Clinical and pathologic findings in 52 consecutively autopsied cases with multiple myeloma

Utilizing 3D Models to Unravel the Dynamics of Myeloma Plasma Cells' Escape from the Bone Marrow Microenvironment

Recent therapeutic advancements have markedly increased the survival rates of individuals with multiple myeloma (MM), doubling survival compared to pre-2000 estimates. This progress, driven by highly effective novel agents, suggests a growing population of MM survivors exceeding the 10-year mark post-diagnosis. However, contemporary clinical observations indicate potential trends toward more aggressive relapse phenotypes, characterized by extramedullary disease and dominant proliferative clones, despite these highly effective treatments. To build upon these advances, it is crucial to develop models of MM evolution, particularly focusing on understanding the biological mechanisms behind its development outside the bone marrow. This comprehensive understanding is essential to devising innovative treatment strategies. This review emphasizes the role of 3D models, specifically addressing the bone marrow microenvironment and development of extramedullary sites. It explores the current state-of-the-art in MM modelling, highlighting challenges in replicating the disease's complexity. Recognizing the unique demand for accurate models, the discussion underscores the potential impact of these advanced 3D models on understanding and combating this heterogeneous and still incurable disease.

Low factor XIII levels and altered fibrinolysis in patients with multiple myeloma

BACKGROUND

Acquired factor FXIII (FXIII) deficiency can be immune- or non-immune mediated and may cause severe bleeding symptoms. The incidence of acquired FXIII deficiency and its etiology in patients with multiple myeloma (MM) are poorly understood.

OBJECTIVES

To assess FXIII levels and the balance of fibrinolysis in newly diagnosed, untreated MM and monoclonal gammopathy of undetermined significance (MGUS) patients.

METHODS

FXIII activity, mixing studies, FXIII-A2B2 antigen, total FXIII-B antigen were measured in platelet-poor plasma from 17 untreated MM patients, 33 untreated MGUS patients, and 30 age and sex-matched healthy controls. Besides routine laboratory measurements, the balance of coagulation and fibrinolysis was evaluated using quantitative fibrin monomer (FM) test, thrombin-antithrombin assay, α2-antiplasmin activity, plasmin-α2-antiplasmin (PAP) complex, D-dimer, plasmin generation assay, clot lysis assay, and ClotPro-TPA test.

RESULTS

FXIII-A2B2 levels were significantly lower in MM patients compared to controls [median (IQR):14.6 (11.2-19.4) vs. 21.8 (17.1-26.4) mg/L, p = 0.0015], whereas total FXIII-B did not differ between groups. Decrease in FXIII activity was parallel to the decrease in FXIII-A2B2. An immune-mediated inhibitory mechanism was ruled out. Free/total FXIII-B was significantly higher in MM patients compared to MGUS and healthy controls, suggesting an etiology of FXIII-A consumption. In MM and MGUS patients, FM, D-dimer, and PAP complex were significantly elevated compared to controls, indicating hypercoagulability and ongoing fibrinolysis.

CONCLUSIONS

Low FXIII levels due to consumption were observed in MM patients at diagnosis. Hypercoagulability and ongoing fibrinolysis were detected in MM and MGUS, indicating that a disturbed hemostasis balance is already present in the latter benign condition.

Recurrence of solitary plasmacytoma in the liver 10 years after the onset of multiple bone lesions

A 79-year-old man presented with a history of solitary plasmacytoma in the bone 10 years ago. Chemoradiotherapy was effective, and remission was maintained with intermittent treatment at relapse of the bone lesions. One year after the last treatment, a follow-up computed tomography (CT) scan revealed multiple liver masses, and a liver biopsy revealed plasmacytoma. There was no clonal plasma cell infiltration in the bone marrow, and the final diagnosis was solitary plasmacytomas of the liver. Although liver involvement is known in relapsed refractory multiple myeloma, solitary plasmacytoma in the relapsed stage confined to the liver is rare, and all previous reports have been from the initial presentation. To the best of our knowledge, this is the first recurrent case of solitary plasmacytoma of the liver.

Bleeding risk in patients with multiple myeloma treated for venous thromboembolism: a MarketScan analysis

Background

Multiple myeloma (MM) is associated with high risk of venous thromboembolism (VTE). Thromboprophylaxis is thoroughly studied in MM. Contrarily, studies assessing the risk of bleeding in people with MM on anticoagulation are lacking.

Objectives

To determine the rate of serious bleeding in patients with MM receiving anticoagulation for VTE and the clinical factors associated with bleeding risk.

Methods

Using the MarketScan commercial database, we identified 1298 people with MM treated with anticoagulation for incident VTE events between 2011 and 2019. Hospitalized bleeding was identified using the Cunningham algorithm. Rates of bleeding were calculated and Cox regression identified risk factors for bleeding.

Results

Bleeding occurred in 51 (3.9%) cases during median follow-up of 1.13 years. Rate of bleeding among patients with MM on anticoagulation was 24.0 per 1000 person-years. In adjusted regression, factors associated with increased bleeding included age (HR, 1.31 per 10-year increase; 95% CI, 1.03-1.65), Charlson comorbidity index (HR, 1.29 per SD increase; 95% CI, 1.02-1.58), use of antiplatelet agents (HR, 2.4; 95% CI, 1.03-5.68), diabetes (HR, 1.85; 95% CI, 1.06-3.26), and renal disease (HR, 1.80; 95% CI, 1.05-3.16). Cumulative incidence of bleeding was 4.7%, 3.2%, and 3.4% for warfarin, low molecular weight heparin, and direct oral anticoagulants, respectively.

Conclusion

In this real-world analysis, the rate of bleeding in people with MM on anticoagulation was comparable to those in other subsets of cancer-related VTE. Bleeding rate was lower with low molecular weight heparin and direct oral anticoagulants than warfarin. Higher comorbidity index, diabetes, antiplatelet agent use, and renal disease were risk factors for serious bleeding.

Clinico-pathological profile of patients with plasma cell neoplasms with special reference to bone marrow fibrosis and amyloid deposition

To clarify the significance of bone marrow fibrosis and amyloid deposition in plasma cell neoplasm, a retrospective cross-sectional study for a period of 3 years was conducted. Patients who underwent bone marrow aspiration and biopsy with suspicion of plasma cell neoplasms were included in the study. The bone marrow findings were correlated with clinical profile of the patient along with biochemical parameters, cytogenetics, Fluorescent in situ hybridization (FISH) wherever available. A total of 273 bone marrow aspirates and biopsies of patients with suspected plasma cell neoplasms were analyzed. There were 181 male patients and 92 female patients (Male: Female = 1.96: 1). There were 245 cases of multiple myeloma (89.7%), 8 cases of primary amyloidosis (2.9%) and 6 monoclonal gammopathy of undetermined significance (MGUS) (2.1%), 5 cases of plasmacytoma (1.8%) and 4 cases of smouldering myeloma (1.4%), 5 cases of POEMS syndrome (1.8%). Bone marrow fibrosis was noted in 12 patients at diagnosis (4.3%). Among the parameters studied, only the mean Hemoglobin was significantly low in patients with marrow fibrosis. Amyloid deposition in various organs including bone marrow, kidney, liver etc., were noted in 17 patients overall (6.2%). In conclusion, the incidence of fibrosis (4.3%) and amyloidosis (6.2%) associated with plasma cell neoplasms were much lower in our study as compared to published studies.

Extramedullary Multiple Myeloma: A Patient-Focused Review of the Pathogenesis of Bone Marrow Escape

Multiple myeloma (MM) is a neoplastic clonal proliferation of plasma cells, predominantly in the bone marrow. The presentation of MM in extramedullary tissue, particularly the liver, is uncommon with only a few reported cases in literature. We report a rare and unusual presentation of kappa light chain restricted MM with progression of disease to involve the liver. MM was initially diagnosed on bone marrow biopsy, initially treated with carfilzomib, lenalidomide and dexamethasone, later changed to bortezomib, daratumumab and dexamethasone. There was subsequent progression with a new biopsy-proven myelomatous liver lesion. The patient could not receive high-dose chemotherapy due to multiple co-morbidities and extent of disease and eventually succumbed to her disease rapidly. This article emphasizes the poor prognosis of extramedullary involvement in MM and the pathogenic mechanisms by which it develops. Based on a review of the literature of other cases and case series of solitary or diffuse myeloma involvement in the liver, high-dose chemotherapy in combination with proteasome inhibitors and immunomodulators has the best success rate with less relapse and progressive disease in extramedullary myeloma. Our analysis concluded that the gain of CD44, loss of CD56, loss of very late antigen-4 (VLA-4), imbalance of the chemokine receptor-4-chemokine ligand-12 (CXCR4-CXCL12) axis, metastasis-associated lung adenocarcinoma 1 (MALAT1) upregulation, RAS pathway activation as well as 13q and 17p deletions show an increased propensity of malignant plasma cells to leave the bone marrow and hone in extramedullary sites giving rise to more aggressive extramedullary diseases. Targeted therapeutics such as CD44v-directed therapy and reactivation of p53 to wild-type conformation could potentially be evaluated as treatment options in the future to improve outcomes in this aggressive form of MM, especially in patients with advanced disease and limited treatment options.

Case Report: A rare case of small bowel obstruction secondary to plasma cell myeloma

Gastrointestinal (GI) involvement of plasma cell neoplasms is extremely rare. Herein, we describe the case of a 74-year-old Caucasian woman who came to our attention with abdominal pain, food vomiting, and weight loss of 10 kg over 1 year. A computed tomography scan of the abdomen revealed circumferential thickening of terminal ileum, for which the patient underwent an urgent 20-cm-long ileal resection. Histopathological and immunophenotypic analysis revealed a plasma cell neoplasm of the ileum. Subsequent investigations found a serum monoclonal immunoglobulin A component, an osteolytic lesion of the left jaw, and a clonal bone marrow plasma cell infiltrate carrying 1q21 amplification. Given the final diagnosis of plasma cell myeloma (PCM), the patient underwent a VMD (bortezomib, melphalan, and dexamethasone) chemotherapy regimen, achieving a complete remission after a 12-month treatment. For disease relapse, two further chemotherapy regimens were later attempted. At the last follow-up 4 years after the diagnosis, the patient is still alive. This case draws attention to the extramedullary presentation of plasma cell neoplasms, even if rare, as a prompt diagnosis seems to result in a better prognosis. In addition, it highlights the relevance of a multidisciplinary approach, involving gastroenterologists, hematologists, and pathologists, to the diagnosis and management of these neoplasms.

Central Nervous System Myeloma and Unusual Extramedullary Localizations: Real Life Practical Guidance

Central nervous system localization of multiple myeloma (CNS-MM) accounts for about 1% of all MM during disease course or even rarer at diagnosis. A difference in the origin, i.e., osteodural or primary dural vs leptomeningeal/intraparenchymal, seems to define two distinct types of intracranial myeloma, with different clinical behavior. CNS-MM may occur also as a presentation of MM. Treatment is still unsatisfactory and many treatments have been reported: chemotherapy, intrathecal therapy, and radiotherapy, with dismal prognosis. Other sites of myeloma localization could be also of interest and deserve description. Because of the rarity and aggressiveness of the disease clinicians are often doubtful on how to treat it since there is no general agreement. Moreover, recent drugs such as the anti CD38 monoclonal antibody, immunomodulatory drugs, and proteasome inhibitors have changed the treatment of patients with MM with a significant improvement in overall response and survival. The role of novel agents in CNS MM management and unusual presentations will be discussed as well as the potential role of other new immunomodulatory drugs and proteasome inhibitors that seem to cross the blood-brain barrier. The purpose of this review is to increase awareness of the clinical unusual presentation and neuroradiological findings, give practical diagnostic advice and treatment options algorithm.

Extramedullary disease in multiple myeloma

When clonal plasma cells grow at anatomic sites distant from the bone marrow or grows contiguous from osseous lesions that break through the cortical bone, it is referred to as extramedullary multiple myeloma (EMD). EMD remains challenging from a therapeutic and biological perspective. The pathogenetic mechanisms are not completely understood and it is generally associated with high-risk cytogenetics which portends poor outcomes. There is a rising incidence of EMD in the era of novel agents, likely a reflection of longer OS, with no standard treatment approach. Patients benefit from aggressive chemotherapy-based approaches, but the OS and prognosis remains poor. RT has been used for palliative care. There is a need for large prospective trials for development of treatment approaches for treatment of EMD.

Multiple Myeloma Plasmacytoid Infiltration of the Gallbladder Presenting as Acute Cholecystitis

Secondary distal plasmacytoma that arise from multiple myeloma is a common hematological malignancy that manifests in later stages of the disease. These plasmacytomas are known to cause extensive systemic organ damage. When extramedullary plasmacytomas reach the gallbladder or biliary ducts, expansion can mimic acute acalculous cholecystitis or cholangiocarcinoma. We report a case of a 56-year-old female with a history of aggressive course IgA κ chain multiple myeloma who presented with right upper quadrant abdominal pain with nausea and vomiting for one week duration. Her laboratory panel revealed liver function tests consistent with gallbladder etiology. Abdominal ultrasound and CT showed no evidence of cholelithiasis precluding to acute acalculous cholecystitis. Initial medical management did not show any improvement. A robotic cholecystectomy was performed, and a pathology review of the specimen found a neoplastic stricture of the gallbladder fundus, the histological evaluation of which revealed plasmacytoid cells originating from her primary multiple myeloma diagnosis. The patient’s condition declined following surgery, postoperative presentation included metastatic liver thrombosis mimicking cholangiocarcinoma and the patient later expired with palliative care.

FDG-PET/CT Variants and Pitfalls in Haematological Malignancies

Hematologic malignancies represent a vast group of hematopoietic and lymphoid cancers that typically involve the blood, the bone marrow, and the lymphatic organs. Due to extensive research and well defined and standardized response criteria, the role of [¹⁸F]FDG-PET/CT is well defined in these malignancies. Never the less, the reliability of visual and quantitative interpretation of PET/CT may be impaired by several factors including inconsistent scanning protocols and image reconstruction methods. Furthermore, the uptake of [¹⁸F]FDG not only reflects tissue glucose consumption by malignant lesions, but also in other situations such as in inflammatory lesions, local and systemic infections, benign tumors, reactive thymic hyperplasia, histiocytic infiltration, among others; or following granulocyte colony stimulating factors therapy, radiation therapy, chemotherapy or surgical interventions, all of which are a potential source of false-positive or negative interpretations. Therefore it is of paramount importance for the Nuclear Medicine Physician to be familiar with, not only the normal distribution of [¹⁸F]FDG in the body, but also with the most frequent findings that may hamper a correct interpretation of the scan, which could ultimately alter the patients management. In this review, we describe these myriad of situations so the interpreting physician can be familiar with them, providing tools for their correct identification and interpretation when possible.

Extraosseous multiple myeloma: imaging spectrum in the abdomen and pelvis

Multiple myeloma represents a subset of plasma cell dyscrasias characterized by the proliferation of plasma cells typically in the bone marrow, representing approximately 1% of all cancers and 15% of hematologic malignancies. Often multiple myeloma is limited to the skeletal system; however, a small percentage (<5%) of patients will develop extraosseous manifestations. We review the current WHO classification of plasma cell dyscrasias and use multimodality imaging including US, CT, MRI, and PET-CT to illustrate the spectrum of extraosseous multiple myeloma in the abdomen and pelvis. Because extraosseous multiple myeloma is associated with a poorer prognosis and decreased survival, it is important for the radiologist to become familiar with a variety of extraosseous manifestations in the abdomen and pelvis, especially in a patient with a known diagnosis of multiple myeloma and the development of an abdominal or pelvic mass.

Concurrent Liver and Mesentery Primary Extraosseous Multiple Myeloma on 18F-FDG PET/CT

ABSTRACT

Extramedullary multiple myeloma (EMM) is a subset of multiple myeloma with a poor prognosis. We report a rare case with biopsy-proven concurrent liver and mesentery primary EMM at the time of initial staging after serologic diagnosis of multiple myeloma. 18F-FDG PET/CT is valuable in detection of EMM when the patient has no osseous lesions and a negative bone marrow biopsy.

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.

Lack of Spleen Signal on Diffusion Weighted MRI is associated with High Tumor Burden and Poor Prognosis in Multiple Myeloma: A Link to Extramedullary Hematopoiesis?

Due to the low frequency of abnormalities affecting the spleen, this organ is often overlooked during radiological examinations. Here, we report on the unexpected finding, that the spleen signal on diffusion-weighted MRI (DW-MRI) is associated with clinical parameters in patients with plasma cell dyscrasias.

Methods: We investigated the spleen signal on DW-MRI together with clinical and molecular parameters in 295 transplant-eligible newly diagnosed Multiple Myeloma (NDMM) patients and in 72 cases with monoclonal gammopathy of undetermined significance (MGUS).

Results: Usually, the spleen is the abdominal organ with the highest intensities on DW-MRI. Yet, significant signal loss on DW-MRI images was seen in 71 of 295 (24%) NDMM patients. This phenomenon was associated with the level of bone marrow plasmacytosis (P=1x10^-10) and International Staging System 3 (P=0.0001) but not with gain(1q), and del(17p) or plasma cell gene signatures. The signal was preserved in 72 individuals with monoclonal gammopathy of undetermined significance and generally re-appeared in MM patients responding to treatment, suggesting that lack of signal reflects increased tumor burden. While absence of spleen signal in MM patients with high risk disease defined a subgroup with very poor outcome, re-appearance of the spleen signal after autologous stem cell transplantation was seen in patients with improved outcome. Our preliminary observation suggests that extramedullary hematopoiesis in the spleen is a factor that modifies the DW-MRI signal of this organ.

Conclusions: The DW-MRI spleen signal is a promising marker for tumor load and provides prognostic information in MM.

Imaging features of immune-mediated genitourinary disease

PURPOSE

Imaging features of immune-mediated genitourinary diseases often overlap, and the same disease may manifest in different ways, so understanding imaging findings in the context of the patient's entire clinical picture is important in providing the correct diagnosis.

METHODS

In this article, diseases mediated by the immune system which affect the genitourinary system are reviewed. Examples of immune-mediated genitourinary disease including IgG4-related disease, post-transplant lymphoproliferative disorder, immunodeficiency-associated lymphoproliferative disorder due to immunosuppressive and immunomodulatory medications, lymphoma, leukemia, myeloma, amyloidosis, and histiocytosis.

RESULTS

Clinical and imaging features will be presented which may help narrow the differential diagnosis for each disease.

CONCLUSION

Recognition of immune-related genitourinary disease is important for appropriate medical management as they may mimic other diseases both by imaging and clinical presentation.

Disseminated Cryptococcosis in a Patient with Multiple Myeloma Treated with Daratumumab, Lenalidomide, and Dexamethasone

We report a case of disseminated cryptococcosis in a patient with multiple myeloma (MM) during treatment with daratumumab, lenalidomide, and dexamethasone (DRd). A 62-year-old woman, who was diagnosed with IgGλ type MM, was treated with three cycles of bortezomib and dexamethasone and subsequently treated with three cycles of DRd before admission. She reached a stringent complete response and presented with lethargy and seizure. Laboratory findings revealed severe CD4 lymphopenia, and Cryptococcus neoformans was detected in her cerebrospinal fluid and blood culture. The risk of developing an opportunistic infection should be considered in patients treated with daratumumab.

A Case of Multiple Myeloma Associated with Extramedullary Plasmacytoma of the Gallbladder Manifesting as Acute Cholecystitis

Multiple myeloma (MM) is a common hematological malignancy that represents 1% of all cancers. MM is distinguished from other plasma cell disorders by prominent bone marrow involvement and systemic organ damage. Extramedullary plasmacytomas of the gall bladder (GB) or biliary ducts, whether solitary or in association with MM, are very rare. We report a case of a 66-year-old female with a history of refractory MM who presented with right upper quadrant abdominal pain. Her laboratory evaluation revealed an abnormal liver panel and lactic acidosis. Abdominal ultrasonography was consistent with acute cholecystitis with no evidence of biliary obstruction or abnormal liver parenchyma. An open cholecystectomy with liver biopsy was performed. The histological evaluation revealed involvement of the GB submucosa and serosa, as well as the liver parenchyma by abnormal plasma cells with lambda light chain restriction. Congo red stain for the GB sample was positive. The patient declined further treatment for MM and was discharged home with comfort measures.

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.

Nonepithelial Neoplasms of the Pancreas, Part 2: Malignant Tumors and Tumors of Uncertain Malignant Potential From the Radiologic Pathology Archives

Almost all neoplasms of the pancreas are derived from pancreatic epithelial components, including the most common pancreatic mass, primary pancreatic ductal adenocarcinoma (PDAC). Nonepithelial neoplasms comprise only 1%-2% of all pancreatic neoplasms. Although some may arise directly from intrapancreatic elements, many originate from mesenchymal, hematopoietic, or neural elements in the retroperitoneal peripancreatic space and grow into the pancreas. Once these tumors reach a certain size, it can be challenging to identify their origin. Because these manifest at imaging as intrapancreatic masses, awareness of the existence and characteristic features of these nonepithelial neoplasms is crucial for the practicing radiologist in differentiating these tumors from primary epithelial pancreatic tumors, an important distinction given the vastly different management and prognosis. In part 1 of this article, the authors reviewed benign nonepithelial neoplasms of the pancreas. This article focuses on malignant nonepithelial neoplasms and those of uncertain malignant potential that can be seen in the pancreas. The most common malignant or potentially malignant nonepithelial pancreatic tumors are of mesenchymal origin and include soft-tissue sarcomas, solitary fibrous tumor, and inflammatory myofibroblastic tumor. These tumors commonly manifest as large heterogeneous masses, often containing areas of necrosis and hemorrhage. The clinical features associated with these tumors and the imaging characteristics including enhancement patterns and the presence of fat or calcification help distinguish these tumors from PDAC. Hematopoietic tumors, including lymphoma and extramedullary plasmacytoma, can manifest as isolated pancreatic involvement or secondarily involve the pancreas as widespread disease. Hyperenhancing paragangliomas or hypervascular metastatic disease can mimic primary pancreatic neuroendocrine tumors or vascular anomalies.

Myeloma light chain cast nephropathy, a review

Multiple Myeloma is a plasma cell proliferative disorder that commonly involves the kidney. Renal impairment is a serious complication during the course of the disease that is associated with increased morbidity and mortality. Light chain cast nephropathy is the predominant pattern of renal injury in Multiple Myeloma. This review article focuses on the pathophysiology and diagnostic approach of myeloma cast nephropathy. The management of precipitating factors as well as anti-plasma cell treatment modalities in the context of renal impairment are also discussed.

Plasma Cell Infiltration of the Kidney as a Manifestation of Myeloma: A Report of Three Cases

Infiltration of renal parenchyma by neoplastic plasma cells in myeloma patients is an unusual finding. We report 3 cases of myeloma, with renal biopsy being the first clue to the diagnosis in one. The plasma cell infiltrate in other two cases was not so evident but immunofluorescence (IF) and immunohistochemical (IHC) stains for light chains helped establish the monoclonal nature of the infiltrate. We surmise that plasma cell infiltration in the kidney can be an important clue to the diagnosis of an underlying myeloma and could in future be regarded as a myeloma-defining event (MDE) if monoclonality is confirmed. This finding could directly affect the prognosis and be a direct indicator of the tumor burden. Further studies are however required to determine the exact prognostic value and precise relationship of such a finding with deranged renal functions in myeloma.

Renal Involvement in Multiple Myeloma

Multiple myeloma (MM) is a plasma cell disorder that represents almost 10% of haematologic malignancies. Renal impairment, one of the most common complications of MM that occurs in 20–50% of patients, can present in a variety of forms and is associated with increased mortality. Myeloma cast nephropathy is the most common cause of kidney disease in MM patients, presenting as acute kidney injury in the majority of patients. The recent introduction of new chemotherapy agents, autologous stem cell transplantation, and the development of novel techniques of light chain removal have been associated with improved renal and patient outcomes in MM patients. Nevertheless, dialysis-dependent patients with MM have higher mortality than other dialysis patients and may be considered for kidney transplantation only if sustained remission has been achieved and sustained for at least 3 years, bearing in mind the risk of disease recurrence. The authors review the most frequent renal manifestations associated with MM, namely myeloma cast nephropathy, light-chain amyloidosis, and monoclonal immunoglobulin deposition disease, focussing on the therapeutic options for acute and chronic kidney disease.

New prognostic biomarkers and therapeutic effect of bevacizumab for patients with non-small-cell lung cancer

BACKGROUND

Several biomarkers have emerged as potential prognostic and predictive markers for non-small-cell lung cancer (NSCLC). Successful inhibition of angiogenesis with the antivascular endothelial growth factor antibody, bevacizumab, has improved the efficacy seen with standard cytotoxic therapy of NSCLC. However, despite such enhanced treatment strategies, the prognosis for patients with advanced NSCLC remains poor.

PATIENTS AND METHODS

We assessed potential biomarkers in 161 NSCLC patients and 42 control patients. Enzyme-linked immunosorbent assay methods were used to evaluate three biomarkers: platelet-derived microparticle (PDMP), high-mobility group box-1 (HMGB1), and plasminogen activator inhibitor-1 (PAI-1). We studied the effects of bevacizumab on the expression of these markers. We also analyzed the relationship of the newly designed risk factor (NDRF) to overall survival and disease-free survival. The NDRF classification of patients was determined from the levels of PDMP, HMGB1, and PAI-1. To determine the individual prognostic power of PDMP, HMGB1, and PAI-1, we evaluated associations between their levels and patient outcomes by Kaplan-Meier survival analysis in a derivation cohort.

RESULTS

PDMP, HMGB1, and PAI-1 levels were higher in NSCLC patients compared with control patients. Notably, the difference in PDMP levels exhibited the strongest statistical significance (p<0.001). Multivariate analysis showed that HMGB1 and PAI-1 levels were significantly correlated with PDMP levels. Patients who received standard chemotherapy with bevacizumab exhibited significantly reduced levels of all three markers compared with patients who received standard chemotherapy. NDRF3 status (high levels of all three markers) was significantly correlated with a poor prognosis (p<0.05 for overall survival and disease-free survival).

CONCLUSION

Our results demonstrate that abnormal levels of PDMP, HMGB1, and PAI-1 are related to each other in NSCLC. Moreover, our findings suggest that the vascular complications associated with these markers may contribute to a poor prognosis for NSCLC patients.

Bortezomib combined with lenalidomide as the first-line treatment for the rare synchronous occurrence of multiple myeloma and pulmonary adenocarcinoma: A case report

BACKGROUND

Simultaneous multiple myeloma (MM) and pulmonary adenocarcinoma is a rare occurrence, and thus, treatment is a challenge. This study reports on 1 such case of MM with concurrent lung cancer, where an accurate diagnosis was made and the patient underwent treatment for both cancers.

CASE SUMMARY

A 68-year-old man presented with 2 months of progressive lower back pain. Visualization with magnetic resonance imaging (MRI) revealed multiple collapsed vertebrae from T12 to S3, as well as an altered signal intensity at the T3 vertebra. The patient was diagnosed with MM upon examination. A chest computed tomography (CT) scan revealed a round mass in the left lower lobe of the lungs, and a CT-guided needle biopsy uncovered a moderately differentiated adenocarcinoma. There were no additional notable findings in the left lung using positron emission tomography computed tomography (PET-CT). Therefore, a diagnosis of MM with pulmonary adenocarcinoma was made. Surgery was performed to excise the lung cancer. Bortezomib was used as first-line induction therapy against both tumors and lenalidomide was used for maintenance. The patient went into complete remission. Using this combined chemotherapy, the patient has survived for over 3 years since a diagnosis was made despite relapsing twice after the first year.

CONCLUSION

This report clearly delineates the diagnosis and treatment of a rare case of synchronous MM and pulmonary adenocarcinoma, as well as depicts a potentially positive outcome for the patient. It also overviews some diagnostic and therapeutic implications for clinicians.

Role of multimodality imaging in the diagnosis of lymphoproliferative malignancies and hematologic disorders of the kidneys

Lymphoproliferative and hematologic disorders of the kidney may present with focal or diffuse renal parenchymal involvement in clinical practice. Radiologic findings of lymphoproliferative and hematologic disorders of the kidney may mimick primary neoplastic and inflammatory disorders of the kidney. All cross-sectional imaging modalities including ultrasonography, computed tomography, and magnetic resonance imaging may be used in the diagnosis of these diseases. Percutaneous biopsy may be used in problematic cases for definitive diagnosis.

[Clinical characteristics of pain syndrome in patients with multiple myeloma]

AIM

To study pain syndrome characteristics in the trunk and extremities of patients with multiple myeloma (MM).

MATERIAL AND METHODS

The study involved 120 patients with MM, aged from 34 to 83 years. The duration of disease was 2-37 months.

RESULTS AND CONCLUSION

The pain syndrome of trunk and extremity localization was revealed in 94% patients, its intensity according to the VAS was 65.5±25.4 mm. At all stages of disease, moderate to severe pain, predominantly related to polyneuropathy (PNP), radiculopathy and osteodestruction, was more frequent. Radicular pain syndrome was revealed in 46% of all MM patients, and in the majority of cases (92%), there were bone destruction lesions. The character of pain in MM should be specified to optimize further management of the patient.

Extramedullary Plasmacytoma of the Gallbladder Detected on Fluorine 18-fluorodeoxyglucose Positron Emission Tomography/Computed Tomography

Extramedullary plasmacytoma is rare in patients with diagnosed multiple myeloma. Soft tissue plasmacytoma of the gallbladder is particularly uncommon and has been described in only a handful of cases. Diagnosis of gallbladder plasmacytoma with fluorine 18-fluorodeoxyglucose (F18-FDG) positron emission tomography/computed tomography (PET/CT) has not previously been reported. We present a 65-year-old female with a history of multiple myeloma who underwent a restaging F18-FDG-PET/CT which showed a focal area of hypermetabolic activity, corresponding to a nodular lesion within the posterior gallbladder wall. The patient underwent successful cholecystectomy, with surgical pathology revealing gallbladder plasmacytoma. A follow-up scan was negative for active malignancy. This is a novel case of gallbladder plasmacytoma diagnosed on whole-body F18-FDG PET/CT – thus demonstrating the clinical value of this imaging modality in staging, restaging, and surveillance for patients with multiple myeloma.

Imaging Manifestations of Hematologic Diseases with Renal and Perinephric Involvement

The kidneys and perinephric tissues can be affected by a variety of hematologic disorders, which usually occur in the setting of multisystem involvement. In many of these disorders, imaging is used to evaluate the extent of disease, guide biopsy, and/or monitor disease activity and patient response to therapy. Lymphoma, leukemia, and multiple myeloma commonly manifest as multiple parenchymal or perinephric lesions. Erdheim-Chester disease and Rosai-Dorfman disease, rare forms of multisystemic histiocytosis, are often identified as perinephric and periureteral masses. Renal abnormalities depicted at imaging in patients with sickle cell disease include renal enlargement, papillary necrosis, and renal medullary carcinoma. Sickle cell disease, along with other causes of intravascular hemolysis, can also lead to hemosiderosis of the renal cortex. Thrombosis of renal veins is sometimes seen in patients with coagulation disorders but more often occurs in association with certain malignancies and nephrotic syndrome. Immunoglobulin G4-related sclerosing disease is another multisystem process that often produces focal renal lesions, seen along with involvement of more characteristic organs such as the pancreas. Perinephric lesions with calcifications should raise the possibility of secondary amyloidosis, especially in patients with a history of lymphoma and multiple myeloma. Although the imaging patterns of renal and perinephric involvement are usually not specific for a single entity, and the same entity can manifest with different or overlapping patterns, familiarity with these patterns and key clinical and histopathologic features may help to narrow the differential diagnosis and determine the next step of care. (©)RSNA, 2016.

Liver involvement by multiple myeloma presenting as hypervascular focal lesions in a patient with chronic hepatitis B infection

Extramedullary myeloma refers to the infiltration of neoplastic monoclonal plasma cells in either organs or soft tissues. The disease is clinically and radiologically underestimated compared with the autopsy findings and is usually associated with a more aggressive clinical course and poorer outcome. A minority of patients with extramedullary myeloma show hepatic involvement, usually in the form of diffuse parenchymal infiltration. When focal infiltration is present, variable imaging findings have been described both on CT scan and MRI. We report the case of a 63-year-old male with hepatitis B virus-related liver disease and biopsy-proven multiple myeloma involving the liver, manifesting as hypervascular focal liver lesions on MRI. A brief review of the literature is also proposed.

Hematologic malignancies of the liver: spectrum of disease

The incidence of hematologic malignancies and their extranodal manifestations is continuously increasing. Previously unsuspected hepatic involvement in hematologic malignancies such as Hodgkin disease and non-Hodgkin lymphoma, posttransplant lymphoproliferative disorder, myeloid sarcoma (chloroma), multiple myeloma, Castleman disease, and lymphohistiocytosis may be seen by radiologists. Although the imaging features of more common hepatic diseases such as hepatocellular carcinoma, metastases, and infection may overlap with those of hepatic hematologic malignancies, combining the imaging features with clinical manifestations and laboratory findings can facilitate correct diagnosis. Clinical features that suggest a hematologic neoplasm as the cause of liver lesions include a young patient (<40 years of age), no known history of cancer, abnormal bone marrow biopsy results, fever of unknown origin, and night sweats. Imaging features that suggest hematologic malignancy include hepatosplenomegaly or splenic lesions, vascular encasement by a tumor without occlusion or thrombosis, an infiltrating mass at the hepatic hilum with no biliary obstruction, and widespread adenopathy above and below the diaphragm. Familiarity with the imaging features of hepatic hematologic malignancies permits correct provisional diagnosis and may influence therapeutic management. For example, when biopsy is performed, core biopsy may be needed in addition to fine-needle aspiration so that the tissue architecture of the neoplasm can be discerned. The predominant treatment of hematologic malignancies is chemotherapy or radiation therapy rather than surgery. Online supplemental material is available for this article.

Imaging features of haematological malignancies of kidneys

Haematological malignancies are relatively uncommon neoplasms of kidneys. Nevertheless, the incidence of these neoplasms is increasing, partly due to more widespread use of computed tomography and magnetic resonance imaging. This article discusses the clinical and imaging features of renal lymphoma, leukaemia, extra-osseous multiple myeloma, and post-transplant lymphoproliferative disorder. Although there is overlap of imaging features with other more common malignancies, such as transitional and renal cell cancers, the combination of imaging findings and the appropriate clinical picture should allow the radiologist to raise a provisional diagnosis of a haematological neoplasm. This has management implications including the preference for image-guided core biopsies and a shift towards medical rather than surgical therapy.

Hematologic malignancies of the pancreas

Hematologic malignancies are relatively uncommon neoplasms of abdominal soft tissue. This article discusses the clinical and imaging features of pancreatic lymphoma, pancreatic extraosseous multiple myeloma, granulocytic sarcoma (chloroma), posttransplant lymphoproliferative disorder, and Castleman disease. The combination of imaging findings and the appropriate clinical presentation should allow the radiologist to raise a provisional diagnosis of hematologic malignancy.

Incidence of infection according to intravenous immunoglobulin use in autologous hematopoietic stem cell transplant recipients with multiple myeloma

BACKGROUND

Although intravenous immunoglobulin (IVIG) is not routinely recommended, many centers still use IVIG during the post-hematopoietic stem cell transplant (HSCT) period.

METHOD

A total of 162 multiple myeloma (MM) patients who underwent autologous (auto-) HSCT between January 2008 and June 2013 were retrospectively reviewed. Primary objective was determination of the impact of IVIG on post-transplant infection, and secondary objectives included identification of overall incidence of infection, type of infection, and risk factors for infection after auto-HSCT in MM patients.

RESULTS

After auto-HSCT, 53 of 162 patients (32.7%) experienced 104 infectious events. Upper respiratory infection was most common (n = 31, 29.8%) and pneumonia (n = 27, 26.0%) and herpes zoster (n = 15, 14.4%) came next. Among the identifiable organisms causing respiratory infection, influenza virus (n = 10) and Pneumococcus (n = 9) were predominant. Incidence of infection was not statistically different according to IVIG use (34.8% in IVIG (-) vs. 31.3% in IVIG (+), P = 0.631). Incidence of infection requiring hospitalization and multiple episodes of infection showed no difference between the groups (P = 0.147, P = 0.156). In a Cox proportional hazard model, none of the factors including age, gender, type of disease, stage, tandem (vs. single) transplantation,and IVIG was prognostic for infectious event after auto-HSCT (P = 0.955, hazard ratio 0.980 with 95% confidence interval 0.481-1.997 for IVIG).

CONCLUSION

In auto-HSCT recipients with MM, incidence of post-transplant infection was not different according to prophylactic IVIG use.

Plasmacytoma of Liver Mimicking Hepatocellular Carcinoma at Multiphasic Computed Tomography Evaluation

Plasmacytoma of liver is a rare hepatic tumor more often seen at autopsy than described in the literature; it is also more likely diagnosed in the setting of multiple myeloma than as isolated extramedullary plasmacytoma. However, when found in the setting of multiple myeloma, it is associated with worse clinical outcome. The authors describe a case of an elderly man presenting with nonspecific chronic abdominal pain and a new 4-cm hepatic mass. At multiphasic computed tomography, the mass demonstrated an enhancement pattern identical to that expected of hepatocellular carcinoma; however, thorough history failed to uncover necessary risk factors for hepatic cirrhosis. Ultrasound-guided core biopsy of the mass, as well as additional clinical and radiologic assessment, subsequently confirmed a diagnosis of multiple myeloma.

New aspects on the pathogenesis of renal disorders related to monoclonal gammopathies

BACKGROUND

Multiple myeloma and other related monoclonal gammopathies are frequently encountered conditions associated with renal damage, especially in elderly population. They are arising from clonal proliferation of plasma cells in bone marrow producing various quantities of abnormal monoclonal immunoglobulins, or their components/fragments.

SUMMARY

These abnormal proteins differ from normal immunoglobulins in the amino acid sequence and in the three-dimensional structure of the molecule, which may determine their toxicity. Kidney seems to be a target organ as a major catabolic site. The pathology of renal disease is highly heterogeneous involving a variety of different mechanisms, which are divided into immunoglobulin dependent and immunoglobulin independent mechanisms. The Ig-dependent mechanisms may involve the four components of the kidney parenchyma, and the primary structure of these proteins determine the pattern of renal disease.

KEY MESSAGE

This review summarizes the existing literature in the pathobiology of multiple myeloma, and the pathological properties of the M-proteins, focusing on the mechanisms of the renal manifestations related to these abnormal proteins, especially glomerular injury. Also it supports the opinion that monoclonal gammopathy of undetermined significance (MGUS) should not be used in cases where there is proven renal impairment due to these proteins, even if it is mild and does not meet the current criteria.

Relapse of multiple myeloma presenting as extramedullary plasmacytomas in multiple organs

Multiple myeloma is a neoplastic plasma cell disorder. It is characterized by collections of abnormal plasma cells accumulating in the bone marrow, where they interfere with the production of normal blood cells. It usually presents as a multisystemic involvement, whose symptoms and signs vary greatly. Some patients have slowly progressive disease while others have aggressive clinical behavior by extramedullary involvement. In addition to renal failure, anemia, hypercalcemia, lytic bone lesions, and immunodeficiency, it also affects multiple organ system, such as pancreas, adrenal glands, kidney, skin, lung, liver, spleen, lymph nodes, and bone. To raise awareness of the variable presentations of this disease, we report a 53-year-old male patient, with multiple myeloma in his first remission who relapsed with extramedullary plasmacytomas (EMPs) involving multiple organs, such as pancreas, adrenal glands, kidney, skin, lung, liver, spleen, and lymph nodes.

Imaging of multiple myeloma: usefulness of MRI and PET/CT

Multiple myeloma is a heterogeneous hematologic disorder of plasma cells with varied bone marrow imaging appearances. With advancements in both treatment and use of advanced imaging over the last several decades, it is important for radiologists to recognize the imaging presentation of the disease and the staging implications of imaging. This paper reviews the staging as it relates to imaging, consensus recommendations for imaging, expected imaging appearances of myeloma, pitfalls, and complications associated with treatment that are demonstrable on imaging.

Bortezomib and dexamethasone for multiple myeloma: higher AST and LDH levels associated with a worse prognosis on overall survival

Background

Bortezomib offers a novel approach to the treatment of multiple myeloma producing rapid control. The aim of this study was to investigate the outcomes of bortezomib and dexamethasone-treated patients with multiple myeloma.

Methods

We conducted a retrospective study of 44 consecutively-treated multiple myeloma patients with bortezomib (1.3 mg/m² on days 1, 4, 8, and 11 of a 21-day cycle or 1.3 mg/m² intravenously 1, 8, 15, and 22 of every 35-day cycle) and dexamethasone.

Results

The median time to progression, progression free survival time, and overall survival time in the treatment groups was 14.9, 14.9, and 38.3 months, respectively. The present study also suggests the possibility that the prognosis of patients with high levels of AST and LDH might be worse.

Conclusions

Our results indicate that the treatment of multiple myeloma with bortezomib and dexamethasone is feasible.

Changing treatment paradigms for patients with plasma cell myeloma: impact upon immune determinants of infection

Plasma cell myeloma (PCM) is increasing in prevalence in older age groups and infective complications are a leading cause of mortality. Patients with PCM are at increased risk of severe infections, having deficits in many arms of the immune system due to disease and treatment-related factors. Treatment of PCM has evolved over time with significant impacts on immune function resulting in changing rates and pattern of infection. Recently, there has been a paradigm shift in the treatment of PCM with the use of immunomodulatory drugs and proteasome inhibitors becoming the standard of care. These drugs have wide-ranging effects on the immune system but their impact on infection risk and aetiology remain unclear. The aims of this review are to discuss the impact of patient, disease and treatment factors on immune function over time for patients with PCM and to correlate immune deficits with the incidence and aetiology of infections seen clinically in these patients. Preventative measures and the need for clinically relevant tools to enable infective profiling of patients with PCM are discussed.

Infections in patients with leukemia and lymphoma

Infectious complications remain a significant issue in the care of patients with hematologic malignancies. Inherent immune defects related to the primary disease process are present in patients with disorders such as chronic lymphocytic leukemia, multiple myeloma, hairy cell leukemia, and Hodgkin lymphoma. Therapy-related immunosuppression is also commonplace in these patients. This includes not only treatment-related neutropenia, but also defects in cell-mediated immunity, such as those that occur with purine analog therapy. In this chapter, we will review the pathogenesis of infection in these disorders, as well as the spectrum of infectious complications seen and suggested strategies for the prevention of infection.

Myeloma-related kidney disease

Multiple myeloma is a malignant plasma cell disorder characterized by the overproduction of monoclonal proteins. The kidney is 1 of the major target organs of multiple myeloma. Most often, this is the result of the monoclonal proteins, which can injure the kidney via several mechanisms. In some cases, direct invasion by myeloma cells and/or bone marrow cells can also result in kidney injury. A kidney biopsy can help distinguish the various myeloma-related kidney diseases and aid in the treatment plan.

Abdominal manifestations of extraosseous myeloma: cross-sectional imaging spectrum

Extraosseous myeloma, defined as the myelomatous involvement outside the skeleton system, is rare and often associated with advanced multiple myeloma. There has been a recent increase in the clinicoradiological incidence of this entity, possibly secondary to increased survival of patients and frequent use of imaging. This has led to the development of new clinical staging guidelines for multiple myeloma, which include the use of imaging modalities positron emission tomography/computed tomography and magnetic resonance imaging for accurate detection and optimal management. The aims of this review were to discuss the significance of identification of extraosseous disease, to describe the spectrum and common sites of extraosseous involvement in the abdomen, and to review the imaging findings of extraosseous myeloma in the abdomen.