Outcome prediction by interim positron emission tomography and IgM monoclonal gammopathy in diffuse large B-cell lymphoma

In diffuse large B-cell lymphoma (DLBCL), a positive interim positron emission tomography (PET) scan predicts treatment failure, but the proportion of high-risk patients thus identified is small. To improve prediction, we combined the interim PET result with the presence or absence of an associated IgM gammopathy. Of 108 DLBCL patients participating in a prospective trial, nine (8%) were interim PET positive and 19 (18%) had an IgM gammopathy. The monoclonal protein was not associated with distinguishing genetic features, and its light chain restriction was not always concordant with the light chain restriction of the lymphoma. The information provided by interim PET and IgM gammopathy was combined to dichotomize the population into sizeable high-risk (1-2 adverse factors) and low-risk groups (no adverse factor) with widely different outcomes (population size, 25% vs. 75%; 3-year risk of progression, 51% vs. 10%; 3-year overall survival, 64% vs. 95%). Multivariable analyses including established risk factors revealed the interim PET result and the IgM gammopathy status to be the only factors significantly associated with outcome. Information about interim PET response and IgM gammopathy may be useful in studies testing risk-adapted treatment strategies.

18F-FDG PET/CT in monoclonal plasma cell disorders

Plasma cell disorders are a heterogeneous group caused by the monoclonal proliferation of lymphoplasmacytic cells in the bone marrow. Multiple Myeloma (MM) is the most serious and prevalent plasma cell dyscrasia, with a median age of onset of 60 years.MM displays significant genetic, biological and clinical heterogeneity with subsequent imaging heterogeneity, evident in contemporary imaging modalities (PET/CT and MRI). Evidence suggests that MM is always preceded by precursor stages of monoclonal gammopathy of undetermined significance (MGUS) and smoldering multiple myeloma.

Internal Organ Involvement in IgG4-related Sialadenitis: A Systemic Review

OBJECTIVE

To provide an overview of internal organ involvement (IOI) in immunoglobulin G4-related sialadenitis (IgG4-RS) patients, with a focus on the prevalence and clinical features of IOI, the analysis of serum IgG4 levels in patients with or without IOI, and the usefulness of positron emission tomography (PET) for examination of the whole body.

METHODS

A systematic search was performed using PubMed, CNKI, Wanfang Data and CQVIP databases.

RESULTS

A total of 99 articles, including 493 IgG4-RS cases, were analysed in this study. The male-to-female ratio was 1.57:1 and the mean age was 61.67 years. IOI was observed in 71.6% patients, including lesions of the pancreas (38.5%), the biliary system and liver (17.8%), distant lymphadenopathy (20.3%), the respiratory system (15.6%), the urinary system (12.0%) and retroperitoneal fibrosis (11.4%). The lesions could occur homeochronously or metachronously with IgG4-RS. The serum IgG4 levels in the IOI-positive and IOI-negative groups were 1,131 ± 952 mg/dL and 659 ± 843 mg/dL, respectively (P < 0.01). The prevalence of IOI and the number of involved internal organs between the PET and the non-PET groups showed no significant difference (P = 0.399 and P = 0.823, respectively), but were significantly higher in the PET group, amongst patients whose first symptom or chief complaint was salivary gland swelling (P = 0.002 and P = 0.001, respectively).

CONCLUSION

IOI is common in IgG4-RS and almost every organ can be affected. High levels of serum IgG4 represent a potential indicator of IOI. Furthermore, PET is a useful tool for evaluation of the whole body.

Localized or diffuse lesions of the submandibular glands in immunoglobulin g4-related disease in association with differential organ involvement

OBJECTIVES

The purpose of this study was to assess the relationship between the sonographic characteristics of the submandibular glands and organ involvement at the initial presentation in patients with immunoglobulin G4 (IgG4)-related disease.

METHODS

We conducted a retrospective study that included 15 patients who had bilateral swollen submandibular glands and elevated serum IgG4 levels between January 2005 and December 2010.

RESULTS

In all 15 patients, sonography revealed the involvement of both sides of the submandibular glands. The sonographic appearance of each gland was classified into two types: localized tumor-forming and diffuse focal types. On the basis of this typing, all 15 patients were classified into two groups: a group with the localized tumor-forming type observed on one or both sides of the glands (n = 10) and a group with the diffuse focal type present on both sides (n = 5). All 10 patients in the former group had lesions in local exocrine organs, such as the lacrimal and parotid glands, with regional lymphadenopathy. In contrast, all 5 patients in the latter group had lesions in abdominal organs, such as autoimmune pancreatitis and sclerosing cholangitis.

CONCLUSIONS

The sonographic patterns of the submandibular glands in patients with IgG4-related disease can be divided into two types: localized tumor-forming and diffuse focal. The distinctive patient groups defined by the sonographic patterns in both glands were associated with differential organ involvement and thus could be used as indicators of the disease extension and specific organ involvement.

Orbital inflammation with IgG4-positive plasma cells: manifestation of IgG4 systemic disease

OBJECTIVE

To describe clinical, radiographic, and morphologic findings in patients with IgG4-positive cells present on orbital biopsy specimens.

DESIGN

Retrospective review (from January 1, 1993, through December 31, 2006) of patients with orbital biopsy specimens that excluded lymphoma; comparison of patients with and without IgG4-positive cells on immunostaining.

RESULTS

Of 21 patients, 11 had increased IgG4-positive cells (defined as >10 cells on biopsy). Symptoms included eyelid or periocular swelling (8 patients) or proptosis (3 patients), with bilateral involvement in 6 patients. Computed tomographic imaging displayed lacrimal gland mass in 10 patients; 6 patients had lesions in other organs. Two patients had increased serum IgG4 levels. In 10 patients without IgG4-positive cells (≤10 cells on biopsy), 6 had proptosis, 1 had eyelid swelling, 2 had eyelid mass, and 1 had diplopia, all unilateral. None had systemic symptoms. Patients with IgG4-positive cells had longer symptom duration, and their biopsy specimens showed more background fibrosis, lymphoid hyperplasia, plasma cells, and eosinophils.

CONCLUSIONS

The clinical appearance, high incidence of bilateral disease, association with lesions in other organs, and increased IgG4 serum levels in some patients-with an increased number of IgG4-positive cells in the biopsy specimen, which shows more background fibrosis, lymphoid hyperplasia, plasma cells, and eosinophils-indicate that these patients have an orbital manifestation of IgG4-associated systemic disease.

[The value of fluorodeoxyglucose positron emission tomography in multiple myeloma]

The aim of this study was investigate the appearance of multiple myeloma on flurorine--18 fluorodeoxyglucose positron emission tomography (FDG-PET). Furthermore the accuracy of FDG-PET in detecting myeloma lesions and its influence on patient's management were evaluated.

METHODS

Altogether 50 patients, 13 patients with newly diagnosed multiple myeloma with negative radiographs, 4 patients with solitary plasmocytoma, 27 patients in remission with suspected relapse and 6 patients with monoclonal gammopathy of unknown significance (MGUS) with suspicion for multiple myeloma or other malignancy underwent FDG-PET examination. The results of routinely performed radiographs, and MR or CT imaging modalities as well as the clinical course were used for verification of the FDG-PET results.

RESULTS

Focally increased tracer uptake was observed in 3 (23 %) of newly diagnosed myeloma patients with negative radiographs and was verified with CT or MR with followed indication for therapy. The FDG-PET was negative in two cases of newly diagnosed multiple myeloma with negative radiographs, no focal infiltration on MR imagination, but with anemia, high monoclonal imunoglobulin and bone marrow infiltration, which was indication for therapy. In all other cases FDG-PET negativity in asymptomatic myeloma had good prognostic significance; these patients are without progression after with a median follow up 14 (7-20) months. Focally increased tracer uptake was found in 5 of the 27 patients in remission. In 4 cases of them it was due to multiple myeloma relapse, in one case due to ovarial carcinoma. Only in 1 patient the PET-FDP failed to recognize extraosseal progression on the scull. 21 patients had true negative FDG-PET imagination, in 1 case disease relapsed 12 months after FDG-PET examination; the other 20 patients are still without progress of this disease with median follow up 15 (7-20) months. FDG-PET was positive in 2 from the 6 patients with MGUS. In one of them carcinoma of thyreoidea was detected, in second the FDG-PET activity was localized in gut, tumor was verified with CT and colonoscopy.

CONCLUSION

In conclusion, FDG PET might contribute to initial staging of radiographs negative multiple myeloma and might be useful for follow up of patients in remission, especially in consecratory multiple myeloma, or in patients with large plasmocelular tumor (> 5 cm) after concomitant radiochemotherapy.

BaselinTc99-MIBI scanning predicts survival in multiple myeloma and helps to differentiate this disease from monoclonal gammopathy of unknown significance

We performed baselineTc(99)-MIBI scanning in 43 patients with multiple myeloma (MM) and in 31 with monoclonal gammopathy of unknown significance (MGUS) patients. We identified two groups of MM patients whose actuarial survival correlated with low or high MIBI scores. MGUS patients had normal or very low scores.

Scintigraphy using (99m)Tc-MIBI (sestamibi), a sensitive parameter of activity of multiple myeloma

Technetium-99m methoxyisobutylisonitrile ((99m)Tc-MIBI) has been shown to be useful in identifying several types of tumors, such as breast, brain, thyroid gland, malignant lymphomas and multiple myeloma. In this study, 102 patients with multiple myeloma (MM) and 32 patients with monoclonal gammopathy of undetermined significance (MGUS) had been evaluated for correlation between (99m)Tc-MIBI and biochemical and hematological markers of activity of the disease. Significant statistical correlation was found between summary score (SS) of (99m)Tc-MIBI scintigrams and beta2-microglobulin (p<0.001), monoclonal immunoglobulin level MIG (p<0.001), serum thymidinekinase - sTK (p<0.001), CRP (p<0.05) and cross-linked carboxyterminal telopeptide of type I collagen - ICTP (p<0.05) bone marrow plasmocytosis-BMPc (p<0.001) and hemoglobin Hb (p<0.001). All 32 patients with MGUS had physiological activity of (99m)Tc-MIBI scintigrams. Technetium-99m methoxyisobutylisonitrile is a useful indicator of activity of MM and helps in differentiating between multiple myeloma and monoclonal gammopathy of undetermined significance.

Association between monoclonal gammopathy of undetermined significance (MGUS) and diffuse idiopathic skeletal hyperostosis (DISH)

PURPOSE

To determine whether an association exists between monoclonal gammopathy of undetermined significance (MGUS) and diffuse idiopathic skeletal hyperostosis (DISH).

MATERIALS AND METHODS

Radiological studies of skeleton were performed in a series of 76 patients (51 males and 25 females) affected by MGUS, observed in a consecutive period of 36 months. They revealed hyperostotic lesions similar to those described in DISH.

RESULTS

Patients affected by MGUS complicated by DISH were 35 (24 males and 11 females). The prevalence of skeletal hyperostosis (46%) appears higher than that reported by the literature in the general population (mean 15 %). Typically, the vertebral column is the predominant site of abnormalities in MGUS as well as in DISH: involvement of dorsal spine was observed in 16 males and 10 females; cervical spine in 12 males and 4 females, and lumbar in 9 males and 2 females. Peripheral ossifying enthesopathy ("whiskering" in the pelvis) was found in 7 cases, 5 males and 2 females.

CONCLUSIONS

DISH is probably an ossifying diathesis of unknown aetiology; its occurrence in multiple myeloma and especially in MGUS is much higher because it is a fortuitous association. Many causes (accidental, dysmetabolic or degenerative) of DISH-like syndrome complicating dysgammaglobulinemias have been supposed, but at the present time this association remains a mere guess. A pathogenetic "event" responsible for hyperostosis may be supposed: in fact, in MGUS bone stimuli induced by osteoclast activating factor (OAF) and plasma cell proliferation -- even if lower than those observed in multiple myeloma -- are much more prolonged in time (see the slow progression of this condition, before it becomes symptomatic), so that the rate of calcium mobilized from skeleton and localized into soft tissues (i.e., tendons and ligaments) is higher. In this manner, the incidence of DISH-like ossification is higher than that observed in multiple myeloma and in the general population.

Whole-body (18)F-FDG PET identifies high-risk myeloma

The purpose of this study was to evaluate the clinical utility of whole-body PET with (18)F-FDG in patients with multiple myeloma and related monoclonal diseases.

METHODS

Between July 1, 1996, and July 2000, 98 (18)F-FDG PET scans were obtained for 66 patients, with 25 patients having 2 or more scans. The results were compared with routine clinical and staging information, including CT and MRI scans, as indicated. Of the 66 patients, 16 had previously untreated active myeloma, 14 had monoclonal gammopathy of undetermined significance (MGUS), 10 had disease in remission, and 26 had relapsing disease.

RESULTS

Negative whole-body (18)F-FDG PET findings reliably predicted stable MGUS. Of the 14 MGUS patients with follow-up of 3-43+ mo, myeloma has developed in only 1 (7%), at 8 mo. Conversely, the 16 previously untreated patients with active myeloma all had focal or diffusely positive scan findings. Four (25%) of 16 previously untreated patients with positive (18)F-FDG PET findings had negative full radiologic surveys. Another 4 (25%) of 16 patients had focal extramedullary disease. This was confirmed by biopsy or other imaging techniques. Extramedullary uptake also occurred in 6 (23%) of 26 patients with relapse. This extramedullary uptake was a very poor prognostic factor both before treatment and at relapse. For example, median survival was 7 mo for patients with disease relapse. Persistent positive (18)F-FDG PET findings after induction therapy predicted early relapse. In 13 (81%) of 16 patients with relapsing disease, new sites of disease were identified. The (18)F-FDG PET results were especially helpful in identifying focal recurrent disease in patients with nonsecretory or hyposecretory disease amenable to local irradiation therapy, which was used in 6 patients.

CONCLUSION

Whole-body (18)F-FDG PET provides important prognostic information, which is clinically useful and complementary to conventional methods of evaluating plasma cell disorders. (18)F-FDG PET is a unique tool for evaluation of nonsecretory myeloma. Residual or recurrent disease after therapy, especially extramedullary disease, is a poor prognostic factor.

Technetium-99m-sestamibi scintigraphy in multiple myeloma and related gammopathies: a useful tool for the identification and follow-up of myeloma bone disease

BACKGROUND AND OBJECTIVES

Technetium-99m 2-methoxy-isobutyl-isonitrile ((99m)Tc-sestamibi) has recently been proposed as a potential tracer in patients with multiple myeloma (MM), as its increased uptake in the bone marrow has been reported as indicator of myeloma activity. We evaluated the role of (99m)Tc-sestamibi scintigraphy in the detection of myeloma bone disease in MM and related gammopathies, and also assessed its relationship with clinical status and stage of the disease, focusing in particular on the early follow-up of a small series of MM patients treated with high-dose therapy.

DESIGN AND METHODS

Forty-six consecutive patients affected by MM or monoclonal gammopathy of undefined significance (MGUS) were studied by whole body scans obtained 20 minutes after administration of 740 MBq of (99m)Tc-sestamibi. A semiquantitative uptake score was used and scintigraphic findings were correlated with clinical and laboratory data.

RESULTS

All the MGUS patients showed a negative (99m)Tc-sestamibi scan. Among the 32 MM patients (25 with active disease and 7 in clinical remission) 24 showed a positive scan, while 8 presented only a physiologic uptake of the tracer. The uptake score correlated significantly with all the most relevant clinical variables. In the follow-up of 8 MM patients treated with high-dose chemotherapy (99m)Tc-sestamibi closely paralleled the activity of myeloma bone disease. Comparison with X-ray skeletal survey showed discordant results in 14 out of the overall 56 scans obtained (27%), with 10 cases of negative (99m)Tc-sestamibi scans but lytic bone lesions revealed by X-ray (7 of them were in clinical remission), and 4 negative X-ray surveys in patients with positive (99m)Tc-sestamibi scans. Overall sensitivity and specificity of (99m)Tc-sestamibi scintigraphy in detecting myeloma bone disease were 90% and 88%, respectively.

INTERPRETATION AND CONCLUSIONS

This study provides additional evidence indicating that (99m)Tc-sestamibi scintigraphy closely reflects myeloma disease activity in bone marrow, with very high sensitivity and specificity. (99m)Tc-sestamibi scintigraphy is therefore suggested as a reliable new tool for the staging and follow-up of myeloma bone disease.

Late blood pool images after Tc-99m tetrofosmin injection in a patient with monoclonal gammopathy of uncertain significance and immunologic disorders

The authors report a case of abnormal biodistribution of Tc-99m tetrofosmin in a patient with immunologic disorders who underwent rest-stress myocardial perfusion scintigraphy to assess the operative risk for surgery of possible relapse of adenocarcinoma of the left maxillary sinus. The patient had monoclonal gammopathy of uncertain significance with a serum electrophoretic pattern of both monoclonal immunoglobulin A and free kappa light chain components and a mild form of idiopathic immunohemolytic anemia. Two different images at rest after injection of Tc-99m tetrofosmin showed a typical blood-pool pattern with absence of detectable myocardial uptake. Other patients injected with the same batch of radiopharmaceutical showed myocardial uptake. A change of the molecular characteristics of tetrofosmin after the injection could not be a factor, because the values of the main chemical and physical parameters of the blood were in the normal range. Accordingly, the authors propose the hypothesis that the monoclonal immunoglobulin A or the free kappa light chains of this patient accidentally recognized one or more epitopes of the tetrofosmin molecule, binding it with high affinity and causing an abnormal biodistribution, characterized by late blood-pool imaging. No similar experiences have been described in the scientific literature.

Hypocomplementemic panniculitis with paraprotein

Two episodes of severe panniculitis accompanied by fever and an acute phase response were the main clinical features in a patient who had an unusual IgG kappa paraprotein. Both episodes responded promptly to steroids. Complement proteins of the early classical pathway were depleted in the patient's serum, and in vitro experiments indicated that the IgG kappa paraprotein activated complement directly. The association of recurrent panniculitis and paraproteinemia-hypocomplementemia has been described in 2 other patients. It should be recognized since its response to steroids is immediate.

Comparison of MRI and computed tomography in the various stages of plasma cell disorders: correlations with biological and histological findings. Myélome-Midi-Pyrénées Group

OBJECTIVE

Our study had a double aim: (i) to evaluate the sensitivity and the specificity of computed tomography (CT) and magnetic resonance imaging (MRI) in the different stages of plasma cell disorders, and (ii) to correlate CT and MRI with the biological, cytological and histomorphometric parameters.

METHODS

Twenty-four patients with MGUS according to Kyle, 12 patients with stage 1 and 12 with stage 3 myeloma, and 30 age-matched controls underwent MRI (sagittal views of the spine and coronal views of pelvis and femurs), CT (axial views from T10 to L5, sacrum, iliac crests), a histomorphometric study, determination of plasmocyte infiltration, and measurement of paraprotein, B2-microglobulin, the ca/cr ratio and osteocalcin.

RESULTS

Heterogeneous osteopenia with microlacunae seen on CT scan and diffuse decreased signal intensity which remained higher than the signal of the intervertebral disk on T1 weighted sequences (MRI) were not peculiar to myeloma. Lacunae larger than 5 mm with trabecular disruption observed on CT, diffuse decreased signal intensity lower than the disk signal, and a multinodular appearance on MRI, not seen in the controls or in patients with MGUS, were observed in all stage 3 myeloma and in 40% of stage 1 myeloma patients. MGUS and stage 1 myeloma patients with abnormal MRI had a higher monoclonal component, plasma cell percentage and hypercellular bone marrow than those with normal MRI findings. MGUS or stage 1 myeloma patients with abnormal CT had a lower trabecular bone volume than those with normal CT.

CONCLUSIONS

CT and MRI both reveal specific lesions in 40% of stage 1 myeloma patients. These methods are thus complementary in bone and bone marrow studies in myeloma.

[Immunoscintigraphy of bone marrow in plasmacytoma]

In 26 patients with plasmocytoma and 4 patients with benign monoclonal gammopathy bone marrow scintigraphy using 99mTc-labelled monoclonal antigranulocyte-antibodies was performed. Focal marrow defects were found in 18/26 patients with plasmocytoma but in none with benign monoclonal gammopathy. The results in plasmocytoma patients correlated well with the clinical staging system of Durie and Salmon. Quantification showed a suppressed bone marrow uptake ratio in 8/26 patients. A marked bone marrow expansion was present in only 2/26 patients. Bone marrow scintigraphy seems to be a valuable diagnostic tool in patients with plasmocytoma, especially as it is able to visualize the degree of bone marrow infiltration in a single protocol and so allows to follow up patients in a simple noninvasive manner.

High-grade B-cell cerebral lymphoma in a patient with anti-myelin-associated glycoprotein IgM paraproteinemic neuropathy

A 74-year-old woman with a sensory neuropathy and IgM M-protein monoclonal gammopathy of undetermined significance developed a fatal B-cell cerebral lymphoma. CSF protein immunofixation revealed intrathecal secretion of a paraprotein of the same heavy- and light-chain isotypes as the serum monoclonal component (IgM-lambda). Reactivation of Epstein-Barr virus was present in the lymphoma cells. Different factors may be involved in the preferential malignant development of the monoclonal B-cell clone within the CNS.

Bone marrow imaging in plasma cell dyscrasias: review of 130 cases

Skeletal radiography, bone and bone marrow scintigraphy have been performed in 130 patients with plasma cell dyscrasias (119 multiple myeloma, 9 MGUS and 2 Waldenström disease). Our results confirm: 1) that radiography is much more sensitive than scintigraphy in the identification of the lesions typical of myeloma, but in the first stage bone scintigraphy and especially bone marrow scintigraphy are more sensitive than x-ray for the detection of regions affected by focal lesions; 2) that bone scintigraphy is of particular value in detecting some abnormalities in specific sites not fully visualized by x-ray; 3) that bone marrow scintigraphy is a valuable diagnostic tool in the early stage of myeloma, especially for evaluating the progression of the disease, because it is able to demonstrate not only focal lesions, but also bone marrow expansion. We believe that bone marrow scintigraphy may be a useful technique in the early diagnosis and follow-up of multiple myeloma, particularly in the detection of unusual forms (i.e., "smouldering" myeloma), but it remains only an "additional" technique for bone imaging.

[Local 133xenon clearance in the eye and comparative in vitro wash-out time determination in patients with monoclonal gammopathy]

The authors investigated the dependence of the local clearance of 133xenon to the viscosity of the blood. Increase of viscosity of blood compared with decrease of local clearance of 133xenon by patients with monoclonal gammopathy were demonstrated. It was also shown that using the Beta-part of radiation of 133xenon is sufficient for looking for wash-out-times of the anterior eye segment. However, use of 133xenon in isotonic solution is also possible in other ophthalmological diseases for differentiation.

[Plasma cell dyscrasias and diffuse idiopathic skeletal hyperostosis. Is it a merely accidental association?]

The radiologic staging of a series of 144 patients (88 males and 56 females) affected with plasma-cell dyscrasias and observed over a 26-month period, revealed both the well-known bone myeloma-related abnormalities and hyperostotic lesions similar to those described in diffuse idiopathic skeletal hyperostosis. The incidence of skeletal hyperostosis was 31.94%, much higher than that reported in literature for the general population (5%). Typically, the axial skeleton is the most common location for abnormalities in multiple myeloma (MM) as well as in DISH: involvement of the dorsal spine was observed in 65% of cases, the cervical spine was involved in 34.8% of patients, and the lumbar spine in 28.3%. Peripheral ossifying enthesopathy, considered as "whiskering" in the pelvis, was found in 12 cases (8.2%), 7 males and 5 females. DISH was indifferently present in both MM (23 cases), with severe osteolysis (stage III) or simple osteoporosis (stage I), and monoclonal gammopathy of undetermined significance (MGUS) (17 cases), usually without any myeloma-related bone lesions, and in Waldenström disease (4 cases). Many hypotheses are discussed as to the possible pathogenesis (e.g.: accidental, dysmetabolic, or degenerative) of hyperostosis in dysgammaglobulinemias, but, to date, they are no more than mere guesses. DISH is a disorder the etiology of which is still unknown: it is likely to be an ossifying diathesis, but its incidence in both illnesses--which are both plasma-cell dyscarsias--is too high for the association to be accidental. Thus, a pathogenetic factor produced by multiple myeloma can be hypothesized, capable of increasing the so-called idiopathic hyperostosis.

Meningeal infiltration by non-myelomatous IgD-secreting plasma cell dyscrasias

Two cases of meningeal invasion by non-myelomatous plasma cell dyscrasias--a plasma cell leukaemia and an extramedullary plasmacytoma--are described. Both were secretors of IgD paraprotein and both were diagnosed in life, characteristics which we have not found in any other published case of plasma cell leptomeningitis. Analysis of our patients and of another 25 cases suggests as predisposing factors of meningeal invasion the male sex, presentation in the form of plasma cell leukaemia, presence of the IgD paraprotein and tumoral involvement of pleura, lung, pericardium and testicles. Aggressive treatment of this neurological complication controlled the meningeal disorder in some cases. However, the majority died of disseminated disease in spite of systemic chemotherapy. Until an effective treatment can be found, able to maintain remission or cure the systemic disease, prophylaxis of the central nervous system in plasma cell dyscrasias does not appear to be advisable.

Bronchoalveolar lavage plasmacytosis in a patient with a plasma cell dyscrasia

A patient with serum monoclonal gammopathy, Bence-Jones proteinuria, and bone marrow plasmacytosis underwent fiberoptic bronchoscopic study for evaluation of interstitial lung disease. Bronchoalveolar lavage fluid contained 47 percent plasma cells, which were monoclonal by immunoperoxidase staining. This is the first time BAL plasmacytosis has been demonstrated in a patient with a plasma cell dyscrasia.

Plasma cell sclerosis of bone: a spectrum of disease

We describe the clinical, radiographic, and pathologic manifestations of a group of disorders characterized by osteosclerosis in association with plasmacytic infiltration of bone marrow. These conditions include multiple myeloma, plasma cell granuloma, sternocostoclavicular hyperostosis, the POEMS syndrome (plasma cell dyscrasia with polyneuropathy, organomegaly, endocrinopathy, M-protein, and skin changes), and chronic symmetric plasma cell osteomyelitis of childhood. Although clinically unrelated in many respects, features shared by these diseases support the existence of a specific factor linking the plasma cell to local osteogenesis.

The POEMS syndrome: report of three cases with radiographic abnormalities

Three cases of a unique multisystemic syndrome with polyneuropathy, organomegaly, endocrinopathy, M protein, and skin changes (the POEMS syndrome) are presented, along with a review of the literature. Clinical and radiographic features of this syndrome and etiological considerations are discussed. A variety of osteosclerotic lesions, nonspecific pleural effusion and ascites are characteristic radiographic manifestations.