Bortezomib administration in a pregnant woman despite its contraindication: a case report

INTRODUCTION: Multiple myeloma is defined as neoplastic proliferation of plasma cells producing monoclonal immunoglobulins which typically presents with bone pain,osteolytic lesions,anemia, hypercalcemia and AKI.Cytogenetic abnormalities such as del17p13 and increased level of LDH are poor prognostic factors for MM.Based on risk stratification and eligibility for autologous hematopoietic cell transplantation,the treatment would be different.Bortezomib and lenalidomide are used in the treatment of MM but they can cause fetal harm during pregnancy.In this report we discuss about a patient who received these medications during pregnancy.CASE PRESENTATION:Our patient is a 38-year-old woman with a 1.5-year history of anemia and LBP.High Ca,ESR,LDH,beta-2 microglobulin;low WBC,Hb and normal BUN,Creatinine levels were measured in lab tests.Bone survey demonstrated osteolytic lesions.SPEP revealed monoclonal spike in the gamma globulin region.Serum immunofixation disclosed high IgG level with increased Bence-Jones protein(kappa light chain)in 24-hour urine.Also serum kappa light chain was elevated.BMA showed dffuse plasma cell infiltration(80%);So she was diagnosed with Multiple Myeloma.Cytogenetic analysis recognized del17p.She received four courses of bortezomib,lenalidomide and dexamethasone.At the end of third course,we found out she was in the 9th week of pregnancy but her treatment continued as before because of refusing abortion and changing medications.In the 38th week she had elective ceasarean.A baby boy was born with normal Apgar score and weight of 3200gr without abnormalities.ASCT was done and re-BMA testing was normal.In the next four-year follow-up, the mother was in complete remission and her son had normal growth.DISCUSSION:MM is a disease of elderly with an average age of 67-70.Four treatment methods during pregnancy consist abortion,novel agents(with accepting fetal risks),observation and starting treatment after delivery,and using steroids.Selecting safe anti-myeloma agents in pregnancy is challenging.VRD regimen(including bortezomib, lenalidomide, dexamethasone)is one of the most effective induction therapies for ASCT candidates.Bortezomib(a proteasome inhibitor)induces apoptosis;its administration during pregnancy may have a teratogenic impact and should be avoided but a few data are available about its safety;also we achieved this in our case report. Lenalidomide(an immunomodulatory agent)is also contraindicated and must be discontinued in pregnancy but patient consent is also needed.CONCLUSSION:Given the limited number of studies,it is understood that very rare cases are reported receiving bortezomib during pregnancy without occurrence of any teratogenic effects and malformations(even in longer follow-up);although bortezomib is considered as a contraindication in pregnancy.

کلیدواژه ها:

Multiple Myeloma ، Bortezomib ، Pregnancy