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Parillo M, Vaccarino F, Quattrocchi CC. Imaging findings in a case of leptomeningeal myelomatosis, a rare but critical central nervous system complication of multiple myeloma. Neuroradiol J 2023; 36:616-620. [PMID: 36627179 PMCID: PMC10569195 DOI: 10.1177/19714009221150849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Leptomeningeal myelomatosis is a rare complication of multiple myeloma (<1% of the patients). There was an increase in the incidence of leptomeningeal myelomatosis during the last decade; the prognosis of leptomeningeal myelomatosis remains poor, (overall median survival from the time of diagnosis of 2 months). We discuss a rare case of a monoclonal gammopathy evolving into multiple myeloma and finally into a rapidly progressing leptomeningeal disease. A 76 year-old woman in hematologic follow-up for advanced stage multiple myeloma in sixth-line treatment had an episode of generalized tonic-clonic seizure with sphincter release followed by altered state of consciousness. The unenhanced head CT scan showed a mild enlargement of the ventricular system without intra-axial or extra-axial hemorrhages nor significant changes in brain parenchyma. The subsequent contrast-enhanced brain MRI revealed a widespread nodular leptomeningeal enhancement characterized by contrast-enhancement of the pia mater extended into the subarachnoid spaces of the sulci and cisterns, involving supra- and sub-tentorial regions and the statoacoustic nerve in the inner ear canal bilaterally. The fluid-attenuated inversion recovery MRI images demonstrated an abnormally elevated signal within the sulci in the parieto-occipital regions. The radiological diagnosis of leptomeningeal myelomatosis was made. The patient died 4 days after the examination. In patients with long-lasting multiple myeloma and onset of neurological signs or symptoms, a contrast-enhanced brain MRI should be performed to assess the actual burden of central nervous system involvement in leptomeningeal myelomatosis; CT may provide a clue to the diagnosis when progressive enlargement of the ventricles over time is noted.
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Affiliation(s)
- Marco Parillo
- Unit of Diagnostic Imaging and Interventional Radiology, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21 - 00128 Roma, Italy
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200 - 00128 Roma, Italy
| | - Federica Vaccarino
- Unit of Diagnostic Imaging and Interventional Radiology, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21 - 00128 Roma, Italy
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200 - 00128 Roma, Italy
| | - Carlo Cosimo Quattrocchi
- Unit of Diagnostic Imaging and Interventional Radiology, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21 - 00128 Roma, Italy
- Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200 - 00128 Roma, Italy
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2
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Perillo T, D'Agostino V, Pagano A, Serino A, Manto A. Sphenoid bone localization in the setting of highly aggressive and refractory Multiple Myeloma: A case report. J Med Imaging Radiat Sci 2023; 54:562-565. [PMID: 37453857 DOI: 10.1016/j.jmir.2023.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 06/15/2023] [Accepted: 06/23/2023] [Indexed: 07/18/2023]
Abstract
Multiple Myeloma (MM) is the most common primary osseous malignancy in adults, and it mainly affects men aged between 50 and 70 years. Although rare, central nervous system (CNS) involvement in MM is possible, and it has very poor prognosis. Therefore, fast and accurate diagnosis of CNS manifestation of MM is paramount. Here we describe a case of sphenoid bone localization in a patient with highly aggressive and refractory MM.
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Affiliation(s)
- Teresa Perillo
- Neuroradiology Unit, "Umberto I" Hospital, Nocera Inferiore, Italy.
| | | | | | | | - Andrea Manto
- Neuroradiology Unit, "Umberto I" Hospital, Nocera Inferiore, Italy
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3
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Tyczyńska A, Turski M, Zarzycka E, Zaucha JM. Isolated Progression of Multiple Myeloma into the Extramedullary Plasmacytoma of Dura Mater: A Case Report and Review of the Literature. Biomedicines 2023; 11:biomedicines11041225. [PMID: 37189843 DOI: 10.3390/biomedicines11041225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 03/12/2023] [Accepted: 03/22/2023] [Indexed: 05/17/2023] Open
Abstract
Multiple myeloma (MM) is a disease caused by the uncontrolled proliferation of clonal plasma cells in bone marrow. Extramedullary plasma cell infiltrations may occur at the time of diagnosis but usually arise during systemic disease progression. Central nervous system (CNS) plasmacytomas are extremely rare (less than 1% of patients with MM) and usually occur as a result of systemic disease progression. The frequency of extramedullary progression to CNS without simultaneous systemic progression is not known. Here, we present a challenging case in which local disease progression to CNS occurred without any signs of systemic progression. The extramedullary plasmacytoma originated from the dura mater of the brain mimicking a brain tumor. We review and discuss further treatment options that are available in such rare clinical scenarios in relation to the treatment already undertaken.
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Affiliation(s)
- Agata Tyczyńska
- Department of Hematology and Transplantology, Medical University of Gdańsk, 80-214 Gdańsk, Poland
| | - Mikołaj Turski
- Student Scientific Circle at the Department of Hematology and Transplantology, Medical University of Gdańsk, 80-210 Gdańsk, Poland
| | - Ewa Zarzycka
- Department of Hematology and Transplantology, Medical University of Gdańsk, 80-214 Gdańsk, Poland
| | - Jan Maciej Zaucha
- Department of Hematology and Transplantology, Medical University of Gdańsk, 80-214 Gdańsk, Poland
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4
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Jankovic D, Kalasauskas D, Keric N, Ottenhausen M, Ringel F. Multiple myeloma presenting as a cervical intraforaminal tumor: A case report and review of literature. Front Surg 2023; 10:1011152. [PMID: 36793317 PMCID: PMC9923170 DOI: 10.3389/fsurg.2023.1011152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 01/02/2023] [Indexed: 01/31/2023] Open
Abstract
Multiple myeloma (MM) is a hematological malignancy with characteristic clonal plasma cell proliferation and production of monoclonal immunoglobulins. Although it can often metastasize to the bony spine, completely extravertebral and extra-/intradural manifestations are exceedingly rare. In this case report, we describe a 51-year-old male patient with cervical extradural and intraforaminal MM who was surgically treated in our department. Clinical findings and radiological images were retrieved from medical records and an imaging system. This unusual localization of MM and similar cases in the literature are reviewed in detail. The patient underwent tumor resection via a ventral approach, and postoperative MRI demonstrated a sufficient decompression of neural structures. No new neurological deficits were observed at subsequent follow-ups. Although 7 cases of extramedullary extradural manifestations of multiple myeloma have been described in the literature so far, this is the first case of intraforaminal extramedullary multiple myeloma located in the cervical spine and treated by surgery.
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5
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Li Y, Sun Z, Qu X. Advances in the treatment of extramedullary disease in multiple myeloma. Transl Oncol 2022; 22:101465. [PMID: 35679743 PMCID: PMC9178475 DOI: 10.1016/j.tranon.2022.101465] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 05/17/2022] [Accepted: 05/26/2022] [Indexed: 11/30/2022] Open
Abstract
Extramedullary multiple myeloma results in an adverse prognosis. Novel agents such as bortezomib, lenalidomide, pomalidomide, isatuximab and selinexor showed efficacy and were recommended to treat EMD. For EMD at special sites, marizomib has advantages in the treatment of CNS-MM; Daratumumab combining with intrapleural bortezomib administration is active in treating myelomatous pleural effusion. Based on treatment experience of EMD in our department, we summarized treatment approach for EMD.
Extramedullary disease (EMD) is characterized by plasma cells outside of bone marrow in multiple myeloma (MM) patients, which results in an adverse prognosis. The cornerstone of treatment consists of combination therapy including proteasome inhibitors, immunomodulatory agents, steroids, followed by consolidative autologous hematopoietic stem cell transplantation in eligible patients. This review summarized the recent advances in the treatment of EMD. Bortezomib based therapy showed efficacy and was recommended to treat EMD. Marizomib had advantages in the treatment of central nervous system-multiple myeloma (CNS-MM) because of its good central nervous system penetrability. Immunomodulatory drugs such as lenalidomide and pomalidomide have been reported to be effective. Isatuximab and selinexor were also active. Based on the treatment experience of EMD in our department, we summarized treatment approach for EMD. However, the benefits of patients with EMD from the new era of novel drugs were limited. Novel drugs combination, monoclonal antibody, molecular targeted therapy, cellular immunotherapy and autologous stem cell transplantation (ASCT) are under investigation. Therapeutic studies and clinical trials specifically target EMD should be conducted. Hopefully, these treatment options for EMD will be demonstrated efficacy in the future.
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6
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Sammartano V, Cerase A, Venanzi V, Mazzei MA, Vangone BE, Gentili F, Chiarotti I, Bocchia M, Gozzetti A. Central Nervous System Myeloma and Unusual Extramedullary Localizations: Real Life Practical Guidance. Front Oncol 2022; 12:934240. [PMID: 35875104 PMCID: PMC9300839 DOI: 10.3389/fonc.2022.934240] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 06/10/2022] [Indexed: 12/22/2022] Open
Abstract
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.
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Affiliation(s)
- Vincenzo Sammartano
- Hematology Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, Azienda Ospedaliero Universitaria Senese, Siena, Italy
| | - Alfonso Cerase
- Neuroimaging (Diagnostic and Functional Neuroradiology) Unit, Azienda ospedaliero-universitaria Senese, Siena, Italy
| | - Valentina Venanzi
- Hematology Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, Azienda Ospedaliero Universitaria Senese, Siena, Italy
| | - Maria Antonietta Mazzei
- Department of Medicine, Surgery and Neuroscience, University of Siena and Department of Radiological Sciences, Unit of Diagnostic Imaging, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Beatrice Esposito Vangone
- Hematology Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, Azienda Ospedaliero Universitaria Senese, Siena, Italy
| | - Francesco Gentili
- Department of Medicine, Surgery and Neuroscience, University of Siena and Department of Radiological Sciences, Unit of Diagnostic Imaging, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Ivano Chiarotti
- Neuroimaging (Diagnostic and Functional Neuroradiology) Unit, Azienda ospedaliero-universitaria Senese, Siena, Italy
| | - Monica Bocchia
- Hematology Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, Azienda Ospedaliero Universitaria Senese, Siena, Italy
| | - Alessandro Gozzetti
- Hematology Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, Azienda Ospedaliero Universitaria Senese, Siena, Italy
- *Correspondence: Alessandro Gozzetti,
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7
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Perillo T, Somma C, Perrotta M, Rivellini F, Barone M, Manto A. Neuroimaging of leptomeningeal myelomatosis: a rare and severe entity. Ann Hematol 2022; 101:2091-2092. [PMID: 35525882 DOI: 10.1007/s00277-022-04860-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 04/28/2022] [Indexed: 11/25/2022]
Affiliation(s)
- Teresa Perillo
- Department of Neuroradiology, "Umberto I" Hospital, Nocera Inferiore, SK, Italy.
| | - Carmela Somma
- Department of Neuroradiology, "Umberto I" Hospital, Nocera Inferiore, SK, Italy
| | - Marianna Perrotta
- Department of Neuroradiology, "Umberto I" Hospital, Nocera Inferiore, SK, Italy
| | - Flavia Rivellini
- Department of Onco-Hematology, "Tortora" Hospital, Pagani, SK, Italy
| | - Marialucia Barone
- Department of Onco-Hematology, "Tortora" Hospital, Pagani, SK, Italy
| | - Andrea Manto
- Department of Neuroradiology, "Umberto I" Hospital, Nocera Inferiore, SK, Italy
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8
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Wang VS, Ahmad A, Mazuera S, Lauritsen CG. Central Nervous System Involvement of Multiple Myeloma Presenting as Short-lasting Unilateral Neuralgiform Headache with Conjunctival Injection and Tearing: A Case Report. Neurohospitalist 2022; 12:544-549. [DOI: 10.1177/19418744221086681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Short-lasting unilateral neuralgiform headache with conjunctival injection and tearing (SUNCT) and short-lasting unilateral neuralgiform headache attacks with cranial autonomic symptoms (SUNA) are part of the trigeminal autonomic cephalalgia (TAC) group of headache disorders. Attacks present with repeated, severe, sharp, stabbing, or throbbing pain. Patients may experience a single attack, recurrent attacks with pain-free interictal periods, or a sawtooth pattern background pain with superimposed stabs. 1 , 2 Although SUNCT typically presents as a primary headache disorder, it may be secondary to an underlying pathology, such as pituitary tumors or posterior fossa lesions, both intra and extra-axial (vascular lesion, tumor, or bony abnormalities). Multiple Myeloma (MM) with central nervous system involvement (CNS MM) most commonly presents with visual changes (36%), radiculopathy (27%), headache (25%), confusion (21%), dizziness (7%) and seizures (6%). 3 , 4 Secondary SUNCT cases have been sparsely described (less than 60), and CNS MM presenting as SUNCT has not been previously described in the literature. 2 , 5 Our case describes a previously unreported clinical presentation of CNS MM. The report highlights the need for a timely and thorough diagnostic work-up of headache in patients with risk factors for a secondary etiology, which in this case included new-onset, autonomic features, older age, and history of malignancy. A misdiagnosis will preclude a potentially life-extending or saving targeted therapy for the underlying illness. We also aim to remind practitioners of the variability in the clinical symptoms of SUNCT, which are known to occur in a significant number of cases, including migrainous features and dull interictal pain.
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Affiliation(s)
- Victor S. Wang
- Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Ayesha Ahmad
- Jefferson Headache Center, Thomas Jefferson University, Philadelphia, PA, USA
| | - Santiago Mazuera
- The Sandra and Malcolm Berman Brain and Spine Institute, Baltimore, MD, USA
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9
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Bladé J, Beksac M, Caers J, Jurczyszyn A, von Lilienfeld-Toal M, Moreau P, Rasche L, Rosiñol L, Usmani SZ, Zamagni E, Richardson P. Extramedullary disease in multiple myeloma: a systematic literature review. Blood Cancer J 2022; 12:45. [PMID: 35314675 PMCID: PMC8938478 DOI: 10.1038/s41408-022-00643-3] [Citation(s) in RCA: 51] [Impact Index Per Article: 25.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 11/26/2021] [Accepted: 03/07/2022] [Indexed: 12/19/2022] Open
Abstract
Extramedullary involvement (or extramedullary disease, EMD) represents an aggressive form of multiple myeloma (MM), characterized by the ability of a clone and/or subclone to thrive and grow independent of the bone marrow microenvironment. Several different definitions of EMD have been used in the published literature. We advocate that true EMD is restricted to soft-tissue plasmacytomas that arise due to hematogenous spread and have no contact with bony structures. Typical sites of EMD vary according to the phase of MM. At diagnosis, EMD is typically found in skin and soft tissues; at relapse, typical sites involved include liver, kidneys, lymph nodes, central nervous system (CNS), breast, pleura, and pericardium. The reported incidence of EMD varies considerably, and differences in diagnostic approach between studies are likely to contribute to this variability. In patients with newly diagnosed MM, the reported incidence ranges from 0.5% to 4.8%, while in relapsed/refractory MM the reported incidence is 3.4 to 14%. Available data demonstrate that the prognosis is poor, and considerably worse than for MM without soft-tissue plasmacytomas. Among patients with plasmacytomas, those with EMD have poorer outcomes than those with paraskeletal involvement. CNS involvement is rare, but prognosis is even more dismal than for EMD in other locations, particularly if there is leptomeningeal involvement. Available data on treatment outcomes for EMD are derived almost entirely from retrospective studies. Some agents and combinations have shown a degree of efficacy but, as would be expected, this is less than in MM patients with no extramedullary involvement. The paucity of prospective studies makes it difficult to justify strong recommendations for any treatment approach. Prospective data from patients with clearly defined EMD are important for the optimal evaluation of treatment outcomes.
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Affiliation(s)
- Joan Bladé
- Department of Hematology, Hospital Clínic, IDIBAPS, University of Barcelona, Barcelona, Spain.
| | - Meral Beksac
- Department of Hematology, Ankara University School of Medicine, Ankara, Turkey
| | - Jo Caers
- Department of Hematology, CHU de Liège, Liège, Belgium
| | - Artur Jurczyszyn
- Plasma Cell Dyscrasia Center, Department of Hematology, Jagiellonian University Medical College, Cracow, Poland
| | - Marie von Lilienfeld-Toal
- Klinik für Innere Medizin II, Abteilung für Hämatologie und Internistische Onkologie, Universitätsklinikum Jena, Jena, Germany
| | | | - Leo Rasche
- Department of Internal Medicine II, University Hospital of Würzburg, Würzburg, Germany
| | - Laura Rosiñol
- Department of Hematology, Hospital Clínic, IDIBAPS, University of Barcelona, Barcelona, Spain
| | - Saad Z Usmani
- Department of Hematologic Oncology and Blood Disorders, Levine Cancer Institute/Atrium Health, Charlotte, NC, USA
| | - Elena Zamagni
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia 'Seràgnoli' and Dipartimento di Medicina Specialistica, Diagnostica e Sperimentale, Università di Bologna, Bologna, Italy
| | - Paul Richardson
- Jerome Lipper Multiple Myeloma Center, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
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10
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Alter DN. Commentary on Significance of Monoclonal Band in Cerebral Spinal Fluid. Clin Chem 2022; 68:280. [PMID: 35104859 DOI: 10.1093/clinchem/hvab256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 11/09/2021] [Indexed: 11/13/2022]
Affiliation(s)
- David N Alter
- Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, GA, USA
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11
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Wang Y, Zu C, Teng X, Yang L, Zhang M, Hong R, Zhao H, Cui J, Xu H, Hongsheng AC, Hu Y, Huang H. BCMA CAR-T Therapy Is Safe and Effective for Refractory/Relapsed Multiple Myeloma With Central Nervous System Involvement. J Immunother 2022; 45:25-34. [PMID: 34874329 DOI: 10.1097/cji.0000000000000391] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 08/04/2021] [Indexed: 11/25/2022]
Abstract
Central nervous system (CNS) involvement is a rare complication of multiple myeloma (MM) that portends an extremely poor prognosis. Although chimeric antigen receptor (CAR)-T cell therapy is considered a promising strategy for patients with MM, the role of CAR-T cell therapy in MM involving the CNS has not been fully elucidated. In this study, we retrospectively analyzed 4 cases of B-cell maturation antigen CAR-T cell therapy for patients with relapsed/refractory MM involving the CNS. Patients received a range of 2-7 lines of prior therapy, including 1 autologous hematopoietic stem cell transplant. The most common adverse event was cytokine release syndrome, which was observed in all 4 patients, including 2 with grade 1 and 2 with grade 2. No patient was complicated with immune effector cell-associated neurotoxicity syndrome. Within the follow-up (median: 257 d, range: 116-392 d), 3 of 4 patients reached complete remission (CR), and 1 patient reached partial response. At the data cutoff, 1 patient continued to remain in CR at day 220, and the patient with partial response died at day 116. The other 2 patients relapsed at 317 and 111 days with CR durations of 287 and 81 days, respectively. Our results show promising effectiveness and acceptable safety of CAR-T cell therapy for heavily pretreated patients with CNS MM.
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Affiliation(s)
- Yiyun Wang
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine
- Institute of Hematology, Zhejiang University
- Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy
- Zhejiang Laboratory for Systems & Precision Medicine, Zhejiang University Medical Center, Hangzhou, Zhejiang Province, China
| | - Cheng Zu
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine
- Institute of Hematology, Zhejiang University
- Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy
- Zhejiang Laboratory for Systems & Precision Medicine, Zhejiang University Medical Center, Hangzhou, Zhejiang Province, China
| | - Xinyi Teng
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine
- Institute of Hematology, Zhejiang University
- Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy
- Zhejiang Laboratory for Systems & Precision Medicine, Zhejiang University Medical Center, Hangzhou, Zhejiang Province, China
| | - Li Yang
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine
- Institute of Hematology, Zhejiang University
- Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy
- Zhejiang Laboratory for Systems & Precision Medicine, Zhejiang University Medical Center, Hangzhou, Zhejiang Province, China
| | - Mingming Zhang
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine
- Institute of Hematology, Zhejiang University
- Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy
- Zhejiang Laboratory for Systems & Precision Medicine, Zhejiang University Medical Center, Hangzhou, Zhejiang Province, China
| | - Ruimin Hong
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine
- Institute of Hematology, Zhejiang University
- Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy
- Zhejiang Laboratory for Systems & Precision Medicine, Zhejiang University Medical Center, Hangzhou, Zhejiang Province, China
| | - Houli Zhao
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine
- Institute of Hematology, Zhejiang University
- Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy
- Zhejiang Laboratory for Systems & Precision Medicine, Zhejiang University Medical Center, Hangzhou, Zhejiang Province, China
| | - Jiazhen Cui
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine
- Institute of Hematology, Zhejiang University
- Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy
- Zhejiang Laboratory for Systems & Precision Medicine, Zhejiang University Medical Center, Hangzhou, Zhejiang Province, China
| | - Huijun Xu
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine
- Institute of Hematology, Zhejiang University
- Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy
- Zhejiang Laboratory for Systems & Precision Medicine, Zhejiang University Medical Center, Hangzhou, Zhejiang Province, China
| | - Alex Chang Hongsheng
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine
- Institute of Hematology, Zhejiang University
- Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy
- Zhejiang Laboratory for Systems & Precision Medicine, Zhejiang University Medical Center, Hangzhou, Zhejiang Province, China
| | - Yongxian Hu
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine
- Institute of Hematology, Zhejiang University
- Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy
- Zhejiang Laboratory for Systems & Precision Medicine, Zhejiang University Medical Center, Hangzhou, Zhejiang Province, China
| | - He Huang
- Bone Marrow Transplantation Center, The First Affiliated Hospital, Zhejiang University School of Medicine
- Institute of Hematology, Zhejiang University
- Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy
- Zhejiang Laboratory for Systems & Precision Medicine, Zhejiang University Medical Center, Hangzhou, Zhejiang Province, China
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12
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Wang Y, Wang L, Zeng Y, Hong R, Zu C, Yin ETS, Zhao H, Wei G, Yang L, Jin A, Hu Y, Huang H. Successful BCMA CAR-T Therapy for Multiple Myeloma With Central Nervous System Involvement Manifesting as Cauda Equina Syndrome-A Wandering Road to Remission. Front Oncol 2021; 11:755584. [PMID: 34868965 PMCID: PMC8635736 DOI: 10.3389/fonc.2021.755584] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 10/26/2021] [Indexed: 11/22/2022] Open
Abstract
Multiple myeloma (MM) with central nervous system (CNS) involvement is rare with only 1% incidence. So far, there is no standard or effective treatment for CNS MM, and the expected survival time is fewer than 6 months. Here, we report a case of MM with CNS involvement presented with cauda equina syndrome (CES) who achieved complete remission after anti-B-cell maturation antigen (BCMA) chimeric antigen receptor T (CAR-T) cell therapy (Chictr.org.cn, ChiCTR1800017404). The expansion of BCMA CAR-T cells was observed in both peripheral blood (PB) and cerebrospinal fluid (CSF). The CAR-T cells peaked at 2.4 × 106/l in CSF at day 8 and 4.1 × 109/l in PB at day 13. The peak concentration of interleukin (IL)-6 in CSF was detected 3 days earlier, and almost five times higher than that in PB. Next, morphological analysis confirmed the elimination of nucleated cells in CSF 1 month after CAR-T cell treatment from 300 cells/μl, and the patient achieved functional recovery with regressed lesion shown in PET-CT. The case demonstrated that BCMA CAR-T cells are effective and safe in this patient population.
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Affiliation(s)
- Yiyun Wang
- Bone Marrow Transplantation Center, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Institute of Hematology, Zhejiang University, Hangzhou, China.,Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China.,Zhejiang Laboratory for Systems & Precision Medicine, Zhejiang University Medical Center, Hangzhou, China
| | - Linqin Wang
- Bone Marrow Transplantation Center, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Institute of Hematology, Zhejiang University, Hangzhou, China.,Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China.,Zhejiang Laboratory for Systems & Precision Medicine, Zhejiang University Medical Center, Hangzhou, China
| | - Yifan Zeng
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Ruimin Hong
- Bone Marrow Transplantation Center, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Institute of Hematology, Zhejiang University, Hangzhou, China.,Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China.,Zhejiang Laboratory for Systems & Precision Medicine, Zhejiang University Medical Center, Hangzhou, China
| | - Cheng Zu
- Bone Marrow Transplantation Center, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Institute of Hematology, Zhejiang University, Hangzhou, China.,Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China.,Zhejiang Laboratory for Systems & Precision Medicine, Zhejiang University Medical Center, Hangzhou, China
| | - Elaine Tan Su Yin
- Bone Marrow Transplantation Center, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Institute of Hematology, Zhejiang University, Hangzhou, China.,Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China.,Zhejiang Laboratory for Systems & Precision Medicine, Zhejiang University Medical Center, Hangzhou, China
| | - Houli Zhao
- Bone Marrow Transplantation Center, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Institute of Hematology, Zhejiang University, Hangzhou, China.,Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China.,Zhejiang Laboratory for Systems & Precision Medicine, Zhejiang University Medical Center, Hangzhou, China
| | - Guoqing Wei
- Bone Marrow Transplantation Center, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Institute of Hematology, Zhejiang University, Hangzhou, China.,Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China.,Zhejiang Laboratory for Systems & Precision Medicine, Zhejiang University Medical Center, Hangzhou, China
| | - Li Yang
- Bone Marrow Transplantation Center, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Institute of Hematology, Zhejiang University, Hangzhou, China.,Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China.,Zhejiang Laboratory for Systems & Precision Medicine, Zhejiang University Medical Center, Hangzhou, China
| | - Aiyun Jin
- Bone Marrow Transplantation Center, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Institute of Hematology, Zhejiang University, Hangzhou, China.,Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China.,Zhejiang Laboratory for Systems & Precision Medicine, Zhejiang University Medical Center, Hangzhou, China
| | - Yongxian Hu
- Bone Marrow Transplantation Center, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Institute of Hematology, Zhejiang University, Hangzhou, China.,Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China.,Zhejiang Laboratory for Systems & Precision Medicine, Zhejiang University Medical Center, Hangzhou, China
| | - He Huang
- Bone Marrow Transplantation Center, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.,Institute of Hematology, Zhejiang University, Hangzhou, China.,Zhejiang Province Engineering Laboratory for Stem Cell and Immunity Therapy, Hangzhou, China.,Zhejiang Laboratory for Systems & Precision Medicine, Zhejiang University Medical Center, Hangzhou, China
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13
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Chen Y, Qiu Y, Fu H, Li J, Chen L, Liao S, Liu T. IgD multiple myeloma with central nervous system involvement: A case report and literature review. Mol Clin Oncol 2021; 15:198. [PMID: 34462654 PMCID: PMC8375031 DOI: 10.3892/mco.2021.2360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 03/17/2021] [Indexed: 11/08/2022] Open
Abstract
Central nervous system (CNS) involvement is a rare manifestation of multiple myeloma (MM) and the optimal management strategies have yet to be determined. The aim of the present study was to describe the case of a 47-year-old male patient with immunoglobulin D-λ MM who presented with multiple extramedullary infiltrations at diagnosis. This patient achieved stringent complete response after 9 cycles of treatment with bortezomib, lenalidomide and dexamethasone, and then received lenalidomide as maintenance therapy. CNS involvement and extramedullary relapse developed 3 months after the last chemotherapy cycle. Despite receiving a second-line treatment protocol, the patient succumbed to the disease within 1 month after recurrence. The characteristics and treatment options for CNS MM are discussed in this case report.
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Affiliation(s)
- Yi Chen
- Fujian Provincial Key Laboratory on Haematology, Fujian Medical University Union Hospital, Fujian Institute of Haematology, Fuzhou, Fujian 350001, P.R. China
| | - Yanyan Qiu
- Fujian Provincial Key Laboratory on Haematology, Fujian Medical University Union Hospital, Fujian Institute of Haematology, Fuzhou, Fujian 350001, P.R. China
| | - Haiying Fu
- Fujian Provincial Key Laboratory on Haematology, Fujian Medical University Union Hospital, Fujian Institute of Haematology, Fuzhou, Fujian 350001, P.R. China
| | - Jing Li
- Fujian Provincial Key Laboratory on Haematology, Fujian Medical University Union Hospital, Fujian Institute of Haematology, Fuzhou, Fujian 350001, P.R. China
| | - Lushan Chen
- Fujian Provincial Key Laboratory on Haematology, Fujian Medical University Union Hospital, Fujian Institute of Haematology, Fuzhou, Fujian 350001, P.R. China
| | - Siqin Liao
- Fujian Provincial Key Laboratory on Haematology, Fujian Medical University Union Hospital, Fujian Institute of Haematology, Fuzhou, Fujian 350001, P.R. China
| | - Tingbo Liu
- Fujian Provincial Key Laboratory on Haematology, Fujian Medical University Union Hospital, Fujian Institute of Haematology, Fuzhou, Fujian 350001, P.R. China
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14
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Miki Y, Kamata K, Akemoto Y, Tsushima F, Sakuraba H, Yamagata K, Kurose A, Fukuda S, Wakabayashi K. Leptomeningeal and intraventricular myelomatosis manifesting an aggressive form of communicating hydrocephalus. Neuropathology 2021; 41:243-249. [PMID: 33973283 DOI: 10.1111/neup.12728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 12/24/2020] [Accepted: 12/29/2020] [Indexed: 11/29/2022]
Abstract
Leptomeningeal myelomatosis (LMM) is a fatal complication that occurs in < 1% of patients with multiple myeloma. Many patients with LMM present with neurologic symptoms referable to cranial neuropathies, while the manifestation of communicating hydrocephalus has been underrecognized. A Japanese man with Bence Jones protein-κ multiple myeloma developed fever and headache at age 54 years. He then became somnolent and went into a coma. Neuroimaging analyses identified rapidly progressive communicating hydrocephalus due to meningitis. He died 83 days after the onset of headache without any response to treatment at age 55 years. No symptoms or signs associated with cranial nerves were found during the course of illness. Postmortem examination revealed hydrocephalus and diffuse infiltration of myeloma cells into the subarachnoid space of the cerebrum, cerebellum, and brainstem. In addition, the interstitial tissue of the choroid plexuses was filled with myeloma cells. These myeloma cells were positive for CD156 and light chain κ. The Ki-67 labeling index in myeloma cells of the central nervous system (CNS) was 30-40%. Histopathological examination further revealed many myeloma cells on the surface of the lateral, third and fourth ventricles and at the area postrema of the medulla oblongata. Patients with LMM can develop an aggressive form of communicating hydrocephalus. Given that cerebrospinal fluid, produced by epithelial cells in the choroid plexuses of the ventricles, passes into the subarachnoid space through the third and fourth ventricles, myeloma cells may invade the CNS through the choroid plexuses.
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Affiliation(s)
- Yasuo Miki
- Department of Neuropathology, Institute of Brain Science, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Kosuke Kamata
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Yui Akemoto
- Department of Anatomic Pathology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Fumiyasu Tsushima
- Department of Radiation, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Hirotake Sakuraba
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Kazufumi Yamagata
- Department of Bioscience and Laboratory Medicine, Hirosaki University Graduate School of Health Sciences, Hirosaki, Japan
| | - Akira Kurose
- Department of Anatomic Pathology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Shinsaku Fukuda
- Department of Gastroenterology and Hematology, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
| | - Koichi Wakabayashi
- Department of Neuropathology, Institute of Brain Science, Hirosaki University Graduate School of Medicine, Hirosaki, Japan
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15
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Claudel A, Talbot A, Harel S, Royer B, Naelle L, Zagdanski AM, Madelaine I, Lemaire P, Arnulf B. Thiotepa intrathecal injections for myelomatous central nervous system involvement. Br J Haematol 2021; 193:e9-e12. [PMID: 33686665 DOI: 10.1111/bjh.17343] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Alexis Claudel
- Immuno-Hematology Department, Saint-Louis Hospital (APHP), University of Paris Diderot-Paris VII (Sorbonne Paris Cité), Paris, France
| | - Alexis Talbot
- Immuno-Hematology Department, Saint-Louis Hospital (APHP), University of Paris Diderot-Paris VII (Sorbonne Paris Cité), Paris, France
| | - Stéphanie Harel
- Immuno-Hematology Department, Saint-Louis Hospital (APHP), University of Paris Diderot-Paris VII (Sorbonne Paris Cité), Paris, France
| | - Bruno Royer
- Immuno-Hematology Department, Saint-Louis Hospital (APHP), University of Paris Diderot-Paris VII (Sorbonne Paris Cité), Paris, France
| | - Lombion Naelle
- Immuno-Hematology Department, Saint-Louis Hospital (APHP), University of Paris Diderot-Paris VII (Sorbonne Paris Cité), Paris, France
| | - Anne-Marie Zagdanski
- Department of Radiology, Saint-Louis Hospital (AP-HP), University of Paris Diderot-Paris VII (Sorbonne Paris Cité), Paris, France
| | - Isabelle Madelaine
- Pharmacy Department, Saint-Louis Hospital (APHP), University of Paris Diderot-Paris VII (Sorbonne Paris Cité), Paris, France
| | - Pierre Lemaire
- Hematology Laboratory, Saint-Louis Hospital (APHP), University of Paris Diderot-Paris VII (Sorbonne Paris Cité), Paris, France
| | - Bertrand Arnulf
- Immuno-Hematology Department, Saint-Louis Hospital (APHP), University of Paris Diderot-Paris VII (Sorbonne Paris Cité), Paris, France
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16
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Tripathi P, Farheen S, Singh A, Yadav P, Sen A. Central nervous system involvement: A rare detour for myeloma cells-case report of an usual presentation! JOURNAL OF APPLIED HEMATOLOGY 2021. [DOI: 10.4103/joah.joah_228_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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17
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Di L, Huang K, Kesayan T, Kroll D, Baz RC, Macaulay RJ, Tran ND. Multiple myeloma presenting as an intramedullary spinal cord tumor: a case report and review of the literature. J Med Case Rep 2020; 14:189. [PMID: 33059729 PMCID: PMC7566029 DOI: 10.1186/s13256-020-02496-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 08/12/2020] [Indexed: 11/23/2022] Open
Abstract
Background Extramedullary disease in multiple myeloma often portends a worse diagnosis. In approximately 1% of cases, multiple myeloma may metastasize to the central nervous system as either leptomeningeal involvement or an intracranial, intraparenchymal lesion. Spinal cord metastases, however, are exceedingly rare. We present a case of spinal cord multiple myeloma as well as a literature review of reported cases. Case presentation A 66-year-old African American man with multiple myeloma presented with acute midthoracic pain and lower extremity paresis and paresthesia. Magnetic resonance imaging of the spine revealed two contrast-enhancing intramedullary enhancing lesions in the T1–T2 and T6–T7 cord. Resection with biopsy yielded a diagnosis of metastatic multiple myeloma. Conclusion To date, only six cases of extramedullary disease to the spinal cord in patients with multiple myeloma have been reported, including our patient’s case. In all cases, neurologic deficit was observed at presentation, and magnetic resonance imaging of the spine revealed an intramedullary, homogeneously enhancing lesion. Current evidence suggests worse prognosis in patients with extramedullary disease to the central nervous system, and treatment paradigms remain debatable.
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Affiliation(s)
- Long Di
- Department of Neurosurgery, University of South Florida, Tampa, FL, USA
| | - Kevin Huang
- Department of Neurosurgery, University of South Florida, Tampa, FL, USA
| | - Tigran Kesayan
- Department of Neuro-Oncology, Moffitt Cancer Center, 12902 USF Magnolia Drive, Tampa, FL, 33612, USA.,Department of Neurology, University of South Florida, Tampa, FL, USA
| | - Derek Kroll
- Department of Neuro-Oncology, Moffitt Cancer Center, 12902 USF Magnolia Drive, Tampa, FL, 33612, USA
| | - Rachid C Baz
- Department of Hematology and Oncology, Moffit Cancer Center, Tampa, FL, USA
| | | | - Nam D Tran
- Department of Neurosurgery, University of South Florida, Tampa, FL, USA. .,Department of Neuro-Oncology, Moffitt Cancer Center, 12902 USF Magnolia Drive, Tampa, FL, 33612, USA.
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18
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Prakash A, Korem S, Inkollu S, Lee P. Multiple Myeloma Relapse as Intracranial Plasmacytoma: A Rare Presentation. Cureus 2020; 12:e8357. [PMID: 32617228 PMCID: PMC7325346 DOI: 10.7759/cureus.8357] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
Multiple myeloma (MM) infrequently involves the central nervous system (CNS). The usual sites of involvement are skull and meninges; however, intracranial tumors are exceedingly rare. We report the case of a 60-year-old female who presented to our center for the complaint of recurrent syncope. The patient was diagnosed with MM approximately one and a half years ago and had received chemotherapy followed by an allogeneic bone marrow transplant and was in remission afterward. We initiated workup for syncope and a brain MRI revealed an intracranial mass. Histopathological studies of the intracranial mass confirm the diagnosis of plasmacytoma and further testing shows relapse of MM. This is a unique case of MM relapse with isolated intracranial plasmacytoma. It usually carries a poor prognosis. Early diagnosis and management are imperative to improve survival.
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Affiliation(s)
- Amulya Prakash
- Internal Medicine, Monmouth Medical Center, Long Branch, USA
| | - Sindhuja Korem
- Internal Medicine, Monmouth Medical Center, Long Branch, USA
| | | | - Patrick Lee
- Oncology, Monmouth Medical Center, Long Branch, USA
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19
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Egan PA, Elder PT, Deighan WI, O'Connor SJM, Alexander HD. Multiple myeloma with central nervous system relapse. Haematologica 2020; 105:1780-1790. [PMID: 32414852 PMCID: PMC7327654 DOI: 10.3324/haematol.2020.248518] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 04/14/2020] [Indexed: 01/30/2023] Open
Abstract
Central nervous system involvement in multiple myeloma is a rare complication but carries a very poor prognosis. We provide a review of current literature, including presentation, treatment and survival data, and describe our experience in a regional hematologic malignancy diagnosis center where, over a 15-year period, ten cases were identified. Although the median age of onset, frequently between 50-60 years, is comparatively young, those diagnosed usually have a preceding diagnosis of multiple myeloma and often have had several lines of treatment. We discuss putative underlying factors such as prior treatment and associations including possible risk factors and features suggestive of a distinct biology. Central nervous system involvement may be challenging to diagnose in myeloma, displaying heterogeneous symptoms that can be confounded by neurological symptoms caused by the typical features of myeloma or treatment side-effects. We discuss the clinical features, imaging and laboratory methods used in diagnosis, and highlight the importance of considering this rare complication when neurological symptoms occur at presentation or, more commonly, during the disease pathway. In the absence of clinical trial data to inform an evidence-based approach to treatment, we discuss current and novel treatment options. Finally, we propose the establishment of an International Registry of such cases as the best way to collect and subsequently disseminate presentation, diagnostic and treatment outcome data on this rare complication of multiple myeloma.
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Affiliation(s)
- Philip A Egan
- Northern Ireland Centre for Stratified Medicine, Ulster University, Derry/Londonderry, Northern Ireland
| | - Patrick T Elder
- Department of Haematology, North West Cancer Centre, Altnagelvin Area Hospital, Derry/Londonderry, Northern Ireland
| | - W Ian Deighan
- Department of Clinical Chemistry, Altnagelvin Area Hospital, Derry/Londonderry, Northern Ireland
| | - Sheila J M O'Connor
- Haematological Malignancy Diagnostic Service, St James's Institute of Oncology, Leeds, England, UK
| | - H Denis Alexander
- Northern Ireland Centre for Stratified Medicine, Ulster University, Derry/Londonderry, Northern Ireland
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20
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Lee W, Chen RC, Swaminathan SK, Ho CL. Extramedullary multiple myeloma with central nervous system and multiorgan involvement: Case report and literature review. J Radiol Case Rep 2020; 13:1-12. [PMID: 32184923 DOI: 10.3941/jrcr.v13i12.3784] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Multiple myeloma is a hematologic malignancy due to monoclonal plasma cell proliferation. It is usually confined to the bone marrow, although extramedullary involvement is known to occur in almost any organ system; myelomatous spread to the central nervous system is a rare manifestation of myeloma. Extramedullary disease is thought to be related to hematogenous spread when myeloma cells show decreased cell surface receptor expression, allowing cells to escape from the bone marrow. Disease outside of the bone marrow generally indicates a poor prognosis; central nervous system involvement is associated with a median prognosis of less than 6 months, thereby requiring more aggressive treatment paradigms. We herein describe an unusual case of a patient with extramedullary multiple myeloma with central nervous system and multiorgan involvement. Despite an aggressive treatment strategy, the patient died a few months later after the initial diagnosis. The etiology, diagnostic criteria, clinical presentation, radiological features and differential diagnosis of this patient with extramedullary multiple myeloma are discussed here. The current treatment strategies are also briefly discussed.
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Affiliation(s)
- Weiyong Lee
- Department of Radiology, Sengkang General Hospital, Singapore
- Department of Diagnostic Radiology, Singapore General Hospital, Singapore
| | - Robert Chun Chen
- Department of Diagnostic Radiology, Singapore General Hospital, Singapore
- Duke-NUS Graduate Medicine School, Singapore
| | | | - Chi Long Ho
- Department of Radiology, Sengkang General Hospital, Singapore
- Duke-NUS Graduate Medicine School, Singapore
- Lee Kong Chian School of Medicine, Singapore
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21
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Chantran Y, Lavillegrand J, Lefrere B, Gaillet A, Aucouturier P, Garderet L. Multiple myeloma with clivus involvement, neurological symptoms, and 45 g/L proteinorachia. Clin Case Rep 2020; 8:5-8. [PMID: 31998476 PMCID: PMC6982496 DOI: 10.1002/ccr3.2404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 08/02/2019] [Accepted: 08/03/2019] [Indexed: 12/02/2022] Open
Abstract
The mechanical obstruction of cerebrospinal fluid (CSF) flow can lead to very high hyperproteinorachia. In myeloma, tumoral clivus obstruction can cause such high proteinorachia, associated with paraprotein detection in the CSF in absence of intrathecal synthesis.
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Affiliation(s)
- Yannick Chantran
- Immunology DepartmentHôpital Saint‐Antoine, AP‐HPParisFrance
- INSERMUMR_S 938Immune System & NeuroinflammationSorbonne UniversitéParisFrance
| | | | | | - Antoine Gaillet
- Service de Réanimation MédicaleHôpital Saint‐AntoineAP‐HPParisFrance
| | - Pierre Aucouturier
- Immunology DepartmentHôpital Saint‐Antoine, AP‐HPParisFrance
- INSERMUMR_S 938Immune System & NeuroinflammationSorbonne UniversitéParisFrance
| | - Laurent Garderet
- UMR_S 938Proliferation and Differentiation of Stem CellsINSERMParisFrance
- Département d'HématologieHôpital Pitié Salpêtrière, AP‐HPParisFrance
- Sorbonne UniversitéParisFrance
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22
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Extramedullary multiple myeloma. Leukemia 2019; 34:1-20. [DOI: 10.1038/s41375-019-0660-0] [Citation(s) in RCA: 81] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2019] [Revised: 07/31/2019] [Accepted: 08/12/2019] [Indexed: 01/07/2023]
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23
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Diffuse Infiltration of Multiple Myeloma With Initial Manifestation of Cavernous Sinus Syndrome Unveiled by 18F-FDG PET/CT. Clin Nucl Med 2019; 44:746-747. [PMID: 31306198 DOI: 10.1097/rlu.0000000000002722] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Intracranial infiltration is a rare complication of multiple myeloma (MM), which is usually seen in advanced stage. Here, we report a 47-year-old woman with only cavernous sinus syndrome as first manifestation. Brain MR revealed cavernous sinus masses, leptomeningeal nodules, and osseous erosion, which were considered metastases. F-FDG PET/CT, which was further performed to identify potential primary lesions, showed increased uptake not only in cavernous sinus and leptomeninges but also in diffuse bone lesions, hepatic nodules, lymph nodes, subcutaneous nodules, and bilateral ovarian masses. Multiple myeloma with intracranial involvement was confirmed by biopsy and cerebrospinal fluid examination.
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24
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Musto P, Statuto T, Valvano L, Grieco V, Nozza F, Vona G, Bochicchio GB, La Rocca F, D'Auria F. An update on biology, diagnosis and treatment of primary plasma cell leukemia. Expert Rev Hematol 2019; 12:245-253. [PMID: 30905220 DOI: 10.1080/17474086.2019.1598258] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Primary plasma cell leukemia (PPCL) is one of the most aggressive hematological malignancies. The prognosis of PPCL patients remains poor, although some improvements have been made in recent years. Areas covered: In this review recent clinical and biological advances in PPCL are reported. Some recommendations for the practical management of these patients are provided, with a particular focus on the role of novel agents and transplant procedures. A brief description of the currently ongoing clinical trials with new drugs is also enclosed. Expert opinion: PPCL still represents a difficult challenge for all hematologists. Here the authors provide a personal view on how the current, generally unsatisfactory results in this neoplastic disorder could be improved. In particular, dedicated studies exploring alternative therapies are necessary and eagerly awaited. Such studies should possibly be based on new biological information that could be of help in identifying novel genetic biomarkers for risk stratification and new actionable molecular targets.
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Affiliation(s)
- Pellegrino Musto
- a Unit of Hematology and Stem Cell Transplantation , IRCCS-CROB, Referral Cancer Center of Basilicata , Rionero in Vulture (Pz) , Italy.,b Department of Hematology of Basilicata , IRCCS-CROB, Referral Cancer Center of Basilicata , Rionero in Vulture (Pz) , Italy.,c Scientific Direction, Laboratory of Clinical Research and Advanced Diagnostics , IRCCS-CROB, Referral Cancer Center of Basilicata , Rionero in Vulture (Pz) , Italy
| | - Teodora Statuto
- c Scientific Direction, Laboratory of Clinical Research and Advanced Diagnostics , IRCCS-CROB, Referral Cancer Center of Basilicata , Rionero in Vulture (Pz) , Italy
| | - Luciana Valvano
- c Scientific Direction, Laboratory of Clinical Research and Advanced Diagnostics , IRCCS-CROB, Referral Cancer Center of Basilicata , Rionero in Vulture (Pz) , Italy
| | - Vitina Grieco
- c Scientific Direction, Laboratory of Clinical Research and Advanced Diagnostics , IRCCS-CROB, Referral Cancer Center of Basilicata , Rionero in Vulture (Pz) , Italy
| | - Filomena Nozza
- c Scientific Direction, Laboratory of Clinical Research and Advanced Diagnostics , IRCCS-CROB, Referral Cancer Center of Basilicata , Rionero in Vulture (Pz) , Italy
| | - Gabriella Vona
- c Scientific Direction, Laboratory of Clinical Research and Advanced Diagnostics , IRCCS-CROB, Referral Cancer Center of Basilicata , Rionero in Vulture (Pz) , Italy
| | | | - Francesco La Rocca
- c Scientific Direction, Laboratory of Clinical Research and Advanced Diagnostics , IRCCS-CROB, Referral Cancer Center of Basilicata , Rionero in Vulture (Pz) , Italy
| | - Fiorella D'Auria
- c Scientific Direction, Laboratory of Clinical Research and Advanced Diagnostics , IRCCS-CROB, Referral Cancer Center of Basilicata , Rionero in Vulture (Pz) , Italy
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25
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Abstract
PURPOSE OF REVIEW To discuss the diagnostic approach, treatment options, and future considerations in the management of plasmacytomas, either solitary or in the context of overt multiple myeloma (MM). RECENT FINDINGS Advanced imaging techniques such as whole-body magnetic resonance imaging and positron emission tomography/computerized tomography are essential for the diagnostic workup of solitary plasmacytomas (SP) to rule out the presence of other disease foci. The role of flow cytometry and clonal plasma cell detection is currently under study together with other prognostic factors for the identification of patients with SP at high risk of progression to overt MM. Solitary plasmacytomas are treated effectively with local radiotherapy whereas systemic therapy is required at relapse. Clonal plasma cells that accumulate at extramedullary sites have distinct biological characteristics. Patients with MM and soft tissue involvement have poor outcomes and should be treated as ultra-high risk. A revised definition of SP that distinguishes between true solitary clonal PC accumulations and SP with minimal bone marrow involvement should be considered to guide an appropriate therapeutic and follow-up approach. Future studies should be conducted to determine optimum treatment approaches for patients with MM and paraskeletal or extramedullary disease.
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26
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Nguyen J, Hassoun H. Multiple myeloma with simultaneous cutaneous and central nervous system involvement. Clin Case Rep 2018; 6:2015-2016. [PMID: 30349719 PMCID: PMC6186883 DOI: 10.1002/ccr3.1626] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Revised: 04/17/2018] [Accepted: 05/08/2018] [Indexed: 11/13/2022] Open
Abstract
Cutaneous involvement in multiple myeloma is an extremely rare occurrence that is underrecognized and akin CNS involvement, typically occurs late in the disease course, and is associated with an aggressive biology. Pathologic examination is key to the diagnosis and a standard of care treatment has not been established for these patients.
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Affiliation(s)
- James Nguyen
- Memorial Sloan‐Kettering Cancer CenterNew YorkNYUSA
| | - Hani Hassoun
- Memorial Sloan‐Kettering Cancer CenterNew YorkNYUSA
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Rafae A, Malik MN, Abu Zar M, Durer S, Durer C. An Overview of Light Chain Multiple Myeloma: Clinical Characteristics and Rarities, Management Strategies, and Disease Monitoring. Cureus 2018; 10:e3148. [PMID: 30345204 PMCID: PMC6191009 DOI: 10.7759/cureus.3148] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Light chain multiple myeloma (LCMM) constitutes approximately 15% of patients with multiple myeloma (MM). It has a poorer prognosis when compared to immunoglobulin (Ig) G or IgA variant. We performed a comprehensive literature search on LCMM and identified a total of 390 articles. After a detailed screening, six studies involving a total of 1054 LCMM patients were included. A literature review revealed bone pain and renal failure as the most common initial sign and symptoms while extramedullary disease (EMD) was acquired later during the progression of the disease. Bortezomib has shown superior efficacy in LCMM patients over nonbortezomib regimens as demonstrated by better overall response rate (95.5% vs. 60%), progression-free survival (PFS) (25% vs. 9% at two years), and overall survival (OS) (24% vs. 9% at five years). Moreover, better PFS was seen, when bortezomib was used in combination with bendamustine compared to dexamethasone (95% vs. 25% at two years). Similarly, better OS (90% at two years) was observed with bortezomib in combination with bendamustine. Monitoring of disease should include serum free light chain levels, as literature review revealed that serum assays were more sensitive in indicating the disease and predicting PFS and OS as compared to urine assays. We provide presentation patterns, clinical rarities, management strategies including their efficacy, and disease monitoring in patients with LCMM in our review paper.
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Affiliation(s)
- Abdul Rafae
- Hematology and Oncology, The University of Arizona, Tucson, USA
| | - Mustafa N Malik
- Hematology and Oncology, The University of Arizona, Tucson, USA
| | | | - Seren Durer
- Hematology and Oncology, University of Arizona, Tucson, USA
| | - Ceren Durer
- Hemtology and Oncology, The University of Arizona, Tucson, USA
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Abstract
PURPOSE OF REVIEW This article reviews the spectrum of neurologic complications associated with lymphoma, leukemia, and paraproteinemic disorders. While leptomeningeal metastasis is the most common complication of lymphoma and leukemia and peripheral neuropathy is the most common complication of paraproteinemic disorders, clinicians need to be familiar with the diverse neurologic complications of these disorders. RECENT FINDINGS Lymphomatous nervous system involvement can be difficult to diagnose, especially when it is the presenting symptom. CSF cytology and flow cytometry, as well as the imaging pattern, assist in diagnosis. Neurologic complications are less common in Hodgkin lymphoma; however, some unique paraneoplastic syndromes are associated with Hodgkin lymphoma, including primary central nervous system angiitis, limbic encephalitis, and cerebellar degeneration. Recent reports suggest that anti-metabotropic glutamate receptor 5 (mGluR5) antibodies are associated with limbic encephalitis and that anti-Tr antibodies are associated with cerebellar degeneration in Hodgkin lymphoma. Polyneuropathy, organomegaly, endocrinopathy, monoclonal plasma cell disorder, and skin changes (POEMS) syndrome is often misdiagnosed as chronic inflammatory demyelinating polyradiculoneuropathy (CIDP). A lambda protein, thrombocytosis, and elevated vascular endothelial growth factor (VEGF) can all be helpful clues in diagnosis. Early recognition is important, as the neuropathy responds to radiation therapy or chemotherapy. SUMMARY Neurologic involvement can occur throughout the disease course in lymphoma and leukemia, including at presentation, with systemic progression, and at relapse. In paraproteinemias, the peripheral neuropathy phenotype, monoclonal protein type, and associated autonomic and systemic features aid in identification of an underlying plasma cell disorder.
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Multiple Myeloma of the Central Nervous System: 13 Cases and Review of the Literature. JOURNAL OF ONCOLOGY 2018; 2018:3970169. [PMID: 29849629 PMCID: PMC5937370 DOI: 10.1155/2018/3970169] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 03/18/2018] [Indexed: 01/16/2023]
Abstract
Central nervous system involvement is a rare complication of multiple myeloma with extremely poor prognosis as it usually fails to respond to therapy. We present 13 cases diagnosed at two centers in Budapest and review the current literature. The majority of our cases presented with high-risk features initially; two had plasma cell leukemia. Repeated genetic tests showed clonal evolution in 3 cases. Treatments varied according to the era, and efficacy was poor as generally reported in the literature. Only one patient is currently alive, with 3-month follow-up, and the patient responded to daratumumab-based treatment. Recent case reports show promising effectivity of pomalidomide and marizomib.
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Elhassadi E, Murphy M, Hacking D, Farrell M. Durable treatment response of relapsing CNS plasmacytoma using intrathecal chemotherapy, radiotherapy, and Daratumumab. Clin Case Rep 2018; 6:723-728. [PMID: 29636948 PMCID: PMC5889271 DOI: 10.1002/ccr3.1451] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Revised: 01/22/2018] [Accepted: 02/01/2018] [Indexed: 12/19/2022] Open
Abstract
CNS myelomatous involvement is a rare complication of multiple myeloma with dismal outcome. This disease's optimal treatment is unclear. Combined approach of systemic therapy, radiotherapy, and intrathecal injections chemotherapy should be considered and autologous stem cell transplant consolidation is offered to eligible patients. The role of Daratumumab in this disease deserves further evaluation.
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Affiliation(s)
- Ezzat Elhassadi
- Department of Haematology University Hospital Waterford Waterford Ireland
| | - Maurice Murphy
- Department of Pathology University Hospital Waterford Waterford Ireland
| | - Dayle Hacking
- Department of Radiotherapy UPMC Whitefield Cancer Centre Waterford Ireland
| | - Michael Farrell
- Department of Radiology University Hospital Waterford Waterford Ireland
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Abstract
Introduction The estimated involvement of the central nervous system in patients with multiple myeloma is rare at about 1%. The infiltration can be identified at the time multiple myeloma is diagnosed or during its progression. However, it is more common in refractory disease or during relapse. Methods This retrospective cohort study reviewed data from medical records of patients followed up at the Gammopathy Outpatient Clinic of Santa Casa de Misericórdia de São Paulo from January 2008 to December 2016. Results Twenty patients were included, with a median follow-up of 33.5 months after central nervous system infiltration. The prevalence was 7%. The median age at diagnosis of multiple myeloma was 56.1 years, with 70% of participants being female. Sixteen patients had central nervous system infiltration at diagnosis of multiple myeloma. Seventeen patients had exclusive osteodural lesions and three had infiltrations of the leptomeninge, of which one had exclusive involvement and two had associated osteodural lesions. The median overall survival was 40.3 months after central nervous system involvement. The median overall survival in the group with central nervous system infiltration at relapse was 7.4 months. The patients with leptomeningeal involvement had a median overall survival of 5.8 months. Conclusion Central nervous system infiltration is a rare condition, but it should be considered as a possibility in patients with multiple myeloma and neurological symptoms. The best treatment regimen for this condition remains unknown and, in most cases, the prognosis is unfavorable.
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Pan J, Chen J, Filicko J, Grosso D, Nagurney M, Alpdogan O, Flomenberg N. Relapsed Multiple Myeloma Presenting as Intracranial Plasmacytoma and Malignant Pericardial Effusion following Recent Allogeneic Stem Cell Transplantation. Case Rep Oncol 2017; 10:582-587. [PMID: 28868016 PMCID: PMC5567077 DOI: 10.1159/000478001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Accepted: 06/02/2017] [Indexed: 12/13/2022] Open
Abstract
Although rare, both central nervous system and pericardial involvement of myeloma have been well described in the literature. Their simultaneous occurrence in relapsed disease, however, has not been previously reported. This case describes a 54-year-old female who was treated for high-risk multiple myeloma with multiregimen chemotherapy and allogeneic hematopoietic stem cell transplantation. Four months after transplant, she was found to have relapsed disease manifesting as an extraosseous, intracranial plasmacytoma and simultaneous malignant pericardial effusion. Her disease characteristics, treatment course, radiologic and pathologic findings are described in detail, and we review the previous literature to determine the various aspects of her disease that may have contributed to her aggressive clinical course.
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Affiliation(s)
- Jonathan Pan
- Department of Medical Oncology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Jason Chen
- Department of Medical Oncology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Joanne Filicko
- Department of Medical Oncology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Dolores Grosso
- Department of Medical Oncology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Michelle Nagurney
- Department of Pathology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Onder Alpdogan
- Department of Medical Oncology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Neal Flomenberg
- Department of Medical Oncology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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