Journal of Clinical Oncology, Vol 21, Issue 17
(September), 2003: 3368-3369
© 2003 American Society for Clinical Oncology
Unusual Locations of Involvement by Malignancies
CASE 1. TESTICULAR PLASMACYTOMA
Atif Shafqat,
Moo-Nahm Yum,
Rafat Abanour,
Kristen N. Ganjoo
Indiana University School of Medicine, Indianapolis, IN
A 52-year-old white male presented to the emergency room with right testicular pain and swelling. He had been diagnosed 2 years earlier with multiple myeloma after he presented with back pain and a compression fracture of the T-8 vertebra. Protein electrophoresis revealed elevated beta globulin with an M-spike of 1.7 gm/dL. Urine immunoelectrophoresis showed a monoclonal-free kappa light chain. Quantitative serum immunoglobulin A level was 1,120 mg/dL. The patient responded well to treatment with four cycles of vincristine, doxorubicin, and dexamethasone chemotherapy and subsequently underwent high-dose chemotherapy with peripheral stem-cell support. He experienced a relapse 3 months before presentation with increasing back pain and increasing immunoglobulin A levels. Spine magnetic resonance imaging revealed a large soft tissue mass in the lumbosacral region with extension into the spinal canal. He was treated with radiation therapy and initiated on prednisone. On the day of admission, he developed acute right testicular pain. There was no preceding history of trauma, fever, chills, urinary symptoms, urethral discharge, or abdominal pain. He was found to have large, firm, tender masses in both testicles, which were confirmed with ultrasound. A computed tomography scan of the abdomen showed bilateral heterogeneous soft tissue masses, with some evidence of necrosis within both testicles. The right testicular mass was 4.9 x 3.7 cm (Fig 1 , arrow), and the left testicular mass was 3.6 x 3.8 cm. The patient underwent an open biopsy of the right testicular mass. Histopathology showed immature and atypical plasma cells infiltrating the interstitial tissue and separating the atrophic tubules with some sertoli cells only (Fig 2). Immunostain with CD138, an antibody directed to syndecan-1, a cell surface proteoglycan present in plasma cell and its precursors, was intensely positive (Fig 3). The patient was treated with external-beam radiotherapy to the testicles with significant resolution of the pain.
This case represents an unusual presentation of a myeloma patient with testicular mass and pain. Extramedullary soft tissue involvement of myeloma is not uncommon in advanced disease. In autopsy studies, 65% to 71% of myeloma patients have shown extraosseous involvement.1,2 Multiple myeloma involving the testicles is, however, quite a rare occurrence. Hayes et al2 found testicular involvement in one of their 38 cases on autopsy. They also reviewed 182 case reports of extramedullary multiple myeloma reported in the literature and found five case reports describing testicular involvement. Gordon et al3 reported two cases, whereas Pasmentier et al1 reported no cases in their series of 57 autopsies. Levin et al4 reviewed 6,000 cases of testicular tumors at the Armed Forces Institute of Pathology. They found only seven reports of myeloma involvement (approximately 0.1%), demonstrating its rarity as a cause of testicular mass. Other cases have also been reported in the literature, which are mostly in the setting of extensive disease.5,6
Treatment experience is limited in the setting of testicular plasmacytoma occurring as a solitary disease site. Reports of treatment with orchiectomy alone, with no recurrence in short-term follow-up, have been noted.5,6 For cases occurring as part of widespread disease, standard chemotherapy for multiple myeloma can be used, in addition to tumoricidal radiation to the testicular masses. In a case such as that of our patient, who presented with advanced disease and prominent pain symptoms, radiation therapy is a good option that can give prompt palliation and local control.
REFERENCES
1. Pasmantier MW, Azar HA: Extraskeletal spread in multiple plasma cell myeloma. Cancer 23:167–174, 1969[Medline]
2. Hayes DW, Bennett WA, Heck FJ: Extramedullary lesion in multiple myeloma: Review of literature and pathologic studies. Arch Pathol 53:262–272, 1952
3. Gordon AJ, Churg JC: Visceral Involvement in Multiple myeloma. N Y State J Med 49:282–283, 1949
4. Levin HS, Mastofi FK: Symptomatic plasmacytoma of the testis. Cancer 25:1193–1203, 1970[Medline]
5. Steinberg D: Plasmacytoma of the Testis. Cancer 36:1470–1472, 1975[Medline]
6. Cavanna L, Fornari F, Civardi G, et al: Extramedullary plasmacytoma of the testicle: Sonographic appearance and ultrasonically guided biopsy. Blut 60:328–330, 1990[Medline]
 CiteULike  Complore  Connotea  Del.icio.us  Digg  Facebook  Reddit  Technorati  Twitter What's this?
|
