Chest X-Ray Reveals Large Pleural Mass
A 70-year-old woman with no history of smoking or asbestos exposure presented with dyspnea on exertion, nonproductive cough, left-sided pleuritic chest pain, and fatigue. Chest radiography revealed a large left pleural effusion and a mass in the left lower lobe. Chest CT confirmed a pleural-based mass of 7.8 × 5.5 cm invading the anterior chest wall. A left-sided thoracentesis revealed a bloody, lymphocyte-predominant exudative pleural effusion, with a white blood cell count of 8,144/μL (26% lymphocytes, 2% neutrophils, 3% monocytes, and 69% other cell-line types). A cytologic examination of the pleural fluid and a biopsy of the pleural mass were performed, followed by aspiration and biopsy of the bone marrow.
E. Multiple myeloma
In adults, 95% of malignant pleural effusions arise from a metastatic source. Lung cancer, breast cancer, and lymphoma account for 75% percent of all cases. In about 6% of cases, the primary site of malignancy cannot be determined. Around half of breast cancer patients develop a pleural effusion in their lifetime, compared with one-quarter of patients with lung cancer and one-third of patients with lymphoma. Pleural effusions can occur in up to 6% of patients with multiple myeloma; however, only 1% of cases are due to primary myelomatous infiltration or pleural involvement.[3-4]
In 40% to 87% of thoracentesis procedures, a cytologic evaluation can confirm the malignancy of a pleural effusion. If pleural fluid cytology is nondiagnostic, direct pleural sampling will usually yield a diagnosis: more than 90% of biopsies are diagnostic.
Here, the lack of a smoking history and of asbestos exposure, and the differential white blood cell count, along with cytologic examination of the pleural fluid, all pointed to a diagnosis of multiple myeloma. The biopsy of the pleural-based mass, followed by a bone marrow aspiration and biopsy, which revealed 24 % atypical plasma cells in the marrow, confirmed the diagnosis. Further work-up with flow cytometric analysis of the pleural fluid revealed a population of plasma cells expressing CD38, CD138, and CD56, and also demonstrated monocytes with cytoplasmic surface kappa light chain in 80% of the cells. Urine protein electrophoresis showed a monoclonal IgG kappa light chain band in the gamma region.
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2. Roberts ME, Neville E, Berrisford RG, et al. Management of a malignant pleural effusion: British Thoracic Society Pleural Disease Guideline 2010. Thorax. 2010;65(suppl 2):ii32-ii40.
3. Zhang LL, Li YY, Hu CP, Yang HP. Myelomatous pleural effusion as an initial sign of multiple myeloma—a case report and review of the literature. J Thorac Dis. 2014;6:E152-E159.
4. Kamble R, Wilson CS, Fassas A, et al. Malignant pleural effusion of multiple myeloma: prognostic factors and outcomes. Leuk Lymphoma. 2005;46:1137-42.