Amish Vora

Plasma Cell Dyscrasia Presenting As Ascites and Omental Mass

A 50-year-old male presented to us with complaints of abdominal distention and pain, vomiting, and breathlessness of 1.5-month duration. On physical examination, the patient had a mass in left hypogastrium that was 10 15 cm in size, nontender, and partially mobile with moderate ascites. He also had bilateral pedal edema and bilateral decreased air entry at the bases of the lungs. The result of hematological tests showed normocytic normochromic anemia with hemoglobin level 8.0 g/dL. Biochemical investigations were suggestive of altered renal functions with serum creatinine of 4.1 mg/dL. The albumin/globulin ratio was 0.23. Chest x-ray confirmed bilateral moderate pleural effusions. Computer tomography of the abdomen showed diffuse thickening of stomach wall involving fundus, body, and antrum with luminal narrowing. The perigastric fat planes were well preserved. There were omental and peritoneal nodular soft tissue masses in the abdomen and pelvis. Nodular masses (probably enlarged lymph nodes) were also detected in the paracaval and the para-aortic region. Extensive ascites with mesenteric edema was noted, though good passage of oral contrast was seen (Fig 1). Moderate bilateral pleural effusions were seen with subsegmental atelectasis of the underlying parenchyma of lung. Upper and lower GI endoscopy was suggestive of extrinsic compression at level of stomach, duodenum, and colon. Ascitic and pleural fluid analysis showed clusters of isolated mature and immature forms of plasmacytoid cells along with reactive mesothelial cells, macrophages, few polymorphs, and lymphocytes. Figure 2A and 2B shows ascitic fluid smear with sheets of plasma cells (Giemsa stain: Fig 2A, 40; Fig 2B, 100). Serum and ascitic fluid electrophoresis showed dense M band in immunoglobulin (Ig) A region (3.5 gm %) with kappa light chain restriction. Urinary Bence Jones Proteins were also positive. Figure 3A and 3B shows transduodenal biopsy with diffuse proliferation of plasmacytoid cells (hematoxylin and eosin: Fig 3A, 10; Fig 3B, 40). Immunohistochemistry revealed positive staining for kappa (Fig 4A) and leucocyte common antigen (Fig 4B). Multiple myeloma work-up with skeletal survey and bone marrow aspiration and biopsy showed no evidence of systemic disease. In view of these findings, a diagnosis of omental plasmacytoma with malignant pleural and peritoneal effusions was made. Extramedullary plasmacytoma (EMP) constitutes 4% of plasma cell tumors. It is defined as a solitary tumor composed of monoclonal proliferation of cells with plasmacytic differentiation at an extramedullary site. It is classified as either primary EMP (when there is absence of coexisting multiple myeloma) or secondary EMP (when it is associated with multiple myeloma). The most common sites for EMP are upper respiratory tract, including the oropharynx, nasopharynx, nasal cavities, nasal sinuses, and larynx. GI involvement by EMPs is rare and is seen in less than 5% of all EMP cases. In a review of EMP, 12 of 161 cases were GI in origin, and only three cases were gastric plasmacytomas. On the other hand, few reports are available of duodenal involvement by plasmacytoma.All the segments of the GI tract may be involved by plasma cell infiltration. The small bowel is the most common site of involvement, followed by stomach, colon, and esophagus. Gastroduodenal plasmacytomas may present with nonspecific GI symptoms like anorexia, weight loss, abdominal pain,

Practical consensus recommendations on ovarian suppression in early breast cancer (adjuvant)

Substantial survival benefits exist for patients with early-stage breast cancer who undergo treatment with single-modality ovarian suppression, but its value is uncertain. Expert oncologist discussed to determine whether additional benefits exist with ovarian suppression plus multiple adjuvant therapy which provides a new treatment option that reduces the risk of recurrence in early breast cancer. This expert group used data from published literature, practical experience and opinion of a large group of academic oncologists to arrive at this practical consensus recommendations for the benefit of community oncologists.

Practical consensus recommendations on duration of adjuvant hormonal therapy in breast cancer

Optimization of adjuvant systemic therapy in women with early-stage hormone receptor-positive breast cancer includes the consideration of chemotherapy and duration of hormone therapy. Adjuvant hormonal therapy significantly improves long-term survival of breast cancer patients with hormone receptor-positive disease. Despite the proven clinical efficacy of tamoxifen and aromatase inhibitors, many breast cancer survivors either fail to take the correct dosage at the prescribed frequency (adherence) or discontinue therapy (persistence). Expert oncologist discussed on the duration of adjuvant hormonal therapy for improvement of OS and quality of life of breast cancer patients by providing reduction in recurrence and mortality. This expert group used data from published literature, practical experience and opinion of a large group of academic oncologists to arrive at this practical consensus recommendations for the benefit of community oncologists.