Soft tissue masses in patients with multiple myeloma: a fine-needle aspiration study of 30 cases with flow cytometry and clinical correlation

A Proposal for the Performance, Classification, and Reporting of Lymph Node Fine-Needle Aspiration Cytopathology: The Sydney System

BACKGROUND

The evaluation of lymph nodes (LN) by fine-needle aspiration cytology (FNAC) is routinely used in many institutions but it is not uniformly accepted mainly because of the lack of guidelines and a cytopathological diagnostic classification. A committee of cytopathologists has developed a system of performance, classification, and reporting for LN-FNAC.

METHODS

The committee members prepared a document that has circulated among them five times; the final text has been approved by all the participants. It is based on a review of the international literature and on the expertise of the members. The system integrates clinical and imaging data with cytopathological features and ancillary techniques. The project has received the endorsement and patronage of the International Academy of Cytology and the European Federation of the Cytology Societies.

RESULTS

Clinical, imaging, and serological data of lymphadenopathies, indications for LN-FNAC, technical procedures, and ancillary techniques are evaluated with specific recommendations. The reporting system includes two diagnostic levels. The first should provide basic diagnostic information and includes five categories: inadequate/insufficient, benign, atypical lymphoid cells of undetermined/uncertain significance, suspicious, and malignant. For each category, specific recommendations are provided. The second diagnostic level, when achievable, should produce the identification of specific benign or malignant entities and additional information by utilizing ancillary testing.

CONCLUSION

The authors believe that the introduction of this system for performing and reporting LN-FNAC may improve the quality of the procedure, the report, and the communication between cytopathologists and the clinicians. This system may lead to a greater acceptance and utilization of LN-FNAC and to a better interdisciplinary understanding of the results of this procedure.

Cytodiagnosis of multiple myeloma presenting as orbital involvement: a case report

Background

Plasma cell neoplasms represent autonomous proliferations of plasma cells and can manifest as diffuse myeloma with systemic involvement (plasma cell myeloma or multiple myeloma), monoclonal gammopathy of undetermined significance (MGUS), or as variants of plasma cell myeloma such as indolent myeloma, smoldering myeloma, osteosclerotic myeloma, plasma cell leukaemia and non-secretory myeloma. Localized neoplastic proliferation of plasma cells presents as solitary plasmacytoma of bone or extramedullary plasmacytoma. Involvement of orbit can occur as a solitary plasmacytoma, or as part of systemic involvement in multiple myeloma, the clinical outcome being significantly worse in the latter setting.

Orbital involvement in multiple myeloma is very rare with less than 50 cases reported in the literature. Early cytological diagnosis of such lesions is vital for timely institution of appropriate therapy. As far as we are aware only six previous cases of cytological diagnosis of multiple myeloma involving the orbit are on record.

Case presentation

A 37 year old male presented with low grade fever showing evening rise, headache, diplopia and swelling in the right periorbital and temporal region. Imaging studies revealed destructive lesion of sphenoid, frontal bone and zygomatic arch with soft tissue component extending to infratemporal fossa and orbit. A fine needle aspirate from the temporal region swelling showed features of a plasmacytoma, and subsequent workup confirmed the presence of systemic disease. A final diagnosis of multiple myeloma with orbital involvement at presentation was made.

Conclusion

Present case describes the extremely rare presentation of multiple myeloma with orbital involvement and highlights the utility of cytology in such lesions. Fine needle aspiration diagnosis of plasmacytoma at extramedullary sites offers an opportunity for non-invasive verification of systemic involvement, and thus plays a major role in early diagnosis and management of these patients.

Hodgkin's lymphoma associated with plasma cell neoplasia: cytological features and review of the literature

Hodgkin's lymphoma (HL) associated with plasma cell neoplasia is extremely rare. Here, we report one case diagnosed by fine-needle aspiration biopsy (FNAB) and review the clinical features of 15 previously reported cases. Our specimen was obtained by FNAB of an enlarged right inguinal lymph node. Air-dried Diff-Quik (DQ)-stained slides and alcohol-fixed slides stained with hematoxylin-eosin (H&E) and Papanicolaou stains were reviewed. The specimen was cellular, consisting of lymphocytes and plasma cells. Flow cytometric analysis revealed a monoclonal (M) plasma-cell population. Admixed large atypical mono- and binucleated cells immunoreactive for CD30 were noted also. A diagnosis of plasma-cell neoplasm associated with classic HL was confirmed histologically after surgical removal of the lymph node. The diagnosis of both HL and plasma-cell neoplasia in the same patient is exceedingly rare. Adding another case to the 15 previously reported cases was unique because our case was diagnosed through FNAB.

[Diagnosis of multiple myeloma based on the material obtained by fine needle aspiration biopsy of the lungs]

The patient presented in this paper was admitted to the hospital for the evaluation of radiologically revealed shadow in both lungs. In the course of diagnostic procedures, fine needle aspiration biopsy of the intrathoracic mass was performed. Cytologic analysis of the smear was performed because of clinical suspicion of plasma cell proliferative disease that was confirmed by bone marrow aspiration. Thus, the cytologic finding of intrathoracic lesion preceded the diagnosis of multiple myeloma.

Detection of Clonality With κ and λ Immunohistochemical Analysis in Cutaneous Plasmacytomas

Context.—Cutaneous plasmacytomas rarely occur in the setting of multiple myeloma. However, since poorly differentiated lesions may resemble other neoplasms, such as carcinoma, melanoma, and lymphoma, the diagnosis of cutaneous plasmacytoma may be difficult.

Objective.—To demonstrate clonality using κ and λ immunohistochemical analysis in cutaneous plasmacytomas and to ascertain whether or not interpretation is hindered by background staining.

Design.—Pathology reports of all patients with the diagnosis of multiple myeloma were reviewed. Twelve patients had cutaneous lesions diagnosed as plasmacytoma, and these lesions were analyzed for light chain restriction with κ and λ immunohistochemical analysis.

Results.—In most cases (11 of 12), monoclonality was demonstrated. In the remaining case, monoclonality could not be established because most cells did not stain for either κ or λ.

Conclusions.—Light chain restriction can be demonstrated in most multiple myeloma–related cutaneous plasmacytomas, establishing the neoplastic nature of the infiltrate.

Fine-needle aspiration diagnosis of plasmacytoma presenting as breast masses in a patient on estrogen therapy for prostate cancer

We describe a 79-yr-old man with a history of androgen-independent metastatic prostate cancer treated with exogenous estrogens presenting with bilateral breast masses associated with bilateral axillary lymphadenopathy. Although the findings on physical examination with the concomitant history of estrogen therapy for metastatic prostate cancer raised the clinical suspicion of breast cancer, fine-needle aspiration (FNA) cytology identified the lesions as multiple myeloma.

Gallium-67 demonstration of extensive soft-tissue involvement of multiple myeloma

A 46-year-old woman with multiple myeloma presented with neurological symptoms in the right upper extremity. After MR imaging of the cervical spine failed to show the cause of her symptoms, Ga-67 scintigraphy demonstrated increased uptake in multiple areas including the right supraclavicular region and bilateral lower extremities. Histology of the specimen obtained from the left thigh proved soft-tissue involvement of myeloma, and extensive extramedullary involvement was diagnosed. Radiotherapy to the right supraclavicular mass relieved her symptoms. Although Ga-67 scintigraphy is generally considered of limited value in multiple myeloma, this modality contributed to the development of an appropriate strategy in this patient with extensive extramedullary involvement.