIS3 mutations, t(11;14), t(4;14) and t(14;16) is seen in pPCL.7, 8, 9

Conclusion

Plasma cell leukaemia (PCL) is the most aggressive form of all plasma cell neoplasms. Prognosis is often dismal in primary PCL (pPCL) with the median overall survival below 1 year if treatment is delayed. Early diagnosis and effective therapy are vital to improve survival in pPCL.

Conflict of Interest

None.

References

1 

R García-Sanz A Orfão M González Primary plasma cell leukemia: clinical, immunophenotypic, DNA ploidy, and cytogenetic characteristicsBlood19999310327

2 

J Bladé RA Kyle Nonsecretory myeloma, immunoglobulin D myeloma, and plasma cell leukemiaHematol Oncol Clin North Am199913612597210.1016/s0889-8588(05)70125-8

3 

S Ngu D Asti G Valecha N Thumallapally M Pant A Bershadskiy Primary plasma cell leukemia: A case report and review of the literatureClin Case Rep2019791702810.1002/ccr3.2339

4 

WI Gonsalves SV Rajkumar RS Go Trends in survival of patients with primary plasma cell leukemia: a population-based analysisBlood201412490712

5 

SH Swerdlow E Campo NL Harris WHO classification of tumours of haematopoietic and lymphoid tissues (revised)4th editionIARCLyon2017

6 

RE Tiedemann N Gonzalez-Paz RA Kyle R Santana-Davila T Price-Troska SA Van Wier Genetic aberrations and survival in plasma cell leukemiaLeukemia200822510445210.1038/leu.2008.4

7 

F Albarracin R Fonseca SH Jung JJ Lee K Kim The role of frontline autologous stem cell transplantation for primary plasma cell leukemia: a retrospective multicenter study (KMM160)Oncotarget201725795172610.18632/oncotarget.18535

8 

WI Gonsalves Fk Buadi SK Kumar Combination therapy incorporating Bcl-2 inhibition with Venetoclax for the treatment of refractory primary plasma cell leukemia with t (11;14)Eur J Haematol20181002215710.1111/ejh.12986

9 

P Musto V Simeon MC Martorelli Lenalidomide and low-dose dexamethasone for newly diagnosed primary plasma cell leukemiaLeukemia2014282225



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Article History

Received : 31-07-2021

Accepted : 03-08-2021

Available online : 12-08-2021


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Article DOI

https://doi.org/10.18231/j.ijpo.2021.063


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