Int J Hematol DOI 10.1007/s12185-015-1800-6
IMAGES IN HEMATOLOGY
Gastric invasion of multiple myeloma presenting as gastrointestinal bleeding Kei Nakajima1 · Yuki Sueki1 · Megumi Koshiishi1 · Ichiro Kawashima1 · Yumi Nozaki1 · Toru Mitsumori1 · Keita Kirito1
Received: 2 March 2015 / Revised: 9 April 2015 / Accepted: 13 April 2015 © The Japanese Society of Hematology 2015
A 62-year-old woman was hospitalized because of melena. She had been diagnosed with Bence Jones κ-type multiple myeloma (MM) 7 years prior. At the diagnosis of multiple myeloma, chromosome analysis of bone marrow cells revealed the karyotype abnormality 46, XX, t(7;8) (q32;q13) in one of 20 cells analyzed. Following the initial diagnosis of MM, she was treated with the combination of vincristine, doxorubicin, and dexamethasone, followed by high-dose melphalan chemotherapy with autologous stem cell transplantation (ASCT) [1]. She achieved only a partial response to these treatments, and was subsequently treated with thalidomide, and then bortezomib, for 3 years. During the clinical course, she developed multiple subcutaneous plasmacytomas. She underwent palliative radiation therapy, and treatment with lenalidomide was started with prophylactic anticoagulants. Three days before the hospitalization for melena, she experienced epigastric pain. At the time of hospitalization, the patient showed marked anemia (Hb 4.8 g/dL); however, her platelet counts were only modestly decreased (141 × 109/L; normal range 155– 345 × 109/L). Emergent esophagogastroduodenoscopy was performed, and massive bleeding was observed in the
* Keita Kirito [email protected] 1
Department of Hematology and Oncology, University of Yamanashi, Chuo‑shi, Japan
gastric body. The patient was treated with red blood cell transfusion and a proton-pump inhibitor. Two days after the initial observation, esophagogastroduodenoscopy was performed again. As shown in Fig. 1a, irregular thickened folds were found at the gastric corpus. The biopsy specimens revealed significant invasion of round cells in the submucosal area (Fig. 1b). Immunohistochemical studies revealed that these cells were positive for CD 138 (Fig. 1c) and κ chain (Fig. 1d), and negative for CD56, CD20 and CD79a. There was no evidence of deposition of amyloids in the stomach wall. Based on these findings, we diagnosed the patient with gastrointestinal invasion of MM. Although we continued the treatment with protonpump inhibitor, we were unable to control the gastrointestinal bleeding and she developed multi-organ failure. She died 3 weeks after admission. Gastrointestinal bleeding is a common complication of hematological malignancies, including MM. A variety of factors are involved in the gastrointestinal bleeding observed in MM patients [2]. First, paraneoprotein impairs the function of platelets and coagulation factors, leading to increased bleeding tendency. Treatments for MM may also increase the risk for bleeding, including from chemotherapy-induced thrombocytopenia, steroid-induced gastric ulcers, or the administration of aspirin or anticoagulants to prevent the thromboembolic complications associated with lenalidomide or thalidomide. Additionally, the deposition of amyloid protein in the gastrointestinal system can cause severe bleeding. In the present case, we found substantial involvement of myeloma cells in the gastric mucosa. Although the incidence is rare, previous case reports have indicated that gastrointestinal involvement of multiple myeloma, including severe gastrointestinal bleeding, may occur [2–5]. The prognosis of these patients is often extremely poor [2, 3].
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K. Nakajima et al.
Fig. 1 a Endoscopic findings of the stomach. b Gastric biopsy showing the infiltration of mononuclear cells in the submucosa (H&E). c Immunostaining with anti-CD138 antibody. d Immunostaining with anti-κ light chain
Clinicians should be aware that gastrointestinal bleeding observed in MM patients may be secondary to gastrointestinal invasion of myeloma cells. Conflict of interest The authors declare no conflicts of interest.
References 1. Watanabe R, Tokuhira M, Kizaki M. Current approaches for the treatment of multiple myeloma. Int J Hematol. 2013;97(3):333–44.
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2. Suvannasankha A, Abonour R, Cummings OW, Liangpunsakul S. Gastrointestinal plasmacytoma presenting as gastrointestinal bleeding. Clin Lymphoma Myeloma. 2008;8(5):309–11. 3. Talamo G, Cavallo F, Zangari M, et al. Clinical and biological features of multiple myeloma involving the gastrointestinal system. Haematologica. 2006;91(7):964–7. 4. Daram SR, Paine ER, Swingley AF. Upper gastrointestinal bleeding in a patient with multiple myeloma. Gastroenterology. 2012;142(2):e8–9. 5. Wang C-C, Chang M-H, Lin C-C. A rare cause of gastrointestinal bleeding. Gastroenterology. 2013;145(3):e1–2.
IMAGES IN HEMATOLOGY
Gastric invasion of multiple myeloma presenting as gastrointestinal bleeding Kei Nakajima1 · Yuki Sueki1 · Megumi Koshiishi1 · Ichiro Kawashima1 · Yumi Nozaki1 · Toru Mitsumori1 · Keita Kirito1
Received: 2 March 2015 / Revised: 9 April 2015 / Accepted: 13 April 2015 © The Japanese Society of Hematology 2015
A 62-year-old woman was hospitalized because of melena. She had been diagnosed with Bence Jones κ-type multiple myeloma (MM) 7 years prior. At the diagnosis of multiple myeloma, chromosome analysis of bone marrow cells revealed the karyotype abnormality 46, XX, t(7;8) (q32;q13) in one of 20 cells analyzed. Following the initial diagnosis of MM, she was treated with the combination of vincristine, doxorubicin, and dexamethasone, followed by high-dose melphalan chemotherapy with autologous stem cell transplantation (ASCT) [1]. She achieved only a partial response to these treatments, and was subsequently treated with thalidomide, and then bortezomib, for 3 years. During the clinical course, she developed multiple subcutaneous plasmacytomas. She underwent palliative radiation therapy, and treatment with lenalidomide was started with prophylactic anticoagulants. Three days before the hospitalization for melena, she experienced epigastric pain. At the time of hospitalization, the patient showed marked anemia (Hb 4.8 g/dL); however, her platelet counts were only modestly decreased (141 × 109/L; normal range 155– 345 × 109/L). Emergent esophagogastroduodenoscopy was performed, and massive bleeding was observed in the
* Keita Kirito [email protected] 1
Department of Hematology and Oncology, University of Yamanashi, Chuo‑shi, Japan
gastric body. The patient was treated with red blood cell transfusion and a proton-pump inhibitor. Two days after the initial observation, esophagogastroduodenoscopy was performed again. As shown in Fig. 1a, irregular thickened folds were found at the gastric corpus. The biopsy specimens revealed significant invasion of round cells in the submucosal area (Fig. 1b). Immunohistochemical studies revealed that these cells were positive for CD 138 (Fig. 1c) and κ chain (Fig. 1d), and negative for CD56, CD20 and CD79a. There was no evidence of deposition of amyloids in the stomach wall. Based on these findings, we diagnosed the patient with gastrointestinal invasion of MM. Although we continued the treatment with protonpump inhibitor, we were unable to control the gastrointestinal bleeding and she developed multi-organ failure. She died 3 weeks after admission. Gastrointestinal bleeding is a common complication of hematological malignancies, including MM. A variety of factors are involved in the gastrointestinal bleeding observed in MM patients [2]. First, paraneoprotein impairs the function of platelets and coagulation factors, leading to increased bleeding tendency. Treatments for MM may also increase the risk for bleeding, including from chemotherapy-induced thrombocytopenia, steroid-induced gastric ulcers, or the administration of aspirin or anticoagulants to prevent the thromboembolic complications associated with lenalidomide or thalidomide. Additionally, the deposition of amyloid protein in the gastrointestinal system can cause severe bleeding. In the present case, we found substantial involvement of myeloma cells in the gastric mucosa. Although the incidence is rare, previous case reports have indicated that gastrointestinal involvement of multiple myeloma, including severe gastrointestinal bleeding, may occur [2–5]. The prognosis of these patients is often extremely poor [2, 3].
13
K. Nakajima et al.
Fig. 1 a Endoscopic findings of the stomach. b Gastric biopsy showing the infiltration of mononuclear cells in the submucosa (H&E). c Immunostaining with anti-CD138 antibody. d Immunostaining with anti-κ light chain
Clinicians should be aware that gastrointestinal bleeding observed in MM patients may be secondary to gastrointestinal invasion of myeloma cells. Conflict of interest The authors declare no conflicts of interest.
References 1. Watanabe R, Tokuhira M, Kizaki M. Current approaches for the treatment of multiple myeloma. Int J Hematol. 2013;97(3):333–44.
13
2. Suvannasankha A, Abonour R, Cummings OW, Liangpunsakul S. Gastrointestinal plasmacytoma presenting as gastrointestinal bleeding. Clin Lymphoma Myeloma. 2008;8(5):309–11. 3. Talamo G, Cavallo F, Zangari M, et al. Clinical and biological features of multiple myeloma involving the gastrointestinal system. Haematologica. 2006;91(7):964–7. 4. Daram SR, Paine ER, Swingley AF. Upper gastrointestinal bleeding in a patient with multiple myeloma. Gastroenterology. 2012;142(2):e8–9. 5. Wang C-C, Chang M-H, Lin C-C. A rare cause of gastrointestinal bleeding. Gastroenterology. 2013;145(3):e1–2.
