Clinical Characteristics and Prognosis of Multiple Myeloma With Myelomatous Pleural Effusion: A Retrospective Single-Center Study

Quiz case: Abnormal haematopoietic cells in pleural effusion

This case was presented because of the number of plasmablasts in a patient with a medical history of multiple myeloma. Flow cytometry is a "gold standard" technique for the diagnosis of haematological malignancies. This technique works for all fluids and should be performed in effusions (pleural, pericardial, ascites) in cases of suspected haematological malignancy. Alternatively, immunohistochemistry using appropriate markers could be performed if flow cytometry is not available. This case illustrates a pleural infiltration by plasmablasts. Myelomatous cells were characterised by immunocytochemistry and flow cytometry.

Liquid extramedullary disease in multiple myeloma strongly predicts a poor prognosis and is associated with bortezomib resistance gene upregulation

BACKGROUND-AIM

Patients with multiple myeloma (MM) relapse with extramedullary disease (EMD) exhibits an aggressive disease course and poor prognostic features. Myelomatous effusion (ME) is a rare subtype of EMD.

METHODS

In this retrospective study, we analyzed the baseline characteristics and therapies of 14 EMD patients relapse with ME and 21 EMD patients relapse without ME.

RESULTS

Patients with ME relapse demonstrated higher concentrations of serum lactate dehydrogenase, a higher fraction in the International Staging System stage III, and poorer event-free survival (EFS) (9.3 vs. 36.57 months; P = 0.0013) and overall survival (OS) (12.06 vs. 42.64 months; P < 0.001). The multivariate analysis showed that the presence of ME (hazard ratio [HR] 12.57; P = 0.003) and lack of autologous hematopoietic stem cell transplantation therapy (HR 4.382; P = 0.014) were predictive factors for poor OS. Using single-cell RNA sequencing, we discovered several bortezomib resistance genes were highly expressed in extramedullary malignant plasma cells.

CONCLUSIONS

The presence of ME strongly predicts a poor prognosis in patients with MM relapse with EMD, and bortezomib resistance genes are highly expressed in extramedullary malignant plasma cells.

Massive Myelomatous Pleural Effusion With Contralateral Mediastinal Shift: A Unique Presentation of Extramedullary Myeloma

Multiple myeloma (MM) is a relatively common malignancy that primarily affects the bone marrow, while extramedullary disease (EMD) occurs in the skin and muscle, lung pleura, lymph nodes, liver, and CNS. Myelomatous pleural effusion (MPE) is a rare extramedullary manifestation of MM in which pleural fluid is composed almost entirely of abnormal plasma cells. MPE and other types of EMD are associated with poor prognosis, and MPE can present emergently due to tension physiology. We report a case of a patient with massive MPE presenting with contralateral midline shift. There are exceedingly few such cases and this report highlights a unique presentation of this rare clinical entity. Epidemiology, radiographic features, diagnosis, treatment, and implications for the prognosis of the disease are discussed.

A Case of Plasmablastic Multiple Myeloma With Extramedullary Disease Manifesting as a Myelomatous Pleural Effusion

Multiple myeloma (MM) is a neoplasm of plasma cell origin characterized by the proliferation of immunoglobulin-producing plasma cells in the bone marrow. Extramedullary disease (EMD) occurs in approximately 10% of patients with MM. Myelomatous pleural effusion (MPE) is a possible manifestation of EMD and has been associated with a poorer prognosis. A 66-year-old female was evaluated after an abnormal serum protein electrophoresis that showed a 2.1 g/dL M-spike in the gamma region, highly suggestive of plasma cell dyscrasia. Imaging subsequently confirmed the bony metastasis. A bone marrow biopsy confirmed plasmablastic MM, and she was started on chemotherapy. She presented three months later with bilateral pleural effusions, with cytology revealing neoplastic plasmacytoid cells. Despite transitioning to dexamethasone, cyclophosphamide, etoposide, and cisplatin (the V-DCEP regimen) due to disease progression, her myeloma remained refractory to treatment, and she expired one month later. MPE in MM is associated with a poor prognosis, with a median overall survival (OS) of 13 months in MPE compared to 37 months in other EMDs. A higher tumor burden and greater multisite extra-medullary lesions are also characteristics of MPE in MM. There is no standard of care for the management of EMD, and salvage regimens such as RVD and V-DCEP are commonly employed. The management of MM with EMD remains a challenge, and more investigation is required before effective treatment regimens may be employed in this setting.