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Sammartano V, Cerase A, Venanzi V, Mazzei MA, Vangone BE, Gentili F, Chiarotti I, Bocchia M, Gozzetti A. Central Nervous System Myeloma and Unusual Extramedullary Localizations: Real Life Practical Guidance. Front Oncol 2022; 12:934240. [PMID: 35875104 PMCID: PMC9300839 DOI: 10.3389/fonc.2022.934240] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 06/10/2022] [Indexed: 12/22/2022] Open
Abstract
Central nervous system localization of multiple myeloma (CNS-MM) accounts for about 1% of all MM during disease course or even rarer at diagnosis. A difference in the origin, i.e., osteodural or primary dural vs leptomeningeal/intraparenchymal, seems to define two distinct types of intracranial myeloma, with different clinical behavior. CNS-MM may occur also as a presentation of MM. Treatment is still unsatisfactory and many treatments have been reported: chemotherapy, intrathecal therapy, and radiotherapy, with dismal prognosis. Other sites of myeloma localization could be also of interest and deserve description. Because of the rarity and aggressiveness of the disease clinicians are often doubtful on how to treat it since there is no general agreement. Moreover, recent drugs such as the anti CD38 monoclonal antibody, immunomodulatory drugs, and proteasome inhibitors have changed the treatment of patients with MM with a significant improvement in overall response and survival. The role of novel agents in CNS MM management and unusual presentations will be discussed as well as the potential role of other new immunomodulatory drugs and proteasome inhibitors that seem to cross the blood-brain barrier. The purpose of this review is to increase awareness of the clinical unusual presentation and neuroradiological findings, give practical diagnostic advice and treatment options algorithm.
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Affiliation(s)
- Vincenzo Sammartano
- Hematology Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, Azienda Ospedaliero Universitaria Senese, Siena, Italy
| | - Alfonso Cerase
- Neuroimaging (Diagnostic and Functional Neuroradiology) Unit, Azienda ospedaliero-universitaria Senese, Siena, Italy
| | - Valentina Venanzi
- Hematology Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, Azienda Ospedaliero Universitaria Senese, Siena, Italy
| | - Maria Antonietta Mazzei
- Department of Medicine, Surgery and Neuroscience, University of Siena and Department of Radiological Sciences, Unit of Diagnostic Imaging, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Beatrice Esposito Vangone
- Hematology Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, Azienda Ospedaliero Universitaria Senese, Siena, Italy
| | - Francesco Gentili
- Department of Medicine, Surgery and Neuroscience, University of Siena and Department of Radiological Sciences, Unit of Diagnostic Imaging, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Ivano Chiarotti
- Neuroimaging (Diagnostic and Functional Neuroradiology) Unit, Azienda ospedaliero-universitaria Senese, Siena, Italy
| | - Monica Bocchia
- Hematology Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, Azienda Ospedaliero Universitaria Senese, Siena, Italy
| | - Alessandro Gozzetti
- Hematology Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, Azienda Ospedaliero Universitaria Senese, Siena, Italy
- *Correspondence: Alessandro Gozzetti,
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Vaid T, Dhawan R, Aggarwal M, Tyagi S. Isolated third cranial nerve palsy as the first presentation of multiple myeloma. BMJ Case Rep 2021; 14:14/3/e239917. [PMID: 33762276 PMCID: PMC7993308 DOI: 10.1136/bcr-2020-239917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 50-year-old woman presented with a right-sided isolated third cranial nerve palsy. MRI brain showed a mass lesion arising from the right clivus with extension into the cavernous sinus. Blood investigations and bone marrow biopsy were suggestive of multiple myeloma with hypercalcaemia and renal dysfunction. It was unclear at first if the intracranial lesion was due to myelomatous involvement or a separate disease entirely. The patient declined consent for a biopsy and cerebrospinal fluid analysis was inconclusive. She was treated with bortezomib based chemotherapy and the palsy resolved by day 6, which helped clinch the rare diagnosis of central nervous system (CNS) involvement by multiple myeloma. Most patients with CNS myeloma have a dismal survival of under 6 months but she is on therapy for relapse 26 months after diagnosis. While placed under the umbrella of CNS myeloma, patients with osteodural myeloma have better outcomes, perhaps due to their distinct aetiopathogenesis.
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Affiliation(s)
- Tejasvini Vaid
- Department of Hematology, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Rishi Dhawan
- Department of Hematology, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Mukul Aggarwal
- Department of Hematology, All India Institute of Medical Sciences, New Delhi, Delhi, India
| | - Seema Tyagi
- Department of Hematology, All India Institute of Medical Sciences, New Delhi, Delhi, India
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Egan PA, Elder PT, Deighan WI, O'Connor SJM, Alexander HD. Multiple myeloma with central nervous system relapse. Haematologica 2020; 105:1780-1790. [PMID: 32414852 PMCID: PMC7327654 DOI: 10.3324/haematol.2020.248518] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 04/14/2020] [Indexed: 01/30/2023] Open
Abstract
Central nervous system involvement in multiple myeloma is a rare complication but carries a very poor prognosis. We provide a review of current literature, including presentation, treatment and survival data, and describe our experience in a regional hematologic malignancy diagnosis center where, over a 15-year period, ten cases were identified. Although the median age of onset, frequently between 50-60 years, is comparatively young, those diagnosed usually have a preceding diagnosis of multiple myeloma and often have had several lines of treatment. We discuss putative underlying factors such as prior treatment and associations including possible risk factors and features suggestive of a distinct biology. Central nervous system involvement may be challenging to diagnose in myeloma, displaying heterogeneous symptoms that can be confounded by neurological symptoms caused by the typical features of myeloma or treatment side-effects. We discuss the clinical features, imaging and laboratory methods used in diagnosis, and highlight the importance of considering this rare complication when neurological symptoms occur at presentation or, more commonly, during the disease pathway. In the absence of clinical trial data to inform an evidence-based approach to treatment, we discuss current and novel treatment options. Finally, we propose the establishment of an International Registry of such cases as the best way to collect and subsequently disseminate presentation, diagnostic and treatment outcome data on this rare complication of multiple myeloma.
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Affiliation(s)
- Philip A Egan
- Northern Ireland Centre for Stratified Medicine, Ulster University, Derry/Londonderry, Northern Ireland
| | - Patrick T Elder
- Department of Haematology, North West Cancer Centre, Altnagelvin Area Hospital, Derry/Londonderry, Northern Ireland
| | - W Ian Deighan
- Department of Clinical Chemistry, Altnagelvin Area Hospital, Derry/Londonderry, Northern Ireland
| | - Sheila J M O'Connor
- Haematological Malignancy Diagnostic Service, St James's Institute of Oncology, Leeds, England, UK
| | - H Denis Alexander
- Northern Ireland Centre for Stratified Medicine, Ulster University, Derry/Londonderry, Northern Ireland
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Abdallah AO, Atrash S, Shahid Z, Jameel M, Grazziutti M, Apewokin S, Kumar NS, Restrepo A, Waheed S, Van Rhee F, Heuck CJ, Johann D, Barlogie B, Usmani SZ. Patterns of Central Nervous System Involvement in Relapsed and Refractory Multiple Myeloma. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2014; 14:211-4. [DOI: 10.1016/j.clml.2013.11.004] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/19/2013] [Revised: 10/25/2013] [Accepted: 11/05/2013] [Indexed: 11/29/2022]
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Bang HI, Yoo JY, Kim KH, Park R, Shin JW, Choi TY, Lee SC, Park HS, Won JH. [A case of central nervous system myelomatosis with complex chromosome aberrations]. Korean J Lab Med 2010; 30:334-8. [PMID: 20805703 DOI: 10.3343/kjlm.2010.30.4.334] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Involvement of the central nervous system is very uncommon in multiple myeloma, observed in approximately 1% of the multiple myeloma patients. We report a case of central nervous system myelomatosis with complex chromosome aberrations in a 62-yr-old female patient, who had previously been diagnosed as multiple myeloma. Fluorescent in situ hybridization revealed 13q deletion, p53 gene deletion and IGH/FGFR3 rearrangement and chromosomal study showed complex chromosome aberrations. After four cycles of chemotherapy, the patient was admitted to the hematology department with severe headache. Plasma cells were found in the cerebrospinal fluid (CSF), and CSF immunoelectrophoresis revealed abnormal precipitin arcs against anti-IgG and anti-lambda antisera. She was given systemic chemotherapy and eight courses of intrathecal chemotherapy, which cleared plasma cells in the CSF. Two months later, she was given autologous stem cell transplantation. Three months after stem cell transplantation, central nervous system myelomatosis progressed to plasma cell leukemia and two months later, the patient expired.
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Affiliation(s)
- Hae In Bang
- Department of Laboratory Medicine, Soonchunhyang University Hospital, Seoul, Korea
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Yun GW, Song IC, Jin SA, Yang YJ, Park NH, Lee HJ, Yun HJ, Kim S, Jo DY. A Case of Central Nervous System Myelomatosis Developing after Allogeneic Hematopoietic Stem Cell Transplantation. THE KOREAN JOURNAL OF HEMATOLOGY 2008. [DOI: 10.5045/kjh.2008.43.3.194] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Gak-Won Yun
- Department of Internal Medicine, College of Medicine, Chungnam National University, Daejeon, Korea
| | - Ik-Chan Song
- Department of Internal Medicine, College of Medicine, Chungnam National University, Daejeon, Korea
| | - Seon-Ah Jin
- Department of Internal Medicine, College of Medicine, Chungnam National University, Daejeon, Korea
| | - Young-Joon Yang
- Department of Internal Medicine, College of Medicine, Chungnam National University, Daejeon, Korea
| | - Nam-Hwan Park
- Department of Internal Medicine, College of Medicine, Chungnam National University, Daejeon, Korea
| | - Hyo-Jin Lee
- Department of Internal Medicine, College of Medicine, Chungnam National University, Daejeon, Korea
| | - Hwan-Jung Yun
- Department of Internal Medicine, College of Medicine, Chungnam National University, Daejeon, Korea
| | - Samyong Kim
- Department of Internal Medicine, College of Medicine, Chungnam National University, Daejeon, Korea
| | - Deog-Yeon Jo
- Department of Internal Medicine, College of Medicine, Chungnam National University, Daejeon, Korea
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Affiliation(s)
- Laurens Nieuwenhuizen
- Department of Internal Medicine, St. Antonius Hospital, Nieuwegein, The Netherlands.
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Petersen SL, Wagner A, Gimsing P. Cerebral and meningeal multiple myeloma after autologous stem cell transplantation. A case report and review of the literature. Am J Hematol 1999; 62:228-33. [PMID: 10589078 DOI: 10.1002/(sici)1096-8652(199912)62:4<228::aid-ajh5>3.0.co;2-3] [Citation(s) in RCA: 64] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Meningeal involvement of multiple myeloma is a very rare complication. Defining meningeal myelomatosis (MeM) as the presence of plasma cells in the cerebrospinal fluid in a patient with multiple myeloma, we have found 53 previously reported cases in the literature, where the diagnosis MeM has been made while the patient was alive. Using Kaplan Meier statistics we have found the median survival, from the time of diagnosis of MeM, to be 1.5 months. We report a case with MeM and possible cerebral myeloma shortly after autologous stem cell transplantation, and compare it with earlier published cases.
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Affiliation(s)
- S L Petersen
- Department of Hematology, Copenhagen University Hospital, Copenhagen, Demark.
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Pizzuti P, Pertuiset E, Chaumonnot F, Chesneau A, Mikol J, Leblond-Missenard V, Fermand JP. [Neuromeningeal sites of multiple myeloma: 3 cases and review of the literature]. Rev Med Interne 1997; 18:646-51. [PMID: 9365740 DOI: 10.1016/s0248-8663(97)82467-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Neurologic manifestations are not unusual in multiple myeloma. Conversely meningeal and cerebral involvement have been very rarely reported. We report here on three patients with multiple myeloma and meningeal or cerebral involvement (two of them with autopsy study): one case of cerebellar involvement associated with secondary plasma cell leukemia and two cases of meningeal involvement. We reviewed the characteristics of 20 cases of meningeal involvement with demonstration of plasma cells at cerebrospinal fluid analysis (18 previously reported cases and our two patients). Meningeal involvement occurs in patients with initially stage III multiple myeloma in 85% of cases and is associated with the occurrence of plasma cell leukemia in 20% of cases. The most frequent neurologic signs are: confusion (60%), altered consciousness (25%), gait disorder (25%), cranial nerve palsy (25%). Meningismus is rarely present. Diagnosis is based on cerebrospinal fluid analysis after lumbar puncture which should be made after cranial magnetic resonance imaging. The diagnosis of intra-cranial haemorrhage and infectious meningitis have to be cautiously ruled out. Despite treatments (systemic and/or intrathecal chemotherapy, radiation therapy), prognosis is very poor: mean time of survival after the occurrence of neurologic signs is about 2 months.
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Affiliation(s)
- P Pizzuti
- Département de médecine interne, hôpital René-Dubos, Pontoise, France
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Weber T, Rieckmann P, Jürgens S, Prange HW, Felgenhauer K. Immunocytochemical analysis of immunoglobulin-containing cells in CSF and blood in inflammatory disorders of the central nervous system. J Neurol Sci 1988; 86:61-72. [PMID: 3171597 DOI: 10.1016/0022-510x(88)90007-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Cells containing immunoglobulins G, A, and M were evaluated in paired cerebrospinal fluid (CSF) and peripheral blood (PB) samples. These were obtained from 12 patients with bacterial meningitis, 14 patients with viral meningitis, 6 cases of lymphocytic meningoradiculitis (LMR), 10 cases of multiple sclerosis (MS), 6 cases of herpes zoster ganglionitis and 27 patients with non-infectious disorders of the CNS. PB cells from 20 healthy donors served as controls. Using alkaline phosphatase (AP)-conjugated antibodies to human immunoglobulin (Ig) G, A, and M in a carrageenan solution it was possible to demonstrate repeatedly intracytoplasmic Igs over more than 1 year without any detectable loss of specificity and staining intensity. Immunoglobulin-containing cells (ICC) could be detected in the CSF of 96% of patients with inflammatory diseases of the central nervous system (CNS) or with MS but not in the control cases.
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Affiliation(s)
- T Weber
- Neurologische Klinik und Poliklinik der Universität Göttingen, F.R.G
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Confavreux C, Caudie C, Touraine F, Ventre JJ, Aimard G, Devic M. Plasma cells in cerebrospinal fluid and multiple sclerosis: diagnostic yield and clinicobiological correlations. Acta Neurol Scand 1986; 74:432-8. [PMID: 3825501 DOI: 10.1111/j.1600-0404.1986.tb07868.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Cerebrospinal fluid (CSF) cytocentrifugation was performed for plasma cells' demonstration in parallel with white cell count (WCC) and quantitative protein assays. Over a 5-year period, 154 consecutive multiple sclerosis (MS) patients were studied and compared to 28 other inflammatory neurological disease, 85 non-inflammatory neurological disease and 29 non-neurological disease cases. CSF cytology was easy to perform, gave definitive results within 2 h and was abnormal in 80 MS patients, 26 of whom had a normal WCC. Its sensitivity in MS was 0.57, i.e. higher than for WCC (0.45) but lower than for IgG index (0.70) and IgG synthesis rate (0.71). Its specificity was 0.86, not significantly different from specificity of WCC, IgG index and IgG synthesis rate. Plasma cells demonstration in MS CSF was neither a disease activity nor a prognosis marker. It was significantly correlated with pleiocytosis and intrathecal IgG synthesis. If these morphologically defined plasma cells are actual B cells, they could represent circulating individuals of the lymphocyte clones active in MS plaques and have a pathogenetic significance.
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Brenner B, Nagler A, Viener A, Sharon R, Carter A. Partial response of meningeal myeloma to craniospinal radiotherapy. SCANDINAVIAN JOURNAL OF HAEMATOLOGY 1986; 37:360-2. [PMID: 3097809 DOI: 10.1111/j.1600-0609.1986.tb02327.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Concomitant occurrence of meningeal involvement and thoracic plasmacytoma was observed in a patient with IgA lambda myeloma. Cerebrospinal fluid analysis revealed IgA-lambda paraprotein and pathological plasma cells. CT scan of the chest and lumbar myelogram excluded spinal cord compression. The patient partially responded to craniospinal irradiation but succumbed to rapidly progressive myeloma 20 weeks following diagnosis of meningeal involvement.
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14
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Walker RW, Thompson EJ. The cerebrospinal fluid in subacute sclerosing panencephalitis and multiple sclerosis. PROGRESS IN BRAIN RESEARCH 1983; 59:375-90. [PMID: 6665129 DOI: 10.1016/s0079-6123(08)63883-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Pelc S, De Maertelaere E. CSF cells in tuberculous meningitis. Humoral and cellular immune response. J Neurol Sci 1981; 49:223-8. [PMID: 6971324 DOI: 10.1016/0022-510x(81)90080-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
In 10 patients with tuberculous meningitis both T and B lymphocyte activation was observed in the CSF from clinical onset of disease. During the course of the illness, the humoral response remained most marked, disappearing by 2 months, while the cellular immune response continued for about another 3 months. This contrasts with acute viral meningitis, in which both responses cease within 1-2 weeks of disease.
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Schädlich HJ, Nekić M, Felgenhauer K. The detection of activated cerebrospinal fluid B lymphocytes by peroxidase conjugated antibodies. J Neurol 1980; 224:77-87. [PMID: 6160220 DOI: 10.1007/bf00313346] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
A method for the preparation of a potent and specific peroxidase-labelled antihuman IgG antibody is described. CSF cells from patients with various neurological diseases were stained. Only in cases of inflammatory diseases was IgG detectable. The stained cells were so-called lymphoid cells. As the demonstrable IgG can be regarded as a product of intracellular synthesis, it is justified to call these cells activated B lymphocytes. The relative portion of activated B cells tends to be high in the first half of the mononuclear phase and depends upon the type of disease. It is low in most cases of bacterial and benign viral meningitis whereas high B cell numbers were found in Bannwarth meningopolyneuritis, mumps meningitis and herpes simplex encephalitis. Albeit there exists a time lag between the maximal number of activated B lymphocytes and the demonstration of the secretory immunoglobulin fraction, quantitative correlation between these two inflammation parameters were demonstrated in cases of acute meningoencephalitis. These correlations were not seen in chronic inflammatory diseases.
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Dommasch D, Grüninger W, Schultze B. Autoradiographic demonstration of proliferating cells in cerebrospinal fluid. J Neurol 1977; 214:97-112. [PMID: 64602 DOI: 10.1007/bf02430348] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The proliferative activity of cells, isolated from 82 human CSF specimens, was examined by 3H-thymidine autoradiography. High labelling indices (LI) were found in acute viral meningitis (up to 8 per cent) and radiculitis (up to 6 per cent). CSF cell proliferation was also shown in the subacute stages of viral diseases and in other inflammatory processes (LI ranging from 0.5 per cent to 3 per cent). Most of the cells labelled from these CSF specimens were large lymphocytes, "lymphoid cells" and plasmacytes. Their presence in CSF is presumed to indicate an immune reaction. By the demonstration of a proliferative activity of these cells, aseptic inflammatory processes can be differentiated from "unspecific" pleocytosis. Because of a correlation between the LI of CSF cells and the stages of some inflammations, this method is suggested for an assessment of pregression or remission of chronic processes, e.g. "chronic meningitis" and multiple sclerosis. It can also be used in experimental research: the same type of mononuclear cells was labelled after having been cultured for 23 hours prior to the incubation with 3H-thymidine. Proliferating tumor cells as well as proliferating non-neoplastic mononuclear cells were demonstrated in CSF from various neoplastic diseases. In the clinical diagnosis of these processes, the method is of limited value. It proved very useful, however, for an assessment of the therapeutic effects of intrathecal cytostatic therapy. CSF specimens from non-inflammatory and non-neoplastic diseases regularly contained very few proliferating cells (LI: less than 0.1).
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Liano H, Gimeno A, Kreisler M, Ramirez G. Cerebrospinal fluid proteins in subacute sclerosing panencephalitis. Correlation of data with clinical and evolutive aspects. Acta Neurol Scand 1971; 47:579-93. [PMID: 4110750 DOI: 10.1111/j.1600-0404.1971.tb07510.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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