Plasmacytoma with ? LN involvement

Plasmacytoma with ? LN involvement

Dr Nilesh Mahale 09 Aug 2010 08:09

53/M
HIV/HBsAg: Non reactive
Lt pleural based mass with some erosion of 5th rib. Enlarged precarinal and pretracheal LN largest 16mm
Mass bx: s/o Plasmactoma
SIEP: No band for IgG, IgA, IgM but band seen for lamda chain.
B2 microglobulin raised (7462ngml: N 1010-1730)
ESR 80 mm
Skeletal survey: No other lesions
BM: Uninvolved
LN tissue diagnosis not available

How common is LN involvement?

Med Onc has planned Thal Dexa
Should we treat LN also? if yes to what dose? what volume (only GTV+margin or entire mediastinum)

Re: Plasmacytoma with ? LN involvement

Nikhilesh Patil 09 Aug 2010 14:29

Hi,
Nice case, extramedullary plasmacytoma's are rare and they are mainly seen in HN region (over 80%) http://www.ncbi.nlm.nih.gov/pubmed/1300176.
Plasmacytoma of the lung is reported as case reports, majority present with pulmonary nodule or hilar mass. Most of the older series suggest surgery and some RT. I think you just treat the site with single modality. For your patient IFRT alone (2-8.1|yG53#2-8.1|yG53 gy/ #). 30-40% of cases, local lymph nodes are involved at presentation or upon relapse (ref: Hu K; Yahalom J Oncology (Williston Park). 2000 Jan;14(1):101-8, 111; discussion 111-2, 115.)

I dont think there is a role for CHEMO here unless it turns out be Multiple Myeloma at a later date.
Nikhilesh

Last edited on 09 Aug 2010 14:33 by Nikhilesh Patil Show more

Re: Plasmacytoma with ? LN involvement

Rohit Malde 09 Aug 2010 16:33

My Diagnosis: Lambda light chain multiple myeloma St III as per the International Staging System for MM.

This chap has a poor prognosis with a median survival of 29 months.

Managment: Chemotherapy +/- RT (painful sites)

Recent Publicaton early this year , strangely enough its titled

"Lambda light chain multiple myeloma presenting as pleural mass " freely available via sciencedirect.

http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B8JJ2-50G75R9-2&_user=10&_coverDate=07%2F06%2F2010&_rdoc=1&_fmt=high&_orig=search&_sort=d&_docanchor=&view=c&_searchStrId=1425629901&_rerunOrigin=google&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=0e2bba34c14cd12a966d358f094bdc4a

Re: Plasmacytoma with ? LN involvement

Santam Chakraborty 10 Aug 2010 15:37

Hi Rohit,
Can you please elaborate how you have arrived at the diagnosis? As per the International Myeloma Working Group Diagnostic Criteria for Monoglonal Gammopathy of Undetermined Significance, Smoldering Multiple Myeloma, and Multiple Myeloma (http://www.nature.com/leu/journal/v23/n1/pdf/leu2008291a.pdf)

Monoclonal gammopathy of undetermined significance (MGUS)	All 3 criteria must be met Serum monoclonal protein < 3 g/100 mL Clonal bone marrow plasma cells < 10% and Absence of end-organ damage, such as hypercalcemia, renal insufficiency, anemia, and bone lesions (CRAB), that can be attributed to the plasma cell proliferative disorder
Smoldering multiple myeloma (also referred to as asymptomatic multiple myeloma)	Both criteria must be met: Serum monoclonal protein (IgG or IgA ≥ 3 g/100 mL and/or clonal bone marrow plasma cells ≥ 10% and Absence of end-organ damage, such as lytic bone lesions, anemia, hypercalcemia, or renal failure, that can be attributed to a plasma cell proliferative disorder
Multiple Myeloma	All 3 criteria must be met except as noted: 1. Clonal bone marrow plasma cells ≥ 10% ; 2. Presence of serum and/or urinary monoclonal protein (except in patients with true nonsecretory multiple myeloma) and; 3. Evidence of end-organ damage that can be attributed to the underlying plasma cell proliferative disorder, specifically Hypercalcemia: serum calcium ≥ 11.5 mg/100 mL or Renal insufficiency: serum creatinine > 1.73 mmol/L or Anemia: normochromic, normocytic with a hemoglobin value of > 2 g/100 mL below the lower limit of normal or a hemoglobin value < 10 g/100 mL or Bone lesions: lytic lesions, severe osteopenia, or pathologic fractures
Solitary Plasmacytoma	All four criteria must be met: Biopsy-proven solitary lesion of bone or soft tissue with evidence of clonal plasma cells + Normal bone marrow with no evidence of clonal plasma cells + Normal skeletal survey and MRI of spine and pelvis (except for the primary solitary lesion) + Absence of end-organ damage such as CRAB lesions that can be attributed to a lymphoplasma cell proliferative disorder

IMHO without further workup including quantitative electrophoresis and workup for systemic end organ damage as noted above it is impossible to put a diagnosis on this patient. What do you think.

If you are thinking in the line of MM then ASCT is the choice of treatment in absence of contraindications
P.S. PDF is available free

In absence of diagnosis of MM the ISS is not useful

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Last edited on 10 Aug 2010 15:51 by Santam Chakraborty Show more

Re: Plasmacytoma with ? LN involvement

Rohit Malde 10 Aug 2010 16:27

I agree Santam, that ISS is useful only if patients meet diagnostic criteria for myeloma.

Perhaps Nilesh could help us with the missing investigations confirming the diagnostic criteria, he can be staged only after that.

Re: Plasmacytoma with ? LN involvement

Dr Nilesh Mahale 11 Aug 2010 04:57

IgG and IgA: 1 and 1.3 g/100 mL
Clonal bone marrow plasma cells 8%
Absence of end-organ damage except minor 5 th rib erosion
S Creat and Hb Normal
Only S Calcium levels to be done (Which I think should come normal)

Re: Plasmacytoma with ? LN involvement

Santam Chakraborty 11 Aug 2010 12:51

based on these its likely to be smouldering myeloma / MUGS (no mention of lambda chain quantization) in absence of end organ damage.
the role of nodal irradiation is controversial - see chapter of MM in Perez - has a nice discussion with references
Would be recommending a dose of 40 -45 Gy

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