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Development of B-lymphoblastic leukemia/lymphoma (BALL) is uncommon in patients with plasma cell neoplasm (PCN). Currently, little is known about risk factors for and characteristics of BALL arising in patients who have undergone treatment for PCN. We reviewed the clinicopathologic features of 14 patients with PCN who developed subsequent BALL and assessed the clonal relationship between these two neoplasms in 5 of the 14 patients. Clinical and laboratory data were extracted from the electronic medical record in accordance with an institutional review board-approved protocol. For the IgH clonality studies DNA was extracted from formalin fixed paraffin embedded tissue and analyzed utilizing the LymphoTrack® IGH FR2/3 Assay -- S5/PGM™ reagents from Invivoscribe Technologies. Next-generation sequencing of libraries was performed on a ThermoFisher Scientific Ion Torrent S5™ sequencer. The LymphoTrack® Software - S5/PGM™ Version 2.4.5 was used to analyze the IGH rearrangement sequences and relative proportion of the sequences was determined as a percentage of total sequencing reads. All PCN patients in our cohort received an autologous stem cell transplant (auto-SCT) with subsequent lenalidomide maintenance therapy. The mean time from the start of lenalidomide treatment after auto-SCT to BALL development was 62 months. None of the BALL cases were Philadelphia chromosome-positive. There was increased incidence of TP53 mutations and deletions (36%). IgH clones were identified in all but one sample. Comparison of the IgH clones from the original PCN and subsequent BALL revealed distinct clones in all 5 patients tested. In 2 of the 5 patients, the original PCN clone was also identified along with the distinct BALL clone. Our study reveals that BALL cases arising in patients with treated PCN are not clonally related to the original disease, and may represent therapy-related malignancy associated to prior treatment including lenalidomide maintenance therapy. More studies are needed to establish the incidence and understand the pathogenesis of this possible therapy-related complication.

Development of B-lymphoblastic leukemia in patients treated for multiple myeloma – A case series of 14 patients