Extramedullary plasmacytoma arising from an adrenal gland

Solitary extramedullary plasmacytoma presenting as an adrenal tumor: case report and literature review

Solitary extramedullary plasmacytoma, an extremely rare case which accounts for about 3% of all plasma cell neoplasms, often occurs in the head and neck region such as para nasal sinuses, nasal cavity and oral cavity, it also occurs in the lymph nodes, lungs, thyroid, intestine, liver, pancreas, testis, breast, or skin. Isolated primary plasmacytoma of adrenal is extremely rare and only nine documented cases have been reported in the literature. We are presenting the 10^th case which is the youngest patient until now with symptoms of fever and hepatosplenomegaly. A 19-year-old female was admitted with an irregular fever for 20 days. After a series of investigations were carried out there were no CRAB symptoms (hypercalcemia, renal failure, anemia and bone lesions), no free light chain and no more than 10% increase in plasma cell on bone marrow examination. Computed tomography (CT) scan revealed a tumor in the left adrenal region, and it was diagnosed to be a solitary extramedullary plasmacytoma on biopsy. She underwent the tumor resection one month after admission and recovered well after operation without fever and was discharged from hospital on the thirteenth post-operative day. She has been followed up for 5 years without any sign and symptom of tumor recurrence. Extramedullary plasmacytoma of adrenal gland in an extremely rare disease and usually diagnosed late in life but it can present in younger patients with variable symptoms. However, the surgical treatment yields excellent long-term results. So, complete surgical resection of the lesion is not only a good diagnostic measure, but also an intent-for-cure treatment for solitary adrenal extramedullary plasmacytoma.

A Giant Solitary Adrenal Plasmacytoma in a Patient with HIV: A Rare Case Report and Review of the Literature

Solitary extramedullary plasmacytoma (EMP) involving the adrenal gland is an extremely rare malignancy. We report a case of a solitary adrenal plasmacytoma in an HIV-positive 50-year-old woman on antiretroviral therapy who presented with a rapidly progressing lumbar left masse. A CT scan objectified a locally advanced left adrenal mass measuring 135mm long axis. A biopsy was taken, and the histopathology with the immunohistochemical study objectified an adrenal gland plasmacytoma. The skeletal survey and the sternal suction biopsy did not show any abnormalities. The diagnosis of a solitary EMP of the adrenal gland was made. There are only 10 cases of solitary adrenal plasmacytoma with only one case associated with an HIV-positive patient reported in the literature. Therefore, this paper is aimed at presenting the second case of an HIV-positive patient diagnosed with solitary adrenal plasmacytoma.

Bilateral extramedullary adrenal plasmacytoma: case report and review of the literature

Extramedullary plasmacytoma (EMP) accounts for only 3% of plasma cell malignancies; others include multiple myeloma, plasma cell leukemia and solitary plasmacytoma of bone. The majority of EMPs are found in the upper respiratory tract. Other sites include the GI tract, bladder, CNS, thyroid, breast, testes, parotid gland, lymph nodes and skin. There are eight cases in the literature of adrenal plasmacytoma, however, only two were bilateral. We describe our recent experience of bilateral adrenal plasmacytoma and review of the literature. While EMP may present as aggressive locally destructive lesions, excellent local control can be achieved in a majority of cases. Follow-up should be lifelong due to risk of progression to multiple myeloma.

Extramedullary plasmacytoma in the presence of multiple myeloma: clinical correlates and prognostic relevance

Objective

We studied the clinical and laboratory features and outcomes of multiple myeloma (MM) with extramedullary plasmocytoma (EP) disease both at diagnosis and during the course of MM.

Patients and methods

Forty-two patients of 467 patients with MM were retrospectively analyzed from both the 100th Hospital of the People’s Liberation Army and Shanghai Changzheng Hospitals. The clinical characteristics, laboratory parameters, responses, risk factors, and outcomes were analyzed.

Results

The median age was 53 years with a male/female sex ratio of 34:8. Twenty-six patients had EP disease at the time of diagnosis, and 16 patients developed EP during the course of the disease. We found that the Durie–Salmon stage, serum lactate dehydrogenase level, beta-2-microglobulin, complete blood counts, albumin, and the type of immunoglobulin (Ig) were not associated with the development of EP disease. Patients who developed EP during the course of MM had a higher ratio of plasmocytes and premature plasmocytes in the bone marrow with lower C-reactive protein level and earlier stage of International Staging System for Lung Cancer at the diagnosis of MM compared with patients who presented with EP at diagnosis. Once the patients developed EP disease, they frequently showed resistance to chemotherapy. With a median follow-up of 30 months, 19 patients were alive. Log-rank univariate analysis showed that patients with EP who had normal C-reactive protein, higher hemoglobin, lower serum lactate dehydrogenase, and stage I of International Staging System for Lung Cancer had longer survival. However, cyclooxygenase multivariate analysis failed to show statistical significance for any factor.

Conclusions

EP disease is the MM end-phase and is not a rare manifestation of MM with a cumulative incidence of 9% of MM. The prognosis is very poor once the diagnosis of EP disease is concurrent with MM.

Adrenal Incidentalomas with Supraphysiologic Response to ACTH Stimulus: A Case Report

We present the diagnostic approach of a patient with adrenal incidentalomas. A 72-year-old African American male had a CT scan of the abdomen showing right and left adrenal masses measuring 5 × 3.5 cm and 3.7 × 2.9 cm, respectively. The patient had negative hormonal workup. The radiologist insisted that the CT findings are consistent with adrenal hyperplasia, and therefore he underwent ACTH stimulation to rule out late-onset congenital adrenal hyperplasia (CAH). The stimulation test revealed that 17-hydroxyprogesterone and 11-deoxycortisol increased to levels high enough to confirm CAH, but cortisol had exaggerated response as well, thus making the diagnosis of CAH unlikely where metabolism is shifted to precursors. Subsequently, the patient underwent screening for Cushing's syndrome (CS) with a dexamethasone suppression test. Patient failed the suppresion test, raising the issue for subclinical CS (SCS), likely due to ACTH-independent macronodular adrenal hyperplasia. Our patient had been diagnosed with MGUS and so far there are only 3 case reports of extramedullary plasmacytoma arising from the adrenals. One was bilateral and one had functional abnormalities. Our differential diagnosis includes subclinical CS with aberrant receptors versus a functioning extramedullary plasmacytoma.

Autologous bone marrow transplanation for extramedullary plasmacytoma presenting as adrenal incidentaloma

Extramedullary adrenal plasmacytoma (EMP) involving the adrenal glands is rarely encountered clinically. We report a A 47-year-old male who presented with bilateral adrenal incidentalomas. After confirming EMP, the patient received two consecutive autologous hematopoietic stem cell transplants (HSCT) using high-dose melphalan. Following HSCT, a serial follow-up helical CT revealed a substantial decrease in the size of both adrenal masses. Serial periodic serum protein and urine electrophoresis and immunofixation showed abrogation of a previously noted monoclonal band. At 50 months follow-up the patient was alive and well. Our patient is the first with EMP to have received an autologous HSCT, which may prove to have a role in therapy due to the immunological effect of the infused donor marrow T-lymphocytes against the clonal proliferation of abnormal plasma cells in extrammedullary sites.This case indicates that an EMP should be added to the differential diagnosis of adrenal incidentalomas.

Uncommon adrenal masses: CT and MRI features with histopathologic correlation

Adrenal glands are common sites of diseases. With dramatically increased use of computed tomography (CT) and magnetic resonance (MR) imaging, more and more uncommon adrenal masses have been detected incidentally at abdominal examinations performed for other purposes. In this article, uncommon adrenal masses are classified as cystic masses (endothelial cysts, epithelial cysts, parasitic cysts, and pseudocysts), solid masses (ganglioneuroma, ganglioneuroblastoma, extramedullary plasmacytoma (EMP), neurilemmoma, and lymphoma), fat-containing masses (myelolipoma, teratoma), and infectious masses (tuberculoma), and the imaging features of these uncommon masses are demonstrated. Although most of these lesions do not have specific imaging features, some fat-containing masses and cystic lesions present with characteristic appearances, such as myelolipoma, teratoma, and hydatid. Combination with histopathologic characteristic of these uncommon masses of adrenal gland, radiological features of these lesions on CT and MR imaging can be accurately understood with more confidences. Moreover, CT and MRI are highly accurate in localization of uncommon adrenal masses, and useful to guide surgical treatments.

Extramedullary plasmacytoma involving the bilateral adrenal glands on MR imaging

We report here on a 64-year-old woman with extramedullary plasmacytoma involving the bilateral adrenal glands. Primary adrenal extramedullary plasmacytoma is extremely rare and only three cases of extramedullary plasmacytoma in the unilateral adrenal gland have currently been reported on. This case is of interest in that the bilateral adrenals were involved. In this article, we present the MRI findings and we briefly review the relevant literature.

Features of extramedullary and extraosseous multiple myeloma: a report of 19 patients from a single center

Extramedullary (EM) localizations at diagnosis or during the course of multiple myeloma (MM) are rare. We conducted a large retrospective study to more accurately describe the clinical and laboratory features of this entity, and the outcome of these manifestations. The charts of 19 eligible patients out of 432 patients with MM were retrieved from the hematology department of the Institut Paoli-Calmettes Cancer Center. Median age was 61 (range: 39-79) with a female/male sex ratio of 8/11. Ten patients were found to have EM and extraosseous tumor at the time of MM diagnosis, and nine patients developed EM tumor during the course of the disease. Neither the stage of the disease, the LDH level, or the type of immunoglobulin (Ig) was found to be associated with the development of EM disease. Patients who developed EM tumor during the course of MM had a lower serum Ig and a higher monoclonal Bence-Jones proteinuria at the diagnosis of MM than patients who presented with EM tumor at diagnosis. Multiple sites were usually involved. Resistance to chemotherapy was frequent and response to thalidomide was poor. Eight out of the 19 patients responded to high-dose chemotherapy. The remaining 11 patients progressed while on therapy. With a median follow-up of 13 months (range: 2-65), six patients are alive, four patients are in partial remission and two patients in present progressive disease. In conclusion, EM tumors are a rare manifestation of MM, with a cumulative incidence of 4.6% of MM. Multiple sites are usually involved. The response to chemotherapy is very poor with a very low response rate to thalidomide. The prognosis is very poor, especially when the diagnosis of EM tumor is concurrent with the diagnosis of MM.

Extramedullary hematopoietic proliferations, extraosseous plasmacytomas, and ectopic splenic implants (splenosis)

Hematopoietic proliferations are well known to present ectopically outside the bone marrow, either in benign or malignant form. As such, they present a distinct problem with respect to morphologic interpretation because of their uncommonality in extramedullary sites and their capacity to simulate other lesions histologically. This review considers extramedullary myeloid tumors ("granulocytic sarcoma," "erythroblastic sarcoma," "megakaryocytic sarcoma"), tumefactive extramedullary hematopoiesis, and the peculiar condition known as "splenosis," with consideration of their clinical, microscopic, and cytohistochemical chararacteristics.

Extraosseous (Extramedullary) Plasmacytoma of the Adrenal Gland

Plasmacytomas are clonal proliferations of atypical plasma cells that manifest a localized osseous or extraosseous growth pattern. Although many represent solitary lesions of bone, fewer arise in extraosseous (extramedullary) tissues. We report a case of a primary extraosseous plasmacytoma of the adrenal gland. Magnetic resonance imaging (MRI) with contrast revealed a 3.5-cm, right adrenal mass with heterogeneous enhancement. Although the mass was small and nonfunctioning, concern for malignancy based on MRI findings prompted laparoscopic resection. Histologic and immunohistochemical findings were consistent with a plasmacytoma. This is the third reported case, to our knowledge, of a primary plasmacytoma of the adrenal gland. The present case is unique in that a contrast MRI was performed, which showed heterogeneous enhancement of the mass, providing further evidence beyond heterogeneous hyperintensity on T2-weighted images for a possible malignant process. Another unique feature is that a biopsy specimen of the lesion was taken, although it was nondiagnostic.