Strategy for the treatment and follow-up of sinonasal solitary extramedullary plasmacytoma: a case series

Clinical Presentation and Outcome of Sinonasal Extraosseous Plasmacytoma in Denmark: A Nationwide Cohort From 1980 to 2017

OBJECTIVES

Extraosseous plasmacytoma (EOP) is a rare plasma cell neoplasm that tends to convert to plasma cell myeloma (PCM) in about 11% to 35% of cases. It has a predilection for the upper respiratory tract, prototypically affecting the nasal cavity and paranasal sinuses. Contemporary first-line treatment is radiotherapy, with more recent studies showing an added benefit of combining radiation with surgery. In this cohort study, we aimed to examine clinical presentation, treatment, and prognosis for all patients nationwide from 1980 through 2017. Furthermore, we determined the size and extension of tumors, investigating the rate at which minimally invasive surgery would have been possible.

METHODS

Patients were found in the national pathology registry, and all biopsies were collected for pathology review by a hematopathologist. We performed survival statistics for overall survival (OS), progression-free survival (PFS), and the cumulative incidence of conversion to PCM.

RESULTS

Twenty-three patients were included. The median age was 65, and patients were primarily men (78%). Tumors were located in either the nasal cavity (57%), maxillary sinus (39%), or sphenoid sinus (4%). In most cases, the tumor was <5 cm (65%) without extension to adjacent structures (60%). The national incidence was 0.02/100,000 person-years, the median symptom duration until diagnosis was 5 months, and none of the patients presented with contiguous spread to regional lymph nodes. Stand-alone radiotherapy was the predominant treatment (61%). In the entire cohort, one patient died from the initial disease, and six patients died from either relapse of EOP or PCM. The 5-year OS, PFS, and conversion rate to PCM were 78%, 56%, and 23%, respectively.

CONCLUSION

SN-EOP responds well to radiotherapy, but relapse and conversion to PCM were not uncommon and entailed a poor prognosis. Most tumors were endoscopically resectable and non-invasive, making the majority of tumors suitable for surgery as an addition to radiation.

Extramedullary plasmacytoma of the sphenoid sinus presenting with visual loss: A case report

A rare case of sphenoid plasmacytoma in a 62‐year‐old woman who was presented with a frozen eye is reported. It was histopathologically confirmed based on transsphenoidal biopsy. Moreover, initial evaluation ruled out systemic dissemination of the disease and solitary plasmacytoma was diagnosed. Surgical removal of the tumor with complementary radiotherapy was performed as a treatment modality.

Analysis of the Treatment and Survival of Sinonasal Extramedullary Plasmacytoma

BACKGROUND

While extramedullary plasmacytomas are infrequently encountered plasma cell malignancies, most cases occur in the head and neck, with a predilection for the sinonasal cavity. Due to the rarity of this disease, the majority of studies on sinonasal extramedullary plasmacytoma (SN-EMP) are case reports or small retrospective case series.

OBJECTIVE

To investigate the impact of patient, disease, and treatment factors on the survival of patients with SN-EMP.

METHODS

The National Cancer Database was queried for all patients with SN-EMP between 2004-2016 (N = 381 cases). Univariate and multivariate analyses were used to examine patient demographics, tumor characteristics, and survival.

RESULTS

The majority of SN-EMP patients were over 60 years old (57.0%), male (69.8%), and white (86.2%). The most common treatment modality was radiotherapy alone (38.6%), followed by surgery plus radiotherapy (37.8%). Five-year overall survival was 74.0% and median survival was 9.1 years. Accounting for patient demographics and tumor characteristics in a multivariate model, the following groups had worse prognosis: 60 and older (HR 1.99, p = 0.031) and frontal sinus primary site (HR 11.56, p = 0.001). Patients who received no treatment (HR 3.89, p = 0.013), chemotherapy alone (HR 5.57, p = 0.008) or radiotherapy plus chemotherapy (HR 2.82, p = 0.005) had significantly lower survival than patients who received radiotherapy alone. Patients who received surgery with radiotherapy (HR 0.57, p = 0.039) had significantly higher survival than patients who received radiotherapy alone.

CONCLUSION

In patients with SN-EMP five-year overall survival was found to be 74.0% with decreased survival associated with a frontal sinus primary site and being aged 60 or older. Patients receiving no treatment, chemotherapy alone, or radiotherapy with chemotherapy was associated with lower survival. Receiving surgery plus radiotherapy was associated with the highest five-year overall survival.

Solitary plasmacytoma in the maxillary sinus: 10-year follow-up

Solitary plasmacytoma (SP) is an uncommon form of plasma cell neoplasm occurring intraosseously or in soft tissue and presents as a single mass of monoclonal plasma cells. SP in the maxillary sinus is rare and can be misdiagnosed as other maxillary sinus tumors. The essential examinations in patients with the initial diagnosis of plasmacytoma are bone marrow biopsy, serum and urine electrophoresis, and kappa/lambda ratio (κ:λ ratio) to rule out multiple myeloma (MM). Herein, a rare case of SP in the maxillary sinus treated by surgery and localized radiation is reported. At the 10-year follow-up examination, local recurrence or disseminated development of MM were not evident.

Extramedullary disease in multiple myeloma

When clonal plasma cells grow at anatomic sites distant from the bone marrow or grows contiguous from osseous lesions that break through the cortical bone, it is referred to as extramedullary multiple myeloma (EMD). EMD remains challenging from a therapeutic and biological perspective. The pathogenetic mechanisms are not completely understood and it is generally associated with high-risk cytogenetics which portends poor outcomes. There is a rising incidence of EMD in the era of novel agents, likely a reflection of longer OS, with no standard treatment approach. Patients benefit from aggressive chemotherapy-based approaches, but the OS and prognosis remains poor. RT has been used for palliative care. There is a need for large prospective trials for development of treatment approaches for treatment of EMD.

Rare case of anaplastic plasmacytoma in the sinonasal tract

BACKGROUND

Extramedullary plasmacytomas are tumors that develop from plasma cells and rarely express anaplastic features. To our knowledge, there have only been three reported cases of anaplastic plasmacytomas of the sinonasal tract in the English literature. We detail the fourth case.

METHODS

A 70-year-old male was seen with a 4-month history of nasal congestion, bloody mucous, and left sided nasal obstruction. On positron emission tomography/computed tomography, the lesion was FDG-avid with an SUV_max of 25.1. A biopsy of the lesion and subsequent immunohistochemical staining confirmed the diagnosis of an anaplastic plasmacytoma.

RESULTS

The patient is undergoing a 5-week course of curative-intent radiation therapy.

CONCLUSION

Extramedullary plasmacytomas with anaplastic features are very rare. We highlight the value of thorough histopathological review and detailed immunostains to arrive at a diagnosis of anaplastic extramedullary plasmacytoma.

Huge Lateral Rectus Solitary Plasmacytoma Causing Shunt Extrusion

A 54-year-old man with a history of radiotherapy for right maxillary sinus plasmacytoma 3 years previously was referred to an orbital clinic with progressive proptosis in his right eye. His vision had deteriorated after an initial improvement after phacoemulsification 2 years before. He had undergone shunt implantation and later shunt removal following plate extrusion with the diagnosis of neovascular glaucoma following CRVO. His vision remained at no light perception afterwards, despite a controlled IOP with topical medications. In his CT scan, a large orbital mass was seen with lateral rectus involvement. He underwent deep orbitotomy for tumor resection following worsening of symptoms, and his symptoms were improved afterwards. Pathology report was consistent with plasmacytoma with anaplastic features. After tumor resection, he underwent another course of radiotherapy with complete remission of symptoms afterwards.

Extramedullary Plasmacytoma Causing Myelopathy Resulting in Gait Imbalance

Plasmacytomas are neoplasms of plasma cells that can involve the bone marrow, the bone itself, or soft tissue without bone marrow involvement. Extramedullary plasmacytomas are most commonly found in the upper respiratory tract in a total of 80% of all cases. Extramedullary plasmacytomas have also been documented in locations such as the central nervous system. This form of plasmacytoma may be seen as a solitary entity or in patients with multiple myeloma. We present a case of a 66-year-old female with a history of multiple myeloma on maintenance therapy with lenalidomide who has been experiencing gait imbalance for the past two months. The patient had a thoracic MRI done that revealed a mass at T7-8 with associated cord compression. She was taken for surgical intervention by neurosurgery. Pathology revealed trabecular bone and cartilage infiltrated by sheets of plasma cells highlighted by immunostaining CD138, monoclonal lambda light chains, consistent with a plasma cell neoplasm (plasmacytoma). The patient’s hospital course was complicated by hypotension resulting in transient ischemic myelopathy that was addressed in the neuro-intensive care unit. The patient was then discharged to an inpatient rehabilitation center. She would follow up with her primary oncologist for localized radiation therapy.

18F-FDG PET/CT in the Evaluation of Solitary Extramedullary Plasmacytoma: A Case Series

The role of fluorine-18-fluorodeoxyglucose positron emission tomography/ computed tomography (¹⁸F-FDG PET/CT) in patients with multiple myeloma (MM) and other plasma cell disorders is well-known. Solitary plasmacytoma (SP), an extremely rare form within this entity accounting for approximately 4% of plasma cell malignancies, can be classified as solitary bone plasmacytoma (SBP) or solitary extramedullary plasmacytoma (SEMP). Extramedullary plasmacytoma (EMP) is a rare neoplasm characterized by the monoclonal proliferation of plasma cells outside the bone marrow. Breast and craniocerebral regions are the uncommon sites of the presentations of EMP, rarely reported in the literature. The most frequent site of presentation is the upper airways. The EMPs have similar pathogenesis as MM; however, they differ in management as they are radiosensitive in nature, and radiotherapy is the preferred treatment modality. As SEMP has a better prognosis than SPB with a lower conversion rate to MM, accurate staging is essential to plan for the treatment. The ¹⁸F-FDG PET/CT has higher sensitivity for the evaluation of treatment response. In the present case series, it was aimed to depict the role of ¹⁸F-FDG PET/CT in newly diagnosed SEMP with different sites of origin to exclude further lesions leading to changes in the treatment plan and treatment response assessment.

Clinical management of extrapleural septal solitary fibrous tumor: A case report

Solitary fibrous tumor (SFT) is a rare neoplasm arising from the pleura, although it can sometimes affect extrapleural sites, including the head and neck. The sinonasal involvement is exceptional. Recent literature defines the SFT as a single spectrum of mesenchymal tumors, including hemangiopericytoma, which is currently considered a cellular phenotypic variant. The current case describes a rare case of a nasal septal SFT. The mass was embolized and then removed through endonasal endoscopic surgery. Histopathologic examination demonstrated positive immunoreactivity for CD34, and negative for keratin and S100 protein confirming the diagnosis of benign nasal SFT. After two years of follow-up, no relapse was observed. Diagnostic assessment of SFT requires nasal endoscopy, imaging and histopathological examination and a long time follow up is mandatory.

Multiple extramedullary plasmacytomas of the trachea and pharyngeal tissue: a case report and literature review

Extramedullary plasmacytoma (EMP) is an infrequent form of plasma cell dyscrasia that presents as a mass of monoclonal plasma cells located in extramedullary soft tissues with no skeletal component. EMP constitutes ~4% of all plasma cell neoplasms and occurs mostly in the upper respiratory tract. Here, we report a rare case of multiple EMPs involving the trachea, laryngopharynx, and oropharynx, which caused symptoms of airway obstruction as the only clinical manifestation. The patient was diagnosed by histopathology of the tissue from bronchoscopic resection and successfully managed with bronchoscopic intervention to treat lesions in the trachea and radiotherapy combined with surgical resection to treat lesions in the pharynx. There was no recurrence after 14 months of follow-up. Endoscopic intervention plays a key role in the rapid diagnosis and treatment of EMP involving the central airways.