Gastrointestinal manifestations of extramedullary plasmacytoma: a narrative review and illustrative case reports

Introduction Solitary extramedullary plasmacytoma are rare, solid-mass tumours which appear immunophenotypically similar to multiple myeloma. The diagnosis and management of gastrointestinal plasmacytoma is complex and requires multidisciplinary input. This study presents a narrative review of intra-abdominal extramedullary plasmacytoma, illustrated with two case studies. Methods The PubMed database was searched without date restrictions for reports of intra-abdominal extramedullary plasmacytoma to synthesise a narrative review. Electronic records were reviewed at a high-volume, quaternary soft-tissue sarcoma centre to identify patients with histopathologically confirmed extramedullary plasmacytoma affecting the gastrointestinal tract. Results Gastrointestinal extramedullary plasmacytomas can present with mass effect or organ-specific dysfunction. Techniques for tissue diagnosis of extramedullary plasmacytoma vary dependent on location, with a formal diagnosis often being made from a resected specimen. Management can include surgery, radiotherapy, systemic chemotherapy or a combination. No high-quality evidence base exists to guide treatment. Two case studies of operated gastrointestinal extramedullary plasmacytoma are presented at different phases of disease progression, with a resultant impact on survival. Conclusion Intra-abdominal extramedullary plasmacytoma is a rare and heterogeneous condition that lacks consensus guidelines for diagnosis and management. Collaboration between international specialist centres will create better quality evidence for treatment of this cohort.

CD3+ CD56+ EBER1+ atypical extraosseous plasmacytoma of the nasal cavity

We present a case of atypical extraosseous plasmacytoma (EP) with a plasmablastic morphology and CD3⁺ CD56⁺ Epstein-Barr virus-encoded RNA-1 (EBER1)⁺ phenotypes of the nasal cavity. A 51-year-old male attended a local hospital with a tumor located in his left nasal cavity that was histologically diagnosed as extranodal NK/T cell lymphoma, nasal type. We reviewed the specimens and re-biopsied the tumor, and confirmed that the tumor was positive for CD3, CD56, and EBER1; however, the tumor showed a plasmablastic morphology without necrosis and angiocentricity, and was positive for CD138, but negative for CD20 and PAX5. Given a plasmablastic morphology and EBER1 positivity, but a relatively low Ki67 index (30%), we diagnosed the case as atypical EP. The CHOP regimen was administered and complete remission achieved. This case indicated that EP should be considered as a differential diagnosis even when a tumor shows large cell morphology and is positive for CD3, CD56, and EBER1.

Unusual malignant neoplasms occurring around dental implants: A report of 2 cases

Osseointegrated implants are now commonplace in contemporary dentistry. However, a number of complications can occur around dental implants, including peri-implantitis, maxillary sinusitis, osteomyelitis, and neoplasms. There have been several reports of a malignant neoplasm occurring adjacent to a dental implant. In this report, we describe 2 such cases. One case was that of a 75-year-old man with no previous history of malignant disease who developed a solitary plasmacytoma around a dental implant in the left posterior mandible, and the other was that of a 43-year-old man who was diagnosed with squamous cell carcinoma adjacent to a dental implant in the right posterior mandible. Our experiences with these 2 cases suggest the possibility of a relationship between implant treatment and an inflammatory cofactor that might increase the risk of development of a malignant neoplasm.

Severe abdominal pain and diarrhea - unusual multiple myeloma presentation with a severe prognosis: a case report

BACKGROUND

Multiple myeloma is a hematologic disease with high mortality rates all over the world. The diagnosis has always been challenging since the first case was reported in 1844. For that reason the diagnostic criteria have evolved over years to include the features of the disease more comprehensively. Unusual presentations are infrequent and a diagnostic challenge. For this reason we report this rare case in which diarrhea and abdominal pain were the initial presenting symptoms of multiple myeloma with a plasmacytoma.

CASE PRESENTATION

An 87-year-old Hispanic man with a past medical history of hypertension, diabetes, and constipation, presented to an emergency department complaining of severe generalized abdominal pain and profuse diarrhea for 3 days. A physical examination revealed generalized pallor and dehydration but no signs of abdominal peritoneal irritation. Laboratory tests revealed neutrophilia and an elevated total protein. He received intravenously administered fluids and antibiotics. His abdominal pain became localized in the infraumbilical area and a small mass was palpated on the right lower quadrant on subsequent examination. An abdominal computed tomography scan showed a tumor lesion surrounded by fluid collection and a computed tomography-guided biopsy of the lesion confirmed it to be a plasmacytoma. A bone marrow biopsy revealed plasmatic cell augmentation but his beta-2 microglobulin levels were inconclusive. The diagnosis of multiple myeloma was finally confirmed with urine immunofixation. Bortezomib was initiated to decrease disease progression, but unfortunately 4 days later he developed acute pulmonary edema, had a cardiac arrest, and died.

CONCLUSIONS

This case illustrates the protean initial manifestations of multiple myeloma and the importance of an accurate diagnosis. Our patient's initial presentation with gastrointestinal complaints is rare and the plasmacytoma location is even rarer, providing a challenging diagnostic problem. Prompt recognition of multiple myeloma is critical to institute appropriate therapy and prevention of disease progression.

Sellar plasmacytomas masquerading as pituitary adenomas: A systematic review

Given the rarity of intracranial plasmacytomas, these lesions are frequently misdiagnosed as pituitary adenomas. We report on the distinguishing characteristics of sellar plasmacytomas from cases in the literature and our experience. A literature search was conducted to collect all documented cases of a plasmacytoma originating in the sellar region. Patient characteristics, medical history, presentation, tumor characteristics, and survival data were collected. An additional case from our institution not previously reported was included. Thirty-one patients with sellar plasmacytomas were studied. Presenting symptoms were most commonly headache (68%), diplopia (65%) and visual field disturbances (10%). Fifteen patients (48%) were initially suspected of having a pituitary adenoma. Pathologic diagnosis of plasmacytoma preceded a finding of multiple myeloma in 14 cases (45%). Thirty patients (90%) had surgical intervention. Adjuvant therapy consisted of radiotherapy for twenty-five patients (81%) and chemotherapy for sixteen (52%). Tumor recurrence was reported for 7 cases (23%). Nine deaths were reported (23%). We demonstrate that cranial nerve involvement is far more common in sellar plasmacytomas than conventional pituitary adenomas. Given the successful management of these tumors with radiotherapy, such deficits, particularly in patients with known multiple myeloma, should impact the diagnostic workup and treatment considerations.

Primary pancreatic plasmacytoma: a rare case report

BACKGROUND

Extramedullary plasmacytoma is a very rare tumor derived from plasma cells and found outside the bone marrow. Most have been identified in patients with the more aggressive anaplastic form of the disease. Only a few cases of primary pancreatic plasmacytoma have been reported.

CASE PRESENTATION

We present a case of a 56-year-old man in whom a pancreatic mass was found incidentally. The lesion was determined to be a pancreatic plasmacytoma after distal pancreatectomy. There are no indications of clinical, laboratory or imaging findings of multiple myeloma nor any association with plasmacytoma in any other places, so the diagnosis of primary pancreatic plasmacytoma was made.

CONCLUSION

Primary pancreatic plasmacytoma is rare and the diagnosis is difficult before surgery.

Pattern of care and impact of prognostic factors on the outcome of head and neck extramedullary plasmacytoma: a systematic review and individual patient data analysis of 315 cases

INTRODUCTION

Head and neck extramedullary plasmacytoma is a rare localized plasma cell neoplasm. We intended to perform this review of the published literature to assess the demographic profile, pattern of care and survival outcomes.

METHODS

Two authors independently searched PubMed, Google search and Cochrane library for eligible studies from 1950 till July 1, 2016, published in English language.

RESULTS

Median age of the cohort was 57 years (range 11-85). Site-wise distributions were paranasal sinuses 22.3% (70), nasal cavity 17.5% (55), nasopharynx 10.8% (34). Median size of SEMP was 3 cm (range 0.3-12 cm). Treatment distribution was radiotherapy (RT) in 52% (164), surgery (S) 19% (60), chemotherapy (C) 5% (16), S + RT 23.49% (74),CRT 1.9% (6), S + C 0.6% (2), S + RT + C 0.95% (3).Radiation was used as a modality in 78.4%(247), surgery in 44.1%(139), chemotherapy in 4.8%(15). Median radiation dose used was 45 Gy with range 20-61 Gy. Median overall survival (OS) was 40 months (range 0.5-298). Median local progression-free survival was 36 months (range 0-298). Median myeloma relapse-free survival was 36 months (range 0.5-298). Five- and 10-year OS was 78.33 and 68.61%. Five-year cause-specific survival (CSS) and 10-year CSS was 90.15 and 83.31%. Five-year LPFS was 94.78%, and 10-year LPFS was 88.43%. Five-year myeloma progression-free survival was 84.46%, and 10-year myeloma PFS was 80.44%. The factors associated with risk of local relapse were site of disease (sinonasal), secretory EMP, type of treatment received (surgery + RT > RT alone > surgery on univariate analysis). Risk factors for myeloma relapse were coexisting diseases, site of disease (sinonasal), bony erosion, size of lesion > 5 cm and type of treatment received on univariate analysis.

CONCLUSION

Our study shows that combined modality S + RT is superior compared to uni-modality in preventing local recurrence. Radiation dose of 45 Gy is optimal. Nodal irradiation has no impact on local recurrence.

Collet-Sicard Syndrome Attributable to Extramedullary Plasmacytoma of the Jugular Foramen

BACKGROUND

Collet-Sicard syndrome is a rare manifestation of skull base disease involving the jugular and hypoglossal foramina. We report the first case of Collet-Sicard attributable to extramedullary plasmacytoma-multiple myeloma (EP-MM) and the second case of EP-MM precipitating a jugular foramen syndrome (JFS)-spectrum disorder.

CASE DESCRIPTION

A 59-year-old woman presented with 4 months of left aural fullness and pulsatile tenderness, positional vertigo, hoarseness, and dysphagia. Examination identified left tongue weakness and nonspecific sensory abnormalities of the ear, pharynx, and throat localizing to cranial nerves IX-XII. Imaging revealed a 3.4 × 1.4 × 2.8 cm lytic lesion extending from the left jugular foramen into the posterior fossa, for which she was referred to neurosurgery and otolaryngology for consideration of resection. A second, much smaller (1.1-cm) lytic lesion in the left posterior occipital bone was incidentally discovered by the surgeon during preoperative consultation. A stereotactic biopsy of the occipital lesion was subsequently recommended, which identified plasma cell neoplasm. Serum studies and skeletal survey were consistent with MM, and a definitive pathologic diagnosis of MM with cranial EP was confirmed by bone marrow biopsy.

CONCLUSION

Tumors of the jugular foramen present with a diverse array of lower cranial nerve deficits, including Collet-Sicard syndrome, a rare subset of JFS-spectrum diseases. Paragangliomas are the most common jugular foramen neoplasms, followed by schwannomas and meningiomas; however, many other rare entities have been reported as masqueraders, and diligent work-up with consideration for preliminary biopsy is recommended, particularly in the presence of additional lesions, equivocal imaging findings, or cases arousing high suspicion.

Skull base plasmacytoma: A unique case of POEMS syndrome with a plasmacytoma causing craniocervical instability

INTRODUCTION

Plasmacytomas, considered to be the solitary counterparts of multiple myeloma, are neoplastic monoclonal plasma cell proliferations within soft tissue or bone. Plasmacytomas often present as a collection of findings known as POEMS-syndrome (Polyneuropathy, Organomegaly, Endocrinopathy, M-Protein spike, and Skin changes).

CASE DESCRIPTION

We present a report of a 47 yo male diagnosed with POEMS-syndrome secondary to a skull base plasmacytoma. The mass resulted in marked instability of the cranio-cervical junction due to bony erosion. Following an induction course of chemotherapy, he showed clinical improvement with a marked reduction in tumor size and underwent an autologous peripheral blood stem cell transplant for systemic treatment of his POEMS-syndrome. Following completion of systemic treatment, he then underwent a definitive occipital-cervical fusion without complications. His neurologic exam upon dismissal was stable with subjective improvement in left upper extremity strength. Postoperative radiographs confirmed spinal alignment and pathological examination of a small biopsy from C1 revealed benign fibrous tissue.

CONCLUSION

To the best of our knowledge, this is the first report of a skull-base plasmacytoma associated with POEMS-syndrome, causing cranio-cervical instability. The approach of systemic therapy combined with temporary external fixation, followed by definitive occipital cervical fusion resulted in a good outcome for this patient.

Russell body gastritis with Dutcher bodies evaluated using magnification endoscopy

Russell body gastritis (RBG) is an unusual type of chronic gastritis characterized by marked infiltration of Mott cells, which are plasma cells filled with spherical eosinophilic bodies referred to as Russell bodies. It was initially thought that Helicobacter pylori (H. pylori) infection was a major cause of RBG and that the infiltrating Mott cells were polyphenotypic; however, a number of cases of RBG without H. pylori infection or with monoclonal Mott cells have been reported. Thus, diagnostic difficulty exists in distinguishing RBG with monoclonal Mott cells from malignant lymphoma. Here, we report an unusual case of an 86-year-old-Japanese man with H. pylori-positive RBG. During the examination of melena, endoscopic evaluation confirmed a 13-mm whitish, flat lesion in the gastric antrum. Magnification endoscopy with narrow-band imaging suggested that the lesion was most likely a poorly differentiated adenocarcinoma. Biopsy findings were consistent with chronic gastritis with many Mott cells with intranuclear inclusions referred to as Dutcher bodies. Endoscopic submucosal dissection confirmed the diagnosis of RBG with kappa-restricted monoclonal Mott cells. Malignant lymphoma was unlikely given the paucity of cytological atypia and Ki-67 immunoreactivity of monoclonal Mott cells. This is the first reported case of RBG with endoscopic diagnosis of malignant tumor and the presence of Dutcher bodies.

Strategy for the treatment and follow-up of sinonasal solitary extramedullary plasmacytoma: a case series

BACKGROUND

Extramedullary plasmacytoma is a rare neoplasm characterized by monoclonal proliferation of plasma cells outside bone marrow. It accounts for 4% of all non-epithelial sinonasal tumors. According to the literature, radiotherapy is the standard therapy for extramedullary plasmacytoma. However, the conversion rate of extramedullary plasmacytoma to multiple myeloma is reported to be between 11 and 33% over 10 years. The highest risk of conversion is reported during the first 2 years after diagnosis, but conversion has been noted up to 15 years after diagnosis. Once conversion to multiple myeloma is complete, less than 10% of patients will survive 10 years.

CASE PRESENTATION

We present three cases of sinonasal extramedullary plasmacytoma who underwent radiotherapy: a 61-year-old white man, a 60-year-old white man, and a 37-year-old white woman. We found long-term survival with stable disease in all three cases.

CONCLUSIONS

The management of solitary extramedullary plasmacytomas of the sinonasal tract is not well established yet. However, the possibility of recurrence and progression to multiple myeloma requires a thorough follow-up protocol. Due to the absence of a standardized protocol for these tumors, we tried to design a tailored long-term follow-up scheme.

Plasmacytoma of the Cervical Spine: A Case Study

OBJECTIVE

The purpose of this case study is to describe the presentation of a patient with plasmacytoma.

CLINICAL FEATURES

A 49-year-old man presented with progressive neck pain, stiffness, and dysphagia to a chiropractic office. A radiograph indicated a plasmacytoma at C3 vertebral body. The lesion was expansile and caused a mass effect anteriorly on the esophagus and posteriorly on the spinal cord. Neurologic compromise was noted with fasciculations and hypesthesia in the right forearm. The patient was referred to a neurosurgeon.

INTERVENTION AND OUTCOME

Surgical resection of the tumor was performed with a vertebral body spacer and surrounding titanium cage. Bony fusion was initiated by inserting bone grafts from the iliac crests into the titanium cage. Additional laboratory analysis and advanced imaging confirmed that the plasmacytoma had progressed to multiple myeloma and radiation and chemotherapy were also necessary.

CONCLUSION

A chiropractor recognized a large, expansile plasmacytoma in the C3 vertebral body and referred the patient for surgical care. This case suggests that all practitioners of manual medicine should provide a careful analysis of the patient's clinical presentation and, if clinically warranted, radiographic examination to determine neck or back pain is due to an underlying malignant condition.

Metastatic Intracerebral Plasmacytoma Treated with Radiation and Thalidomide, Dexamethasone with Cyclophosphamide Chemotherapy

Intracerebral plasmacytoma is an extremely rare disease for which no treatment protocol has been established. The authors present a case of metastatic intracerebral plasmacytoma that was partially resected and treated with radiation therapy. For tumor recurrence, a combination chemotherapy regimen was initiated. A 48-year-old male patient presented with dizziness and memory loss. Conventional magnetic resonance imaging (MRI) of the brain revealed a multilobulated mass with enhancing cystic and solid components measuring 7 × 7 × 6 cm in the left frontal lobe. The patient had undergone subtotal gastrectomy and transverse colectomy 8 years before admission and had been diagnosed with extraosseous plasmacytoma. At the time of the current presentation, the patient underwent craniotomy for the parenchymal lesion. Partial tumor resection was performed. Histologic and immunohistochemical examinations confirmed the diagnosis of plasmacytoma. Fractionated radiotherapy was administered, and no enhancing mass was observed on follow-up MRI. One year after radiotherapy, tumor recurrence was observed in a different area of the cerebral parenchyma. Combination thalidomide, dexamethasone, and cyclophosphamide chemotherapy was administered. After three cycles of chemotherapy, the tumor was well controlled on MRI. Hereafter, two more times of tumor recurrence occurred in the other sites of the cerebral parenchyma, but with chemoradiation therapy, the tumor was well suppressed. The findings of this case suggest that the cerebral parenchyma can be one of the metastatic sites for extraosseous plasmacytoma. In addition, combination chemotherapy with thalidomide, dexamethasone, and cyclophosphamide may be a useful treatment option for intracerebral plasmacytoma.

Unusual course of generalized lymph node primary plasmacytoma in a patient with Sjögren's syndrome: a case report

BACKGROUND

Primary lymph node plasmacytoma is a rare disease that typically involves lymph nodes of the neck. In only 15% of cases is the disease generalized. Here, we present a case of generalized lymph node plasmacytoma in a patient with Sjögren's syndrome with an unusual course.

CASE PRESENTATION

A 48-year-old white woman presented to our hospital with enlargement of groups of lymph nodes, liver, and spleen. Her medical history was consistent with a 12-year course of Sjögren's syndrome. Blood and urine immunochemistry showed a massive (72 g/l) M-gradient formed from immunoglobulin Aκ in the serum and monoclonal free κ-type light chains in her urine. A skeletal X-ray revealed no bone destruction. Cytological and histological bone marrow assays showed no signs of plasma cell infiltration. The microarchitecture of her neck and inguinal lymph nodes was destroyed. Only small remnants of B cell follicles were found, while the interfollicular areas were expanded and infiltrated by CD138, MuM1, CD43, and IgAκ-positive plasma cells. After nine cycles of doxorubicin, cyclophosphamide, vincristine, and prednisolone chemotherapy, complete remission was achieved. However, the lymphoma relapsed 3 months later, with histological verification in her femoral lymph node. Despite the absence of subsequent adequate therapy, she gradually achieved complete remission of plasmacytoma with the disappearance of paraproteins.

CONCLUSIONS

Currently, primary lymph node plasmacytoma is generally considered a nodal marginal zone lymphoma with an extensive plasmacytic differentiation. In our case, despite the critical histological and immunohistochemical evaluation of three lymph node biopsies from different anatomical areas at different times, no signs of nodal marginal zone lymphoma were found. An 18-year follow-up of our patient with primary lymph node plasmacytoma demonstrated an extremely unusual clinical course. Initially, primary lymph node plasmacytoma was refractory to chemotherapy. However, subsequently, she underwent a complete spontaneous remission of plasmacytoma.

Difficult endoscopic diagnosis of a pancreatic plasmacytoma: Case report and review of literature

A 71-year-old man, with history of plasmacytoma in relapse since one year, was hospitalized for a initial presentation of acute pancreatitis and hepatitis. Although there was a heterogeneous infiltration around the pancreas head, the diagnosis of an extramedullary localization of his plasmacytoma was not made until later. This delayed diagnosis was due to the lack of specific radiologic features and the lack of dilatation of biliary ducts at the admission. A diagnosis was made with a simple ultrasound guided paracentesis of the low abundance ascites after a transjugular hepatic biopsy, an endoscopic ultrasound-guided fine needle aspiration of the pancreatic mass, and a failed attempt of biliary drainage through endoscopic retrograde cholangiopancreatography. In order to document the difficulty of this diagnosis, characteristics of 63 patients suffering from this condition and diagnosis were identified and discussed through a systematic literature search.

Solitary plasmacytoma of temporal bone: A rare case report

Solitary plasmacytoma of base of skull is a rare disease. It presents with headache, swelling, and other vague symptoms. Systemic work-up to rule out multiple myeloma is necessary. Radiotherapy is the treatment of choice. We, here, present a case of solitary plasmacytoma of base of skull in right temporal bone in a 50-year-old female treated with surgery and radiotherapy.

Immunoglobulin A Lambda Multiple Myeloma in a Patient with HIV: An Unusual Cause of Massive Ascites

Multiple myeloma (MM) is a neoplastic proliferation of plasma cells with overproduction of monoclonal immunoglobulins and infiltration into the bone and other organs. Ascites can develop in patients with lymphoproliferative and solid malignancies involving the peritoneum. However, ascites is unusual in MM and rarely the initial presenting sign or symptom. The development of ascites can be due to peritoneal infiltration or secondary to hepatic involvement, heart failure, or kidney failure. Ascites in MM reflects a more aggressive stage, and the reported prognosis is poor, with a median survival of 1-2 months. Here we present a rare case of immunoglobulin A lambda MM presenting with massive myelomatous ascites.

Relapse of Multiple Myeloma Presenting as Lower Lip Numbness

Multiple myeloma (MM) is an uncommon malignancy characterised by the proliferation of clonal plasma cells. There are few published reports describing the extramedullary presentation of MM manifesting primarily in the head and neck region. In addition, the occurrence of an isolated relapse of MM in these sites is exceedingly rare. We report a 56-year-old female who presented to the Sultan Qaboos University Hospital, Muscat, Oman, in 2010 with sudden-onset numbness of the lower lip. She had a history of MM in remission following chemotherapy and a bone marrow transplant. Clinical and radiographic examinations were indicative of a possible relapse of MM, which was subsequently confirmed by bone marrow aspiration and histopathological evaluation. This unique case highlights the unusual site of relapse of a haematolymphoid malignancy.

ERG expression in multiple myeloma-A potential diagnostic pitfall

INTRODUCTION

ERG expression has been described as a frequent event in prostate cancer indicating poor prognosis and promoting oncogenesis. It has also been demonstrated in Ewing's sarcoma, acute myeloid leukemia and acute T-lymphoblastic leukemia but could not be found in other epithelial tumors, Hodgkin's or Non-Hodgkin's lymphoma. We aimed to analyze ERG expression in multiple myeloma, following an index case of a patient with metastases of unknown origin in the spine strongly expressing ERG, which were thought to be of prostatic origin but turned out to be plasmacytic lesions.

MATERIAL AND METHODS

We subsequently selected 12 formalin-fixed, paraffin-embedded tissue samples of multiple myeloma from our archives and performed immunohistochemical staining for ERG.

RESULTS

All 12 analyzed cases showed strong nuclear expression of ERG in >90% of tumor cells (myeloma cells).

CONCLUSIONS

This report highlights a potential and critical diagnostic pitfall in biopsy specimens where morphology is only of limited assistance in reaching the correct diagnosis. It urges pathologists to exercise caution in cases where strong ERG-positivity implicates the presence of a prostatic neoplasia and illustrates the need for further immunohistochemical examination.

Successful treatment of primary advanced gastric plasmacytoma using a combination of surgical resection and chemotherapy with bortezomib: A case report

•

No general treatment guidelines have been established for gastricplasmacytoma.

•

Combination therapy with chemotherapy involving bortezomib and autologous peripheral blood stem-cell transplantation after the resection could be one of the useful options for the advanced gastricplasmacytoma.

Introduction

Extramedullary plasmacytoma (EMP) is a plasma cell neoplasm that presents as a solitary tumor. EMP in the gastrointestinal organs are extremely uncommon.

Presentation of case

A 36-year-old man was admitted to our hospital with advanced anemia. He had no specific medical history. Gastroendoscopic findings showed an 8.0-cm submucosal tumor with ulcer on the greater curvature of the gastric body. Fine-needle aspiration was performed, and the pathologic diagnosis of the submucosal tumor was a plasmacytoma. Therefore, the patient was diagnosed with gastric plasmacytoma. A total gastrectomy was performed with lymphadenectomy. The result of intraoperative peritoneal lavage cytology was positive. Histological examination revealed serosa-exposed plasmacytoma of the stomach with lymph nodes metastasis. Additionaly the patient received a three-drug chemotherapy regimen (bortezomib, cyclophosphamide, and dexamethasone [VCD]) from 3 weeks after the operation. After 4 cycles of chemotherapy, the patient received autologous peripheral blood stem-cell transplantation (auto-PBSCT). Eighteen months after diagnosis, the patient is in complete remission with no evidence of local relapse or evolution to multiple myeloma.

Conclusions

This is the first reported case of advanced gastric plasmacytoma using adjuvant chemotherapy involving bortezomib and auto-PBSCT after the resection, and the patient has maintained a good course over a year. This protocol could be a new way to treat these tumors.

Intracranial Involvement by Plasma Cell Neoplasms

OBJECTIVES

Intracranial plasma cell neoplasms (PCNs) arising from the skull, dura, or brain parenchyma are rare tumors and there is only a limited experience in the literature with these lesions.

METHODS

We performed a retrospective clinicopathologic study of fourteen cases of intracranial PCN at our institution encountered over a 26-year-period.

RESULTS

The fourteen patients ranged in age from 30-74 years (median 66 years) and included seven males. For eight patients, their intracranial lesions were the initial presentation of multiple myeloma (MM). Three patients had prior history of MM; their intracranial tumors showed blastic plasma cell morphology, and all three died secondary to MM. The remaining three patients did not or have not developed MM.

CONCLUSIONS

PCNs rarely arise in the intracranial compartment. Intracranial PCN may be the initial presentation of MM. Anecdotally, blastic morphology appears to manifest more aggressive behavior.

Ileo-ileal Intussusception and Bowel Obstruction Caused by Plasmablastic Lymphoma of Small Bowel- A Rare Entity in Rare Location

Intussusception of small bowel is considered a rare cause of bowel obstruction in adults accounting for only about 1% of bowel obstruction in adults. Intussusception in adults is uncommon with 95% cases of intussusceptions occurring in children. Adult intussusception from small intestinal lymphoma is also rare with only 36 cases reported in the literature between 2000 and 2011. Plasmablastic lymphoma (PBL) is an aggressive lymphoid neoplasm usually seen in the oral cavity in the clinical setting of human immunodeficiency virus (HIV) infection. Plasmablastic lymphoma of the small intestine is extremely rare. Here, we report a case of plasmablastic lymphoma of small bowel with ileoileal intussusception in an HIV-negative immunocompetent male patient.

Oculomotor Nerve Palsy as a Rare Presentation and First Sign of Multiple Myeloma

Acquired oculomotor nerve palsy has varied aetiologies like vascular (diabetes, heart disease, atherosclerosis and posterior communicating artery aneurysm), space occupying lesions or tumours, inflammation, infection, trauma, demyelinating disease like Multiple sclerosis, autoimmune disorders such as Myasthenia gravis, postoperatively as a complication of neurosurgery, cavernous sinus thrombosis etc. Cranial Nerve palsies as one of the first symptoms of multiple myeloma have been reported sparsely in literature. We report a case of a 60-year-old woman who developed sudden onset right-sided pupil sparing oculomotor nerve palsy along with a tender swelling at right sternoclavicular joint. Cranial and orbital magnetic resonance imaging and cerebrospinal fluid examination demonstrated no abnormalities. Immunological investigations and histopathological analysis of sternoclavicular joint swelling confirmed the diagnosis of IgG type multiple myeloma. After confirmation of diagnosis we started her with appropriate chemotherapy, after which the palsy resolved within one month. The cause of the palsy was probably due to nerve ischemia due to hyper viscosity of the serum.

A multicenter phase 2 study of pomalidomide plus dexamethasone in patients with relapsed and refractory multiple myeloma: the Japanese MM-011 trial

Background

The immunomodulatory agent pomalidomide in combination with low-dose dexamethasone has demonstrated efficacy and safety for the treatment of relapsed and refractory multiple myeloma (RRMM) in phase 2 and 3 trials. However, these trials enrolled very few Asian patients.

Methods

This phase 2 study investigated pomalidomide plus low-dose dexamethasone in 36 Japanese patients with RRMM after ≥2 prior therapies.

Results

Patients enrolled in the study had a relatively high disease burden (81 % Durie–Salmon stage II or III) and were heavily pretreated (median, 6.5 prior antimyeloma regimens). The overall response rate was 42 % (1 patient with complete response and 14 with partial response), with an additional 44 % (16 patients) achieving stable disease (SD). Response rates in patients aged ≤65 years and >65 years were 47 and 35 %, respectively. None of the five patients with extramedullary disease achieved a response, with three of them maintaining SD of short duration. Median progression-free survival was 10.1 months after a 7.7-month median follow-up, and the median overall survival was not reached. The most frequent grade ≥3 adverse events (AEs) were neutropenia (64 %), anemia (42 %), and thrombocytopenia (31 %). The most frequent nonhematologic grade ≥3 AEs were pneumonia and decreased appetite (8 % each). Adverse events in patients aged >65 years were similar to those in patients aged ≤65 years, except for a higher rate of grade ≥3 pneumonia.

Conclusions

Collectively, the results of this study demonstrate that pomalidomide plus low-dose dexamethasone is an effective and safe treatment for Japanese patients with RRMM, although careful attention needs to be paid to serious infections.

Trial registration: Clinicaltrials.gov NCT02011113