Disclaimer: The information contained within the Grand Rounds Archive is intended for use by doctors and other health care professionals. These documents were prepared by resident physicians for presentation and discussion at a conference held at Baylor College of Medicine in Houston, Texas. No guarantees are made with respect to accuracy or timeliness of this material. This material should not be used as a basis for treatment decisions, and is not a substitute for professional consultation and/or peer-reviewed medical literature. Extramedullary Plasmacytoma of the Head and Neck Histony Dalrymple and Henry Bence-Jones, a clinical pathologist, first described the neoplastic proliferation of plasma cells characterized by marked proteinuria and bone pain in 1846. In 1873, Rustizky in Kiev coined the term Multiple Myeloma, after describing the case of a 47-year-old farm servant, who developed a tumor under the skin of his temple which displaced his eye. Autopsy revealed eight additional lesions which originated in the bone marrow. Schridde in 1905 was the first person to describe an extramedullary plasmacytoma, and Ewing and Foote in 1952 were the first to present a large series of cases. Plasma Cells Plasma cells are terminally-differentiated B lymphocytes which are typically found in the red pulp of the spleen, medulla of the lymph nodes, tonsils, lamina propria of the entire gastrointestinal tract, mucosa of the nose and upper airway, and sites of inflammation. Plasma cells are characterized by basophilic cytoplasm with an eccentrically placed nucleus. They range in size from 14 to 20 micrometers. Plasma cells main function is to produce immunoglobulins or antibodies. Immunolobulins Immunoglobulins molecules are composed of two heavy chains and two light chains. Each molecule is composed of only one type of heavy chain and one type of light chain. Approximately 110 amino acid residues on the amino terminal ends of each heavy and light chain constitute the variable region and determine the 'idiotype' or unique antigen binding ability of each antibody. The remainder of each molecule is not involved in antigen recognition and is called the constant region and is identical to other immunoglobulin molecules of the same class, subclass, and allotype. There are two distinct types of light chains kappa and lambda. In serum, two-thirds are kappa and one-third are lambda. Each are composed of between 210-220 amino acids and have a constant and variable portion. They are catabolized by the kidney. There are five types of heavy chains alpha, delta, gamma, mu, and epsilon which correspond the classes of antibodies IgA, IgD, IgG, IgM, and IgE. IgA occurs as monomers and dimers and is the most common antibody in secretions and protects the mucous membranes. IgD is found in trace concentrations in the serum and acts a cell surface receptor on many B cells. Its function is unknown. IgG is made up of 4 subclasses and is the major serum immunoglobulin. Most IgG subclasses activate the classical complement pathway. IgG can act as an opsonin by cross binding antigen to Fc receptors on neutrophils and macrophages and can sensitize target cells. IgM exists as a pentamer, efficiently fixes complement, and is the first class to be produced during development. IgE binds to the Fc receptors on mast cells and basophils. IgE-antigen results in degranulation and release of pharmacological mediators. As we are all well aware, IgE is the principal antibody in Type I hypersensitivity reactions. Plasma Cell Disorders Plasma cell neoplasms are a group of clinical disorders characterized by monoclonal expansion of plasma cells that elaborate a single, homogenous immunoglobulin molecule or fragment. These cells secrete immunoglobulin, and if present in a sufficient quantity, they may be detected in a patient's serum and urine using electrophoresis and are typically referred to as paraproteins, M proteins, or myeloma proteins. Monoclonal light chains which appear in the urine are known as Bence-Jones proteins. The clinical manifestations of the plasma cell disorders are directly related to the expansion of these neoplastic cells, the secretion of immunoglobulin molecules or subunits, and the host's response. In order to understand the importance of recognizing extramedullary plasmacytoma of the head and neck, we have begin by discussing the most common of all plasma cell neoplasms. Mutliple Myeloma Multiple myeloma is a systemic malignancy of plasma cells which is highly treatable but rarely curable. Multiple myeloma represents 1% of all malignancies and is reported to have an incidence of three per one hundred thousand per year. Multiple myeloma has a slight male to female predominance, typically occurs in patients from sixty to seventy-five years old. Patients with multiple myeloma typically present with bone pain which is precipitated by movement. Bone lesions occur in 70% of patients and usually involve the hematopoetic bones in the axial skeleton such as the skull, spine, and pelvis but may occur in the mandible in up to 30% of patients. They typically appear "punched out" as in this skull radiograph. These lesions are purely osteolytic and can result in acute and chronic hypercalcemia. Patients may also develop pathologic fractures. Patients with multiple myeloma are also susceptible to bacterial infections, most commonly pneumonia and pyelonephritis caused by streptococcus pneumonia, staphylococcus aureus, klebsiella pneumonia, escheria coli, and other gram negative organisms. These infections are typically recurrent. Renal failure is also a common feature caused by hypercalcemia, and tubular damage associated with the overexcretion of light chains. Normochromic, normocytic anemia occurs in up to 80% of patients is and related to the replacement of bone marrow cells by expanding tumor and possibly by the elaboration of factors which inhibit hematopoesis. Anemia, hypercalcemia, and renal failure all may lead to weakness and fatigue. The classic triad in the diagnosis of multiple myeloma is detection of serum or urine monoclonal or M protein, greater than 10% plasmacytosis on bone marrow examination, and the presence of lytic bone lesions on x-ray. Treatment of multiple myeloma depends on the stage of the disease and patients symptoms. A commonly employed staging system is based on hemoglobin levels, calcium levels, bone structure, renal function, paraprotein production, and myeloma cell mass. Asymptomatic patients may be carefully observed with serial evaluation of serum calcium and creatinine, skeletal x-rays, hematologic parameters, and serum and urine M-protein levels. Symptomatic patients are typically treated with chemotherapy. The standard treatment includes the use of an akylating agent, most commonly Melphalan, combined with prednisone. Several other regimens of combination chemotherapy have been described in the literature and appear to produce similar outcomes. Treatment with high-dose chemotherapy with subsequent bone marrow transplantation, and the use of biologic response modifiers are all currently under evaluation in clinical trials. Symptomatic bony lytic lesions and lytic lesions of the spine can be irradiated and this is particularly useful in patients with CT or MRI evidence of spinal cord compression. Prior to the introduction of chemotherapy the median survival of patients diagnosis with multiple myeloma was 6 to 9 months, with chemotherapy the mean survival has been extended to 40 to 46 months in stage one disease and 24-30 months in stage three disease. Due to the poor prognosis associated with multiple myeloma, it is important for the otolaryngologist to be aware of its manifestations, so that the appropriate diagnosis is not delayed, and so that other disorders, such as extramedullary plasmacytoma can be differentiated. Otolaryngologic Manifestations Otolaryngologic manifestations of multiple myeloma according to Creston in 1978 include: Amyloidosis, involvement of the mandible and maxilla, epistaxis and the presence of solitary lesions in the head and neck. Amyloidosis occurs in approximately 15% of patients with multiple myeloma and has been found to involve skeletal muscle and the GI tract from tongue to rectum. The most common areas affected in the head and neck include the skin, the larynx leading to hoarseness, and the tongue and esophagus leading to dysphagia. Approximately 30% of patients are reported to have lytic lesions of the mandible and/or maxilla, with mandibular lesions more common. Frequently, multiple lesions are present. Epistaxis and postoperative bleeding have also been reported in multiple myeloma patients, and may be caused by inhibiting proteins produced by the tumor cells, or in the case of epistaxis, from ulceration and infection of an isolated lesion. Solitary lesions including solitary plasmacytoma of bone, and extramedullary plasmacytoma have also been reported in the head and neck, and will be the focus of the rest of this talk. Amyloidosis, lytic lesions of the mandible and maxilla, epistaxis, postoperative bleeding, and solitary lesions of the head and neck have all been reported as presenting symptoms of multiple myeloma, and all warrant a high index of suspicion, further evaluation, and close follow-up. Plasma Cell Disorders of the Head and Neck Batasakis, in 1983, described the interrelationships between the different neoplastic plasma cell disorders presenting in the head and neck. Progenitor cells located in the bone marrow differentiate into bone marrow plasma cells which are the cells of origin for multiple myeloma, and solitary plasmacytoma of bone. It is generally accepted in the literature that solitary plasmacytoma of bone is an early manifestation of multiple myeloma and will eventually become disseminated multiple myeloma. Extramedullary progenitor cells differentiate into submucosal plasma cells which are the origin of extramedullary plasmacytomas. Extramedullary plasmacytomas may remain localized or become disseminated which Batsakis states is a distinct disorder from Multiple Myeloma since it has a different dissemination pattern and a better prognosis. Finally, he recognizes that extramedullary plasmacytoma may become multiple myeloma. The distinction between multiple myeloma, and extramedullary plasmacytoma has been debated in the literature for many years. Plasma Cell Granuloms Plasma cell granuloma is another plasma cell lesion which merits discussion because it is typically found in the oral cavity. This lesion is not a neoplastic process, nor is it associated with a monoclonal expansion of a single plasma cell, instead this is a reactive, inflammatory lesion which usually involves the gingiva. Maxillary and mandibular gingiva are equally involved. Bone loss may occur. These lesions have no sex predilection, and may occur at any age. They are microscopically characterized by a vascular stroma with reactive inflammatory cells, including but not limited to plasma cells. No cytologic abonormalities are usually present. Russell bodies, which are intracytoplasmic eosinophilic hyaline droplets, may be present. Treatment of this condition is frequently unsuccessful, and may include excision, cryotherapy, or radiation. Solitary Plasmacytoma of the Bone Solitary plasmacytoma of bone is a plasma cell neoplasm that presents as a solitary lytic lesion of bone with no evidence of disseminated multiple myeloma. Patients are typically male and the median age of presentation is approximately, one decade earlier than the presenting age of multiple myeloma. Patients present with bone pain or neurologic dysfunction caused by spinal cord or nerve root compression by the tumor mass. Solitary plasmacytoma of bone rarely occurs in the head and neck, but when it does it has a predilection for the molar and premolar areas. It more commonly occurs in the spine, pelvis, and femur. Radiographically the lesions appear as large multicystic area of rarefaction or a 'soapbubble' appearance compared with the small, sharply, demarcated, destructive lesions of multiple myeloma. Treatment is radiotherapy, Mendenhall et al in 1980 recommended at least 4000 rads, and noted a decrease in local failures from 31% to 6% when comparing to patients who received lower doses. Surgery is reserved for patients who have developed a functional disability as a result of the lesion. These patients are always at risk to develop multiple myeloma and dissemination usually occurs 3-5 years after primary diagnosis. Survival is reported to be on the order of 114 months unless multiple myeloma develops than it is less than 30 months. Patients may have paraproteins present in their urine or serum at the time of presentation, but should disappear with treatment. Persistence indicates residual tumor or dissemination and warrants further evaluation. Extramedullary Plasmacytomas Extramedullary plasmacytomas are localized plasma cell neoplasms which arise within the soft tissues, by definition they cannot arise within bone. They represent less than 1% of all head and neck neoplasms according to Fu, et al in 1978. In Knowling, et al's series of 822 patients with plasma cell neoplasms, 94% had multiple myeloma, 3% had solitary plasmacytoma of bone, and 3% had extramedullary plasmacytomas. These lesions are important for otolaryngologists to recognize since, according to Wiltshaw in 1976, 80% of extramedullary plasmacytomas occur in the head and neck and 10-20% of cases may present with multiple lesions. Extramedullary plasmacytoma affects men 3-4 times more often in women and typically occurs in the 6th to 7th decade with over 95% of cases occurring in patients above 40 years of age. The etiology of the extramedullary plasmacytoma is unknown. Proposed risk factors include chronic antigenic stimulation such as osteomyelitis, cholecystitis, rheumatoid arthritis, bacterial flora. Plasmacytoma formation has been demonstrated in laboratory mice treated with salmonella flagellar antigen and with bovine serum albumin. Genetic factors, radiation exposure, smoking, and occupational exposures have also been implicated in the myeloma literature as possible etiologic agents. The most common location for extramedullary plasmacytoma is the nasopharynx and paranasal sinus, representing nearly 4% of all nonepithelial tumors of the nasal cavity, nasopharynx, and paranasal sinuses according to Fu, et al in 1978. In Wax, et als 1993 review of the AFIP Otolaryngologic Tumor Registry, 75% of extramedullary plasmacytomas occurred in sinonasal/nasopharyngeal area, 12% in the oropharynx, 8% in the larynx, other sites in the head and neck that have been reported include tongue, minor salivary glands, thyroid, parotid, orbit, temporal bone. Outside of the head and neck, extramedullary plasmacytoma has been reported in the pleura, mediastinum, spermatic cord, ovary, intestines, kidney, pancreas, breast, and skin. Most of the symptoms related to extramedullary plasmacytoma can be related to their specific location in the head and neck. In Kapadia et al's series of 20 patients of extramedullary plasmacytoma of the head and neck 80% of patients presented with the complaint of a mass or swelling, 35% of patients complained of airway obstruction, 35% complained of epistaxis, 20% of localized pain, 15% with proptosis, 10% with nasal discharge, 10% with regional lymphadenopathy, and 5% with a VI nerve palsy. Other presentations reported in the literature include the Collet-Sicard variant of the jugular foramen syndrome, bilateral maxillary sinus involvement, and a midline forehead swelling, reminiscent of a pott's puffy tumor, from a frontal sinus lesion. Physical examination usually reveals a pedunculated or slightly raised submucosal dark-red to grayish-red swelling which bleeds easily with manipulation. The mucosa is typically intact by ulceration and necrosis may occur in advanced cases. Cervical lymph node metastasis is reported to occur in 12-26% of cases at initial presentation. Biopsy of the lesion is the first step in confirming the diagnosis. Deep biopsies must be taken since the tumor is submucosal and the mucosa may be thickened from an inflammatory reaction. Microscopically, extramedullary plasmacytomas appear as a monocellular proliferation of plasma cells set in a sparse matrix. Nuclear and cellular atypia may be minimal or prominent. The plasma cells have round eccentric nuclei with dense nuclear chromatin clumps arranged along the nuclear membrane in a cartwheel fashion. Cytoplasm is abundant, slightly basophilic, and a perinuclear halo typically appears and corresponds to the Golgi apparatus. Plasmacytic, plasmablastic, and anaplastic subtypes have been described, but Batsakis states that histologic appearance is not a reliable indicator of biologic activity. Local amyloid deposits have been found in 11-38% of cases, systemic amyloidosis is very rare. Using immunohistochemical techniques, a monoclonal staining patterning demonstrating either one heavy chain class, one light chain type, or both can be demonstrated, as found in multiple myeloma and other B cell neoplasms. Extramedullary plasmacytoma should be clearly distinguished from reactive plasma cell infiltrates with polyclonal staining patterns and proliferation of other cell types which do not manifest cytoplasmic immunoglobulins. It is important to note that FNA usually can not provide adequate tissue for immunohistochemistry, making diagnosis difficult. FNA can be used to differentiate from squamous cell carcinoma or may be diagnostic in local or regional recurrences. Histopathologic examination can not distinguish multiple myeloma from an extramedullary plasmacytoma, further evaluation is necessary to exclude the presence of systemic disease and confirm the diagnosis of extramedullary plasmacytoma. In Abemayor, et als 1988 review of plasma cell disorders, they recommend a complete blood count with white blood cell count and platelet count, bone marrow biopsy, serum biochemistry including calcium, blood urea nitrogen, creatinine, uric acid, serum protein, serum and urine electophoresis, and a skeletal survey to rule out multiple myeloma. Normal bone marrow examination, absence of lytic bone lesions on skeletal series, and low paraprotein levels are necessary to establish the diagnosis of extramedullary plasmacytoma. High levels of paraprotein in the serum or urine should raise the clinicians suspicion of a disseminated process, since paraprotein levels correlate directly with tumor burden. After a diagnosis is confirmed, extramedullary plasmacytoma can be staged as follows: Stage I is localized and controllable disease, Stage II is local extension or involvement of the lymph nodes, and stage III is disseminated disease. According to Batsakis, the natural history of extramedullary plasmacytoma may be characterized in the following five ways:
Some of the specific sites where extramedullary plasmacytoma may present, require a little bit more discussion. Extramedullary plasmacytomas represent less than 0.2% of laryngeal neoplasms. The majority of patients with laryngeal plasmacytomas present with slowly progressive hoarseness over a period of several months to years. Acute presentations are rare, and are probably related to tumor hemorrhage or infection. Dysphagia, stridor, and pain are late symptoms. In Pahor et als, series of 35 patients in1978, 15 were supraglottic, 10 were glottic and 3 were subglottic in location. The most common sites of occurrence in decreasing order of frequency are epiglottis, vocal cords, false cords, ventricles, then subglottis. Kost recommends radiotherapy with 3000 to 5000 rads over 3 to 5 weeks, and notes no difference in local recurrence or dissemination rates between patients treated with surgery or radiotherapy. Rubin et al in 1990, reported a case of extramedullary plasmacytoma involving the thyroid and reviewed 40 similar cases that appeared in the literature. They found that in contrast to all extramedullary plasmacytomas, there was an equal sex distribution, regional lymphadenopathy was noted in 43% of patients with thyroid lesions and had no effect on prognosis. Serum monoclonal antibodies were noted in 33% of patients with IgG the most common, urine paraprotein was found in 11% of those cases. Thyroid scans revealed a cold nodule in 9/11 patients, and thyroid function tests revealed half of the patients tested to be euthyroid and the other half to be hypothyroid. Bone marrow examination was normal in all patients tested. Interestingly, concurrent chronic lymphocytic thyroiditis, also known as Hashimoto's thyroiditis, was detected in 63% of these patients suggesting an autoimmune association. Treatment consisted of surgery alone in 40% of patients, surgery and external beam radiation in 44%, surgery, external beam radiation and chemotherapy in 14% of patients, and 1 patient with I-131 and external beam radiation. No difference in outcome was noted between groups. 6 of the 40 patients had a local recurrence, and 2 patients developed multiple myeloma 4 years after initial therapy. Less than 20 salivary gland plasmacytomas have been reported in the literature, facial nerve function was not affected in any of the cases. Due to the large variety of salivary pathologies, 5/14 cases in the literature reviewed by Kerr, et al in 1991 had incorrect initial histologic diagnosis and included: sarcoid, undifferentiated carcinoma, and inflammatory lesions. One patient with a parotid extramedullary plasmacytoma reported in the literature also had Sjogren's syndrome. It is uncertain whether the two disorders are related, but it is interesting since the incidence of lymphoma is increased in patients with Sjogren's syndrome. Kerr recommends post-operative radiation therapy, even though parotid and submandibular gland lesions are usually totally removed as excisional biopsies because both patients with recurrences reported in the literature, were treated with surgery alone. Seven cases have been reported in the literature of extramedullary plasmacytoma of the temporal bone. They were all located in the mucosally lined middle ear and mastoid which is in contrast to multiple myeloma which typically involves the petrous apex if the temporal bone is involved. Abemayor et al point out that temporal bone extramedullary plasmacytomas may arise from clonal expansion of local lymphocyte deposits in the middle ear and mastoid mucosa, rather than through hematogenous spread like multiple myeloma. Panosian notes that multiple head and neck extramedullary plasmacytomas were found in 2 of 3 patients with temporal bone extramedullary plasmacytomas reported in the english literature. Kandiloros, et al recommend combined surgery and radiotherapy for mastoid disease. Disseminated Extramedullary Plasmacytoma According to Wiltshaw, 40% of extramedullary plasmacytomas spread beyond the site of presentation and its draining lymph nodes. Of these, 62% had soft tissue and visceral deposits, including skin, liver and subcutaneous tissues and 81% developed lesions in bone. Spread to bone demonstrates no preference for active hematopoetic tissue like myeloma and frequently involves long bones. Multiple myeloma is reported to develop in 17-31% of cases. The prognosis for disseminated extramedullary plasmacytoma is better than multiple myeloma. Treatment The treatment of extramedullary plasmacytoma of the head and neck is controversial. Some authors advocate radiation therapy alone and others advocate surgery alone. Wax, et al in 1993 recommend surgery in cases that are localized and can be removed with minimal morbidity, otherwise they recommend radiotherapy. Surgery or radiation can than be used for salvage in the case of local recurrence. Abemayor, et al in 1988, recommend radiation therapy, with surgery only for diagnostic purposes or to remove residual disease. While it is agreed that extramedullary plasmacytomas are radiosensistive, there is no consensus in the literature about the ideal dose of radiation therapy. Regimens have been described which use anywhere from 3000 to 8000 rads, over periods from 3 to 6 weeks. It is also noted in the literature that the lesions tend to regress slowly. Chemotherapy is used for disseminated disease. Dr. Bergsagel, an oncologist at the University of Toronto, and noted expert on plasma cell disorders, said in 1996, "We still treat localized extramedullary plasmacytomas with irradiation, and include the regional lymph nodes in the field. This therapy will always arrest the growth of the plasmacytoma, but may not cause the tumor to regress and disappear. The reason we do not advocate surgery alone for localized extramedullary plasmacytomas is because they recur so frequently following local resection, and also because it is usually possible to find circulating mononuclear cells (lymphocytes, or plasma cells) marked with surface immunoglobulin carrying the same idiotype as the M-protein, in patients with plasma cell tumors. This treatment is easy, and effective (~70 % are progression-free at the time of death). I must admit, however, that I know of no clinical trial comparing the two approaches to treatment." Results of Therapy Wilthaw in 1976, reviewed the outcome of 32 patients with long term follow-up, and found the local recurrence rate to be 21% for radiotherapy alone, and 20% for surgery alone. The recurrence rate was 46% for patients treated with combined therapy, which probably reflects the fact that more extensive disease was being treated. In her review of the literature, she noted that 35% of patients developed disseminated disease regardless of initial treatment. Patients who developed local recurrences were more likely to develop disseminated disease. Wiltshaw's findings are supported by Rubin, et als 1990 review of 14 series including 219 cases in the literature. They found that 55% of patients treated with radiation therapy alone, and 54% of patients treated with surgery alone had no evidence of disease. Mortality and recurrence were also noted to not be significantly different between the two groups. Patients treated with combined therapy had worse outcomes probably since they had more extensive disease to begin with. Factors associated with poor prognosis in the literature include the presence of bone destruction, large primary tumor, recurrence, and tumors located in the sphenoid, maxillary sinus, orbit, and larynx. Histologic appearance and lymph node involvement are not reported to be of any prognostic significance. According to Kapadia, 17 to 31% of patients diagnosed with extramedullary plasmacytoma will develop multiple myeloma. Because extramedullary plasmacytoma can recur as disseminated multiple myeloma long term follow-up is important. Cases of recurrence have been reported 28 and 36 years after initial treatment in the literature. Median survival of patients with extramedullary plasmacytoma is reported to vary between 4-10 years. Summary Multiple myeloma is the most common plasma cell neoplasm encountered and is a systemic disease associated with a poor prognosis, that may present with head and neck manifestations. Solitary plasmacytoma of bone, presents as a solitary bone lesion, and usually progresses to multiple myeloma within 3-5 years. 80% of extramedullary plasmacytomas occur in the head and neck, and these lesions are associated with the best long term prognosis It is important to recognize the clinical manifestations of plasma cell neoplasms of the head and neck, and perform a full evaluation to rule out systemic disease. All of these patients require life time follow-up to monitor for disease progression, dissemination or recurrence. Case Presentation A 49-year-old male was referred to the Otolaryngology Clinic at the Veterans Affairs Medical Center for evaluation of an asymptomatic mass noted on the right soft palate during a routine physical examination by his primary care physician. The patient's past medical history was only remarkable for a ninety-pack year smoking history and alcohol use. Examination in the clinic revealed a soft tissue mass on the right soft palate adjacent to the uvula. The patient could not tolerate a biopsy under local anesthesia, so he was admitted to the hospital and underwent examination under general anesthesia, direct laryngoscopy, esophagoscopy. A 1.8 cm x 1.2 cm x 1.0 cm soft tissue mass, which arose from the right soft palate between the tonsillar fossa and uvula, was excised. Histopathologic evaluation revealed large sheets of plasma cells with dysplastic features in a sparse matrix. The patient was referred to the Hematology service for further work-up including serum protein electrophoresis, urine protein electrophoresis, and skeletal survey, which were all unremarkable. The patient is currently without evidence of disease seven months postoperatively. 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