simultaneous multiple myeloma ( mm ) and pulmonary adenocarcinoma is a rare occurrence , and thus , treatment is a challenge .
this study reports on 1 such case of mm with concurrent lung cancer , where an accurate diagnosis was made and the patient underwent treatment for both cancers .
visualization with magnetic resonance imaging ( mri ) revealed multiple collapsed vertebrae from t12 to s3 , as well as an altered signal intensity at the t3 vertebra .
the patient was diagnosed with mm upon examination . a chest computed tomography ( ct ) scan revealed a round mass in the left lower lobe of the lungs , and a ct - guided needle biopsy uncovered a moderately differentiated adenocarcinoma .
there were no additional notable findings in the left lung using positron emission tomography computed tomography ( pet - ct ) .
bortezomib was used as first - line induction therapy against both tumors and lenalidomide was used for maintenance .
the patient has survived for over 3 years since a diagnosis was made despite relapsing twice after the first year .
this report clearly delineates the diagnosis and treatment of a rare case of synchronous mm and pulmonary adenocarcinoma , as well as depicts a potentially positive outcome for the patient .
multiple myeloma ( mm ) is a neoplasm of b cells characterized by excessive proliferation of abnormal plasma cells .
these malignant plasma cells produce immunoglobulins that are detectable in the serum and/or urine of affected patients .
a diagnosis of a secondary solid neoplasm in patients with mm is uncommon , and the pathogenesis underlying this is unknown . it has been suggested that mm patients may have immunological tolerance for developing solid tumors due to an impaired immune system .
synchronous occurrence of mm and lung cancer in a patient is a rare occurrence . upon performing a literature search on pubmed
, only 5 such cases were found with only 1 of these cases including a pulmonary adenocarcinoma . due to this rareness
this report covers the clinical features and treatment for a case of synchronous mm and pulmonary adenocarcinoma . following treatment ,
both cancers have remained stable , and the patient continues to receive medical follow - up .
a 68-year - old man was admitted to the department of hematology at the affiliated cancer hospital of zhengzhou university in february 2013 presenting with 2 months of progressive lower backache . with the exception of his back pain
, he was otherwise in good health and he had no documented history of disease .
the physical examination revealed the pain was located in the back and extended to the waist , and there was slight decrease in breath sound on the left side of the chest .
magnetic resonance imaging ( mri ) revealed the collapse of multiple vertebrae from t12 to s3 , as well as an altered signal intensity in the t3 vertebra .
laboratory test results included a hemoglobin level of 10.7  g / dl , an elevated total serum protein level of 96 
g / l , a reversed a / g ratio of 0.6 , a serum creatinine level of 140  mol / l , a serum urea nitrogen level of 11.3  mmol / l , and a serum beta-2 microglobulin level of 8.55  mg / dl .
analysis using serum electrophoresis and immunoelectrophoresis ( iep ) revealed a monoclonal band that was igg with a kappa light chain ( fig .
bone marrow ( bm ) aspirate had an increased population of abnormal , dysplastic plasma cells ( 23% ) ( fig .
ct scan uncovered a round mass with ground glass opacities in the left lower lobe of the lungs ( fig .
. a ct - guided needle biopsy of the left lung revealed a moderately differentiated adenocarcinoma ( fig .
this plasmacytoma consisted of atypical plasma cells with irregular nuclei and cytoplasmic vacuolation , as assessed by haematoxylin and eosin ( h&e ) staining ( fig . 2c ) .
immunostaining demonstrated a predominance of cd138 + cells ( data not shown ) . aside from the findings involving the left lung and multiple vertebrae ,
based on the patient evaluation described above , a diagnosis of durie - salmon stage iib / iss stage iii mm was made with co - occurring stage i moderately differentiated lung adenocarcinoma .
( a ) pretreatment , an immunoglobin g monoclonal band containing a kappa light chain was visualized using immunoelectrophoresis ( iep ) analysis .
( a ) there was an increased population of abnormal plasma cells with dysplastic features in the bone marrow ( wright staining 1000 ) .
( b ) a ct - guided needle biopsy of the left lung sampled moderately - differentiated adenocarcinoma ( h&e 600 ) . ( c )
pathological analysis of the t3 tissue found diffuse infiltration of plasma cells with unclear intranuclear findings and unevenly distributed nuclei ( h&e 600 ) .
a ) before treatment , ct - scans revealed a round mass with ground glass opacities in the lower left lobe of the lungs .
( b ) after surgery , the ct - scan displayed the shadow of the left lower lung wedge resection .
the patient was given cyclophosphamide ( 200  mg / m , days 15 ) and dexamethasone ( 10  mg , days 15 ) to relieve the symptoms of the lower backache .
ten days post - diagnosis , a left lower lobectomy , as well as hilar and mediastinal lymph node dissection , was performed using video - assisted thoracic surgery ( vats ) ( fig .
3b ) . chemotherapy was then started in april 2013 , consisting of 4 cycles of bortezomib ( 1.0  mg / m given on days 1 , 4 , 8 , and 11 from start of treatment ) and dexamethasone ( 20  mg give on days 1 , 2 , 4 , 5 , 8 , 9 , 11 , and 12 from start of treatment ) .
the patient experienced no severe complications during the 3 cycles of chemotherapy with the exception of mild peripheral neuritis . during the fourth cycle , the patient suffered from bronchopneumonia that clinically manifested as a fever and a cough with yellow sputum . a sputum culture and drug sensitivity test identified vancomycin - sensitive staphylococcus aureus as the infecting agent .
however , the dose of dexamethasone was reduced to 10  mg from the original 20  mg .
the patient achieved complete remission ( cr ) by the end of the 4 cycles of chemotherapy ( fig .
home maintenance therapy of lenalidomide ( 10  mg / day , days 128 from start of treatment ) was started in november 2013 .
the patient was seen for regular follow - up and was in cr until august 2014 when a repeat chest ct scan revealed a recurrence of the lung cancer .
in addition , iep analysis found that the igg and kappa light chain levels were once again elevated . because the patient could not financially
afford bortezomib , treatment was changed to gemcitabine ( 1.0  g / m given on days 1 and 8 from start of treatment ) with cisplatin ( 20  mg / m given on days 14 from start of treatment ) and dexamethasone ( 10  mg given on days 14 from start of treatment ) .
after 4 cycles , the patient achieved partial remission ( pr ) and was maintained with lenalidomide at home .
the patient presented again at the hospital in november 2015 with chest tightness and shortness of breath .
a repeat chest ct scan revealed another relapse of the lung cancer with pleural effusion .
therapy was initiated and consisted of 4 cycles of vinorelbine ( 25  mg / m given on days 1 and 8 from start of treatment ) and cisplatin ( 20  mg / m given on days 14 from start of treatment ) .
pr was again achieved , and the patient was again maintained on lenalidomide at home . through april 2016 ,
the patient continued with regular follow - ups , and both cancers have remained stable and have not progressed .
the presence of a second primary tumor is rare and can easily be missed or misdiagnosed .
specifically , a patient presenting with mm in conjunction with primary lung adenocarcinoma is very rare with only 1 published case , which resulted in a poor prognosis .
however , some studies have found an association between mm and an increased risk of secondary malignancy , including hematologic malignancies and solid cancers . currently , the pathogenesis behind the occurrence of secondary cancers in mm patients is unknown and may be complicated by biological factors , familial or genetic predisposition , endocrine factors , and immune dysfunction .
it is unclear whether there are separate factors that facilitate the occurrence of a second solid tumor or the same pathogenic factors implicated in mm pathogenesis contribute to the development of a second tumor .
when mm occurs concurrently with another solid tumor , mm is typically diagnosed during follow - up and comprehensive inspections of patients with known solid tumors .
however , in the case presented here , the presenting symptom was bone pain , and mm was the initial diagnosis following examinations of bm , ep , iep , and so on . during a comprehensive diagnostic work - up , a mass was found in the left lung using ct . because extramedullary infiltration occurs in some cases of mm ,
a ct - guided needle biopsy was performed to assess the nature of the mass in the left lung and the soft tissue mass in the t3 vertebra .
a pet - ct scan was also performed to aid in assessing tumor stage and clinical decision - making .
after extensive work - up , the patient was diagnosed with durie  salmon stage iib / iss stage iii mm and stage i moderately differentiated lung adenocarcinoma . due to the extreme rarity of cases similar to the one described in this article
treatment was directed at the solid tumor due to its more advanced state , and the resulting prognosis was associated with this primary cancer .
some scholars have postulated that a primary malignancy of the hematopoietic system may result in an even worse prognosis than a primary solid tumor , but this remains to be confirmed . in this case , both of the neoplasms were in advanced stages .
the first aim of treatment was to relieve the patient 's discomfort from the lower back pain , which was clearly due to the mm , and , thus , simple chemotherapy was used to alleviate the symptoms . following this ,
choosing the optimal chemotherapy agents for treatment was complicated by the presence of 2 cancers rather than just 1 , and , thus , drugs were chosen that would treat both types of cancer .
bortezomib , a dipeptide proteasome inhibitor , is an antineoplastic agent approved for the treatment of mm and relapsed mantle - cell lymphoma that has been shown to be significantly cytotoxic against human nonsmall - cell lung cancer ( nsclc ) cell lines in vitro and in a phase - i / ii study .
bortezomib was used in conjunction with dexamethasone as the first - line therapy and the patient responded in a manner similar to mm patients without lung cancer .
cr was achieved after four treatment cycles , and lenalidomide was used subsequently as a home maintenance therapy .
lenalidomide , an immunomodulatory drug , was originally approved to treat mm , but has also been reported to induce apoptosis in nsclc cells .
again , chemotherapy drugs were chosen that had been proven effective against both types of cancer : gemcitabine , vinorelbine , and dexamethasone . using these therapeutics ,
pr was achieved and the patient was again given home maintenance therapy of lenalidomide . since his diagnosis , the patient has survived for over 3 years and continues to be monitored for recurrence of the mm and/or lung cancer . in summary , a patient presented with symptoms typical of mm . using both comprehensive and targeted methods of examination
prior to this case , only 1 other similar case has been reported in the literature . due to the stage of lung cancer ,
chemotherapy agents were chosen for treatment based on their ability to work against both types of cancer .
therefore , bortezomib was used as the first - line therapy and lenalidomide was used for at home maintenance . with this treatment plan ,
we have thus far achieved a satisfactory therapeutic effect as the patient is currently alive with both malignancies stable and nonprogressing .
 abstractbackground : simultaneous multiple myeloma ( mm ) and pulmonary adenocarcinoma is a rare occurrence , and thus , treatment is a challenge . 
 this study reports on 1 such case of mm with concurrent lung cancer , where an accurate diagnosis was made and the patient underwent treatment for both cancers.case summary : a 68-year - old man presented with 2 months of progressive lower back pain . visualization with magnetic resonance imaging ( mri ) revealed multiple collapsed vertebrae from t12 to s3 , as well as an altered signal intensity at the t3 vertebra . 
 the patient was diagnosed with mm upon examination . 
 a chest computed tomography ( ct ) scan revealed a round mass in the left lower lobe of the lungs , and a ct - guided needle biopsy uncovered a moderately differentiated adenocarcinoma . 
 there were no additional notable findings in the left lung using positron emission tomography computed tomography ( pet - ct ) . 
 therefore , a diagnosis of mm with pulmonary adenocarcinoma was made . 
 surgery was performed to excise the lung cancer . 
 bortezomib was used as first - line induction therapy against both tumors and lenalidomide was used for maintenance . 
 the patient went into complete remission . using this combined chemotherapy , 
 the patient has survived for over 3 years since a diagnosis was made despite relapsing twice after the first year.conclusion:this report clearly delineates the diagnosis and treatment of a rare case of synchronous mm and pulmonary adenocarcinoma , as well as depicts a potentially positive outcome for the patient . 
 it also overviews some diagnostic and therapeutic implications for clinicians . 
Background:
Case summary:
Conclusion:
Introduction
Case presentation
Discussion