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Ann Thorac Surg 2004;78:1448-1449
© 2004 The Society of Thoracic Surgeons

Case report

Primary Solitary Endobronchial Plasmacytoma

Evgeny Edelstein, MD, PhDa, Anthony A. Gal, MDb, Karen P. Mann, MD, PhDb, Joseph I. Miller, Jr, MDc, Kamal A. Mansour, MDc,*

a Department of Pathology, Meir Hospital, Saphir Medical Center, Kfar Saba, Israel
b Department of Pathology and Laboratory Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
c Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia, USA

Accepted for publication July 25, 2003.

* Address reprint requests to Dr Mansour, Division of Cardiothoracic Surgery, 1365 Clifton Rd, NE, Atlanta, GA 30322, USA
kamal_mansour{at}emoryhealthcare.org


   Abstract
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 Abstract
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Twenty-two cases of pulmonary plasmacytoma have been reported in the literature and verified by immunohistochemistry or other diagnostic tests. The treatment for this rare tumor has included various combinations of surgical resection, chemotherapy, and radiation therapy. We report a case of a middle-age man who underwent endoscopic debulking followed by laser ablation for a pulmonary plasmacytoma, which showed a prominent endobronchial location with clinical and histopathologic verification.


   Introduction
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 Abstract
 Introduction
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Pulmonary plasmacytomas are rare tumors of plasma cell origin. Twenty-two thoroughly evaluated cases have been reported in the nonsurgical English literature [1–6]. These tumors need to be distinguished from reactive inflammatory processes, marginal zone B-cell lym-phoma of mucosa-associated lymphatic tissue type with plasmacytoid differentiation [7], and plasma cell granuloma [1]. We report a primary pulmonary plasmacytoma with a predominantly endobronchial location that was treated by yttrium-aluminum-garnet (YAG) laser ablation. There was no evidence of recurrence in 8 months.

The patient is a 47-year old, morbidly obese, nonsmoking, white man. Approximately 1 year ago he noted a cough that in the past several months had become productive in nature. He complained of wheezing and shortness of breath. At an outside hospital, a computed tomographic scan revealed a mass in the left mainstem bronchus just to the left of the carina (Fig 1). Flexible fiberoptic bronchoscopy disclosed a mass at the left proximal bronchus, which was not in continuation with the carina. A biopsy was not performed at that time for fear of bleeding.



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  		Fig 1. Computed tomographic scan of the chest demonstrating near total occlusion of the left main bronchus (arrow).

 
The patient was admitted to Emory University Hospital and underwent rigid bronchoscopy. Immediately to the left of the carina there was a globular tan-white mass with near total occlusion of the bronchus. The entire mass was removed piecemeal by a biopsy forceps, and the tumor base was electrocauterized. A frozen section of the tumor showed a plasma cell lesion with the differential diagnosis of plasmacytoma versus plasma cell granuloma. At the end of the procedure the left mainstem bronchus was widely patent. There were no postoperative complications, and the patient was discharged home on the first postoperative day breathing normally. Six weeks later, once the diagnosis was confirmed, he underwent YAG laser ablation of residual disease. Workup to rule out multiple myeloma was completed. Skeletal survey showed no other sites of involvement. Serum electrophoresis was normal, and Bence Jones proteinuria was absent. Bone marrow examination demonstrated no abnormalities.

The surgical specimen consisted of multiple pieces of tan tissue measuring 2.5 x 1.2 x 0.8 cm in aggregate. On microscopic examination there were sheets of plasma cells beneath an intact respiratory mucosa. Some of these plasma cells showed mild cytologic atypia, slight nuclear enlargement, and rare mitotic figures (Fig 2). In addition, there was a background infiltrate of mature lymphocytes and foci of fibrosis with numerous multinucleated giant cells. A Congo red stain for amyloid was negative. Immunohistochemical stains revealed that the tumor cells stained for kappa light chain, but they were negative for lambda light chain. They additionally lacked expression of leukocyte common antigen (CD45), B-cell antigen CD20, and T-cell antigen CD3. Flow cytometry was nondiagnostic, owing to poor sample preservation.



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  		Fig 2. Photomicrograph depicting a monotonous population of plasma cells with mild cytologic atypia. (Medium power, hematoxylin & eosin stain.)

 
Repeat bronchoscopy with brushings 8 months later showed reactive changes with no evidence of malignancy.


   Comment
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Extramedullary plasmacytomas are extremely uncommon neoplasms of plasma cell derivation. The vast majority of tumors arise in the head and neck region, especially in the upper respiratory tract [6]. Typically in the lung they present as a solitary nodule or less commonly as lobar consolidation or diffuse pulmonary infiltrates [1–5]. Although plasmacytomas frequently involve lung and the large airways, an exophytic growth into the bronchial lumen is uncommon. Our review of the litera-ture has disclosed five convincing cases that showed a predominant endobronchial location [2–5]. As in many previously reported cases, we had a problem in making the diagnosis of pulmonary plasmacytoma at frozen section. A review of the permanent sections and conformation of clonality using immunohistochemical studies for kappa and lambda light chains confirmed the diagnosis of plasmacytoma.

The treatment for pulmonary plasmacytoma is usually resection alone or combination of surgery with chemotherapy or radiotherapy [1–6]. The five previous cases of endobronchial plasmacytoma were treated by various modalities: bronchial resection or lobectomy (three cases), bronchoscopic ablation after chemotherapy and radiotherapy (one case), and bronchoscopic laser vaporization (one case) [2–5].

Although most extramedullary plasmacytomas are typically solitary, they may be indicative of a systemic plasma cell dyscrasia. In a study of 958 cases of multiple myeloma, 6 patients presented with an extramedullary plasmacytoma in the lung [7]. In the previously reported cases of pulmonary plasmacytoma, 9 of 22 patients (40%) ultimately developed multiple myeloma [1–6], often 10 to 12 years after the initial diagnosis [8]. Therefore, it is essential that a thorough evaluation should be undertaken to exclude systemic disease either at initial presentation or at some point in the future. These patients should have serum and urine electrophoresis, skeletal bone survey, and a bone marrow examination and should be monitored by close clinical follow-up.


   References
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 Abstract
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 Comment
 References
 

  1. Koss MN, Hochholzer L, Moran CA, Frizzera G. Pulmonary plasmacytomas: a clinicopathologic and immunohistochemical study of five cases. Ann Diagn Pathol. 1998;2:1–11[Medline]
  2. Kennedy JY, Kneafsey DY. Two cases of plasmacytoma of the lower respiratory tract. Thorax. 1959;14:353–355
  3. Okada S, Ohtsuki H, Midorikawa O, Hosimoto K. Bronchial plasmacytoma identified by immunoperoxidase technique on paraffin embedded section. Acta Pathol Jpn. 1982;32:149–155[Medline]
  4. Brackett LE, Myers JR, Sherman CB. Laser treatment of endobronchial extramedullary plasmacytoma. Chest. 1994;106:1276–1277[Abstract/Free Full Text]
  5. Piard F, Yaziji N, Jarry O, et al. Solitary plasmacytoma of the lung with light chain extracellular deposits: a case report and review of the literature. Histopathology. 1998;32:356–361[Medline]
  6. Batsakis JG, Medeiros JL, Luna MA, El-Naggar AK. Plasma cell dyscrasia of the head and neck. Ann Diagn Pathol. 2002;6:129–140[Medline]
  7. Kintzer JS, Rosenow EC, Kyle RA. Thoracic and pulmonary abnormalities in multiple myeloma: a review of 958 cases. Arch Intern Med. 1978;138:727–730[Abstract/Free Full Text]
  8. Meis JM, Butler JJ, Osborne BM, Ordonez NG. Solitary plasmacytomas of the bone and extramedullary plasmacytomas: a clinicopathologic and immunohistochemical study. Cancer. 1987;59:1475–1485[Medline]



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This Article
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Joseph I. Miller, Jr
Kamal A. Mansour
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Right arrow Trachea and bronchi

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