A Case Report of Leptomeningeal Myelomatosis and Rapid Improvement with Regimen Consisting of Daratumumab, Pomalidomide, Vincristine, Procarbazine, and Dexamethasone

Abstract

Central nervous system (CNS) involvement in multiple myeloma (MM) (MM-CNS) in the form of leptomeningeal myelomatosis or brain parenchyma plasmacytoma is rare, causing challenges in clinical diagnosis and treatment. We would like to report a case of leptomeningeal myelomatosis and illustrated the challeges. A 61-year-old man was diagnosed with MM with left paravertebral plasmacytoma, R-ISS II with high suspicion of double-hit MM, either biallelic aberrancy of TP53 or del(17p) and IGH aberrancy depending on the definition chosen, treated with lenalidomide-bortezomib-dexamethasone and local radiotherapy, later developed systemic relapse and progression to MM-CNS in the form of leptomeningeal myelomatosis. A modified CNS-based treatment not reported before, consisting of daratumumab, pomalidomide, vincristine, procarbazine, and dexamethasone, brought a rapid clinical improvement and warrants a further study. Incorporation of intrathecal thiotepa into the regimen would likely increase the efficacy.

Imaging findings in a case of leptomeningeal myelomatosis, a rare but critical central nervous system complication of multiple myeloma

“…25,26 Furthermore, a recent case report showed that the use of a new therapeutic strategy consisting of systemic administration of daratumumab, pomalidomide, vincristine, procarbazine, and dexamethasone (Dara-PVPD) resulted in a clinical improvement in an LMM patient. 27 The choice of these agents was conditioned by their efficacy against plasma cell disorders and their ability to cross the BBB, although some studies have shown that the penetrance into the CNS of systemic daratumumab might be limited, resulting in reduced effectiveness. 28 The use of radiotherapy is controversial in terms of efficacy and toxicity; focused radiotherapy is commonly used in the treatment of focal masses either in the brain or spine, but its role is limited in diffuse CNS involvement.…”