Pattern of care and impact of prognostic factors on the outcome of head and neck extramedullary plasmacytoma: a systematic review and individual patient data analysis of 315 cases

Head and Neck Extramedullar Plasmacytoma

PURPOSE

This study aimed to contribute to the literature by sharing experience of head-neck extramedullary plasmacytoma (EMP), which are rarely seen.

METHODS

A total of 11 patients treated for head and neck region EMP between 2000 and 2023 were screened retrospectively.

RESULTS

The 11 patients comprised 9 men and 2 women with a mean age of 55.1 ± 16.2 (range, 16-74) years. The most affected regions were seen to be the sinonasal tract, larynx, and tonsils. In the histopathological examination, plasma cells had a mature or anaplastic appearance, and one of the kappa and lambda light chains was positive and the other was completely negative. The serum electrophoresis and bone marrow flow cytometry results were negative. Of the patients with confirmed EMP diagnosis, 8 were treated with radiotherapy (RT) alone, 1 patient with maxillectomy, and 1 patient endoscopic sinus surgery followed by RT. RT was applied at a dose of 44 to 50 Gy for 22 to 25 sessions. In 1 patient, RT and chemotherapy were applied together.

CONCLUSION

In cases presenting with a submucosal, destructive tumor in the head and neck region, especially in the sinonasal region, EMP should be kept in mind. When histopathological results are confirmed, a differential diagnosis from multiple myeloma (MM) is required. Flow cytometry is of guidance in the differentiation of EMP from extranodal lymphoma. However, it should be noted that the effect of RT may be less in EMPs originating from the paranasal sinus compared with other anatomic regions, and surgery may be required before or after RT. A radiation dose of 45 Gy is sufficient for local control. Patients require long-term follow-up, as there is a possibility of EMP transforming to MM.

Outcome Analysis of Solitary Extramedullary Plasmacytoma in the Head and Neck: A Clinical Perspective

INTRODUCTION

Solitary extramedullary plasmacytomas (SEP) of the head and neck are rare and pose unique challenges. This study aimed to explore the clinical spectrum and treatment outcomes of these neoplasms using multimodal management.

METHODS

A retrospective review of 13 patients with SEP of the head and neck. Data on demographics, clinical presentation, diagnostics, treatment, and survival outcomes were analyzed.

RESULTS

One patient refused the treatment and was lost to follow-up. Another one received operation alone. The other 11 patients underwent surgical resection when feasible and showed favorable responses to radiation. Two of them (16.7%) experienced local recurrence, and another two patients (16.7%) progressed to multiple myeloma (MM) within the first 2 years following the initial treatment. Tumor > 2.6 cm significantly affected the post-radiation prognosis.

CONCLUSION

Although radiotherapy yields favorable immediate outcomes in our limited case series, a subset of cases progresses to MM within the initial 2 years. Despite all tumors being categorized as Stage I, tumor size may still influence prognosis.

Sinonasal extramedullary plasmacytoma: A case report and review of the literature

Primary solitary extramedullary plasmacytoma is a malignant neoplasm characterized by the monoclonal proliferation of plasma cells outside the bone marrow. The tumor rarely occurs in the sinonasal tract, accounting for about 4% of all non-epithelial sinonasal tumors. Herein, the authors describe a rare case of sinonasal extramedullary plasmacytoma in a 33-year-old man who presented with a 3-month history of progressively increasing nasal mass, causing obstruction. A CT scan showed a soft tissue mass measuring 5*8*3 cm in the right and left nasal cavities, obstructing the nasal airway. The mass extended to the right maxillary sinus. Histopathology and immunohistochemical tests confirmed it to be plasmacytoma. Lymphomas with prominent plasmacytic differentiation and multiple myeloma workups were negative. The patient initially refused treatment. After counseling, the patient consented to undergo surgery and later radiotherapy treatment. At one-year follow-up, the patient is disease-free with no signs of recurrence. Plasmacytomas are either medullary or extramedullary neoplasms. The latter are extremely rare tumors, more commonly presenting in the submucosal tissue of the upper respiratory tract. A mass or swelling causing nasal or pharyngeal symptoms is by far the most common presentation of this entity in the head and neck region. Because these lesions are radiosensitive, radiotherapy is a recommended treatment approach. Further studies are needed to better understand the prognosis and effective treatment regimens.

Primary head and neck lymphoid neoplasms in adolescents and young adults: demographics, distribution and survival outcomes

Primary head and neck lymphoid neoplasms(PHNLN) are described as a series of lymphoid system-derived neoplasms which originally arising from head and neck region. Our study is aimed to present a panoramic view of PHNLN among adolescent and young adult(AYA) patients aged from 15 to 39 years-old. The individual patient information was obtained from Surveillance, Epidemiology and End Results(SEER) database. Male patients outnumbered female patients in most pathological subtypes, with noticeable male predilection observed in Burkitt lymphoma and diffuse large B-cell lymphoma(DLBCL). Classical Hodgkin lymphoma(CHL) accounted for 92.23% of Hodgkin lymphoma. Mature B-cell neoplasms constituted the majority of non-Hodgkin lymphoma(NHL). DLBCL was the most common pathological subtype, followed by follicular lymphoma(FL). Tonsil, salivary glands (especially parotid gland) and nasal cavity were the most three frequent extranodal organs involved. Patients with extranodal involvement exhibited worse prognosis compared to those with lymph node confinement. Patients who suffered from precursor NHL and mature T/NK-cell NHL exhibited prolonged disease-specific survival compared to those with HL, PCN and mature B-cell NHL. AYA patients with absence of other SPM showed dramatic lower risk of death than those with occurrence of SPM. Patients with HL had a favourable survival advantage over those with mature B-cell NHL. Patients with precursor NHL and mature T/NK-cell NHL were at remarkable higher risk of death than those with mature B-cell NHL. Our study elucidated the demographics, distribution of anatomic sites and pathological subtypes, and survival outcomes of PHNLN among AYA population, enhancing comprehension of this rare sort of cancer entities.

Radiotherapy vs Surgery for Survival and Locoregional Control of Head and Neck Extramedullary Plasmacytoma: A Systematic Review and Meta-Analysis

Importance

There are significant gaps in the literature pertaining to the locoregional control and survival rates of extramedullary plasmacytoma (EMP) with respect to various treatment approaches.

Objective

To systematically evaluate the differences in radiotherapy and surgical outcomes in EMP.

Data Sources

Databases including PubMed, Scopus, Web of Science, Embase, and ScienceDirect were systematically searched from their inception up to November 2023.

Study Selection

Articles reporting radiotherapy and surgical outcomes of head and neck EMP were included.

Data Extraction and Synthesis

A random-effects model for meta-analysis was used to obtain pooled estimates and calculate hazard ratios for survival and odds ratios for recurrence and progression of EMP.

Main Outcomes and Measures

Survival, tumor control, and progression rates to multiple myeloma (MM) between radiation therapy and surgery for EMP of the head and neck.

Results

Of 742 included patients from 12 studies, 527 (71.0%) were male, and the median (IQR) age was 59.1 (53-62) years. A total of 505 patients (68.1%) received radiotherapy only, while 237 (31.9%) underwent surgery-only treatment for EMP. All included patients had an initial diagnosis of EMP without MM. Comparable trends were observed in overall survival and disease-free survival (DFS) rates at 2, 3, 5, and 10 years between patients with EMP treated with radiotherapy only and surgery only. Notably, there were no significant differences in recurrence rate (odds ratio, 0.65; 95% CI, 0.20-2.06) between radiotherapy-only and surgery-only treatment. However, radiotherapy-only treatment of EMP was associated with decreased odds of progression to MM compared with surgery (odds ratio, 0.4; 95% CI, 0.1-0.9). Sensitivity analysis revealed that the radiotherapy-only population had significantly better 5-year DFS (hazard ratio, 0.55; 95% CI, 0.31-0.96) compared with surgery-only treatment.

Conclusions and Relevance

This systematic review and meta-analysis provides evidence that patients with EMP receiving radiotherapy had significantly lower chances of progression to MM compared with surgery-only therapy. Additionally, radiotherapy had better 5-year DFS outcomes compared with surgery. Comparable outcomes in terms of overall survival rates, recurrence, and mortality rates were noted between radiotherapy-only and surgery-only EMP treatment groups.

Sequential therapy for extramedullary plasmacytoma of the palate: a rare case report with seven years of follow-up and literature review

BACKGROUND

Extramedullary plasmacytoma (EMP) is a rare solitary malignancy that accounts for 3% of plasma cell neoplasms, and EMP with a primary occurrence in the palate is extremely uncommon. Owing to the long course of EMP and the limited available data on treatment outcomes, there are no definitive guidelines for its management, especially for high-risk patients who are more susceptible to early progression to multiple myeloma.

CASE PRESENTATION

In this study, we review nine relevant studies and describe a 54-year-old woman who presented with an asymptomatic nonulcerative mass localized in the palate. After initial radical surgical resection of the lesion, the patient was definitively diagnosed with EMP with minimal plasmacytosis in the bone marrow, and adjuvant intensity-modulated radiation therapy with a minimum dose of 39.6 Gy was administrated in the surgical area. There was no evidence of local recurrence, nodal metastasis or progression to multiple myeloma (MM) during the seven-year follow-up period.

CONCLUSION

Given the atypical clinical features of palate EMP reported in the literature and the encouraging results of our patient, sequential therapy involving surgery and adjuvant radiotherapy for primary palatal lesions in high-risk EMP patients without nodal involvement could be an effective treatment modality.

Distribution and survival outcomes of primary head and neck hematolymphoid neoplasms in older people: a population-based study

Primary head and neck hematolymphoid neoplasms (PHNHLN) are defined as a series of hematolymphoid system-derived neoplasms which primarily emanate in head and neck region. Due to the rarity and absence of symptomatic specificity, PHNHLN is easily neglected. The objective of this study is to investigate demographics, pathological subtype distribution, anatomical location, survival outcomes and prognostic factors of PHNHLN among older patients aged ≥ 60. The individual patient information in our study was derived from Surveillance, Epidemiology and End Results database. Descriptive epidemiological methods were used to analyze the distribution of histologic subtypes and primary anatomical sites. Kaplan-Meier survival curves and log-rank test were conducted to evaluate the effect of variables on the prognosis. Cox hazard regression was conducted to identify the independent prognostic factors. The male-to-female ratio in most pathological subtypes was close to 1:1. The most common pathological subtype was diffuse large B-cell lymphoma. The most commonly involved sites outside the lymph nodes were salivary glands, especially parotid gland, followed by tonsil, thyroid gland and tongue. The prognosis of mature T- and NK-cell non-Hodgkin lymphoma (NHL) was bleaker than Hodgkin lymphoma, mature B-cell NHL and plasma cell neoplasm. Age at diagnosis, presence of second primary malignancy (SPM), pathological subtype, Ann-Arbor stage, chemotherapy and radiation were independent prognostic factors of overall survival. Our study comprehensively reported the subtype distribution, anatomical sites and survival outcomes of PHNHLN among older patients, improving understanding of this rare group of cancer entities.

Survival trends and prognostic factors for patients with extramedullary plasmacytoma: A population-based study

Background

Extramedullary plasmacytoma (EMP) is a localized plasma cell neoplasm that originates from tissues other than bone. The survival trends and prognostic factors of patients with EMP in recent years remain unreported.

Methods

We used the SEER databases to extract the data. Survival curves were calculated using the Kaplan-Meier method and a nomogram was created based on the Cox's proportional hazards model.

Results

A total of 1676 cases of EMP were identified. Patients in period-2 (2008-2016) show similar survival (p=0.8624) to those in period-1(1975-2007). Age, gender, race, and sites were prognostic of patient outcomes. And the use of surgery was associated with improved survival. The patients were randomly assigned to the training cohort and the validation cohort in a ratio of 2:1. Four factors including age, gender, race, and sites were identified to be independently predictive of the overall survival of patients with EMP. A prognostic model (EMP prognostic index, EMP-PI) comprising these four factors was constructed. Within the training cohort, three risk groups displayed significantly different 10-year survival rates: low-risk (73.0%, [95%CI 66.9-78.2]), intermediate-risk (39.3%, [95%CI 34.3-44.3]), and high-risk (22.6%, [95%CI 15.3-30.9]) (p<0.0001). Three risk groups were confirmed in the internal validation cohort. We also constructed a 5-factor nomogram based on multivariate logistic analyses.

Conclusion

The survival of patients with EMP did not improve in recent years. The EMP-PI will facilitate the risk stratification and guide the risk-adapted therapy in patients with EMP.

[Extramedullary plasmacytoma of the larynx：a case report]

This paper reported a case of extramedullary plasmacytoma of the larynx. The patient presented with persistent hoarseness and foreign body sensation in pharynx for 5 months. Left anterior laryngeal mass, left epiglottis fold distention was found during laryngoscopy. Cervical image examination showed that the left side wall of the glottis was thickened and showed a lump-like change, part of which protrusion into the laryngeal cavity, the laryngeal chamber became narrow, and the growth of thyroid cartilage was broken outwards and reached the level of the hyoid bone. After completing the examination, the laryngeal tumor resection and biopsy were performed under the suspension laryngoscope. Pathologic findings showed that diffuse proliferation of small cells was observed in laryngeal subepithelial fibrous tissue, with local appearance of private, atypia and mitosis. Combined with immunohistochemical results, it was consistent with plasma cell tumor.

An Unusual Case of Multiple Myeloma with Light-Chain Cast Nephropathy Secondary to a Very Large Plasmacytoma without Bone Marrow Involvement

Here, we report a case of a patient who presented to Strong Memorial Hospital with new-onset renal failure and anemia and was found to have multiple myeloma with lambda light-chain cast nephropathy secondary to a very large (14 cm × 14 cm × 12 cm) plasmacytoma without bone marrow involvement. This case is notable as solitary plasmacytomas are almost never seen with concomitant myeloma-defining CRAB criteria or significantly elevated serum free light-chain ratios. Although solitary plasmacytomas are typically definitively treated with radiation, this case highlights that systemic treatment may be helpful in certain clinical scenarios.

[Benefits of radiotherapy for patients with solitary plasmacytoma or multiple myeloma]

BACKGROUND

Treatment options for patients with solitary plasmacytoma (SP) or multiple myeloma (MM) should be discussed in an interdisciplinary context. This systematic review focuses on the importance of radiotherapy in MM and SP.

OBJECTIVE

Summary of local radio-oncological treatment options for patients with SP and MM.

MATERIALS AND METHODS

Based on a systematic literature search, the current evidence on the topic was analyzed and summarized.

RESULTS

Patients with SP should be primarily treated with radiotherapy with or without surgery. Irradiation concepts may vary depending on risk factors and manifestation (solitary bone plasmacytoma vs. solitary extramedullary plasmacytoma). Although local control rates are high after radiotherapy, progression to multiple myeloma frequently occurs. In patients with MM, radiation is mainly used in palliative settings for pain relief, prevention of fractures or in patients who suffer from neurological symptoms due to spinal cord compression. Irradiation dose and fractionation should be selected based on treatment indication and general condition of the patient.

CONCLUSION

Although most patients receive systemic treatment at initial diagnosis, approximately 40% of patients with MM will require radiation during the course of their disease. While radiation is mainly used for palliation in patients with MM, it represents the primary and curative treatment option in patients with SP.

Surgery results in low relapse and progression rates in extramedullary plasmacytoma of the head and neck: A case cohort and review of the literature

Extramedullary plasmacytoma of the head and neck is a rare indolent neoplasm. Radiotherapy is often the preferred treatment option with excellent local control and survival. The risk of local recurrence or transformation to multiple myeloma is 10-30%. In our case-cohort, thorough, sensitive initial evaluation for disseminated clonal disease and the incorporation of surgery led to excellent results with no recurrences or systemic progression.

Anaplastic extraosseous (extramedullary) plasmacytoma in the right nostril

Extraosseous (extramedullary) plasmacytomas are rare plasma cell neoplasms that can result in an erroneous and/or delayed diagnosis as often they are not considered in the differential diagnosis due to their rarity. Furthermore, the anaplastic type is one of the most difficult to recognize in biopsies. We report the case of a patient with an extraosseous plasmacytoma occluded in the right nostril. Its prompt and accurate diagnosis resulted in early treatment and a good outcome, despite the tumour being anaplastic with the risk of progressing into a plasma cell myeloma. The patient shows no recurrence or disease progression after 10 years of follow-up. Our case highlights the clinical and pathological characteristics of this rare disorder that should be considered in order to improve diagnostic criteria and thus early treatment. We also reviewed the pertinent literature.

Myeloma of Laryngeal Cartilage: Literature Review and Case Study

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Impact of radiation dose on local control and survival in extramedullary head and neck plasmacytoma

Background

Patients with plasma-cell neoplasia usually suffer from systemic disease, although a minority (< 5%) may present with solitary involvement of bone or soft tissue (extramedullary plasmacytoma (EMP)). Radiotherapy (RT) is a state-of-the-art treatment for these tumors offering long term curation.

Methods and materials

Between January 2005 and January 2017, twenty-seven patients underwent RT at our institution. The aim of this study was to analyse the effectiveness of various RT doses for different forms of EMP.

Results

A total of 33 radiation courses were administered to 27 patients with a median age of 56 years. The median RT dose was 45 Gy (range: 12–55.8). The local control rate was 76% (93% for primary EMP vs. 61% for the secondary EMP lesions; P < 0.05). A complete response (CR) rate to local RT was achieved for 42% lesions (67% for primary EMP vs. 22% for the secondary EMP lesions; P < 0.01). The overall response rate (ORR) for the EMP lesions treated with high-dose regimens (> 45 Gy) versus low-dose regimens (≤ 45 Gy) was 87% versus 67%, respectively (P = 0.2). The median survival with high-dose RT group was significantly longer (P = 0.02). In subgroups analysis, primary EMP patients treated with high-dose RT had a non-significant higher ORR (100% vs. 80%, respectively; P = 0.3,) longer duration of LC (P = 0.3) with a longer survival (P = 0.05) than patients in low-dose group. No significant difference has been detected in secondary EMP patients treated with high-dose RT regarding ORR (60% vs. 62%, respectively; P = 1), and survival (P = 0.4).

Conclusion

RT is an efficacious treatment modality in the treatment of EMP. A radiation dose ≤45 Gy confer a comparable CR rate to high-dose regimens and appears to be an effective treatment for controlling local EMP progression. Radiation dose-escalation may be beneficial for particular subgroups of patients.

Lymphomas of the head and neck region: an update

The field of haematopathology is rapidly evolving and for the non-specialized pathologist receiving a specimen with the possibility of a lymphoid malignancy may be a daunting experience. The coincidence of the publication, in 2017, of the WHO monographies on head and neck and haematopoietic and lymphoid tumours prompted us to write this review. Although not substantially different from lymphomas elsewhere, lymphomas presenting in this region pose some specific problems and these are central to the review. In addition, differences in subtype frequency and morphological variations within the same entity are discussed. The difficulty in diagnosis related to some specimens led us to briefly mention common subtypes of systemic lymphomas presenting in the head and neck region.