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Year : 2002  |  Volume : 12  |  Issue : 4  |  Page : 533-535
Solitary plasmacytoma of the calcaneum (SPC)- Radiograph and CT findings in SPC : a rare bone tumor


Mohan Dai Oswal Cancer Treatment & Research Foundation, G.T. Road, Sherpur, Chowk, Ludhiana-141009, India

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Keywords: Plasmacytoma/DI, Plasmacytoma/DT, plasmacytoma/RT, Calcaneus, Multiple Myeloma/DI, Foot/RA, Skull/RA, Pelvis/RA, Spine/RA, Vincristine/AD, Human: Female, Middle Age, Case Report,

How to cite this article:
Shrimali R, Garg L, Setia V, Jain S. Solitary plasmacytoma of the calcaneum (SPC)- Radiograph and CT findings in SPC : a rare bone tumor. Indian J Radiol Imaging 2002;12:533-5

How to cite this URL:
Shrimali R, Garg L, Setia V, Jain S. Solitary plasmacytoma of the calcaneum (SPC)- Radiograph and CT findings in SPC : a rare bone tumor. Indian J Radiol Imaging [serial online] 2002 [cited 2014 Dec 18];12:533-5. Available from: http://www.ijri.org/text.asp?2002/12/4/533/28533

   Introduction Top


Solitary plasmacytoma of bone is a unifocal localized neoplastic proliferation of monoclonal plasma cells with varying degree of differentiation. It accounts for 3% -10% of all plasma cell malignancies. Other forms of plasma cell neoplasm include- multiple myeloma (most common) and extramedullary plasmacytoma [1].

To the best of our knowledge this is only the fifth case of solitary plasmacytoma of bone(SPB) in the foot and second case of SPB in calcaneum.


   Case Report Top


A fifty four year old woman presented with pain and swelling in the left hind foot region for last 2 years following trivial trauma. The swelling had increased in size progressively with inability to bear weight for the last 1 month.

Operative History - operated for a (L) breast lump 12 years back, CAD (ballooning done); hypertension and impaired hearing.

Local Examination: of the left foot showed diffuse swelling in the hind foot region. The heel was broadened. A diffuse swelling, soft in consistency, was palpable on the lateral side of the heel; mild tenderness was there, local temperature was normal. Movements of the subtalar joint were restricted and painful. Ankle joint movements were normal and pain free. There was no regional lymphadenopathy.

Radiographs of the left foot (AP with Lateral views) [Figure - 1]a were taken which showed - an expansile lesion of the calcaneum with multiple foci of irregular lytic destruction in it. There was also a suggestion of cortical break through it at places.

The X-rays were followed by 5 mm thick axial and coronal CT sections.(SOMATOM AR.C) [Figure - 2]aandb which were viewed on both soft tissue and bone windows, an expansile lytic lesion involving the left calcaneum was seen. The matrix was of uniform soft tissue attenuation, cortical breach was visible at a few places. Early extraosseous soft tissue extension was discernible. The CT findings correlated well with the histopathological picture of the tissue taken from the calcaneum.

A complete skeletal survey was performed by taking radiographs of the skull, pelvis and spine to rule out a multifocal nature of the disease. These were normal. This was followed by a 99m TC- MDP bone scan which showed abnormal uptake in the left calcaneum only. No other bony lesion was traced, confirming the solitary nature of the disease. Other biochemical investigations performed in support of the diagnosis were

1. Urine for Bence Jones protein - Negative

2. Serum protein electrophoresis - increased in 2 and gamma Globulin fraction.

A.G ratio - 0.67

Total Proteins - 6.1 G/DL

3. 2 microgloblin - increased - 4183 NG/ML

4. Patients HB- 9.6 gm% serum creatinine 0.9 mg/ dl. Blood Urea - 30.5 mg/dl.(with in normal limits)

The treatment plan was a below-knee amputation of the left leg, as the tumor tissue had extended into the subtalar joint and was already extraosseous. However the patient refused to go in for a below-knee amputation. So we were left with the choice of chemotherapy and radiotherapy only. The patient was then given Radiotherapy with a tumor dose of 30 grays in 12fraction over 5 wks followed by CCT Inj adrianamycin, Inj. Vincristine for 9 cycles.

After chemo-radiation, the patient was relieved of his pain in the hind foot region dramatically. The swelling in the hind region decreased in size. Radiological follow up did not show any appearance of new defects. A follow up X-ray after 10 months showed [Figure - 1]b.- increased sclerosis with decrease in size of the lytic areas. The cortical rim was better defined and visible throughout signifying osseous regeneration. By the end of 1-1/2 years (following treatment) the laboratory results have been nearing normal with 2 microglobulin 2300 NG/ML. A. G. ratio - 1.2. The patient will continue to be monitored for possible progression that is so commonly associated with plasma cytoma.


   Discussion Top


Sprinkle, III and santangelo L [2] considered solitary plasmacytoma of bone as a localized, slow growing and well defined tumor. Other names of the uncommon lesion include plasma cell granuloma, pseudoplasma cell granuloma, solitary myeloma and benign myeloma. The disease is more common in men than in women with a peak incidence between the fourth and sixth decade. Pain is the most commonly reported presenting symptom and usually becomes manifest or worsens during the night [2]. SPB occur most commonly in the spine, ribs, pelvis, skull, sternum and proximal long bone of the extremities, although any part of the skeleton, including phalanges, may be involved [4].

Radiologically, solitary plasmacytoma of bone may appear as a lytic lesion or as an area of bone expansion with thinning and destruction of the overlying cortex and a "bubbly" or trabeculated appearance. The margins are usually well defined, sharply demarcated and characteristically without a sclerotic reaction [1].

Suggestive differential diagnosis include - chronic osteomyelitis, osteolytic metastasis, osteoid osteoma, osteoblastoma, inclusion cyst Brown tumor of hyperparathyroid, ABC and benign giant cell tumour [2].

Histopathological features include very thick mat of cells with scanty intercellular stroma with extensive cytoplasm deeply stained and basophilic. The round nucleus is eccentric and there is clear perinuclear halo [5].

Requirements for diagnosis of SPB include the presence of a solitary bone lesion, plasma cell histology, a negative skeletal survey, less than (10% plasma cells in a random bone marrow sample and no incidence of anemia, hypercalcaemia or renal involvement that could be attributed to underlying multiple myeloma, some also require a follow up of 3 years without evidence of dissemination [1]

Early and aggressive action to eradicate the tumor is advised. For treatment antiblastic drugs, that is - Cyclophosphamide, Vincristine, Adriamycin, associated with steroids are used [5]. Radiation treatment is often used to relieve pain and to prevent a pathological fracture where there are major and circumscribed osteolysis [5].

Local recurrence of solitary plasmacytoma of bone is estimated to be less than 5% when treated with radiation therapy alone. Dissemination occurs in 35-75% of SPB patients [3].Once there has been progression to multiple myeloma survival beyond two years is unusual [4].

Till may 1997, only 5 cases of SPB have been reported in the foot including two in the cuneiform [1], one in the cuboid [1],[6],one in the calcaneum [1],[2] and one in the talus [1],[3]. To the best of our knowledge no further cases have been reported since then. This is the 2nd case of the solitary plasmacytoma of the calcaneum.

The rarity of these lesions in the bones of the foot has been attributed to the nature of malignant osseous disease and the propensity these conditions have for proximal areas of the extremities.


   Summary Top


This particular case is significant in view of the rarity of the lesion and also because it illustrates the requisite diagnostic criteria (clinical as well as para clinical) for a positive identification of this pathologic entity; moreover the case also illustrates the course of the disease following definitive specialized treatment.


   Acknowledgments Top


We are thankful to Dr. Raman Arora, Head of Medical Oncology and Dr. R. R. Saggar Sr. Consultant, Department of Orthopedics and Dr. Sandeep Jain, Department of Orthopaedics



 
   References Top

1.Khoddami M, Fernandes B.J; "Solitary IgA Myeloma of the Foot. A Case Report and Review of Literature" Volume 87, Number 5, May 1997.  Back to cited text no. 1    
2.Sprinkle RLB III, Santangelo L, Devgarte R. " Solitary Plasmacytoma of bone in calcaneum" JAPMA 78:636, 1988  Back to cited text no. 2    
3.Lasker JC, Bishop JO, Wilbanks JH et. Al. solitary myeloma of the talus bone" Cancer 68; 202, 991  Back to cited text no. 3    
4.Newcott EP " A solitary plasmacytoma in the foot' JAPMA 77;187,1987.  Back to cited text no. 4    
5.F. Enneking "Bone and soft tissue tumours" Skeletal lesions in plasmacytoma 559-574 edition 1990 by Auto gaggi Editore, Bologna.  Back to cited text no. 5    
6.Burkins JK, Bonatus TJ; "Solitary plasmacytoma of the cuboid foot ankle" 8;344,1988.  Back to cited text no. 6    

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Correspondence Address:
R Shrimali
Mohan Dai Oswal Cancer Treatment & Research Foundation, G.T. Road, Sherpur, Chowk, Ludhiana-141009
India
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[Figure - 1], [Figure - 2]

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    Introduction
    Case Report
    Discussion
    Summary
    Acknowledgments
    References
    Article Figures

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