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LETTER TO EDITOR  
Year : 2011  |  Volume : 54  |  Issue : 3  |  Page : 657-658
Multiple myeloma masquerading as metastatic breast carcinoma


Department of Pathology, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, India

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Date of Web Publication20-Sep-2011
 

How to cite this article:
Saroha V, Mandal S, Singh T. Multiple myeloma masquerading as metastatic breast carcinoma. Indian J Pathol Microbiol 2011;54:657-8

How to cite this URL:
Saroha V, Mandal S, Singh T. Multiple myeloma masquerading as metastatic breast carcinoma. Indian J Pathol Microbiol [serial online] 2011 [cited 2019 Jul 18];54:657-8. Available from: http://www.ijpmonline.org/text.asp?2011/54/3/657/85142


Sir,

A 70-year-old lady presented to the surgical clinic with back pain, low-grade fever and pallor of 2 months' duration. She had mastectomy for right-sided infiltrating duct carcinoma (stage I) breast 2 years back. On examination, she had pallor. There was no icterus or lymphadenopathy. Her breast examination did not reveal any evidence of recurrence.

X-ray spine revealed a lytic lesion in the T7, T8 region. Hemogram findings revealed a hemoglobin level of 7.5 g/ dL; normal total leukocyte count, differential leukocyte count and platelet count; and erythrocyte sedimentation rate of 55 mm in the first hour. Serum calcium was found raised to 15 mg/ dL, while the alkaline phosphatase levels were normal.

The bone marrow aspiration [Figure 1]a and biopsy [Figure 1]b performed to rule out metastatic breast carcinoma showed presence of large atypical cells (single arrow) with high nucleo-cytoplasmic ratio, nuclear pleomorphism with prominent nucleoli. The plasma cells (double arrow) were found raised to 12% of marrow-nucleated cells. Erythropoiesis, myelopoiesis and megakaryopoiesis were normal. A provisional diagnosis of metastatic breast carcinoma was made.

Immunohistochemistry (IHC) was carried out with cytokeratin (CK), anti-kappa and anti-lambda to confirm the nature of these atypical cells. The atypical cells were positive for kappa [Figure 1]c and negative for CK [Figure 1]d and lambda. The plasma cells were also found to be positive for kappa and negative for lambda. Serum electrophoresis performed showed presence of M band [Figure 1]e, leading to a diagnosis of multiple myeloma.
Figure 1: (a) Bone marrow aspirate smears (Giemsa, ×400), (b) Bone marrow biopsy (H and E, ×400) showing atypical cells (single arrow) with high nucleo-cytoplasmic ratio, nuclear pleomorphism and prominent nucleoli along with plasma cells (double arrow), (c) Atypical cells positive for kappa (H and E, ×400), (d) Atypical cells negative for CK (IHC, ×400), (e) M band on serum electrophoresis

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Breast cancer frequently metastasizes to bone. Our patient also presented with a lytic bone lesion; however, we suspected a diagnosis other than metastatic breast carcinoma, as relapse of early breast cancer (stage I in our case) or development of metastasis is rare.

The plasma cells were just 12% on initial presentation in our case, but there were many atypical cells resembling malignant epithelial cells, which later turned out to be myeloma cells on IHC. Increased plasma cells may be seen around some epithelial malignancies; however, their polyclonal nature differentiates them from monoclonal plasma cells in myeloma.

Hypercalcemia and anemia are common in both diseases; the M-spike on serum protein electrophoresis and an extensive skeletal disease on x-rays with normal bone scans favor a diagnosis of multiple myeloma. Moreover, while metastatic breast cancer lesions can be blastic or lytic, myeloma bone lesions are purely osteolytic due to increased osteoclast activity and suppressed osteoblast activity. [1]

Newer lesions in patients with cancer should be diagnosed carefully. These include metastasis of breast cancer and secondary malignancies like tumors of gastrointestinal, gynecologic, cerebral origin; and leukemias which may be seen following breast cancer treatment. [2] Factors that may help decide whether the metastasis might have arisen from a secondary malignancy include the age of the patient; the underlying biology of the primary site; grade and radiographic characteristics of the metastatic lesion; the stage and grade of the primary; and tumor markers. This is even more important as prognosis of breast cancer metastatic to bone is poor, whereas multiple myeloma has a better prognosis. [3],[4]

 
   References Top

1.Roodman GD. Mechanisms of bone metastasis. N Engl J Med 2004;350:1655-64.  Back to cited text no. 1
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2.Harvey EB, Brinton LA. Second cancer following cancer of the breast in Connecticut, 1935-82. Natl Cancer Inst Monogr 1985;68:99-112.  Back to cited text no. 2
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3.Hishinuma T, Hoshi A, Asakawa H. Prognostic factors in breast cancer with bone metastasis. J Jpn Soc Cancer Ther 1997;32:179-85.  Back to cited text no. 3
    
4.Hawkins T, Horvath N, Rawling C, Bayly J, Andary C, Dyson P, et al. An incremental response to high-dose therapy in multiple myeloma. Bone Marrow Transplant 1996;17:929-35.  Back to cited text no. 4
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Correspondence Address:
Vijay Saroha
Department of Pathology, Room No. 62, Maulana Azad Medical College, Bahadur Shah Zafar Marg, New Delhi - 110 002
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.85142

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