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LETTER TO EDITOR  
Year : 2014  |  Volume : 57  |  Issue : 4  |  Page : 659-660
Anaplastic: Plasmablastic plasmacytoma of the vocal cord


1 Department of Pathology, Max Healthcare, New Delhi, India
2 ENT Practice, New Delhi, India

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Date of Web Publication11-Oct-2014
 

How to cite this article:
Abrari A, Bakshi V. Anaplastic: Plasmablastic plasmacytoma of the vocal cord. Indian J Pathol Microbiol 2014;57:659-60

How to cite this URL:
Abrari A, Bakshi V. Anaplastic: Plasmablastic plasmacytoma of the vocal cord. Indian J Pathol Microbiol [serial online] 2014 [cited 2021 Dec 9];57:659-60. Available from: https://www.ijpmonline.org/text.asp?2014/57/4/659/142728


Sir,

We report a case of a laryngeal extra medullary plasmacytoma, with anaplastic morphology-in a nonimmune-compromised male patient - and emphasize the differentials to be considered and excluded, when dealing with an anaplastic or blastic plasmacytoma, which is a rare variant, for laryngeal location.

The patient, a 56-year-old, male, who presented with progressively worsening breathlessness and stridor was evaluated by flexible, followed by direct laryngoscopy, and found to have a nodular thickening of the right vocal cord, jeopardizing the airway and abutting the anterior commissure. A punch biopsy obtained was submitted for histopathology.

Microscopy revealed predominance of undifferentiated tumor cells with large vesicular nuclei, occasionally conspicuous nucleoli, and scant cytoplasm; a population of cells with plasmacytoid features were seen scattered - initially thought of as a tumor associated inflammatory reaction [Figure 1].
Figure 1: Photomicrograph panel 1 – submucosal infiltrate of round cells (clockwise 1-4), with high grade anaplastic/blastic morphology (clockwise - 4), scattered plasma cells (clockwise - 3)

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The initial immunohistochemistry (IHC) panel, included broad spectrum cytokeratin (clone AE1/AE3), cytokeratin 5/6, leukocyte common antigen (LCA), c-kit (CD117), Synaptophysin, Chromogranin, CD56, Vimentin, Desmin, epithelial membrane antigen (EMA), Myogenin, CD34, Bcl2, CD99, S-100 and HMB 45. The infiltrating cells marked for CD56, focal EMA, CD117 and Vimentin. Rest of the markers were was negative.

The second phalanx of IHC markers included CD38, CD 138, CD20, MUM1, kappa and lambda light chains, CD30, CD3 and Ki67. Diffuse and strong expression of CD38, CD138, MUM-1, focal trace CD20, almost 100% kappa light chain restriction and 60% Ki67 proliferation index were observed [Figure 2].
Figure 2: Photomicrograph panel 2 – CK negative tumor cells, the overlying native epithelium is positive (clockwise - 1), kappa light chain (clockwise - 2), CD38 and CD138 (clockwise -3 and 6); S-100 and CD34 (clockwise -4 and -5 respectively)

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A histopathologic diagnosis of anaplastic/plasmablastic plasmacytoma was given.

Further work-up of the patient by imaging with computed tomography and magnetic resonance showed the disease to be limited to the right vocal cord. Absence of serum/urine paraprotein, finding of <5% reactive plasma cells in bone marrow, and normal skeletal survey essentially excluded a systemic (multiple) myeloma. The patient was also confirmed to be EBV sero-negative.

This patient was managed with XRT (local field irradiation), improved symptomatically, with complete resolution of the lesion on laryngoscopy and imaging, and is disease free at present and under close clinical surveillance.

Anaplastic/plasmablastic plasmacytoma is a quintessential undifferentiated round cell tumor. The high grade anaplastic cell morphology brings into the differential diagnosis, a plethora of malignancies including-lymphoma, melanoma, undifferentiated carcinoma, neuroendocrine tumor, rhabdomyosarcoma and neuroblastoma, all having vastly differing biologic potentials, prognoses, predicators and management protocols. [1],[2]

Even if the population of plasma cells is accompanying the undifferentiated cells- as was observed in this case - it cannot be presumed to be a presumptive evidence of plasmacytic differentiation/neoplasm, as a lympho-plasmacytic reaction is common enough in tumors of almost any lineage. [3]

As seen in this case the morphologically malignant cells expressed CD138, CD38, CD56, CD30, MUM1, were monotypic for kappa light chain and negative for LCA and CD20 - this profile favored a clonal plasma cell phenotype against marginal zone/plasmablastic lymphoma, which would have been strongly CD20 and LCA immunopositive. [4] Clinico-radiologic and biochemical work-up ruled out multiple myeloma as described preceding.

The other differentials systematically excluded, on extended IHC were undifferentiated, neuroendocrine and basaloid carcinomas (cytokeratin, CK5/6, chromogranin, synaptophysin, negative); melanoma (S-100, HMB45 negative); rhabdomyosarcoma (desmin, myogenin negative); myeloid sarcoma (LCA, CD117, CD34 negative), anaplastic large cell lymphoma (LCA, CD3 negative).

This preceding extensive immune-histochemical investigation built upon a cogent index of differentials, correlated with clinic-radiologic and biochemical inputs - was able to provide us with a precise diagnosis, of rare yet potentially treatable malignancy, at this site-successfully managed by local radiation therapy alone. [4],[5]

 
   References Top

1.
Vanan I, Redner A, Atlas M, Marin L, Kadkade P, Bandovic J, et al. Solitary extramedullary plasmacytoma of the vocal cord in an adolescent. J Clin Oncol 2009;27:e244-7.  Back to cited text no. 1
    
2.
De Zoysa N, Sandler B, Amonoo-Kuofi K, Swamy R, Kothari P, Mochloulis G. Extramedullary plasmacytoma of the true vocal fold. Ear Nose Throat J 2012;91:E23-5.  Back to cited text no. 2
    
3.
Ghatak S, Dutta M, Kundu I, Ganguly RP. Primary solitary extramedullary plasmacytoma involving the true vocal cords in a pregnant woman. Tumori 2013;99:e14-8.  Back to cited text no. 3
    
4.
González Guijarro I, Díez González L, Rodriguez Acevedo N, Pallas Pallas E. Extramedullary plasmacytoma of the larynx. A case report. Acta Otorrinolaringol Esp 2011;62:320-2.  Back to cited text no. 4
    
5.
Sasaki R, Yasuda K, Abe E, Uchida N, Kawashima M, Uno T, et al. Multi-institutional analysis of solitary extramedullary plasmacytoma of the head and neck treated with curative radiotherapy. Int J Radiat Oncol Biol Phys 2012;82:626-34.  Back to cited text no. 5
    

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Correspondence Address:
Dr. Andleeb Abrari
K 29 F, SFS Flats, Saket, New Delhi -110017
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.142728

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    Figures

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