Case Report Multiple Myeloma Breast Involvement: A Case Report

Abstract

Multiple Myeloma involving the breast is very rare and the diagnosis is challenging because the clinical and radiological features of breast multiple myeloma are indistinguishable to other forms of breast disease whether primary or metastatic. In this article the authors report a case presented with breast masses, which were found to be extra osseous Multiple Myeloma. e patient was managed for multiple spinal lesions that were primarily thought to be metastasis from primary breast cancer.

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Case Report
Multiple Myeloma Breast Involvement: A Case Report
Heba O. E. Ali ,1 Zafar Nasir,2 and Ahmed M. S. M. Marzouk3,4
1Consultant Breast Radiology, Altnagelvin Area Hospital, WHSC Trust, Glenshane Rd, Londonderry BT47 6SB, UK
2Consultant Radiology, Altnagelvin Area Hospital, WHSC Trust, Glenshane Rd, Londonderry BT47 6SB, UK
3Consultant General Surgery, Altnagelvin Area Hospital, WHSC Trust, Glenshane Rd, Londonderry BT47 6SB, UK
4Consultant General Surgery, Faculty of Medicine, Cairo University, Al-Saray Street, El Manial, Cairo 11956, Egypt
Correspondence should be addressed to Heba O. E. Ali; hebaosama@live.com
Received 27 May 2019; Accepted 26 August 2019; Published 9 October 2019
Academic Editor: Atsushi Komemushi
Copyright © 2019 Heba O. E. Ali et al. is is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Multiple Myeloma involving the breast is very rare and the diagnosis is challenging because the clinical and radiological features
of breast multiple myeloma are indistinguishable to other forms of breast disease whether primary or metastatic. In this article
the authors report a case presented with breast masses, which were found to be extra osseous Multiple Myeloma. e patient was
managed for multiple spinal lesions that were primarily thought to be metastasis from primary breast cancer.
1. Introduction
Multiple myeloma (MM) is a hematological malignancy
characterized by the clonal proliferation of plasma cells in
the bone marrow with increased formation of monoclonal
immunoglobulins [1]. e average patient age at diagnosis
is sixth decade of life, and the disease is very rarely seen in
patients aged <40 years. MM can aect extraosseous sites as
solitary lesions (extramedullary plasmacytoma) or as a pres-
entation of MM relapse in less than 5% of cases. Moreover,
MM in the breast has been rarely documented [2–4]; the rst
case of MM in the breast was reported in 1925 [4]. Since
then, only 20 other patients with breast involvement have
been documented in the literature till date [5]. Here we
report an unusual presentation of MM, focusing on the imag-
ing ndings.
2. Case Report
A 40-year-old woman complaining of severe back pain for
several months, which then progressed to bilateral lower
limb weakness, visited our hospital. Her medical history was
unremarkable. Initial magnetic resonance imaging (MRI) of
the spine revealed multiple, variable-sized, well-dened,
round lesions with so tissue masses compressing the spinal
cord (Figure 1). Spinal xation was performed (Figure 2).
e initial diagnosis was considered to be metastasis of
unknown origin. Clinical examination revealed a lump in
the le breast, which was believed to be the primary breast
neoplasm and was further investigated; meanwhile, bone
biopsy was arranged.
Mammography was performed, which revealed dense
breasts (Figures 3 and 4). Ultrasonography (US) of both
breasts revealed a well-dened hypoechoic solid lesion in the
le breast 4 o’clock in location at the site of the clinically pal-
pable lump, measuring 18 mm × 13 mm; US revealed a second
similar lesion at 1 o’clock in location, measuring 16 mm × 7 mm
(Figures 5 and 6); these lesions were both classied as U3.
Subsequently, US-guided core biopsies of both lesions were
performed (Figures 7 and 8).
Pathological examination revealed large sheets of atypical
plasma cells, which displayed rounded nuclei with coarse
chromatin and conspicuous nucleoli; abundant eosinophilic
cytoplasm was present in some cells. Mitotic gures and apop-
totic cells were readily identied. Immunohistochemistry
revealed that the atypical cells were positive for CD138 and
CD56 and focally positive for CD79a; the cells were lambda
restricted. e appearance was entirely consistent with a
plasma cell neoplasm involving the breast. e features were
similar in both breast lesions.
T11 biopsy and bone marrow trephine revealed atypical
plasma cell inltrate/neoplasm (Figure 9).
Hindawi
Case Reports in Radiology
Volume 2019, Article ID 2079439, 5 pages
https://doi.org/10.1155/2019/2079439

Case Reports in Radiology2
3. Discussion
MM, a disease of plasma cells, aects individuals in their mid-
dle age with an incidence of 3–4 cases/100,000 individuals in
the United States population. A majority of the patients with
plasma cell neoplasia present with generalized disease at diag-
nosis; a minority of patients present with a single extramed-
ullary mass of monoclonal plasma cells (plasmacytoma) either
in bone (97%) or so tissues (3%) which may present as soli-
tary lesion or as a relapse of MM which is explained by clonal
evolution due to variety of theories [6]. A breast mass is a very
rare presentation in MM, and most plasmacytomas in the
breast have been identied in women with a mean age of pres-
entation of 53 years [6–10].
Breast MM can be single or multiple. Unilateral and bilat-
eral presentations have been reported, with lesion sizes rang-
ing between 1 cm and 7.5 cm; further, axillary lymph node
involvement has been reported [8]. ese tumors may present
as solitary plasmacytic tumors without the evidence of
F 1:MRI shows multiple, variable-sized, well-dened round
lesions.
F 2:Post-spinal decompression and spinal xation MRI.
F 3: Mammogram CC view showing dense breasts
(inconclusive).
F 4: Mammogram MLO view showing dense breasts
(inconclusive).
F 5: Ultrasound of the le breast showing a well-dened
hypoechoic solid mass lesion, measuring 16 mm × 7 mm.

3Case Reports in Radiology
concurrent MM or can precede, occur at the same time, or
present aer the diagnosis of MM [9]. An average time of
1.5–2.5 years is needed by 30%–50% of extramedullary plas-
macytoma cases to progress to MM [11].
In this report, the patient showed unusual presentation
because she was young; MM is typically a disease of older
adults with the median age at diagnosis being 66 years. Only
10%, 2%, and 0.3% of patients are younger than the ages of 50,
40, and 30 years, respectively [12, 13]. Clinically, most patients
with MM in the breast will present with a palpable mass; how-
ever, skin thickening and inammation can occur and be con-
fused with breast abscess or inammatory carcinoma [14].
e dierential diagnosis of such a mass that presents within
the clinical context of plasma cell neoplasms includes primary
epithelial neoplasm of the breast, plasma cell mastitis, non-
Hodgkin’s lymphoma with plasmacytic features, epithelioid
malignant melanoma, and pseudolymphoma [15]. e fea-
tures of MM in the breast (Table 1) are indistinguishable from
those of the other forms of breast diseases, whether primary
or metastatic; therefore, same imaging protocol that is applied
for any suspicious breast mass is used for plasmacytic tumors.
In a mammogram, MM can present as single or multiple
well-dened, ill-dened, or speculate mass lesions or even
with microcalcications. which represent nonspecic ndings
[7]. In our case, the mammogram was inconclusive owing to
the patient’s age.
US ndings typically include well-dened hypoechoic or
hyperechoic solid mass lesions [7]; in our case, the results of
US resembled a broadenoma. In MRI ndings, MM appears
hypointense on T1WIs and hyperintense on T2WIs and shows
early ring enhancement with washout in postcontrast images
[7]. Breast plasmacytomas demonstrate low-grade uptake of
18-uorodeoxyglucose, but PET-CT can assess the extent of
disease [14].
Because mammography, US, and MRI ndings may not
be diagnostic, the dierential diagnosis for primary carci-
noma, other lymphoproliferative diseases, and even benign
masses depends on histopathological evaluation [4]. Breast
MM/plasmacytoma treatment depends on the systemic
extent of the disease. Although chemotherapy and radiother-
apy are the most frequent treatment options, surgical resec-
tion and lymph node dissection can also be considered
[8, 13–17].
4. Conclusion
In conclusion, there are no denite radiological features for
MM in the breast. When multiple breast masses are detected,
secondary involvement of a hematological disorder, metastatic
F 6:Ultrasound of the le breast showing a second well-dened
hypoechoic s olid mass, measuring 18 mm × 13 mm.
F 7:Ultrasound-guided core biopsy image of the rst lesion
(14-gauge needle).
F 8: Ultrasound-guided core biopsy of the second lesion
(14-gauge needle).
T 1:Radiological features of plasmacytoma breast lesions.
Possible radiological features of plasmacytoma breast lesions
(Nonspecic)
Mammogram
(i) Hyperdense, round or oval, masses with well- or ill-dened
margins.
(ii) Diuse inltration.
(iii) Microcalcications (rare).
Ultrasound
(i) Echo-poor or hypoechoic well-dened masses with
hypervascularity.
(ii) Mixed hypo- to hyperechoic lesions with indistinct margins.
(iii) Posterior acoustic features:
(1) Enhanced or no acoustic transmission.
(2) Posterior acoustic shadowing.
Magnetic resonance
(i) Hypointense on T1WIs.
(ii) Hyperintense on T2WIs.
(iii) Early ring enhancement with washout in postcontrast images.

Case Reports in Radiology4
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Ethical Approval
is article follows the ethical guidelines in accordance with
the Declaration of Helsinki (1964).
Conflicts of Interest
e authors declare that they have no conicts of interest.
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