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Correspondence |

Lenalidomide in Nonmalignant DisordersLenalidomide and Refractory Sarcoidosis: A New Ray of Hope for Refractory Sarcoidosis FREE TO VIEW

Kamal Kant Sahu, MD; Subhash Chander Varma, MD
Author and Funding Information

From the Department of Clinical Hematology, Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Nehru Hospital.

CORRESPONDENCE TO: Subhash Chander Varma, MD, Department of Clinical Hematology, Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Nehru Hospital, 4th Floor, F block, Sector 12, Chandigarh 160012, India; e-mail: hematpgi@gmail.com


CONFLICT OF INTEREST: None declared.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2015;148(6):e188-e189. doi:10.1378/chest.15-1934
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To the Editor:

We congratulate Jafari Giv et al1 on their interesting observation in a recent issue of CHEST (August 2015). In our institute, we frequently prescribe lenalidomide in oncology practice and, hence, would like to share our experience.

Lenalidomide has revolutionized treatment of hematologic malignancies since its introduction in 2004. With its US Food and Drug Administration approval for treatment of multiple myeloma, relapsed mantle cell lymphoma, and transfusion-dependent myelodysplastic syndrome (MDS), lenalidomide holds a key place in the therapeutic armamentarium.2,3 Its pleotropic effect is due to an antitumor effect, antiangiogenic activity, and immunomodulatory role. In particular, anticytokine action (ie, against tumor necrosis factor-α, IL-6, IL-12) of immunomodulatory drugs has therapeutic implications in some nonmalignant conditions like cutaneous sarcoidosis and erythema nodosum leprosum.3 Hence, with the available literature and dramatic response in lung function of the index patient, lenalidomide has proven its pivotal role beyond doubt in sarcoidosis. Myelosuppression, diarrhea, increased risk of thrombosis, and opportunistic infections are therapy-related side effects that pulmonologists should be well aware of while prescribing lenalidomide.3,4 Accordingly, we suggest regular monitoring of CBCs and renal function tests apart from the serial lung function tests and imaging studies during therapy. Thromboprophylaxis with oral anticoagulants or aspirin should also be coprescribed with lenalidomide.

With respect to the index patient with 5q-MDS, there are a few atypical findings that we would like to mention. First, contrary to the index patient, general dysplasia in the erythroid and myeloid lineages is uncommon and limited to the megakaryocytic lineage only. Second, MDS usually has hypercellular or normocellular marrow with hypocellularity (approximately 10% of cases), being an uncommon finding. Third, thrombocytosis (one-third to one-half of cases) is another characteristic finding usually seen in patients of 5q-MDS. The presence of thrombocytosis and therapy with lenalidomide (inherent thrombotic tendency due to class effect) increases the chance of thromboembolic episodes.

This report has certainly set the stage for future work needed in this field. If approved, lenalidomide will be a boon for both the frustrated treating physician and the patient with refractory sarcoidosis. At present, it is premature to comment about the exact dose (5, 10, 15, or 25 mg), schedule (number of cycles needed), and duration of lenalidomide in isolated cases of sarcoidosis without underlying malignancy. Development of secondary malignancies is another important concern while considering duration of lenalidomide therapy.4,5

Through this letter, we aimed to bring out important facts regarding therapy with lenalidomide and related side effects. Many queries regarding treatment protocol need to be answered before lenalidomide therapy is generalized for refractory sarcoidosis. We conclude that a well-structured prospective randomized clinical trial is needed to investigate the challenges related to the role of immunomodulatory drugs in refractory sarcoidosis.

References

Jafari Giv M, Yoosuff A, Bazargan A. Use of lenalidomide in 5q-myelodysplastic syndrome provides novel treatment prospects in management of pulmonary sarcoidosis. Chest. 2015;148(2):e35-e37. [CrossRef] [PubMed]
 
Zeldis JB, Knight R, Hussein M, Chopra R, Muller G. A review of the history, properties, and use of the immunomodulatory compound lenalidomide. Ann N Y Acad Sci. 2011;1222:76-82. [CrossRef] [PubMed]
 
Bodera P, Stankiewicz W. Immunomodulatory properties of thalidomide analogs: pomalidomide and lenalidomide, experimental and therapeutic applications. Recent Pat Endocr Metab Immune Drug Discov. 2011;5(3):192-196. [CrossRef] [PubMed]
 
Qiao SK, Guo XN, Ren JH, Ren HY. Efficacy and safety of lenalidomide in the treatment of multiple myeloma: a systematic review and meta-analysis of randomized controlled trials. Chin Med J (Engl). 2015;128(9):1215-1222. [CrossRef] [PubMed]
 
Tan M, Fong R, Lo M, Young R. Lenalidomide and secondary acute lymphoblastic leukemia: a case series [published ahead of print July 31, 2015]. Hematol Oncol. doi:10.1002/hon.2248.
 

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References

Jafari Giv M, Yoosuff A, Bazargan A. Use of lenalidomide in 5q-myelodysplastic syndrome provides novel treatment prospects in management of pulmonary sarcoidosis. Chest. 2015;148(2):e35-e37. [CrossRef] [PubMed]
 
Zeldis JB, Knight R, Hussein M, Chopra R, Muller G. A review of the history, properties, and use of the immunomodulatory compound lenalidomide. Ann N Y Acad Sci. 2011;1222:76-82. [CrossRef] [PubMed]
 
Bodera P, Stankiewicz W. Immunomodulatory properties of thalidomide analogs: pomalidomide and lenalidomide, experimental and therapeutic applications. Recent Pat Endocr Metab Immune Drug Discov. 2011;5(3):192-196. [CrossRef] [PubMed]
 
Qiao SK, Guo XN, Ren JH, Ren HY. Efficacy and safety of lenalidomide in the treatment of multiple myeloma: a systematic review and meta-analysis of randomized controlled trials. Chin Med J (Engl). 2015;128(9):1215-1222. [CrossRef] [PubMed]
 
Tan M, Fong R, Lo M, Young R. Lenalidomide and secondary acute lymphoblastic leukemia: a case series [published ahead of print July 31, 2015]. Hematol Oncol. doi:10.1002/hon.2248.
 
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