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

Radiotherapy vs Surgery for Survival and Locoregional Control of Head and Neck Extramedullary Plasmacytoma: A Systematic Review and Meta-Analysis

Importance

There are significant gaps in the literature pertaining to the locoregional control and survival rates of extramedullary plasmacytoma (EMP) with respect to various treatment approaches.

Objective

To systematically evaluate the differences in radiotherapy and surgical outcomes in EMP.

Data Sources

Databases including PubMed, Scopus, Web of Science, Embase, and ScienceDirect were systematically searched from their inception up to November 2023.

Study Selection

Articles reporting radiotherapy and surgical outcomes of head and neck EMP were included.

Data Extraction and Synthesis

A random-effects model for meta-analysis was used to obtain pooled estimates and calculate hazard ratios for survival and odds ratios for recurrence and progression of EMP.

Main Outcomes and Measures

Survival, tumor control, and progression rates to multiple myeloma (MM) between radiation therapy and surgery for EMP of the head and neck.

Results

Of 742 included patients from 12 studies, 527 (71.0%) were male, and the median (IQR) age was 59.1 (53-62) years. A total of 505 patients (68.1%) received radiotherapy only, while 237 (31.9%) underwent surgery-only treatment for EMP. All included patients had an initial diagnosis of EMP without MM. Comparable trends were observed in overall survival and disease-free survival (DFS) rates at 2, 3, 5, and 10 years between patients with EMP treated with radiotherapy only and surgery only. Notably, there were no significant differences in recurrence rate (odds ratio, 0.65; 95% CI, 0.20-2.06) between radiotherapy-only and surgery-only treatment. However, radiotherapy-only treatment of EMP was associated with decreased odds of progression to MM compared with surgery (odds ratio, 0.4; 95% CI, 0.1-0.9). Sensitivity analysis revealed that the radiotherapy-only population had significantly better 5-year DFS (hazard ratio, 0.55; 95% CI, 0.31-0.96) compared with surgery-only treatment.

Conclusions and Relevance

This systematic review and meta-analysis provides evidence that patients with EMP receiving radiotherapy had significantly lower chances of progression to MM compared with surgery-only therapy. Additionally, radiotherapy had better 5-year DFS outcomes compared with surgery. Comparable outcomes in terms of overall survival rates, recurrence, and mortality rates were noted between radiotherapy-only and surgery-only EMP treatment groups.

Laryngeal plasmacytoma in a patient with Down's syndrome

Extramedullary plasmacytoma is a rare localized plasma cell neoplasm typically found in soft tissues outside the bone marrow. Predominantly occurring in the head and neck region, particularly in the sinonasal and nasopharyngeal areas, it presents a diagnostic challenge due to its uncommon nature. Herein, we report a 38-year-old female patient with Down's syndrome with a 2-year complaint of intermittent dysphonia, hoarseness, and progressive respiratory distress, including dyspnea, fatigue, and biphasic stridor. Examination via flexible laryngoscopy revealed a white lesion, prompting direct microscopic laryngeal surgery to excise a 1x1 cm mass. Histological findings confirmed the diagnosis as solitary extramedullary plasmacytoma. Notably, this represented the first documented case of laryngeal solitary extramedullary plasmacytoma in a patient with Down's syndrome. This case underscores the importance of considering tumor development in the larynx among individuals with Down's syndrome, highlighting the necessity for tailored management strategies to address such occurrences effectively. Increasing awareness of this association can aid in early detection and appropriate treatment of tumors in this population.

A prognostic nomogram and risk classification system of elderly patients with extraosseous plasmacytoma: a SEER database analysis

BACKGROUND

The survival trends and prognostic factors of patients with extraosseous plasmacytoma (EOP) or extramedullary plasmacytoma (EMP) have not been reported in recent years. The objective of this study was to develop a novel nomogram and risk stratification system for predicting the overall survival (OS) of elderly patients with EOP based on the Surveillance, Epidemiology, and End Results (SEER) database.

METHODS

The demographic characteristics of 900 patients aged 60 years and above, diagnosed with EOP between 2000 and 2019, were extracted from the SEER database. The patient population was randomly divided into a training cohort and an internal validation cohort in a ratio of 7:3. Univariate and multivariate Cox regression analyses were conducted to identify independent predictors of prognosis in elderly EOP patients, followed by developing a nomogram for prognostic assessment. The performance of the model was evaluated through receiver-operating characteristic (ROC) curves, C-index, calibration curves for calibration accuracy assessment, and decision curve analysis (DCA) to assess its clinical utility. All elderly EOP patients were stratified into three risk subgroups by cutoff value utilizing X-tile software based on their total OS scores for comparative analysis purposes. Kaplan-Meier (K-M) survival curve analysis was employed to validate any observed differences in OS among these three risk groups.

RESULTS

Six factors including age, year of diagnosis, marital status, primary site, surgery, and prior tumor history were identified to be independently predictive of the OS of elderly patients with EOP, and these predictors were included in the construction of the nomogram. The 1-, 3-, and 5-year area under the curves (AUCs) for OS were 0.717, 0.754, and 0.734 in the training cohort and 0.740, 0.730, and 0.765 in the validation cohort, respectively. The C-index values in the two cohorts were 0.695 and 0.690. The calibration curves and DCA exhibit commendable consistency and validity, respectively, thereby demonstrating their robust performance. The training set was stratified into low-, medium-, and high-risk subgroups based on the optimal cutoff points (167.8 and 264.8) identified. The K-M curve and cumulative risk curve exhibited statistically significant disparities in survival rates among the groups.

CONCLUSIONS

We developed a nomogram and risk classification system, which can serve as an intuitive and effective tool for clinicians to enhance the prediction of OS in elderly EOP patients, thereby facilitating the formulation of more rational and personalized treatment strategies.

Distribution and survival outcomes of primary head and neck hematolymphoid neoplasms in older people: a population-based study

Primary head and neck hematolymphoid neoplasms (PHNHLN) are defined as a series of hematolymphoid system-derived neoplasms which primarily emanate in head and neck region. Due to the rarity and absence of symptomatic specificity, PHNHLN is easily neglected. The objective of this study is to investigate demographics, pathological subtype distribution, anatomical location, survival outcomes and prognostic factors of PHNHLN among older patients aged ≥ 60. The individual patient information in our study was derived from Surveillance, Epidemiology and End Results database. Descriptive epidemiological methods were used to analyze the distribution of histologic subtypes and primary anatomical sites. Kaplan-Meier survival curves and log-rank test were conducted to evaluate the effect of variables on the prognosis. Cox hazard regression was conducted to identify the independent prognostic factors. The male-to-female ratio in most pathological subtypes was close to 1:1. The most common pathological subtype was diffuse large B-cell lymphoma. The most commonly involved sites outside the lymph nodes were salivary glands, especially parotid gland, followed by tonsil, thyroid gland and tongue. The prognosis of mature T- and NK-cell non-Hodgkin lymphoma (NHL) was bleaker than Hodgkin lymphoma, mature B-cell NHL and plasma cell neoplasm. Age at diagnosis, presence of second primary malignancy (SPM), pathological subtype, Ann-Arbor stage, chemotherapy and radiation were independent prognostic factors of overall survival. Our study comprehensively reported the subtype distribution, anatomical sites and survival outcomes of PHNHLN among older patients, improving understanding of this rare group of cancer entities.

Clinical Presentation and Outcome of Sinonasal Extraosseous Plasmacytoma in Denmark: A Nationwide Cohort From 1980 to 2017

OBJECTIVES

Extraosseous plasmacytoma (EOP) is a rare plasma cell neoplasm that tends to convert to plasma cell myeloma (PCM) in about 11% to 35% of cases. It has a predilection for the upper respiratory tract, prototypically affecting the nasal cavity and paranasal sinuses. Contemporary first-line treatment is radiotherapy, with more recent studies showing an added benefit of combining radiation with surgery. In this cohort study, we aimed to examine clinical presentation, treatment, and prognosis for all patients nationwide from 1980 through 2017. Furthermore, we determined the size and extension of tumors, investigating the rate at which minimally invasive surgery would have been possible.

METHODS

Patients were found in the national pathology registry, and all biopsies were collected for pathology review by a hematopathologist. We performed survival statistics for overall survival (OS), progression-free survival (PFS), and the cumulative incidence of conversion to PCM.

RESULTS

Twenty-three patients were included. The median age was 65, and patients were primarily men (78%). Tumors were located in either the nasal cavity (57%), maxillary sinus (39%), or sphenoid sinus (4%). In most cases, the tumor was <5 cm (65%) without extension to adjacent structures (60%). The national incidence was 0.02/100,000 person-years, the median symptom duration until diagnosis was 5 months, and none of the patients presented with contiguous spread to regional lymph nodes. Stand-alone radiotherapy was the predominant treatment (61%). In the entire cohort, one patient died from the initial disease, and six patients died from either relapse of EOP or PCM. The 5-year OS, PFS, and conversion rate to PCM were 78%, 56%, and 23%, respectively.

CONCLUSION

SN-EOP responds well to radiotherapy, but relapse and conversion to PCM were not uncommon and entailed a poor prognosis. Most tumors were endoscopically resectable and non-invasive, making the majority of tumors suitable for surgery as an addition to radiation.

A case report of extramedullary plasmocytoma-rare pathology in the larynx

Extramedullary plasmocytoma is a rare finding. The diagnosis is made by histological and immunohistochemical examination. Hematological evaluation is mandatory to rule out multiple myeloma. Radiotherapy is treatment of choice with good results.

Plasmacytoma of the Head and Neck: Case Series and Review of the Literature

Solitary plasmacytoma is a rare neoplasm characterized by localized proliferation of monoclonal plasma cells and is classified as solitary bone or solitary extramedullary plasmacytoma. Here, we present two rare cases of plasmacytoma of the head and neck. The first is a 78-year-old male who presented with a 3-month history of epistaxis and progressive obstruction of the right nasal passage. Computerized tomography (CT) imaging revealed a mass in the right nasal cavity with destruction to the maxillary sinus. An excisional biopsy was performed revealing anaplastic plasmacytoma. The second is a 64-year-old male with a past medical history significant for prostate cancer who presented with a 2-month history of left ear pain and progressive non-tender temporal swelling. A PET/CT revealed a highly avid, destructive, and lytic left temporal mass with no other evidence of distant disease. A left temporal craniectomy and infratemporal fossa dissection revealed plasma cell dyscrasia with monoclonal lambda in situ hybridization. Although plasmacytomas are uncommon tumors of the head and neck, they may mimic other entities that require different treatment. Prompt and accurate diagnosis is critical for appropriate therapeutic decisions and prognosis.

Solitary Extramedullary Plasmacytoma of the Head and Neck: A Report of Three Cases Treated With Curative Radiotherapy and a Review of the Dose-Control Relationship

Solitary plasmacytoma is an uncommon hematologic malignancy characterized by the monoclonal proliferation of abnormal plasma cells in the bone or extramedullary tissues and the absence of other multiple myeloma-defining clinical characteristics. Mostly, solitary extramedullary plasmacytoma (SEP) occurs in the head and neck region, also called solitary extramedullary plasmacytoma of the head and neck (SEPHN). Although the standard of care for SEPHN is not well established, either a surgical approach or localized external beam radiotherapy (EBRT) can be used as a definitive treatment. Due to the high radiosensitivity of SEPHN, EBRT has been associated with adequate therapeutic effects in the management of SEP, with the advantage of being a noninvasive modality that yields high rates of local control with a reasonable toxicity profile. We present a case series of three patients with SEPHN treated with EBRT at our institution with clinical outcomes.

Oral Extramedullary Plasmacytoma Treatment Using a Combination of Marginal Excision and Strontium-90 Therapy in Five Dogs

Extramedullary plasmacytoma (EMP) is a benign round cell tumor that is most commonly found in cutaneous locations in dogs and occurs less frequently in the oral cavity. They are highly radiosensitive, are distinct from systemic multiple myeloma syndrome and wide surgical excision is typically curative. This report describes five cases of non-invasive oral EMP in dogs treated with a combination of marginal excision and strontium-90 plesiotherapy. All five cases had narrow or incomplete margins on histopathologic evaluation but experienced no recurrence after combination therapy. Plesiotherapy radiation may offer a potential adjunct treatment for non-invasive oral EMP by providing a superficial dose of radiation that complements a less invasive surgical removal. The combination of plesiotherapy and marginal excision may offer an alternative to wide surgical excision for non-invasive oral EMPs.

Survival trends and prognostic factors for patients with extramedullary plasmacytoma: A population-based study

Background

Extramedullary plasmacytoma (EMP) is a localized plasma cell neoplasm that originates from tissues other than bone. The survival trends and prognostic factors of patients with EMP in recent years remain unreported.

Methods

We used the SEER databases to extract the data. Survival curves were calculated using the Kaplan-Meier method and a nomogram was created based on the Cox's proportional hazards model.

Results

A total of 1676 cases of EMP were identified. Patients in period-2 (2008-2016) show similar survival (p=0.8624) to those in period-1(1975-2007). Age, gender, race, and sites were prognostic of patient outcomes. And the use of surgery was associated with improved survival. The patients were randomly assigned to the training cohort and the validation cohort in a ratio of 2:1. Four factors including age, gender, race, and sites were identified to be independently predictive of the overall survival of patients with EMP. A prognostic model (EMP prognostic index, EMP-PI) comprising these four factors was constructed. Within the training cohort, three risk groups displayed significantly different 10-year survival rates: low-risk (73.0%, [95%CI 66.9-78.2]), intermediate-risk (39.3%, [95%CI 34.3-44.3]), and high-risk (22.6%, [95%CI 15.3-30.9]) (p<0.0001). Three risk groups were confirmed in the internal validation cohort. We also constructed a 5-factor nomogram based on multivariate logistic analyses.

Conclusion

The survival of patients with EMP did not improve in recent years. The EMP-PI will facilitate the risk stratification and guide the risk-adapted therapy in patients with EMP.

Extramedullary plasmacytoma: Tumor occurrence and therapeutic concepts-A follow-up

BACKGROUND

Extramedullary plasmacytoma (EMP) is a solitary tumor consisting of neoplastic plasma cells, with very little to no bone marrow involvement. EMPs are usually located in the head and neck region, but can also occur along the digestive tract, in lungs, or extremities.

METHODS

Following our publication on EMP, which appeared in 1999 (Cancer 85:2305-14), we conducted a literature search for EMP-related reports published between 1999 and 2021. The documented cases, as well as 14 of our own patients from the ENT Clinic Erlangen, were extensively analyzed.

RESULTS

Between 1998 and 2021, 1134 patients with EMP were reported, for whom information about the tumor localization was available. Among those, 62.4% had EMP in the head and neck area and 37.6% in other body regions. Data on therapy were reported in 897 patients, including 34.3% who received radiation, 28.1% surgery, 22.6% a combination of surgery and radiation, and 15.9% another therapy. In 76.9% patients no recurrence or transformation to multiple myeloma (MM) was reported, 12.8% showed local recurrence and 10.2% developed MM. Radiotherapy alone was associated with a tendency for increased occurrence of MM. In patients with EMP of head and neck area, combination therapy (surgery and radiation) resulted in a 5-year overall survival rate of 98.3%, surgery alone of 92.4%, and radiotherapy of 92.7%.

CONCLUSIONS

Collectively, our analyses indicate that surgical resection alone can achieve long-term tumor control in patients with EMP, if the tumor can be removed within safe limits without causing serious functional impairment. However, if this is not certain, either radiation or a combination of surgery and radiation therapy is suggested as an effective means of local tumor control.

Analysis of the Treatment and Survival of Sinonasal Extramedullary Plasmacytoma

BACKGROUND

While extramedullary plasmacytomas are infrequently encountered plasma cell malignancies, most cases occur in the head and neck, with a predilection for the sinonasal cavity. Due to the rarity of this disease, the majority of studies on sinonasal extramedullary plasmacytoma (SN-EMP) are case reports or small retrospective case series.

OBJECTIVE

To investigate the impact of patient, disease, and treatment factors on the survival of patients with SN-EMP.

METHODS

The National Cancer Database was queried for all patients with SN-EMP between 2004-2016 (N = 381 cases). Univariate and multivariate analyses were used to examine patient demographics, tumor characteristics, and survival.

RESULTS

The majority of SN-EMP patients were over 60 years old (57.0%), male (69.8%), and white (86.2%). The most common treatment modality was radiotherapy alone (38.6%), followed by surgery plus radiotherapy (37.8%). Five-year overall survival was 74.0% and median survival was 9.1 years. Accounting for patient demographics and tumor characteristics in a multivariate model, the following groups had worse prognosis: 60 and older (HR 1.99, p = 0.031) and frontal sinus primary site (HR 11.56, p = 0.001). Patients who received no treatment (HR 3.89, p = 0.013), chemotherapy alone (HR 5.57, p = 0.008) or radiotherapy plus chemotherapy (HR 2.82, p = 0.005) had significantly lower survival than patients who received radiotherapy alone. Patients who received surgery with radiotherapy (HR 0.57, p = 0.039) had significantly higher survival than patients who received radiotherapy alone.

CONCLUSION

In patients with SN-EMP five-year overall survival was found to be 74.0% with decreased survival associated with a frontal sinus primary site and being aged 60 or older. Patients receiving no treatment, chemotherapy alone, or radiotherapy with chemotherapy was associated with lower survival. Receiving surgery plus radiotherapy was associated with the highest five-year overall survival.

Solitary Extramedullary Plasmacytoma of the Lacrimal Sac With Associated Crystal-Storing Histiocytosis

PURPOSE

To report a rare case of crystal-storing histiocytosis associated with solitary extramedullary plasmacytoma of the lacrimal sac and to review literature on the 2 entities to summarize important diagnostic, management, and prognostic considerations.

METHODS

A case report of the ophthalmologic presentation, pathology workup, and oncologic management is presented. Literature search with focus on lesions occurring in ophthalmic sites and management guidelines from expert panels and working groups.

RESULTS

Crystal-storing histiocytosis associated with solitary extramedullary plasmacytoma arose within the lacrimal sac of a previously healthy middle-aged woman and presented as a painless nodule with epiphora. The biopsy tissue showed sheets of crystal-filled histiocytes, interspersed with monoclonal plasma cells and rarely demonstrated plasma cell phagocytosis. Imaging and laboratory studies confirmed the localized nature.

CONCLUSIONS

Crystal-storing histiocytosis is an uncommon entity in which crystals, most commonly arising from altered immunoglobulins, aggregate within histiocytes and form symptomatic mass lesions. It has been reported in ophthalmic regions in patients with a concurrent lymphoproliferative or plasma cell disorder and can rarely predate a malignancy. The current case is notable because crystal-storing histiocytosis occurs with a localized process, solitary extramedullary plasmacytoma, and presents in an unusual site, the lacrimal sac. Tissue biopsy with multimodal pathological evaluation is necessary to make the diagnosis. Ophthalmologists should recognize that crystal-storing histiocytosis is commonly associated with a hematologic malignancy and, when appropriate, refer the patient for oncologic management. Surveillance may be indicated in cases with no established etiology. Solitary extramedullary plasmacytoma should also be monitored, as a proportion of cases progress to multiple myeloma.

Potential effect of epigenetic drugs in the treatment of multiple-site extramedullary plasmacytoma involving the respiratory system: a case report and review of the literature

We report the case of a 23-year-old man with a medical history of idiopathic thrombocytopenic purpura (ITP) and newly diagnosed with the Epstein-Barr virus (EBV)-positive multiple-site extramedullary plasmacytoma (EMP), which involves the respiratory system. The patient was referred to our hospital because of progressive nasal congestion and nasal mass. Nasopharyngoscopy and bronchoscopy were performed. The biopsy pathological hematoxylin and eosin (HE) staining indicated plasma cell myeloma, and further immunohistochemistry CD99(+), CD79a(+), CD38(+), MUM-1(+), and Lambda(+) confirmed the diagnosis. The patient's bone marrow was normal, and hypercalcemia, renal insufficiency, anemia, evident bone lesions were not observed. Serum immunoglobulin quantification, serum protein electrophoresis, and blood and urine light chain quantification were all within the normal range. The serum immunofixation electrophoresis was negative, and the serum-free light chain was normal. These results could rule out multiple myeloma (MM) and prove to be EMP involving the nasal cavity, main bronchus, lung, and left hip. No desired effect was achieved after receiving PAD (bortezomib, adriamycin, and dexamethasone) and VRD (bortezomib, lenalidomide, and dexamethasone) treatments. Even if the tumor was remarkably relieved after receiving the 2-course CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone) regimen, secondary resistance to CHOP unfortunately occurred in this case. We attempted to apply epigenetic therapy in the treatment of refractory multiple EMP. Although no complete remission (CR) was achieved, the maximum standard uptake value (SUVmax) in tumor lesions was significantly lower than before, and the patient's symptoms significantly improved. The patient tolerated decitabine and chidamide. We speculated that epigenetic drugs have potential effect in the treatment of multiple-site EMP.

Expert consensus on resection of chest wall tumors and chest wall reconstruction

Chest wall tumors are a relatively uncommon disease in clinical practice. Most of the published studies about chest wall tumors are usually single-center retrospective studies, involving few patients. Therefore, evidences regarding clinical conclusions about chest wall tumors are lacking, and some controversial issues have still to be agreed upon. In January 2019, 73 experts in thoracic surgery, plastic surgery, science, and engineering jointly released the Chinese Expert Consensus on Chest Wall Tumor Resection and Chest Wall Reconstruction (2018 edition). After that, numerous experts put forward new perspectives on some academic issues in this version of the consensus, pointing out the necessity to further discuss the points of contention. Thus, we conducted a survey through the administration of a questionnaire among 85 experts in the world. Consensus has been reached on some major points as follows. (I) Wide excision should be performed for desmoid tumor (DT) of chest wall. After excluding the distant metastasis by multi-disciplinary team, solitary sternal plasmacytoma can be treated with extensive resection and adjuvant radiotherapy. (II) Wide excision with above 2 cm margin distance should be attempted to obtain R0 resection margin for chest wall tumor unless the tumor involves vital organs or structures, including the great vessels, heart, trachea, joints, and spine. (III) For patients with chest wall tumors undergoing unplanned excision (UE) for the first time, it is necessary to carry out wide excision as soon as possible within 1–3 months following the previous surgery. (IV) Current Tumor Node Metastasis staging criteria (American Joint Committee on Cancer) of bone tumor and soft tissue sarcoma are not suitable for chest wall sarcomas. (V) It is necessary to use rigid implants for chest wall reconstruction once the maximum diameter of the chest wall defect exceeds 5 cm in adults and adolescents. (VI) For non-small cell lung cancer (NSCLC) invading the chest wall, wide excision with neoadjuvant and/or adjuvant therapy are recommended for patients with stage T_3-4N_0-1M₀. As clear guidelines are lacking, these consensus statements on controversial issues on chest wall tumors and resection could possibly serve as further guidance in clinical practice during the upcoming years.

[Benefits of radiotherapy for patients with solitary plasmacytoma or multiple myeloma]

BACKGROUND

Treatment options for patients with solitary plasmacytoma (SP) or multiple myeloma (MM) should be discussed in an interdisciplinary context. This systematic review focuses on the importance of radiotherapy in MM and SP.

OBJECTIVE

Summary of local radio-oncological treatment options for patients with SP and MM.

MATERIALS AND METHODS

Based on a systematic literature search, the current evidence on the topic was analyzed and summarized.

RESULTS

Patients with SP should be primarily treated with radiotherapy with or without surgery. Irradiation concepts may vary depending on risk factors and manifestation (solitary bone plasmacytoma vs. solitary extramedullary plasmacytoma). Although local control rates are high after radiotherapy, progression to multiple myeloma frequently occurs. In patients with MM, radiation is mainly used in palliative settings for pain relief, prevention of fractures or in patients who suffer from neurological symptoms due to spinal cord compression. Irradiation dose and fractionation should be selected based on treatment indication and general condition of the patient.

CONCLUSION

Although most patients receive systemic treatment at initial diagnosis, approximately 40% of patients with MM will require radiation during the course of their disease. While radiation is mainly used for palliation in patients with MM, it represents the primary and curative treatment option in patients with SP.

Rare Diseases of the Nose, the Paranasal Sinuses, and the Anterior Skull Base

Due to their low incidence and thus resulting limited diagnostic criteria as well as therapeutic options, rare diseases of the nose, the paranasal sinuses, and the anterior skull base are a significant challenge. The value as of which a disease has to be considered as rare amounts to a maximum of 5 patients per 10 000 people. Within these diseases, however, there are extreme differences. Some rare or orphan diseases like for example the inverted papilloma belong to regularly diagnosed and treated diseases of larger departments of oto-rhino-laryngology whereas other rare diseases and malformations have only been described in less than 100 case reports worldwide. This fact emphasizes the necessity of bundling the available experience of diagnostics and therapy. The present article gives an overview about rare diseases of the nose, the paranasal sinuses, and the anterior skull base from the field of diseases/syndromes of the olfactory system, malformations of the nose and paranasal sinuses, ventilation and functional disorders as well as benign and malignant tumors. The classification and data on diagnostic and therapeutic options were established based on the current literature.

Long-term Outcomes After Definitive Radiation Therapy for Solitary Plasmacytoma

OBJECTIVE

Definitive radiotherapy (RT) with or without surgery is the standard of care for solitary plasmacytoma. Here, we report clinical outcomes for this rare malignant neoplasm.

PATIENTS AND METHODS

We retrospectively reviewed the medical records of adults with solitary plasmacytoma treated with definitive RT between 1963 and 2015 at a single institution, and assessed disease control, survival, and toxicity per Common Terminology Criteria for Adverse Events (CTCAE), version 4.

RESULTS

A total of 42 patients with solitary plasmacytoma of the bone (SPB, n=27) or extramedullary plasmacytoma (EMP, n=15) were treated with definitive RT with (n=11) or without (n=31) surgical resection. The median age at diagnosis was 59 years (range: 28 to 76 y).Twenty-two patients had tumors ≥5 cm and 20 had tumors <5 cm. Immunoglobulins were elevated in 23 patients and M-protein in 14. The median RT dose was 45 Gy (range: 15 to 54 Gy) over a median 25 fractions (range: 1 to 38 fractions) with 3 patients receiving twice-daily fractionation and 6 received elective nodal irradiation. No patients received adjuvant chemotherapy. The median follow-up was 10.3 years. The 10-year local control rate after RT was 88%. Five patients who developed a local recurrence had SPB ≥5 cm. The 10-year multiple myeloma-free survival rates were: overall, 47%; SPB, 24%; and EMP, 87% (P=0.0012). The 10-year cause-specific survival rate was 75%: 64% for SPB versus 93% for EMP (P=0.0116). The 10-year overall survival rate was 60%. Three patients experienced late grade 2+ toxicity.

CONCLUSIONS

Definitive RT with moderate doses results in excellent local control. We observed a higher rate of progression to multiple myeloma and lower survival in patients with SPB compared with EMP.

Multiple Myeloma, Version 3.2021, NCCN Clinical Practice Guidelines in Oncology

Multiple myeloma is a malignant neoplasm of plasma cells that accumulate in bone marrow, leading to bone destruction and marrow failure. This manuscript discusses the management of patients with solitary plasmacytoma, smoldering multiple myeloma, and newly diagnosed multiple myeloma.

Radiotherapy for the treatment of solitary plasmacytoma: 7-year outcomes by a mono-institutional experience

OBJECTIVES

Solitary plasmacytoma (SP) is characterized by a single mass of clonal plasma cells. Definitive RT can result in long-term local control of the SP. Due to the small number of patients and narrow range of doses, phase III randomized trials are lacking. The aim of this study is to further support the potential use of RT for the treatment of SP.

METHODS

Clinical data of all patients treated for SP at our Institution between 1992 and 2018 were reviewed. A total of 42 consecutive patients were analyzed.

RESULTS

The median follow-up was 84.8 months. Radiation dose did not differ significantly as a function of sex, type of SP (solitary bone plasmacytoma or as extramedullary plasmacytoma), tumor size; conversely differs significantly as a function of age (p = 0.04). The 5y-OS and 10y-OS were, respectively, 96 and 91%. Local recurrences developed in 21.4% of patients (9/42). 16 patients progressed to MM (38.1%). The 5y-progression to MM free survival (PMFS) and the 10y-PMFS were, respectively, 68.6 and 61.9%.

CONCLUSIONS

Our data confirm that good results are achievable with RT to treat SP, but they don't allow defining a dose-effect correlation; therefore, it remains uncertain which is the most effective dose and whether lower doses can guarantee adequate disease control.

The predictive value of serum myeloma protein in solitary plasmacytoma

Purpose

To identify the clinical usefulness of serum M protein and to establish a rationale for regular follow-up with serum protein electrophoresis in solitary plasmacytoma.

Materials and Methods

Sixty-nine patients with solitary plasmacytoma and solitary plasmacytoma with minimal marrow involvement according to the International Myeloma Working Group criteria were retrospectively reviewed.

Results

At a median follow-up of 6.2 years, 5-year local control (LC), 5-year multiple myeloma-free survival (MMFS), 5-year failure-free survival (FFS), and 5-year overall survival (OS) were 82.6%, 44.1%, 41.8%, and 85.1%, respectively. Among the patients whose initial serum M protein was present or not evaluated, 37.3% of patients showed disappearance of serum M protein after various treatment. MMFS of these patients were comparable to non-secretory plasmacytoma with undetectable levels of M protein, and significantly better than patients with persistent M protein. Increase of serum M protein ≥0.1 g/dL was most predictive of treatment failure with area under the curve of 0.731.

Conclusion

Patients who eventually showed persistence of serum M protein after treatment showed worse MMFS and FFS compared to those whose serum M protein disappeared or who had initially non-secretory disease. The increase of serum M protein level ≥0.1 g/dL from current nadir was predictive of treatment failure. Therefore, regular follow-up with serum M protein is highly recommended especially unless the patient had initially non-secretory disease.

Extramedullary Plasmacytoma: Long-Term Clinical Outcomes in a Single-Center in China and Literature Review

The aim is to analyze the clinical outcomes of patients with extramedullary plasmacytoma (EMP) and review the characteristics of this disease. We retrospectively reviewed the clinical data of a cohort of 22 patients diagnosed with EMP between 1983 and 2017. Baseline characteristics and progression data were collected to calculate the incidence of progression to multiple myeloma (MM) and to analyze survival rates and outcomes. Previous major cohort studies were reviewed and compared with this study. Extramedullary plasmacytomas were located in the head and neck in 17 (77%) of the 22 patients. The median time between onset and diagnosis was 7 months, and the median age at diagnosis was 52.5 years (range 15-72 years). Extramedullary plasmacytoma occurred more frequently in men with an approximate ratio of 2.1:1. The majority of patients underwent surgery (13/22, 59.1%) and half received radiation (11/22, 50%). A small proportion of patients received chemotherapy (2/22, 9.1%). There was a median follow-up time of 98.5 months. The 5-year overall survival, progression-free survival, and MM-free survival rates were 84.2%, 67.3% and 75.9%, respectively. Complete resection without major functional damage is a promising option that can favorably improve prognosis in patients with resectable disease. Patients with regional lymph node metastasis or positive immunoelectrophoresis results require more aggressive treatment and may have poorer prognosis.

Retrospective analysis of plasmacytoma in Kansai Myeloma Forum Registry

We retrospectively analyzed 51 patients with solitary plasmacytoma diagnosed from October 2002 to September 2018 from a cohort of 3575 patients with plasma cell dyscrasias registered in the Kansai Myeloma Forum. Twenty-seven patients had solitary bone plasmacytoma (SBP) and 24 had extramedullary plasmacytoma (EMP), with prevalence of 0.8% and 0.7%, respectively. The most frequent M protein was IgG (40%) in SBP, whereas non-secretory proteins were most frequent (50%) in EMP. Five-year overall survival was 78.2% in SBP and 80.8% in EMP (P = 0.894). Among patients with SBP, 44% progressed to MM with a median time of 10.5 months (2.4-93.3 months), whereas 8% of EMP patients progressed to MM with a median time of 18.6 months (13.0-24.2 months). The most frequent treatment was radiotherapy (41%) or observation (41%) in SBP, and chemotherapy (54%) in EMP. No statistically significant difference was observed upon univariate analysis of prognostic factors including age, sex, performance status, and IgG M protein. Our results suggest that there are biological differences between SBP and EMP in real-world settings.

Extramedullary Solitary Plasmacytoma with Anaplastic Features of the Nasopharynx

Extramedullary plasmacytomas (ESPs) are rare forms of plasma cell dyscrasias and usually are seen in the upper aerodigestive tract. ESPs with anaplastic features are extremely rare, and no treatment guidelines exist. We present a 75-year-old gentleman presented with left nasal blockage, and on examination, a polypoid left nasal mass was seen. He was, then, referred to ENT after a CT scan revealed a mass in the left nasopharynx for a biopsy. The preliminary reports suggested a high-grade lymphoma; however, after further testing, it was revealed to be an anaplastic plasma cell neoplasm. PET scan, bone marrow biopsy, serum and urine protein electropheresis, serum immunofixation and light chains were all unremarkable for systemic disease. Differential diagnosis included plasmablastic lymphoma, NK/T cell lymphoma-nasal type, and squamous cell cancers of the head and neck. He was treated with radiation alone given his comorbidities. Given there are no treatment guidelines, we would like to highlight this rare case and discuss different potential management options such as radiation, chemotherapy, surgery, or a combination of different modalities.

Surgical Resection of Solitary Bone Plasmacytoma of Atlas and Reconstruction with 3-Dimensional-Printed Titanium Patient-Specific Implant

BACKGROUND

Solitary plasmacytoma of bone (SPB) is a rare malignancy of localized osseous lesion consisting of neoplastic monoclonal plasma cells. Recommended treatment of SPB includes a combination of surgery and radiation therapy. We present a rare case of SPB lesion in the atlas requiring surgical resection, followed by restoration of atlas stability with a custom 3-dimensional-printed (3DP) patient-specific implant (PSI).

CASE DESCRIPTION

A 57-year-old man presented with severe neck pain. Assessment by radiographs, computed tomography, and magnetic resonance imaging was found to harbor a single osteolytic lesion at the C1 (atlas) vertebra. Diagnostic tumor screening returned negative results. Transoral biopsy suggested solitary plasmacytoma. Spinal instability was apparent-hence the decision for surgical intervention via the retropharyngeal external approach to resect the lesion. Atlas reconstruction and stabilization were achieved using a custom 3DP titanium PSI. Subsequent pathologic findings confirmed plasma cell infiltration of the atlas. Histologic evaluations and cytogenetic risk analysis indicated a non-high-risk SPB. The patient was given localized radiation therapy at 57 Gy in 27 fractions. Her neurologic complaints were subsequently relieved, and mobility was restored 7 days postoperatively.

CONCLUSIONS

No consensus on the appropriate surgical approaches and perioperative strategies for spinal SPB exists. Surgical intervention is recommended when vertebral instability is evident, followed by radiation therapy to minimize local recurrence and/or progression to multiple myeloma. The use of 3D modeling for preoperative planning improves intraoperative accuracy and avoids iatrogenic injuries to vital anatomic structures. Customized 3DP-PSI to restore atlas stability is an effective option for the treatment of spinal SPBs.

Maximizing the Clinical Benefit of Radiotherapy in Solitary Plasmacytoma: An International Multicenter Analysis

Objective: Although local definitive radiotherapy (RT) is considered the standard of care for solitary plasmacytoma (SP), the optimal RT parameters for SP patients have not been defined. The aim of this retrospective study is to analyze the effectiveness of various RT doses, volumes, and techniques, as well as to define the relevant prognostic factors in SP. Methods: Between 2000 and 2019, 84 patients, including 54 with solitary bone plasmacytoma (SBP) and 30 with extramedullary plasmacytoma (EMP), underwent RT at six institutions. Results: The overall RT median dose was 42 Gy (range, 36.0–59.4). The median follow-up period was 46 months. Overall, the local control (LC) rate was 96%, while the complete remission (CR) rate was 46%. The 5-year local relapse-free survival (LRFS), multiple myeloma-free survival (MMFS), progression-free survival (PFS), and overall survival (OS) rates were 89%, 71%, 55%, and 93%, respectively. Using an RT dose above 40 Gy was associated with a higher complete remission (CR) rate and a lower rate of local relapse. Modern irradiation techniques were associated with a trend toward a higher LC rate (98% vs. 87% for conventional, p = 0.09) and a significantly lower local relapse rate (6% vs. 25% for conventional, p = 0.04). However, RT dose escalation and technique did not lead to a significant effect on MMFS, PFS, and OS. Univariate analyses identified several patient characteristics as potentially relevant prognostic factors. In SBP patients, systemic therapy administration was associated significantly with MMFS and PFS rates. Conclusion: Using an RT dose >40 Gy and modern RT techniques may improve the local control and reduce the rate of relapse, without a significant impact on survival rates. The addition of systemic therapies may improve the MMFS and PFS rates of SBP patients.

Solitary Extramedullary Plasmacytoma of the Sphenoid Sinus: A Case Report

Solitary extramedullary plasmacytomas are rare, discrete mass of neoplastic monoclonal plasma cells in the soft tissue with no evidence of multiple myeloma. They constitute 3 % of all plasma cell tumors and less than 1 % of head and neck malignancies. A 43 year old lady presented to our clinic with complains of diplopia and headache for 4 weeks. Computed Tomography scan showed a mass lesion in the sphenoid sinus eroding the sinus floor, right wall, basisphenoid and parasellar area. A biopsy of the mass reported as plasmacytoma. Systemic examination revealed no evidence of dissemination of the disease confirming the diagnosis of a solitary extramedullary plasmacytoma. The patient was subjected to 25 fractions of radiotherapy. Here, we report a rare case of solitary extramedullary plasmacytoma of the sphenoid sinus.

Solitary Plasmacytoma Treated by Lenalidomide-Dexamethasone in Combination with Radiation Therapy: Clinical Outcomes

PURPOSE

The study evaluates the results of the concurrent use of lenalidomide-dexamethasone with intensity modulated radiation therapy (IMRT) for solitary plasmacytoma in terms of toxicity and outcome.

METHODS AND MATERIALS

Forty-six patients were treated for histologically proven solitary plasmacytoma (SP) between June 2007 and June 2018 in our Department (Curie Institute, Paris, France). All patients received IMRT. The median total dose was 40 Gy (range, 40-46). Prescription of concurrent lenalidomide-dexamethasone with radiation therapy was left to the discretion of the referring hematologist-oncologist and started the first day of radiation therapy for 4 cycles.

RESULTS

Twenty-seven solitary plasmacytoma were treated with IMRT alone and 19 with lenalidomide-dexamethasone in association with IMRT. At 5 years, the local control, multiple myeloma-free survival (MMFS), and progression-free survival (PFS) rates were 96.3%, 85.4%, and 60%. MMFS and PFS were significantly higher in the IMRT plus lenalidomide-dexamethasone group compared with IMRT alone group (100% vs 77.1%, P = .02 and 81.7% vs 48.4%, P = .047, respectively). No major toxicity was found in either group.

CONCLUSIONS

Lenalidomide-dexamethasone in association with IMRT in the treatment of solitary plasmacytoma is safe and improves MMFS and PFS. Further prospective and comparative studies are needed to confirm these results.

PET with Fluorodeoxyglucose F 18/Computed Tomography as a Staging Tool in Multiple Myeloma

In the past decade novel treatment options have dramatically prolonged the survival of patients with multiple myeloma. PET combined with computed tomography (CT) is a sensitive and reliable functional imaging tool that enables diagnosis and assessment of response to chemotherapy/radiotherapy, and combines high sensitivity in identifying both lytic lesions and extramedullary soft-tissue masses with the ability to provide reliable prognostic information in the management of patients with myeloma. This review comprises a comprehensive overview of PET with fluorodeoxyglucose F 18/CT imaging in combination with other convenient imaging procedures, and attempts at standardization with emphasis on post-therapy findings in patients with myeloma.

Extramedullary Plasmacytoma of the Right Main Bronchus

Extramedullary plasmacytomas are rare tumors that typically involve the head and neck region. Only three reports exist in the literature of extramedullary plasmacytomas that involve the lower airways. We report the case of a 54-year-old woman with EMP of the right mainstem bronchus treated with sleeve resection.

Nasal plasmacytoma: a rare cause of persistent epistaxis

Extramedullary plasmacytoma (EP) is a rare neoplasm characterized by monoclonal proliferation of plasma cells without features of multiple myeloma. EP constitutes 3% of all plasma cell tumors. Most of the cases of EP occur in the head and neck regions, especially in the aerodigestive tract. We present a case of recurrent epistaxis for 6 months and extensive workup revealed EP of the right nasal cavity. Primary care physicians and otolaryngologists should be aware of this very rare but a plausible cause of epistaxis and keep EP in the differential diagnosis of recurrent epistaxis.

Radiation Therapy for Solitary Plasmacytoma and Multiple Myeloma: Guidelines From the International Lymphoma Radiation Oncology Group

PURPOSE

To develop guidelines for the work-up and radiation therapy (RT) management of patients with plasma cell neoplasms.

METHODS AND MATERIALS

A literature review was conducted covering staging, work-up, and RT management of plasma cell neoplasms. Guidelines were developed through consensus by an international panel of radiation oncologists with expertise in these diseases, from the International Lymphoma Radiation Oncology Group. RT volume definitions are based on the International Commission on Radiation Units and Measurements.

RESULTS

Plasma cell neoplasms account for approximately one-fifth of mature B-cell neoplasms in the United States. The majority (∼95%) are diagnosed as multiple myeloma, in which there has been tremendous progress in systemic therapy approaches with novel drugs over the last 2 decades, resulting in improvements in disease control and survival. In contrast, a small proportion of patients with plasma cell neoplasms present with a localized plasmacytoma in the bone, or in extramedullary (extraosseous) soft tissues, and definitive RT is the standard treatment. RT provides long-term local control in the solitary bone plasmacytomas and is potentially curative in the extramedullary cases. This guideline reviews the diagnostic work-up, principles, and indications for RT, target volume definition, treatment planning, and follow-up procedures for solitary plasmacytoma. Specifically, detailed recommendations for RT volumes and dose/fractionation are provided, illustrated with specific case scenarios. The role of palliative RT in multiple myeloma is also discussed.

CONCLUSIONS

The International Lymphoma Radiation Oncology Group presents a standardized approach to the use and implementation of definitive RT in solitary plasmacytomas. The modern principles outlining the supportive role of palliative RT in multiple myeloma in an era of novel systemic therapies are also discussed.

Treatment approaches and outcomes in plasmacytomas: analysis using a national dataset

Solitary plasmacytomas are uncommon plasma cell disorders, which may present as a single bone lesion (P-bone) or extramedullary plasmacytoma (P-EM). There is a paucity of large studies analyzing prognostic factors and outcomes of plasmacytomas. While the treatment of choice is radiation therapy (RT), there is a lack of data evaluating optimal RT dose. In this study, we sought to answer these questions by utilizing the National Cancer Database plasmacytoma data from 2000 to 2011. A total of 5056 patients were included in the study (median age 62 years; range 52-72). To obtain a pure plasmacytoma cohort, potential multiple myeloma patients were excluded from the study (bone marrow involvement, systemic chemotherapy use). P-bone constituted 70% of the patients. The median overall survival (OS) of P-EM was significantly longer than P-bone (132 vs. 85 months), and for soft/connective tissue it was worse than remainder of P-EM (82 vs. 148 months). On multivariable analysis, factors associated with worse OS included older age (≥65), presence of P-bone, and treatment with a radiation dose <40 Gy.

Extramedullary plasmacytoma of the trachea: A case report and review of the literature

RATIONALE

Extramedullary plasmacytomas (EMPs) are rare solitary soft tissue tumors characterized by monoclonal proliferation of plasma cells. Most lesions occur in the head and neck, but primary tracheal lesions are very rare.

PATIENT CONCERNS

In this report, we describe a case of tracheal EMP discovered in a 48-year-old man who presented with a history of progressive dyspnea.

DIAGNOSES

Computed tomography (CT) revealed a well-defined nodular mass in the posterior wall of trachea without signs of invasion of the tracheal walls. Then, a reddish mass occluding approximately 90% of the trachea was evidenced by bronchoscopic examination.

INTERVENTIONS

The patient was treated with surgery followed by adjuvant radiotherapy to achieve better local control.

OUTCOMES

After the surgery, there was immediate symptomatic relief. There was no recurrence or metastasis during a 6-month follow-up.

LESSONS

This study presents a rare case of tracheal EMP occluding approximately 90% of the lumen that was successfully managed by surgery followed by radiotherapy.

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.

Solitary Extramedullary Plasmacytoma of the Cricoid Cartilage-Case Report

Solitary plasmacytoma (SP) is an extremely rare form of hematologic malignancy that can be classified as solitary bone plasmacytoma or solitary extramedullary plasmacytoma. Here, we report a patient who presented with progressive shortness of breath and foreign body sensation in his throat. Fluorodeoxyglucose positron emission tomography/computed tomography (¹⁸F-FDG-PET/CT) demonstrated an abnormal FDG-avid soft tissue mass arising from the larynx involving the cricoid cartilage without additional suspicious lesions. Histology revealed an abundance of plasma cells; immunohistochemistry was positive for CD138 expression and lambda chains, and negative for CD20. Comprehensive imaging studies and panendoscopy of the ENT tract confirmed solitary disease involvement. Following additional systemic work-up, a diagnosis of extramedullary plasmacytoma was rendered. The patient underwent definitive radiotherapy using intensity-modulated radiation therapy (total dose of 46 Gy, divided in 23 fractions of 200 cGy). Serial PET/CT showed the stepwise resolution of abnormal FDG uptake and resolution of the cricoid cartilage lesion. With 22 months of follow-up, the patient remains free of disease. We describe the rare case of SP presenting as a FDG-avid hypermetabolic soft tissue mass in the cricoid cartilage, which should be considered in the differential diagnosis of laryngeal tumors. Of note, SP is radiosensitive; favorable outcome can be expected once treated with doses of 40–50 Gy. FDG PET/CT is helpful in diagnosis and response assessment for this disease.

Clinical findings in 25 patients with sinonasal or nasopharyngeal extramedullary plasmacytoma in a four-decade single-centre series

OBJECTIVES

Extramedullary plasmacytoma in the sinonasal tract or nasopharynx is rare. The aim of the study was to review data on symptoms, clinical findings, treatment and follow-up of plasmacytomas in the sinonasal and nasopharyngeal regions in order to delineate the main clinical characteristics and the optimal management.

METHOD

Twenty-five patients with sinonasal or nasopharyngeal plasmacytoma, diagnosed and treated at the Helsinki University Hospital during a 39-year period from 1975 to 2013 were retrospectively reviewed.

RESULTS

There were 18 males and 7 females with a median age of 66 years (range, 36-80). Sixty-eight percent received only radiotherapy or (chemo)radiotherapy. Forty-seven percent of them had a complete response to primary radiotherapy and one patient had a complete response after receiving additional brachytherapy. Four patients were treated primarily with surgery only. Two of them had a local recurrence, but were then successfully treated with radiotherapy. Altogether, four patients received a combination of surgery and (chemo)radiotherapy. Forty-four percent were alive with no evidence of disease after a median follow-up time of 78 months. Forty percent died of their disease and 16% died of other causes.

CONCLUSIONS

Our study supports radiotherapy as a treatment of choice, but for small tumours surgery alone or in combination with radiotherapy may also be considered.

Solitary Plasmacytoma

Solitary plasmacytoma is a rare disease characterized by a localized proliferation of neoplastic monoclonal plasma cells, without evidence of systemic disease. It can be subdivided into solitary bone plasmacytoma if the lesion originates in bone, or solitary extramedullary plasmacytoma if the lesion involves a soft tissue. The incidence of solitary bone plasmacytoma is higher than solitary extramedullary plasmacytoma. Also, the prognosis is different: even if both forms respond well to treatment, overall survival and progression-free survival of solitary bone plasmacytoma are poorer than solitary extramedullary plasmacytoma due to its higher rate of evolution in multiple myeloma. However, the recent advances in the diagnosis of multiple myeloma can better refine also the diagnosis of plasmacytoma. Flow cytometry studies and molecular analysis may reveal clonal plasma cells in the bone marrow; magnetic resonance imaging or 18 Fluorodeoxyglucose positron emission tomography could better define osteolytic bone lesions. A more explicit exclusion of possible occult systemic involvement can avoid cases of misdiagnosed multiple myeloma patients, which were previously considered solitary plasmacytoma and less treated, with an unavoidable poor prognosis.

Due to the rarity of the disease, there is no uniform consensus about prognostic factors and treatment. Radiotherapy is the treatment of choice; however, some authors debate about the radiotherapy dose and the relationship with the response rate. Moreover, the role of surgery and chemotherapy is still under debate. Nevertheless, we must consider that the majority of studies include a small number of patients and analyze the efficacy of conventional chemotherapy; few cases are reported concerning the efficacy of novel agents.

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.

Long-term outcome of patients with solitary plasmacytoma treated with radiotherapy: A population-based, single-center study with median follow-up of 13.7 years

In this single-center, population-based, and retrospective study, we analyzed the outcome of 49 patients with solitary bone plasmacytoma (SBP) and 28 patients with solitary extramedullary plasmacytoma (SEP), all treated with radiotherapy. Laminectomy was performed in 18/30 SBP patients with vertebral involvement and tumour resection in 10 SEP patients. Overall survival and cause of death for each patient were compared to 5 sex-, age-, and residency-matched individuals from the normal population. Response (complete and partial) was achieved in 94% of SBP and 96% of SEP patients. Relapse rates were higher in SBP (65%) compared to patients with SEP (18%) (P < .01). Only one in-field relapse was identified for the whole series. Ten- and 15-year overall survival, progression free survival (PFS) and multiple myeloma free survival (MMFS) for patients with SBP were 60%/41%, 25%/17%, and 33%/33%. Corresponding values for patients with SEP were 67%/54%, 57%/44%, and 91%/91%. SBP patients had significantly shorter PFS and MMFS compared to SEP patients (P < .01 for both). Only two of the SEP patients developed multiple myeloma and no patient in the whole series progressed to multiple myeloma later than 10 years after diagnosis. Unlike for SEP, the major cause of death among SBP patients was multiple myeloma (49%). Compared to matched normal population, no increased risk of death from secondary malignancies or cardiovascular disease was observed. Positive predictors in SBP patients were for overall survival age <60 years, combined laminectomy and radiotherapy and radiotherapy dose >40 gray, for PFS tumour size <6 cm and combined laminectomy and radiotherapy and for MMFS tumour size <6 cm. Radiotherapy confers excellent local control in both SEP and SBP patients; however, the challenge is to prevent development of multiple myeloma in patients with SBP.

Solitary plasmacytoma: population-based analysis of survival trends and effect of various treatment modalities in the USA

Background

Solitary plasmacytoma (SP) is a localized neoplastic plasma cell disorder with an annual incidence of less than 450 cases. Given the rarity of this disorder, it is difficult to conduct large-scale population studies. Consequently, very limited information on the disorder is available, making it difficult to estimate the incidence and survival rates. Furthermore, limited information is available on the efficacy of various treatment modalities in relation to primary tumor sites.

Methods

The data for this retrospective study were drawn from the Surveillance, Epidemiology and End Results (SEER) database, which comprises 18 registries; patient demographics, treatment modalities and survival rates were obtained for those diagnosed with SP from 1998 to 2007. Various prognostic factors were analyzed via Kaplan-Meier analysis and log-rank test, with 5-year relative survival rate defined as the primary outcome of interest. Cox regression analysis was employed in the multivariate analysis.

Results

The SEER search from 1998 to 2007 yielded records for 1691 SP patients. The median age at diagnosis was 63 years. The patient cohort was 62.4% male, 37.6% female, 80% Caucasian, 14.6% African American and 5.4% other races. Additionally, 57.8% had osseous plasmacytoma, and 31.9% had extraosseous involvement. Unspecified plasmacytoma was noted in 10.2% of patients. The most common treatment modalities were radiotherapy (RT) (48.8%), followed by combination surgery with RT (21.2%) and surgery alone (11.6%). Univariate analysis of prognostic factors revealed that the survival outcomes were better for younger male patients who received RT with surgery (p < 0.05). Additionally, patients who received neoadjuvant RT had increased survival rates compared to those receiving adjuvant RT (86% vs 73%, p < 0.05). Furthermore, the analyses revealed that 5-year survival rates for patients with axial plasmacytoma were superior when RT was combined with surgery (p < 0.05). In the multivariate analysis, age <60 years and treatment with either RT or surgery showed superior survival rates. Progression to multiple myeloma (MM) was noted in 551 patients. Age >60 years was associated with a lower 5-year survival in patients who progressed to MM compared to those who were diagnosed initially with MM (15.1 vs 16.6%). Finally, those who received RT and progressed to MM still had a higher chance of survival than those who were diagnosed with MM initially and treated with RT/surgery (21.8% vs 15.9%, p < 0.05).

Conclusions

A review of the pertinent literature indicates that we provided the most comprehensive population-based analysis of SP to date. Moreover, our study contributes to the establishment of the optimal SP treatment modality, as RT is the favored option in frontline settings. Consensus is currently lacking regarding the benefits of combined treatment including surgery. Thus, the findings reported here elucidate the role of primary treatment modalities while also demonstrating the quantifiable benefits of combining RT with surgery in relation to different primary tumor sites. While our results are promising, they should be confirmed through further large-scale randomized studies.

Electronic supplementary material

The online version of this article (doi:10.1186/s12885-016-3015-5) contains supplementary material, which is available to authorized users.

Case Report: Metastatic Infratemporal Soft Tissue Myeloma Presenting as a Numb Lower Lip

This is a case of a patient presenting to his general dental practitioner (GDP) with altered sensation in his lower lip with no obvious cause. Due to a prompt referral, the patient was investigated and diagnosed with an extramedullary presentation of multiple myeloma. A numb lip can present in general dental practice, although this is not common. There are several causes, for example, dental infection or fractured mandible. Clinical relevance: It is very important for the dental practitioner to recognize when there could be a potential sinister underlying cause and prompt referral, under the two week rule referral system, is indicated

Management of extramedullary plasmacytoma: Role of radiotherapy and prognostic factor analysis in 55 patients

Objective

To investigate potential prognostic factors affecting patient outcomes and to evaluate the optimal methods and effects of radiotherapy (RT) in the management of extramedullary plasmacytoma (EMP).

Methods

Data from 55 patients with EMP between November 1999 and August 2015 were collected. The median age was 51 (range, 22-77) years. The median tumor size was 3.5 (range, 1.0-15.0) cm. The median applied dose was 50.0 (range, 30.0-70.0) Gy. Thirty-nine patients (70.9%) presented with disease in the head or neck region. Twelve patients received RT alone, 9 received surgery (S) alone, 3 received chemotherapy (CT) alone, and 3 patients did not receive any treatment. Combination therapies were applied in 28 patients.

Results

The median follow-up duration was 56 months. The 5-year local recurrence-free survival (LRFS), multiple myeloma-free survival (MMFS), progression-free survival (PFS) and overall survival (OS) rates were 79.8%, 78.6%, 65.2% and 76.0%, respectively. Univariate analysis revealed that RT was a favourable factor for all examined endpoints. Furthermore, head and neck EMPs were associated with superior LRFS, MMFS and PFS. Tumor size <4 cm was associated with superior MMFS, PFS and OS; serum M protein negativity was associated with superior MMFS and PFS; age ≥50 years and local recurrence were associated with poor MMFS. The dose ≥45 Gy group exhibited superior 5-year LRFS, MMFS and PFS rates (94.7%, 94.4%, 90.0%, respectively), while the corresponding values for the dose <45 Gy group were 62.5% (P=0.008), 53.3% (P=0.036) and 41.7% (P<0.001).

Conclusions

Involved-site RT of at least 45 Gy should be considered for EMP. Furthermore, patients with head and neck EMP, tumor size <4 cm, age <50 years and serum M protein negativity had better outcomes.

Multiple Myeloma Presenting as Thyroid Plasmacytoma

Thyroid gland and thyroid cartilage infiltration in multiple myeloma (MM) are rare. Here, we discuss a patient who presented with hoarseness of voice and was found to have a hypodense lesion in right lobe of thyroid involving thyroid and cricoid cartilage. Fine-needle aspiration cytology with immunohistochemistry revealed extramedullary plasmacytoma of thyroid. MM was ruled out initially by serum protein electrophoresis, immunofixation, and bone marrow biopsy. Later, lytic lesions were found in multiple bones on radiation planning scan and he was finally diagnosed as case of MM with thyroid involvement. Treatment strategies of MM and thyroid plasmacytoma are also discussed briefly.