Pancreatic Plasmacytoma Presenting

Muslim Atiq
1
, Syed Abbas Ali
2
, Shyam Dang
1
, Somashekhar G Krishna
1
,
Elias Anaisse
2
, Kevin W Olden
1
, Farshad Aduli
1
1
Division of Gastroenterology and Hepatology,
2
Myeloma Institute of Research and Therapy;
University of Arkansas for Medical Sciences. Little Rock, AR, USA
ABSTRACT
Context Pancreatic plasmacytoma is a rare entity and presents with features of mass lesion of pancreas. Case report We present an
interesting case of pancreatic plasmacytoma with life threatening gastrointestinal bleeding secondary to isolated gastric varices.
Conclusion This case highlights the importance of considering it in differential diagnosis of patients with anemia, recurrent
pancreatitis or jaundice and isolated gastric varices, prompting a CT scan to evaluate for any pancreatic mass lesions.
INTRODUCTION
Extramedullary plasmacytomas are neoplastic plasma
cell proliferation outside the bone marrow [1, 2].
Pancreatic plasmacytomas are rare, with only a few
case reports in the literature [3, 4, 5]. We describe a
case of pancreatic plasmacytoma presenting as gastric
variceal hemorrhage secondary to splenic vein
thrombosis. The purpose of this report is to highlight
this rare manifestation of multiple myeloma especially
with regards to gastrointestinal manifestations of the
disease.
CASE REPORT
A 49-year-old Caucasian female with history of
diabetes type II, hypertension and congestive heart
failure underwent work up for recurrent episodes of
acute pancreatitis and was found to have a pancreatic
mass. The first episode of acute pancreatitis was at an
outside facility around 3 months prior to presentation at
our institution. Imaging results at our institution
revealed a pancreatic mass. Fine needle aspiration of
the lesion was consistent with monoclonal plasma cell
dyscrasia. Bone marrow biopsy confirmed the
diagnosis of multiple myeloma. She smoked one pack
of cigarettes per day; however she denied any alcohol
use. Chemotherapy was being contemplated when she
started to have acute onset of hematemesis with drop in
hemoglobin requiring transfusion of packed red blood
cells.
After hemodynamic resuscitation an esophagogastro-
duodenoscopy was performed. It showed normal
esophagus, without esophageal varices. The
gastroesophageal junction appeared normal. Retro-
flexion in the stomach showed presence of prominent
gastric varices with active bleeding. Endoscopic
sclerotherapy with sodium morrhuate was performed
with control of bleeding. Repeat CT scan of abdomen
revealed a 3.9 cm mass in the body of the pancreas
(Figure 1). The tumor resulted in the invasion and
occlusion of the splenic artery and vein. Multiple
collateral vessels were visible near the splenic hilum
and along the lesser and greater curvatures of the
stomach.
Received September 27th, 2008 - Accepted December 4th, 2008
Key words Esophageal and Gastric Varices; Gastrointestinal
Hemorrhage; Pancreatitis; Plasmacytoma
Correspondence Farshad Aduli
Division of Gastroenterology, University of Arkansas for Medical
 
Figure 1. A 3.9x3.4 cm mass is noted associated with the posterior
aspect of the body of the pancreas, with the loss of fat plane between
pancreas and retroperitoneum.

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Patient responded well to the endoscopic sclerotherapy.
No further intervention was needed. Based on the
tumor invasion of the splenic vein and artery, decision
was made to start patient on chemotherapy. Over the
following three months, she underwent myelosup-
pressive chemotherapy followed by stem cell
collection. Later, she underwent myeloablative
chemotherapy followed by autologous hematopoietic
peripheral stem cell transplantation. It resulted in
prompt decrease in size of tumor to 1.8x1.2 cm. Patient
has remained free of any recurrent variceal
hemorrhage. Repeat endoscopic assessment indicated
complete resolution of gastric varices.
DISCUSSION
Plasmacytoma is plasma cell tumor involving organs
outside the bone marrow, and it may be primary or
secondary [6]. Solitary plasmacytoma is defined as a
neoplastic proliferation of plasma cells which originate
in almost any tissue throughout the body, without any
sign of systemic spread [7, 8]. Approximately 10% of
extra medullary plasmacytomas occur in the
gastrointestinal tract, the stomach being the most
frequent site [7, 8].
On sonography, pancreatic infiltration by myeloma has
been described as a heterogeneous focal mass most
often located in the head of the pancreas that is
hypoechoic relative to the normal parenchyma and
shows fine internal echoes [9].
The CT features of this condition have been described
as a lobulated mass with homogeneous i.v. contrast
enhancement [9]. Diffuse enlargement of the pancreatic
gland has been cited in only a few cases [10].
To our knowledge, this is the first case of pancreatic
plasmacytoma with tumoral infiltration of splenic
vasculature resulting in gastric varices and hemorrhage.
This diagnosis should be considered in patient with
multiple myeloma and gastrointestinal bleeding.
Treatment should focus on hemodynamic resuscitation,
endoscopic control of bleeding if needed and
chemotherapy to allow tumoral mass reduction.
Conflict of interest The authors have no potential
conflicts of interest
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