A 62-year-old female presented with worsening back pain for 2 months after a fall. She had a history of monoclonal gammopathy of undetermined significance and was found to have vertebral fractures on spinal imaging with magnetic resonance imaging. Incidental solid lesions were noted in the pancreas and liver. She was referred for endoscopic ultrasound and fine needle aspiration of the pancreas lesions. Endoscopy demonstrated several ulcerated nodular lesions in the duodenum (Figure 1).
Figure 1. Endoscopy demonstrating several ulcerated nodular lesions in the duodenum.
Histologic examination of snare biopsies identified a fragment of duodenal tissue with a diffuse infiltrate of neoplastic cells in the lamina propria and submucosa with positive staining for anti-CD138, consistent with plasmacytoma with plasmablastic morphology (Figure 2). In the distal body and tail of the pancreas and the left lobe of the liver, hypoechoic lesions were noted (Figure 3). Fine needle aspiration of the pancreas and liver lesions using a 25-gauge needle was also consistent with plasmacytoma. The patient subsequently underwent a bone marrow biopsy, consistent with multiple myeloma (MM).
Figure 2. Immunohistochemical stain highlighting diffuse positive staining with anti-CD138 labeling the neoplastic plasma cells.
Figure 3. EUS showing hypoechoic lesion in the left lobe of the liver.
Extramedullary spread of MM can occur either at diagnosis or during the course of the disease.1,2 Extramedullary disease at the time of MM diagnosis is rare, with an incidence of 7%.1 Patients presenting with extramedullary disease are at higher risk of subsequent extramedullary relapses.2 This case highlights an incidental finding of plasmcytoma with a subsequent diagnosis of multiple myeloma. The diagnosis of both extramedullary disease and MM contributed to the patient’s prognosis of extramedullary relapses.
Author contributions: All authors participated equally in manuscript preparation and literature review. RS Cho is the article guarantor.
Financial disclosure: None to report.
Informed consent: The patient passed away in 2012, so the patient’s spouse provided informed consent for this case report.
Correspondence: Ryan Cho, Brooke Army Medical Center, Internal Medicine, 3551 Roger Brooke Drive, San Antonio, TX, 78234 (firstname.lastname@example.org).
Received: June 13, 2014; Accepted: August 15, 2014
- Dores GM, Landgren O, McGlynn KA, et al. Plasmacytoma of bone, extramedullary plasmacytoma, and multiple myeloma: Incidence and survival in the United States, 1992–2004. Br J Haematol. 2009;144(1):86–94. Article | PubMed
- Varettoni M, Corso A, Pica G, et al. Incidence, presenting features and outcome of extramedullary disease in multiple myeloma: A longitudinal study on 1,003 consecutive patients. Ann Oncol. 2010;21(2):325–330. Article | PubMed
© 2014 Cho et al. This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivs 3.0 Unported License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-nd/3.0.