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Non Hodgkins Lymphoma Case Studies

Case Studies: Relapsed/Refractory Waldenstrom Macroglobulinemia

Steven P. Treon, MD, PhD, describes the case of a 42-year-old male who develops relapsed/refractory Waldenstrom macroglobulinemia.

Relapsed/Refractory Waldenstrom Macroglobulinemia

A 42-Year-Old Male With Relapsed/Refractory Waldenström Macroglobulinemia

September 2016

  • A 42-year old male presented with blurry vision and nosebleeds.
  • Physical examination revealed retinal hemorrhages, adenopathy, and splenomegaly.
  • Laboratories revealed a hematocrit of 18% (normal 34.8-43.6%)
    • Platelets of 50,000/mm3 (normal 155,000-410,000/mm3)
    • Leukocyte count of 1,500/mm3 (normal 3,800-9,200/mm3)
  • Serum total protein was high prompting a workup that revealed an IgMλ monoclonal protein and serum IgM level of 12,400 mg/dL.
  • CT scans showed bulky adenopathy (> 5 cm)
  • A bone marrow biopsy revealed that 80% of the intertrabecular space was involved with lymphoplasmacytic lymphoma.
  • Immunohistochemistry demonstrated CD20 expressing bone marrow disease.
  • Molecular diagnostic testing for MYD88 and CXCR4 is pending

Treatment

  • The patient began several emergent rounds of plasmapheresis, and his vision and energy improved.
  • His retinal exam improved and repeat serum IgM level was 3,892 mg/dL.
  • The molecular diagnostic studies showed MYD88 L265P and CXCR4 nonsense mutations to be present in the tumor cells.
  • The patient received bendamustine alone for two cycles, then rituximab was added to bendamustine for 2 more cycles. He attained a major response.

September 2018

  • Two years later, he relapsed with progressive adenopathy (< 5 cm), symptomatic anemia, and his serum IgM rose to 5,459 mg/dL.
  • Patient was started on rituximab/ibrutinib combination therapy.
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