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MR findings of plasmacytoma with calcified amyloid deposition
EUROPEAN JOURNAL OF RADIOLOGY
ELSEVIER
European Journal of Radiology21 (1995) 152-154
MR findings of plasmacytoma with calcified amyloid deposition R a f a e l a Soler*, E s t h e r R o d d g u e z , A l v a r o G a r c i a , R o s a
Fernfindez
l)epartment of Radiology, Hospital Juan Canalejo, Xubias de Arriba, 84, 15006 La Coru~a, Spain
Received4 August 1995;accepted 12 October 1995
Keyword~: Plasmacytoma; Amyloidosis; Calcification; Bone, neoplasms
1. Introduction
Plasmacytoma is a rare variant of multiple myeloma characterized by malignant focal infiltration of plasma cells that usually arises in the persistent red marrow areas. Although amyloid deposition associated with plasma cell dyscrasias is well known, only a few cases of calcified amyloid deposition with plasmacytoma simulating the radio[~raphic findings of chondrosarcoma have been reported [1-4]. We report the MR findings of one case of plasmacytoma with scattered feci of calcification in amyloid deposition simulating chondrosarcoma. To our knowledge, this is the first case of calcified plasmacytoma documented by MR.
and areas of low signal intensity due to foci of mineralization (Fig. 2a). On axial T2-weighted images, the tumor signal was slightly greater than that of fat. After intravenous injection of gadolinium-DTPA on
2. Case report A 64-year-old woman presented with a 5-month history of a painless mass in the fight shoulder. Physical examination revealed a firm painless mass in the right scapula, wilh decreased range of motion about the shoulder joint, laboratory studies were unremarkable except for an Ig G X light chain spike on serum protein electrophoresis. Urinalysis was negative for BenceJones protein. Bone :marrow from iliac crest showed no evidence of increased plasma cells. Plain radiographs disclosed a large round, slightly lobulated mass containing flocculent and dense calcifications, arising from the right scapula (Fig. 1). MR imaging was performed[ using a 0.5 T (Philips, Gyroscan T5). Tl-weighted axial images showed a large lobulated mass of the scapula with intermediate signal intensity * Corresponding author, Tel.: +34 981 187000.
Fig. 1. Plain radiograph of right shoulder showsa large mass with calcifications in the scapula.
0720-048X/95/$09.50 © 1995ElsevierScienceIreland Ltd. All rights reserved SSDI 0720-048X(95)0717-5
R. Soler et al./ European Journal of Radiology 21 (1995) 152-154
a
153
b
Fig. 2. (a) AxialTl-weightedimagesdiscloseda well-definedlobulatedmass arisingfrom right scapula of intermediatesignal intensity(black arrows) mixedwith areas of low signal intensity(white arrows). (b) Tl-weightedimages after administrationof Gd-DTPA at a similar level as in (a) showsdiscreteinhomogeneonsenhancementof the tumor (arrows)with non-enhancingareas of low signal intensitydue to the calcifiedmatrix (asterisks).
axial Tl-weighted images, the tumoral mass showed discrete and inhomogeneous enhancement (Fig. 2b). A bone marrow study with coronal images on spin echo Tl-weighted, T2-weighted and STIR sequences ineluding the spine, bone pelvis and proximal femora was performed and no other areas of neoplastic involvement were identified. Pereutaneous needle biopsy of the scapular lesion revealed amorphous acellular material that stained positive for amyloid with central loci of calcifications. Clusters of mature plasma cells within the calcified amyloid matrix and giant cell reaction at the periphery of the amyloid were also present. The patient was treated with local radiation therapy. 3. Discussion Solitary plasmacytoma is a hematologic malignancy composed of plasma cells. It is the most uncommon form of the various plasma cell tumors, which include extramedullary plasmacytoma, osteosclerotic myeloma, and multiple myeloma [1]. About 75% of patients are between the ages of 50 and 70 years, and the lesion is rare in patients younger than 30 years [5]. Males are affected twice as often as females. Progressive bone pain, soft tissue mass, fever or severe pain are the most common symptoms. The most frequent locations are the vertebrae, pelvis, ribs, skull and scapula, though other bones may be affected [1,3]. Amyloidosis occurs in 10-15% of patients with myeloma. The amyloid fibrils have affinity for calcium, and radiographically detectable calcified amyloid deposits have been described in soft tissues [6]. However, the radiographic demonstra-
tion of calcified amyloid deposition associated with plasmacytoma has been seen in only a few cases and consisted of lyric lesions with soft tissue mass and punctare calcifications simulating a chondrosarcoma [1-4]. The MR findings of myeloma have been described as a non-specific pattern of homogeneous decrease in signal intensity on Tl-weighted images and bright signal intensity on T2-weighted images [7]. Only a few reports have described the MR appearance of amyloid, which typically shows homogeneous or heterogeneous intermediate signal intensity on Tl- and T2-weighted images [8]. Atypical cases of hyperintense signal on T l- and T2weighted images have been reported in amyloid goiter [9]. To our knowledge, no report describing the MR findings of plasmacytoma with calcified amyloid deposition simulating chondrosarcoma has been published. In our case, MR imaging showed a large lobulated mass of intermediate signal intensity on Tl-weighted images and hyperintense signal on T2-weighted images with focus of low signal intensity due to calcifications and inhomogeneous enhancement after gadolinium-DTPA injection. MR imaging has been used to identify the cartilaginous nature of tumors [10] and gadolinium-DTPA to increase the specificity of MR imaging in defining the various components of cartilaginous tumors [11]. A lobulated growth pattern is a well-known characteristic of low grade chondrosarcomas and enchondromas [101. The gadolinium enhanced MR findings of rings and arcs are considered specific for low grade chondrosarcomas and inhomogeneous or homogeneous enhancement patterns have been reported in high grade chondrosarcomas [11]. Our patient shares the morphological
154
R. Soler et al./ European Journal of Radiology 21 (1995) 152-154
findings of low grade chondrosarcomas and the gadolinium-DTPA enhancement characteristics of high grade chondrosarcomas and, based exclusively in the MR and plain radiog~phic findings, a chondrosarcoma could not be excludc~l. In summary, plasmacytoma with calcified amyloid deposition is a rare tu~nor that shares imaging findings with cartilaginous tu~nors. Although the imaging findings of lobulated, enhancing mass with foci of low signal intensity at MR imaging and calcifications on plain radiographs are not specific, the diagnosis of plasmacytoma with calcified amyloid deposition may be suggested in a patient with a high serum monoclonal protein. References [!] Mulder JD, van Rijssei TG. Case report 233. Skeletal Radiol 1983; 10: 53-55. [2] Gabbay S, Bennett RD, Amato J, Cherny El. Controversies in management of ste[nal tumors. Ann Thorac Surg 1989; 48: 428-431. [3] Resnick D, Niwayama G. Plasma cell dyscrasias and dysgammagiobulinemias. Diagnosis of Bone and Joint Disorders. 2nd ed. Philadelphia, PA: Saunders, 1988; 2360-2386.
[4] Reinus WR, Kyriakos M, Gilula LA, Brower AC, Merkel K. Plasma cell tumors with calcified amyloid deposition mistaken for chondrosarenma. Radiology 1993; 189: 505-509. [5] lshida T, Doffman HD. Plasma cell myeioma in unusually young patients: a report of two cases and review of the literature. Skeletal Radiol 1995; 24: 47-51. [6] Urban BA, Fishman EK, Goldman SM, Scott WW, Humphrey RL, Hruban RH. CT evaluation of amylodosis: spectrum of disease. Radiographics 1993; 13: 1295-1308. [7] Libshitz HI, Malthouse SR, Cunnungham D, MacVicar AD, Husband JE. Multiple myeloma: appearance at MR imaging. Radiology 1992; 182: 833-837. [8] Tagiiabue JR, Stull MA, Lack EE, Lloyd RJ, Nelson MC. Amyloid arthropathy of the left ankle. Case report 610. Skeletal Radiol 1990; 19: 448--452. [9] Hatabu H, lida Y, Kasagi K, Yamamoto K, Hidaka A, Tatsumi H, Higuehi K, Komishi J. Amyloid goiter: radiologic findings. AIR 1990; 155: 193-194. [10] Cohen EK, Kressel HY, Frank TS, Falion M, Burk DL, Dalinka MK, Schiebler ML. Hyaline cartilage-origin bone and soft-tissue neoplasms: MR appearance and histoiogic correlation. Radiology 1988; 167: 477--481. [1 I] Geirnaerdt MJA, Bloem JL, Eulderink F, Hogendoorn PCW, Taminiau AHM Cartilaginous tumors: correlation of gadolinium enhanced MR imaging and histopathologic findings. Radiology 1993; 186: 813-817.
ELSEVIER
European Journal of Radiology21 (1995) 152-154
MR findings of plasmacytoma with calcified amyloid deposition R a f a e l a Soler*, E s t h e r R o d d g u e z , A l v a r o G a r c i a , R o s a
Fernfindez
l)epartment of Radiology, Hospital Juan Canalejo, Xubias de Arriba, 84, 15006 La Coru~a, Spain
Received4 August 1995;accepted 12 October 1995
Keyword~: Plasmacytoma; Amyloidosis; Calcification; Bone, neoplasms
1. Introduction
Plasmacytoma is a rare variant of multiple myeloma characterized by malignant focal infiltration of plasma cells that usually arises in the persistent red marrow areas. Although amyloid deposition associated with plasma cell dyscrasias is well known, only a few cases of calcified amyloid deposition with plasmacytoma simulating the radio[~raphic findings of chondrosarcoma have been reported [1-4]. We report the MR findings of one case of plasmacytoma with scattered feci of calcification in amyloid deposition simulating chondrosarcoma. To our knowledge, this is the first case of calcified plasmacytoma documented by MR.
and areas of low signal intensity due to foci of mineralization (Fig. 2a). On axial T2-weighted images, the tumor signal was slightly greater than that of fat. After intravenous injection of gadolinium-DTPA on
2. Case report A 64-year-old woman presented with a 5-month history of a painless mass in the fight shoulder. Physical examination revealed a firm painless mass in the right scapula, wilh decreased range of motion about the shoulder joint, laboratory studies were unremarkable except for an Ig G X light chain spike on serum protein electrophoresis. Urinalysis was negative for BenceJones protein. Bone :marrow from iliac crest showed no evidence of increased plasma cells. Plain radiographs disclosed a large round, slightly lobulated mass containing flocculent and dense calcifications, arising from the right scapula (Fig. 1). MR imaging was performed[ using a 0.5 T (Philips, Gyroscan T5). Tl-weighted axial images showed a large lobulated mass of the scapula with intermediate signal intensity * Corresponding author, Tel.: +34 981 187000.
Fig. 1. Plain radiograph of right shoulder showsa large mass with calcifications in the scapula.
0720-048X/95/$09.50 © 1995ElsevierScienceIreland Ltd. All rights reserved SSDI 0720-048X(95)0717-5
R. Soler et al./ European Journal of Radiology 21 (1995) 152-154
a
153
b
Fig. 2. (a) AxialTl-weightedimagesdiscloseda well-definedlobulatedmass arisingfrom right scapula of intermediatesignal intensity(black arrows) mixedwith areas of low signal intensity(white arrows). (b) Tl-weightedimages after administrationof Gd-DTPA at a similar level as in (a) showsdiscreteinhomogeneonsenhancementof the tumor (arrows)with non-enhancingareas of low signal intensitydue to the calcifiedmatrix (asterisks).
axial Tl-weighted images, the tumoral mass showed discrete and inhomogeneous enhancement (Fig. 2b). A bone marrow study with coronal images on spin echo Tl-weighted, T2-weighted and STIR sequences ineluding the spine, bone pelvis and proximal femora was performed and no other areas of neoplastic involvement were identified. Pereutaneous needle biopsy of the scapular lesion revealed amorphous acellular material that stained positive for amyloid with central loci of calcifications. Clusters of mature plasma cells within the calcified amyloid matrix and giant cell reaction at the periphery of the amyloid were also present. The patient was treated with local radiation therapy. 3. Discussion Solitary plasmacytoma is a hematologic malignancy composed of plasma cells. It is the most uncommon form of the various plasma cell tumors, which include extramedullary plasmacytoma, osteosclerotic myeloma, and multiple myeloma [1]. About 75% of patients are between the ages of 50 and 70 years, and the lesion is rare in patients younger than 30 years [5]. Males are affected twice as often as females. Progressive bone pain, soft tissue mass, fever or severe pain are the most common symptoms. The most frequent locations are the vertebrae, pelvis, ribs, skull and scapula, though other bones may be affected [1,3]. Amyloidosis occurs in 10-15% of patients with myeloma. The amyloid fibrils have affinity for calcium, and radiographically detectable calcified amyloid deposits have been described in soft tissues [6]. However, the radiographic demonstra-
tion of calcified amyloid deposition associated with plasmacytoma has been seen in only a few cases and consisted of lyric lesions with soft tissue mass and punctare calcifications simulating a chondrosarcoma [1-4]. The MR findings of myeloma have been described as a non-specific pattern of homogeneous decrease in signal intensity on Tl-weighted images and bright signal intensity on T2-weighted images [7]. Only a few reports have described the MR appearance of amyloid, which typically shows homogeneous or heterogeneous intermediate signal intensity on Tl- and T2-weighted images [8]. Atypical cases of hyperintense signal on T l- and T2weighted images have been reported in amyloid goiter [9]. To our knowledge, no report describing the MR findings of plasmacytoma with calcified amyloid deposition simulating chondrosarcoma has been published. In our case, MR imaging showed a large lobulated mass of intermediate signal intensity on Tl-weighted images and hyperintense signal on T2-weighted images with focus of low signal intensity due to calcifications and inhomogeneous enhancement after gadolinium-DTPA injection. MR imaging has been used to identify the cartilaginous nature of tumors [10] and gadolinium-DTPA to increase the specificity of MR imaging in defining the various components of cartilaginous tumors [11]. A lobulated growth pattern is a well-known characteristic of low grade chondrosarcomas and enchondromas [101. The gadolinium enhanced MR findings of rings and arcs are considered specific for low grade chondrosarcomas and inhomogeneous or homogeneous enhancement patterns have been reported in high grade chondrosarcomas [11]. Our patient shares the morphological
154
R. Soler et al./ European Journal of Radiology 21 (1995) 152-154
findings of low grade chondrosarcomas and the gadolinium-DTPA enhancement characteristics of high grade chondrosarcomas and, based exclusively in the MR and plain radiog~phic findings, a chondrosarcoma could not be excludc~l. In summary, plasmacytoma with calcified amyloid deposition is a rare tu~nor that shares imaging findings with cartilaginous tu~nors. Although the imaging findings of lobulated, enhancing mass with foci of low signal intensity at MR imaging and calcifications on plain radiographs are not specific, the diagnosis of plasmacytoma with calcified amyloid deposition may be suggested in a patient with a high serum monoclonal protein. References [!] Mulder JD, van Rijssei TG. Case report 233. Skeletal Radiol 1983; 10: 53-55. [2] Gabbay S, Bennett RD, Amato J, Cherny El. Controversies in management of ste[nal tumors. Ann Thorac Surg 1989; 48: 428-431. [3] Resnick D, Niwayama G. Plasma cell dyscrasias and dysgammagiobulinemias. Diagnosis of Bone and Joint Disorders. 2nd ed. Philadelphia, PA: Saunders, 1988; 2360-2386.
[4] Reinus WR, Kyriakos M, Gilula LA, Brower AC, Merkel K. Plasma cell tumors with calcified amyloid deposition mistaken for chondrosarenma. Radiology 1993; 189: 505-509. [5] lshida T, Doffman HD. Plasma cell myeioma in unusually young patients: a report of two cases and review of the literature. Skeletal Radiol 1995; 24: 47-51. [6] Urban BA, Fishman EK, Goldman SM, Scott WW, Humphrey RL, Hruban RH. CT evaluation of amylodosis: spectrum of disease. Radiographics 1993; 13: 1295-1308. [7] Libshitz HI, Malthouse SR, Cunnungham D, MacVicar AD, Husband JE. Multiple myeloma: appearance at MR imaging. Radiology 1992; 182: 833-837. [8] Tagiiabue JR, Stull MA, Lack EE, Lloyd RJ, Nelson MC. Amyloid arthropathy of the left ankle. Case report 610. Skeletal Radiol 1990; 19: 448--452. [9] Hatabu H, lida Y, Kasagi K, Yamamoto K, Hidaka A, Tatsumi H, Higuehi K, Komishi J. Amyloid goiter: radiologic findings. AIR 1990; 155: 193-194. [10] Cohen EK, Kressel HY, Frank TS, Falion M, Burk DL, Dalinka MK, Schiebler ML. Hyaline cartilage-origin bone and soft-tissue neoplasms: MR appearance and histoiogic correlation. Radiology 1988; 167: 477--481. [1 I] Geirnaerdt MJA, Bloem JL, Eulderink F, Hogendoorn PCW, Taminiau AHM Cartilaginous tumors: correlation of gadolinium enhanced MR imaging and histopathologic findings. Radiology 1993; 186: 813-817.