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IJHOSCR
International Journal of Hematology- Oncology and Stem Cell Research
5
Case Report
IJHOSCR 10(1) - ijhoscr.tums.ac.ir – January, 1, 2016
A patient with Multiple myeloma and Renal cell
carcinoma
Farhad Shahi1, Marziye Ghalamkari2, Mehrzad Mirzania1, Mahdi Khatuni2
1Department of Hematology and Medical Oncology, Cancer Research Center, Cancer Institute, Imam Khomeini Hospital Complex, Tehran
University of Medical Sciences, Tehran, Iran
2Internal Medicine Resident, Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
Corresponding Author: Marziye Ghalamkari, MD. Imam Khomeini Hospital Complex, Tehran University of Medical Sciences, Tehran, Iran
Tel: +9861192379
Fax: +9866581593
Email: dr.ghalam@yahoo.com Rec eived: 25, Jun, 2015
Accepted: 13, Sep, 2015
ABSTRACT
The coexistence of two malignancies is rarely seen. A little association between hematologic malignancies
especially multiple myeloma and renal cell carcinoma has been reported in the recent past. Several case series
revealed a bidirectional association between these two malignancies which may be due to the common risk
factors, similar cytokine growth requirements and clinical presentation. Here, we aim to describe a patient
who had multiple myeloma and in his work up renal cell carcinoma was found out incidentally. We would like
to create awareness among clinicians for the coincidence of Renal cell carcinoma and Multiple myeloma.
Keywords: Multiple myeloma, Renal cell carcinoma, Secondary hematologic malignancy
INTRODUCTION
Multiple myeloma (MM) represents a malignant
proliferation of monoclonal plasma cells that
synthesize abnormal amounts of immunoglobulin or
immunoglobulin fragments. Approximately, 24,050
new cases of myeloma were diagnosed in 2014 in
the United States. Myeloma accounts for 1.3% of all
malignancies in whites and 13% of all hematologic
cancers.1
The median age at onset is approximately 65 years,
although occasionally myeloma occurs as early as
the second decade of life. The etiology of human
myeloma is unknown. Environmental exposure to
radiation and chemicals has been associated with
an increased incidence of myeloma.2 Clinical
manifestations are heterogeneous and include the
formation of tumors, monoclonal immunoglobulin
production, and decreased immunoglobulin
secretion by normal plasma cells leading to
hypogammaglobulinemia, impaired hematopoiesis
resulting in anemia and other cytopenias, osteolytic
bone disease, hypercalcemia and renal dysfunction.
Renal cell carcinoma (RCC) is a result of malignant
proliferation of the epithelial cells of proximal
convoluted tubule of nephron and accounts for 95%
of malignant neoplasm of kidney. The incidence is
now nearly 65,000 cases annually in US.3
The development of secondary hematologic and
solid malignancies such as acute leukemia, MDS,
CLL, lymphoma and second solid tumor has been
reported after therapy in MM patients. Also
multiple primary malignancies like prostate, bladder
and non Hodgkin lymphoma have been reported in
patients with RCC.4 Cytogenetic abnormality, stem
cell disorder, radiation therapy, chemotherapy and
the malignancy itself may be prognostic risk factors
for the development of secondary malignancy. The
role of cytokines especially IL6 has been magnified
in renal cell carcinoma cells which may stimulate
myeloma cells and myeloma cells decrease after
nephrectomy.5
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There has been some case series about the
relationship between RCC and MM. A cohort study
revealed a bidirectional association between RCC
and MM that lead to the same risk factors. These
shared risk factors include: obesity, hypertension,
and smoking. They share same lytic bone lesions
and similar cytokine requirement.6
Here we discuss one patient with MM and RCC.
CASE
Our patient was a 46 year old man who initially
presented with 3 month history of progressive back
pain that eventually led to acute bilateral
paraparesia. He was an office manager from north
of Iran without any history of trauma or radiation
and chemical exposure. He did not mention any
specific medical or drug history. Significant findings
on physical examination were point tenderness
over lower thoracic area, paresthesia and paresis
(muscle force: 3/5) of both lower extremities. Other
examinations were normal. Radiological work up
included: a thoracolumbar MRI which showed T7-
spinal body destruction (pathological fracture) with
compressive effect on spinal cord and multiple high
intensity spinal bone lesions (Figure1).
He underwent emergent spinal surgery and fixation
of the spine. The pathology of the resected T7-
lesion showed “plasmacytoma”. The specimen was
reevaluated by another pathologist and the
diagnosis of plasmacytoma was confirmed.
In further work up serum protein electrophoresis
revealed M spike with IgG level 3764 mg/dl (700-
1600) (Figure 2).
Urine protein electrophoresis showed elevated
lambda light chain. Bone marrow aspiration
revealed mild to moderate increased in plasma cells
with atypical forms (12% moderate atypical plasma
cells) confirming the diagnosis of multiple myeloma.
Cytogenetic showed: 46XY, inv (9) (p11q12)
compatible with apparently normal male. Other lab
data was almost normal (Table 1).
Skull X-ray was normal without any punched out
lesion. Spinal radiologic evaluations did not show
any other abnormality except diffuse osteopenia. A
Bone scan was negative.
During patient’s work up, an abdominal ultra-
sonography revealed a mass in left kidney.
Figure 1: T7-spinal body destruction (pathological fracture)
Farhad Shahi, et al. IJHOSCR, 1 January. Volume 10, Number 1
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Figure 2: Serum protein electrophoresis revealed M spike
Table 1: Laboratory data at presentation of our patient
Our patient
Normal range
White blood cells (103/μL)
8
4.5-10
Hemoglobin (gr/dl)
13.2
13-15.5
Creatinine (mg/dl)
0.8
0.5 to 1.0
Calcium (mg/dl)
8.5
8.5-10.5
ESR 1th hour (mm/h)
35
<50
LDH (U/L)
369
50-150
Albumin (g/dl)
3.9
3.5-5.5
B2-microglobulin (mg/l)
1.7
<2
CT scan showed a well-defined solid mass (34 x 46 x
36 mm) within the left kidney (Figure 3). Core
needle biopsy of the mass was performed and
pathology was consistent with RCC (papillary type).
The patient received radiation to spinal lesions and
underwent partial left nephrectomy. The pathology
showed a 5 cm renal cell carcinoma (Papillary type,
nuclear grade 2) mass involving renal parenchyma
without invasion to vascular or lymphatic system.
He recovered well post operatively and
subsequently started on chemotherapy for multiple
myeloma (Vincristine, Adriamycin, and
Dexamethasone). After four courses of
chemotherapy, serum protein electrophoresis got
normal; we changed chemotherapy to thalidomide
(200/d) for the next four months.
DISCUSSION
The incidence of second malignancies is rising due
to the successful treatment of primary malignancies
and increase life expectancy. In multiple myeloma,
the risk of a secondary myelodysplastic syndrome
or acute leukemia is approximately 3% at 5 years
and 9% at 10 years. Some authors have suggested
that higher cumulative doses of melphalane is a risk
factor for developing secondary malignancy7 but
our patient did not receive any chemotherapy
before.
Sehgal reported a rare case of metastatic prostatic
cancer to bone marrow and MM as secondary
malignancy. He suggested that probably bone
marrow microenvironment play a crucial role in the
development of myeloma.8 Sporadic case reports
have revealed dual malignancies occurring in renal
cell carcinoma; such as prostate, bladder, lung,
breast, colon and non-Hodgkin lymphoma which
were the most common malignancies.4
Ojha et al. report 69 case of RCC in 34,156 patients
diagnosed with MM in Dana-Farber Cancer Institute
in Boston during 1973 and 2006. Ojha and his
colleagues suggest that MM was 1.51 times more
likely to be found in RCC patients than in the
general population.6
In 2008, Bhandari et al. reported six cases of RCC in
their 600 cases of plasma cell dyscrasia during ten
years;4 Dutcher and Wiernik have reported an
increase incidence of hematologic malignancies in
families of patients with RCC. Interestingly the large
majority (94%) of these hematologic malignancies
were B-cell origin.9 Our patient’s family history was
negative for any malignant disease; although his
MM. was diagnosed initially and then RCC. It has
been hypothesized that one malignancy produces a
tumor stimulating hormone like IL6 or TNFα which
may increase the risk of second malignancy.5 Padhi
and his colleagues have described a 69 year old man
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Figure 3: CT scan revealed a well-defined solid mass (34 x 46 x
36 mm) within the left kidney
with refractory MM whose serum IL6 was markedly
elevated.10 Other risk factors may be:
environmental factors (tobacco, occupation and
pollution, ultra violate light), genetic factors,
metabolic syndrome, previous medical treatment,
sex and hormonal factors.11 Although various
hypotheses have been explained the same risk
factors as mentioned above, no common etiology
has been reported, yet. Besides these, therapeutic
strategies employed for MM have been tried for
RCC with partial success; which may support the
probable common pathophysiology.4
In this case report, we have reviewed a patient with
concomitant malignancies. It is not obvious which
malignancy was first occurred as RCC discovered
incidentally in multiple myeloma work up. Because
our patient’s RCC was in low stages and operable,
we first treated the renal tumor; then, he
underwent chemotherapy for his myeloma.
CONCLUSION
This finding may be useful for further evaluation
of the shared risk factors and etiologies of both
malignancies. And hopefully lead to more
awareness among physicians that a potential
second malignancy in MM may be RCC and vice
versa. Therefore, any new lytic bone lesion in a
patient with prior renal cell carcinoma should be
investigated for potential myeloma; especially when
there is not any other metastatic lesion.
ACKNOWLEDGEMENT
The authors would like to express their
appreciation to the following for their valuable
comments: Dr. Mohsen Rajayee Nejad, Dr Farshad
Sheybayi Moghaddam, Dr Seyed Reza Safayi and Dr
Mohsen Sfandbod.
CONFLICT OF INTEREST
The authors of this paper do not have any conflict
of interest to disclose.
REFERENCES
1. Munchi N, Longo D, Anderson K. Plasma cell
disorders In: Kasper D, Fauci A, Hauser S, et al.
Harrison principles of internal medicine, 19th ed.
Mc Graw Hill pub. 2015,712.
Farhad Shahi, et al. IJHOSCR, 1 January. Volume 10, Number 1
60
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2. Kaushansky K, Lichman M, Beutler E, et al.
Williams Hematology, 8th ed, E book, 2010; 2120.
3. Scher H, Rosenberge J, Motzer R. Bladder and
renal cell carcinoma. In: Kasper D, Fauci A, Hauser S,
Longo D, et al. Harrison principles of internal
medicine, 19th ed. Mc Graw Hill pub. 2015; 578.
4. Bhandari MS, Mazumder A, Jagannath S, et al.
Association between renal cell carcinoma and
plasma cell dyscrasia. Clin lymphoma myeloma.
2008; Vol 8, No 3: 188-190.
5. Sakai A, Kawano M, Kuramoto A. Interleukin 6
produced by renal cell carcinoma cells and
progression of MM. N Engl J Med. 1991; 324: 1893-
4.
6. Ojha RP, Evans EL, Felini MJ, et al. The association
between renal cell carcinoma and multiple
myeloma: insights from population-based data. BJU
Int. 2011 Sep; 108 (6): 825-30.
7. Greer J, Arber D, Glader B, et al. Wintrobe’s
clinical hematology, 13th edition. 2014; 2092.
8. Sehgal T, Sharma S, Naseem S, et al. Synchronous
occurrence of prostate carcinoma and multiple
myeloma: a case report. Indian J Hematol Blood
transfuse. 2014 sep; 30 (Suppl 1): 359-362.
9. Dutcher J, Wiernik P. Renal cell carcinoma in
patients with a personalor family history of
hematologic malignancy. Clin Adv Hematol Oncol.
2015; Vol 13, No (6): 392-397.
10. Padhi S, Mokkapan S, Varghese R, et al.
Plasmablastic multiple myeloma following clear cell
renal cell carcinoma. BMJ Case Rep. 2014; 10.
11. Badros A, Karakunnel J, Dawson N. Multiple
myeloma and renal cell carcinoma possible
association. Leukemia and Lymphoma. 2007; 48:
1662-4.
