Multiple myeloma

Case contributed by Dr Ammar Ashraf

Presentation

Backache and chest wall pain for 6 months. There is also a history of 5 kg weight loss in the last 6 months. No history of trauma, or fever. Past history of PTCA for coronary artery disease and sleeve gastrectomy.

Patient Data

Age: 65 years
Gender: Male
X-ray

Chest

A well-defined opacity is seen in the peripheral right hemithorax. It has positive incomplete border sign and extrapleural sign, which are suggestive of extra-pulmonary pathology (pleural or extra-pleural). Erosions of the inferior border of right 6th as well as the posterior aspect of the right 7th ribs (bony involvement) are seen. The heart is mildly enlarged. The lungs are clear. Dorsal spondylosis.

CT

Chest

Findings: Multiple variable-sized lytic lesions are seen in the whole visualized bony skeleton. A soft tissue component is seen along with a few rib lesions, with the largest component seen along the right 4th rib. Multiple mildly enlarged mediastinal lymph nodes are seen. Enlarged thyroid gland with retrosternal extension and a few small nodules in both lobes. No pleural/pericardial effusion, pneumothorax/pneumomediastinum, or suspicious pulmonary nodule/mass is seen.

Conclusion: Multiple lytic lesions involving the visualized bony skeleton. Prime diagnostic consideration is multiple myeloma; another possibility can be bone metastases.

CT

Abdomen

Findings: Multiple variable-sized lytic lesions are seen in the whole visualized bony skeleton. Mildly enlarged liver with cirrhotic morphology. No obvious focal hepatic lesion is seen. Mild splenomegaly, a few radiopaque gallbladder stones, and a few bilateral small renal cortical cysts are seen. A few lymph nodes, with the largest one measuring 10 mm in short axis are noted at porta hepatis. Surgical staples are seen around the greater curvature of the stomach (past history of sleeve gastrectomy).

Conclusion: Multiple lytic lesions involving the visualized bony skeleton. Prime diagnostic consideration is multiple myeloma; another possibility can be bone metastases.

X-ray

Skull

Multiple variable-sized punched out lytic lesions are seen in the skull vault (raindrop skull).

Case Discussion

  1. Procedure: Ultrasound-guided Tru-cut biopsy of the right upper anterior chest wall mass.

    Diagnosis: Plasma cell neoplasm consistent with multiple myeloma. The immunostains with the antibodies anti-CD138, CD38, CD79a, and MUM-1 are positive. CD20 and EMA are negative. 
  2. Laboratory investigations:
  • Free Kappa=2650.00 mg/L (normal range=3.30-19.40)
  • Free lambda=12.40 mg/L (normal range=5.71-26.30)
  • Free Kappa/Free Lambda Ratio=213.71 (normal range=0.26-1.65 ratio).

 3. Bone marrow biopsy. Consistent with IgG KAPPA restricted multiple myeloma. Approximately 10-15% plasma cells are CD38+, CD138+, IgG K+ on core biopsy immunohistochemical stains; and flow cytometry (0.3%). 

4. Currently, patient is receiving chemotherapy (VRD protocol).

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Case information

rID: 77492
Published: 4th Aug 2020
Last edited: 2nd Aug 2021
Inclusion in quiz mode: Included
Institution: King Abdulaziz Hospital Al Ahsa (MNGHA)