Evolution of solitary plasmacytoma of the sternum to multiple

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Rev Esp Med Nucl Imagen Mol. 2013;32(5):328–329
Interesting image
Evolution of solitary plasmacytoma of the sternum to multiple myeloma with
multifocal extramedullary liver involvement. Contribution of 18 F-FDG PET–CT夽
Evolución de un plasmocitoma solitario del esternón a un mieloma múltiple con afectación
extramedular multifocal hepática. Aportación de la 18 F-FDG PET-TAC
J. Banzo a,∗ , L. Palomera b , M.A. Ubieto a , E. Bonafonte b , E.F. Rambalde c , S.M. Ayala c
a
Unidad de Medicina Nuclear, Grupo Hospitalario Quirón La Floresta (Proyecto OTRI [Oficinas de Transferencia de Resultados de Investigación] de Investigación,
Grupo Hospitalario Quirón y Universidad de Zaragoza), Zaragoza, Spain
b
Servicio de Hematología, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
c
Servicio de Medicina Nuclear, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
a r t i c l e
i n f o
Article history:
Received 5 October 2012
Accepted 26 October 2012
Solitary plasmacytoma (SP) is a malignant tumor lesion
characterized by an infiltrate of atypical plasma cells. According to
its localization it may be in either bone or extramedullary.1 There
is no evidence of systemic multiple myeloma (MM) in SP: imaging
techniques show a single lesion, bone marrow biopsy is normal,
<10% of plasma cells, and there is no organic dysfunction related to
the hypercalcemia, anemia, renal failure or lytic bone alterations.
A significant proportion of patients evolve to MM. Extramedullary
disease (ED) may be synchronic with the infiltration of the bone
marrow (BM) or may appear during the course of MM as a
pattern of recurrence. An increase in the incidence of ED has been
observed, probably in relation to the use of PET and MR in the diagnosis and the prolongation of life of patients with the use of new
chemotherapy agents and autotransplantation of BM. Focal or multifocal hepatic ED is rare and is associated with a poor prognosis.2
The evaluation of MM by PET–CT is under debate, and despite
the rise in the number of papers in the last years, it is difficult to
know its diagnostic precision. In a recent metaanalysis, the sensitivity of PET and PET–CT in MM was of 61.1% for intramedullary
involvement and 96% for ED.3 The new Durie–Salmon PLUS staging
Fig. 1. 59-year-old patient with a history of sternal plasmacytoma treated with radiotherapy. Six months later the patient was admitted for somnolence, nausea and pain
in the thoracic column and in the costal ribcage. Physical examination revealed deformity of the manubrium of the sternum and a low level of consciousness. Laboratory
parameters were: Hb: 9.4 g/L, calcemia: 12.6 mg/dL, LDH: 635 U/L, urea: 59 mg/dL and creatinine: 1.6 mg/dL. Distorsion of the lambda chains was observed with a lack of
expression of the heavy chains in serum and important urine elimination of the lambda chains (Bence–Jones protein: 9.2 g/24 h). The study with 18 F-FDG PET–CT demonstrated
a destructive lesion in the manubrium of the sternum which was slightly hypermetabolic (arrows) with an infiltrate of plasma cells shown by biopsy.
夽 Please cite this article as: Banzo J, Palomera L, Ubieto MA, Bonafonte E, Rambalde EF, Ayala SM. Evolución de un plasmocitoma solitario del esternón a un mieloma múltiple
con afectación extramedular multifocal hepática. Aportación de la 18 F-FDG PET-TAC. Rev Esp Med Nucl Imagen Mol. 2013;32:328–9.
∗ Corresponding author.
E-mail address: jbanzoma@unizar.es (J. Banzo).
2253-8089/$ – see front matter © 2012 Elsevier España, S.L. and SEMNIM. All rights reserved.
Documento descargado de http://www.elsevier.es el 18/11/2016. Copia para uso personal, se prohíbe la transmisión de este documento por cualquier medio o formato.
J. Banzo et al. / Rev Esp Med Nucl Imagen Mol. 2013;32(5):328–329
329
Fig. 2. Numerous hypermetabolic lesions in the humerus, costal ribcage, lumbar column, pelvis and femurs corresponding to lytic bone lesions, some with festooned
endosteum or with a soft-tissue mass. Multiple hypermetabolic nodules in the right liver lobe (arrows). The liver biopsy showed aberrant plasma cells of plasmablastic
appearance. With the diagnosis of MM with bone and liver plasmacytomas, treatment with bortezomib–prednisome–melphalan was initiated, showing an improvement in
the symptomatology and reduction of the size of the hepatic lesions and the disappearance of Bence–Jones protein in urine. Four months later the disease progressed with
the appearance of a large tumor in the right ankle and extrapleural masses, widening of the mediastinum, costal fractures and alveolar edema in the chest plaque, followed
by patient death due to multiorgan failure.
system incorporates advanced imaging techniques which include
PET and MR, providing both with complementary information.
The case presented here illustrates the capacity of PET–CT to
diagnose rare multifocal ED in the liver in a patient with sternal SP
evolving to MM (Figs. 1 and 2).
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