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Vol. 75. Núm. 3.
Páginas 357-359 (Julio 2010)
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Vol. 75. Núm. 3.
Páginas 357-359 (Julio 2010)
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Diagnosis of pancreatic plasmacytoma by endoscopic ultrasound-fine needle aspiration
Diagnóstico de un plasmocitoma pancreático mediante biopsia por aguja fina guiada por ultrasonido endoscópico
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ELA Artifona, L. Okawaa, ER. Babaa, EGH Mouraa, P. Sakaia, TJ. Savidesa
a Biliary and Interventional Endoscopy Unit. Ana Costa Hospital, Santos, Brazil. Gastrointestinal Endoscopy Unit. University of S??o Paulo, S??o Paulo, Brazil
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Plasmacytoma presents more frequently in middle age men with aerodigestive tract involvement, especially in the head and the neck. Gastrointestinal tract involvement is uncommon, but the organ most commonly involved is the stomach. We report the first case in the literature in which final diagnosis was made by fine-needle aspiration biopsy guided by endoscopic ultrasound with adequate sample for pathologic analysis. The treatment of this entity is systemic chemotherapy but its effectiveness is limited.Plasmacytoma should be taken into account in differential diagnosis of pancreatic masses.
Keywords:
Plasmocitoma, neoplasias, ultrasonido endoscópico, aspiración con aguja fin, masa pancreática, Brasil
El grupo de pacientes con la mayor incidencia de plasmocitomas está compuesto por hombres de edad media, con involucro del tracto aerodigestivo, especialmente en cabeza y cuello. La afectación del tracto gastrointestinal no es común; el órgano afectado con mayor frecuencia es el estómago. Presentamos en primer caso en la bibliografía en el que el diagnóstico definitivo fue hecho mediante una punción con aguja fina guiada por ultrasonido endoscópico, lo que permitió obtener un adecuado material para el análisis histopatológico. La única posibilidad de tratamiento es la quimioterapia sistémica, pero su efectividad es limitada. El plasmocitoma debe ser considerado en el diagnóstico diferencial de masas pancreáticas de origen desconocido.
Palabras clave:
Plasmacytoma, neoplasms, endoscopic ultra-sound, fine-needle aspiration, pancreatic masses, Brazil
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?? Introduction

The solitary plasmacytoma usually affects the bone tissue, but its extramedullary form, with incidence around 5%, may be related to secondary invasion by multiple myeloma.1 The primary form is extremely rare. We report the first case in the literature of pancreatic plasmacytoma diagnosed by ultrasound-guided fine needle aspiration (EUS- FNA).

?? Case report

Forty-two years-old male patient, with diagnosis of solitary plasmacytoma in the right shoulder since 2002, was treated initially with local radio-therapy with resolution of the lesion. In December 2004, new plasmacytomas in knee and ankle were diagnosed and were treated with radiotherapy and steroids (dexamethasone). Good response was achieved, but in November 2007 a new plasmacytoma in the right thigh was diagnosed, and lambda light chain was detected in the urine. At this time, there were no target organ injuries or bone marrow plasmacytosis, but because of the multiple plasmacytomas systemic treatment was chosen. This treatment was conducted with radiotherapy and chemotherapy (cyclophosphamide, dexamethasone, thalidomide - seven cycles), without response. A new chemotherapy protocol with bortezomib, dexamethasone and thalidomide was started. After completing the second chemotherapy cycle of this protocol, the patient developed cholestatic jaundice and was admitted for investigation. A CT scan of the abdomen showed a large expansive lesion in the head of the pancreas (Figure 1). Patient underwent ERCP to clear the biliary tree and EUS was performed. This study showed hypoechoic and heterogeneous mass in the head of the pancreas. FNA was performed and samples were obtained for pathologic analysis (Figure 2). The cytology report revealed small cell neoplasm with immunohistochemical profile consistent with plasmacytoma producing lambda light chain (Figure 3).

?? Figure 1. CT scan showing a large and expansive lesion in the head of the pancreas.

?? Figure 2. EUS showing hypoechoic and heterogeneus mass in the head of the pancreas.

?? Figure 3. A) cytology (1000x); B) H & E Staining - Paraffin (400x); C) lambda light chain (400x). All sequence of images confirmed the presence of plasma-cytoma.

Chemotherapy protocol was changed to bortezomib, dexamethasone and cyclophosphamide. Four cycles of chemotherapy were administered with partial response. Patient died because infectious complications after the fourth cycle f chemotherapy.

?? Discussion

Extramedullary plasmacytomas are malignant tumors of monoclonal plasma cells. Progression to multiple myeloma is seen in approximately 11 to 30% of cases within 10 years. The group with highest incidence is composed of middle age men with aerodigestive tract involvement, especially in the head and the neck.1 The gastrointestinal tract involvement is uncommon, but the organ most commonly involved is the stomach.2 Rarely, the pancreas is infiltrated by plasmacytes, either as solitary plasmacytoma or extramedullary invasion by multiple myeloma.3-5 The diagnosis is based on the finding of extramedullary monoclonal plasma cells without proliferation of plasmacytes in bone marrow.6

Computed tomography (CT) is the most widely used method for assessing these cases. The most frequent location is the head, but there are reports of diffuse involvement 7 and two plasmacytomas in the same pancreas.8

The CT-guided fine needle aspiration can make the diagnosis.9 Due to the similar cytomorphology of the plasmacytes in relation to neuroendocrine cells, pancreatic extramedullary plasmacytoma can be mistakenly diagnosed as a neuroendocrine tumor. Immunohistochemistry for light chains, associated with neuroendocrine markers, is essential for the differential diagnosis,10 and it was demonstrated in the present case.

EUS showed a hypoechoic, heterogeneous, well defined mass in relation to the normal pancreatic echotexture, easily accessible to puncture, with the well known advantages over CT-guided puncture. This is the first case described in the literature of successful EUS FNA in the diagnosis of plasmacytoma.

Treatment options include surgery, radiotherapy, chemotherapy, and combinations of them.11 Studies indicate that this tumor is highly radiosensitive and chemosensitive.2,12,13 However, as in our case and in other studies,11,14 the prognosis and the chemotherapy sensitivity can be poor and the disease course can be very aggressive.


Correspondence: Everson L. A. Artifon, M.D., Ph.D, F.A.S.G.E. Director, Biliary and Interventional Endoscopy - Ana Costa Hospital; Associate

Professor of Medicine-University of Sao Paulo. Rua Guimaraes Passos, 260 - Apto 121, Vila Mariana, Sao Paulo-SP, Brazil, 01508-010

Phone / Fax: 55-11-3069-6221.

Email: eartifon@hotmail.com

Recibido el 13 de abril de 2010;

aceptado el 23 de abril de 2010.

Bibliography
[1]
Fowel.l, AJ, Polle.r, DN, Ellis RD..
Diffuse luminal ulceration resulting from duodenal plasmacytoma..
, 65 (Gastrointestinal Endosc 2007), pp. 707-708
[2]
Nolan KD, Mone MC, Nelson EW..
Plasma cells neoplasms..
Review of disease progression and report of a new variant, 14 (Surg Oncol 2005), pp. 85-90
[3]
Attwell A, Dee E, Russ P, Nash R, Shah R..
Multiple myeloma involving the porta hepatic and peritoneum causing biliary obstruction and malignant as-cites..
, 50 (Dig Dis Sci 2005), pp. 1068-1071
[4]
Coban S, Koklu S, Ertugrul I, Kuzu I, Bahar K..
Obstructive jaundice in a patient with multiple myeloma..
, 19 (J Gastroenterol Hepatol 2004), pp. 836-838
[5]
Hirata S, Yamaguchi K, Bandai S, Izumo A, Chijiwa K, Tanaka M..
Secondary extramedullar plasmacytoma involving the pancreas..
, 9 (J Hepatobiliary Pancreat Surg 2002), pp. 111-115
[6]
Shapiro M, Kimchi NA, Herbert M, et al..
Gastric plasmacytoma and Helicobacter pylori infection..
, 39 (J Clin Gastroenterol 2005), pp. 1
[7]
Wilson TE, Korobkin M, Francis IR..
Pancrea-tic plasmacytoma: CT findings..
, 152 (AJR 1989), pp. 1227-8
[8]
Olson MC, Kalbhen CL, Posniak HV..
Pancreatic plasmacytoma in a patient with multiple myeloma: CT and ultrasound findings..
, 18 (Abdom Imaging 1993), pp. 323-4
[9]
Hiller N, Goitein O, Ashkenazi YJ..
Plasmacytoma of the pancreas..
, 6 (Isr Med Assoc J 2004), pp. 704-705
[10]
Dodd LG, Evans DB, Symmans F, Katz RL..
Fine-needle aspiration of pancreatic extramedullary plasmacytoma: Possible confusion with islet cell tumor..
, 10 (Diagn Cytopathol 1994), pp. 371-4
[11]
Yoshida T, Soda K, Yamada S, et al..
Biclonal extramedullary plasmacytoma arising in the peritoneal cavity: report of a case..
, 34 (Surg Today 2004), pp. 379-382
[12]
Kadokura M, Tanio N, Nonaka M, et al..
A surgical case of solitary plasmacytoma of rib origin with biclonal gammopathy..
, 30 (Jpn J Clin Oncol 2000), pp. 191-195
[13]
Das-Gupta EP, Sidra GM, Bessell EM, Lush RJ, Byrne JL, Russell NH..
High-dose melphalan followed by radical radiotherapy for the treatment of massive plasmacytoma of the chest wall..
, 32 (Bone Marrow Transplant 2003), pp. 759-761
[14]
Damaj G, Mohty M, Vey N, et al..
Features of extramedullary and extraosseous multiple myeloma: a report of 19 patients from a single center..
, 73 (Eur J Haematol 2004), pp. 402-406
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