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Mahsa Jafari Giv, MBBS (Hons); Ali Bazargan, MD
Author and Funding Information

From the Department of Haematology, St. Vincent’s Hospital.

CORRESPONDENCE TO: Mahsa Jafari Giv, MBBS (Hons), Department of Haematology, St. Vincent’s Hospital (Melbourne), 59 Victoria Parade, Fitzroy, Melbourne, VIC, Australia 3065; e-mail: mahsa.jafarigiv@svha.org.au


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):e189. doi:10.1378/chest.15-2026
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To the Editor:

We thank Drs Sahu and Varma for commending our novel observation of the efficacy of lenalidomide in a patient with stage IV pulmonary sarcoidosis who unexpectedly showed a remarkable response, leading us to a hypothesis about the potential role of lenalidomide to manage refractory sarcoidosis.1 Lenalidomide is increasingly being investigated and utilized as a novel therapeutic agent to manage various nonmalignant disorders, including refractory cutaneous lupus erythematous and primary systemic light chain amyloidosis.2,3

Although some concerns exist about the development of secondary hematologic malignancies in patients with multiple myeloma treated with long-term lenalidomide, such concerns do not relate to the development of solid tumors, and they have not yet been fully substaintiated.4 Several factors, including duration, dose and regimen intensity of therapy, use of lenalidomide with oral melphalan, and patient factors, such as age, tumor microenvironment, and ethnicity, have all been suggested as potential risk factors.5 With more widespread and prolonged use of lenalidomide in hematologic conditions and nonmalignant disorders, further insight into this matter can be expected to emerge, enabling clinicians to make accurate risk and benefit assessments and consider implementation of effective screening protocols.

We agree with Drs Sahu and Varma that, at present, there is no evidence or consensus on the relevant dose of lenalidomide in patients with refractory sarcoidosis. However, the dose, intensity, and duration of exposure of these patients to lenalidomide is likely to be considerably less than what is commonly used in multiple myeloma, potentially reducing the reported incidence of adverse reactions. In the presented case report, the patient received lenalidomide 10 mg/d, whereas most randomized control trials in multiple myeloma, which have been included in the meta-analysis referred to by Drs Sahu and Varma, administered doses of 20 to 25 mg/d, and the reported incidence of adverse side effects, concerns about toxicities, and risks of secondary malignancies need to be considered with clear recognition of this fact.6

The risk of thrombosis with lenalidomide remains a concern. Therefore, for the time being VTE prophylaxis should be considered with careful assessment of risk and benefit in individual patients.

With respect to this patient, we agree with Drs Sahu and Varma that hypocellularity is not a common feature. The patient had macrocytic anemia and thrombocytosis. Although the bone marrow showed evidence of multilineage dysplasia, dysplasia was nonetheless more prominent in megakaryocytes, and cytogenic analysis confirmed evidence of deletion 5q.

It has now been 12 months since the patient commenced 10 mg/d lenalidomide. She has tolerated the medication without any side effects. Her hemoglobin level remains within normal range, and there is no evidence of recurrence of the underlying pulmonary sarcoidosis. This case and the aforementioned considerations provide further stimulus, optimism, and direction for investigating the utility of lenalidomide in patients with 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]
 
Cortés-Hernández J, Ávila G, Vilardell-Tarrés M, Ordi-Ros J. Efficacy and safety of lenalidomide for refractory cutaneous lupus erythematosus. Arthritis Res Ther. 2012;14(6):R265. [CrossRef] [PubMed]
 
Kastritis E, Roussou M, Gavriatopoulou M, et al. Long-term outcomes of primary systemic light chain (AL) amyloidosis in patients treated upfront with bortezomib or lenalidomide and the importance of risk adapted strategies. Am J Hematol. 2015;90(4):E60-E65. [CrossRef] [PubMed]
 
Palumbo A, Bringhen S, Kumar SK, et al. Second primary malignancies with lenalidomide therapy for newly diagnosed myeloma: a meta-analysis of individual patient data. Lancet Oncol. 2014;15(3):333-342. [CrossRef] [PubMed]
 
Ailawadhi S, Swaika A, Razavi P, Yang D, Chanan-Khan A. Variable risk of second primary malignancy in multiple myeloma patients of different ethnic subgroups. Blood Cancer J. 2014;4:e243. [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]
 

Figures

Tables

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]
 
Cortés-Hernández J, Ávila G, Vilardell-Tarrés M, Ordi-Ros J. Efficacy and safety of lenalidomide for refractory cutaneous lupus erythematosus. Arthritis Res Ther. 2012;14(6):R265. [CrossRef] [PubMed]
 
Kastritis E, Roussou M, Gavriatopoulou M, et al. Long-term outcomes of primary systemic light chain (AL) amyloidosis in patients treated upfront with bortezomib or lenalidomide and the importance of risk adapted strategies. Am J Hematol. 2015;90(4):E60-E65. [CrossRef] [PubMed]
 
Palumbo A, Bringhen S, Kumar SK, et al. Second primary malignancies with lenalidomide therapy for newly diagnosed myeloma: a meta-analysis of individual patient data. Lancet Oncol. 2014;15(3):333-342. [CrossRef] [PubMed]
 
Ailawadhi S, Swaika A, Razavi P, Yang D, Chanan-Khan A. Variable risk of second primary malignancy in multiple myeloma patients of different ethnic subgroups. Blood Cancer J. 2014;4:e243. [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]
 
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