Extramedullary facial plasmacytomas with anaplastic features: a diagnostic dilemma with implications for treatment

Rare case of anaplastic plasmacytoma in the sinonasal tract

BACKGROUND

Extramedullary plasmacytomas are tumors that develop from plasma cells and rarely express anaplastic features. To our knowledge, there have only been three reported cases of anaplastic plasmacytomas of the sinonasal tract in the English literature. We detail the fourth case.

METHODS

A 70-year-old male was seen with a 4-month history of nasal congestion, bloody mucous, and left sided nasal obstruction. On positron emission tomography/computed tomography, the lesion was FDG-avid with an SUV_max of 25.1. A biopsy of the lesion and subsequent immunohistochemical staining confirmed the diagnosis of an anaplastic plasmacytoma.

RESULTS

The patient is undergoing a 5-week course of curative-intent radiation therapy.

CONCLUSION

Extramedullary plasmacytomas with anaplastic features are very rare. We highlight the value of thorough histopathological review and detailed immunostains to arrive at a diagnosis of anaplastic extramedullary plasmacytoma.

Exosome-carried microRNA-based signature as a cellular trigger for the evolution of chronic lymphocytic leukemia into Richter syndrome

Even if considered a cumulative and not a proliferative CD5+ B-cell neoplasm, chronic lymphocytic leukemia (CLL) has a proliferation rate higher than that recognized earlier, especially in the lymphoid tissues. Some patients with CLL develop a clinical syndrome entitled Richter syndrome (RS). Understanding CLL genetics and epigenetics may help to elucidate the molecular basics of the clinical heterogeneity of this type of malignancy. In the present project we aimed to identify a microRNA species that can predict the evolution of therapy-resistant CLL towards RS. In the first phase of our study, microRNA-19b was identified as a possible target, and in the second phase, we transfected three different CLL cell lines with microRNA-19b mimic and inhibitor and assessed the potential role on leukemia cells in vitro. The mechanism by which miR-19b acts were identified as the upregulation of Ki67 and downregulation of p53. This was further supported through RT-PCR and western blotting on CLL cell lines, as well as by next generation sequencing on two patients diagnosed with CLL that evolved into RS.

Richter syndrome in chronic lymphocytic leukemia: updates on biology, clinical features and therapy

Richter syndrome (RS) or Richter transformation is the development of secondary aggressive lymphoma in the setting of underlying chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL). Most frequently CLL transforms into diffuse large B-cell lymphoma (DLBCL) (90%) and rarely (10%) into Hodgkin lymphoma, termed Hodgkin variant of Richter syndrome (HvRS). RS is generally characterized by an aggressive clinical course and poor prognosis. In recent years, major advances have been made in understanding genetic events which relate to the progression of CLL or transformation into RS. Better understanding of the molecular pathways has revealed that RS is not a single homogeneous entity. The majority of cases are clonally related to the original CLL clone, while a minority develop from an unrelated clone. This review summarizes new data relating to the molecular biology and the genetic/epigenetic changes occurring during Richter transformation, and also considers the clinical features and therapy for both DLBCL-RS and Hodgkin variant-RS.

Afectación cutánea específica en pacientes con mieloma múltiple. Estudio clínico-patológico, inmunohistoquímico y citogenético de 40 casos

INTRODUCTION

Specific cutaneous involvement in patients with multiple myeloma is very rare. When it does occur, it is in patients with advanced stages of multiple myeloma and with a large tumorous mass. In this study, we analyzed 40 patients with specific cutaneous involvement from multiple myeloma, with no bony lesions underlying the skin lesions, and we reviewed the related literature.

OBJECTIVES

We were particularly interested in the clinical course of these patients, including survival once skin metastases had developed and the possible influence of the different treatments administered.

MATERIAL AND METHODS

The study was completed by determining the histopathological pattern, the immunohistochemical profile, the type of immunoglobulin and immunoglobulin light chain produced by the neoplastic plasma cells that infiltrated the skin, as well as the cytogenetic characteristics of these cells.

RESULTS

From a clinical standpoint, the skin lesions consisted of multiple nodules or plaques with erythematous or violaceous coloration, and variable location. Histopathologically, two patterns were seen: nodular and diffuse interstitial. The plasma cells showed cytological atypia, and in one case they displayed a spindle shape, giving the lesion a sarcomatoid appearance. Immunohistochemically, these neoplastic plasma cells were strongly positive for CD79a, CD138, and EMA, while the immunoexpression of CD38 and CD43 was less intense and constant. In 39 of the 40 patients, the type of monoclonal immunoglobulin produced by the neoplastic plasma cells in the skin lesions was determined: 18 patients had IgA myeloma (5 IgAkappa and 13 IgAlambda), 19 patients had IgG myeloma (15 IgGkappa and 4 IgGlambda) and 2 patients had IgDlambda myeloma. The 22 cases in which immunoglobulin heavy chain gene rearrangement studies by PCR were carried out for the JH gene showed monoclonal rearrangement, while viral studies to try to identify genetic material of the HHV-8 virus and the Epstein-Barr virus gave negative results in all cases. These 22 cases studied using FISH showed the deletion of the rb-1 retinoblastoma gene in the neoplastic plasma cells that infiltrated the dermis. Despite aggressive chemotherapy, all of the patients died a few months after the skin lesions developed.

CONCLUSIONS

In our series, a perfect correlation was seen between the findings of serum electrophoresis and the immunohistochemistry of the skin lesions with regard to the type of immunoglobulin and the immunoglobulin light chain restriction produced by the neoplastic plasma cells. Patients with multiple myeloma have a very short survival period once specific skin lesions appear, regardless of the therapy administered. The deletion of the rb 1 gene may be a prognosis marker to identify those patients with especially aggressive forms of multiple myeloma.

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.

Soft tissue masses in patients with multiple myeloma: a fine-needle aspiration study of 30 cases with flow cytometry and clinical correlation

BACKGROUND

To the authors' knowledge, the prognostic significance of plasma cell cytology in soft tissue (ST) masses from patients with multiple myeloma (MM) is unknown. Myeloma patients usually are monitored by bone marrow (BM) aspirates and biopsies to assess plasma cell differentiation, tumor burden, and response to treatment. Monitoring of ST lesions by fine-needle aspiration (FNA) is not performed routinely. The objective of the current study was to examine ST masses in MM patients using FNA and to classify and determine the prognostic significance of MM in these lesions based on cytologic features.

METHODS

FNAs of 30 ST masses from 27 patients with a history of MM were examined for disease involvement. In the patients with MM, the cytologic features were evaluated and the lesions were graded as low grade, intermediate grade, or high grade based on the classification of Bartl et al. for MM in BM specimens. Concurrent BM samples as well as cytogenetic and flow cytometric results also were reviewed.

RESULTS

Twenty-seven of the FNA specimens (90%) were positive for MM, and three specimens (10%) were negative (one case each of lipoma, keratinous cyst, and aspergillosis). Among the MM cases, 5 (18.5%) were low grade, 15 (55.6%) were intermediate grade, and 7 (25.9%) were high grade (blastic MM). Simultaneous BM involvement was present in 23.5% of low-grade MM (4 of 17 cases), 35.3% of intermediate-grade MM (6 of 17 cases), and 71% of high-grade MM (5 of 7 cases). Clinically, 10 of 24 patients (42%) died within 9 months (median, 2 months). Patients with high-grade myeloma (blastic MM) in ST masses appeared to have worse survival; 43% (3 of 7 patients) died by a median time of 2 months, compared with 12% of patients with low-grade and intermediate-grade MM (2 of 17 patients).

CONCLUSIONS

FNA of ST masses appears to improve the management of MM patients by providing diagnostic material, samples for ancillary studies, and prognostic information. ST MM can be classified reliably into grades of prognostic significance utilizing the classification of Bartl et al. Intermediate-grade MM was the most frequent subtype present in ST masses.

Metastatic cutaneous plasmacytoma: a case report associated with IgA lambda multiple myeloma and a review of the literature of metastatic cutaneous plasmacytomas associated with multiple myeloma and primary cutaneous plasmacytomas

We present the case of a 67-year-old Japanese woman with immunoglobulin A lambda (IgA lambda) multiple myeloma (MM). She had firm nodular cutaneous lesions on the trunk and scalp without adjacent bone involvement. The patient was diagnosed as having IgA lambda MM of stage IIIA with 52% plasmacytosis in the bone marrow six months before the appearance of the cutaneous lesions. The abnormal plasma cells showed moderate to marked dysplasia in both the bone marrow and skin lesions. The abnormal plasma cells in the bone marrow exhibited abnormal karyotypes: 41, XX, der (1) t (1p; 1q), -4, -10, -14, -16, -17, 17p+, that differed from the "unfavorable" karyotype reported previously. We reviewed the cases of metastatic cutaneous plasmacytoma in MM and cases of primary cutaneous plasmacytoma that have been reported in English or Japanese and identified the Ig class. Among the 83 cases of metastatic cutaneous plasmacytomas in MM, IgG, IgA, IgD, and Bence-Jones protein were found in 52%, 23%, 16%, and 6%, respectively. A disproportionately high frequency of IgD lambda MM was found to have spread to the skin, compared with the frequency of IgD MM itself, which was present in only around 2% of the MM cases. Among the 18 primary cutaneous plasmacytomas, IgG, IgA, and Bence-Jones protein were found in 56%, 11%, and 17%, respectively, but no IgD was found.