A Multiple Myeloma Patient Presenting with Multiple Hepatic Masses

Abstract

A 47-year-old male with Multiple Myeloma (MM) presented with a history of worsening jaundice and intermittent abdominal discomfort for one month. Physical examination was unremarkable except for the icterus and palpable, nontender liver extending 2 cm below the right costal margin. The liver function test was more consistent with an obstructive pathology. MRCP showed at least six hepatic masses- largest of which measured 16.4 11.2 cm, severe upper abdominal and retroperitoneal adenopathy and moderate to severe intrahepatic biliary duct dilatation due to extrinsic compression of Common Bile Duct (CBD) by a 6.0 5.7 cm porta-hepatis mass. A CAT-scan guided hepatic-mass-biopsy showed plasmacytoma. Endoscopic Retrograde Cholangiopancreatography with stent placement in CBD was done and the patient was discharged upon clinical improvement. Multiple Myeloma is a monoclonal, plasma-cell neoplasm that usually produces large amount of a specific immunoglobulin. Though Extramedullary plasmacytoma (EMP) is not uncommon feature of MM, it is rarely considered as a specific part of the clinical picture of MM. Though the most common mechanism for development of EMP is local growth of the malignant tissue outside the bone, it can also be formed in various distant organs via hematogenous spread of the malignant plasma cells. Hepatic plasmacytoma is considered a rare entity and literature is limited to few case notes. Out of two distinct pathologic variants of hepatic plasmacytoma, infiltrative plasma-cell lesion are more common that macroscopic-nodular form. There are reports of nodular-hepatic plasma cell tumor being diagnosed incidentally or presenting with clinical features of hepatocellular injury and/or cholestasis. We have presented a rare case of hepatic plasmacytoma in MM with intrahepatic and porta-hepatis macroscopic nodules occurring simultaneously. This clinical picture of obstructive jaundice with multiple liver masses, a porta-hepatis mass and severe abdominal adenopathy usually generates differential diagnoses of primary liver tumor, metastases, gall bladder carcinoma, cholangiocarcinoma or abscesses. If a patient has pre-existing multiple myeloma, plasmacytoma should invariably be added to the differential diagnosis.




J Med Cases. 2013;4(10):673-675
doi: https://doi.org/10.4021/jmc1470w