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CASE REPORT
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Breast and thyroid involvement in multiple myeloma: The cytological diagnosis and a rare case report


1 Department of Pathology, Government Medical College, Kota, Rajasthan, India
2 Pushpadi Cancer Care Center, Kota, Rajasthan, India

Date of Submission21-Apr-2020
Date of Decision19-Aug-2020
Date of Acceptance21-Sep-2020

Correspondence Address:
Lakshmi Agarwal,
Department of Pathology, Government Medical College, Rangbari Road, Kota, Rajasthan
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjdrdypu.mjdrdypu_201_20

  Abstract 


Extra medullary involvement of multiple myeloma is a known phenomenon, but breast and thyroid are rarely involved. This patient presented in onco-surgery OPD with breast lump and thyroid enlargement. The diagnosis of multiple myeloma involving both organs was made in a retrograde fashion. FNAC played a key role in diagnosing this lesion. A thorough clinical, radiological evaluation, strong suspicion and immunohistochemistry helped confirm the diagnosis of multiple myeloma.

Keywords: Breast lump, lymphoma, multiple myeloma, thyroid enlargement



How to cite this URL:
Agarwal L, Agarwal M, Rai N, Saxena R. Breast and thyroid involvement in multiple myeloma: The cytological diagnosis and a rare case report. Med J DY Patil Vidyapeeth [Epub ahead of print] [cited 2021 Dec 6]. Available from: https://www.mjdrdypv.org/preprintarticle.asp?id=319167




  Introduction Top


Multiple myeloma is a disseminated B-cell lineage neoplasm characterized by monoclonal proliferation of the plasma cells in the bone marrow.[1] Extramedullary involvement of multiple myeloma is a known phenomenon.[2] Although rare, single organ involvement is quite frequent in the literature. The present case report deals with multiple organ involvement, where the diagnosis of multiple myeloma was performed in a retrograde fashion. Till date, no case has been reported on simultaneous involvement of the breast and thyroid.


  Case Report Top


A 70-year-old female presented to the surgical oncology outpatient department with a breast mass. Systemic examination revealed a nontender, left breast mass measuring 4 cm × 4 cm at the upper outer quadrant with multiple small axillary nodes of 2 months' duration and a solitary thyroid nodule at the left lobe of 2 years' duration. The previous fine-needle aspiration cytology (FNAC) from the breast mass was reported as infiltrating duct carcinoma (IDC) and from the thyroid mass was reported as an immunoblastic variety of non-Hodgkin's lymphoma. The repeat FNAC from the breast and thyroid lesion was performed using the 24-gauge needle attached with a 10 ml syringe. The aspirate was blood mixed in nature. Multiple smears were made. They were air-dried and fixed in methanol. Smears were stained by May–Grunwald–Giemsa stain. Smears from both the thyroid and breast lesions reveal a significant increase in the plasma cells [Figure 1]a, [Figure 1]b, [Figure 1]c, [Figure 1]d. Numerous immature plasma cells, Mott cells, and bi and multinucleated plasma cells were also seen. Based on the morphology of cells, the diagnosis of the plasma cells' neoplasm was favored. The complete blood count revealed hemoglobin of 12.6 gm% and total leukocytes count of 6000/μl. Peripheral smear examination revealed no abnormal cells. Bone marrow aspirate was done and showed 60% of plasma cells in different stages of maturations [Figure 1]e and [Figure 1]f. Further workup of the patient revealed osteolytic lesions in the rib and punched out lesions in the skull. The serum electrophoresis showed M band [Figure 2]. Thus, the final diagnosis of multiple myeloma was performed and was treated with systemic therapy. The patient is doing well for the past 2 years.
Figure 1: (a and b) Cytosmear from the breast lesion reveals plasma cells at different stages of maturation (Giemsa stain, ×400). (c and d) Smear from the thyroid mass reveals bare nuclei of the plasma cells and a few cells with intact cytoplasm (Giemsa stain, ×200, ×400). (e and f) Smears from bone marrow aspirations showing the significant increase in plasma cells (Giemsa stain, ×100, ×400)

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Figure 2: Serum protein electrophoresis showing M band

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  Discussion Top


Multiple myeloma is a systemic disease with marrow involvement. Extraosseous site involvement is not uncommon and can involve any organ.[1],[2] Among all organs, breast and thyroid are rarely involved and never simultaneously. Only 13 cases of breast plasmacytoma were reported till 2009.[3] In the breast, myeloma presents as an extramedullary manifestation with known bone marrow involvement and rarely occurs in the absence of marrow disease. The extension of a plasma cell malignancy to the thyroid is exceedingly very rare, although a few cases of thyroid involvement by multiple myeloma have been reported.[4]

Plasmacytoid cells on FNAC of the breast mass are seen in many diseases of the breast, which include lobular carcinoma of the breast, pleomorphic lobular carcinoma, infiltrating duct cell carcinoma of apocrine type, carcinoma with endocrine differentiation, plasmacytoma of breast, and non-Hodgkin's lymphomas.[5],[6] Thus, differentiating plasmacytoma/extraosseous myeloma from the disease of the primary tissue is critical for management.

Extramedullary plasmacytoma of the thyroid usually presents with painless, firm, nontender, mobile, multinodular, or diffuse thyroid mass with no associated cervical lymphadenopathy (usually misinterpreted as goiter). On FNAC of the thyroid, plasmacytoid cells are seen in thyroiditis, medullary carcinoma of the breast, non-Hodgkin's lymphomas, and plasmacytomas.[7] Plasma cells can be differentiated from plasmacytoid cells by the presence of paranuclear halo, cartwheel chromatin, lack of intracytoplasmic mucin, and presence of multinucleated cells along with Russell and Dutcher bodies. A trucut biopsy of the lesion can be done for confirmations if the aspirate is inconclusive. Plasma cells are positive for CD138, MUM1, CD56, and PAX5 on immunohistochemistry (IHC).

It is important to differentiate it from epithelial malignancy since the principal mode of treatment in multiple myeloma is systemic therapy, whereas in plasmacytoma, it is a localized treatment either radiotherapy or surgery. In the present case, the patient presented with breast mass along with thyroid nodules and bony lesion which raised suspicion against the previous diagnosis of IDC. Repeat FNAC both from the breast and the thyroid mass revealed similar findings with raised plasma cells which prompted us to evaluate in the line of multiple myeloma.

Sometimes, the cytological diagnosis of multiple myeloma is difficult due to lack of clinical or instrumental features that allow us to differentiate between multiple myeloma and carcinoma or lymphoma. Clinical correlation and IHC can confirm the diagnosis.


  Conclusion Top


The extension of a plasma cell malignancy to the thyroid and breast is exceedingly rare. We highlight the rarity of thyroid and breast involvement in hematological malignancies in contrast to the relative frequency of primary carcinoma or metastasis that originates from the other site. A thorough clinical evaluation along with relevant investigations confirms the diagnosis of multiple myeloma. IHC can also help in diagnosing this. It was not done in the present case since the diagnosis was confirmed by the bone marrow and protein electrophoresis findings.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Varettoni M, Corso A, Pica G, Mangiacavalli S, Pascutto C, Lazzarino M. Incidence, presenting features and outcome of extramedullary disease in multiple myeloma: A longitudinal study on 1003 consecutive patients. Ann Oncol 2010;21:325-30.  Back to cited text no. 1
    
2.
Pasmantier MW, Azar HA. Extra skeletal spread in multiple plasma cell myelomas. Cancer 1969;23:167-74.  Back to cited text no. 2
    
3.
Fayyaz A, Ghani UF. Multiple breast masses in a case of multiple myeloma. J Coll Physicians Surg Pak 2009;19:529-30.  Back to cited text no. 3
    
4.
Alarion N, Kelly A, Fouilhoux G, Darcha C, Trechot I, da Costa V, et al. Case of thyroid involvement by multiple myeloma. J Clin Oncol 2013;31:e380-2.  Back to cited text no. 4
    
5.
Merino MJ. Plasmacytoma of the breast. Arch Pathol Lab Med 1984;108:676-8.  Back to cited text no. 5
    
6.
Proctor NS, Rippey JJ, Shulman G, Cohen C. Extramedullary plasmacytoma of the breast. J Pathol 1975;116:97-100.  Back to cited text no. 6
    
7.
Avila A, Villalpando A, Montoya G, Luna MA. Clinical features and differential diagnoses of solitary extramedullary plasmacytoma of the thyroid: A case report. Ann Diagn Pathol 2009;13:119-23.  Back to cited text no. 7
    


    Figures

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