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Background. Plasmacytoma is a plasma cell dyscrasia originating from a single clone of plasma cells of B-lymphocyte lineage and produces
a monoclonal immunoglobulin. Transthoracic ne-needle aspiration (TTNA) under ultrasound (US) guidance is a well-validated technique
for the diagnosis of many neoplasms and has been shown to be safe and cost eective, with diagnostic yields comparable to more invasive
techniques. However, the role of TTNA in the diagnosis of thoracic plasmacytoma is not well established.
Objective. e aim of this study was to assess the utility of TTNA and cytology in conrming a diagnosis of plasmacytoma.
Methods. All cases of plasmacytoma diagnosed from January 2006 to December 2017 by the Division of Pulmonology, Tygerberg Hospital,
were retrospectively identied. All patients who underwent an US-guided TTNA and of whose clinical records could be retrieved were
included in this cohort. e International Myeloma Working Group’s denition of a plasmacytoma was used as the gold standard.
Results. A total of 12 cases of plasmacytoma were identied and 11 patients included (one patient was excluded owing to missing medical
records). Six of the 11 patients (mean age 59.5 ± 8.5years) were male. Radiologically, most had multiple lesions (n=7), most commonly
bony (n=6) with vertebral body involvement (n=5) and pleural-based lesions (n=2). Rapid onsite evaluation (ROSE) was performed and
documented in 6 of the 11 cases, and a provisional diagnosis of plasmacytoma was suggested in 5 of the 6 patients (83.3%). e nal
laboratory cytological diagnoses of all 11 cases were compatible with plasmacytoma which was further conrmed via a bone marrow biopsy
(n=4) and by serum electrophoresis (n=7).
Conclusion. US-guided ne-needle aspiration is feasible and is useful to conrm a diagnosis of plasmacytoma. Its minimally invasive nature
may be the ideal investigation of choice in suspected cases.
Keywords. Plasmacytoma, ultrasound, transthoracic ne-needle aspiration.
Afr J Thoracic Crit Care Med 2022;28(4):167-171. https://doi.org/10.7196/AJTCCM.2022.v28i4.242
Plasmacytoma is a plasma cell dyscrasia originating from a single clone
of plasma cells of B-lymphocyte lineage and produces a monoclonal
immunoglobulin.[1] Plasma cell neoplasms generally present as either
a single lesion (solitary plasmacytoma) or multiple lesions (multiple
myeloma).
A plasmacytoma can present as a solitary lesion occurring within
the axial skeleton[2] or as an extramedullary plasmacytoma that occurs
within so tissue, which accounts for 5-10% of all types of plasma
cell neoplasms.[1,3,4]
The evaluation of a patient with a suspected extramedullary
plasmacytoma should include a biopsy of the suspected lesion, a bone
marrow aspiration and biopsy and ancillary laboratory investigations
including a full blood count, renal function, serum calcium, serum
free monoclonal light chain through serum protein electrophoresis
and a 24-hour urine analysis for protein electrophoresis.
Patients with plasma cell neoplasms usually have high serum
protein levels.[5] Although a presumptive diagnosis is oen based on
a monoclonal peak on plasma electrophoresis[6,7] and the presence of
urinary Bence Jones protein, a tissue diagnosis is required to make a
denitive diagnosis.[5-8]
Plasmacytomas can be distinguished from most neoplasms based on
the morphological appearance of the plasma cells and on their clonal
nature. is can be established via immunostaining for kappa and
lambda light chains or by ow cytometry. Typically, plasma cells in
plasmacytoma will be positive for CD138 and CD38, and show light
chain restriction (i.e. stain positive for either kappa or lambda but
not both).[8]
Transthoracic ne-needle aspiration (TTNA) under ultrasound
(US) guidance is a well-validated technique for the diagnosis of lung
cancer and many other neoplasms, and has been shown to be safe
and cost eective, with diagnostic yields comparable to more invasive
techniques.[9,10] However, the role of TTNA in the diagnosis of thoracic
plasmacytoma is not well established.
e aim of this study was to assess the utility of US-guided TTNA
and cytology in conrming a diagnosis of plasmacytoma.
Methods
Patient population
All cases of plasmacytoma diagnosed from January 2006 to December
2017 by the Division of Pulmonology, Tygerberg Hospital, were
e utility of chest ultrasound-guided ne-needle biopsy in the
diagnosis of plasmacytoma
S S Benbarka,1 MD, FCP (SA), MMed (Int); P T Shubert,2 MB ChB, FCPath (Anat), MMed (Anat), MSc MedSc(Cytopath), MPhil(Paed Path);
E M Irusen,1 MB ChB, FCP (SA), PhD; B W Allwood,1 MB ChB, FCP (SA), MPH, Cert Pulm (SA), PhD;
C F N Koegelenberg,1 MB ChB, MMed (Int), FCP (SA), FRCP (UK), Cert Pulm (SA), PhD
1 Division of Pulmonology, Department of Medicine, Stellenbosch University and Tygerberg Academic Hospital, Cape Town, South Africa
2 Division of Anatomical Pathology, Department of Pathology, Stellenbosch University and NHLS, Tygerberg Academic Hospital, Cape Town, South Africa
Corresponding author: S Benbarka (ssbenbarka.bbss@gmail.com)
168 AJTCCM VOL. 28 NO. 4 2022
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retrospectively identied by searching the National Health Laboratory
Service (NHLS) pathology data base. All patients who underwent a
US-guided TTNA during this period and of whom clinical records
could be retrieved were included in a retrospective cohort. Tygerberg
Hospital is a 1 380-bed, tertiary public hospital in South Africa serving
approximately three million people. Ethical approval for the current
study was provided by the Stellenbosch University Research Ethics
Committee, protocol number (S17/02/043). e cases were reviewed
for age, gender, presentation and anatomical involvement.
Transthoracic ultrasound
During the study period, a respiratory physician routinely performed
the sonography with a standard 3.75-MHz sector probe. e patients’
positions for scanning were determined by the corresponding
computed tomography (CT) scan. All procedures were performed in
a bronchoscopy suite. e intended puncture site was subsequently
identied and marked, and the direction and depth of interest for the
procedure documented. e site of aspiration was the epicentre of
chest wall contact, and the intended direction towards the observed
or anticipated location of the mass lesion while care was taken to avoid
any major blood vessels or viscera. All procedures were subsequently
performed ‘freehand’ (not under direct real-time US guidance).
Transthoracic ne-needle aspirations
Aspirations were performed with 22-G spinal needles of 40 mm or
90 mm length as needed (Tae-Cang, Kong Ju City, Korea) connected
to a 10 ml syringe under sterile conditions with local anaesthesia
and no sedation. Aspirates (all from slightly dierent directions and
depths) were directly expressed onto slides, smeared and submitted
for rapid onsite evaluation (ROSE) using both Di-Quik (Rapidi;
Clinical Sciences Diagnostics, Southdale, South Africa) and rapid
Papanicolaou staining methods.
Rapid onsite evaluation (ROSE) of cytology specimens
A cytopathologist was generally present at the majority of the TTNA
procedures to perform ROSE of the specimens to assess their adequacy
for laboratory evaluation, collect all necessary specimens (including
cell blocks) and provide a preliminary diagnosis.
Data collection
The International Myeloma Working Group’s definition of a
plasmacytoma was used as the gold standard.[11]
Results
A total of 12 cases of plasmacytoma were identied in the present
study and included 11 patients (one patient’s medical records could
not be retrieved). Six of the 11 patients (mean age 59.5 ± 8.5years)
were male (Table1). e clinical presentations of the 11 patients are
also summarised in Table1. Radiologically, most of the patients had
multiple lesions (n=7), most commonly bony (n=6) with vertebral
body involvement (n=5) and pleural-based lesions (n=2).
ROSE was performed and documented in 6 of the 11 cases, and
a provisional diagnosis of plasmacytoma was suggested in 5 of the
6patients (83.3%). e nal cytological diagnoses of all 11 cases were
compatible with plasmacytoma/myeloma (n=11) and were further
conrmed by ow cytometry (n=5), bone marrow biopsy (n=4) and
serum protein electrophoresis (n=7). Hypercalcaemia was present in
3 cases and 2 subjects were HIV positive.
Cytological ndings in a plasma cell dyscrasia (plasmacytoma) show
a dis-cohesive aspirate with rather monomorphic, morphologically
identiable plasma cells, including mono- and binucleated variants
(Figs1 and 2). ese cells are typically medium-sized, show little
pleomorphism with round, eccentrically located nuclei with a
clumped ‘clock face’ chromatin pattern and a perinuclear cytoplasmic
clearing or hof. Small nucleoli may be seen. Some radiological ndings
from the patients included in this study are shown in Figs3-5. ese
ndings varied from single to multiple pleural-based masses, with or
without rib destruction or vertebral body invasion. e lung appeared
invaded in most cases. Fig.6 is complementary to Fig.4.
Discussion
In this retrospective study, we found that plasmacytoma was diagnosed
in all cases through US-guided TTNA with ROSE. US-guided biopsy
of the chest wall, pleural-based, and pulmonary lesions abutting the
chest wall, performed by pulmonologists, is feasible and has utility. It
has the advantage of multi-planar imaging, real-time technique, and
the absence of radiation exposure to patients.[12,13]
Fine-needle aspiration (FNA) cytology is a well-established
procedure for the diagnosis of a so-tissue mass or any lesion in the
body.[14,15] ere is a paucity of high-quality data on the utility of US-
guided TTNA in the diagnosis of plasmacytoma, given the fact that
it remains a rare condition.[16,17] There are mainly case reports of
plasmacytoma found in the pancreas, stomach, thyroid, tonsil, larynx
and liver where FNA biopsy (FNAB) was successfully performed.[18,19]
Endoscopic ultrasound-guided FNA has also been used in diagnosing
plasmacytoma of the pancreas.[20] Gastro-intestinal plasmacytoma is
rare and accounts for 10% of all plasmacytoma cases.[21]
Extramedullary plasmacytomas are very rare tumours and
can be easily misdiagnosed for carcinoma (particularly well-
dierentiated adenocarcinoma), non-Hodgkin lymphoma and rarely
for fibrous histiocytoma, rhabdomyosarcoma, dermatofibroma
and sarcoma.[22,23] A definitive diagnosis needs a cellular and
well-preserved cytology sample with a predominance of a
relatively monomorphic,morphologically identiable plasma cell
population. ese cellscan include bi- and multi-nucleated forms;
some pleomorphisms can be seen with larger cells and nucleoli.
Not all neoplastic cells contain an abundance of cytoplasm with a
perinuclear hof, and a careful search is needed. As these tumours
are relatively uncommon, the cytopathologist must be aware of this
possibility and a further examination for other cells needs to be
undertaken to exclude other possibilities such as an inammatory
myobroblastic tumour or IgG4 sclerosing diseases. If the plasma
cells demonstrate pleomorphism or blastic nuclear features, then a
plasmablastic lymphoma or diuse large B-cell lymphoma can be
considered. Plasma cells may also contain large vacuoles in their
cytoplasm, mimicking a signet-ring cell carcinoma.[24,25]
FNA cytology is used to make a perioperative diagnosis as a
minimally invasive procedure, especially if ROSE is made available
simultaneously.[26] e accuracy of the sample is dependent on the
level of experience of the team, the size of the mass, the needle size
and, ideally, no blood contamination. e advantages of using ROSE
for a rapid diagnosis have been demonstrated in numerous retrospective
AJTCCM VOL. 28 NO. 4 2022 169
RESEARCH
Table1. Clinical and investigative data of the patients (N=11)
Case
Age
(years) Sex Presentation Lesion ROSE
Serum
calcium
Serum
creatinine
1 56 M Lower-limb weakness Multiple Plasmacytoma 2.81 109
2 75 M Chest mass Single ND 2.17 112
3 63 F Paraspinal mass Single Plasmacytoma 2.46 43
4 45 M Rib mass Multiple ND 2.17 69
5 52 F Le lung tumour Multiple ND 3.52 73
6 62 F Chest wall mass Multiple ND 2.42 63
7 52 M Ptosis with lung mass Multiple Myeloma/plasmacytoma or
adenocarcinoma 2.36 74
8 70 F Pleural-based mass Single Adenocarcinoma* 2.50 66
9 58 M Lower-limb weakness Multiple Myeloma 2.62 110
10 63 F Pleural-based mass Multiple Myeloma 2.35 94
11 58 M Right lung mass tumour Single ND 2.48 88
M = male; F = female; ROSE = rapid on-site evaluation; ND = not documented.
*is case was misdiagnosed as well-dierentiated adenocarcinoma on-site. is is a pitfall which the cytopathologist needs to be aware of.
Fig.1. Cytological ndings compatible with plasmacytoma (plasma
cell dyscraisa). e cells are monomorphic and medium sized, show
eccentrically located nuclei with a ‘clock face’ chromatin pattern and a
small nucleolus. Occasional bi-nucleated forms are seen (Papanicolaou
stain, 400x).
Fig.2. Di-Quick stained image with neoplastic plasma cells, highlighting
the plasmacytoid nature of the neoplastic plasma cells (400x).
Fig.3. A le posterior-lateral, pleural-based mass with lung inltration,
without marked rib destruction. e lesion on the computed tomography
scan was reported to be suggestive of lung cancer, but ultimately proven
to be a plasmacytoma.
Fig.4. Computed tomography image of a le lateral chest wall mass
with marked rib destruction by a plasmacytoma and a lytic lesion of
the le scapula.
170 AJTCCM VOL. 28 NO. 4 2022
RESEARCH
studies.[27-29] e impacts of using ROSE were most noticeable in the
improvement of sample adequacy when performed by pathologists and
at centres where initial sample adequacy rates without ROSE were low.[30]
ROSE was used in the current study and has been shown to increase
the diagnostic yield in transthoracic FNAs of lung cancer as well as
decreasing the procedure time. Given the small number of patients
in the present study, an estimation of its full impact could not be
determined.
e advantages of TTNA use under US guidance with ROSE are
numerous. Benefits include an increase in the sample accuracy,
improvement in sample processing quality, adequacy of the material
and improvement in communication between multiple subspecialty
teams, which yielded good results in the present study.
e present study also investigated the immune status of patients.
ere is a well-known association between plasma cell tumour and
immunosuppressed patients, including HIV infection. Two patients
were HIV positive in the present study, suggesting that routine testing
should be recommended.
Our study has some limitations, most notably its retrospective design
and that the ROSE ndings were not always clearly documented.
Given the incidence of plasmacytoma in the general population, only
a large-scale multinational study would accurately establish the utility
of ultrasound-guided FNA in the diagnosis of plasmacytoma.
In conclusion, US-guided FNA was found to be feasible and has utility
in diagnosing plasmacytoma. Its minimally invasive nature may be the
ideal investigation of choice in suspected cases.
Declaration. EMI, BWA and CFNK are members of the editorial board.
We declare that this study is our own original work and that it has not
previously, neither in its entirety nor in part, been submitted to any
university for degree purposes.
Acknowledgements. We thank the personnel of the Pulmonology
Department at Stellenbosch University for their complete support in
publishing this work.
Author contributions. This is a joint work by all listed authors.
Funding. None received.
Conflicts of interest. None.
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Fig.5. A magnetic resonance image (MRI) of a patient who presented
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Accepted 27 September 2022.
