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Thalambedu N, Damalcheruvu P, Ogunsesan Y, Patel T, Bachu R, Shrivastava T, Hussain M, Sethi J, Thanendrarajan S. Sixth Nerve Palsy From Multiple Myeloma in Central Nervous System: Case Series and Review of Current Literature. Cureus 2023; 15:e40998. [PMID: 37503472 PMCID: PMC10371386 DOI: 10.7759/cureus.40998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/26/2023] [Indexed: 07/29/2023] Open
Abstract
We reported two cases of the central nervous system (CNS) multiple myeloma (MM) with unusual presentation of sixth nerve palsy. The first patient developed in the setting of newly diagnosed MM and the second patient in the relapsed refractory setting. One underwent surgery, and the other received radiation. Both patients received systemic chemotherapy and noted improvement. We also performed a comprehensive literature review of previously published cases of sixth nerve palsy from MM. This review highlights the importance of recognizing this presentation of CNS multiple myeloma to avoid delays in diagnosis and to get appropriate management in time.
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Affiliation(s)
- Nishanth Thalambedu
- Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, USA
| | | | - Yetunde Ogunsesan
- Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, USA
| | - Tanvi Patel
- Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, USA
| | - Ramya Bachu
- Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, USA
| | - Trilok Shrivastava
- Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, USA
| | - Munawwar Hussain
- Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, USA
| | - Jaskirat Sethi
- Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, USA
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Muacevic A, Adler JR, Sidhu AS, Chang J, Lui F. Isolated Hypoglossal Nerve Palsy Secondary to Oligosecretory Multiple Myeloma. Cureus 2023; 15:e33361. [PMID: 36751257 PMCID: PMC9897323 DOI: 10.7759/cureus.33361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/03/2023] [Indexed: 01/06/2023] Open
Abstract
Isolated hypoglossal nerve (CN XII) palsy is rare. Neurological complications of multiple myeloma (MM) are quite common, most often due to hyperviscosity and paraprotein-related neuropathy. Direct compression of CN XII can be caused by plasmacytoma, yet direct invasion by MM is extremely rare. We are reporting a very unusual case of a 45-year-old man who presented with an isolated right CN XII palsy. The cause revealed by MRI is stenosis of the hypoglossal canal resulting from lytic bony erosion. Despite negative serum and urine protein electrophoresis tests, the final diagnosis of oligosecretory MM was confirmed by serum-free light chain test and bone marrow biopsy. The causes and diagnosis of isolated XII nerve palsy and oligosecretory MM are discussed.
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Łuczkowska K, Kulig P, Baumert B, Machaliński B. Brain-derived neurotrophic factor: focus on the pathogenesis of multiple myeloma and the development of treatment-induced peripheral neuropathy. Leuk Lymphoma 2022; 63:3044-3051. [PMID: 35999712 DOI: 10.1080/10428194.2022.2113535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
For many years, intensive research has been carried out on the in-depth understanding of the pathogenesis of multiple myeloma (MM). Nevertheless, the multifactorial nature of the disease, the development of drug resistance, and the side effects of therapy, make it difficult to effectively treat patients. One of the many factors involved in the pathogenesis of MM is brain-derived neurotrophic factor (BDNF). This factor is widely described as a neuroregenerative and neuroprotective agent, but it also regulates non-neuronal cell functions, such as proliferation, apoptosis, and viability. Therefore, BDNF appears to be a good therapeutic target in MM. On the other hand, its decreased concentration during treatment closely correlates with the development of peripheral neuropathy (PN). BDNF dualism requires a detailed understanding of its action on individual molecular mechanisms. Perhaps the optimization of the BDNF level will contribute to the improvement of MM treatment and the reduction of chemotherapy side effects.
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Affiliation(s)
- Karolina Łuczkowska
- Department of General Pathology, Pomeranian Medical University, Szczecin, Poland
| | - Piotr Kulig
- Department of General Pathology, Pomeranian Medical University, Szczecin, Poland
| | - Bartłomiej Baumert
- Department of Bone Marrow Transplantation, Pomeranian Medical University, Szczecin, Poland
| | - Bogusław Machaliński
- Department of General Pathology, Pomeranian Medical University, Szczecin, Poland.,Department of Bone Marrow Transplantation, Pomeranian Medical University, Szczecin, Poland
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Perillo T, Somma C, Perrotta M, Rivellini F, Barone M, Manto A. Neuroimaging of leptomeningeal myelomatosis: a rare and severe entity. Ann Hematol 2022; 101:2091-2092. [PMID: 35525882 DOI: 10.1007/s00277-022-04860-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 04/28/2022] [Indexed: 11/25/2022]
Affiliation(s)
- Teresa Perillo
- Department of Neuroradiology, "Umberto I" Hospital, Nocera Inferiore, SK, Italy.
| | - Carmela Somma
- Department of Neuroradiology, "Umberto I" Hospital, Nocera Inferiore, SK, Italy
| | - Marianna Perrotta
- Department of Neuroradiology, "Umberto I" Hospital, Nocera Inferiore, SK, Italy
| | - Flavia Rivellini
- Department of Onco-Hematology, "Tortora" Hospital, Pagani, SK, Italy
| | - Marialucia Barone
- Department of Onco-Hematology, "Tortora" Hospital, Pagani, SK, Italy
| | - Andrea Manto
- Department of Neuroradiology, "Umberto I" Hospital, Nocera Inferiore, SK, Italy
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Silverman RF, Hanson L, Salahi N, Li Z, Boruk M, Hodgson NM. Case Report: Cavernous Sinus Syndrome as the Initial Presentation of Multiple Myeloma. FRONTIERS IN OPHTHALMOLOGY 2022; 2:849343. [PMID: 38983538 PMCID: PMC11182293 DOI: 10.3389/fopht.2022.849343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 02/17/2022] [Indexed: 07/11/2024]
Abstract
Multiple myeloma (MM) is the second most common hematologic malignancy and most common primary bone malignancy. Ocular manifestations of MM are extremely rare and may be the first presentation leading to diagnosis. Ophthalmologists routinely encounter cavernous sinus syndrome, and there is a wide range of possible etiologies. Here, we present a case of a patient presenting with diplopia, ptosis, and ophthalmoplegia found to have a cavernous sinus plasmacytoma with systemic workup consistent with MM. MM is a rare cause of cavernous sinus syndrome and should be considered in the setting of a skull base mass.
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Affiliation(s)
| | - Lawrence Hanson
- Department of Ophthalmology, SUNY Downstate, Brooklyn, NY, United States
| | - Navid Salahi
- Department of Pathology, SUNY Downstate, Brooklyn, NY, United States
| | - Zhonghua Li
- Department of Pathology, SUNY Downstate, Brooklyn, NY, United States
| | - Marina Boruk
- Department of Otolaryngology, SUNY Downstate, Brooklyn, NY, United States
| | - Nickisa M Hodgson
- Department of Ophthalmology, SUNY Downstate, Brooklyn, NY, United States
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Hoppe J, Kalckreuth T, Metelmann M, Rumpf JJ, Klagges S, Dietzsch S, Scherlach C, Kuhnt T, Kortmann RD, Seidel C. [Skull base metastases with cranial nerve deficits : Clinical profile of a severe disease]. DER NERVENARZT 2022; 93:812-818. [PMID: 35024880 PMCID: PMC9363291 DOI: 10.1007/s00115-021-01229-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 10/11/2021] [Indexed: 11/30/2022]
Abstract
Hintergrund und Ziele Schädelbasismetastasen sind eine seltene Manifestation onkologischer Erkrankungen. Wenn Hirnnerven beteiligt sind, können schon kleine Läsionen erhebliche funktionelle Beeinträchtigungen hervorrufen. Spezifische klinische Charakteristika wie neurologische Symptome, assoziierte Primärtumoren, Prognose und optimale Therapie der Erkrankung sind schlecht definiert und sollen in dieser Arbeit systematisch dargestellt werden. Methoden Mit einem monozentrischen retrospektiven Ansatz wurden Schädelbasismetastasen bei Patienten, die im Zeitraum von 2006 bis 2018 behandelt wurden, detailliert hinsichtlich klinischer Charakteristika, der durchgeführten Therapie und des weiteren Erkrankungsverlaufs analysiert. Ergebnisse Insgesamt 45 Patienten mit Schädelbasismetastasen und Hirnnervenausfällen wurden erfasst. Die häufigsten Primärtumoren waren Prostatakarzinom (27 %), Mammakarzinom (22 %) und multiples Myelom (16 %). Die am häufigsten betroffenen Hirnnerven waren Nervus trigeminus (42 %), Nervus oculomotorius (33 %) und Nervus facialis (27 %). 84 % aller Patienten wiesen außerhalb der Schädelbasis liegende weitere Knochenmetastasen auf. Eine durale Infiltration oder eine Meningeosis neoplastica lagen bei je 13 % der Patienten vor. Nach Bestrahlung waren 61 % der Patienten hinsichtlich der auf die Schädelbasismetastase zurückzuführenden Symptome klinisch stabil, bei 22 % hatten sich die Symptome gebessert. Das mediane Gesamtüberleben betrug 8 Monate (Spanne: 0,4–51 Monate). Bei Patienten, die mit einer dosiseskalierten Bestrahlung behandelt wurden, bestand eine längere Überlebenszeit (16,4 Monate vs. 4,7 Monate). Dieser Effekt persistierte auch in der multivariaten Analyse unter Berücksichtigung der Faktoren Karnofsky-Index, Metastasenanzahl, Primärtumor und Bestrahlungsdosis (HR 0,37, p = 0,02). Diskussion Schädelbasismetastasen mit Hirnnervenausfällen haben ein vielgestaltiges Bild und oft eine schlechte Prognose. Um potenziell eine Überlebenszeitverbesserung zu erreichen, sind präzise Diagnostik und Therapie Voraussetzung. Prospektive kontrollierte Untersuchungen sind notwendig.
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Affiliation(s)
- J Hoppe
- Department of Radiation-Oncology, University Hospital Leipzig, Leipzig, Deutschland
| | - T Kalckreuth
- Department of Radiation-Oncology, University Hospital Freiburg, Freiburg, Deutschland
| | - M Metelmann
- Department of Neurology, University Hospital Leipzig, Leipzig, Deutschland
| | - J J Rumpf
- Department of Neurology, University Hospital Leipzig, Leipzig, Deutschland
| | - S Klagges
- Sächsisches Krebsregister Leipzig, Leipzig, Deutschland
| | - S Dietzsch
- Department of Radiation-Oncology, University Hospital Leipzig, Leipzig, Deutschland
| | - C Scherlach
- Department of Neuroradiology, University Hospital Leipzig, Leipzig, Deutschland
| | - T Kuhnt
- Department of Radiation-Oncology, University Hospital Leipzig, Leipzig, Deutschland
| | - R D Kortmann
- Department of Radiation-Oncology, University Hospital Leipzig, Leipzig, Deutschland
| | - C Seidel
- Department of Radiation-Oncology, University Hospital Leipzig, Leipzig, Deutschland. .,, Stephanstr. 9a, 04103, Leipzig, Deutschland.
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Sivakolundu KP, Vijaya Prakash A, Savage NM, Kota VK, Zarkua K. A Rare Case of Epidural Myeloma Presenting as Recurrent Subdural Bleeding. Cureus 2021; 13:e17794. [PMID: 34660004 PMCID: PMC8496494 DOI: 10.7759/cureus.17794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2021] [Indexed: 11/09/2022] Open
Abstract
Multiple myeloma (MM) is an incurable clonal B-cell malignancy that usually presents with neoplastic monoclonal plasma cells in either bone or soft tissues. Central nervous system involvement of the myeloma (CNS-MM), such as dural myeloma or intraparenchymal infiltration, or diffuse leptomeningeal involvement, is uncommon. Dural involvement of myeloma without parenchymal or leptomeningeal disease is even rarer, with only seven cases reported previously. We present a case of epidural myeloma in a 50-year-old man with known kappa light chain MM, presenting with multiple episodes of subdural hemorrhage and progressive neurological deficits. He initially presented with severe back pain, hypercalcemia, and acute kidney injury (AKI). Further evaluation showed lytic bone lesions and elevated kappa light chains, and bone marrow biopsy showed 32% of clonal plasma cells. He was initially treated with bortezomib, lenalidomide, and dexamethasone combination, followed by pomalidomide and daratumumab. Eventually, he developed two episodes of subdural hemorrhage and left-sided seventh cranial nerve palsy, which was treated conservatively and monitored by computed tomography (CT) of the head. However, he gradually developed multiple cranial nerve palsies, weakness, and urinary incontinence. Cerebrospinal fluid (CSF) analysis showed elevated protein without any aberrant immunophenotype. Magnetic resonance imaging (MRI) of the brain showed diffuse smooth dural enhancement with extensive calvarial and skull base marrow replacement; MRI of the spine showed diffuse epidural enhancement in thoracic and lumbar regions, findings consistent with epidural myeloma. The patient received three doses of cranial irradiation but, unfortunately, could not tolerate further treatment and opted for hospice care. Intracranial hemorrhage is common in MM patients, and it is important to consider CNS involvement in patients presenting with recurrent subdural hemorrhage and to perform imaging (preferably MRI) earlier in the disease course. Due to its rarity, the treatment of CNS-MM is very heterogeneous. Thus, case reporting is important to accumulate data on this rare presentation.
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Affiliation(s)
- Keerthana P Sivakolundu
- Department of General Medicine, Government Kilpauk Medical College, Chennai, IND.,Department of Hematology and Oncology, Georgia Cancer Center at Augusta University, Augusta, USA
| | - Aviraag Vijaya Prakash
- Department of Hematology and Oncology, Georgia Cancer Center at Augusta University, Augusta, USA
| | - Natasha M Savage
- Department of Pathology, Medical College of Georgia at Augusta University, Augusta, USA
| | - Vamsi K Kota
- Department of Hematology and Oncology, Georgia Cancer Center at Augusta University, Augusta, USA
| | - Kristina Zarkua
- Department of Hematology and Oncology, Georgia Cancer Center at Augusta University, Augusta, USA
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Williams GR, Butala AA, Manjunath SH, Maxwell RJL, Anstadt EJ, Waxman AJ, Jones JA, Plastaras JP, Paydar I. Radiation Therapy for Plasma Cell Disease of the Brain and Skull: Poor Palliation and Survival After Treatment for Central Nervous System Involvement. Adv Radiat Oncol 2021; 6:100720. [PMID: 34409212 PMCID: PMC8360930 DOI: 10.1016/j.adro.2021.100720] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 04/19/2021] [Accepted: 05/03/2021] [Indexed: 11/29/2022] Open
Abstract
Purpose Myeloma lesions of the head can present with central nervous system (CNS) involvement (leptomeningeal disease or brain metastasis), cranial neuropathy (CN), or impending neurologic involvement (INI). We analyzed response and survival after palliative radiation therapy (RT) to the brain and/or skull for myeloma lesions to determine whether CNS involvement fared worse than other RT indications. Methods and Materials We retrospectively analyzed 54 palliative RT courses administered at our institution from 2008 to 2019. Eleven courses were administered for CNS disease, 28 for CN, and 15 for INI. Demographic, disease, and RT variables were recorded as well as clinical response, radiographic response, and survival. Univariate analyses were performed for differences between groups, effects of clinical and RT treatment factors on response, as well as dose response. Survival was analyzed with the Kaplan-Meier method and compared by the log-rank test. Results This heavily pretreated cohort received a median of 20 to 24 Gy, most often to the base of skull, orbit(s), calvarium, or whole brain. Any clinical response (partial or complete vs no response or progressive disease) was significantly more likely for patients with CN and INI when collectively compared with patients with CNS disease (P < .001). Dose response was significant for doses ≥15 and 20 Gy for the whole cohort (P = .026 and .005, respectively) and patients with CN/INI (P = .023 and .002, respectively). Additionally, patients with high-risk cytogenetics were less likely to clinically respond (P = .009). Patients with CNS disease had worse survival (P = .005). Conclusions Patients with leptomeningeal disease/brain metastasis have poor clinical response and survival after RT and their responses do not demonstrate a dose response. Given these poor outcomes, the potential benefit of RT may be limited for some patients who may be alternatively managed by supportive care or short RT courses. Patients with CN/INI have longer survival and better response rates and may benefit from RT courses ≥15 to 20 Gy.
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Affiliation(s)
| | | | | | | | | | - Adam J Waxman
- Division of Medical Oncology, University of Pennsylvania, Philadelphia, Pennsylvania
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