Radiotherapy for extramedullary plasmacytoma of the head and neck

Complete remission of localised gastric plasmacytomas following definitive radiotherapy

AIMS

Primary gastric extramedullary plasmacytoma is an extremely rare condition and there is scant information in the literature concerning its natural history or therapy. There have been anecdotal reports of surgical resection, with or without Helicobacter pylori eradication, but there are no useful reports of the role of radiotherapy. We report the clinicopathologic outcome of radical radiotherapy as a primary treatment modality.

METHODS

We identified two patients with biopsy-proven primary gastric extramedullary plasmacytoma. Routine staging investigations were performed and H. pylori status was determined. Radical radiotherapy to 41.4 Gy in 23 fractions was delivered using conformal techniques. The target volume was the stomach with a 1-cm margin. Prophylactic anti-emetic was administered prior to each fraction. Post-treatment endoscopies and biopsies were performed at 3-monthly intervals to assess clinicopathological response. Treatment-related toxicities were documented.

RESULTS

Both patients achieved durable (>12 months) pathologically confirmed complete remissions without significant toxicities.

CONCLUSION

Radical radiotherapy offers the potential for cure and organ preservation with low toxicity. It should be considered a favourable alternative to surgery in the management of this rare disease entity.

[Persistent extramedullary plasmacytoma of the nose after radiotherapy]

Solitary extramedullary plasmacytomas of the head and neck are rare tumors. These tumors are known to be very radiosensitive and therefore radiotherapy is often considered as the treatment of choice. We present the case of a solitary extramedullary plasmacytoma of the nose which did not respond sufficiently to radiotherapy, i.e. persistence of the tumor led to surgical treatment. After a discussion of the recent literature we primarily recommend the excision of this type of tumor whenever possible.

Radiotherapy of solitary plasmacytoma

Solitary plasmacytoma of the bone (SBP) or extramedullary plasmacytoma (EP) are rare neoplasms amenable to local radiotherapy. In this retrospective analysis, we report the University Heidelberg experience in the treatment of solitary plasmacytoma. From 1995 to 2008, 18 patients were treated with local radiotherapy. Ten patients suffered from SBP, eight patients showed a single extramedullary lesion. Local radiotherapy with a median dose of 45 Gy yielded excellent local control with only one patient suffering from local relapse. SBP and EP had significantly different 5-year multiple myeloma-free survival rates of 36.8% and 86.7%, respectively. However, no significant difference in overall survival could be detected. Radiotherapy can achieve excellent local control of solitary plasmacytoma. Progression to multiple myeloma, especially in the case of SBP, remains to be addressed by further studies.

Multi-institutional analysis of solitary extramedullary plasmacytoma of the head and neck treated with curative radiotherapy

PURPOSE

The purpose of this study was to elucidate the efficacy and optimal method of radiotherapy in the management of solitary extramedullary plasmacytoma occurring in the head and neck regions (EMPHN).

METHODS AND MATERIALS

Sixty-seven patients (43 male and 24 female) diagnosed with EMPHN between 1983 and 2008 at 23 Japanese institutions were reviewed. The median patient age was 64 years (range, 12-83). The median dose administered was 50 Gy (range, 30-64 Gy). Survival data were calculated by the Kaplan-Meier method.

RESULTS

The median follow-up duration was 63 months. Major tumor sites were nasal or paranasal cavities in 36 (54%) patients, oropharynx or nasopharynx in 16 (23%) patients, orbita in 6 (9%) patients, and larynx in 3 (5%) patients. The 5- and 10-year local control rates were 95% and 87%, whereas the 5- and 10-year disease-free survival rates were 56% and 54%, respectively. There were 5 (7.5%), 12 (18%), and 8 (12%) patients who experienced local failure, distant metastasis, and progression to multiple myeloma, respectively. In total, 18 patients died, including 10 (15%) patients who died due to complications from EMPHN. The 5- and 10-year overall survival (OS) rates were 73% and 56%, respectively. Radiotherapy combined with surgery was identified as the lone significant prognostic factor for OS (p = 0.04), whereas age, gender, radiation dose, tumor size, and chemotherapy were not predictive. No patient experienced any severe acute morbidity.

CONCLUSIONS

Radiotherapy was quite effective and safe for patients with EMPHN. Radiotherapy combined with surgery produced a better outcome according to survival rates. These findings require confirmation by further studies with larger numbers of patients with EMPHN.

Radiotherapy

Solitary plasmocytoma occurring in bone (solitary plasmocytoma of the bone, SBP) or in soft tissue (extramedullary plasmocytoma, EP) can be treated effectively and with little toxicity by local radiotherapy. Ten-year local control rates of up to 90% can be achieved. Patients with multiple myeloma often suffer from symptoms such as pain or neurological impairments that are amenable to palliative radiotherapy. In a palliative setting, short treatment schedules and lower radiation doses are used to reduce toxicity and duration of hospitalization. In future, low-dose total body irradiation (TBI) may play a role in a potentially curative regimen with nonmyeloablative conditioning followed by allogenic peripheral blood stem cell transplantation.

Delayed cerebral radiation necrosis following treatment for a plasmacytoma of the skull

Background:

Cerebral radiation necrosis is a relatively common complication of radiation therapy for intracranial malignancies which can also rarely be encountered after radiation of extracranial lesions of the head and neck. We present the first reported case of cerebral radiation necrosis in a patient who underwent radiation therapy for a plasmacytoma of the skull.

Case Description:

A 68-year-old male with multiple myeloma presented with an enhancing right frontal mass, 8 years after receiving radiation therapy for a plasmacytoma of the left frontal skull. The patient underwent a diagnostic and therapeutic craniotomy for a presumed neoplastic lesion. The pathologic diagnosis made in this case was delayed radiation necrosis. The patient was followed for over a year during which this process continued to evolve before the ultimate resolution of his clinical symptoms and radiographic abnormality.

Conclusion:

This case highlights the importance of considering radiation necrosis in the differential diagnosis of any patient with an intracranial mass and a history of radiation for an extracranial head and neck malignancy, regardless of timing and laterality. This case also provides unique insights into the ongoing debate regarding the role of the aberrant immune response in the pathogenesis of delayed cerebral radiation necrosis.

Solitary pulmonary plasmacytoma: report of two cases

We report two cases of solitary plasmacytoma of the lung. Computed tomographic scan disclosed in case A a solid tissue formation in a cystic pulmonary lesion and in case B a solitary nodule. Suggesting aspergilloma in A and pulmonary malignancy in B diagnostic thoracotomies were performed and the respective findings were resected. In both cases a diagnosis of plasmacytoma was made. Postoperatively multiple myeloma was ruled out. Solitary pulmonary plasmacytoma is a very rare condition and to the best of our knowledge plasmacytoma within a cystic lung lesion has not been described so far. After curative resection treatment the prognosis of these circumscript lesions should be excellent.