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Presented by Edward McCarthy, M.D. and prepared by Maryam Farinola M.D.
Case 5: A 70-year-old woman had pain in her leg.
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1. Question
Week 214: Case 5
A 70-year-old woman had pain in her leg. A radiograph showed an aggressive lytic lesions involving both her femur and tibia.images/mm 1.jpg
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images/mm 3.jpgCorrect
Answer: Multiple myeloma
Histology: Multiple myeloma almost always produces lytic lesions in bone. In most cases, there are multiple lesions. However, occasionally a solitary myeloma may present as a single lytic lesion with no other sites of involvement. Only a staging study can differentiate multiple myeloma from solitary myeloma. Multiple myeloma consists of sheets of plasma cells. Sometimes they may be so poorly differentiated as to their plasmacytic nature. However, a CD138 stain should be performed on any round cell tumors. CD 138 is specific for plasma cells. To corroborate the neoplastic nature of these cells, a kappa and lambda immunostain should be performed. Myeloma will be monoclonal and either for only kappa or only lambda.
Discussion: Although lymphoma of bone occurs in this age group and shows sheets of rounded cells, the plasmacytoid nature is usually not present. Furthermore, a CD 138 stain will be negative. Usually, primary lymphomas of bone are B-cell lymphomas and stain strongly with a CD2O stain.
The lesion is not metastatic carcinoma because epithelial cells are not present. In this age group metastatic carcinoma should always be a strong consideration. Often, a keratin stain must be performed to absolutely exclude the diagnosis of metastatic carcinoma.
Although osteomyelitis may demonstrate many plasma cells, this case is not osteomyelitis because the plasma cells will be monoclonal. In addition, chronic osteomyelitis produces a radiodense pattern unlike this case that shows an aggressive radiolytic pattern.
Incorrect
Answer: Multiple myeloma
Histology: Multiple myeloma almost always produces lytic lesions in bone. In most cases, there are multiple lesions. However, occasionally a solitary myeloma may present as a single lytic lesion with no other sites of involvement. Only a staging study can differentiate multiple myeloma from solitary myeloma. Multiple myeloma consists of sheets of plasma cells. Sometimes they may be so poorly differentiated as to their plasmacytic nature. However, a CD138 stain should be performed on any round cell tumors. CD 138 is specific for plasma cells. To corroborate the neoplastic nature of these cells, a kappa and lambda immunostain should be performed. Myeloma will be monoclonal and either for only kappa or only lambda.
Discussion: Although lymphoma of bone occurs in this age group and shows sheets of rounded cells, the plasmacytoid nature is usually not present. Furthermore, a CD 138 stain will be negative. Usually, primary lymphomas of bone are B-cell lymphomas and stain strongly with a CD2O stain.
The lesion is not metastatic carcinoma because epithelial cells are not present. In this age group metastatic carcinoma should always be a strong consideration. Often, a keratin stain must be performed to absolutely exclude the diagnosis of metastatic carcinoma.
Although osteomyelitis may demonstrate many plasma cells, this case is not osteomyelitis because the plasma cells will be monoclonal. In addition, chronic osteomyelitis produces a radiodense pattern unlike this case that shows an aggressive radiolytic pattern.
