Solitary clival plasmocytomas: Misleading clinical and radiological features of a rare pathology with a specific biological behaviour

Solitary plasmacytoma of the skull base: A case report and literature review

Plasmacytoma of the skull base is a rare entity. We present a case of sphenoid plasmacytoma in a 51-year-old woman who had nasal obstruction, intermittent epistaxis, headaches, decreasing visual acuity, and diplopia. Computed Tomography (CT) scan and magnetic resonance imaging (MRI) showed a large heterogeneous, expansile lesion measuring 75 mm × 54 mm, centered on the sphenoidal bone and the clivus. Biopsy confirmed the diagnosis of solitary plasmacytoma after ruling out systemic spread by the initial assessment. The patient was successfully managed by external beam radiotherapy and a complete response was obtained after 12 months of follow-up.

Novel case of primary intracranial solitary plasmacytoma presenting with significant intratumoral hemorrhage

Background:

Solitary plasmacytoma is a localized lesion comprising monoclonal neoplastic proliferation of plasma cells. This disease is rarely encountered and few reports have described primary intracranial solitary plasmacytoma (PISP).

Case Description:

We report a case of PISP that presented initially as status epilepticus and exhibited massive intratumoral hemorrhage at the subcortical area. To the best of our knowledge, this is the first recorded presentation of this pathology in this manner. Following evacuation of the hematoma and decompressive craniectomy, the patient underwent radiation therapy and showed no sign of tumor recurrence at 3 years after diagnosis.

Conclusion:

This case reveals that PISP can present as subcortical intraparenchymal hemorrhage. It should be emphasized that the precise diagnosis of this disease is of utmost importance, because solitary plasmacytoma without a background of multiple myeloma responds well to radiation therapy.

An Exceptional Case of Diplopia and Ptosis: Extramedullary Plasmacytoma of the Clivus With Multiple Myeloma

Intracranial plasmacytoma is an exceedingly rare presentation of plasma cell neoplasms. Usually presenting late in the course of the disease, progression from the presentation can be abrupt. Hence, a low threshold to biopsy the lesion should be maintained during diagnostic evaluation. Multiple myeloma workup should also be sent and treated concomitantly along with local treatment. Here, we present a case of extramedullary plasmacytoma of the clivus leading to progressive visual deficits with undiagnosed multiple myeloma requiring pulse steroids, intracranial irradiation, and high-dose chemotherapy with improvement in symptoms.

Complete Resolution of Skull Base Solitary Plasmacytoma Using Proton-Beam Radiotherapy: A Case Report

Cranial solitary plasmacytomas are uncommon lesions, and localization to the skull base is rare. Here we present a case in a 36-year-old woman who complained of dizziness and mild headaches. Radiographic imaging indicated the presence of a solitary skull base lesion in the posterior cranial fossa. Laboratory tests and imaging excluded systemic disease. A biopsy of the lesion confirmed the diagnosis of plasmacytoma. The patient was treated with proton-beam radiation and had a complete clinical and radiographic resolution, demonstrating the previously unreported utility of monotherapy with proton-beam radiation in such cases.

Temporal Galeofascial Flap for Reconstruction After Transmaxillary Approaches to the Clival Region

BACKGROUND

A paramount concern after transmaxillary approaches has been skull base reconstruction. Regional pedicled flaps represent the best reconstructive option. We have described a technique to harvest a lateral-based multilayered vascularized flap for skull base reconstruction after resection of large tumors using the transmaxillary transpterygoid approach (TMTPA).

METHODS

We performed a cadaver study using the TMTPA to harvest the combined temporal galeofascial flap (CTGF). The first layer, with major sealing capabilities, is composed by a temporoparietal galeal-pericranial flap. The second layer is composed by temporal muscle fascia to provide mechanical support for flap dural engrafting.

RESULTS

The CTGF provides excellent coverage of both the clival dural lining and the ipsilateral pterygopalatine fossa structures (×1.6). The CTGF is pliable and easy to harvest. It offers great flexibility in flap content and design, providing a large quantity of vascularized tissue. The vascular pedicle derives from the superficial temporal vessels, which can ensure flap trophism.

CONCLUSIONS

CTGF represents an effective option as a regional multilayered pedicled flap for skull base reconstruction after resection of clival tumors using the TMTPA. The flap pedicle, owing to its anatomical location, will often be preserved even after repeated microsurgical or endoscopic procedures, providing a technical alternative for reconstruction even in patients who have undergone multiple surgeries with low residual availability of regional flaps.

Temporal myofascial segmentation for multilayer reconstruction of middle cranial fossa floor after extradural subtemporal approach to the clival and paraclival region

BACKGROUND

Skull-base reconstruction represents a concern after resection of middle fossa (MF) tumors by the extradural subtemporal transzygomatic approach (ESTZ). Regional pedicled flaps appear to be the best option. This study describes a technique for temporal myofascial segmentation to harvest a multilayered vascularized flap for MF reconstruction, which might preserve temporal muscle (TM) function and its blood supply.

METHODS

The technique to harvest a combined segmented temporal myofascial flap (CSTMF) is described. The flap consists in a temporal fascial (TFF) and a muscle flap (TMF), composed by TM anterior-medial bundle (AMB).

RESULTS

CSTMF provides wide coverage of dural lining, through the TFF, and of dead-space, through the TMF. The possibility to tailor TMF according to the need, anatomically preserving the blood supply, enables to significantly increase its volume.

CONCLUSION

CSTMF represents an effective option as regional multilayered pedicled flap for MF reconstruction, potentially preserving TM function and minimizing the cosmetic impact.

Clinical features, radiological profiles, and surgical outcomes of primary intracranial solitary plasmacytomas: a report of 17 cases and a pooled analysis of individual patient data

PURPOSE

We aim to delineate the clinical characteristics of patients with primary intracranial solitary plasmacytoma (PISPC) and prognostic factors for their outcomes.

METHODS

This study retrospectively reviewed 17 patients with PISPC from our center and an additional 70 cases of PISPC published previously to analyze outcome predictors.

RESULTS

The entire cohort included 38 (43.7%) males and 49 (56.3%) females with a mean age of 54 years. Skull base tumors were found in 49 (56.3%) patients. Gross total resection (GTR) was achieved in 31 (35.6%) patients. Postoperative adjuvant treatments, including radiotherapy (RT) alone, chemotherapy (CMT) alone, and RT + CMT were administered in 49 (56.3%) patients, 3 (3.5%) patients, and 16 (18.4%) patients, respectively. After a median follow-up of 24 (mean 42.4) months, the 5-year disease progression-free survival (PFS), recurrence-free survival (RFS), multiple myeloma (MM)-free survival (MMFS), and overall survival (OS) were 52.9%, 76.2%, 69.6%, and 76.1%, respectively. Multivariate analysis unveiled that a skull base tumor location (HR 2.395, p = 0.040) and no RT (HR 3.115, p = 0.004) were negative prognostic factors for PFS, no RT (HR 10.526, p = 0.003) for RFS, each 1-year increase in age (HR 1.039, p = 0.049) for MMFS, and increasing age (HR 1.052, p = 0.043) and CMT (HR 6.022, p = 0.005) were risk factors for OS. However, GTR did not benefit the aforementioned outcomes.

CONCLUSION

For patients with presumed PISPC, a biopsy followed by RT is recommended for skull base PISPC. However, the role of CMT is still not clear. Our findings need to be verified in a larger prospective cohort in the future. Systematic review registration number CRD42018098782.

Plasmacytoma of the Skull-base: A Rare Tumor

Plasmacytoma of the skull-base is a rare entity. Differential diagnosis includes chordoma, osteosarcoma, carcinoma nasopharynx, meningioma, metastatic carcinoma, lymphoma, and multiple myeloma. Accurate and precise diagnosis is extremely important for plasmacytoma of the skull-base as its treatment and prognosis is different from other skull-base lesions. A 41-year-old man presented with concerns of headache, diplopia, and left eye strabismus. A magnetic resonance image (MRI) of his brain showed a large expansile mass measuring 51 mm involving the clivus and central skull-base. Trans-sphenoidal tumor decompression was done. A biopsy confirmed the plasmacytoma. A positron emission tomography-computed tomography (PET-CT) scan showed a single 2-(18F) fluoro-D-glucose (FDG) avid lesion at the skull-base. The results of all other relevant investigations such as hemoglobin, renal function test, serum calcium, serum protein immunoelectrophoresis, serum quantitative immunoglobulin, bone marrow biopsy, serum lactate dehydrogenase, and beta-2 microglobulin levels were within normal limits. He was treated with radical radiotherapy. He developed complete clinical response after radiotherapy.

Endoscopic Resection of Clival Malignancies

Surgical management of clival lesions presents numerous therapeutic challenges because of the close proximity of surrounding critical structures. With a detailed understanding of the endoscopic endonasal approach and relevant considerations, appropriate lesions can be removed in a safe and minimally invasive manner. Use of this technique as a primary approach represents the standard of care for many lesions at leading skull base centers, although adjunct techniques may be necessary in extensive lesions and those with significant lateral extension.

Sellar and clival plasmacytomas: case series of 5 patients with systematic review of 65 published cases

PURPOSE

Parasellar plasmacytomas are rare tumors localized to the sellar region arising from plasma cells. Knowledge of clinical, imaging, surgical, and pathological characteristics is limited to single case reports.

METHODS

A retrospective analysis of five primary cases was conducted, followed by systematic review of English language articles using PubMed in accordance with PRISMA guidelines.

RESULTS

Five primary case patients include four men and one woman, ages 60-77, followed up to 3 years. A systematic review identified 65 additional patients, of whom 65% presented with cranial nerve palsies and 15% with hypopituitarism. Sixteen percent had history of known multiple myeloma (MM) while 37% were diagnosed concurrently with MM on presentation of parasellar plasmacytoma. Imaging showed median tumor size of 38 mm (range, 4-70 mm), with MRI intensity similar to that of other sellar masses. Surgical biopsy with immunohistochemical studies confirmed plasmacytoma diagnosis. Eighty-one percent underwent parasellar radiotherapy, and chemotherapy initiated in 59% of the 69 patients with MM. Overall survival rate was 74% at follow-up (median 12 months), with 18% having parasellar recurrences and 38% progressing to systemic MM after presentation of a solitary plasmacytoma (median 3 months).

CONCLUSIONS

Parasellar plasmacytomas are rare tumors that should be considered in the differential diagnosis for lesions involving the sella and arising from the clivus, especially when cranial nerve paresis is apparent, even in the absence of known MM. Although recurrence rates for parasellar plasmacytoma is low, patients should be monitored for progression to MM. Treatment depends on the presence of systemic disease at diagnosis.

Cerebral Venous Thrombosis with Papilloedema Secondary to Skull Base Plasmacytoma

A 60-year-old woman with history of multiple myeloma was in remission after stem cell transplant 6 years prior. She was undergoing work-up for headaches that were thought to be secondary to a right mastoiditis seen on magnetic resonance imaging (MRI). On routine eye exam, papilloedema was noted. A lumbar puncture was performed, with elevated opening pressure with normal constituents. She was an atypical age for idiopathic intracranial hypertension, and her mastoiditis raised concern for secondary cerebral venous sinus thrombosis. Magnetic resonance venography (MRV) was performed showing poor flow in the right sigmoid sinus, and computed tomography venography (CTV) showed lack of contrast enhancement distal to the right sigmoid sinus, consistent with occlusion. There was also an enhancing mass inferior to the right occipital bone. Biopsy confirmed recurrent plasma cell myeloma. She was treated with chemotherapy, radiation, and warfarin for presumed cerebral venous sinus thrombosis.

Stereotactic biopsy approach to the upper clivus through the middle fossa floor that avoids pneumatised cavities and the intradural compartment

BACKGROUND

Biopsies of clival lesions are usually performed, under general anaesthesia, through an anterior endoscopic approach or, alternatively, through a trans-nasal or trans-oral stereotactic approach.

METHODS

A 57-year-old man with a symptomatic osteolytical lesion of the clivus, who refused general anaesthesia, underwent a sterotactically guided biopsy of the lesion by an antero-lateral approach through the temporal and sphenoid bones.

RESULTS

Biopsy was successfully performed and the resulting diagnosis was myeloma. The patient was comfortable during and after surgery and there were no complications.

CONCLUSIONS

The present stereotactic antero-lateral approach to the biopsy of the upper clivus can be considered an useful adjunct to the current trans-oral and transnasal approaches that often require general anaesthesia.

Plasmacytoma of the Skull Base: A Meta-Analysis

Objective Extramedullary plasmacytomas are rare tumors. In the current study we aim to characterize its clinical course at the skull base and define the most appropriate therapeutic protocol. Methods We conducted a meta-analysis of articles in the English language that included data on the treatment and outcome of plasmacytoma of the base of skull. Results The study cohort consisted of 47 patients. The tumor originated from the clivus and sphenoclival region in 28 patients (59.5%), the nasopharynx in 10 patients (21.2%), the petrous apex in 5 patients (10.6%), and the orbital roof in 4 patients (8.5%). The chief complaints at presentation included recurrent epistaxis and cranial nerve palsy, according to the site of tumor. Twenty-two patients (46.8%) had surgical treatment; 25 (53.2%) received radiation therapy. Adjuvant therapy was administered in 11 cases (50%) with concurrent multiple myeloma. The 2-year and 5-year overall survival rates were 78% and 59%, respectively. Clear margin resection was achieved in a similar proportion of patients who underwent endoscopic surgery and open surgery (p = 0.83). A multivariate analysis of outcome showed a similar survival rate of patients treated surgically or with radiotherapy. Conclusions The mainstay of treatment for plasmacytoma is based on radiation therapy, but when total resection is feasible, endoscopic resection is a valid option.

Plasmacytoma of the Clivus Presenting as Bilateral Sixth Nerve Palsy

Background and Importance Plasmacytomas are monoclonal proliferations of plasma cells that may arise within soft tissue or bone. The skull base is a rare site for plasmacytomas to occur, and few cases have been reported in the literature. When present in the skull base, plasmacytomas may result in cranial neuropathies and often progress to multiple myeloma more rapidly than other intracranial or skeletal plasmacytomas.

Clinical Presentation A 69-year-old man presented with a primary complaint of diplopia and an examination consistent with bilateral abducens nerve palsy. No other deficits were noted. Magnetic resonance imaging of the skull base demonstrated a large T1 isointense moderately enhancing lesion centered within the clivus. Endoscopic biopsy of the mass revealed sheets and aggregates of mature monoclonal plasma cells. The patient's initial systemic work-up revealed that this was a solitary lesion, and he was treated with radiation therapy to the skull base with a durable local effect at 18-month follow-up. Unfortunately he progressed to multiple myeloma with peripheral osteolytic lesions but has been stabilized on chemotherapeutics.

Conclusion The clivus is an unusual site for intracranial plasmacytomas, and enhancing lesions must be differentiated from chordoma. Characteristic findings on histopathology include an immunoglobulin light-chain restricted clonal proliferation of plasma cells. Treatment is most commonly radiotherapy with surgery reserved for biopsy and palliation. Clinicians should be aware of the increased risk of progression to multiple myeloma in skull base plasmacytomas.

Solitary lesions of the clivus: what else besides chordomas? An extensive clinical outlook on rare pathologies

BACKGROUND

Solitary non-chordomatous lesions of the clivus are rare pathologies, which represent a diagnostic challenge. This study provides an overview of the clinical, radiological and prognostic characteristics of non-chordomatous clival lesions, highlighting current therapeutic options.

METHODS

Twenty-two non-chordomatous lesions of the clivus were collected. A retrospective analysis of clinical and radiological patterns as well as survival data was conducted.

RESULTS

Clinical presentation was a result of local mass effect. Imaging features, although mainly specific, were not always diagnostic. Extent of surgery was gross total in 45.5 % of cases. Depending on the histology, biological behaviour and presence of seeding, adjuvant treatment was performed, tailoring the treatment strategy to the single patient.

CONCLUSIONS

Solitary non-chordomatous lesions of the clival bone are more prevalent than expected. They should be approached with a correct differential diagnosis, considering specific epidemiological, radiological, and histopathological characteristics, to minimise diagnostic bias and allow the planning of the best treatment strategy.