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Extramedullary plasmocytoma: A rare malignancy in renal transplant recipient
i n d i a n j o u r n a l o f t r a n s p l a n t a t i o n x x x ( 2 0 1 5 ) 1 e4
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/ijt
Case Report
Extramedullary plasmocytoma: A rare malignancy in renal transplant recipient Keyur Dave a,*, Madan M. Bahadur b, Ganapathi M. Bhat c, Samir Shah d a
Registrar, Jaslok Hospital and Research Centre, India Consultant Nephrologist, Jaslok Hospital and Research Centre, India c Consultant Oncologist, Jaslok Hospital and Research Centre, India d Consultant Hematologist, Jaslok Hospital and Research Centre, India b
article info
abstract
Article history:
Extramedullary plasmacytoma in a post renal transplant recipient is an extremely rare
Received 9 January 2015
type of post transplant lymphoproliferative disorder (PTLD) which warrants significant
Accepted 28 April 2015
reduction in immunosuppressive therapy leading to increased risk of rejections and even
Available online xxx
graft loss. We describe a 49 year old male patient who after 14 years of renal transplant presented with extramedullary plasmacytomas in pancreas, gums, subcutaneous tissue
Keywords:
and transplant kidney. He was treated with high dose melphalan followed by rescue
Extramedullary plasmacytoma
autologous hematopoetic stem cell transplant and concurrent reduction in immunosup-
Post transplant lymphoproliferative
pression following which he achieved complete remission maintained on 5 years of follow
disorder (PTLD)
up with astable allograft function. This case, to best of our knowledge is first case to be
Autologous hematopoetic stem cell
successfully managed with a rescue autologous hematopoetic stem cell transplant in a
transplant (AHSCT)
renal transplant patient with multifocal extramedullary plasmacytomas.
Renal transplant
1.
Copyright © 2015, Indian Society of Organ Transplantation. All rights reserved.
Introduction
The incidence of PTLD is 1.5% in solid organ transplant recipients, least noted in renal transplant recepients (<1%).1 Plasma cell dyscrasia, a type of PTLD, is extremely rare amounting to less than 4% of all PTLDs.2 As with all other PTLDs, the initial management includes significant reduction in immunosuppression followed by use of chemotherapeutic agents similar to that used in immunocompetent patients.3 Immunosuppression reduction predisposes to allograft
rejections and even graft loss making management of such patients difficult. We describe a case of successfully treated multifocal extramedullary plasmacytoma in renal transplant recipient with reduction in immunosuppression, high dose melphalan followed by rescue autologous hematopoetic stem cell transplantation. Our patient not only achieved complete remission but also remained in sustained remission for 5 years with stable allograft function. Successful AHSCT in kidney transplant recipient is rarely done and our case would be the first such reported case in Indian literature.
* Corresponding author. Department of Nephrology, 7th floor, Jaslok Hospital and Research Centre, Peddar Road, Mumbai, 400026, India. Tel.: þ91 (0)9881199360, þ91 (0)2266573163. E-mail address: [email protected] (K. Dave). http://dx.doi.org/10.1016/j.ijt.2015.04.005 2212-0017/Copyright © 2015, Indian Society of Organ Transplantation. All rights reserved.
Please cite this article in press as: Dave K, et al., Extramedullary plasmocytoma: A rare malignancy in renal transplant recipient, Indian Journal of Transplantation (2015), http://dx.doi.org/10.1016/j.ijt.2015.04.005
2
2.
i n d i a n j o u r n a l o f t r a n s p l a n t a t i o n x x x ( 2 0 1 5 ) 1 e4
Case report
49 year old male patient underwent an unrelated living donor kidney transplant in 1994. He did not receive induction immunosuppression and was put on Prednisolone, Cyclosporine and Azathioprine. The post operative course was uneventful and he followed up in OPD with stable allograft function. 14 years post transplant in July 2008, patient presented with gingival enlargement, epigastric mass and rapidly developing multiple subcutaneous swellings on neck and back. There was no history of antecedent febrile episode prior to these complaints. General examination showed normal vitals with multiple soft, non tender lumps over the neck and back. There was significant gingival hypertrophy with no other systemic features attributable to cyclosporine toxicity. Systemic examination revealed a firm, non tender, epigastric, immobile mass with no organomegaly or lymphadenopathy. Hemogram showed Hb 9 mg/dl, TLC 8700/mm3, Platelets 2 lacs/mm3. Renal function tests showed a rise in creatinine to 2.9 mg/dl from previous levels of 1.4 mg/dl. Ultrasound abdomen showed a lobulated mass of size 1.8 2.5 cm involving the body of pancreas. Another soft tissue mass was seen in right lower pole of transplanted kidney in right iliac fossa with multiple nodular deposits in retroperitoneum. These findings were confirmed on MRI abdomen and pelvis. EBV DNA by PCR was done to rule out active EBV replication showed undetectable viral copies. USG guided FNAC specimens were obtained from the pancreatic, gingival and subcutaneous masses. Histopathology showed the presence of plasma cells with Dutcher's bodies confirming the masses as plasmacytomas (Fig 1). Hematology consultation was sought who advised serum free light chain assay and skeletal survey which was normal. Bone marrow aspiration showed only of 2% plasma cells with no evidence of plasmacytomas. Thus, diagnosis of Extramedullary plasmacytoma post renal transplant was arrived at and immediately Cyclosporine (300 mg bd) was reduced to half dose (150 mg bd) while Azathioprine (120 mg) and Prednisolone (10 mg) were continued at same dose. In consultation with hematology e oncology services, 6 cycles of chemotherapy consisting of Bortezomib and Dexamethasone were given. Following this serum creatinine decreased to 1.4 mg/dl. PET CT scan however revealed persistent metabolically active lesions in right hemimandible and lower pole of transplant kidney (Fig 2).
Persistence of metabolically active lesions despite chemotherapy prompted us to do rescue autologous hematopoetic stem cell transplant. Initial peripheral blood stem cell harvest after 4 days of inj G-CSF 10 mg/kg for 4 days yielded poor result. Repeat harvest was attempted after giving inj cyclophosphamide 3 g/m2 and inj G-CSF 10 mg/kg for 4 days. Inj Melphalan 140 mg/m2 was given one day prior to AHSCT and stem cell harvestcontaining MNC 8.23 108/kg and CD 34 þ cells 1.63 106/kg was transfused. Patient showed engraftment on Day 11 with ANC >500/mm3 for consecutive 3 days after which G CSF was omitted. His maintenance immunosuppressants at reduced doses e cyclosporine 150 mg bd, Azathioprine 120 mg daily, and prednisolone 10 mg were continued. PET CT repeated on Day 90 showed complete resolution of the previous metabolically active lesions (Fig. 3). Hence, maintenance immunosuppression was gradually increased to pre PTLD doses by post engraftment Day 150. Patient has been following up with yearly PET CT for past five years (Fig. 4) with sustained complete remission and stable allograft function with serum creatinine of 1.9 mg/dl.
3.
Discussion
PTLD can develop as a consequence of poor immune surveillance, susceptibility to viral infections (especially EBV), chronic antigenic stimulation due to presence of foreign allograft antigens, cytokines like IL-6, IL-10 and immunosuppresion effect of drugs in recipients of solid organ transplants.4 These disorders range from reactive, polyclonal plasmacytic hyperplasia to those that are morphologically and genotypically indistinguishable from typical non-Hodgkin's lymphomas.5 In some case reports, myeloma and polymorphic PTLD have been reported in <2 months to 15 years following solid organ transplant. In a large series of PTLD after renal transplants, the incidence of myeloma was reported as 0.2%.6 We report possibly the first case of multifocal extramedullary plasmacytoma which presented after 14 years of renal transplantation. In literature we found cases of post transplant extramedullary plasmacytoma, however none had multiple lesions.7 Although most reported plasma cell myeloma PTLD cases have localized collections of plasma cells and bone marrow involvement, other clinical findings of
Fig. 1 e Histopathology images showing Plasma cells in FNAC specimens from gums and skin lesions. Please cite this article in press as: Dave K, et al., Extramedullary plasmocytoma: A rare malignancy in renal transplant recipient, Indian Journal of Transplantation (2015), http://dx.doi.org/10.1016/j.ijt.2015.04.005
i n d i a n j o u r n a l o f t r a n s p l a n t a t i o n x x x ( 2 0 1 5 ) 1 e4
3
Fig. 2 e Pet CT Image after bortezomib cycles.
Fig. 3 e PET CT Image at Day 90 post engraftment of autologous hematopoetic stem cell transplant. Please cite this article in press as: Dave K, et al., Extramedullary plasmocytoma: A rare malignancy in renal transplant recipient, Indian Journal of Transplantation (2015), http://dx.doi.org/10.1016/j.ijt.2015.04.005
4
i n d i a n j o u r n a l o f t r a n s p l a n t a t i o n x x x ( 2 0 1 5 ) 1 e4
cell dyscrasias and that too in renal transplant settings is a rarity. Our case is unique and first reported in Indian medical literature where multifocal extramedullary plasmacytoma completely responded to AHSCT and patient remained in complete remission for 5 years with a stable renal graft function. Hence, High dose chemotherapy followed by AHSCT could definitely be used to achieve complete remission in Bortezomib refractory plasmacytomas presenting as PTLDS in renal transplant settings and preserving renal graft function.
Conflicts of interest All authors have none to declare.
Financial support None.
Acknowledgement We thank Dr A. Chitale and Dr. Vishal Ramteke for their help in preparing the manuscript.
references
Fig. 4 e Follow up PET CT after 5 years follow up showing no metabolic activity.
typical plasma cell myeloma such as lytic bone lesions and hypercalcemia were frequently absent. Hence, a high index of suspicion is required for timely diagnosis and treatment. The prognosis of post transplant plasma cell dyscrasia is not well known, but may have poor outcomes compared with other PTLDS. Response to bortezomib for treatment of extramedullary plasmacytoma is 40e50%.7 Renal failure is not uncommon and could result from rejection in renal transplant recipients following reduction or stoppage of immunosuppressive drugs or may be secondary to renal effects of lesions. The twin goals of efficient treatment of malignancy for complete remission and to maintain renal graft function are to be achieved. High dose chemotherapy with autologous stem cell transplantation is becoming a treatment of choice in treating refractory malignancies especially myelomas in younger patients in non transplant settings8,9 but no data currently is available in renal transplant settings. In our case not only were the extramedullary plasmacytomas multifocal unlike previously reported cases it also did not respond to conventional immunosuppression reduction and Bortezomib. In India rescue autologous hematopoetic stem cell transplant is not often done for treatment of plasma
1. Leblond V, Sutton L, Dorent R, et al. Lymphoproliferative disorders after organ transplantation: a report of 24 cases observed in a single center. J Clin Oncol. 1995;13:961e968. 2. Sheil AGR, Flavel S, Disney APS, et al. Cancer in dialysis and transplant patients. Transpl Proc. 1985;17:195e198. 3. Starzl TE, Nalesnik MA, Porter KA, et al. Reversibility of lymphomas and lymphoproliferative lesions developing under cyclosporine-steroid therapy. Lancet. 1984;1:583e587. 4. Binnani Pooja, Bahadur MM, Kedia Nikhil. Disease recurrence in a transplant kidney in a patient with extramedullary plasmacytoma. Indian J Med Pediatr Oncol. JulyeSep 2010;31. 5. Sharma S, Rana C, Vinod P. Plasma cell myeloma in a renal transplant recipient: a case report and review of literature. Indian J Nephrol. 2011 Oct-Dec;21(4):270e272. 6. Sheil AG, Flavel S, Disney AP, Mathew TH, Hall BM. Cancer incidence in renal transplant patients treated with azathioprine or cyclosporine. Transpl Proc. 1987;19:2214e2216. 7. Muzaffar Mahvish, Chaudhary Rekha, Li Xin, Ratnam Shobha. Post renal transplant plasma cell dyscrasia presenting as retroperitoneal plasmacytoma: a case report and literature review. Dialysis Transplant. 2011;40(3):130e132. 8. Lazarus Hillard M, Phillips Gordon L, Herzig Roger H, Hurd David D. High-dose melphalan and the development of hematopoietic stem-cell transplantation: 25 years later. J Clin Oncol. (May 10), 2008;26:2240e2243. 9. Moreau P, Facon T, Attal M, et al. Comparison of 200 mg/m2 melphalan and 8 Gy total body irradiation plus 140 mg/m2 melphalan as conditioning regimens for peripheral blood stem cell transplantation in patients with newly diagnosed multiple myeloma: final analysis of the Intergroupe Francophone du Mye'lome 9502 randomized trial. Blood. 2002;99:731e735.
Please cite this article in press as: Dave K, et al., Extramedullary plasmocytoma: A rare malignancy in renal transplant recipient, Indian Journal of Transplantation (2015), http://dx.doi.org/10.1016/j.ijt.2015.04.005
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/ijt
Case Report
Extramedullary plasmocytoma: A rare malignancy in renal transplant recipient Keyur Dave a,*, Madan M. Bahadur b, Ganapathi M. Bhat c, Samir Shah d a
Registrar, Jaslok Hospital and Research Centre, India Consultant Nephrologist, Jaslok Hospital and Research Centre, India c Consultant Oncologist, Jaslok Hospital and Research Centre, India d Consultant Hematologist, Jaslok Hospital and Research Centre, India b
article info
abstract
Article history:
Extramedullary plasmacytoma in a post renal transplant recipient is an extremely rare
Received 9 January 2015
type of post transplant lymphoproliferative disorder (PTLD) which warrants significant
Accepted 28 April 2015
reduction in immunosuppressive therapy leading to increased risk of rejections and even
Available online xxx
graft loss. We describe a 49 year old male patient who after 14 years of renal transplant presented with extramedullary plasmacytomas in pancreas, gums, subcutaneous tissue
Keywords:
and transplant kidney. He was treated with high dose melphalan followed by rescue
Extramedullary plasmacytoma
autologous hematopoetic stem cell transplant and concurrent reduction in immunosup-
Post transplant lymphoproliferative
pression following which he achieved complete remission maintained on 5 years of follow
disorder (PTLD)
up with astable allograft function. This case, to best of our knowledge is first case to be
Autologous hematopoetic stem cell
successfully managed with a rescue autologous hematopoetic stem cell transplant in a
transplant (AHSCT)
renal transplant patient with multifocal extramedullary plasmacytomas.
Renal transplant
1.
Copyright © 2015, Indian Society of Organ Transplantation. All rights reserved.
Introduction
The incidence of PTLD is 1.5% in solid organ transplant recipients, least noted in renal transplant recepients (<1%).1 Plasma cell dyscrasia, a type of PTLD, is extremely rare amounting to less than 4% of all PTLDs.2 As with all other PTLDs, the initial management includes significant reduction in immunosuppression followed by use of chemotherapeutic agents similar to that used in immunocompetent patients.3 Immunosuppression reduction predisposes to allograft
rejections and even graft loss making management of such patients difficult. We describe a case of successfully treated multifocal extramedullary plasmacytoma in renal transplant recipient with reduction in immunosuppression, high dose melphalan followed by rescue autologous hematopoetic stem cell transplantation. Our patient not only achieved complete remission but also remained in sustained remission for 5 years with stable allograft function. Successful AHSCT in kidney transplant recipient is rarely done and our case would be the first such reported case in Indian literature.
* Corresponding author. Department of Nephrology, 7th floor, Jaslok Hospital and Research Centre, Peddar Road, Mumbai, 400026, India. Tel.: þ91 (0)9881199360, þ91 (0)2266573163. E-mail address: [email protected] (K. Dave). http://dx.doi.org/10.1016/j.ijt.2015.04.005 2212-0017/Copyright © 2015, Indian Society of Organ Transplantation. All rights reserved.
Please cite this article in press as: Dave K, et al., Extramedullary plasmocytoma: A rare malignancy in renal transplant recipient, Indian Journal of Transplantation (2015), http://dx.doi.org/10.1016/j.ijt.2015.04.005
2
2.
i n d i a n j o u r n a l o f t r a n s p l a n t a t i o n x x x ( 2 0 1 5 ) 1 e4
Case report
49 year old male patient underwent an unrelated living donor kidney transplant in 1994. He did not receive induction immunosuppression and was put on Prednisolone, Cyclosporine and Azathioprine. The post operative course was uneventful and he followed up in OPD with stable allograft function. 14 years post transplant in July 2008, patient presented with gingival enlargement, epigastric mass and rapidly developing multiple subcutaneous swellings on neck and back. There was no history of antecedent febrile episode prior to these complaints. General examination showed normal vitals with multiple soft, non tender lumps over the neck and back. There was significant gingival hypertrophy with no other systemic features attributable to cyclosporine toxicity. Systemic examination revealed a firm, non tender, epigastric, immobile mass with no organomegaly or lymphadenopathy. Hemogram showed Hb 9 mg/dl, TLC 8700/mm3, Platelets 2 lacs/mm3. Renal function tests showed a rise in creatinine to 2.9 mg/dl from previous levels of 1.4 mg/dl. Ultrasound abdomen showed a lobulated mass of size 1.8 2.5 cm involving the body of pancreas. Another soft tissue mass was seen in right lower pole of transplanted kidney in right iliac fossa with multiple nodular deposits in retroperitoneum. These findings were confirmed on MRI abdomen and pelvis. EBV DNA by PCR was done to rule out active EBV replication showed undetectable viral copies. USG guided FNAC specimens were obtained from the pancreatic, gingival and subcutaneous masses. Histopathology showed the presence of plasma cells with Dutcher's bodies confirming the masses as plasmacytomas (Fig 1). Hematology consultation was sought who advised serum free light chain assay and skeletal survey which was normal. Bone marrow aspiration showed only of 2% plasma cells with no evidence of plasmacytomas. Thus, diagnosis of Extramedullary plasmacytoma post renal transplant was arrived at and immediately Cyclosporine (300 mg bd) was reduced to half dose (150 mg bd) while Azathioprine (120 mg) and Prednisolone (10 mg) were continued at same dose. In consultation with hematology e oncology services, 6 cycles of chemotherapy consisting of Bortezomib and Dexamethasone were given. Following this serum creatinine decreased to 1.4 mg/dl. PET CT scan however revealed persistent metabolically active lesions in right hemimandible and lower pole of transplant kidney (Fig 2).
Persistence of metabolically active lesions despite chemotherapy prompted us to do rescue autologous hematopoetic stem cell transplant. Initial peripheral blood stem cell harvest after 4 days of inj G-CSF 10 mg/kg for 4 days yielded poor result. Repeat harvest was attempted after giving inj cyclophosphamide 3 g/m2 and inj G-CSF 10 mg/kg for 4 days. Inj Melphalan 140 mg/m2 was given one day prior to AHSCT and stem cell harvestcontaining MNC 8.23 108/kg and CD 34 þ cells 1.63 106/kg was transfused. Patient showed engraftment on Day 11 with ANC >500/mm3 for consecutive 3 days after which G CSF was omitted. His maintenance immunosuppressants at reduced doses e cyclosporine 150 mg bd, Azathioprine 120 mg daily, and prednisolone 10 mg were continued. PET CT repeated on Day 90 showed complete resolution of the previous metabolically active lesions (Fig. 3). Hence, maintenance immunosuppression was gradually increased to pre PTLD doses by post engraftment Day 150. Patient has been following up with yearly PET CT for past five years (Fig. 4) with sustained complete remission and stable allograft function with serum creatinine of 1.9 mg/dl.
3.
Discussion
PTLD can develop as a consequence of poor immune surveillance, susceptibility to viral infections (especially EBV), chronic antigenic stimulation due to presence of foreign allograft antigens, cytokines like IL-6, IL-10 and immunosuppresion effect of drugs in recipients of solid organ transplants.4 These disorders range from reactive, polyclonal plasmacytic hyperplasia to those that are morphologically and genotypically indistinguishable from typical non-Hodgkin's lymphomas.5 In some case reports, myeloma and polymorphic PTLD have been reported in <2 months to 15 years following solid organ transplant. In a large series of PTLD after renal transplants, the incidence of myeloma was reported as 0.2%.6 We report possibly the first case of multifocal extramedullary plasmacytoma which presented after 14 years of renal transplantation. In literature we found cases of post transplant extramedullary plasmacytoma, however none had multiple lesions.7 Although most reported plasma cell myeloma PTLD cases have localized collections of plasma cells and bone marrow involvement, other clinical findings of
Fig. 1 e Histopathology images showing Plasma cells in FNAC specimens from gums and skin lesions. Please cite this article in press as: Dave K, et al., Extramedullary plasmocytoma: A rare malignancy in renal transplant recipient, Indian Journal of Transplantation (2015), http://dx.doi.org/10.1016/j.ijt.2015.04.005
i n d i a n j o u r n a l o f t r a n s p l a n t a t i o n x x x ( 2 0 1 5 ) 1 e4
3
Fig. 2 e Pet CT Image after bortezomib cycles.
Fig. 3 e PET CT Image at Day 90 post engraftment of autologous hematopoetic stem cell transplant. Please cite this article in press as: Dave K, et al., Extramedullary plasmocytoma: A rare malignancy in renal transplant recipient, Indian Journal of Transplantation (2015), http://dx.doi.org/10.1016/j.ijt.2015.04.005
4
i n d i a n j o u r n a l o f t r a n s p l a n t a t i o n x x x ( 2 0 1 5 ) 1 e4
cell dyscrasias and that too in renal transplant settings is a rarity. Our case is unique and first reported in Indian medical literature where multifocal extramedullary plasmacytoma completely responded to AHSCT and patient remained in complete remission for 5 years with a stable renal graft function. Hence, High dose chemotherapy followed by AHSCT could definitely be used to achieve complete remission in Bortezomib refractory plasmacytomas presenting as PTLDS in renal transplant settings and preserving renal graft function.
Conflicts of interest All authors have none to declare.
Financial support None.
Acknowledgement We thank Dr A. Chitale and Dr. Vishal Ramteke for their help in preparing the manuscript.
references
Fig. 4 e Follow up PET CT after 5 years follow up showing no metabolic activity.
typical plasma cell myeloma such as lytic bone lesions and hypercalcemia were frequently absent. Hence, a high index of suspicion is required for timely diagnosis and treatment. The prognosis of post transplant plasma cell dyscrasia is not well known, but may have poor outcomes compared with other PTLDS. Response to bortezomib for treatment of extramedullary plasmacytoma is 40e50%.7 Renal failure is not uncommon and could result from rejection in renal transplant recipients following reduction or stoppage of immunosuppressive drugs or may be secondary to renal effects of lesions. The twin goals of efficient treatment of malignancy for complete remission and to maintain renal graft function are to be achieved. High dose chemotherapy with autologous stem cell transplantation is becoming a treatment of choice in treating refractory malignancies especially myelomas in younger patients in non transplant settings8,9 but no data currently is available in renal transplant settings. In our case not only were the extramedullary plasmacytomas multifocal unlike previously reported cases it also did not respond to conventional immunosuppression reduction and Bortezomib. In India rescue autologous hematopoetic stem cell transplant is not often done for treatment of plasma
1. Leblond V, Sutton L, Dorent R, et al. Lymphoproliferative disorders after organ transplantation: a report of 24 cases observed in a single center. J Clin Oncol. 1995;13:961e968. 2. Sheil AGR, Flavel S, Disney APS, et al. Cancer in dialysis and transplant patients. Transpl Proc. 1985;17:195e198. 3. Starzl TE, Nalesnik MA, Porter KA, et al. Reversibility of lymphomas and lymphoproliferative lesions developing under cyclosporine-steroid therapy. Lancet. 1984;1:583e587. 4. Binnani Pooja, Bahadur MM, Kedia Nikhil. Disease recurrence in a transplant kidney in a patient with extramedullary plasmacytoma. Indian J Med Pediatr Oncol. JulyeSep 2010;31. 5. Sharma S, Rana C, Vinod P. Plasma cell myeloma in a renal transplant recipient: a case report and review of literature. Indian J Nephrol. 2011 Oct-Dec;21(4):270e272. 6. Sheil AG, Flavel S, Disney AP, Mathew TH, Hall BM. Cancer incidence in renal transplant patients treated with azathioprine or cyclosporine. Transpl Proc. 1987;19:2214e2216. 7. Muzaffar Mahvish, Chaudhary Rekha, Li Xin, Ratnam Shobha. Post renal transplant plasma cell dyscrasia presenting as retroperitoneal plasmacytoma: a case report and literature review. Dialysis Transplant. 2011;40(3):130e132. 8. Lazarus Hillard M, Phillips Gordon L, Herzig Roger H, Hurd David D. High-dose melphalan and the development of hematopoietic stem-cell transplantation: 25 years later. J Clin Oncol. (May 10), 2008;26:2240e2243. 9. Moreau P, Facon T, Attal M, et al. Comparison of 200 mg/m2 melphalan and 8 Gy total body irradiation plus 140 mg/m2 melphalan as conditioning regimens for peripheral blood stem cell transplantation in patients with newly diagnosed multiple myeloma: final analysis of the Intergroupe Francophone du Mye'lome 9502 randomized trial. Blood. 2002;99:731e735.
Please cite this article in press as: Dave K, et al., Extramedullary plasmocytoma: A rare malignancy in renal transplant recipient, Indian Journal of Transplantation (2015), http://dx.doi.org/10.1016/j.ijt.2015.04.005