1. Plasmacytomas By Godfrey Thuku MSIV

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

3. Case presentation 42yr old Hispanic female with a slowly growing right scalp cyst since May 2009 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 Symptoms of left arm and fingers tingling, headaches. No systemic signs Cyst was approx 5cm in circumference, no erythema, tenderness to palpation, no discharge Cyst was approx 5cm in circumference, no erythema, tenderness to palpation, no discharge No history of Trauma to the site 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 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. Neuro; Completely neurologically intact.

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

10. Plasma cell disorders Plasma cell granulomas – monoclonal expansion of single plasma cell. Its an inflammatory process 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 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 Extramedullary plasmacytomas – localized cell neoplasms arising within soft tissues Solitary bone plasmactyoma – solitary lytic bone lesion Solitary bone plasmactyoma – solitary lytic bone lesion Multiple myeloma – rarely curable systemic malignancy of plasma cells. Multiple myeloma – rarely curable systemic malignancy of plasma cells.

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

12. Pathology; especially to rule out plasmagranuloma 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 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. 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. MRI showed a mass in left clivus extending to foramen magnum. Tumor was unresponsive to dexamethasone for six months Tumor was unresponsive to dexamethasone for six months Decision made to treat it as a plasmacytoma Decision made to treat it as a plasmacytoma Treated with fractioned cyberknife, 400 cGy for five days Treated with fractioned cyberknife, 400 cGy for five days

15. Pros Pros No screw-induced numbness No screw-induced numbness Rare cases of pin site cellulitis with AVM’s Rare cases of pin site cellulitis with AVM’s Potential infections 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 Pt had complete radiographic response within three months Serial head MRI for 12+ months without neurological toxicity 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) 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 Has a solitary mass in left carvenous sinus Probable metastases from breast, surgery done but pathology revealed a plasmacytoma. Systemic evaluation showed MM Probable metastases from breast, surgery done but pathology revealed a plasmacytoma. Systemic evaluation showed MM Pt underwent gamma knife radiosurgery followed by chemo. Pt underwent gamma knife radiosurgery followed by chemo.

17. Pros Tumor responded very rapidly to radiation 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 Proper diagnostic work-up, including systemic labs Literature indicates plasmacytomas are very radiosensitive. Literature indicates plasmacytomas are very radiosensitive. Would not hesitate to use radiosugery Would not hesitate to use radiosugery