Ann Thorac Surg 2009;87:e25-e26. doi:10.1016/j.athoracsur.2008.11.066
© 2009 The Society of Thoracic Surgeons
Case Reports
A Rare Case of Solitary Plasmacytoma Mimicking a Primary Lung Tumor
Kazimierz Go
dziuk, MD, PhD,
Mariusz K
dra, MD,
Pawe
Rybojad, MD, PhD,
Dariusz Sagan, MD, PhD*
Department of Thoracic Surgery, Medical University of Lublin, Lublin, Poland
Accepted for publication November 24, 2008.
* Address correspondence to Dr Sagan, Department of Thoracic Surgery, Medical University of Lublin, SPSK4, Jaczewskiego 8, Lublin, 20-090, Poland (Email: dariusz.sagan{at}am.lublin.pl).
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Abstract
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Extramedullary plasmacytomas, especially located in the thorax, are very rare. We present a 31-year-old patient who was diagnosed with a solitary plasmacytoma located in the lung mimicking a primary lung tumor. After several weeks, this developed into multiple myeloma.
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Introduction
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Plasmacytoma is a progressive neoplastic disease characterized by diffuse or localized plasmacytic infiltrations and excessive production of monoclonal antibodies (class immunoglobulin G, A, D, or E) or immunoglobulin free 
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-light chains. Plasmatic cells infiltrations are usually located in flat bones, including the pelvis, vertebral column, ribs, and skull. Extraosseous location is extremely rare, and may affect any organ. Patients may present with vague bone pains, renal failure with proteinuria, and recurrent bacterial infections, often as a type of pneumonia. Patients may have hypercalcemia, normochromic anemia, and elevated erythrocyte sedimentation rate. The roentgenogram examination reveals characteristic osteolytic lesions located in the tabular bones. In addition, M-band peak may be observed in serum protein electrophoresis. Only 25 histologically confirmed reports of pulmonary plasmacytoma have been published thus far.
A 31-year-old man was admitted to the Thoracic Surgery Department of the Medical University of Lublin with a solitary pulmonary lesion suspected of being a primary lung cancer (Figs 1 and 2).
In the preceding 4 months, the patient had recurrent respiratory infections, including an episode of severe pneumonia. The admission chest roentgenogram showed a 4-cm-diameter perihilar tumor located in the left lung and a small amount of fluid in the right pleural cavity. Bronchoscopy showed a concentric cone-shaped stricture of the left upper lobe bronchus. A bronchoscopic biopsy specimen collected from the site did not confirm malignancy. Because of persisting fluid in the right pleural cavity, antibiotics and anti-inflammatory treatment were administered, which reduced the symptoms within several days.
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Fig 2. Computed tomography scan confirmed the presence of a 4-cm-diameter perihilar tumor located in the left lung and a small amount of fluid in the right pleural cavity.
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A left thoracotomy was undertaken to establish the diagnosis. The surgeon confirmed the presence of a tumor in the upper lobe infiltrating segmental bronchi S1 to S3 and the hilus of the lung. The frozen section of tumor specimens revealed plasmacytoma. A left upper lobectomy was performed.
Antibiotic therapy was maintained in the postoperative period because of transient episodes of fever. A postoperative sternal bone marrow biopsy specimen showed no abnormalities. After recovery, the patient was discharged from the hospital with no signs of prior disease.
Urine analysis several weeks later detected the Bence-Jones protein, and analysis of specimens from repeated bone marrow biopsies revealed plasmacytic infiltrations. Multiple myeloma was diagnosed, and the patient was admitted to the Department of Hematology, where after CD34+ plasma cell mobilization, he received a chemotherapy with vincristine, Adriamycin (Pharmacia and Upjohn, New York, NY), and dexamethasone. Consequently, he underwent an autologous peripheral blood stem cell transplant.
After 14 months of follow-up, a contrast-enhanced computed tomography scan detected a mass (26 x 19 mm) located in the epiphrenic region of the right lung (Fig 3). The patient was readmitted, and the lesion was removed by a wedge resection. Histopathologic examination of the specimen identified clusters of plasmatic cells, which were not malignant and therefore could not be considered as a recurrence. After the 30-month period of follow-up, the patient has remained relapse-free.
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Fig 3. After 14 months, computed tomography showed a 26- x 19-mm tumor in the epiphrenic region of the right lung.
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Comment
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Extramedullary existence of plasmacytoma is rare, and is observed in only 5% of all patients with plasmacytoma [1, 2]. The incidence of thoracic cases is low [3]. If endobronchial, most are in the upper airway [4], and lower airway involvement is rare. Plasmacytoma infiltrations may also develop in the chest wall [5] or skin [6] in the form of solitary or multiple lesions. Plasmacytic infiltrations may involve mediastinal lymph nodes [2, 7] that present as a mediastinal tumor, or in the parenchyma of the lung as a diffuse interstitial infiltrate [7–9].
Plasmacytoma as a solid pulmonary tumor, as reported in this patient, is rare, with only 25 reports described [2, 4]. In reported cases, the pulmonary mass was usually accompanied by intrabronchial infiltrations. Endoscopic biopsy specimens mostly failed to reveal the histopathologic diagnosis. In about half of the plasmacytoma cases, monoclonal immunoglobulins are detected in the blood plasma. Transthoracic percutaneous fine needle biopsy of the pulmonary lesion fails to detect plasmacytoma in most patients [6, 7]. About 40% of the previously reported cases of pulmonary plasmacytoma ultimately developed into multiple myeloma [4]. Several weeks after discharge, repeated tests of our patient (bone marrow biopsy, urine analysis) revealed the development of multiple myeloma.
The clinical experience of most authors is that anatomic pulmonary resection is the best treatment of pulmonary plasmacytoma and is performed in 91% of reported cases [2]. In 25% it is combined with chemotherapy or radiotherapy and provides good effect. Late results of chemotherapy/radiotherapy alone are significantly worse [6].
Solitary plasmacytoma presenting as a solid pulmonary tumor is rare; therefore, a thorough evaluation should be undertaken to exclude systemic disease. Surgical resection combined with complementary chemotherapy and consecutive autologous bone marrow stem cell transplantation may become a treatment of choice.
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References
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- Etienne G, Grenouillet M, Ghiringhelli C, et al. Plasmocytome pulmonaire: a propos se deux nouvelles observations et revue de la litterature Rev Med Interne 2004;25:591-595.[Medline]
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- Murata K, Ishikawa S, Horie Y, et al. A case of multiple myeloma presenting as giant chest wall tumors with calcification Nihon Kokyuki Gakkai Zasshi 2003;41:846-850.[Medline]
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Abstract
Introduction
