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A case of retroperitoneal extramedullary plasmacytoma with multiple metastases
Journal of Clinical Imaging 24 (2000) 365 ± 367
A case of retroperitoneal extramedullary plasmacytoma with multiple metastases Naoto Watanabea,*, Makoto Morijiria, Masashi Shimizua, Kyo Noguchia, Takako Miyazakib, Akiharu Watanabeb, Hikaru Setoa a
Department of Radiology, Toyama Medical and Pharmaceutical University, Sugitani 2630, Toyama 930-0194, Japan b Department of Internal Medicine, Toyama Medical and Pharmaceutical University, Toyama 930-0194, Japan Received 1 June 2000; received in revised form 1 August 2000
Abstract We investigated a patient with extramedullary plasmacytoma in the retroperitoneal space with multiple metastases using abdominal CT scan and 67Ga scintigraphy. Abdominal enhanced CT revealed the retroperitoneal tumor mimicking lymphoma. 67Ga scintigraphy showed multiple tumor localization. We could detect retroperitoneal extramedullary plasmacytoma with multiple metastases using 67Ga scintigraphy. This retroperitoneal tumor may appear similar to lymphoma on CT. D 2001 Elsevier Science Inc. All rights reserved. Keywords: Extramedullary plasmacytoma;
67
Ga scintigraphy; Abdominal CT
1. Introduction
2. Case report
Extramedullary plasmacytoma is an uncommon plasmacell tumor, which may arise in many parts of the body including the skin, lymph nodes, and viscera, but which predominantly occurs in the submucosa of the upper aerodigestive tract [1]. Extramedullary plasmacytoma has been evaluated with CT [2,3]. Extramedullary plasmacytoma in the retroperitoneal space has not been extensively examined using CT. 67 Ga has been attempted for the detection of various malignant tumors including multiple myeloma [4]. However, only limited information is available concerning 67Ga imaging in patients with extramedullary plasmacytoma [5,6]. The purpose of this paper is to report the imaging findings of a patient with extramedullary plasmacytoma in the retroperitoneal space with multiple metastases using CT and 67Ga.
A 49-year-old man had cervical lymph node swelling and abdominal pain. A right arm mass, cervical lymph nodes and abdominal mass were palpable. A skeletal survey revealed no osteolytic lesions. Urinalysis disclosed Bence Jones protein. Bone marrow aspirate contained 5% plasma cells of normal appearance. Extramedullary plasmacytoma was confirmed by biopsy from a cervical lymph node. The main tumor was present in the retroperitoneal space. CT scan revealed multiple neck lymph nodes swelling and a large tumor formation which involved the right kidney, in the right retroperitoneal space. Abdominal enhanced CT showed the abdominal tumor to encase the abdominal aorta creating a ``floating aorta'' appearance and displacing the right renal artery and vein and the inferior vena cava-like lymphoma (Fig. 1). Planar images were obtained at 48 h postinjection of 3 mCi (111 MBq) of 67Ga citrate using a large field-of-view gamma camera (Shimazu, SNC-510R, Japan). Anterior planar imaging revealed tumor uptake in the left neck, right and left supra-clavicular fossae, and right axilla and high tumor uptake in the right arm and right upper abdomen (Fig. 2). This patient died of respiratory and renal failure due to disseminated intravascular coagulation about 1 year after admission. Autopsy was performed. Extramedullary plas-
* Corresponding author. Tel.: +81-76-434-2281; fax: +81-76-4345031. E-mail address: [email protected] (N. Watanabe).
0899-7071/01/$ ± see front matter D 2001 Elsevier Science Inc. All rights reserved. PII: S 0 8 9 9 - 7 0 7 1 ( 0 0 ) 0 0 2 4 7 - 3
366
N. Watanabe et al. / Journal of Clinical Imaging 24 (2000) 365±367
Fig. 1. Abdominal enhanced CT showed ``floating aorta'' and displaced right renal artery and vein and the inferior vena cava similar to lymphoma.
macytoma in the retroperitoneal lymph node with multiple organ invasion including bone marrow was confirmed. 3. Discussion Plasmacytoma is a tumor composed of monoclonal plasma cells arranged in clusters or sheets. It is divided into four categories: (a) multiple myeloma, (b) solitary plasmacytoma of bone, (c) plasma cell leukemia and (d) extramedullary plasmacytoma [7]. The interrelationship of the various plasma-cell tumors including extramedullary plasmacytoma remains unclear. Progression to multiple myeloma varies from 10% to 30% in extramedullary plasmacytoma [1,8]. Specific criteria for the diagnosis of extramedullary plasmacytoma vary [1,8 ± 12]. Corwin and Lindberg [10] required less than 10% plasma cells in the bone marrow, while Knowling et al. [8] required normal bone marrow biopsy for the diagnosis. Soesan et al. [11] have accepted the diagnosis of extramedullary plasmacytoma for those plasma cell tumors, which presented in an extramedullary site and did not arise from bone marrow with breach through the bone cortex. The detection of urinary Bence Johns protein does not necessarily preclude the diagnosis [12]. In our case, plasmacytoma was proven
by biopsy and autopsy. Bone marrow with 5% plasma cells was identified. There is concern that contrast media administered intravenously may be a cause of acute renal failure in myeloma patients. Although the administration of contrast media to myeloma patients is not totally risk-free, it may be performed if the clinical need arises and the patient is wellhydrated [13]. In this patient, enhanced abdominal CT was performed to evaluate the major vascular system. CT findings in many cases of extramedullary plasmacytoma have been reported. CT may demonstrate nonspecific findings of enhancing soft tissue tumors [14 ± 16]. However, to our knowledge, CT findings of extramedullary plasmacytoma arising in the retroperitoneal space have not been described extensively. We showed the abdominal CT findings of ``floating aorta'' and displaced vascular system mimicking lymphoma. The abdominal aorta remains intact, but is circumferentially encased and ventrally displaced by confluent nodal masses. Thus, a ``floating aorta'' appearance was displayed on CT. This case was not distinguishable from lymphoma on CT. Localization of 67Ga citrate in tumor was originally reported by Edwards and Hayes in 1969 [17]. Waxman et al. [4] demonstrated that 67Ga scans were positive in 56% of 18 patients with multiple myeloma. They suggested that
N. Watanabe et al. / Journal of Clinical Imaging 24 (2000) 365±367
367
medullary plasmacytoma with multiple metastases using Ga scintigraphy.
67
References
Fig. 2. 67Ga imaging revealed tumor uptake in the left neck, right and left supra-clavicular fossae, and right axilla, and high tumor uptake in the right arm and right upper abdomen.
67
Ga scintigraphy is less sensitive in the detection of osseous myeloma. Collins et al. [5] described a 67Ga study in which there was increased activity directly adjacent and overlying the liver, as well as in the superior mediastinum in a patient with extramedullary plasmacytoma. Aburano et al. [6] reported a case of Tc-99m DTPA uptake in extramedullary plasmacytoma of the retroperitoneum, although 67Ga did not accumulate there. Therefore, the usefulness of 67Ga imaging in the evaluation of extramedullary plasmacytoma is still not well defined. In our case, 67Ga scintigraphy demonstrated multiple tumor accumulation. We could detect retroperitoneal extra-
[1] Wiltshaw E. The natural history of extramedullary plasmacytoma and its relation to solitary myeloma of bone and myelomatosis. Medicine 1976;55:217 ± 328. [2] Bhimani S, Griffin W, Virapongse C, Altemeyer V, Kier EL. CT findings in a nasopharyngeal extramedullary plasmacytoma. J Comput Assist Tomogr 1983; 7:1081 ± 3. [3] Wax MK, Yun KJ, Omar RA. Extramedullary plasmacytomas of the head and neck. Head Neck Surg 1993;109:877 ± 85. [4] Waxman AD, Siemens JK, Levine AM, Holdorf D, Suzuki R, Singer FR, Bateman J. Radiographic and radionuclide imaging in multiple myeloma: the role of gallium scintigraphy: concise communication. J Nucl Med 1981;22:232 ± 6. [5] Collins MC, Demmi EL, DeLong JF. A retronephric extramedullary plasmacytoma demonstrating avid uptake of Ga-67. Clin Nucl Med 1983;8:179. [6] Aburano T, Yokoyam K, Michigishi T, Tonami N, Hisada K. Tc-99m DTPA uptake in extramedullary plasmacytoma of the retroperitoneum. Clin Nucl Med 1988;13:903 ± 6. [7] Dolin S, Dewar JP. Extramedullary plasmacytoma. Am J Pathol 1956; 32:83 ± 103. [8] Knowling MA, Harwood AR, Bergsagel DE. Comparison of extramedullary plasmacytomas with solitary and multiple plasma cell tumors of bone. J Clin Oncol 1983;1:255 ± 62. [9] Conklin R, Alexanian R. Clinical classification of plasma cell myeloma. Arch Intern Med 1975;135:139 ± 43. [10] Corwin J, Lindberg RD. Solitary plasmacytoma of bone vs. extramedullary plasmacytoma and their relationship to multiple myeloma. Cancer 1979;43:1007 ± 13. [11] Soesan M, Paccagnella A, Chiarion-Sileni V, Salvagno L, Fornasiero A, Sotti G, Zorat PL, Favaretto A, Fiorentino M. Extramedullary plasmacytoma: clinical behaviour and response to treatment. Ann Oncol 1992;3:51 ± 7. [12] Susnerwala SS, Shanks JH, Banerjee SS, Scarffe JH. Extramedullary plasmacytoma of the head and neck region: clinicopathological correlation in 25 cases. Br J Cancer 1997;75:921 ± 7. [13] McCarthy CS, Becker JA. Multiple myeloma and contrast media. Radiology 1992;183:519 ± 21. [14] Kondo M, Hashimoto S, Inuyama Y, Okamoto R, Yamada F. Extramedullary plasmacytoma of the sinonasal cavities: CT evaluation. J Comput Assist Tomogr 1986;10:841 ± 4. [15] Miyazaki T, Kohno S, Sakamoto A, Komori K, Kumagae K, Hara K, Kishikawa M. A rare case of extramedullary plasmacytoma in the mediastinum. Intern Med 1992;31:1363 ± 5. [16] Fukuya T, Yoshimitsu K, Kitagawa S, Masuda K, Ueyama T, Haraguchi Y. Plasmacytoma of the pancreatic head. Gastrointest Radiol 1989;14:226 ± 8. [17] Edwards CL, Hayes RL. Tumor scanning with gallium citrate. J Nucl Med 1969;10:103 ± 5.
A case of retroperitoneal extramedullary plasmacytoma with multiple metastases Naoto Watanabea,*, Makoto Morijiria, Masashi Shimizua, Kyo Noguchia, Takako Miyazakib, Akiharu Watanabeb, Hikaru Setoa a
Department of Radiology, Toyama Medical and Pharmaceutical University, Sugitani 2630, Toyama 930-0194, Japan b Department of Internal Medicine, Toyama Medical and Pharmaceutical University, Toyama 930-0194, Japan Received 1 June 2000; received in revised form 1 August 2000
Abstract We investigated a patient with extramedullary plasmacytoma in the retroperitoneal space with multiple metastases using abdominal CT scan and 67Ga scintigraphy. Abdominal enhanced CT revealed the retroperitoneal tumor mimicking lymphoma. 67Ga scintigraphy showed multiple tumor localization. We could detect retroperitoneal extramedullary plasmacytoma with multiple metastases using 67Ga scintigraphy. This retroperitoneal tumor may appear similar to lymphoma on CT. D 2001 Elsevier Science Inc. All rights reserved. Keywords: Extramedullary plasmacytoma;
67
Ga scintigraphy; Abdominal CT
1. Introduction
2. Case report
Extramedullary plasmacytoma is an uncommon plasmacell tumor, which may arise in many parts of the body including the skin, lymph nodes, and viscera, but which predominantly occurs in the submucosa of the upper aerodigestive tract [1]. Extramedullary plasmacytoma has been evaluated with CT [2,3]. Extramedullary plasmacytoma in the retroperitoneal space has not been extensively examined using CT. 67 Ga has been attempted for the detection of various malignant tumors including multiple myeloma [4]. However, only limited information is available concerning 67Ga imaging in patients with extramedullary plasmacytoma [5,6]. The purpose of this paper is to report the imaging findings of a patient with extramedullary plasmacytoma in the retroperitoneal space with multiple metastases using CT and 67Ga.
A 49-year-old man had cervical lymph node swelling and abdominal pain. A right arm mass, cervical lymph nodes and abdominal mass were palpable. A skeletal survey revealed no osteolytic lesions. Urinalysis disclosed Bence Jones protein. Bone marrow aspirate contained 5% plasma cells of normal appearance. Extramedullary plasmacytoma was confirmed by biopsy from a cervical lymph node. The main tumor was present in the retroperitoneal space. CT scan revealed multiple neck lymph nodes swelling and a large tumor formation which involved the right kidney, in the right retroperitoneal space. Abdominal enhanced CT showed the abdominal tumor to encase the abdominal aorta creating a ``floating aorta'' appearance and displacing the right renal artery and vein and the inferior vena cava-like lymphoma (Fig. 1). Planar images were obtained at 48 h postinjection of 3 mCi (111 MBq) of 67Ga citrate using a large field-of-view gamma camera (Shimazu, SNC-510R, Japan). Anterior planar imaging revealed tumor uptake in the left neck, right and left supra-clavicular fossae, and right axilla and high tumor uptake in the right arm and right upper abdomen (Fig. 2). This patient died of respiratory and renal failure due to disseminated intravascular coagulation about 1 year after admission. Autopsy was performed. Extramedullary plas-
* Corresponding author. Tel.: +81-76-434-2281; fax: +81-76-4345031. E-mail address: [email protected] (N. Watanabe).
0899-7071/01/$ ± see front matter D 2001 Elsevier Science Inc. All rights reserved. PII: S 0 8 9 9 - 7 0 7 1 ( 0 0 ) 0 0 2 4 7 - 3
366
N. Watanabe et al. / Journal of Clinical Imaging 24 (2000) 365±367
Fig. 1. Abdominal enhanced CT showed ``floating aorta'' and displaced right renal artery and vein and the inferior vena cava similar to lymphoma.
macytoma in the retroperitoneal lymph node with multiple organ invasion including bone marrow was confirmed. 3. Discussion Plasmacytoma is a tumor composed of monoclonal plasma cells arranged in clusters or sheets. It is divided into four categories: (a) multiple myeloma, (b) solitary plasmacytoma of bone, (c) plasma cell leukemia and (d) extramedullary plasmacytoma [7]. The interrelationship of the various plasma-cell tumors including extramedullary plasmacytoma remains unclear. Progression to multiple myeloma varies from 10% to 30% in extramedullary plasmacytoma [1,8]. Specific criteria for the diagnosis of extramedullary plasmacytoma vary [1,8 ± 12]. Corwin and Lindberg [10] required less than 10% plasma cells in the bone marrow, while Knowling et al. [8] required normal bone marrow biopsy for the diagnosis. Soesan et al. [11] have accepted the diagnosis of extramedullary plasmacytoma for those plasma cell tumors, which presented in an extramedullary site and did not arise from bone marrow with breach through the bone cortex. The detection of urinary Bence Johns protein does not necessarily preclude the diagnosis [12]. In our case, plasmacytoma was proven
by biopsy and autopsy. Bone marrow with 5% plasma cells was identified. There is concern that contrast media administered intravenously may be a cause of acute renal failure in myeloma patients. Although the administration of contrast media to myeloma patients is not totally risk-free, it may be performed if the clinical need arises and the patient is wellhydrated [13]. In this patient, enhanced abdominal CT was performed to evaluate the major vascular system. CT findings in many cases of extramedullary plasmacytoma have been reported. CT may demonstrate nonspecific findings of enhancing soft tissue tumors [14 ± 16]. However, to our knowledge, CT findings of extramedullary plasmacytoma arising in the retroperitoneal space have not been described extensively. We showed the abdominal CT findings of ``floating aorta'' and displaced vascular system mimicking lymphoma. The abdominal aorta remains intact, but is circumferentially encased and ventrally displaced by confluent nodal masses. Thus, a ``floating aorta'' appearance was displayed on CT. This case was not distinguishable from lymphoma on CT. Localization of 67Ga citrate in tumor was originally reported by Edwards and Hayes in 1969 [17]. Waxman et al. [4] demonstrated that 67Ga scans were positive in 56% of 18 patients with multiple myeloma. They suggested that
N. Watanabe et al. / Journal of Clinical Imaging 24 (2000) 365±367
367
medullary plasmacytoma with multiple metastases using Ga scintigraphy.
67
References
Fig. 2. 67Ga imaging revealed tumor uptake in the left neck, right and left supra-clavicular fossae, and right axilla, and high tumor uptake in the right arm and right upper abdomen.
67
Ga scintigraphy is less sensitive in the detection of osseous myeloma. Collins et al. [5] described a 67Ga study in which there was increased activity directly adjacent and overlying the liver, as well as in the superior mediastinum in a patient with extramedullary plasmacytoma. Aburano et al. [6] reported a case of Tc-99m DTPA uptake in extramedullary plasmacytoma of the retroperitoneum, although 67Ga did not accumulate there. Therefore, the usefulness of 67Ga imaging in the evaluation of extramedullary plasmacytoma is still not well defined. In our case, 67Ga scintigraphy demonstrated multiple tumor accumulation. We could detect retroperitoneal extra-
[1] Wiltshaw E. The natural history of extramedullary plasmacytoma and its relation to solitary myeloma of bone and myelomatosis. Medicine 1976;55:217 ± 328. [2] Bhimani S, Griffin W, Virapongse C, Altemeyer V, Kier EL. CT findings in a nasopharyngeal extramedullary plasmacytoma. J Comput Assist Tomogr 1983; 7:1081 ± 3. [3] Wax MK, Yun KJ, Omar RA. Extramedullary plasmacytomas of the head and neck. Head Neck Surg 1993;109:877 ± 85. [4] Waxman AD, Siemens JK, Levine AM, Holdorf D, Suzuki R, Singer FR, Bateman J. Radiographic and radionuclide imaging in multiple myeloma: the role of gallium scintigraphy: concise communication. J Nucl Med 1981;22:232 ± 6. [5] Collins MC, Demmi EL, DeLong JF. A retronephric extramedullary plasmacytoma demonstrating avid uptake of Ga-67. Clin Nucl Med 1983;8:179. [6] Aburano T, Yokoyam K, Michigishi T, Tonami N, Hisada K. Tc-99m DTPA uptake in extramedullary plasmacytoma of the retroperitoneum. Clin Nucl Med 1988;13:903 ± 6. [7] Dolin S, Dewar JP. Extramedullary plasmacytoma. Am J Pathol 1956; 32:83 ± 103. [8] Knowling MA, Harwood AR, Bergsagel DE. Comparison of extramedullary plasmacytomas with solitary and multiple plasma cell tumors of bone. J Clin Oncol 1983;1:255 ± 62. [9] Conklin R, Alexanian R. Clinical classification of plasma cell myeloma. Arch Intern Med 1975;135:139 ± 43. [10] Corwin J, Lindberg RD. Solitary plasmacytoma of bone vs. extramedullary plasmacytoma and their relationship to multiple myeloma. Cancer 1979;43:1007 ± 13. [11] Soesan M, Paccagnella A, Chiarion-Sileni V, Salvagno L, Fornasiero A, Sotti G, Zorat PL, Favaretto A, Fiorentino M. Extramedullary plasmacytoma: clinical behaviour and response to treatment. Ann Oncol 1992;3:51 ± 7. [12] Susnerwala SS, Shanks JH, Banerjee SS, Scarffe JH. Extramedullary plasmacytoma of the head and neck region: clinicopathological correlation in 25 cases. Br J Cancer 1997;75:921 ± 7. [13] McCarthy CS, Becker JA. Multiple myeloma and contrast media. Radiology 1992;183:519 ± 21. [14] Kondo M, Hashimoto S, Inuyama Y, Okamoto R, Yamada F. Extramedullary plasmacytoma of the sinonasal cavities: CT evaluation. J Comput Assist Tomogr 1986;10:841 ± 4. [15] Miyazaki T, Kohno S, Sakamoto A, Komori K, Kumagae K, Hara K, Kishikawa M. A rare case of extramedullary plasmacytoma in the mediastinum. Intern Med 1992;31:1363 ± 5. [16] Fukuya T, Yoshimitsu K, Kitagawa S, Masuda K, Ueyama T, Haraguchi Y. Plasmacytoma of the pancreatic head. Gastrointest Radiol 1989;14:226 ± 8. [17] Edwards CL, Hayes RL. Tumor scanning with gallium citrate. J Nucl Med 1969;10:103 ± 5.