Gastrointestinal tumour masses due to multiple myeloma: a pathological mimic of malignant lymphoma

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

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

Secondary extramedullary plasmacytoma of sigmoid colon in a patient with multiple myeloma: a case report

Background

Extramedullary plasmacytoma is an uncommon tumor that most often involves the nasopharynx or upper respiratory tract. Extramedullary plasmacytoma is a type of plasma cell neoplasm that can present as a primary tumor or secondary to another plasma cell neoplasm, such as multiple myeloma. Secondary extramedullary plasmacytoma is usually noted in the advanced stages of the disease. Involvement of the gastrointestinal tract occurs in approximately 10% of cases.

Case presentation

A 71-year-old Caucasian woman with known diverticular disease of the colon and multiple myeloma diagnosed 3 years previously, with monoclonal bands of immunoglobulin A, lambda light chains, and multiple osteolytic lesions, presented to our hospital with abdominal pain, abdominal discomfort, and pneumoperitoneum. She underwent left colectomy for diverticulitis with perforation, and an extramedullary secondary colonic plasmacytoma was found in histopathological examination of the sigmoid colon.

Conclusions

Plasmacytoma is known to occur in extraosseous sites. The stomach and small intestine are the most commonly involved sites in the gastrointestinal tract. Secondary extramedullary plasmacytoma of the colon is rare. Colonic plasmacytoma may have varying clinical presentations, such as inflammatory bowel disease and multiple colonic strictures. Although these cases are rare, treating physicians as well as radiologists, pathologists, and surgeons should be aware of this entity.

A Case of Concurrent Gastric and Pancreatic Plasmacytomas in a Patient With Multiple Myeloma: An Extremely Rare Entity

Multiple myeloma (MM), a plasma cell tumor, is primarily a disease of the bone marrow. Extramedullary plasmacytoma, also a plasma cell tumor, is very rare in the gastrointestinal tract and the pancreas, and only a handful cases have been documented till now. Gastric and pancreatic plasmacytomas are usually seen in elderly patients; however, cases in patients as young as 32 years of age have been reported. Commonly, patients with gastric plasmacytoma present with nonspecific symptoms like epigastric pain, abdominal fullness, anorexia, and weight loss, or serious conditions like massive upper gastrointestinal bleeding and gastric outlet obstruction. Patients with pancreatic plasmacytoma commonly present with obstructive jaundice. In this article, we present the case of a 79-year-old man with a history of MM for 3 years, diagnosed with gastric and pancreatic masses, which turned out to be plasmacytomas. To our knowledge, simultaneous occurrence of gastric and pancreatic plasmacytomas is extremely uncommon with less than 5 cases reported in the literature. We also compiled all the individual cases of gastric and pancreatic MM that have been reported in literature till now.

Massive Bone Marrow Crystal-Storing Histiocytosis in a Patient with Iga-Lambda Multiple Myeloma and Extensive Extramedullary Disease. A Case Report

We report a case of multiple myeloma (MM) displaying an unusual course, with metastatic spread in uncommon sites (gastroduodenal and upper respiratory tract, breast, skin and liver) and with a fatal outcome. In our patient this plasma cell neoplasm was associated with a rare condition named crystal-storing histiocytosis (CSH), resulting from the storage in reactive histiocytes of crystalline immunoglobulin inclusions. These crystal-forming paraprotein components are secreted by the neoplastic plasma cells and give rise to the crystalline material of the histiocytes only after their ingestion and degradation by the same histiocytes. In this disorder crystal-storing cells may be present in various tissues (in our case mainly in bone marrow), often with functional alterations of the involved organs. In our opinion the association of this “atypical” MM with CSH is to be considered an uncommon event.

Extramedullary plasmacytoma mimicking colon carcinoma: an unusual presentation and review of the literature

A 72-year-old woman presented to outpatient clinic with fatigue, light-headedness, dyspnoea and dark stool suggestive of lower gastrointestinal bleeding. She was previously diagnosed with multiple myeloma and completed 9 cycles of chemotherapy with bortezomib, lenalidomide and dexamethasone. She had very good partial response. A CT scan of the abdomen revealed a 9 cm mass at the hepatic flexure of the large intestine with an apple core deformity causing a marked narrowing of the lumen. Colonoscopy confirmed a large, nearly obstructing ulcerative mass in the distal right colon. The patient underwent a right hemicolectomy, distal ileal resection and lymph node dissection. Histopathology confirmed the mass as a plasmacytoma. Postoperatively, the patient was started with bortezomib and liposomal doxorubicin followed by carfilzomib. She showed excellent response to the chemotherapy.

Secondary extramedullary plasmacytoma causing small bowel intussusception in a patient with multiple myeloma - A case report

INTRODUCTION

Multiple myeloma is a monoclonal, immunoproliferative plasma-cell neoplasm of the B lymphoid cells. Extramedullary plasmacytoma is a type of plasma-cell neoplasm that can present as a primary tumour or secondary to another plasma-cell neoplasm, such as multiple myeloma. Secondary extramedullary plasmacytoma is usually noted in the advanced stages of the disease with ileum involvement being very rare.

PRESENTATION OF CASE

We report a rare case of a 58-year-old man, with known multiple myeloma, re-presenting with evidence of small bowel obstruction, secondary to an intussusception due to a malignant plasma cell deposit, which was successfully resected at laparotomy. Previous two similar admissions, prior to this index admission, failed to arrive at this difficult rare diagnosis.

DISCUSSION

Primary and secondary extramedullary plasmacytoma mainly affects the upper aero-digestive tract. Involvement of the ileum, as in this case, is a rare complication. Prognosis of secondary extramedullary plasmacytoma affecting the gastrointestinal tracts is unknown, due to the small number of cases reported in the literature, but suggestive of a poor prognosis. The role of surgery is often palliative to deal with resolvable life-threatening emergencies and where possible to prolong life.

CONCLUSION

The case adds to the current literature of the rare event of visceral secondary extramedullary plasmacytoma involving the gastrointestinal tract, in the course of multiple myeloma and highlights the need for a high index of suspicion for such uncommon complications, to avoid delay in diagnosis and treatment.

Gastrointestinal lymphoproliferative disorders

Malignant lymphomas can be first detected in some patients in endoscopic biopsies of the gastrointestinal (GI) tract. However, their recognition and accurate classification often pose problems for the pathologist for several reasons. First, the small sampling size limits pattern recognition and the number of ancillary studies which can be performed. Second, the immune system of the GI tract is capable of intense hyperplastic responses which may mimic lymphoma. Third, in a fashion similar to cutaneous lesions, those in the alimentary tract may be visualized and biopsied at a very early phase in their development when differentiation into neoplasia may be incomplete. Some forms of immune response actually pass through a poorly defined transition into lymphoma. Examples of such 'dysplasia' of the gut immune system include Helicobacter gastritis, coeliac disease and multicentric lymphoid hyperplasia associated with underlying immunodeficiency. With ever increasing endoscopic scrutiny of the gut by gastroenterologists, it is not surprising that the frequency of these indeterminate cases seems to be growing. In combination with careful clinical correlation and conventional microscopic analysis, selective immunohistochemical studies currently constitute the most powerful ancillary method in the pathologist's effort to recognize and classify GI lymphomas accurately.

Primary extramedullary plasmacytoma of the esophagus

An uncommon manifestation of plasma cell neoplasia occurs outside the bone marrow and is designated "extramedullary plasmacytoma." These are usually encountered in mucosal sites of the head and neck region. The gastrointestinal tract may be secondarily involved in multiple myeloma or be the site of primary extramedullary plasmacytomas (PEMPs). The esophagus is the least common site of gastrointestinal PEMP. A 58-year-old man presented with dysphagia for solids over a period of 2 months. Otherwise, he was well and systemic examination did not reveal anything of note. After a nondiagnostic biopsy, the patient was subjected to esophago-gastrectomy. Gross examination of the esophagus revealed a large polypoid tumor. Histologically, it was composed of mature plasma cells, plasmablasts (some of which appeared anaplastic), and a minor admixture of lymphoid cells. Focally, the infiltrate permeated the squamous epithelium simulating lymphoepithelial lesions. The neoplastic cells were positive for epithelial membrane antigen, CD79a, IgG, and kappa, while the lymphoid cells were predominantly B cells. The patient did not have a monoclonal gammopathy. Skeletal x-rays and bone trephine examination were both normal. PEMP is biologically and prognostically different to other plasma cell neoplasms. Although rare, esophageal PEMP should be considered in the differential diagnosis of so-called undifferentiated malignant tumors of the esophagus.