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Stirpe E, Bardaro F, Köhl J. Pleural effusion and Waldenström macroglobulinemia: if cytology and flow cytometric findings do not match. A case report. Monaldi Arch Chest Dis 2023. [PMID: 37700705 DOI: 10.4081/monaldi.2023.2665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Accepted: 08/28/2023] [Indexed: 09/14/2023] Open
Abstract
Pleural effusion is a rare complication of lymphoplasmacytic lymphoma. When it occurs, traditional investigation techniques may not always be successful. The flow cytometry is a fast and precise diagnostic technique, which can be helpful in the diagnosis of pleural localization of hematological diseases. We present a case report of a pleural localization of Waldenström macroglobulinaemia detected by flow cytometry.
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Affiliation(s)
- Emanuele Stirpe
- Department of Respiratory Diseases, Bolzano Hospital, Bolzano.
| | | | - Johanna Köhl
- Department of Respiratory Diseases, Bolzano Hospital, Bolzano.
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Barnes M, Sharma P, Kumar V, Kaell A, LiPera W. Pleural fluid MYD88 L265P mutation supporting diagnosis and decision to treat extramedullary Waldenstrom's macroglobulinemia: a case report. J Med Case Rep 2020; 14:98. [PMID: 32654665 PMCID: PMC7358196 DOI: 10.1186/s13256-020-02404-x] [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: 10/16/2019] [Accepted: 05/22/2020] [Indexed: 11/20/2022] Open
Abstract
Background Our case of a patient with untreated lymphoplasmacytic lymphoma/Waldenstrom’s macroglobulinemia with extramedullary pleural effusion is the first documented case of pleural fluid MYD88 L265P mutation status in a community hospital setting. Our patient was intolerant to 420 mg ibrutinib, but still achieved a lasting complete remission, as defined by National Comprehensive Cancer Network guidelines, with a dose reduction to 240 mg of ibrutinib. Case presentation A 72-year-old Caucasian (white) man diagnosed with monoclonal immunoglobin M kappa lymphoplasmacytic lymphoma/Waldenstrom’s macroglobulinemia monitored without treatment for 2 years, presented with dyspnea and a left pleural effusion. At presentation, computed tomography scans of his chest, abdomen, and pelvis showed layering left pleural effusion and para-aortic lymphadenopathy. Pleural fluid cytology demonstrated B-cell lymphoma of the lymphoplasmacytic subtype, with monoclonal kappa B-cell population on flow and a positive MYD88 L265P mutation. The pleural effusion recurred post-thoracentesis and he achieved a lasting complete remission as defined by National Comprehensive Cancer Network guideline with 240 mg ibrutinib. Conclusions Our discussion details a comprehensive literature review of extramedullary pulmonary involvement in Waldenstrom’s macroglobulinemia. Establishing a malignant etiology for pleural effusion in Waldenstrom’s macroglobulinemia can be challenging, as standard techniques may be insensitive. Allele-specific polymerase chain reaction for detecting MYD88 L265P mutations is more sensitive for confirming lymphoplasmacytic lymphoma/Waldenstrom’s macroglobulinemia in pleural fluid. Extramedullary pulmonary involvement usually presents post-diagnosis of Waldenstrom’s macroglobulinemia and responds well to Waldenstrom’s macroglobulinemia-directed treatment regimens. Allele-specific polymerase chain reaction is a sensitive assay for detecting MYD88 L265P mutations in pleural fluid to support the diagnosis of malignant pleural effusion in the setting of Waldenstrom’s macroglobulinemia and helps guide the treatment decision to use ibrutinib. Although intolerant of ibrutinib 420 mg, our patient achieved complete and sustained remission of pleural effusion with a dose of 240 mg with progression free survival of over 30 months.
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Affiliation(s)
- Martin Barnes
- Department of Internal Medicine, Mather Hospital/Northwell Health, 75 North Country Rd, Port Jefferson, NY, 11777, USA.
| | - Pritha Sharma
- Department of Internal Medicine, Mather Hospital/Northwell Health, 75 North Country Rd, Port Jefferson, NY, 11777, USA
| | - Vikas Kumar
- Department of Internal Medicine, Mather Hospital/Northwell Health, 75 North Country Rd, Port Jefferson, NY, 11777, USA
| | - Alan Kaell
- Department of Internal Medicine, Mather Hospital/Northwell Health, 75 North Country Rd, Port Jefferson, NY, 11777, USA
| | - William LiPera
- New York Cancer & Blood Specialists, 49 Route 347, Port Jefferson Station, NY, 11776, USA
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Pan ST, Wang RC, Kuo CC, Hsieh YC, Su YZ, Chuang SS. MYD88 L265P mutation analysis is a useful diagnostic adjunct for lymphoplasmacytic lymphoma with pleural effusion. Pathol Int 2019; 69:601-607. [PMID: 31556196 DOI: 10.1111/pin.12854] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 08/19/2019] [Indexed: 01/26/2023]
Abstract
Lymphoplasmacytic lymphoma (LPL) is a marrow-based lymphoma, rarely involving extramedullary sites, particularly the pleural cavities. The distinction of lymphomatous pleural effusion (PE) in LPL patients from benign effusion is challenging. We conducted this study to examine whether MYD88 L265P mutation analysis is useful in distinguishing benign from lymphomatous PE in four patients with LPL, in which the initial marrow specimens were all positive for MYD88 mutation. In one case each with plasma cell- or lymphocyte-predominant PE, MYD88 mutation was positive, confirming lymphomatous effusion. The other lymphocyte-predominant PE was negative for MYD88 mutation, but was clonally related to a previous nodal biopsy and this PE was also considered to have LPL involvement. The fourth case developed large B-cell lymphoma in the PE 30 months later. The PE specimen was negative for MYD88 mutation but was clonally related to the diagnostic marrow tissue, indicating large cell transformation. Four cases of small lymphocyte-predominant benign PE from patients without history of lymphoma were examined and were all negative for MYD88 L265P mutation. In conclusion, in this small case series we showed that MYD88 L265P mutation analysis could serve as a useful adjunct in distinguishing benign from lymphomatous PE in patients with LPL.
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Affiliation(s)
- Shien-Tung Pan
- Department of Pathology, Tungs' Taichung MetroHarbor Hospital, Taichung, Taiwan
| | - Ren Ching Wang
- Department of Pathology and Laboratory Medicine, Taichung Veterans General Hospital, Taichung, Taiwan.,Department of Nursing, School of Nursing, Hungkuang University, Taichung, Taiwan
| | - Chun-Chi Kuo
- Department of Pathology, Chi-Mei Medical Center, Tainan, Taiwan
| | - Yen-Chuan Hsieh
- Department of Pathology, Chi-Mei Medical Center, Tainan, Taiwan
| | - Ying-Zhen Su
- Department of Pathology, Chi-Mei Medical Center, Tainan, Taiwan
| | - Shih-Sung Chuang
- Department of Pathology, Chi-Mei Medical Center, Tainan, Taiwan.,Department of Pathology, School of Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan.,Department of Pathology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
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Abdulfattah O, Rahman EU, Bhattarai B, Dahal S, Alnafoosi Z, Trauber D, Enriquez D, Schmidt F. Lung consolidation as a rare presentation of lymphoplasmacytic lymphoma with extramedullary Waldenström's macroglobulinemia. J Community Hosp Intern Med Perspect 2018; 8:68-72. [PMID: 29686791 PMCID: PMC5906769 DOI: 10.1080/20009666.2018.1440854] [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: 12/21/2017] [Accepted: 02/09/2018] [Indexed: 11/10/2022] Open
Abstract
Objectives: Lymphoplasmacytic lymphoma (LPL) is a mature B cell lymphoma that usually involves the bone marrow, spleen and lymph nodes. Extramedullary involvement, including the lung, is rarely reported. Case description: A 73-year-old female initially presented to our hospital complaining of productive cough of white-colour sputum for three weeks duration. She reported unintentional weight loss of ten pounds over the last five months. There was no history of haemoptysis, fever, night sweats, chills, recent infections or hospitalization. Chest imaging showed right lower lobe consolidation, small right pleural effusion. She was treated with oral antibiotic for pneumonia. After two months, a follow up chest imaging revealed persistent right lower lobe consolidation. Therefore, she was worked up for the possibility of malignancy. Bronchoscopy showed polypoid nodularities surrounded by black discoloured mucosa in the sub-segmental bronchi of the right lower lobe, and biopsy specimen revealed atypical B cell lymphocytic infiltrate. Polymerase chain reaction confirmed a clonal B-cell gene rearrangement supportive for a low-grade B-cell Lymphoma. Subsequently; serum immunofixation showed IgM of 1491 mg/dL (normal range 26–217 mg/dl) with normal levels of IgG and IgA. Urine contained free kappa light chains. Cytology with immunophenotyping of pleural fluid revealed lymphoplasmacytic lymphocytes. This combination of lab and bronchoscopy findings established the diagnosis of extramedullary Waldenström’s macroglobulinemia. Conclusion: Waldenström’s macroglobulinemia, a manifestation of LPL, is associated with an IgM monoclonal gammopathy in the blood. Extramedullary involvement including the lung is rarely seen in LPL. Physicians need to be aware of this rare presentation.
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Affiliation(s)
- Omar Abdulfattah
- Medicine Department, Pulmonary and Critical Care Division, Interfaith Medical Center, Brooklyn, NY, USA
| | - Ebad Ur Rahman
- Medicine Department, Interfaith Medical Center, Brooklyn, NY, USA
| | - Bikash Bhattarai
- Medicine Department, Pulmonary and Critical Care Division, Interfaith Medical Center, Brooklyn, NY, USA
| | - Sumit Dahal
- Medicine Department, Interfaith Medical Center, Brooklyn, NY, USA
| | - Zainab Alnafoosi
- Medicine Department, Interfaith Medical Center, Brooklyn, NY, USA
| | - David Trauber
- Medicine Department, Hematology/Oncology Division, Interfaith Medical Center, Brooklyn, NY, USA
| | - Danilo Enriquez
- Medicine Department, Pulmonary and Critical Care Division, Interfaith Medical Center, Brooklyn, NY, USA
| | - Frances Schmidt
- Medicine Department, Pulmonary and Critical Care Division, Interfaith Medical Center, Brooklyn, NY, USA
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Gustine JN, Meid K, Hunter ZR, Xu L, Treon SP, Castillo JJ. MYD88
mutations can be used to identify malignant pleural effusions in Waldenström macroglobulinaemia. Br J Haematol 2016; 180:578-581. [DOI: 10.1111/bjh.14386] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Joshua N. Gustine
- Bing Center for Waldenström Macroglobulinemia; Dana-Farber Cancer Institute; Boston MA USA
| | - Kirsten Meid
- Bing Center for Waldenström Macroglobulinemia; Dana-Farber Cancer Institute; Boston MA USA
| | - Zachary R. Hunter
- Bing Center for Waldenström Macroglobulinemia; Dana-Farber Cancer Institute; Boston MA USA
| | - Lian Xu
- Bing Center for Waldenström Macroglobulinemia; Dana-Farber Cancer Institute; Boston MA USA
| | - Steven P. Treon
- Bing Center for Waldenström Macroglobulinemia; Dana-Farber Cancer Institute; Boston MA USA
- Department of Medicine; Harvard Medical School; Boston MA USA
| | - Jorge J. Castillo
- Bing Center for Waldenström Macroglobulinemia; Dana-Farber Cancer Institute; Boston MA USA
- Department of Medicine; Harvard Medical School; Boston MA USA
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Mansour AM, Arevalo JF, Badal J, Moorthy RS, Shah GK, Zegarra H, Pulido JS, Charbaji A, Amselem L, Lavaque AJ, Casella A, Ahmad B, Paschall JG, Caimi A, Staurenghi G. Paraproteinemic maculopathy. Ophthalmology 2014; 121:1925-32. [PMID: 24950591 DOI: 10.1016/j.ophtha.2014.04.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2014] [Revised: 03/06/2014] [Accepted: 04/09/2014] [Indexed: 11/26/2022] Open
Abstract
PURPOSE Paraproteinemia relates to monoclonal gammopathy-producing pathologic antibodies with serous macular detachment being an uncommon ocular manifestation. We ascertained the clinical course of maculopathy in paraproteinemia and investigated the effect of various therapeutic methods on the resolution of subretinal deposits. DESIGN Multicenter, retrospective, observational case series. PARTICIPANTS The records of patients with paraproteinemia with optical coherence tomography (OCT) documentation of serous macular detachment were reviewed. METHODS Data collection included coexisting morbidity, rheology data (immunoglobulin level, hematocrit, and blood viscosity), clinical examination results, and OCT findings. MAIN OUTCOME MEASURES Best-corrected visual acuity (BCVA), height and basal area of the serous macular detachment, and systemic versus local therapies. RESULTS A total of 33 cases were collected: 10 new and 23 previously reported in the literature. Diabetes was present in 7 patients, systemic hypertension in 9 patients, and anemia in 18. Mean initial immunoglobulin level was 6497 mg/dl, and mean serum viscosity was 5.5 centipoise (cP). Mean logarithm of the minimum angle of resolution initial vs. final BCVA was 0.55 (Snellen equivalent, 20/71) vs. 0.45 (20/56) in the right eye and 0.38 (20/48) vs. 0.50 (20/63) in the left eye. After mean follow-up of 7 months (range, 0-51 months). Systemic therapies included plasmapheresis (18), chemotherapy (30), blood transfusions (2), transplantation of progenitor hematopoietic cells (2), and oral rituximab (10). Immunoglobulin levels normalized in 8 patients and were unchanged in 1 after plasmapheresis, chemotherapy, or both. Ocular therapy in 8 patients included vitrectomy (1), laser photocoagulation (4), intravitreal bevacizumab (5), intravitreal triamcinolone (2), intravitreal dexamethasone implant (1), intravitreal rituximab (1), and sub-Tenon corticosteroid (1). The maculopathy resolved partially or completely in 17 patients and worsened or remained unchanged in 14 patients over median follow-up of 7 months. Maculopathy was unilateral in 9 cases and occurred at a lower initial immunoglobulin level in diabetics. There was a positive correlation between area of the detachment and serum viscosity. CONCLUSIONS Paraproteinemic maculopathy can be unilateral. Decreasing the blood immunoglobulin level is the primary goal of therapy for paraproteinemic maculopathy, and this can be achieved by a systemic route. Coexisting diabetes facilitates leakage of immunoglobulins at lower levels than in nondiabetics.
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Affiliation(s)
- Ahmad M Mansour
- Departments of Ophthalmology, American University of Beirut and Rafic Hariri University Hospital, Beirut, Lebanon.
| | - J Fernando Arevalo
- Retina Departments, The King Khaled Eye Specialist Hospital, Riyadh, Kingdom of Saudi Arabia, and Wilmer Eye Institute, The Johns Hopkins University, Baltimore, Maryland
| | - Josep Badal
- Department of Ophthalmology, Hospital Moises Broggi Sant Joan Despi, Barcelona, Spain
| | - Ramana S Moorthy
- Associated Vitreoretinal and Uveitis Consultants, Department of Ophthalmology, Indiana University School of Medicine, Indianapolis, Indiana
| | | | | | - Jose S Pulido
- Department of Ophthalmology, Mayo Clinic, Rochester, Minnesota
| | - Abdulrazzak Charbaji
- Department of Statistics and Research Methodology, Lebanese American University and Lebanese University, Beirut, Lebanon
| | - Luis Amselem
- Department of Ophthalmology, Hospital Moises Broggi Sant Joan Despi, Barcelona, Spain
| | | | - Antonio Casella
- Department of Ophthalmology, Universidade Estadual de Londrina, Parana, Brazil
| | | | - Joshua G Paschall
- Associated Vitreoretinal and Uveitis Consultants, Department of Ophthalmology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Antonio Caimi
- Department of Clinical Science "Luigi Sacco," Sacco Hospital, University of Milan, Milan, Italy
| | - Giovanni Staurenghi
- Department of Clinical Science "Luigi Sacco," Sacco Hospital, University of Milan, Milan, Italy
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Amin CJ, Rabinowitz I. An unusual reoccurrence of Waldenstrom's macroglobulinemia as pleural effusions that had a discordant response with treatment. ACTA ACUST UNITED AC 2005; 27:200-2. [PMID: 15938727 DOI: 10.1111/j.1365-2257.2005.00666.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
A 77-year-old female with a past medical history of Waldenstrom's macroglobulinemia presented with progressive shortness of breath and a newly diagnosed left pleural effusion. Numerous diagnostic studies were performed on the patient and finally a pleural biopsy confirmed pulmonary involvement of Waldenstrom's macroglobulinemia. As past studies have shown, Waldenstrom's involvement as a pulmonary process is uncommon. Unexpectedly, treatment with rituximab and fludarabine did decrease the patient's serum immunoglobulin M levels, but her pleural effusions never improved.
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Affiliation(s)
- C J Amin
- Department of Internal Medicine, University of New Mexico School of Medicine, University of New Mexico, Albuquerque, NM 87131-0001, USA.
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Ortapamuk H, Alp A. Lung uptake on a bone scan: a case of pulmonary Waldenstrom's macroglobulinemia. Ann Nucl Med 2002; 16:487-9. [PMID: 12508840 DOI: 10.1007/bf02988647] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Pulmonary involvement secondary to Waldenstrom's macroglobulinemia (WMG) is described in a 40-year-old male by incidental findings on a bone scan. He was examined for right leg pain, and bone scan revealed unexpected pulmonary uptake of Tc-99m MDP. CT scan of the thorax revealed pleural effusion and slightly disseminated micronoduler density increase in the right lung and parenchymal infiltration in the left lung. Transdermal lung biopsy demonstrated diffuse infiltration of lymphoplasmocytoids. Reporting the presence of pulmonary involvement is important because it may prevent morbidity from pulmonary dysfunction.
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Affiliation(s)
- H Ortapamuk
- Division of Nuclear Medicine, Department of Radiology, Ankara Numune Research and Training Hospital, Ankara, Turkey.
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