Solitary Plasmacytoma in the Setting of Langerhans Cell Histiocytosis

Langerhans cell histiocytosis (LCH) is an intriguing disorder characterized by the accumulation of specialized dendritic cells called Langerhans cells in several diverse tissues and body sites. It has been cited in numerous case reports to be associated with a wide variety of malignant neoplasms. Although many hypotheses have been suggested, the basis for such associations remains essentially unknown. We describe another association here that to our knowledge has not been reported thus far: a solitary plasmacytoma occurring at a site of previous involvement by LCH. This constitutes a new addition to the now fairly lengthy list of malignant neoplasms that have been reported to occur in the setting of LCH. The possible reasons for such an association are discussed along with a brief review of LCH.

[Intracranial tumor behavior of plasma cell neoplasms. Report of 2 cases and literature review]

BACKGROUND

Multiple myeloma is a plasmatic cell neoplasm that is characterized by skeletal destruction, renal failure, anemia and hypercalcemia. The skull plasmacytomas represent less than 1% of the head and neck tumors, they can be the primary lesion or occur as a secondary manifestation of multiple myeloma in 20-30% of the patients, or they can even manifest several years later after the diagnosis of plasmacytoma. Although some of the lesions may be surgically accessible, the aggressive natural behavior will complicate the evolution of the patients. We present two cases of Mexican women with intracranial plasmacytomas, one of them associated with multiple myeloma.

CLINICAL CASES

The first case was a 24 year-old woman diagnosed with a multiple myeloma with plasmacytic-plasmablastic bone infiltration that was removed in 90%. She presented a local recurrence that required a second intervention for removal. The second case was a 62 year-old female with a malignant intracranial tumor of plasma cells that was totally resected. Both patients received adjuvant treatment based on chemotherapy and radiation therapy with favorable results. The patients died at 5 and 1.5 years respectively due to renal failure secondary to systemic disease.

CONCLUSIONS

We propose chemotherapy and radiation therapy as an essential part of treatment for this condition, as the aggressive behavior of the neoplasms can complicate the evolution, despite being surgically accessible.

Maxillary solitary recurrent plasmacytoma: a case report

Solitary plasmacytoma is a very rare form of neoplasia, part of the monoclonal gammopathies. It represents a tumoral proliferation of plasma cells in the form of a solitary mass which can be located in the bone marrow or extramedullary.Initial symptoms are vague and nonspecific. Being such a rare affliction, there is little information in the literature. Early diagnosis is difficult but very important due to therapy outcome.A high risk of progression towards a multiple myeloma has been reported. We present a rare case of a 52-year-old patient diagnosed with multiple solitary plasmacytomas. The tumours were separated from one another in time, over a 14 years period. The various medullograms did not show any sign of medullary plasma cell infiltrate. Initially, the affliction responded to chemotherapy, but later the haematologist recommended surgical resections followed by reconstruction.The maxillary localization required excision of the tumour with the preservation of the eye bulb despite the destruction of the orbital floor and with the regain of ocular functionality as well as aesthetic rehabilitation. This evolution highlights the benefits of surgical treatment in conjunction with chemotherapy in the treatment of this entity.

Solitary plasmacytoma of the medial clavicle

Medial clavicular pain has a broad differential diagnosis that includes traumatic, atraumatic, and neoplastic etiologies. Dedicated imaging studies (eg, computed tomography, magnetic resonance imaging) play an essential role in evaluating and diagnosing disorders of the medial clavicle. In this article, we report a case of medial clavicular pain caused by a rare neoplasm, a solitary plasmacytoma of bone. This case illustrates the importance of accurate diagnosis that is facilitated by thorough evaluation and computed tomographic imaging of the medial clavicle.

Screening of multiple myeloma by polyclonal rabbit anti-human plasmacytoma cell immunoglobulin

Antibody-based immunotherapy has been effectively used for tumor treatment. However, to date, only a few tumor-associated antigens (TAAs) or therapeutic targets have been identified. Identification of more immunogenic antigens is essential for improvements in multiple myeloma (MM) diagnosis and therapy. In this study, we synthesized a polyclonal antibody (PAb) by immunizing rabbits with whole human plasmacytoma ARH-77 cells and identified MM-associated antigens, including enlonase, adipophilin, and HSP90s, among others, via proteomic technologies. 3-(4,5-Dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide assay showed that 200 µg/mL PAb inhibits the proliferation of ARH-77 cells by over 50% within 48 h. Flow cytometric assay indicated that PAb treatment significantly increases the number of apoptotic cells compared with other treatments (52.1% vs. NS, 7.3% or control rabbit IgG, 9.9%). In vivo, PAb delayed tumor growth and prolonged the lifespan of mice. Terminal deoxynucleotidyl transferase dUTP nick end labeling assay showed that PAb also induces statistically significant changes in apoptosis compared with other treatments (P<0.05). We therefore conclude that PAb could be used for the effective screening and identification of TAA. PAb may have certain anti-tumor functions in vitro and in vivo. As such, its combination with proteomic technologies could be a promising approach for sieving TAA for the diagnosis and therapy of MM.

[Clinical analysis on extramedullary plasmacytoma in the upper airway]

OBJECTIVE

To investigate the clinical manifestation, treatment and prognosis of extramedullary plasmacytoma(EMP) in the upper airway, and to improve the diagnosis and outcome of EMP treatment.

METHOD

Clinical data of 26 EMP cases were reviewed retrospectively, and then compared with multiple myeloma(MM) patients presenting with lesions in upper airway.

RESULT

Of 26 cases, 9 cases with the tumors occurred in nasal cavities, 7 in nasal sinuses, 6 in pharyngeal, 4 in throat, mainly manifesting with local masses and relevant symptoms. The manifestations of clinical, endoscopy findings and pathologic results in EMP patients were not distinguishable from the lesions of MM patients, while MM patients often accompanied by other findings, such as anemia and bone damage. Involvement of neck lymph nodes was more common in MM patients than in EMP patients. Ten patients were treated with surgery, and 16 patients with surgery and radiotherapy. Of the seven EMP patients with involvement of neck lymph nodes, four patients received additional chemotherapy besides surgery and radiotherapy, and no local relapse and MM happened in them, while of the three patients only received surgery and radiotherapy, one local relapse were found and one progressed to MM.

CONCLUSION

The diagnosis of EMPs mainly depends on pathological results. The judgment of pathologists and application of molecular biology technology are vital for the diagnosis of EMP in upper airway, and MM must be excluded very carefully in the diagnosis of EMP. Surgery combined with radiotherapy is the main treatment for EMP in the upper airway, and the prognosis is good but the follow-up should be taken. Besides surgery and radiotherapy, chemotherapy is beneficial for the EMP patients accompanied with lesions in neck lymph nodes.

Testicular plasmacytoma as presentation of multiple myeloma: case report and review of the literature

OBJECTIVE

We present the case of a patient with testicular plasmacytoma as initial presentation of multiple myeloma, and we carry out a literature review of this uncommon pathology.

METHODS

63 year-old male who consulted for a testicular mass for three months. After clinical and diagnostic studies he underwent radical orchiectomy.

RESULTS

Pathologic study of the specimen revealed the presence of round cells, some with plasmocytic aspect. Immunohistochemical studies gave the final diagnosis of plasmacytoma. Studies on disease extension showed rounded lytic lesions spread over the vault of the skull bones. Bone marrow studies, as well as bone biopsy showed infiltration by plasma cell neoplasia in more than 90%, consistent with the diagnosis of multiple myeloma. The patient received treatment, developing disease progression and subsequently died from the disease.

CONCLUSIONS

Solitary plasmacytoma represents only 6% of all plasma cell neoplasms. Testicular presentation is an unusual event, representing 2% of cases. Although this is usually an autopsy finding, it may constitute the first manifestation of multiple myeloma or exceptionally be the unique location of a plasma cell neoplasm. To date there are few reports published in the literature. This case constitutes a contribution for the knowledge of testicular plasmacytoma.

Adenopathy and extensive skin patch overlying a plasmacytoma (AESOP) syndrome

In our manuscript we describe the cutaneous manifestations of a rare condition termed Adenopathy and Extensive Skin Patch Overlying Plasmacytoma (AESOP) syndrome. We emphasize the importance of clinically following and subsequently removing the osteolytic tumor to make the diagnosis.

Primary cutaneous plasmacytoma occurring after pacemaker implantation and recurring in scar tissue

Primary cutaneous plasmacytomas are rare and little is known about their treatment and progression. We describe for the first time the predilection of primary cutaneous plasmacytoma to occur in a scar or sites of trauma. We report an 89-year-old man who presented with a slowly expanding asymptomatic mass over his pacemaker implantation, 1 year after insertion. Further investigation ruled out multiple myeloma and histology confirmed it to be a cutaneous plasmacytoma. This was treated successfully by local radiotherapy after extraction of the pacemaker and implantation of a new pacemaker on the opposite side. The patient subsequently developed an additional cutaneous plasmacytoma over the new pacemaker site, followed by the development of progressive multiple myeloma. Primary cutaneous plasmacytoma can show predilection for sites of trauma or surgery. Surgical excision of the plasmocytoma and local radiotherapy may be a reasonable strategy in the first initially after pacemaker removal.

Extramedullary plasmocytoma relapsing at differents sites: an unusual presentation

Extramedullary plasmacytoma (EMP) is an uncommon plasma cell neoplasm results from plasma cell proliferation and consists of monoclonal plasmacytic infiltration, without bone marrow involvement and any other systemic characteristics of multiple myeloma. EMP accounts for 3% of all plasma cell neoplasms and approximately 80% to 90% of EMP involve submucosa of the upper aerodigestive, while scrotal, dermis and retroperitoneal infiltration are very rare. There are no consensus guidelines for treatment, but EMP is highly radiosensitive, surgery may be considered for some sites, but 11 at 30% can progress in multiple myeloma. We report here an exceptional case of recurrent EMP in much localization. It's about a man 72 years old with initially testicular plasmocytoma who generalized the plasmacytic infiltration after 16 months in skin and progressively in mediastinal and retroperitoneal plasmacytoma, without any medullar and bone involvement.

Extramedullary plasmacytoma of the true vocal fold

We report a rare case of extramedullary plasmacytoma (EMP) of the true vocal fold. Our patient, a 62-year-old woman, presented with dysphonia. On workup, fiberoptic laryngoscopy detected a lesion arising from the anterior half of her left true vocal fold. No evidence of other pathology was noted. The patient underwent radical radiotherapy, and the lesion resolved. Follow-up revealed no sign of recurrence. A type of myeloma, EMP is rare, especially in the larynx. To the best of our knowledge, our patient represents the sixth case of glottic EMP to be reported in the literature.

Primary isolated extramedullary plasmacytoma of mesentry: a rare case report

Extramedullary plasmacytoma (EMP) is an uncommon entity that most commonly involves nasopharynx and upper repository tract. Involvement of GIT occurs in approximate 10% of cases. According to WHO plasma cell tumors have been classified into two main groups: Multiple myeloma and plasmacytoma. Plasmacytoma includes solitary plasmacytoma of bone and solitary extramedullary plasmacytoma. EMP can be either primary without evidence of bone marrow involvement or may occur simultaneously with multiple myeloma representing extramedullary spread of the disease. It may occur in association with multiple myeloma and it may precede, accompany or follow the onset of multiple myeloma. Diagnosis of primary EMP requires the exclusion of associated multiple myeloma as shown by negative Bence Jones Proteins in urine, normal serum electrophoresis, normal bone marrow biopsy, normal skeletal survey and normal calcium levels. Here we present a case of 55-year male who came to Nephrology Department for urinary tract infection and pain abdomen. Patient was referred to Radiology for ultrasonography which revealed bilateral renal parenchymal disease with a well-defined mass in the mesentry which was further confirmed on computed tomography. Patient was surgically operated and diagnosis of primary EMP of mesentry was made on histopathological examination. Only three cases have been reported so far in the literature.

Trends and outcomes of modern staging of solitary plasmacytoma of bone

Over the years, the definition of solitary plasmacytoma of bone (SPB) has shifted in part due to more modern testing capabilities. We hypothesized that outcomes data based on antiquated testing would not reflect outcomes using modern staging. To address both how widely applied adequate diagnostic staging is and what the progression rates of SPB as defined with state-of-the-art staging are, we performed a retrospective chart review of those patients with a diagnosis of SPB seen at our institution over the past decade. Two groups were studied: all patients with SPB (n = 127); and those patients referred to our institution for an indication other than progression (n = 91). The median PFS for those two groups were 26 months and 42 months, respectively. At baseline, only a minority of patients had state-of-the-art staging. The 5 patients with both modern imaging and a negative bone marrow had a 21 month PFS of 100%. Patients with plasmacytoma plus, one plasmacytoma but bone marrow consistent with monoclonal gammopathy of undetermined significance, fare worse than true SPB. The use of modern testing is imperative to characterize a patient's risk for progression. PET/CT plays an important role in the diagnostic work-up.

Skull base plasmacytoma with conductive hearing loss and an external auditory canal mass

Skull base plasmacytomas are rare and difficult to differentiate clinically and radiologically from other tumors of the head and neck. Because of the risk of progression to multiple myeloma, early diagnosis is essential. We report the case of a 65-year-old woman who presented with left-sided conductive hearing loss and an external auditory canal mass. The tumor was removed along with much of the tympanic membrane, and it was found to be a plasmacytoma. The patient was subsequently diagnosed with multiple myeloma and treated with chemoradiation before being lost to follow-up.

Metastases and primary tumors around dental implants: A literature review and case report of peri-implant pulmonary metastasis

OBJECTIVE

To perform a literature review on peri-implant metastases and primary malignoma and report a case of a pulmonary metastasis around dental implants of the anterior mandibular jaw that mimicked peri-implantitis.

METHOD AND MATERIALS

A literature search of publications from June 1980 to June 2011 in the PubMed/Medline database was performed to collect information about the type, incidence, and localization of malignant primary tumors and metastases around dental implants and to evaluate potential risk factors. A descriptive statistic was performed based on the collected data with regard to the type and/or origin of tumor, its localization, and the patient's age and sex.

RESULTS

A total of 1,795 articles were considered for evaluation. Peri-implant metastases are described in three articles, and peri-implant primary tumors were found in 14 publications. Of all peri-implant metastases, no associated risk factors are mentioned. Those of the peri-implant tumors are alterations of the peri-implant mucosa (such as oral lichen planus, verrucous leukoplakia, and ulcer). Most of the primary tumors are squamous cell carcinoma. The mean age of the patients with peri-implant metastases was 68 years; for the peri-implant primary tumors, it was 71 years.

CONCLUSION

Peri-implant metastases and primary tumors are rare. Every untypical or refractory reaction to the treatment of peri-implantitis is suspicious for malignancy as long as the contrary remains unproven.

Solitary plasmacytoma of the tonsillar site associated with actinomyces infection: the possible role of IL-6

ExtraMedullary Plasmacytoma (EMP) is a rare plasma cell tumor. It can occur in the upper aerodigestive tract and presents as a large nodule causing local compressive symptoms. A 79-year old woman presented to Otorhinolaryngology Department with progressive hearing loss and no other symptoms. Following PET/TC examination due to the suspicion of a lymphoproliferative disease, the patient underwent tonsillectomy and the diagnosis of solitary EMP was formulated. In addition to that, the histological examination of the tonsillar tissue revealed large colonies of filamentous bacteria, showing abundant sulphur granules and Splendore-Hoeppli phenomenon; these evidences indicating the presence of a chronic Actinomyces infection. Immunohistochemical analysis demonstrated a marked IL-6 immunoreactivity of the neoplastic plasma cells. Interestingly, a marked IL-6 immunoreactivity was also found in the tissue surrounding the Actinomyces colonies. In the present study we report for the first time a solitary EMP associated with Actinomycosis. It is tempting to speculate that the unsuspected and untreated Actinomyces infection, through chronic IL-6 production, could contribute to the neoplastic transformation of plasma cells.

Primary solitary extramedullary plasmacytoma of the tongue

Extramedullary plasmacytomas are rare malignancies. Most cases (80%) are seen in the head and neck region, where they represent 1% of all head and neck malignancies. We report a case of an extramedullary plasmacytoma of the tongue that was treated successfully with three-dimensional conformal radiotherapy. The patient was a 50-year-old woman who was admitted to our hospital with bilateral pain and ulceration on the sides of her tongue. Findings on magnetic resonance imaging and positron-emission tomography did not demonstrate any mass within the tongue or any lymphatic or distant metastasis. A tissue biopsy identified a plasma cell neoplasm. The patient was treated with a total dose of 50 Gy delivered in 2-Gy daily fractions. After 54 months of post-treatment follow-up, she exhibited no sign of systemic myeloma or local recurrence. This case is presented not only for the rarity of the tumor type, but also for its unusual location.

Sellar plasmacytomas: a concise review

The diagnosis of a sellar plasmacytoma is often missed and is mistaken for a non functioning pituitary adenoma. We reviewed the literature on reported cases of sellar plasmacytoma in order to identify its clinical presentation, laboratory, radiological and pathological characteristics. We describe the management of these cases after the correct diagnosis was made and provide insight to preoperative diagnosis of this entity. Preoperative diagnosis may help avoid unnecessary surgical resection of an otherwise radiosensitive tumor. We also report and describe in detail a new case of sellar plasmacytoma that we have recently evaluated.

Solitary plasmacytoma of the bone involving young individuals, is there a role for preceding trauma?

Solitary plasmacytoma of the bone (SPB) is a rare plasma cell neoplasm that usually presents as a lytic lesion mainly localized within the axial skeleton. The occurrence of SPB in young individuals is exceedingly rare but has been sporadically reported before. We report a case of SPB involving a 21 year-old male with a prior history of trauma at the same site. We also reviewed all previous cases of SPB in young individuals that were accessible to us to investigate the incidence of prior trauma in such cases and to investigate a potential role that trauma may play in the pathogenesis of such lesions.

[Clinical analysis of multiple myeloma with extramedullary plasmacytomas]

OBJECTIVE

To explore the clinical features, treatment and prognosis of multiple myeloma (MM) with extramedullary plasmacytomas (EM).

METHODS

A total of 43 patients were enrolled and divided into 2 groups. Group-1 had 12 patients of EM occurring after the diagnosis of MM while Group-2 included 31 EM patients at the initial diagnosis of MM.

RESULTS

The male-to-female proportion was 23:20 and there was a median age of 53 years. The distribution of different isotypes was IgG (n = 15), IgA (n = 9), IgD (n = 2), κ light chain (n = 6), λ light chain (n = 6), biclonal myeloma (n = 3) and nonsecretory myeloma (n = 2). The sites of complicating plasmacytoma included skin, muscle and spinal canal. Nine patients received bortezomib plus DECP (cisplatin, etoposide, cyclophosphamide and prednisone) and 2 patients underwent traditional chemotherapy in Group-1. The outcomes were as follows: complete remission (CR, n = 2), partial remission (PR, n = 4) and death (n = 5). And 11 patients received traditional chemotherapy in Group-2, 7 attained PR and 4 died. Twenty patients received bortezomib plus other chemotherapeutic drugs in Group-2. The outcomes were as follows: CR (n = 12), PR (n = 7) and death (n = 1). The median overall survival (OS) was 36 months (range: 10 - 120) in Group-1 and 23 months (range: 5 - 52) in Group-2 respectively. In Group-1, the estimated 3- and 5-year OS were 54.21% and 27.10% respectively. And in Group-2, the estimated 3- and 4-year OS were 39.83% and 13.28% respectively.

CONCLUSIONS

The EM patients show aggressive, complicated and diverse clinical courses and the unusual manifestation of multiple organ involvement by plasma cells. Traditional chemotherapy has a poor efficacy and the prognosis is unfavorable, especially for EM with concurrent MM. The combined treatment of bortezomib with second-line chemotherapy may achieve curative effects.

Spinal involvement with spinal cord compression syndrome in hematological diseases

Primary spinal involvement in hematological diseases is rare.

PURPOSE

The purpose of this article is studying diagnostic and treatment strategies in patients with spinal cord primary hematologic tumors causing spinal cord compression syndrome.

PATIENTS AND METHODS

We report two cases with spinal cord primary hematologic tumors causing spinal cord compression syndrome. One patient had a diffuse large B-cell non-Hodgkin's lymphoma located in the thoracic spine and the second patient had a plasmocytic plasmacytoma located in the thoraco-lumbar spine.

RESULTS

Both patients underwent surgery, with resection of the intracanalar tumor and spinal cord decompression and adjuvant systemic and intrathecal chemotherapy. Neurological outcome was favorable with partial remission of spinal cord compression syndrome. Finally, patients developed secondary dissemination and succumbed due to progression of the hematological disease.

CONCLUSIONS

Clinical onset and radiographic evaluation is uncharacteristic in early stages. Spinal MRI is mandatory in cases with rebel pain, unresponsive to conservative treatment. Surgery is indicated in all patients with spinal cord compression syndrome. Early diagnosis is associated with better prognosis. Recommended treatment is surgical resection and systemic and intrathecal chemotherapy adapted to histological form of each tumor. In selected cases, if indicated radiotherapy can also be associated.

A case of extramedullary solitary plasmacytoma arising at the uterine cervix

Extramedullary plasmacytomas are localized plasma cell neoplasms that arise in tissues other than bone and bone marrow. Primary plasmacytomas of the female genital tract are extremely rare and present a substantial diagnostic challenge. We report a case of a 38-year-old woman who presented with an endocervical polypoid. Surgical removal of the polyp was carried out. The final pathological report revealed primary plasmacytoma of the uterine cervix. The diagnosis was further facilitated by the use of immunohistochemistry and clonal immunoglobulin heavy-chain gene rearrangement. We performed a simple hysterectomy by laparoscopy on the patient and kept a close follow-up. She has remained well for more than eight years. The clinical characteristics and histopathologic findings of plasmacytoma of the uterine cervix are discussed.

Blastic plasmacytoid dendritic cell neoplasm: cytopathologic findings

Blastic plasmacytoid dendritic cell neoplasm (BPDCN) is a rare, aggressive hematopoietic neoplasm, which in the past was also known variously as blastic NK cell lymphoma, agranular CD4+ natural killer cell leukemia, and CD4+/CD56+ hematodermic neoplasm. BPDCN is now believed to arise from plasmacytoid dendritic cells, but its exact etiology is still unknown. We report here on the cerebrospinal fluid (CSF) cytology of a BPDCN, a hypercellular specimen comprised of malignant, singly dispersed cells with scant to moderate amounts of pale blue, agranular cytoplasm, and uniform round to oval nuclei, fine chromatin, prominent nucleoli, occasional cytoplasmic microvacuoles, and pseudopodia. Neither mitoses nor karyorrhexis were identified. Flow cytometry of the CSF demonstrated that the malignant cells expressed bright CD45, HLA-DR and CD33, dim CD4, heterogeneous CD56, and partial CD123. The importance of clinical, histopathological, and phenotypic correlation is emphasized. Clinical and histopathological correlation and a literature review are also presented. The poor clinical outcome makes it important to accurately report this rare tumor in a CSF specimen.

Extraosseous plasmacytoma of the lacrimal duct

OBJECTIVE

Extraosseous plasmacytoma (EOP) is a rare plasma cell proliferative disorder that commonly affects the head and neck region. We report the first case of a plasmacytoma of the lacrimal duct.

METHODS

A 66-year-old man presented with an isolated plasmacytoma of the right lacrimal duct and was treated surgically.

RESULTS

The tumour grew slowly for a few months. CT scan and MRI showed a right lateral nasal mass extending from the right lacrimal duct toward the floor of the right maxillary sinus. The lesion was removed completely by endoscopic nasal surgery.

DISCUSSION

EOP accounts for up to 3% of all plasma cell tumours. Management of this rare lesion involves surgery and radiotherapy with or without adjuvant chemotherapy. Guided by a literature review, we discuss the diagnostic and therapeutic management of EOP.

Extramedullary plasmacytomas in the context of multiple myeloma

Plasmacytoma is a frequent complication of multiple myeloma, either at diagnosis or within disease progression. The extramedullary disease confers a poorer prognosis and is biologically distinct with high-risk molecular and histological features, being resistant to conventional treatments. Radiation therapy remains the most effective treatment for extramedullary lesions to achieve local control. There are very limited data from randomized trials regarding the most appropriate systemic treatment. Case reports such as those presented here, as well as retrospective analysis of series, suggest that lenalidomide is an effective agent, in combination with dexamethasone, in this setting. Additional studies are needed to define the proper management of this condition.

[Primary bilateral testicular plasmacytoma: a case report]

A 66-year-old man presented with swelling of the right testis where ultrasonography revealed a heterogeneous mass. The pathological diagnosis after right high inguinal orchiectomy was peripheral T cell lymphoma. Eighteen months later, the patient became aware of left testicular swelling and magnetic resonance imaging indicated recurrence of lymphoma. The pathology diagnosis after left high inguinal orchiectomy was plasmacytoma. Reevaluating the pathology of the previously resected right testicular tumor, we decided on the basis of positive immunostaining for CD38 and CD138 that the tumor in the right testis was also a plasmacytoma. Radiation therapy was applied to the left scrotum and the left inguinal area because plasmacytoma cells had invaded the spermatic cord. Multiple bone metastases and upper pharyngeal metastasis developed 5 months after the left orchiectomy, and in spite of multiple courses of combination chemotherapy the patient died of disseminated disease.

[A case of extramedullary plasmacytoma of the lung diagnosed by video-assisted thoracic surgery]

A 69-year-old man who had had a history of abnormal chest radiograph was admitted. Chest computed tomography showed an 18 x 18 mm apparently-circumscribed mass in the right posterior-basal segment. We performed right lower lobe wedge resection via video-assisted thoracic surgery to establish a definitive diagnosis. The mass was an apparently-circumscribed, gray and solid tumor, the microscopic findings of which included diffuse proliferation of plasma cells with an abnormal profile. Immunohistochemical staining revealed IgG-kappa light chain monoclonality. Absence of M protein in the serum and urine was confirmed. Bone-marrow puncture and positron-emission tomography revealed normal findings. Thus a diagnosis of extramedullary plasmacytoma (EMP) of the lung was made. We report trends of the immunoglobulin isotype of EMP in Japan. Since it has been reported that some of the cases in EMP progress to multiple myeloma (MM), careful observation and follow-up is needed hereafter. In the present case, no recurrence or progress to MM was observed within the first year after surgery.

Plasmacytoma of the thyroid gland

Among the clinical presentation of plasma cell proliferative disorders the extramedullary plasmacytomas are the most infrequent after multiple myeloma and plasma cell tumours of the bones. The plasmacytoma of the thyroid gland to our knowledge has never been reported from Pakistan so far. We present the clinical picture and clinical challenges posed in diagnosis and treatment by this unusual proliferative disorder.

Crystal storing histiocytosis of the tongue as the initial presentation of multiple myeloma

Crystal-storing histiocytosis (CSH) is a rare consequence of abnormal accumulation of immunoglobulins which may arise in a number of different clinical scenarios. In this report, we describe the case of a male patient who presented with an apparently innocuous lesion on the dorsum of tongue which showed the typical features of CSH. Subsequent investigations revealed an associated plasmacytoma, and the patient developed further systemic lesions. The rarity of such lesions presents diagnostic difficulties, yet accurate diagnosis underpins the timely implementation of appropriate therapy.

Two cases of plasmacytoid variant of urothelial carcinoma of urinary bladder: systemic chemotherapy might be of benefit

We report two cases of the plasmacytoid variant of urothelial carcinoma of urinary bladder in which systemic chemotherapy was effective. In the first case, a 76-year-old man presented with dysphasia. Magnetic resonance imaging (MRI) and computed tomography revealed a brain tumor and a bladder tumor. Resection of the brain tumor and transurethral resection of the bladder tumor were performed. The pathological diagnosis was plasmacytoid variant of urothelial carcinoma of urinary bladder with brain metastasis (pT1N0M1). Three cycles of adjuvant MVAC (methotrexate, vinblastine, adriamycin, and cisplatin) chemotherapy were performed. He has no evidence of recurrence 96 months after resection of brain metastasis. In the second case, a 76-year-old man presented with hematuria. MRI revealed a bladder tumor with abdominal wall invasion, and a transurethral biopsy was performed. The pathological diagnosis was plasmacytoid variant of urothelial carcinoma of urinary bladder (cT4bN0M0). After three cycles of neoadjuvant GC (gemcitabine and cisplatin) chemotherapy, MRI demonstrated a complete response. Radical cystectomy was performed, and the pathological diagnosis was pT0pN0. Although there was no evidence of recurrence 9 months after radical cystectomy, he died from other causes. Our two cases suggest that systemic chemotherapy might be effective for the plasmacytoid variant of urothelial carcinoma.

The role of helical tomotherapy in the treatment of bone plasmacytoma

We evaluated the early clinical outcome of patients with solitary bone plasmacytoma (SP) or a solitary lesion of multiple myeloma (MM) treated with helical tomotherapy (HT) compared with 3D conformal radiotherapy (3D-CRT), in terms of target coverage and exposure of critical organs. Ten patients with SP and 3 patients with a solitary lesion of MM underwent radiation therapy (RT) delivered by HT, to a dose of 40 Gy in 20 fractions. Treatment planning was then performed with 3D-CRT and the dosimetric parameters of both techniques were compared. Patients were also assessed for response to treatment and acute toxicities. With a median follow-up of 13 months, 78% of patients with pain before RT had resolution of their symptoms. Coverage of target lesion was adequate with both techniques in 12 of 13 patients. Target coverage was significantly lower for HT (V(95%) = 98.55% vs. 97.15%; p = 0.04, for 3D-CRT and HT, respectively). Target overdoses were also lower with HT (V(105%) = 2.01% vs. 0.19%; p= 0.16), although nonsignificant. Finally, there were no significant differences in organs-at-risk irradiation between both techniques. The early treatment tolerance was excellent, with no toxicity higher than grade I. RT of SP and MM with a solitary lesion can be safely delivered with HT, with no major acute side effects and good symptomatic control. Finally, HT provides a dosimetry similar to that of 3D-CRT in terms of organs-at-risk sparing and target volume coverage.

Metaphase cytogenetic techniques in multiple myeloma

Metaphase chromosome studies in multiple myeloma (MM) are performed as part of the diagnostic workup, as surveillance to monitor the therapeutic response, and at relapse to help direct therapy. Unfortunately, the abnormal clones in many patients have a low proliferative activity and therefore, in many cases, the analyzable metaphase cells are derived from normal hematopoiesis. This limitation has been overcome in part by the use of fluorescence in situ hybridization (FISH) of interphase nuclei, which is an important adjunct to metaphase analysis. However, the metaphase karyotype remains the primary cytogenetic tool used at our institute for diagnostic and prognostic purposes. To maximize the possibility of detecting abnormal cells in conventional metaphase studies, we routinely employ at least three different cell harvest techniques on each marrow specimen. These include a direct harvest, a 24 h culture, and either a synchronized or unsynchronized 48 h culture. Recently, fine needle aspirates of solitary plasmacytomas guided by magnetic-resonance imaging have also been shown to provide diagnostic metaphase karyotypes. Regardless of the origin or quality of the specimen, some uninformative cytogenetic results may simply be due to insufficient number and type of cultures being initiated and subsequently examined.

Primary testicular plasmocytoma

A case of Primary Testicular Plasmocytoma (PTP) in an 81-year-old man with a painless nodule in the left testis is reported. All possible pre-operative investigations were carried out, but the diagnosis of PTP was possible only after microscopic examination of the resected testis.

Plasmacytoma in the thyroid

OBJECTIVE

The paper presents a case of plasmacytoma unexpectedly found in a goiter. PATIENT MATERIAL AND METHODS: The patient presented with compressive symptoms, including dyspnea and dysphagia and had no documented prior history of multiple myeloma. Physical examination revealed thyromegaly with no specific nodule. Computerized tomographic (CT) scan of the neck and chest showed diffuse homogenous enlargement of both the thyroid lobes extending into the mediastinum. Total thyroidectomy was done because of the compressive symptoms.

RESULTS

Pathology revealed evidence of fibrosis surrounding small nodules of residual follicles with massive infiltration by plasma cells. The pathologic diagnosis was plasmacytoma.

CONCLUSION

Plasmacytoma should be added to the list of causes of diffuse thyromegaly.

[A case of extramedullary plasmacytoma of testis converted to multiple myeloma]

A 55-year-old male was referred to our hospital with the chief complaint of painless right scrotal swelling. Serum tumor marker levels were all within the normal range. A right radical orchiectomy was performed and the histopathological diagnosis was plasmacytoma. Chest and abdominal computed tomographic scan and bone scintigraphy did not show metastasis. Serum and urine protein electrophoresis and bone marrow biopsy were negative. Diagnosis was primary testicular plasmacytoma (extramedullary plasmacytoma). Eleven months after the operation, multiple bone lesions appeared and our diagnosis was conversion to multiple myeloma.