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Year : 2003  |  Volume : 13  |  Issue : 4  |  Page : 383-386
Extra osseous manifestations of multiple myeloma-two case reports

Department of Radio-diagnosis, Gujarat Caner and Research Institute, Asarwa, Ahmedabad- 380016, India

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Keywords: Multiple myeloma, Pancreatic mass, Testes, Extra - osseous Myeloma

How to cite this article:
Shah S S, Shah D M, Shah S, Patel S. Extra osseous manifestations of multiple myeloma-two case reports. Indian J Radiol Imaging 2003;13:383-6

How to cite this URL:
Shah S S, Shah D M, Shah S, Patel S. Extra osseous manifestations of multiple myeloma-two case reports. Indian J Radiol Imaging [serial online] 2003 [cited 2021 Feb 25];13:383-6. Available from:

   Introduction: Top

Multiple myeloma amounts for ten percent of malignant myeloproliferative diseases[1]. Extra osseous manifestations are found in less than five percent of cases of multiple myeloma. They can arise in any tissue and their presence has been associated with more aggressive disease [2].

Presented here are two cases; first of obstructive jaundice due to focal masses in pancreas in a patient with multiple myeloma and second of testicular involvement in a patient again of multiple myeloma.

   Case 1 Top

A forty-year-old man with left shoulder pain was diagnosed as having multiple myeloma. After one year of chemotherapy, patient presented with pain in abdomen and jaundice and pain in right side of chest. Blood chemistry showed increased direct bilirubin to suggest obstructive jaundice. Serum protein electrophoresis showed elevated gamma globulin fraction with presence of a monoclonal band. Chest P/A view showed an expansile osteolytic lesion in anterior end of right third rib [Figure - 1]. Left shoulder radiograph showed expansile osteolytic lesion in upper end of humerus [Figure - 2]. An ultrasound examination of abdomen was performed on Siemens Sonoline Elegra machine using 3.5 MHz. probe. It revealed moderate dilatation of intrahepatic biliary radicles in both lobes [Figure - 3] along with dilatation of common bile duct [14mm] upto lower end down to the level of head pancreas where it was involved by pancreatic head mass [Figure - 4]. There were three focal well-defined hypoechoic masses in head, body and tail of pancreas, largest in the body of pancreas measuring 82x56 mm [Figure - 5].

The patient had CT scan done outside which confirmed the sonographic findings mentioned above and showed well defined homogenous hypodense masses with changes of obstructive jaundice in liver [Figure - 6]. The patient underwent triple bypass surgery and open biopsy was taken which revealed plasma cell myeloma [Figure - 7].

   Case 2 Top

A 38-year-old man; known case of multiple myeloma involving spine, presented with painless scrotal swelling. Scrotal ultrasound was performed on Siemens Sonoline Elegra machine using 7.5 MHz probe, which showed that both testes were enlarged in size and showed heterogeneous hypoechoic echopattern [Figure - 8],[Figure - 9]. No associated hydrocele was noted. FNAC from testes was performed which showed myelomatous infiltration of testes. Post chemotherapy and post radiotherapy followup showed total resolution of the infiltration [Figure - 10].

   Discussion Top

Multiple myeloma is a malignant plasma cell neoplasm mainly involving the bone marrow. Advanced cases may show involvement of extramedullary sites[7]. Clinopathologic studies have identified extraosseous sites of involvement in two thirds of patients with multiple myeloma. Liver, spleen and lymph nodes are most frequent distant sites of involvement [2]. Liver function abnormalities are present in 25-50 percent of patients with multiple myeloma and are most often amounted for by plasma cell infiltration of liver [1]. Common bile duct obstruction by a myelomatous mass is rare but has been previously reported in patient with solitary multiple myeloma of the innominate bone [3],[4] and in long standing multiple myeloma [5].

In one series a review of 57 autopsied cases of multiple myeloma was done which revealed gross involvement of pancreas in 3 patients out of 57 patients [6].

In summary, jaundice in myeloma patient is usually due to liver infiltration but ultrasound or CT is indicated to rule out biliary obstruction by a myelomatous mass so that proper treatment can be instituted.

Testicular infiltration by multiple myeloma is extremely rare, even in autopsy series. In one series review of 15 patients with extra osseous myeloma was done; out of which only one case of testicular involvement was recorded [7]. It is depicted on ultrasound as diffuse infiltration, producing diffusely enlarged hypoechoic testes. Rarely it may also be seen as focal hypoechoic lesions surrounded by normal testicular parenchyma [8]. Differentiation from various other infiltrations like leukemia, lymphoma, metastatic infiltration, is based on clinical history, biochemical criteria, biopsy with histopathology and immunohistochemistry analysis.

   References Top

1.Mitchell DG; Hill MC, Obstructive jaundice due to multiple myeloma of the pancreatic head: CT evaluation. Journal of Computed Assisted Tomography 9;1118,1985.  Back to cited text no. 1    
2.Maulopoulos, Christine A.J. Granfield, Meletios A. Extraosseous multiple myeloma: Imaging features. AJR 1993; 161: 1083-1087  Back to cited text no. 2    
3.Twomey BP, Katz D. Computed Tomography in the diagnosis of extramedullary plasmacytoma. CT 1983: 7: 407-8  Back to cited text no. 3    
4.Matsubayashi T, Tanaka T, Furuta M, Nakayima M. Case report: Poorly differentiated plasma cell myeloma with widespread involvement of soft tissues and multiple organs. Skeletal radiol 1979; 4: 228-32  Back to cited text no. 4    
5.Rice N T, Woodring JH, Mostowy L, Purcell M.. Pancreatic plasmacytoma. Sonographic & Computed tomographic findings, Journal of Clinical Ultrasound 1981; 9: 46-8  Back to cited text no. 5    
6.Pasmantier MW, Azar HA. Extraskeletal spread in multiple plasma cell myeloma. A review of 57 autopsied cases. Cancer 1969; 23: 167-174.  Back to cited text no. 6    
7.Marc Z. Simmons, Jeffery A. Miller, Charles D. Levine. Myelomatous involvement of liver: Unusual ultrasound appearance. Journal of Clinical Ultrasound 1997; 25:145-148.  Back to cited text no. 7    
8.Gale J T; Bowiee J D, Mahony B S. Myeloma of the testicle: Sonographic appearances. Journal of Clinical Ultrasound 1987; 15: 280.  Back to cited text no. 8    

Correspondence Address:
S S Shah
Department of Radio-diagnosis, Gujarat Caner and Research Institute, Asarwa, Ahmedabad- 380016
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  [Figure - 1], [Figure - 2], [Figure - 3], [Figure - 4], [Figure - 5], [Figure - 6], [Figure - 7], [Figure - 8], [Figure - 9], [Figure - 10]


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