Saudi Journal of Kidney Diseases and Transplantation

CASE REPORT
Year
: 2010  |  Volume : 21  |  Issue : 5  |  Page : 931--934

Plasmacytoma of the kidney


Ritesh Mongha1, Srinivas Narayan1, Arindam Dutta1, Sushma Sharma2, Chatterjee Uttara3, Anup Kumar Kundu1,  
1 Department of Urology, Institute of Post-Graduate Medical Education and Research, Kolkata, India
2 Department of General Medicine, Institute of Post-Graduate Medical Education and Research, Kolkata, India
3 Department of Pathology, Institute of Post-Graduate Medical Education and Research, Kolkata, India

Correspondence Address:
Ritesh Mongha
Senior Resident, Department of Urology, IPGMER & SSKM Hospital, Kolkata
India

Abstract

Extramedullary plasmacytoma is a rare malignant neoplasm typically arising outside the bone marrow of patients who show no clinical evidence of multiple myeloma. Kidney is a rare site for plasmacytoma. We present here a case of primary renal plasmacytoma confirmed on histo­pathology of the specimen and immuno-histochemistry studies. Patient was treated with radical nephrectomy followed by radiotherapy. The case is presented due to its rarity.



How to cite this article:
Mongha R, Narayan S, Dutta A, Sharma S, Uttara C, Kundu AK. Plasmacytoma of the kidney.Saudi J Kidney Dis Transpl 2010;21:931-934


How to cite this URL:
Mongha R, Narayan S, Dutta A, Sharma S, Uttara C, Kundu AK. Plasmacytoma of the kidney. Saudi J Kidney Dis Transpl [serial online] 2010 [cited 2021 Apr 23 ];21:931-934
Available from: https://www.sjkdt.org/text.asp?2010/21/5/931/68895


Full Text

 Introduction



Extramedullary plasmacytoma is a very rare malignant neoplasm arising outside the bone marrow. 80-90% of tumors develop in the head and neck area, especially in the aero digestive tract making up to 1% of the tumors of head and neck region. While solitary plasmacytoma of bone is viewed as a localized form of plasma cell neoplasm. [1] They are associated with a much better prognosis than multiple myeloma. [2] We present a case of renal plasmacytoma, a rare pa­thological variety of renal neoplasm. Our case was proved to be a solitary extramedullary, re­nal plasmacytoma following a series of detailed clinical, biochemical, hematological, and radio­logical investigations ruling out other sites of myeloma. Management of renal plasmacytoma is also discussed.

 Case History



A 58 years old male patient presented with three months history of pain right lumbar region. He had no history of hematuria, stone disease, hypertension, diabetes, weight loss or anorexia. Patient had ballotable lump right lumbar region. His Hb% was 12.8 g%, total leukocyte count 7800/mm 3 , differential count: neutrophils 68%, lymphocyte 24%, Eosinophill 5% and basophills 3% . His renal and liver function tests were nor­mal (Urea 28 mg%, Creatinine 1.1 mg%, Total bilirubin 0.8 mg%, ALT 32 IU/L, AST 27 IU/L, Alkaline phosphatase 118 IU/L). Serum Calcium was 9.1 mg% . Chest X-ray was normal. Ultra­sound revealed a mass occupying the lower half of right kidney. Contrast enhanced CT-scan showed a large heterogeneously enhancing mass 9.74 cm Χ 6.92 cm Χ 9.10 cm involving postero-medial aspect of right kidney [Figure 1]. Fat planes with surrounding structures were main­tained and renal vessels were normal. Right ra­dical nephrectomy was done. Post operative pe­riod was uneventful. Histopathology of the resec­ted specimen showed sheets of round monomor­phic cells with vesicular and eccentric nucleus (H & E Χ 250) [Figure 2]. High power view (H & E Χ 400) showed plasma cells with basophilic cytoplasm, eccentric nuclei and typical periphe­ral condensation of the chromatin [Figure 3]. Lymph nodes were free from tumor deposits. The tumor had positive immunostaining for lambda chains, vimentin, and VS38, characte­ristic of plasma cells. It was negative for kappa chains, cytokeratin (CK), MPO, CD45 and CD20.{Figure 1}{Figure 2}{Figure 3}

In view of histopathology report, patient was investigated for other sites of myeloma. Urine Bence Jones proteins were negative, serum elec­trophoresis showed no M-band and bone marrow biopsy was normal. This all proved it to be primary renal plasmacytoma. Adjuvant radia­tion therapy was given in doses of 45 Gy in 25 fractions. Patient at one year follow showed no evidence of recurrence.

 Discussion



Extramedullary plasmacytoma is defined as a solitary tumor composed of monoclonal proli­feration of cells with plasmacytic differentiation in an extramedullary site. Extramedullary plas­macytomas are uncommon tumors, with a worldwide annual incidence of 3 per 100,000 populations. Solitary extramedullary plasma­cytomas account for less than 3-10% of all plasma cell neoplasms. [3] Extramedullary plasma­cytomas are three times more common in male and the median age is 55 years which is around ten years younger than the patients with mul­tiple myeloma. [4],[5],[6] Only few case report of extra medullary plasmacytoma affecting the kidney are published in the literature. [7],[8],[9] The diagnosis of localized plasmacytoma can be made only after detailed clinical, biochemical, hematological, and radiological investigations excluding the possibility of localized presentation of mul­tiple myeloma such as in our case.

Radiological findings in renal plasmacytoma are indistinguishable from those of renal cell carcinoma and tissue biopsy showing monocle­nal plasma cell histology with out any evidence of multiple Myeloma is the only way of diag­nosis. [6] In our case histopathology revealed plas­macytoma, thus immunohistochemical staining was carried out which showed monoclonal im­munoglobulin. It has been reported that failure to stain for CD45 and CD20 is highly charac­teristic for neoplastic plasma cells. [10] VS38 is a newly available monoclonal antibody for detec­ting plasma cell differentiation in routine sec­tions. [11] The neoplastic cells in our case were positive for VS38 and negative for CD45 and CD20. The immunohistochemical study suppor­ted the diagnosis of plasmacytoma. Subsequently bone marrow biopsy, urinary Bence Jones Pro­teins and Serum protein electrophoresis ruled out systemic disease and confirmed the diag­nosis of primary renal plasmacytoma.

Soft tissue plasmacytoma can be classified into 3 clinical stages: Stage I-Limited to an extra­medullary site, Stage II-Involvement of regio­nal lymph nodes, Stage III-Multiple metastasis (although it is no longer a solitary plasmacy­toma). [12] The treatment for extramedullary plas­macytoma is surgery, radiotherapy, or a combi­nation of both. Plasmacytomas are generally very radiosensitive. [1],[2] Combined therapy (sur­gery and radiotherapy) is an accepted treatment depending on the resectability of the lesion. In fact, combination treatment may provide the best results. The optimal dose for local control is 40-50 Gy (depending on tumor size) deli­vered over 4-6 weeks. [1] Chemotherapy is advi­sable for patients who have a generalized extra­medullary plasmacytoma, refractory or relapsed disease. Regimens used for multiple myeloma can be considered. [13]

In solitary extramedullary plasmacytoma the 10-year overall survival rate is 70%. [13] The rate of progression to multiple myeloma is lower than in solitary bone plasmacytoma, ranging from 11-30% at ten years. [5] In a review of 721 cases of extra medullary plasmacytoma, after treatment, approximately 65% of patients were free of recurrence and did not progress to mul­tiple myeloma, 22% experienced recurrence, and 15% of cases evolved into multiple myeloma. [4] Our patient has been free of local recurrence and systemic disease at one year follow up.

In conclusion, plasmacytoma of the kidney is a rare tumor and needs extensive investigations to rule out multiple myeloma. The treatment is nephrectomy and localized radiotherapy.

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