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CASE REPORT
Year : 2011  |  Volume : 28  |  Issue : 2  |  Page : 136-138  

Multiple myeloma with lung plasmacytoma


1 Department of Pulmonary Medicine, Chatrapati Sahuji Maharaj Medical University (Earlier KGMU), Kanpur, India
2 Department of Tuberculosis and Respiratory Diseases, G.S.V.M. Medical College, Kanpur, India

Date of Web Publication30-Apr-2011

Correspondence Address:
Rajendra Prasad
Department of Pulmonary Medicine, C.S.M. Medical University (Earlier KGMU), UP, Lucknow - 226 003
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-2113.80331

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   Abstract 

Malignant myeloma (MM) is a clonal proliferation of plasma cells with multiple osteolytic lesions. Extramedullary dissemination of multiple myeloma in lung is relatively uncommon. Hereby, we present a case of multiple myeloma with lung plasmacytoma of lung in a 45-years-old, non-smoker, female.

Keywords: Extramedullary dissemination, lung, malignant myeloma


How to cite this article:
Prasad R, Verma SK, Sodhi R. Multiple myeloma with lung plasmacytoma. Lung India 2011;28:136-8

How to cite this URL:
Prasad R, Verma SK, Sodhi R. Multiple myeloma with lung plasmacytoma. Lung India [serial online] 2011 [cited 2019 Aug 23];28:136-8. Available from: http://www.lungindia.com/text.asp?2011/28/2/136/80331


   Introduction Top


Multiple myeloma (MM) is a systemic disease process primarily involving the bone marrow. In MM, the normal bone marrow is replaced by malignant plasmacytes, which produce monoclonal proteins and this disease process mainly involves the axial skeleton. MM constitutes about 1% of all malignancies and 10% of hematologic malignancies. [1] Extra-medullary plasmacytomas form a small percentage of plasma cell tumors, and majority of which primarily occur in the head and neck. However, the occurrence of extramedullary disease is very uncommon in MM. [2] Hereby, we present a case of multiple myeloma with lung plasmacytoma of lung, in a 45-years-old, non-smoker, female.


   Case Report Top


A 45-year-old female, non smoker was admitted to our department with complaints of right-sided chest pain and breathlessness for one year duration; loss of appetite for six-month duration; and about 6-kg weight loss over four weeks. The pain was moderate in intensity, constant, and localized primarily to the upper part of the chest wall both anteriorly and posteriorly. The pain increased to some extent on movement. She had taken antitubercular drugs for last six months.

Physical examination revealed pallor. Local examination revealed about 6 Χ 6 cm hard swelling, just below right breast, tender and fixed to underlying structure.

Her chest radiograph revealed opacity in the right lung with lytic lesions over right clavicle and erosion of the right fifth rib [Figure 1].
Figure 1: Chest radiograph revealing opacity in the right lung with lytic lesions over right clavicle and erosion of the right fifth rib.

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Routine investigation showed hemoglobin: 5.1 g%, total leukocyte count: 5,500/mm 3 , differential count: neutrophils 64%, lymphocyte 34%, eosinophil 2% and platlets count: 1.7 lacs|mm 3 , serum creatinine 1.9 mg/dl and 24 h urinary protein 330 mg/dl. Her whole skeletal survey revealed no abnormality except thorax.

A computed tomographic scan of the thorax (CT thorax) revealed soft tissue mass in the right anterior chest wall with rib destruction and lytic lesions in lateral end of right clavicle and posterior end of fifth rib suggestive of metastatic deposits [Figure 2]. Thus, a possibility of metastatic disease was raised. Biopsy of the lung mass revealed atypical plasma cells arranged in sheets with pulmonary parenchymal cells suggestive of malignant myeloma. Her skull X-ray revealed multiple lytic lesions [Figure 3]. Serum protein electrophoresis was done which revealed raised total proteins (11 g/dl) with normal albumin, alfa-1, alfa-2, and beta globulin but markedly raised gamma globulin (5 g/dl) and the electrophoresis showed an M-spike in the beta-gamma inter zone. Serum immunoglobulin determination revealed markedly raised IgG immunoglobulin (3000 g/dl). Beta-2 microglobulin was 3815 ng/ml. Urinary examination for Bence Jones' proteins was positive. Bone marrow biopsy revealed a hypocellular marrow with more than 75% plasma cells and reduced myeloid and erytheroid cells.
Figure 2: Computed tomographic scan of the thorax (CT thorax) revealing soft tissue mass in the right anterior chest wall with rib destruction and lytic lesions in lateral end of right clavicle and posterior end of fifth rib suggestive of metastaic deposits

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Figure 3: Skull radiograph revealing multiple lytic lesions

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Thus, diagnosis of MM with lung plasmacytoma was made on the basis of plasma cell infiltration of the bone marrow, the lytic bone lesions, the presence of monoclonal immunoglobulins in the serum and the myeloma plasma cells in the lung mass. The patient was planned to be referred to the oncology department for chemotherapy but was not willing to undergo any form of definitive treatment.


   Discussion Top


In multiple myeloma, bone marrow is infiltrated with aggregates of abnormal plasma cells and that leading to multifocal destructive bone lesions.

Extramedullary plasmacytoma accounts for about 3% of plasma cell malignancies and approximately 80% of which, in the upper respiratory tract namely oronasopharynx and paranasal sinuses. [2],[3] But association of multiple myeloma with lung plasmacytoma is found to be extremely rare. [4],[5]

The most typical thoracic manifestations of multiple myeloma are bony involvement of the thoracic cage. While other manifestations are pneumonia, intra-parenchymal mass lesions, mediastinal lymphadenopathy, reticulonodular shadows, interstitial pattern and intrapulmonary calcification (details of manifestations are given in [Table 1], as reported by various authors).
Table 1: Comparative analysis of pulmonary manifestations in multiple myeloma by various authors


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Despite advances in the diagnosis of MM, it remains an incurable disease, because the disease follows a relapsing course in majority of patients, regardless of the treatment regimen or initial response to treatment.

Newly diagnosed patients with good performance status are best treated with autologus stem cell transplantation. These patients are treated with high dose chemotherapy (HDCT) with vincristine, melphalan, cyclophosphamide and prednisone (VMCP) alternating with vincristine, carmustine, doxorubicin and prednisone (BVAP) combined with bone marrow transplantation, it improves the response rate, even free survival and overall survival in multiple myeloma. Induction therapy in patients ineligible for transplantation (old age, coexisting conditions, poor physical condition) includes thalidomide in combination with melphalan and prednisone or melphalan and prednisolone. Recently, the management of patients with MM has been transformed by introduction of three novel agents: thalidomide, lenalidomide, and bortezomib. [11],[12]

The differential diagnoses of multiple myeloma are metastatic carcinoma, lymphoma, bone neoplasm and chronic lymphocytic leukemia. [13]

The prognosis of patients with pulmonary multiple myeloma is poor. [8] This contrasts with the reports of long survival rates with primary pulmonary plasmacytomas of the lung. [9]

 
   References Top

1.Longo DL, Anderson KC. Plasma cell disorders. In: Kasper DL, Braunward E, Fauci AS, Hauser SL, Longo DL, Jameson JL, editors. Harrison's principles of internal medicine. 16 th ed. New York, NY: McGraw-Hill; 2005. p. 657-58.  Back to cited text no. 1
    
2.Shih LY, Dunn P, Leung WM, Chen WJ, Wang PN. Localised plasmacytomas in Taiwan: Comparison between extramedullary plasmacytoma and solitary plasmacytoma of bone. Br J Cancer 1995;71:128-33.  Back to cited text no. 2
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3.Alexiou C, Kau RJ, Dietzfelbinger H, Kremer M, Spiess JC, Schratzenstaller B, et al. Extramedullary plasmacytoma: Tumour occurrence and therapeutic concepts. Cancer 1999;85:2305-14.  Back to cited text no. 3
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4.Sullivan PO, Muller NL. Pulmonary and nodal multiple myeloma mimicking lymphoma. Br J Radiol 2006;79:e25-7.  Back to cited text no. 4
    
5.Ramnik K, Duggal RK, Ramachandran KA. Multiple Myeloma with Extra-Medullary Dissemination in the Lung. JIACM 2002;3:93-5.  Back to cited text no. 5
    
6. Shin MS. Diverse Roentgenographic mainsfestations of the rare pulmonary involvement in myeloma. Chest 1992;102:946-8.  Back to cited text no. 6
    
7.Weber CK, Friedrich JM, Merkle E, Prummer O. Reversible metastatic pulmonary calcification in a patient with multiple myeloma. Ann Hematol 1996;72:329-32.  Back to cited text no. 7
    
8.Koss MN, Hochholzer L, Moran CA, Frizzera G. Pulmonary plasmacytomas: A clinicopathologic and immunohistochemical study of 5 cases. Ann Diagn Pathol 1998;2:1-11.  Back to cited text no. 8
    
9.Oymak FS, Karaman A, Soyuer I, Karaman H, Gülmez I, Demir R, et al. Pulmonary and chest wall involvement in multiple myeloma. Tuberk Toraks 2003;51:27-32 .  Back to cited text no. 9
    
10.Damaj G, Mohty M, Vey N, Dincan E, Bouabdallah R, Faucher C, et al. Features of extramedullary and extraosseous multiple myeloma: A report of 19 patients from a single center. Eur J Haematol 2004;73:402-6.  Back to cited text no. 10
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11.Singhal S. Antitumor activity of thalidomide in refaractory multiple myeloma. N Engl J Med 1999;341:1565-71.  Back to cited text no. 11
    
12.Richardson P. A phase 2 study of bortezomaib in relapsed, refractory myeloma. N Engl J Med 2003;348:2609-17.  Back to cited text no. 12
    
13.Kushwaha RAS, Verma SK, Mehra S, Prasad R. Pulmonary and nodal multiple myeloma with a pleural effusion mimicking bronchogenic carcinoma. J Cancer Res Ther, 2009;5:297-299  Back to cited text no. 13
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1]


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[Pubmed] | [DOI]



 

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