Plasmacytomas

1. Plasmacytomas By Godfrey Thuku MSIV

2. Outline • Case Presentation • Types of plasma disorders • Radiosurgery treatment

3. Case presentation • 42yr old Hispanic female with a slowly growing right scalp cyst since May 2009 • Symptoms of left arm and fingers tingling, headaches. No systemic signs • Cyst was approx 5cm in circumference, no erythema, tenderness to palpation, no discharge • No history of Trauma to the site • PMH; Hypertension and hypercholesterolemia. PSH; 2 cesarean sections. FMH; Hypertension, stroke, CAD, hypercholestrolemia. SH; Does not smoke or drink. PE; 2 inch diameter lesion on the right scalp. Rest of exam intact • Neuro; Completely neurologically intact.

4. 1st OR visit 2nd OR visit • Aborted excision of scalp cyst • During dissection an irregular contour was noted as well as calcified areas. • High suspicion lesion was not a cyst or lipoma. • Obtained skull x-rays which demonstrated a clear defect in the skull. • Right frontal craniectomy • Stereotatic surgical planning • Resection of tumor attached to dura • Dura resection • Dural reconstruction

10. Plasma cell disorders • Plasma cell granulomas – monoclonal expansion of single plasma cell. Its an inflammatory process • Plasmacytoma – a discrete solitary mass of neoplastic monoclonal plasma cells within in either bone or tissue • Extramedullary plasmacytomas – localized cell neoplasms arising within soft tissues • Solitary bone plasmactyoma – solitary lytic bone lesion • Multiple myeloma – rarely curable systemic malignancy of plasma cells.

11. Clinical features Multiple Myeloma • Median age – 60-75 • Gender – slight male predominance • Bone pain precipitated by movement • High levels of Monoclonal protein

12. Pathology; especially to rule out plasmagranuloma • Lab tests; CBC, Biochemical screen including electrolytes and corrected sodium, serum and urine proteins, immunoglobulin levels, full skeletal survey

13. Treatment Radiotherapy – treatment of choice Recommended dose – 40gy in 20 fractions for SBP of 5cm or less.

14. 63yr old man with Hx of successful stem cell rescue with vertex headaches and hoarseness. • MRI showed a mass in left clivus extending to foramen magnum. • Tumor was unresponsive to dexamethasone for six months • Decision made to treat it as a plasmacytoma • Treated with fractioned cyberknife, 400 cGy for five days

15. Pros No screw-induced numbness Rare cases of pin site cellulitis with AVM’s Potential infections Cons Can be compromised by patient motion esp around the skull base No histologic confirmation of diagnosis • Pt had complete radiographic response within three months • Serial head MRI for 12+ months without neurological toxicity

16. 70yr old female with Hx of infiltrative ductal carcinoma had developed cavernous sinus syndrome (headache, left side numbness and earache, double vision) • Has a solitary mass in left carvenous sinus • Probable metastases from breast, surgery done but pathology revealed a plasmacytoma. Systemic evaluation showed MM • Pt underwent gamma knife radiosurgery followed by chemo.

17. Pros Tumor responded very rapidly to radiation Cons Clinical symptoms never resolved Lack of proper diagnosis work-up

18. Conclusions • Proper diagnostic work-up, including systemic labs • Literature indicates plasmacytomas are very radiosensitive. • Would not hesitate to use radiosugery