Refractory plasmablastic type myeloma with multiple extramedullary plasmacytomas and massive myelomatous effusion: remarkable response with a combination of thalidomide and dexamethasone

Extramedullary Involvement of Lymph Nodes in Multiple Myeloma

Myeloma multiplex is a malignant disease of bone marrow plasma cells. It is usually confined to the bone marrow, but in rare cases, patients can develop extramedullary disease. The involvement of lymph nodes is rare and can be a diagnostic challenge. Here, we describe a 36-year-old male patient who presented with abdominal pain and discomfort initially. An abdominal ultrasound followed by computed tomography (CT) revealed retroperitoneal and mesenteric lymph node enlargement. Biopsies of the abdominal lymph node and infiltrated colon showed a plasma cell infiltrate positive for CD79α, CD38, CD138, kappa light chain and VEGF2. Multiple myeloma with extramedullary localization was diagnosed. After six cycles of chemotherapy consisting of doxorubicin, dexamethasone and thalidomide followed by autologous haematopoietic cell transplantation, the patient achieved complete remission. Specifically, a CT scan after therapy showed enlarged lymph nodes in the abdomen, but PET CT scans did not detect any metabolically active foci. Thee years after the completion of therapy, the patient remains in remission. This case illustrates a rare presentation of extramedullary myeloma involving the abdominal lymph nodes, which could have been potentially mistaken for a lymphoid malignancy.

Myelomatous pleural effusion: A rare case entity reported from a tertiary care cancer center in South India

Multiple myeloma (MM) is a plasma cell neoplasm and constitutes 10% of hematologic malignancies. Malignant myelomatous pleural effusions are very rare and occur in <1% of cases of MM. In this article, we report a rare case of a patient who initially presented with pleural effusion and was subsequently found to be secondary to MM with an underlying raised IgG paraprotein. The patient symptomatically improved and was in partial remission with palliative radiotherapy, VTD chemotherapy, and bisphosphonates.

Solitary pleural myeloma diagnosed by semi-rigid thoracoscopy: A case report and literature review

Multiple myeloma (MM) is characterized by abnormal proliferation of neoplastic plasma cells. Pleural effusion as an initial presentation of this disease is rare, as is true pleural myeloma. We herein present a case of solitary pleural myelomatous lesion in a 70-year-old male patient diagnosed by pleural biopsy via semi-rigid thoracoscopy followed by histopathological examination. Furthermore, a review of the related English literature identified 22 cases of pleural myeloma, only 3 of which were diagnosed by video-assisted thoracoscopy. To the best of our knowledge, this is the first reported case of a solitary pleural myelomatous lesion diagnosed by pleural biopsy via semi-rigid thoracoscopy. Patients with MM with pleural involvement, including the present case, appear to have a short survival despite aggressive treatment. Our patient received chemotherapy with bortezomib, epiadriamycin and dexamethasone; however, he deteriorated rapidly after one cycle of chemotherapy and succumbed to the disease 8 weeks after the initial presentation. According to our experience, semi-rigid thoracoscopy is an effective and safe method for obtaining a pleural specimen for histopathological evaluation.

A case of extramedullary plasmablastic plasmacytoma successfully treated using a combination of thalidomide and dexamethasone and a review of the medical literature

A 56-year-old man developed epistaxis, hoarseness, and swelling of a finger in March 2010. On the basis of biopsies of the masses in the pharynx and finger, he was diagnosed with extramedullary plasmablastic plasmacytoma, with somewhat immature CD45(+), MPC-1(-), and CD49e(-). CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisolone) and VCAP (vincristine, cyclophosphamide, doxorubicin, and prednisolone) therapy was ineffective, but combination therapy with thalidomide and dexamethasone was highly effective. Thalidomide monotherapy successfully maintained partial remission for approximately 7 months. A mass appeared in the right neck in February 2011, and a biopsy confirmed recurrence. Changes to CD45 negativity and MPC-1 partial positivity were seen, while CD49e negativity persisted, suggesting that the plasmablastic plasmacytoma had reverted to a more immature state. Bortezomib therapy was started in March 2011 and was effective. However, during the second round of treatment, the patient developed acute lung injury, which was improved by steroid pulse therapy. After the discontinuation of bortezomib, the extramedullary mass increased rapidly, and the patient died of multiple organ failure. An autopsy showed that plasmablastic plasmacytomas had infiltrated into multiple organs. Extramedullary plasmacytomas and those that revert to an immature state are associated with a poor prognosis, so further treatment improvements are needed in the future.

Cranial plasmacytoma: a case series and review of the literature

Plasmacytomas are malignant proliferations of plasma cells which can occur with different plasma cell dyscrasias. Solitary plasmacytomas of bone or extraosseous plasmacytomas, depending on the tissue of origin, develop in isolation without systemic manifestations of multiple myeloma. Three cases of cranial plasmacytomas are described, two in patients with multiple myeloma and one extraosseous plasmacytoma. Management options are discussed.

Extramedullary disease in plasma cell myeloma: the iceberg phenomenon

Extramedullary (EM) plasmacytomas (EMPs) that are not progression of intramedullary (IM) plasma cell myeloma (PCM) are usually indolent. In contrast, EM spread of IM PCM is associated with a poor prognosis. The recently introduced Durie-Salmon PLUS staging system includes EM disease in the poor prognosis category. One study noted an increase in EM disease both at diagnosis and during follow-up of PCM in 2000-2007 compared with previous years raising concerns that adoption of novel agents (thalidomide, lenalidomide and bortezomib) and greater use of hematopoietic cell transplantation (HCT) might be contributory to this. It is uncertain if this is a true increase or merely greater detection due to the increasing use of more sensitive imaging techniques (computerized tomography, magnetic resonance imaging and ¹⁸F-fluorodeoxyglucose positron emission tomography) or a reflection of the evolving natural history of PCM in an era when patients are living longer (median overall survival before 1996 was 29.9 months vs 44.8 months after 1996). Recent studies suggest there are important biological differences between PCM with or without EM spread that are offering clues that might explain the propensity for dissemination and a more aggressive clinical course. For example, EM relapse in PCM with and without deletion 13 was 30.8 vs 5.6%, suggesting the biology of a plasma cell subclone before HCT can affect the nature of the relapse after HCT. This article will explore the clinical, biological and treatment implications of EM spread of PCM. In addition, the impact of extramedullary disease on the outcomes of autologous and allogeneic HCT for PCM will be analyzed. Allogeneic HCT early in the course of high-risk PCM with EM disease is a consideration since graft vs myeloma effects may be essential to achieve maximal survival benefits.

Myelomatous pleural effusion-A case report

Multiple myeloma is a malignant proliferation of plasma cells, predominantly involving the bone marrow and skeletal system. Pleural effusions are rarely associated with multiple myeloma and most often signify a concurrent disease process, e.g. amyloidosis.^1,2 Malignant myelomatous pleural effusions are even more unusual, occurring in less than 1% of cases of multiple myeloma.¹

Here we report the case of a patient with multiple myeloma presenting with a myelomatous pleural effusion at disease recurrence.

Multiple myeloma with extramedullary disease

Plasmacytoma is a tumor mass consisting of atypical plasma cells. Incidence of plasmacytomas associated with multiple myeloma range from 7% to 17% at diagnosis and from 6% to 20% during the course of the disease. In both situations, occurrence of extramedullary disease has been consistently associated with a poorer prognosis of myeloma. Extramedullary relapse or progression occurs in a variety of clinical circumstances and settings, and therefore requires individualization of treatment. Alkylating agents, bortezomib, and immunomodulatory drugs, along with corticoids, have been used to treat extramedullary relapse but, because of the relatively low frequency or detection rate of extramedullary relapse, no efficacy data are available from controlled studies in this setting.

Extramedullary plasmacytomas in the context of multiple myeloma

Plasmacytoma is a frequent complication of multiple myeloma, either at diagnosis or within disease progression. The extramedullary disease confers a poorer prognosis and is biologically distinct with high-risk molecular and histological features, being resistant to conventional treatments. Radiation therapy remains the most effective treatment for extramedullary lesions to achieve local control. There are very limited data from randomized trials regarding the most appropriate systemic treatment. Case reports such as those presented here, as well as retrospective analysis of series, suggest that lenalidomide is an effective agent, in combination with dexamethasone, in this setting. Additional studies are needed to define the proper management of this condition.

Successful treatment of extramedullary tumors with low-dose thalidomide in patients with multiple myeloma

Extramedullary tumor (EMT) is a poor prognostic factor of multiple myeloma (MM). The majority of patients report poor efficacy of thalidomide in MM with EMT, and bortezomib is the preferred choice of treatment. We report two cases of MM with EMTs in which thalidomide was highly beneficial. Case 1 has been in remission for ten months with 100 mg every other day of thalidomide monotherapy, which is the lowest dose to be reported in a successfully treated case of MM with EMT. Case 2 eventually became refractory, but low dose thalidomide gave excellent disease control over a period of eleven weeks, despite the EMT being in a highly aggravated state. Some reports have speculated that EMT cases with preceding bone marrow transplantation (BMT) are an exception and have a good response to thalidomide, but the present two cases have no history of BMT. In conclusion, low dose thalidomide can be effective in MM with EMT and should be considered as a treatment option, especially in the elderly.