Urol Radiol 14:211-213 (1992)
Urologic Radiology © Springer-VerlagNewYorkInc. 1992
CT of Uterine Cervical Myeloma: Case Report Caryl G. Salomon,1 H a r o l d V. Posniak,1 a n d J o s e p h M. Pyle, I I I 2 Departments of ~Diagnostic Radiology and 2Pathology, Loyola University Medical Center, Maywood, Illinois, USA
Abstract.
M y e l o m a t o u s i n v o l v e m e n t o f the uterine cervix is rare and, to our knowledge, has not been reported previously in the radiologic literature. This report describes the c o m p u t e d t o m o g r a p h i c (CT) findings a n d reviews differential diagnostic considerations.
Key words:
Cervix, n e o p l a s m s -- C o m p u t e d tom o g r a p h y -- M y e l o m a -- Pelvis.
N e o p l a s m s involving the uterine cervix are usually o f cervical or uterine origin. This report describes a case o f m y e l o m a t o u s i n v o l v e m e n t o f the uterine cervix a n d discusses the a p p e a r a n c e on c o m p u t e d t o m o g r a p h i c (CT) e x a m i n a t i o n . T o our knowledge, no prior report o f this rare entity has been m a d e in the radiologic literature.
Case Report A 67-year-old black woman was referred for evaluation of severe bone pain of 3 to 4 weeks' duration. Multiple lytic skeletal lesions of varying size were seen on plain radiographs. Serum protein immunoelectrophoresis revealed elevated IgG with a lambda light-chain component compatible with monoclonal IgG lambda paraprotein multiple myeloma. Chemotherapy was instituted resulting in symptomatic relief of bone pain and improvement in laboratory abnormalities. Seven months after initial diagnosis, the patient returned with complaints of a brown, malodorous vaginal discharge which had been present for several months and had recently increased. Symptoms had been controlled initially with vaginal douching, followed by treat-
Address offprint requests to: Caryl G. Salomon, M.D., Department of Radiology, Loyola University Medical Center, 2160 South
First Avenue, Maywood, IL 60153, USA
ment with Metronidazole for "probable vaginitis." Concomitant with the increase in gynecologic symptoms was a rise in IgG levels and a recurrence of bone pain. Pelvic examination revealed an exophytic 4 x 5 cm cervical mass. Cervical biopsy yielded tumor (Fig. 1) consisting of sheets of immunoblasts with pronounced plasmacytoid features, with prominent golgi zones, abundant eosinophilic cytoplasm, and vesicular-to-hyperchromatic nuclei with a "spoke wheel" configuration. There was high-grade plasmacytoid lymphoid proliferation. Immunohistochemical stains for kappa and lambda were negative. Findings were compatible with multiple myeloma. CT examination several days following biopsy demonstrated a mass in the uterine cervix (Fig. 2) measuring 4 x 5 x 6 cm. The lesion contours were slightly lobulated and the margins were somewhat indistinct. There was deformity of the lumen of both bladder and rectum with obliteration of anterior and posterior fat planes suggesting invasion. However, there was no extension to the pelvic side walls. There were no other pelvic or abdominal masses or lymphadenopathy. Multiple lytic bone lesions were present (Fig. 3).
Discussion I n v a s i v e s q u a m o u s cell c a r c i n o m a o f the uterine cervix represents the m o s t c o m m o n malignancy in the female r e p r o d u c t i v e system in A m e r i c a n w o m e n younger than 50 years o f age. W o m e n o v e r 70 years o f age h a v e the lowest risk o f developing this neop l a s m [1]. O t h e r malignancies o f epithelial origin involving the cervix are a d e n o c a r c i n o m a , adenos q u a m o u s c a r c i n o m a , and small cell carcinoma. Cervical malignancies m a y also be o f m e s e n c h y m a l origin, including endocervical stromal sarcoma, carc i n o s a r c o m a , a d e n o s a r c o m a , l e i o m y o s a r c o m a , and, in infants, e m b r y o n a l r h a b d o m y o s a r c o m a . O t h e r p r i m a r y malignancies involving the cervix include G a r t n e r duct t u m o r ( m e s o n e p h r o m a ) , m e l a n o m a , a n d carcinoid [2]. Metastatic i n v o l v e m e n t is m o s t c o m m o n l y due to local extension o f n e o p l a s m s originating in the e n d o m e t r i u m , rectum, or bladder. Intrapelvic h e m a t o g e n o u s or l y m p h a t i c metastases oc-
212
C.G. Salomon et al.: Uterine Cervical Myeloma
Fig. 1. Low-power photomicrograph of the cervical biopsy showing intact overlying squamous epithelium and infiltrating malignant plasma cells with marked nuclear atypia, abundant cytoplasm, and brisk mitotic rate.
Fig. 2. Large cervical mass (large arrows). Punctate focus of air (small arrow) is most likely the result of recent biopsy.
cur less frequently, associated with ovarian or endometrial adenocarcinoma. O t h e r regional sources o f metastases include transitional cell c a r c i n o m a o f the bladder, c h o r i o c a r c i n o m a , or uterine sarcomas. Metastases f r o m distant p r i m a r y neoplasms are rare. These h a v e been reported f r o m c a r c i n o m a s o f the
gastrointestinal tract, breast, kidneys, gallbladder, pancreas, lung, a n d thyroid, and m e l a n o m a [1]. In rare instances, there is i n v o l v e m e n t o f the uterine cervix in patients with l e u k e m i a a n d l y m p h o m a , and, e v e n m o r e rarely, l y m p h o m a m a y be limited to the uterine cervix [3-6].
213
C.G. Salomon et al.: Uterine Cervical Myeloma
g
t
The cervical smear revealed primitive plasmacytoid cells. Serum protein electrophoresis yielded a monoclonal IgA kappa peak [1 l]. The clinical presentation of the patient in the present case report is similar to the latter, with the exception that multiple myeloma had already been diagnosed at the time of discovery of the cervical mass. The concomitant occurrence of bone pain, serologic abnormalities, and vaginal discharge in a patient with multiple myeloma should alert the clinician to possible, though rare, cervical involvement. CT examination is useful in determining the extent of disease involvement and identifying local skeletal lesions. References
Fig. 3. crum.
Lytic lesions are demonstrated in both ilia and the sa-
The cervix may be involved by benign neoplasm, including leiomyomas, hemangiomas, lymphangiomas, lipomas, neurofibromas (very rare), and papillary adenofibromas [ 1]. Inflammatory processes may also involve the cervix. A case of chronic plasma cell cervicitis in which histologic examination demonstrated plasma cells, neutrophils, lymphocytes, and histiocytes has been described [7]. This entity is differentiated from multiple myeloma by the presence of mature plasma cells and polyclonal expression of immunoglobulins. Extramedullary lesions in multiple myeloma are most commonly found in the spleen, lymph nodes, liver, and kidneys [8-10]. A review of the literature revealed only two reported cases of uterine involvement with multiple myeloma [9]. The first reported case ofendocervical involvement with multiple myeloma resulting in a positive cervical smear is from 1978 [11]. In this case, the patient presented with hip and groin pain, occasional postmenopausal vaginal spotting, uterine enlargement, and an endocervical polypoid mass measuring 0.4 x 0.6 cm.
1. Kurman ILl (ed): Blaustein "s Pathology of the Female Genital Tract, 3rd ed. New York: Springer-Verlag, 1987, pp 158175, 218-256 2. Disaia PJ, Creasman WT: Clinical Gynecologic Oncology, 3rd ed. St. Louis: C.V. Mosby, 1989, p 74 3. Johnson CE, Soule EH: Malignant lymphoma as a gynecologic problem: Report of five cases including one primary lymphosarcoma of the cervix uteri. Obstet Gynecol 2:149157, 1957 4. Ceelen GH, Sakurai M: Vaginal cytology in leukemia. Acta Cytol 6:370-372, 1962 5. Nasiell M: Hodgkin's disease limited to the uterine cervix: A case report including cytological findings in the cervical and vaginal smears. Acta Cytol 8:16-18, 1964 6. Miketic LM, Carroll R, Harris NL, Linggood RM: Computed tomography in the evaluation of lymphoma of the uterine cervix. Comput Tomogr 12:154-158, 1988 7. Qizilbash AH: Chronic plasma cell cervicitis: A rare pitfall in gynecological cytology. Acta Cytol 18:198-200, 1974 8. Churg J, Gordon AJ: Multiple myeloma: Lesions of the extra-osseous hematopoietic system. Am J Clin Patho120:934945, 1950 9. Hayes DW, Bennett WA, Heck FJ: Extramedullary lesions in multiple myeloma: Review of literature and pathologic studies. Arch Patho153:262-272, 1952 10. Pasmantier MW, Azar HA: Extraskeletal spread in multiple plasma cell myeloma: A review of 57 autopsied cases. Cancer 23:167-174, 1969 l 1. Figueroa JM, Huffaker AK, Diehl EJ: Malignant plasma cells in cervical smear. Acta Cytol 22:43-45, 1978
Urologic Radiology © Springer-VerlagNewYorkInc. 1992
CT of Uterine Cervical Myeloma: Case Report Caryl G. Salomon,1 H a r o l d V. Posniak,1 a n d J o s e p h M. Pyle, I I I 2 Departments of ~Diagnostic Radiology and 2Pathology, Loyola University Medical Center, Maywood, Illinois, USA
Abstract.
M y e l o m a t o u s i n v o l v e m e n t o f the uterine cervix is rare and, to our knowledge, has not been reported previously in the radiologic literature. This report describes the c o m p u t e d t o m o g r a p h i c (CT) findings a n d reviews differential diagnostic considerations.
Key words:
Cervix, n e o p l a s m s -- C o m p u t e d tom o g r a p h y -- M y e l o m a -- Pelvis.
N e o p l a s m s involving the uterine cervix are usually o f cervical or uterine origin. This report describes a case o f m y e l o m a t o u s i n v o l v e m e n t o f the uterine cervix a n d discusses the a p p e a r a n c e on c o m p u t e d t o m o g r a p h i c (CT) e x a m i n a t i o n . T o our knowledge, no prior report o f this rare entity has been m a d e in the radiologic literature.
Case Report A 67-year-old black woman was referred for evaluation of severe bone pain of 3 to 4 weeks' duration. Multiple lytic skeletal lesions of varying size were seen on plain radiographs. Serum protein immunoelectrophoresis revealed elevated IgG with a lambda light-chain component compatible with monoclonal IgG lambda paraprotein multiple myeloma. Chemotherapy was instituted resulting in symptomatic relief of bone pain and improvement in laboratory abnormalities. Seven months after initial diagnosis, the patient returned with complaints of a brown, malodorous vaginal discharge which had been present for several months and had recently increased. Symptoms had been controlled initially with vaginal douching, followed by treat-
Address offprint requests to: Caryl G. Salomon, M.D., Department of Radiology, Loyola University Medical Center, 2160 South
First Avenue, Maywood, IL 60153, USA
ment with Metronidazole for "probable vaginitis." Concomitant with the increase in gynecologic symptoms was a rise in IgG levels and a recurrence of bone pain. Pelvic examination revealed an exophytic 4 x 5 cm cervical mass. Cervical biopsy yielded tumor (Fig. 1) consisting of sheets of immunoblasts with pronounced plasmacytoid features, with prominent golgi zones, abundant eosinophilic cytoplasm, and vesicular-to-hyperchromatic nuclei with a "spoke wheel" configuration. There was high-grade plasmacytoid lymphoid proliferation. Immunohistochemical stains for kappa and lambda were negative. Findings were compatible with multiple myeloma. CT examination several days following biopsy demonstrated a mass in the uterine cervix (Fig. 2) measuring 4 x 5 x 6 cm. The lesion contours were slightly lobulated and the margins were somewhat indistinct. There was deformity of the lumen of both bladder and rectum with obliteration of anterior and posterior fat planes suggesting invasion. However, there was no extension to the pelvic side walls. There were no other pelvic or abdominal masses or lymphadenopathy. Multiple lytic bone lesions were present (Fig. 3).
Discussion I n v a s i v e s q u a m o u s cell c a r c i n o m a o f the uterine cervix represents the m o s t c o m m o n malignancy in the female r e p r o d u c t i v e system in A m e r i c a n w o m e n younger than 50 years o f age. W o m e n o v e r 70 years o f age h a v e the lowest risk o f developing this neop l a s m [1]. O t h e r malignancies o f epithelial origin involving the cervix are a d e n o c a r c i n o m a , adenos q u a m o u s c a r c i n o m a , and small cell carcinoma. Cervical malignancies m a y also be o f m e s e n c h y m a l origin, including endocervical stromal sarcoma, carc i n o s a r c o m a , a d e n o s a r c o m a , l e i o m y o s a r c o m a , and, in infants, e m b r y o n a l r h a b d o m y o s a r c o m a . O t h e r p r i m a r y malignancies involving the cervix include G a r t n e r duct t u m o r ( m e s o n e p h r o m a ) , m e l a n o m a , a n d carcinoid [2]. Metastatic i n v o l v e m e n t is m o s t c o m m o n l y due to local extension o f n e o p l a s m s originating in the e n d o m e t r i u m , rectum, or bladder. Intrapelvic h e m a t o g e n o u s or l y m p h a t i c metastases oc-
212
C.G. Salomon et al.: Uterine Cervical Myeloma
Fig. 1. Low-power photomicrograph of the cervical biopsy showing intact overlying squamous epithelium and infiltrating malignant plasma cells with marked nuclear atypia, abundant cytoplasm, and brisk mitotic rate.
Fig. 2. Large cervical mass (large arrows). Punctate focus of air (small arrow) is most likely the result of recent biopsy.
cur less frequently, associated with ovarian or endometrial adenocarcinoma. O t h e r regional sources o f metastases include transitional cell c a r c i n o m a o f the bladder, c h o r i o c a r c i n o m a , or uterine sarcomas. Metastases f r o m distant p r i m a r y neoplasms are rare. These h a v e been reported f r o m c a r c i n o m a s o f the
gastrointestinal tract, breast, kidneys, gallbladder, pancreas, lung, a n d thyroid, and m e l a n o m a [1]. In rare instances, there is i n v o l v e m e n t o f the uterine cervix in patients with l e u k e m i a a n d l y m p h o m a , and, e v e n m o r e rarely, l y m p h o m a m a y be limited to the uterine cervix [3-6].
213
C.G. Salomon et al.: Uterine Cervical Myeloma
g
t
The cervical smear revealed primitive plasmacytoid cells. Serum protein electrophoresis yielded a monoclonal IgA kappa peak [1 l]. The clinical presentation of the patient in the present case report is similar to the latter, with the exception that multiple myeloma had already been diagnosed at the time of discovery of the cervical mass. The concomitant occurrence of bone pain, serologic abnormalities, and vaginal discharge in a patient with multiple myeloma should alert the clinician to possible, though rare, cervical involvement. CT examination is useful in determining the extent of disease involvement and identifying local skeletal lesions. References
Fig. 3. crum.
Lytic lesions are demonstrated in both ilia and the sa-
The cervix may be involved by benign neoplasm, including leiomyomas, hemangiomas, lymphangiomas, lipomas, neurofibromas (very rare), and papillary adenofibromas [ 1]. Inflammatory processes may also involve the cervix. A case of chronic plasma cell cervicitis in which histologic examination demonstrated plasma cells, neutrophils, lymphocytes, and histiocytes has been described [7]. This entity is differentiated from multiple myeloma by the presence of mature plasma cells and polyclonal expression of immunoglobulins. Extramedullary lesions in multiple myeloma are most commonly found in the spleen, lymph nodes, liver, and kidneys [8-10]. A review of the literature revealed only two reported cases of uterine involvement with multiple myeloma [9]. The first reported case ofendocervical involvement with multiple myeloma resulting in a positive cervical smear is from 1978 [11]. In this case, the patient presented with hip and groin pain, occasional postmenopausal vaginal spotting, uterine enlargement, and an endocervical polypoid mass measuring 0.4 x 0.6 cm.
1. Kurman ILl (ed): Blaustein "s Pathology of the Female Genital Tract, 3rd ed. New York: Springer-Verlag, 1987, pp 158175, 218-256 2. Disaia PJ, Creasman WT: Clinical Gynecologic Oncology, 3rd ed. St. Louis: C.V. Mosby, 1989, p 74 3. Johnson CE, Soule EH: Malignant lymphoma as a gynecologic problem: Report of five cases including one primary lymphosarcoma of the cervix uteri. Obstet Gynecol 2:149157, 1957 4. Ceelen GH, Sakurai M: Vaginal cytology in leukemia. Acta Cytol 6:370-372, 1962 5. Nasiell M: Hodgkin's disease limited to the uterine cervix: A case report including cytological findings in the cervical and vaginal smears. Acta Cytol 8:16-18, 1964 6. Miketic LM, Carroll R, Harris NL, Linggood RM: Computed tomography in the evaluation of lymphoma of the uterine cervix. Comput Tomogr 12:154-158, 1988 7. Qizilbash AH: Chronic plasma cell cervicitis: A rare pitfall in gynecological cytology. Acta Cytol 18:198-200, 1974 8. Churg J, Gordon AJ: Multiple myeloma: Lesions of the extra-osseous hematopoietic system. Am J Clin Patho120:934945, 1950 9. Hayes DW, Bennett WA, Heck FJ: Extramedullary lesions in multiple myeloma: Review of literature and pathologic studies. Arch Patho153:262-272, 1952 10. Pasmantier MW, Azar HA: Extraskeletal spread in multiple plasma cell myeloma: A review of 57 autopsied cases. Cancer 23:167-174, 1969 l 1. Figueroa JM, Huffaker AK, Diehl EJ: Malignant plasma cells in cervical smear. Acta Cytol 22:43-45, 1978
