Double Hematological Malignancy: An Unusual Presentation in Three Cases

The occurrence of more than one hematological malignancy in the same patient is an unusual pathologic condition and may pose a difficult challenge during decision to start various chemotherapy regimens. Cases of solid tumors of lung and gastrointestinal tract have been noted secondary to treatment of hematological malignancies but the occurrence of two hematological malignancies concomitantly is a rare presentation. We describe three cases of coexistent hematological malignancies at our institution. First case describes a 77 yo male with synchronously occurring B cell Non Hodgkin Lymphoma: marginal zone lymphoma (main bone marrow population); Chronic Lymphocytic leukemia (Fluorescent-in–situ hybridization test positive for trisomy 12) and a Monoclonal Beta, elevated IgM, elevated B2. BM evaluation revealed involvement by both processes. The patient has been started on Rituximab recently. The second case is an 85 yo male with findings with peripheral blood flow cytometry consistent with chronic lymphocytic leukemia of B-cell immunophenotype and lymph node biopsy consistent with Follicular Lymphoma. He was found to be BCL2 + on BM and had a normal Karyotype: 46, XY. He was treated with Rituximab ×8 cycles. A follow up PET scan showed partial response. Our third case was an 83 yo man with simultaneous presentation of myelodysplastic syndrome (MDS) and multiple myeloma (MM). This patient had MDS (Refractory anemia with Ring sideroblasts RARS type) and smoldering Multiple myeloma (monoclonal plasma cells 10–15%) bone marrow infiltration which over a course of 3 years transformed into full blown Multiple Myeloma with bone marrow revealing 30–40% plasma cells and osteolytic lesions on skeletal survey. Cytogenetic were normal. He was treated with Lenalidomide (after failure of ESA) and became transfusion in dependent for one year (Hgb rose from baseline of 6–7 to 13 g/dL), after progression to active multiple myeloma he was treated with Thalidomide and Dexamthesone. He achieved a partial response on SPEP. Subsequently he was treated for MDS progression with Azacytidine for 5 cycles with minor hematological benefit (transfusion was less frequently), he recently succumbed to his disease, he was transfusion dependent and became acutely ill after an acute episode of diverticulitis. Patients with MM, MDS have been reported after chemotherapy but few cases documenting the coexistence of MDS and MM at diagnosis have been reported in the literature. Conclusion: In this report, we describe a three cases of double hematological clonal processes or malignancy, all diagnosed at same time, without preceding hematological disorder or chemotherapy, and all required treatment.