Extramedullary involvement in multiple myeloma

Recurrent Cutaneous Manifestation in Multiple Myeloma

Cutaneous involvement is an uncommonly encountered manifestation in multiple myeloma (MM), more commonly observed in patients with aggressive subtypes, and often resistant to conventional therapies. Due to its infrequency, reported clinical characteristics have been diverse and relatively non-specific. Particularly uncommon is lower extremity involvement. In this case report, we present a unique case of a patient with refractory immunoglobulin G lambda MM, who subsequently developed recurrence in the lower leg, while being on systemic therapy. Initially, the lesion resembled squamous cell carcinoma, posing a diagnostic challenge. Through meticulous histopathological and immunohistochemical evaluation, cutaneous involvement by MM was confirmed. This case highlights the importance of maintaining a high clinical suspicion for cutaneous involvement in patients with MM who present with new skin lesions, as early diagnosis is crucial for appropriate management.

NK Cells in the Lymph Nodes and Their Role in Anti-Tumour Immunity

The lymph nodes are vital to enable adaptive immune responses to infection. Natural killer (NK) cells are cytotoxic lymphocytes that directly kill cancer cells and modulate the activation of other immune cells during anti-tumour immune response. NK cells in the lymph nodes are involved in the regulation of T-cell and B-cell populations and the clearance of viral infections. In solid tumours, lymph nodes are a frequent site of metastasis and immune cell priming, whilst in haematological malignancies, tumour cells can proliferate in the lymph nodes. Thus, lymph nodes are an important site in anti-tumour immunity and therapy resistance. It is therefore crucial to identify strategies to increase recruitment and overcome suppression of NK cells in the lymph node microenvironment to improve tumour clearance. In this review, we summarise the literature interrogating NK cell phenotype and function in the lymph nodes in the context of infection and cancer and evaluate both current and potential strategies to mobilise and activate NK cells within the lymph nodes of cancer patients.

Unveiling Multiple Myeloma: Actively Bleeding Extramedullary Gastric Myelomas Lead to Diagnosis

Multiple myeloma (MM) is a disease of plasma cell replication, leading to a disruption of hematopoiesis, which commonly presents clinically with anemia and fatigue. Extramedullary myelomas are plasma cell collections in bone or soft tissue associated with MM and most often occur later in the disease process. We present a case of a patient with symptomatic anemia with actively bleeding gastric nodules, which were later found to be extramedullary gastric myelomas when pathology demonstrated kappa-restricted plasma cell neoplasms. To confirm the overall diagnosis, a bone marrow biopsy verified the patient had MM.

Impact of extramedullary multiple myeloma on outcomes with idecabtagene vicleucel

Idecabtagene vicleucel (Ide-cel) has demonstrated excellent efficacy and durable responses in patients with relapsed/refractory multiple myeloma (RRMM). However, the outcomes with ide-cel in patients with extramedullary disease (EMD) remain incompletely characterized. We included patients with RRMM treated with ide-cel between May 2021 and April 2023 across 11 US academic institutions. Visceral or soft tissue lesions non-contiguous from bone was classified as EMD. Time-to-event analyses were performed from date of ide-cel infusion. Among 351 patients, 84 (24%) had EMD prior to infusion. The median follow-up from ide-cel infusion was 18.2 months (95% CI: 17-19.3). The day 90 overall response rates (ORR) were 52% vs. 82% for the EMD and non-EMD cohorts, respectively (p < 0.001). The median progression-free survival (PFS) was 5.3 months (95% CI: 4.1-6.9) for the EMD cohort vs. 11.1 months (95% CI: 9.2-12.6; p < 0.0001) for the non-EMD cohort. In a multivariable analysis, EMD was an independent predictor of inferior PFS [hazard ratio 1.5 (1.1-2.2), p = 0.02]. The median overall survival was 14.8 months [95% CI: 9-Not reached (NR)] vs. 26.9 months (26.3 vs. NR, p = 0.006) for the EMD and non-EMD cohorts, respectively. Extramedullary disease represents an independent predictor of inferior day 90 ORR and PFS among patients treated with ide-cel.

Research progress of the chemokine/chemokine receptor axes in the oncobiology of multiple myeloma (MM)

BACKGROUND

The incidence of multiple myeloma (MM), a type of blood cancer affecting monoclonal plasma cells, is rising. Although new drugs and therapies have improved patient outcomes, MM remains incurable. Recent studies have highlighted the crucial role of the chemokine network in MM's pathological mechanism. Gaining a better understanding of this network and creating an overview of chemokines in MM could aid in identifying potential biomarkers and developing new therapeutic strategies and targets.

PURPOSE

To summarize the complicated role of chemokines in MM, discuss their potential as biomarkers, and introduce several treatments based on chemokines.

METHODS

Pubmed, Web of Science, ICTRP, and Clinical Trials were searched for articles and research related to chemokines. Publications published within the last 5 years are selected.

RESULTS

Malignant cells can utilize chemokines, including CCL2, CCL3, CCL5, CXCL7, CXCL8, CXCL12, and CXCL13 to evade apoptosis triggered by immune cells or medication, escape from bone marrow and escalate bone lesions. Other chemokines, including CXCL4, CCL19, and CXCL10, may aid in recruiting immune cells, increasing their cytotoxicity against cancer cells, and inducing apoptosis of malignant cells.

CONCLUSION

Utilizing anti-tumor chemokines or blocking pro-tumor chemokines may provide new therapeutic strategies for managing MM. Inspired by developed CXCR4 antagonists, including plerixafor, ulocuplumab, and motixafortide, more small molecular antagonists or antibodies for pro-tumor chemokine ligands and their receptors can be developed and used in clinical practice. Along with inhibiting pro-tumor chemokines, studies suggest combining chemokines with chimeric antigen receptor (CAR)-T therapy is promising and efficient.

Amyloidoma and Plasmacytoma Presented as a Solitary Lung Nodule in a Patient of Multiple Myeloma With AL-Amyloidosis: A Case Report and Review of Literature

Nodular amyloidoma in the lungs is a rare entity, also the occurrence of extramedullary plasmacytoma (EMP) in the lungs is rare. To have concomitant EMP and amyloidoma presented as a single lung mass is even rarer. There was only one similar case reported in the abstract form previously. Our case did not respond to many novel chemotherapy agents, suggesting that this combination of amyloidoma and plasmacytoma belonged to a poor prognosis entity, requiring different treatment modalities, such as early bone marrow transplantation or CART (chimeric antigen receptors T) therapy.

A Rare Case of Extra-Medullary Portacaval Plasmacytoma in a Patient With Relapsed Multiple Myeloma

Multiple myeloma (Kahler disease) is a monoclonal plasma cell immunoproliferative neoplasm originating within the bone marrow that involves the production of monoclonal immunoglobulins, mostly IgG and IgA. Extramedullary plasmacytoma (EMP) is a subset of plasma cell neoplasms that can develop in patients at the time of diagnosis with multiple myeloma, or relapse of the disease. Symptoms related to plasmacytomas depend on the primary location. Here in, we present a rare case of extramedullary plasmacytoma involving the portacaval space in an 83-year-old African American female with relapsed multiple myeloma. She was treated successfully with radiation therapy with complete resolution of the mass. In this case report, we aim to discuss the clinical features along with diagnostic methods and treatment for extramedullary plasmacytomas with emphasis on utilizing a multidisciplinary approach in managing these rare cases.

Relapse with plasmacytoma after upfront autologous stem cell transplantation in multiple myeloma

Please present P values consistently.Plasmacytoma has been reported to be associated with a poor prognosis in patients with multiple myeloma (MM). In this study, we evaluated the incidence of relapse with plasmacytoma and survival outcomes after upfront autologous stem cell transplantation (ASCT). This study retrospectively analyzed the data of 303 patients with MM who underwent upfront ASCT between April 2000 and April 2018 at eight institutes in the Republic of Korea. In total, 52 patients (17.1%) had plasmacytoma at MM relapse after upfront ASCT, of whom, 27 had paramedullary plasmacytoma (PMD) and 25 had extramedullary plasmacytoma (EMD). Patients with initial plasmacytoma were more likely to have plasmacytoma at MM relapse than those without initial plasmacytoma (37.1% vs. 11.2%). Over a median follow-up of 66.0 months, patients with plasmacytoma at relapse had significantly inferior overall survival (OS) than those without plasmacytoma (43.9 vs. 100.7 months, P < 0.001), but the OS did not significantly differ between patients with EMD and those with PMD (42.2 vs. 56.6 months, P=0.464). After MM relapse, all patients received salvage therapy, and progression-free survival after relapse was significantly shorter in patients with plasmacytoma than in those without (6.4 vs. 12.4 months, P = 0.007). This study showed that plasmacytoma frequently developed at MM relapse after upfront ASCT in patients with plasmacytoma at the time of diagnosis. Plasmacytoma at relapse was significantly associated with a poor prognosis.

Oligosecretory myeloma with gastrointestinal tract involvement: an unusual presentation and literature review

A woman in her 70s with vague gastrointestinal (GI) symptoms and unintentional weight loss was referred to endoscopy clinic for investigation and consideration of GI malignancy. CT of the thorax, abdomen and pelvis showed a suspicious mass in the oesophago-gastric junction with a lytic lesion on S1-S2 sacrum. A subsequent upper GI endoscopy revealed two raised, ulcerated tumours on the lesser curvature of the stomach. By the time an MRI of the whole spine was done which revealed multiple metastases involving thoracic, lumbar and sacral skeleton, she had developed leg weakness and paraesthesias, consistent with the imaging findings. A positron emission tomography/CT scan further confirmed the above findings. The initial working diagnosis was primary GI tumour with bony metastases. However, she was later referred to the haematology team after the immunohistochemistry of the tumour showed that it was of a plasma cell origin (CD138 positive) associated with lambda light chain deposits. Serum-free light chain showed a raised lambda light chain of 272 mg/L and kappa light chain of 11.3 mg/L and involved/uninvolved light chain ratio of 24. Bone marrow biopsy confirmed a plasma cell myeloma with moderate disease burden. Monoclonal lambda chains were demonstrated on immunofixation but negative on serum protein electrophoresis and hence a diagnosis of oligosecretory myeloma with GI involvement was made. Subsequent management involved physiotherapy, pain management and chemotherapy, where this woman was commenced on Velcade (generically known as bortezomib), thalidomide and dexamethasone and she continued to experience clinical and biochemical improvement.

Natural Killer Cells in the Malignant Niche of Multiple Myeloma

Natural killer (NK) cells represent a subset of CD3- CD7+ CD56+/dim lymphocytes with cytotoxic and suppressor activity against virus-infected cells and cancer cells. The overall potential of NK cells has brought them to the spotlight of targeted immunotherapy in solid and hematological malignancies, including multiple myeloma (MM). Nonetheless, NK cells are subjected to a variety of cancer defense mechanisms, leading to impaired maturation, chemotaxis, target recognition, and killing. This review aims to summarize the available and most current knowledge about cancer-related impairment of NK cell function occurring in MM.

Relapsing Extramedullary Multiple Myeloma Presenting As Acute Liver Failure

Extramedullary spread of multiple myeloma was thought to be uncommon but with recent advancements in imaging and increased patient survival, the incidence of the extraosseous disease has risen in living individuals. Despite this, the extraosseous spread of multiple myeloma has been under-diagnosed and under-reported. Timely diagnosis of this extraosseous disease is clinically important, as it indicates a more aggressive disease variant and carries a poor prognosis.

Research progress on treatment of extramedullary multiple myeloma

ABSTRACTObjectives: Extramedullary multiple myeloma (EMM) is a relatively less frequent subentity of multiple myeloma (MM) and is generally considered to be a poor prognostic factor. Novel agents and hematopoietic stem cell transplantation (HSCT) have led to a significant improvement in the progression-free survival and overall survival of patients with MM, but outcomes of EMM remain dismal. Little is known regarding the role of novel therapies in this setting. This review summarizes the current available data regarding the roles of proteasome inhibitors, immunomodulators, monoclonal antibodies, chimeric antigen receptor (CAR)-T cell therapy and HSCT in EMM.Methods: A systematic literature review through PubMed was conducted to summarize the published evidence on the therapeutic developments of novel agents and HSCT in EMM. Literature sources published in English were searched, using the terms multiple myeloma, extramedullary and treatment.Results: Long-term outcomes of EMM patients remain dismal despite the utilization of novel agents and HSCT. The standard therapy of EMM has not been established. EMM should be managed as high-risk disease and treated accordingly.Discussion and conclusion: This review will provide an insight on the current and emerging treatment strategies as well as their efficacy in EMM. Further subgroup analyses in large prospective trials focusing on EMM is needed to help optimize the therapy.

Radiation response of soft-tissue extramedullary plasmacytoma in multiple myeloma-A case report

We report the case of a 79-year-old female patient previously treated for multiple myeloma that was referred to our hospital due to a growing painless right arm tumor. Imaging and pathology results confirmed the diagnosis of extramedullary plasmacytoma. The patient underwent external beam radiotherapy with complete clinical response at follow-up.

Multiple myeloma: therapeutic delivery of antibodies and aptamers

Multiple myeloma is the second most common hematological malignancy in adults, accounting for 2% of all cancer-related deaths in the UK. Current chemotherapy-based regimes are insufficient, as most patients relapse and develop therapy resistance. This review focuses on current novel antibody- and aptamer-based therapies aiming to overcome current therapy limitations, as well as their respective limitations and areas of improvement. The use of computer modeling methods, as a tool to study and improve ligand-receptor alignments for the use of novel therapy development will also be discussed, as it has become a rapid, reliable and comparatively inexpensive method of investigation.

Risk factors in multiple myeloma: is it time for a revision?

Although therapeutic strategies have been adapted to age and comorbidities for a long time, almost all multiple myeloma (MM) patients currently receive similar treatment, whatever their disease risk category. However, high-risk MM patients still constitute an unmet medical need and should benefit from the most efficient drug combinations. Herein, we review and discuss how to optimally define risk and why a revision of the current definition is urgently needed.

Relapsing Multiple Myeloma Presenting as Cardiac Tamponade and Obstructive Uropathy

Cardiac tamponade is a rare manifestation of relapsing extramedullary multiple myeloma and portends poor prognosis. No cases of cardiac tamponade with co-occurring renal obstruction from plasmacytoma have been reported in the literature, making this case a unique presentation of relapsing multiple myeloma. The presence of known malignancy should not limit our differential diagnosis when evaluating patients with signs of cardiac tamponade.

Role and Therapeutic Targeting of SDF-1α/CXCR4 Axis in Multiple Myeloma

Simple Summary

The SDF-1α/CXCR4 axis plays crucial roles in proliferation, survival, invasion, dissemination, and drug resistance in multiple myeloma. This review summarizes the pleiotropic role of the SDF-1α/CXCR4 axis in multiple myeloma and introduces the SDF-1α/CXCR4 axis-targeted therapies in multiple myeloma.

Abstract

The C-X-C chemokine receptor type 4 (CXCR4) is a pleiotropic chemokine receptor that is expressed in not only normal hematopoietic cells but also multiple myeloma cells. Its ligand, stromal cell-derived factor 1α (SDF-1α) is produced in the bone marrow microenvironment. The SDF-1α/CXCR4 axis plays a pivotal role in the major physiological processes associated with tumor proliferation, survival, invasion, dissemination, and drug resistance in myeloma cells. This review summarizes the pleiotropic role of the SDF-1α/CXCR4 axis in multiple myeloma and discusses the future perspective in the SDF-1α/CXCR4 axis-targeted therapies in multiple myeloma.

PET/CT F18-FDG with soft tissue plasmacytomas in multiple myeloma

Multiple myeloma is characterized by malignant proliferation of clonal plasma cells. Usually, appears as a generalized disease but it can present as solitary bone plasmacytoma or a solitary soft tissue mass or extramedullary plasmacytoma. In the case of extramedullary involvement, it could present as soft tissue plasmacytomas and the prognosis is poor. The 18F-FDG PET/CT could be a valuable tool for characterization of the medullary and extramedullary involvement. We present a case of F18-FDG PET/CT with extramedullary involvement with soft tissue plasmacytomas in the setting of MM.

Management of patients with difficult-to-treat multiple myeloma

Newer treatments for multiple myeloma (MM) have improved response rates and survival for many patients. However, MM remains challenging to treat due to the propensity for multiple relapses, cumulative and emergent toxicities from prior therapies and increasing genomic complexity that arises due to clonal evolution. In particular, patients with relapsed/refractory MM often require increased complexity of treatment, yet still experience poorer outcomes compared with patients who are newly diagnosed. Additionally, several patient subgroups, including those with extramedullary disease and patients who are frail and/or have multiple comorbidities, have an unfavorable prognosis and remain undertreated. This review (based on an Updates-in-Hematology session at the 25th European Hematology Association Annual Congress 2020) discusses the management of these difficult-to-treat patients with MM.

Extramedullary relapse of multiple myeloma presenting as a breast lump

Multiple myeloma (MM) involving the breast tissue is rare. We report the case of a 70-year-old woman with a background of previously treated MM in remission presenting with a breast lump. Histology showed a plasma cell neoplasm and subsequent staging investigations showed widespread extramedullary relapse of MM. Despite its rarity, this diagnosis should be considered within the differential diagnosis of breast masses as it can arise de novo or may be the first presenting feature of myeloma. The importance of the multidisciplinary team approach with triple assessment of the breast, as well as recent advances in knowledge regarding extramedullary disease in myeloma and novel treatment approaches in MM are discussed.

Outside the box-Surgery for aggressive plasmacytoma in scar

This report introduces the concept of large-scale surgery and reconstruction when all other medical means of treatment have failed. In select cases, this may act as a mode of buying time and allowing the patient to receive second- or third-line treatments.

Extramedullary Multiple Myeloma with Hepatic Involvement

Hepatic involvement with space-occupying lesions seen in patients with multiple myeloma (MM) is a rare phenomenon. We present two cases of extramedullary multiple myeloma (EMM), with different presentations to highlight the diversity of clinical presentation. Clinically relevant hepatic involvement of myeloma is uncommon and can pose management problems. Hepatic involvement of EMM is indicative of a poor prognosis. Early recognition can help stage and prognosticate the disease.

Clinical Characteristics and Prognostic Analysis of Multiple Myeloma with Extramedullary Disease: A SEER-Based Study

Background

Extramedullary disease (EMD), an infrequent manifestation of multiple myeloma (MM), can present at diagnosis or develop during the disease course. EMD can be clinically divided into bone-related EMD (EMD-B) and soft tissue-related EMD (EMD-S). The purpose of our study is to investigate the clinical characteristics, survival outcomes, and prognostic factors of MM patients with EMD.

Methods

A total of 155 MM patients with EMD were ultimately enrolled in our study by retrieving the Surveillance, Epidemiology, and End Results (SEER) database. The Kaplan–Meier survival curves and log-rank test for overall survival (OS) and myeloma-specific survival (MSS) were conducted to compare each potential variable. Variables with a p value <0.1 in the univariate Cox regression were incorporated into the multivariate Cox model to determine the independent prognostic factors, with a hazard ratio (HR) >1 representing adverse prognostic factors.

Results

The median age at diagnosis was 63 years old. EMD-B occurred in 99 patients (63.90%), while EMD-S occurred in 56 cases (36.10%). Patients with EMD-S had a significant survival disadvantage in MSS (HR = 1.844, 95% CI 1.117–3.042, p = 0.017) and OS (HR = 1.853, 95% CI 1.166–2.942, p = 0.009) compared to those with EMD-B. Patients with EMD interval ≤24 months were at higher risk of death than those with EMD at diagnosis in MSS (HR = 1.885, 95% CI 1.175–3.346, p = 0.042) and in OS (HR = 1.33, 95% CI 1.119–2.529, p = 0.036). Patients with EMD interval >24 months were at a lower risk of death as opposed to those with EMD at diagnosis.

Conclusion

Age at MM diagnosis, site of EMD, and time interval from diagnosis to EMD occurrence were independent prognostic factors in MM patients with EMD. EMD-B bore a better prognosis than EMD-S.

Standardization of 18F-FDG–PET/CT According to Deauville Criteria for Metabolic Complete Response Definition in Newly Diagnosed Multiple Myeloma

PURPOSE

18F-Fluorodeoxyglucose (FDG) positron emission tomography (PET)/computed tomography (CT) is currently the standard technique to define minimal residual disease (MRD) status outside the bone marrow (BM) in patients with multiple myeloma (MM). This study aimed to define criteria for PET complete metabolic response after therapy, jointly analyzing a subgroup of newly diagnosed transplantation-eligible patients with MM enrolled in two independent European randomized phase III trials (IFM/DFCI2009 and EMN02/HO95).

PATIENTS AND METHODS

Two hundred twenty-eight patients were observed for a median of 62.9 months. By study design, PET/CT scans were performed at baseline and before starting maintenance (premaintenance [PM]). The five-point Deauville scale (DS) was applied to describe BM (BM score [BMS]) and focal lesion (FL; FL score [FS]) uptake and tested a posteriori in uni- and multivariable analyses for their impact on clinical outcomes.

RESULTS

At baseline, 78% of patients had FLs (11% extramedullary), 80% with an FS ≥ 4. All patients had BM diffuse uptake (35.5% with BMS ≥ 4). At PM, 31% of patients had visually detectable FLs (2% extramedullary), 24% and 67.7% of them with an FS of 3 and ≥ 4, respectively. At PM, 98% of patients retained residual BM diffuse uptake, which was significantly lower than at baseline (mainly between BMS 2 and 3, BMS was ≥ 4 in only 8.7% of patients). By both uni- and multivariable analysis, FS and BMS < 4 were associated with prolonged progression-free survival (PFS) and overall survival (OS) at PM (OS: hazard ratio [HR], 0.6 and 0.47, respectively; PFS: HR, 0.36 and 0.24, respectively)

CONCLUSION

FL and BM FDG uptake lower than the liver background after therapy was an independent predictor for improved PFS and OS and can be proposed as the standardized criterion of PET complete metabolic response, confirming the value of the DS for patients with MM.

18F-FDG PET/CT in the Evaluation of Solitary Extramedullary Plasmacytoma: A Case Series

The role of fluorine-18-fluorodeoxyglucose positron emission tomography/ computed tomography (¹⁸F-FDG PET/CT) in patients with multiple myeloma (MM) and other plasma cell disorders is well-known. Solitary plasmacytoma (SP), an extremely rare form within this entity accounting for approximately 4% of plasma cell malignancies, can be classified as solitary bone plasmacytoma (SBP) or solitary extramedullary plasmacytoma (SEMP). Extramedullary plasmacytoma (EMP) is a rare neoplasm characterized by the monoclonal proliferation of plasma cells outside the bone marrow. Breast and craniocerebral regions are the uncommon sites of the presentations of EMP, rarely reported in the literature. The most frequent site of presentation is the upper airways. The EMPs have similar pathogenesis as MM; however, they differ in management as they are radiosensitive in nature, and radiotherapy is the preferred treatment modality. As SEMP has a better prognosis than SPB with a lower conversion rate to MM, accurate staging is essential to plan for the treatment. The ¹⁸F-FDG PET/CT has higher sensitivity for the evaluation of treatment response. In the present case series, it was aimed to depict the role of ¹⁸F-FDG PET/CT in newly diagnosed SEMP with different sites of origin to exclude further lesions leading to changes in the treatment plan and treatment response assessment.

Daratumumab efficacy in extramedullary orbital myeloma

Daratumumab is very efficacious in multiple myeloma. Few reports are present about efficacy in extramedullary myeloma. We report here daratumumab efficacy in extramedullary ocular myeloma in a young 46-year-old man diagnosed 3 years earlier and relapse refractory to five previous lines of therapy.

Extramedullary Myeloma of the Uterus on 18F-FDG PET/CT: A Rare Manifestation of Multiple Myeloma

Involvement of the uterus by myeloma is an extremely rare manifestation of extramedullary multiple myeloma (MM), denoting a poor prognosis. Extramedullary MM occurs in 7% to 18% of newly diagnosed patients with MM, and 6% to 20% of patients can develop it later. We present a case of extramedullary MM of the uterus suspected on F-FDG PET/CT as a site of disease recurrence in a 47-year-old woman previously in remission. Further evaluation with pelvic MRI identified an infiltrative process involving the uterus, and subsequent tissue sampling confirmed malignant plasma cell infiltration of the uterus. This case highlights a rare site of myeloma recurrence, which can be detected by F-FDG PET/CT.

Role of Imaging in the Evaluation of Minimal Residual Disease in Multiple Myeloma Patients

The International Myeloma Working Group (IMWG) recently introduced the evaluation of minimal residual disease (MRD) within the multiple myeloma (MM) response criteria, and MRD negativity assessed inside and outside the bone marrow is currently considered the most powerful predictor of favorable long-term outcomes. However, MRD evaluation has thus far relied on flow-cytometry or molecular-based methods, despite the limitations associated with the patchy infiltration of bone marrow (BM) plasma cells and the presence of extra-medullary (EMD). On the contrary, imaging-based sensitive response assessment through the use of functional rather than morphological whole-body (WB) imaging techniques, such as positron emission tomography with computed tomography (PET/CT) and magnetic resonance imaging (MRI), likely is a promising strategy to overcome these limitations in evaluating response to therapy and in the assessment of the MRD status in MM patients. However, despite the significant advances in the development and availability of novel functional imaging techniques for MRD evaluation, a worldwide standardization of imaging criteria for acquisition, interpretation, and reporting is yet to be determined and will be object of future investigations.

A Case with Hepatic Involvement Mimicking Metastatic Disease in Multiple Myeloma

Multiple myeloma is a type of plasma cell disorder and can be seen in different forms. According to current knowledge, it is not a curable disease. Smoldering multiple myeloma (SMM) is an asymptomatic clonal plasma cell disorder and distinguished from monoclonal gammopathy of undetermined significance by a much higher risk of progression to multiple myeloma. We present a 53-year-old female patient who started with SMM which turned into multiple myeloma after four years. Despite 26 cycles of lenalidomide treatment, we performed the second autologous stem transplantation. After 12 years from the diagnosis of the disease, it was transformed into plasma cell leukemia and widespread nodular lesions were seen in the liver. Different presentations could be seen due to malignant plasma cell infiltrations or primary amyloidosis. Liver involvement is one of them and is less common than other organ involvement. We report a case of myeloma presenting with extensive nodular involvement in the liver and misdiagnosed as metastatic disease. It is important because of its rarity and change of the treatment approach.

Quantification of tumor burden in multiple myeloma by atlas-based semi-automatic segmentation of WB-DWI

Background

Whole-body diffusion weighted imaging (WB-DWI) has proven value to detect multiple myeloma (MM) lesions. However, the large volume of imaging data and the presence of numerous lesions makes the reading process challenging. The aim of the current study was to develop a semi-automatic lesion segmentation algorithm for WB-DWI images in MM patients and to evaluate this smart-algorithm (SA) performance by comparing it to the manual segmentations performed by radiologists.

Methods

An atlas-based segmentation was developed to remove the high-signal intensity normal tissues on WB-DWI and to restrict the lesion area to the skeleton. Then, an outlier threshold-based segmentation was applied to WB-DWI images, and the segmented area’s signal intensity was compared to the average signal intensity of a low-fat muscle on T1-weighted images. This method was validated in 22 whole-body DWI images of patients diagnosed with MM. Dice similarity coefficient (DSC), sensitivity and positive predictive value (PPV) were computed to evaluate the SA performance against the gold standard (GS) and to compare with the radiologists. A non-parametric Wilcoxon test was also performed. Apparent diffusion coefficient (ADC) histogram metrics and lesion volume were extracted for the GS segmentation and for the correctly identified lesions by SA and their correlation was assessed.

Results

The mean inter-radiologists DSC was 0.323 ± 0.268. The SA vs GS achieved a DSC of 0.274 ± 0.227, sensitivity of 0.764 ± 0.276 and PPV 0.217 ± 0.207. Its distribution was not significantly different from the mean DSC of inter-radiologist segmentation (p = 0.108, Wilcoxon test). ADC and lesion volume intraclass correlation coefficient (ICC) of the GS and of the correctly identified lesions by the SA was 0.996 for the median and 0.894 for the lesion volume (p < 0.001). The duration of the lesion volume segmentation by the SA was, on average, 10.22 ± 0.86 min, per patient.

Conclusions

The SA provides equally reproducible segmentation results when compared to the manual segmentation of radiologists. Thus, the proposed method offers robust and efficient segmentation of MM lesions on WB-DWI. This method may aid accurate assessment of tumor burden and therefore provide insights to treatment response assessment.

Correlation Between Uptake of 18F-FDG During PET/CT and Ki-67 Expression in Patients Newly Diagnosed With Multiple Myeloma Having Extramedullary Involvement

The aim of this study was to evaluate the relationship of prognosis of patients with multiple myeloma having extramedullary involvement (EMM) with the ¹⁸F- fluorodeoxyglucose(18F-FDG) maximum standardized uptake value and the expression of Ki-67 in biopsy samples. Sixty-five patients were newly diagnosed with multiple myeloma presenting with EMM at our hospital from January 2005 to January 2015. Of these 65 patients, 20 were enrolled in this study. Over the last decade, both the maximum standardized uptake value and Ki-67 expression in these extramedullary lesions significantly correlated with progression-free survival, respectively (P= .039, P =.009). After combining—the maximum standardized uptake value and the Ki-67 expression as an integral—there was a significant correlation between both the overall survival (P = .027) and progression-free survival (P= .014). Patients have poor outcomes when EMM is detected at presentation. Both the maximum standardized uptake value and Ki-67 expression could aid in accurately evaluating EMM patient prognosis.

Single-cell RNA sequencing reveals chemokine self-feeding of myeloma cells promotes extramedullary metastasis

In this study, we aimed to determine the mechanisms underlying the initial extramedullary translocation of myeloma cells from bone marrow into peripheral blood. We found that clonal circulating plasma cells (cPCs) are more frequently detected by flow cytometry in extramedullary plasmacytoma (EMP) patients and worsen their prognosis. It is technically much easier to collect single cPCs using FACS than it is to perform EMP biopsy. Therefore, combining EMP imaging with cPC detection may be a promising strategy for prognostic stratification. Here, using single-cell transcriptome analysis, we found that the chemokine CXCL12, a key molecule involved in CXCR4-dependent cell retention in the bone marrow, is abnormally upregulated in cPCs and might initially enable cPCs to evade bone marrow retention and translocate into the bloodstream.

Hematogenous extramedullary relapse in multiple myeloma - a multicenter retrospective study in 127 patients

The current study assesses the characteristics and outcomes of multiple myeloma (MM) patients, treated with novel agents for hematogenous extramedullary (HEMM) relapse. Consecutive patients diagnosed with HEMM between 2010-2018 were included. Patients' characteristics at diagnosis and at HEMM presentation, response to treatment, survival and factors predicting survival were recorded and analyzed. A group of 127 patients, all diagnosed with HEMM by imaging (87.3%) and/or biopsy (79%), were included. Of those, 44% were initially diagnosed with ISS3, 57% presented with plasmacytomas, and 30% had high-risk cytogenetics. Median time to HEMM was 32 months. In multivariate analysis, ISS3 and bone plasmacytoma predicted shorter time to HEMM (P = .005 and P = .008, respectively). Upfront autograft was associated with longer time to HEMM (P = .002). At HEMM, 32% of patients had no BM plasmacytosis, 20% had non-secretory disease and 43% had light-chain disease. Multiple HEMM sites were reported in 52% of patients, mostly involving soft tissue, skin (29%), and pleura/lung (25%). First treatment for HEMM included proteasome inhibitors (50%), immunomodulatory drugs (IMiDs) (39%), monoclonal antibodies (10%), and chemotherapy (53%). Overall response rate (ORR) was 57%. IMiDs were associated with higher ORR (HR 2.2, 95% CI 1.02-4.7, P = .04). Median survival from HEMM was 6 months (CI 95% 4.8-7.2). Failure to achieve ≥VGPR was the only significant factor for worse OS in multivariate analyses (HR = 9.87, CI 95% 2.35 - 39, P = .001). In conclusion, HEMM occurs within 3 years of initial myeloma diagnosis and is associated with dismal outcome. The IMiDs might provide a higher response rate, and achievement of ≥VGPR predicts longer survival.

Myeloma of Laryngeal Cartilage: Literature Review and Case Study

BACKGROUND

Myeloma of laryngeal cartilage (MLC) is a rare plasma cell neoplasm which has not been well characterized. However, it is an important differential diagnosis of laryngeal cartilage mass as it can indicate the presence of underlying systemic hematological diseases, such as multiple myeloma (MM), that is associated with poor prognosis. This article is the first of its kind and aims to educate clinicians on future diagnosis and management of similar cases.

METHODS

Search of MLC was performed on the medical literature databases of Medline, PUBMED, and EMBASE. Additionally, institutional database at Gold Coast University Hospital Radiology Department was queried for relevant cases. Based on 16 cases that met the inclusion criteria, the etiology, epidemiology, clinical evaluation, investigations, management, and prognosis of MLC was summarized.

RESULTS

Of all, 94% of MLC occur in males and 81% in those older than 60 years. It is more commonly a manifestation of systemic MM, rather than localized extramedullary plasmacytoma (EMP), 81% and 19% respectively. Additionally, 67% of laryngeal EMPs progress to MM within 3 years from initial diagnosis. Although treatments involving both local and systemic therapy were effective at relieving local symptoms, 39% of MLC patients died during the follow-up period-all of which were due to septicemia caused by secondary infections.

CONCLUSION

Myeloma of laryngeal cartilage is a relatively rare condition that requires accurate diagnosis in order to promptly manage the potentially underlying systemic hematological disease. Currently, more case reports and analytical studies are required to provide evidence-based guidance on etiology, diagnosis, and management of this condition.

Blastic variant of plasma cell myeloma mimicking squamous cell carcinoma of the uterine cervix in a super-morbidly obese female

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Plasmablastic plasma cell myelomas of the cervix can mimic the more common cervical squamous cell carcinoma.

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It can be difficult to differentiate plasmablastic lymphoma of the cervix from cervical plasmablastic plasma cell myeloma.

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The clinician must rely on clinical, laboratory, and radiologic findings to diagnose genital plasma cell myeloma.

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Prompt diagnosis of this rare clinical condition can potentially allow timely treatment with systemic chemotherapy.

Comparison of Whole-Body DWI and 18F-FDG PET/CT for Detecting Intramedullary and Extramedullary Lesions in Multiple Myeloma

OBJECTIVE. The purpose of this study was to compare the ability of whole-body (WB) DWI and ¹⁸F-FDG PET/CT in detecting intramedullary and extramedullary lesions in multiple myeloma. MATERIALS AND METHODS. The study included 49 patients with multiple myeloma who had undergone WB DWI and PET/CT. Intramedullary lesions for each region were scored by a scoring system using WB DWI and PET/CT separately. Extramedullary lesions seen separately on WB DWI and PET/CT per patient were recorded. Patients with diffuse lesions of the whole spine seen using both modalities were defined as group A, and those with such lesions seen on WB DWI only were defined as group B. The mean scores assigned to intramedullary lesions using the two modalities, the numbers of extramedullary lesions detected by WB DWI and PET/CT, and the mean percentages of plasma cells in the two patient groups were compared. RESULTS. Scores were higher for WB DWI than for PET/CT in all regions of the body (p < 0.05) except the skull, both in patients with a new diagnosis of multiple myeloma and in previously treated patients. Mean (± SD) percentages of plasma cells were significantly higher in group A than group B (50.458% ± 16.036% vs 18.682% ± 15.524%; p = 0.00). The mean number of extramedullary lesions detected by WB DWI was slightly higher than the mean number detected by PET/CT, although there was no statistical difference (4.48 ± 6.70 vs 4.39 ± 6.46 lesions; p = 0.86). CONCLUSION. For detecting intramedullary lesions, WB DWI is more sensitive than PET/CT in all regions except the skull, both in patients with a new diagnosis and previously treated patients and especially in patients with a low percentage of plasma cells. For detecting extramedullary lesions, WB DWI has sensitivity equivalent to that of PET/CT. The use of both modalities may offer complementary information.

Extramedullary disease in multiple myeloma - controversies and future directions

Extramedullary disease of multiple myeloma (EM) remains a treatment challenge even in the era of new drugs. While many reports analyzing various aspects of EM have been published, mechanism of EM development has not been clarified yet. This review summarizes current knowledge about this clinical entity, including its history, diagnostics, imaging methods, incidence, prognosis, current treatment options, risk factors and known molecular mechanisms that might be involved in pathogenesis of EM.

Imaging in multiple myeloma: How? When?

Bone disease is the most frequent feature of multiple myeloma (MM) and represents a marker of end-organ damage; it is used to establish the diagnosis and to dictate the immediate need for therapy. For this reason, imaging plays a significant role in the management of MM patients. Although conventional radiography has traditionally been the standard imaging modality, its low sensitivity in detecting osteolytic lesions and inability to evaluate response to therapy has called for the use of more sophisticated techniques, such as whole-body low-dose computed tomography (WBLDCT), whole-body magnetic resonance imaging, and ¹⁸F-fluorodeoxyglucose-positron emission tomography/computed tomography (PET/CT). In this review, the advantages, indications of use, and applications of the 3 techniques in the management of patients with MM in different settings will be discussed. The European Myeloma Network and the European Society for Medical Oncology guidelines have recommended WBLDCT as the imaging modality of choice for the initial assessment of MM-related lytic bone lesions. Magnetic resonance imaging is the gold-standard imaging modality for detection of bone marrow involvement, whereas PET/CT provides valuable prognostic data and is the preferred technique for assessment of response to therapy. Standardization of most of the techniques is ongoing.

Intracranial multiple myeloma with intraparenchymal involvement: Case report and literature review

Intraparenchymal extension of multiple myeloma is a rare manifestation of the disease. Here, we present a case of a patient with multiple myeloma lesions situated adjacent to the meninges and intraparenchymally.

Multiple Liver Nodules Mimicking Metastatic Disease as Initial Presentation of Multiple Myeloma

Multiple myeloma is a malignant clonal proliferation of plasma cells in the bone marrow preceded by monoclonal gammopathy of undetermined significance. Initial presentation of multiple myeloma as extramedullary spread in soft tissues particularly in the liver is uncommon. We report a case of a 74-year-old African American female who presented with epigastric pain, hematemesis, elevated alkaline phosphatase, and gamma-glutamyl transferase. Initial impression was peptic ulcer disease; however, ultrasound and CT scan of the abdomen showed multiple liver nodules and perihepatic lymphadenopathy suggestive of metastatic disease. Biopsy of the liver nodules showed CD138 and kappa light chain-restricted positive cells consistent with extramedullary spread of multiple myeloma to the liver. The patient achieved partial response after 6 months of treatment with Velcade, cyclophosphamide, and dexamethasone (VCD). Due to severe neutropenia from cyclophosphamide, regimen was switched to Velcade, Revlimid, and dexamethasone (VRD) which resulted to very good partial response in 1 year which eventually persisted after 4 years. No controlled prospective studies have defined the standard treatment for multiple myeloma with extramedullary spread particularly to the liver. Treatment of multiple myeloma with extramedullary disease follows guidelines for multiple myeloma.

Multiple Cranial Nerve Palsy Concomitant with Leptomeningeal Involvement in Multiple Myeloma: A Case Report and Review of Literature

Neurologic symptoms are quite common in multiple myeloma, but direct invasion of central nervous system is extremely rare. Leptomeningeal multiple myeloma, as a rare neurological manifestation of multiple myeloma, presents with impairment of consciousness, cranial nerve palsies and convulsions. Here, we describe a 52-year- old male patient, known case of multiple myeloma, who presented with bilateral visual loss and difficulty in swallowing.

Extramedullary Involvement of Lymph Nodes in Multiple Myeloma

Myeloma multiplex is a malignant disease of bone marrow plasma cells. It is usually confined to the bone marrow, but in rare cases, patients can develop extramedullary disease. The involvement of lymph nodes is rare and can be a diagnostic challenge. Here, we describe a 36-year-old male patient who presented with abdominal pain and discomfort initially. An abdominal ultrasound followed by computed tomography (CT) revealed retroperitoneal and mesenteric lymph node enlargement. Biopsies of the abdominal lymph node and infiltrated colon showed a plasma cell infiltrate positive for CD79α, CD38, CD138, kappa light chain and VEGF2. Multiple myeloma with extramedullary localization was diagnosed. After six cycles of chemotherapy consisting of doxorubicin, dexamethasone and thalidomide followed by autologous haematopoietic cell transplantation, the patient achieved complete remission. Specifically, a CT scan after therapy showed enlarged lymph nodes in the abdomen, but PET CT scans did not detect any metabolically active foci. Thee years after the completion of therapy, the patient remains in remission. This case illustrates a rare presentation of extramedullary myeloma involving the abdominal lymph nodes, which could have been potentially mistaken for a lymphoid malignancy.

Synchronous colorectal cancer and multiple myeloma with chest wall involvement: Is this a coincidence?

Multiple primary malignant neoplasms (MPMNs) are rare malignant neoplasms that simultaneously or successively occur in the same patient as 2 or more primary malignancies. Currently, an increasing number of cases are being reported. In general, MPMNs more commonly occur as 2 solid tumors or 2 hematological malignancies. Cases of MPMN that involve a solid tumor and a hematological malignancy are rare. Here, we report a case of synchronous colorectal cancer (CRC) and multiple myeloma (MM) with chest wall involvement. After reviewing the literature, we believe that there may be a distinct syndrome involving CRC and MM. The patient in our case study suffered refractory anemia following surgery and 2 cycles of chemotherapy. Initially, the anemia was considered to be a common manifestation of CRC in this patient. Interestingly, although he received a blood transfusion, his hemoglobin levels remained low. He later developed hematuria, proteinuria, multiple osteoporosis in the costal bones, and thrombocytopenia. These new symptoms drew our attention, and we considered a diagnosis of synchronous primary CRC and MM, with the anemia as a symptom of MM. Based on the results of a bone marrow aspirate, MM was confirmed. Therefore, when CRC is associated with refractory anemia, we should not only assume that anemia is a classical symptom of CRC, a result of chronic blood loss, nutritional deficiencies, or myelosuppression due to chemotherapy, but we should also consider that it may reflect the possibility of a coexisting hematologic malignancy. As the treatment of these 2 malignancies is different, early diagnosis and treatment based on definitive diagnosis as early as possible will be beneficial to overall prognosis.

Incidental Discovery of Multiorgan Extramedullary Plasmacytomas in the Setting of Newly Diagnosed Multiple Myeloma and Delayed Hemolytic Transfusion Reaction

Extramedullary plasmacytomas (EMPs) are defined by the presence of clonal plasma cell proliferation outside of the bone marrow, portending an overall poor prognosis. This case highlights extramedullary plasmacytomas as an unusual presenting manifestation of multiple myeloma. Through incidental discovery during a delayed hemolytic transfusion reaction workup, EMPs were found in the liver, spleen, and possibly the lung. Though rare at presentation, this case emphasizes that the presence of EMPs should be considered at the outset as it not only impacts the treatment regimen for such patients but also considerably affects prognosis.

International Myeloma Working Group consensus criteria for response and minimal residual disease assessment in multiple myeloma

Treatment of multiple myeloma has substantially changed over the past decade with the introduction of several classes of new effective drugs that have greatly improved the rates and depth of response. Response criteria in multiple myeloma were developed to use serum and urine assessment of monoclonal proteins and bone marrow assessment (which is relatively insensitive). Given the high rates of complete response seen in patients with multiple myeloma with new treatment approaches, new response categories need to be defined that can identify responses that are deeper than those conventionally defined as complete response. Recent attempts have focused on the identification of residual tumour cells in the bone marrow using flow cytometry or gene sequencing. Furthermore, sensitive imaging techniques can be used to detect the presence of residual disease outside of the bone marrow. Combining these new methods, the International Myeloma Working Group has defined new response categories of minimal residual disease negativity, with or without imaging-based absence of extramedullary disease, to allow uniform reporting within and outside clinical trials. In this Review, we clarify several aspects of disease response assessment, along with endpoints for clinical trials, and highlight future directions for disease response assessments.

Neuro-Myelomatosis of the Brachial Plexus - An Unusual Site of Disease Visualized by FDG-PET/CT: A Case Report

Patient: Female, 63

Final Diagnosis: Extramedullary involvement of multiple myeloma

Symptoms: Right shoulder/upper arm, neuropathic pain

Medication: High-dose dexamethasone therapy

Clinical Procedure: FDG PET/CT

Specialty: Hematology • Nuclear Medicine