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Unusual Cases in Multiple Myeloma and a Dramatic Response in Metastatic Lung Cancer

CASE 2. Plasma Cell Myeloma Coexisting With Metastatic Breast Carcinoma in the Bone Marrow

European Institute of Oncology, and the University of Milan, School of Medicine, Milan, Italy

A 43-year-old woman underwent left mastectomy with axillary, supraclavicular, and thoracic wall radiotherapy for a T1bNxMx invasive ductal and lobular carcinoma in 1982. In 1995, she had a hysterectomy and bilateral salpingo-oophorectomy for a uterine leiomyoma. In January 2003, routine laboratory tests revealed an immunoglobin (Ig) G M component of 5.5 g/dL with urine positive for Bence-Jones protein, elevated levels of CA15.3 (97 U) and anemia (Hb, 8 mg/dL). She underwent a bone marrow biopsy that revealed a nodular intertrabecular and interstitial proliferation of plasma cells intermingled with larger cells with abundant pale cytoplasm and convoluted nuclei (Fig 1A). Immunophenotyping revealed IgG monoclonality in the plasma cells, and immunoreactivity (IR) for cytokeratins AE1/AE3 in the larger atypical cells, which also expressed high levels (90%) of estrogen receptors (Fig 1B: IR for immunoglobulin light chains [blue] in the neoplastic plasma cells, and simultaneous cytoplasmic IR for cytokeratins [red] and nuclear immunoreactivity for estrogen receptor [brown] in the larger metastatic breast cancer cells) in the absence of progesterone receptor and Her-2 immunoreactivity. The hematopoietic lineages were hypoplasic (20% of the bone marrow cellularity), with mild erythrodysplasia. A plasma cell myeloma (PCM, Bartl's grade 2 and stage II)¹ coexistent with metastatic carcinoma, and highly suggestive for a mammary origin, was diagnosed. Because chest x-rays, bone scan, and ultrasonography showed asymptomatic osteolytic pelvic, bilateral humeral, and rib lesions (Fig 2; arrow) in the absence of thoracic and abdominal metastases, the PCM was staged as IIIA. The patient was then treated with four cycles of vincristine, adriamycin, and dexamethasone and intravenous bisphosphonates. Furthermore, for peripheral-blood stem-cell (PBSC) mobilization, she also received high-dose cyclophosphamide, obtaining a harvest of 4.67 x 10⁹ CD34+/kg, which was cryopreserved. Following these therapies, the M component and bone marrow plasma cell infiltration decreased (from 5.5 g/dL to 2.49 g/dL and from 50% to 27% of bone marrow cellularity, respectively), whereas the CA15.3 serum levels and the metastatic breast tumor burden in the bone marrow remained unchanged. The patient then received a combined modality regimen containing letrozole and vincristine, melphalan, cyclophosphamide, and methylprednisolone.

View larger version (72K): [in this window] [in a new window]   Fig 1.

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Authors' Disclosures of Potential Conflicts of Interest

The authors indicated no potential conflicts of interest.

REFERENCES

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2. Curtis RE, Boice JD Jr, Stovall M, et al: Risk of leukemia after chemotherapy and radiation treatment for breast cancer. N Engl J Med 326:1745-1751, 1992[Abstract]

3. Levi F, Te VC, Randimbison L, et al: Cancer risk in women with previous breast cancer. Ann Oncol 14:71-73, 2003[Abstract/Free Full Text]

4. Steinfeld AD, Shore RE: Second malignancies following radiotherapy for testicular seminoma. Clin Oncol (R Coll Radiol) 2:273-276, 1990

5. Boice JD Jr, Day NE, Andersen A, et al: Second cancers following radiation treatment for cervical cancer: An international collaboration among cancer registries. J Natl Cancer Inst 74:955-975, 1985

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This Article Full Text (PDF) Purchase Article View Shopping Cart Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Save to my personal folders Download to citation manager Rights & Permissions Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Pruneri, G. Articles by Viale, G. Search for Related Content PubMed PubMed Citation Articles by Pruneri, G. Articles by Viale, G. Social Bookmarking                            What's this?