Home About us Editorial board Ahead of print Current issue Search Archives Submit article Instructions Subscribe Contacts Login 


 
 Table of Contents  
LETTER TO THE EDITOR - DOCUMENTING A CASE
Year : 2011  |  Volume : 7  |  Issue : 3  |  Page : 366-367

Oncological progression of bone plasmacytoma to POEMS syndrome


Department of Radiotherapy, Acharya Tulsi Regional Cancer Research and Treatment Centre, SP Medical College, Bikaner, Rajasthan, India

Date of Web Publication2-Nov-2011

Correspondence Address:
Narendra Kumar Rathore
Room No. 34, P.G. Hostel, PBM Hospital campus, Bikaner, Rajasthan
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.87016

Rights and Permissions

How to cite this article:
Rathore NK, Sharma A, Sathpathy SP, Walke R. Oncological progression of bone plasmacytoma to POEMS syndrome. J Can Res Ther 2011;7:366-7

How to cite this URL:
Rathore NK, Sharma A, Sathpathy SP, Walke R. Oncological progression of bone plasmacytoma to POEMS syndrome. J Can Res Ther [serial online] 2011 [cited 2019 Oct 16];7:366-7. Available from: http://www.cancerjournal.net/text.asp?2011/7/3/366/87016

Sir,

POEMS syndrome is defined by the presence of polyneuropathy (P), organomegaly (O), endocrinopathy (E), monoclonal gammopathy (M), skin changes (S), papilledema, edema, pleural effusion, ascites and thrombocytosis. Virtually all patients will have either at least one bone lesion or coexistent Castelmans disease. All features of the disease are not required to make the diagnosis. The peak incidence of POEMS syndrome is in the 5 th and 6 th decades. It is frequently confused with chronic inflammatory demyelinating polyneuropathies. The mainstay of therapy includes irradiation, corticosteroids, alkylators-based therapy and high-dose chemotherapy with peripheral blood stem cell transplantation

We describe a case of POEMS syndrome that first presented as vertebral plasmocytoma and than progressed to POEMS syndrome after asymptomatic period of 8 years.

A 59-year-old male patient was presented with history of lower limb paresis. MRI showed architectural disruption of D6 vertebra with soft tissue component and epidural cord compression. Laminectomy was performed. Morphology of tumor tissue was suggestive of plasma cell tumor. Bone marrow biopsy and aspirations were negative. Sign and symptoms of end organ damage were absent. Rest of routine investigation was normal including calcium, hemogram, 24-hour urine for Bence-jone protein, renal and liver function tests. One month later, adjuvant external radiotherapy was delivered as single fraction of 8 Gray followed by ten fractions of 3 Gray and eight cycles of adjuvant chemotherapy were delivered using vincristine, adriamycin and dexamethasone.

Patient was remain asymptomatic for 8 years than presented with lower limbs weakness with difficulty in walking and numbness in all limbs. Neurological examination revealed bilateral motor paresis in lower limbs and glove-stocking type of anesthesia in all limbs. Routine investigations showed moderate hepatomegaly with fatty changes, mild cardiomegaly and abnormal raised random blood sugar. MRI showed altered signal intensities in approximately all vertebral bodies predominantly in D1 and D2, post surgery changes at D6 and D7 [Figure 1] and spondolytic protrusions at C5-C6 level causing significant cord compression [Figure 2]. Cervicomedullary junction was normal and no adjacent soft tissue component was found. Endocrinal evaluation revealed diabetes mellitus type-2. The bone marrow biopsy and aspiration were negative for plasma cells. Twenty-four-hour urine test was negative for Bence-Jones protein. The monoclonal M-protein was detected only on immunofixation and was not evident on electrophoresis. Skin changes, ascites and effusion were not appeared.
Figure 1: Altered signal intensities multiple vertebral bodies and postsurgery changes at D6 and D7

Click here to view
Figure 2: Significant cord compression at C5-C6 level

Click here to view


POEMS syndrome is a chronic progressive polyneuropathy with a predominant motor disability. The acronym POEMS (polyneuropathy, organomegaly, endocrinopathy, M protein, and skin changes) refers to several dominant features of the syndrome; however, there are associated features not included in the acronym including sclerotic bone lesions, Castleman disease, papilledema, thrombocytosis, peripheral edema, ascites, effusions, polycythemia, fatigue and clubbing. [1],[2],[3]

To make the diagnosis, a patient should have the following: the peripheral neuropathy, osteosclerotic myeloma (i.e., clonal plasma cell dyscrasia and at least one sclerotic bone lesion) or Castleman disease and at least one of the other features. [3] Though the majority of patients have osteosclerotic myeloma, these same patients usually have only 5% bone marrow plasma cells or less, and rarely have hypercalcemia or renal insufficiency. These characteristics and the superior median survival differentiate POEMS syndrome from multiple myeloma.

Our patient presented mainly with symptoms of polyneuropathy, motor weakness and endocrinopathy with previous history of plasmocytoma. While multiple myeloma is usually characterised by the development of lytic bone lesions, there have been rare cases associated with widespread osteosclerotic lesions. [4] In our patient, distinction from multiple myeloma is based on the absence of dispersed plasma cells on bone marrow biopsy and aspiration, absence of Bence-Jones protein in urine and absence of related organ impairment. It is interesting to note that the monoclonal M-protein was detected only on immunofixation and was not evident on electrophoresis. This is a recognized phenomenon that is reflective of the low magnitude of the protein spike in POEMS and should be borne in mind when investigating clinically suspected cases. [3]

The plasma cells are virtually always λ-restricted. Although the pathophysiological mechanism is not well understood, there is a correlation between treating the underlying plasmaproliferative disorder (clone) and clinical improvement. Radiation therapy produces substantial improvement of the neuropathy in more than half of the patients who have a single lesion or multiple lesions in a limited area. If there are widespread lesions, conventional chemotherapy or high-dose chemotherapy and peripheral blood support may be helpful.

The overall median survival of patients with POEMS was 13.7 years in a large series. Those with clubbing or extravascular volume overload had median survivals of 2.6 and 6.6 years, respectively. [3] Patients with POEMS syndrome have limited response to plasmapharesis and intravenous immunoglobulin therapy. [5] Those with single or multiple osteosclerotic lesions in a limited area are usually treated with radiation and more than 50% of patients will have some response. [3] Some patients with solitary osteosclerotic lesions respond to surgical excision. [5] There have been reports of patients responding to excision of larger lesions even in the presence of more diffused lesions with marked improvement in polyneuropathy. [6] In those who have not responded, high-dose chemotherapy and peripheral blood stem cell transplant have been suggested. [3] These options should be considered in patients who do not respond to standard therapy. This case also illustrates the importance of immunofixation in detecting low levels of monoclonal protein when investigating a demyelinating polyneuropathy, the need for close monitoring, re-evaluation and consideration of aggressive surgical therapy and high-dose chemotherapy with stem cell support in patients with POEMS who do not respond to initial treatment.

 
 > References Top

1.Soubrier MJ, Dubost JJ, Sauvezie BJ. POEMS syndrome: A study of 25 cases and a review of the literature. French Study Group on POEMS Syndrome. Am J Med 1994;97:543-53.  Back to cited text no. 1
[PUBMED]    
2.Nakanishi T, Sobue I, Toyokura Y, Nishitani H, Kuroiwa Y, Satoyoshi E, et al. The Crow-Fukase syndrome: A study of 102 cases in Japan. Neurology 1984;34:712-20.  Back to cited text no. 2
[PUBMED]    
3.Dispenzieri A, Kyle RA, Lacy MQ, Rajkumar SV, Therneau TM, Larson DR, et al. POEMS syndrome: Definitions and long-term outcome. Blood 2003;101:2496-506.  Back to cited text no. 3
[PUBMED]  [FULLTEXT]  
4.Lacy MQ, Gertz MA, Hanson CA, Inwards DJ, Kyle RA. Multiple myeloma associated with diffuse osteosclerotic bone lesions: A clinical entity distinct from osteosclerotic myeloma (POEMS syndrome). Am J Hematol 1997;56:288-93.  Back to cited text no. 4
[PUBMED]  [FULLTEXT]  
5.Schey S. Osteosclerotic myeloma and 'POEMS' syndrome. Blood Rev 1996;10:75-80.  Back to cited text no. 5
[PUBMED]  [FULLTEXT]  
6.Rotta FT, Bradley WG. Marked improvement of severe polyneuropathy associated with multifocal osteosclerotic myeloma following surgery, radiation and chemotherapy. Muscle Nerve 1997;20:1035-7.  Back to cited text no. 6
[PUBMED]  [FULLTEXT]  


    Figures

  [Figure 1], [Figure 2]


This article has been cited by
1 Association of osteonecrosis of the jaws and POEMS syndrome in a patient assuming rituximab
Alessandro Allegra,Giacomo Oteri,Andrea Alonci,Francesco Bacci,Giuseppa Penna,Viviana Minardi,Valerio Maisano,Caterina Musolino
Journal of Cranio-Maxillofacial Surgery. 2013;
[Pubmed] | [DOI]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  >Article Figures
  In this article
>References

 Article Access Statistics
    Viewed2924    
    Printed100    
    Emailed0    
    PDF Downloaded222    
    Comments [Add]    
    Cited by others 1    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]