Mri in Multiple Myeloma with Orbital and Dural Invasion

Orbital Involvement in Multiple Myeloma

PURPOSE

To characterize clinical and radiographic features, management, and outcomes of patients with orbital involvement of multiple myeloma (MM).

METHODS

A retrospective chart review identified patients with MM and orbital involvement confirmed by histopathology at a single institution between 1995 and 2021. A comprehensive literature review was performed via PubMed to identify all previously reported cases of orbital MM.

RESULTS

Retrospective review identified 7 patients (43% male, mean age 68.7 years). Presenting symptoms included proptosis and diplopia. Orbital lesions were primarily located laterally (42.8%) with associated extraocular muscle (57.1%) or lacrimal gland (42.9%) involvement. Five patients (71.4%) had a previous diagnosis of systemic MM. Six patients received chemoradiation (85.7%). All patients had improvement of orbital disease with 2 patients deceased due to disease at follow-up (mean 8.9 months). Literature review identified 111 cases (46.8% male, mean age 58.6 years). 48.6% presented with orbital disease as the first manifestation of systemic MM. Lesions were most commonly located superolaterally (20.2%) with extraocular muscle infiltration (25.2%), lacrimal gland involvement (7.2%), and orbital bony destruction (39.6%). Treatments included chemoradiation, chemotherapy, or radiation alone. Approximately half (51.4%) of patients experienced improvement in orbital disease following treatment, and 48.6% were deceased at follow-up (mean 20.1 months).

CONCLUSIONS

This study provides a new retrospective study and updated comprehensive literature review regarding orbital MM. Given its poor prognosis, characterization of orbital MM is essential for early diagnosis. Orbital MM is often unilateral, located superolaterally, and may represent the first manifestation of systemic disease. Treatment includes chemotherapy and radiation, which may improve orbital disease; however, the overall prognosis remains poor.

Five cases of orbital extramedullary plasmacytoma: diagnosis and management of an aggressive malignancy

Purpose: Multiple myeloma is an insidious haematological malignancy characterised by monoclonal proliferation of plasma cells in the bone marrow. Extramedullary plasmacytoma is a rare manifestation of multiple myeloma and usually occurs in the upper respiratory tract. Orbital involvement is particularly uncommon, but may be associated with devastating visual impairment and poor clinical outcomes. Therefore, this article aims to highlight the need for multidisciplinary management of orbital extramedullary plasmacytoma. Methods: This is a retrospective observational case series of five patients. All presented to the authors for management of orbital extramedullary plasmacytomas from 2004 to 2015 at Prince of Wales and Mater Hospitals in Sydney, Australia. Medical records were reviewed for pertinent information including demographics, disease features, management strategy, and clinical progress. The study met Medical Ethics Board standards and is in accordance with the Helsinki Agreements. Results: This case series of five patients underscores the poor prognosis of orbital extramedullary plasmacytoma. Despite aggressive multidisciplinary management, four of these five patients succumbed to their illness during the study period. However, multidisciplinary management did manage to minimise symptoms and preserve quality of life. Conclusions: On a case-by-case basis, patients may derive palliative benefit from orbital surgery in conjunction with radiotherapy and chemotherapy. Orbital surgeons are encouraged to work within a multidisciplinary framework of medical specialists, including haematologists and radiation oncologists, when determining the optimal management plan in cases of orbital extramedullary plasmacytoma.

Orbital multiple myeloma: a diagnostic challenge

Orbital involvement in multiple myeloma is unusual. We describe the case of an 85-year-old woman who presented with right eye proptosis, reduced visual acuity and diplopia. Computed tomography showed a lobulated, enhancing soft tissue mass arising from the right greater wing of the sphenoid with intraconal, lacrimal gland and ocular muscle involvement. Histopathology revealed predominantly atypical plasma cells in a background of reactive lymphocytes, with monoclonality towards kappa light chain protein, suggestive of multiple myeloma. This case illustrates the diagnostic imaging challenge of orbital multiple myeloma.

Frontal skull craniotomy combined with moderate-dose radiotherapy effectively ameliorate a rare case of non-secretory, multiple myeloma with orbital involvement

BACKGROUND

Orbital infiltration in patients with multiple myeloma is a rare condition, with less than 50 cases reported in the medical literature. Most patients undergo conservative treatment because multiple myeloma is a disseminated systemic disease.

CASE PRESENTATION

A 43-year-old male subject with multiple myeloma and long-term survival presented with orbital involvement. The subject lacked the typical features and poor prognostic factors associated with multiple myeloma, such as renal failure, hypercalcemia, and paraprotein in the serum and urine. The orbital computed tomographic scan revealed the tumor encasing the optic nerve, but without prominent bony destruction. Therefore, a frontal skull craniotomy with an epidural entrance to the orbital space was performed, to completely extirpate the orbital mass. The surgical procedure was followed by moderate-dose radiation therapy. After 32 months of follow-up care, the subject is doing well with excellent local control.

CONCLUSION

Although the effectiveness and applicability of this approach remains to be determined, this case report demonstrates that accurate and early detection combined with local surgical treatment and appropriate radio/chemotherapy, can be applied to effectively extend an orbital multiple myeloma patient's life.

Characteristics of orbital multiple myeloma: a case report and literature review

Multiple myeloma is a plasma cell malignancy that destroys skeletal, renal, and neurological function. Orbital involvement is rare, but has been considered an initial presentation for the malignancy. Furthermore, an association between the subtype of multiple myeloma and the likelihood of orbital infiltration has been suggested. We present a case of an orbital mass that was a recurrence of multiple myeloma. A literature search was performed to evaluate the presentation characteristics of orbital multiple myeloma, plasmacytoma and primary (or solitary) extramedullary plasmacytoma. Past reports were analyzed for age, sex, symptoms at presentation, time from symptom onset to presentation, prior diagnosis before presentation for orbital symptoms, radiological characteristics, immunoglobulin subtype, and survival times. Less than half of published cases had orbital multiple myeloma as the primary presentation. Proptosis is the major presenting sign of orbital multiple myeloma, and radiological evaluation shows that the majority of masses originate in the superotemporal quadrant. The dominant immunoglobulin subtype was IgG.