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Brief Communication | Musculoskeletal Imaging

http://dx.doi.org/10.3348/kjr.2015.16.1.146
pISSN 1229-6929 · eISSN 2005-8330
Korean J Radiol 2015;16(1):146-153

Pelvic Solitary Plasmacytoma: Computed Tomography


and Magnetic Resonance Imaging Findings with
Histopathologic Correlation
Ying Wang, MM1, Xiu-Liang Zhu, MD1, Mohamad Wasil Peeroo, MB2, Zi-Hua Qian, MM1, Dan Shi, MM1,
Shu-Mei Wei, MD3, Ri-Sheng Yu, MD1
Departments of 1Radiology and 3Pathology, Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China; 2Zhejiang
University School of Medicine, Hangzhou 310012, China

Objective: To describe the imaging features of pelvic solitary plasmacytoma and to correlate them with the pathologic
grade.
Materials and Methods: A retrospective study was performed on the imaging features of 10 patients with a histological
diagnosis of pelvic solitary plasmacytoma. The imaging studies were assessed for bone expansion, cortical destruction,
signal intensity/density of soft tissue mass and enhancement manifestations, which were then correlated to the pathologic
grade.
Results: The imaging features of pelvic solitary plasmacytoma revealed 3 different types: multilocular type (n = 5),
unilocular type (n = 2) and complete osteolytic destruction type (n = 3) on computed tomography and MRI. Pathologically,
the tumors were classified into low, intermediate and high grades. Features such as multilocular change, perilesional
osteosclerosis, slight expansion, local bone cortex disruptions and masses inside bone destruction, often suggest a low-
grade solitary plasmacytoma; complete osteolytic destruction, huge soft tissue mass, and osseous defects imply a higher
pathologic grade.
Conclusion: Pelvic solitary plasmacytoma has various imaging manifestations, while a slight expansile osteolytic feature
with multilocular change or homogeneous enhancement highly suggests its diagnosis. The distinctive imaging features of
pelvic solitary plasmacytoma are well correlated to the pathologic grade.
Index terms: Plasmacytoma; Pelvic neoplasms; Computed tomography; Magnetic resonance imaging; Pathologic grade

INTRODUCTION disorder (1). It can be classified into 2 groups according


to its location; solitary plasmacytoma of the bone and
Solitary plasmacytoma is characterized by a localized extramedullary plasmacytoma (2, 3). The axial skeleton is
accumulation of neoplastic monoclonal plasma cells the most common location for the osseous lesions, while
without proof of a systemic plasma cell proliferative the upper respiratory tract is the most common location for
Received May 20, 2014; accepted after revision October 24, 2014. extramedullary lesions. The male to female ratio is 2:1 and
Corresponding author: Ri-Sheng Yu, MD, Department of Radiology, the median age at presentation is 55 years (4). However,
Second Affiliated Hospital, Zhejiang University School of Medicine, preceding trauma may increase incidence of solitary
No. 88 Jiefang Road, Hangzhou 310009, China.
plasmacytoma of the bone in younger people (5).
• Tel: (86571) 87783860 • Fax: (86571) 87784556
• E-mail: cjr.yurisheng@vip.163.com Solitary plasmacytoma has a significantly higher
This is an Open Access article distributed under the terms of risk for progression to multiple myeloma. A moderate-
the Creative Commons Attribution Non-Commercial License dose radiotherapy combined with surgery is occasionally
(http://creativecommons.org/licenses/by-nc/3.0) which permits
unrestricted non-commercial use, distribution, and reproduction in suggested for optimal treatment with sufficient local
any medium, provided the original work is properly cited. control. Nevertheless, for patients with high-grade

146 Korean J Radiol 16(1), Jan/Feb 2015 kjronline.org


Pelvic Solitary Plasmacytoma: Imaging Findings with Histopathologic Correlation

histology, adjuvant chemotherapy may be considered (3). The scan parameters were 120 kV, 160 mA, with a slice
Holland et al. (6) showed that chemotherapy delays the thickness of 5 mm. Six cases had 90–100 mL of the
progression time of plasmacytoma to multiple myeloma. nonionic contrast agent (iopamidol 300 mg L/mL) injected
The histologic grade is also linked to prognosis. The at an injection rate between 3.5–4.0 mL/s, for enhanced
patient with low-grade extramedullary plasmacytoma scanning. Images were obtained separately at the arterial
reported recurring or developing myeloma at 120 months, phase (25–32 seconds after injection) and the venous
while the high-grade tumor progressed at 26 months (7). phase (60–90 seconds after injection).
Solitary plasmacytoma of the bone has a poorer prognosis Eight of the 10 cases of pelvic solitary plasmacytoma
than extramedullary plasmacytoma. The median time of (including 2 cases after radiotherapy) underwent MRI. MR
progression to multiple myeloma following diagnosis was 25 scanning was performed using a 1.5-T or 3.0-T magnet
and 45 months in solitary plasmacytoma of the bone and (Signa, GE Medical Systems, Milwaukee, WI, USA) with
extramedullary plasmacytoma, respectively (8). an 8-channel torso-array coil. Axial T1-weighted images
The radiologic findings of this disease have not been and T2-weighted images were obtained from 8 patients,
well documented thus far. We found only a small number of and additional contrast-enhanced T1-weighted images
case reports on the radiological findings of pelvic solitary (Omniscan, GE Healthcare, Princeton, NJ, USA, 0.2 mL/kg
plasmacytoma and they mostly involved the sacrum (2, body weight) were obtained from all patients. The imaging
9-12). The imaging features with pathologic correlation parameters for T1-weighted images and T2-weighted
have not been reported previously. Thus, the goal of the images were as follows: repetition time/echo time of 440–
present study was to characterize the radiologic findings of 550/7.4–8.6 ms and 2600–4000/80–126 ms. Additional
pelvic solitary plasmacytoma and correlate those findings diffusion weighted single-shot echo-planar imaging (DWI)
with its pathology. was performed in 3 patients under breath-hold using the
following parameters: 4000/72.3 ms, 6 mm thickness,
MATERIALS AND METHODS matrix size = 128 x 128, b value = 0 and 700 s/mm2.

Subjects Image Analysis


We searched the pathology department database for cases Two radiologists separately reviewed all CT and MR images
of pelvic plasmacytoma diagnosed between December 2005 and both were blinded to the identity of the patient and
and March 2013. Thirty-four individuals were identified the clinical outcome. Any discordance was resolved by
and chosen during this step. One author reviewed all consensus. The images were then analyzed for the following
the detailed medical record reports and imaging studies, features: bone expansion, cortical destruction, signal
including computed tomography (CT), magnetic resonance intensity/density of soft tissue mass and enhancement
(MR), radionuclide bone imaging and 18F-fluorodeoxyglucose manifestations.
positron emission tomography. Twenty cases who presented
with multiple myeloma at the time of diagnosis were Pathologic Examination and Analysis
excluded. Therefore, a total of 10 patients (6 males and The pathologic specimens were obtained from the 10
4 were females; age range, 35 to 75 years; mean age, patients with pelvic solitary plasmacytoma for pathologic
55.5 years) were analyzed in the study. The most frequent correlation. The histological diagnosis of solitary
clinical signs and symptoms were skeletal pain (n = 8), plasmacytoma of the bone was based on the World
pathologic fractures (n = 6) and local masses (n = 2); lymph Health Organization classification system for hematologic
node enlargement was not seen in this group of cases. The malignancies: it requires a single area of bone damage
median follow-up period was 31.5 months (range, 2–82 due to clonal plasma cell hyperplasia; histologically
months). normal marrow aspirate and trephine samples; normal
skeletal survey results; no anemia, hypercalcemia, or renal
Radiological Examination impairment attributable to plasma cell dyscrasia; little or
CT scanning was performed with a 16-slice multidetector no serum or urinary monoclonal immunoglobulin (level
CT scanner (Somatom Sensation, Siemens Medical Systems, of 0.20 g/L, possibly indicative of multiple myeloma);
Erlangen, Germany). All patients received a plain scanning. and no additional lesions visible upon MR scan of the

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Wang et al.

spine 9 (3, 13, 14). Cases were graded according to the Cytoplasm was confined to a fairly narrow rim. Perinuclear
histological grading criteria devised by Bartl et al. (15) for hof was inconspicuous or absent.
multiple myeloma. This involves a 3-tiered grading system The correlation between the imaging findings and
summarized as follows: the pathologic features was assessed by a radiologist
Grade I (low grade), comprised of the Marschalko and who reviewed the CT images, and by a pathologist who
small cell types. Figure 1A showed a Marschalko type in reviewed the pathologic reports and the histological slices.
which the plasma cells were indistinguishable from normal Pathologic reviews were made while paying particular
cells, although mitotic figures were seen. attention to specific features in the solitary plasmacytoma
Grade II (intermediate grade), consisted of the cleaved, lesions.
polymorphous, and asynchronous cell types. Figure 2A
showed the asynchronous type in which there is marked RESULTS
discrepancy of maturation between the nucleus and
cytoplasm. At least 50% of the cells had enlarged nuclei CT Findings
with prominent nucleoli, while the abundant basophilic All 10 cases of pelvic solitary plasmacytoma revealed 3
cytoplasm and perinuclear hof were maintained. different CT findings:
Grade III (high grade), represented the plasmablastic 1) The multilocular type: 5 cases, with 2 cases in
type. Figure 3A showed a plasmablastic type with large the sacrum and the ilium respectively, and 1 case in
nuclei and very prominent centrally located nucleoli. the ischium. The 2 cases in the sacrum showed a slight

A B

C
Fig. 1. Unilocular type solitary plasmacytoma in 58-year-old female (case 6).
A. Pathologic hematoxylin and eosin staining (x 400) demonstrates low-grade plasmacytoma with plasma cells indistinguishable from normal
cells. B. Unenhanced CT shows slight expansile osteolytic lesion with perilesional osteosclerosis. C. Contrast-enhanced CT shows lesion with
marked homogeneous enhancement.

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Pelvic Solitary Plasmacytoma: Imaging Findings with Histopathologic Correlation

expansile osteolytic lesion with multilocular change, MR Findings


consisting of the mass itself and the remaining sacrum. MRI in 8 patients revealed the following:
The 2 cases in the ilium showed slight expansion, partial 1) Seven cases before radiotherapy showed low signal
multilocular change (Fig. 2B, C). The case involving the intensity lesions on T1-weighted images, with high signal
ischium showed expansile osteolytic lesion with bone cortex intensity lesions on T2-weighted images in 5 of the 7
disruptions. Three of the 5 cases with contrast-enhanced CT cases (Fig. 4A). The other 2 cases showed heterogeneous
scanning, showed marked homogeneous enhancement. low signal intensity lesions on T1-weighted images and
2) The unilocular type: 2 cases in the sacrum, showed heterogeneous high signal intensity on T2-weighted images;
slight expansile osteolytic lesion with marked homogeneous high signal intensity lesions on DWI (Fig. 4B) in 3 cases;
enhancement in both cases and perilesional osteosclerosis homogeneous enhancement in 5 cases and heterogeneous
in 1 case (Fig. 1B, C). enhancement in 2 cases (Fig. 3B).
3) The complete osteolytic destruction type: 3 cases 2) Two cases after radiotherapy showed low signal
in the ilium, showed slight expansion, bone cortex intensity on both T1-weighted images and T2-weighted
disruptions, osseous defects, and a large soft tissue mass images (Fig. 5); and heterogeneous enhancement on
extending outside the bone structure. One of the 3 cases meglumine gadoterate-enhanced T1-weighted image.
with contrast-enhanced CT scanning, showed marked
homogeneous enhancement.

A B

C
Fig. 2. Multilocular type solitary plasmacytoma in 52-year-old man (case 3).
A. Pathologic hematoxylin and eosin staining (x 400) demonstrates intermediate-grade plasmacytoma with plasma cells containing large
eccentric nuclei with prominent nucleoli and abundant basophilic cytoplasm. B, C. Bone window CT shows slight expansile osteolytic lesion with
partial multilocular change (B) and local bone cortex interruption (C) in right ilium.

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Wang et al.

A B
Fig. 3. Complete osteolytic destruction type solitary plasmacytoma in 75-year-old female (case 9).
A. Pathologic hematoxylin and eosin staining (x 400) demonstrates high-grade plasmacytoma with many cells exhibiting plasmablastic features
with frequent mitoses. B. Enhanced T1-weighted image in axial plane shows heterogeneous enhancement of soft tissue mass in right ilium.

A B
Fig. 4. Multilocular type solitary plasmacytoma in 57-year-old female (case 2).
A, B. Axial fat suppressed T2-weighted sequences (A) and diffusion-weighted imaging (B) shows high signal with linear low signal within lesion
in sacrum.

Correlation of Pathologic Results with the Imaging homogeneous heterogeneous enhancement.


Findings MRI findings of the pelvic solitary plasmacytoma (7
All tumors were consistent with a diagnosis of solitary cases before radiotherapy) correlated with the pathologic
plasmacytoma of the bone, with 3 cases in Grade I, 4 in features revealed the following: 1) Grade I showed well-
Grade II, and 3 in Grade III. defined lesions with marked homogeneous enhancement,
The CT findings correlated with the pathologic grades and the remaining bone inside or around the lesion showed
revealed the following: 1) Grade I showed slight expansion, linear low signal inside on T2-weighted images and DWI. 2)
bone cortex thinning and disruption, complete multilocular Grade II showed masses of homogeneous signal intensity
change or unilocular change with perilesional osteosclerosis inside the bone structure, less remaining viable bone,
and lesions with marked homogeneous enhancement. 2) homogeneous enhancement and high signal on DWI. 3)
Grade II showed partial multilocular change or unilocular Grade III showed huge masses extending outside the bone
change without osteosclerosis, bone cortex disruptions and structure with homogeneous (1/3) or heterogeneous (2/3)
masses inside the bone structure with marked homogeneous signal intensities.
enhancement. 3) Grade III showed complete osteolytic The imaging features and the pathologic findings were
destruction, bone cortex disruptions and osseous defects, summarized in Table 1.
and a large soft tissue mass outside the bone with

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Pelvic Solitary Plasmacytoma: Imaging Findings with Histopathologic Correlation

Outcomes
One of 3 cases with Grade I pathology, had a recurrence
of low-grade tumor at 36 months after diagnosis and
subsequently developed disseminated bone disease of
myeloma at 38 months. Two of the 4 cases progressed to
multiple myeloma at 25 and 33 months after diagnosis,
respectively. One of the 3 cases in Grade III developed
recurrence at 12 months.

DISCUSSION

Imaging reports have indicated that solitary


plasmacytoma of the bone are mostly located in
the vertebra and long bone (16, 17). The number of
Fig. 5. Multilocular type solitary plasmacytoma in 56-year- publications on the imaging of pelvic solitary plasmacytoma
old man (case 1). T1-weighted images and T2-weighted images
in sagittal plane show low signal of lesions and high signal of fifth is very limited. The published radiological findings of
lumbar vertebra after radiotherapy. solitary plasmacytoma of the bone were mostly an expansile

Table 1. Summary of Imaging Features and Pathologic Grades in 10 Cases


Radiological Findings Pathologic
Case Age/Sex Site
CT MRI Grade
After radiotherapy: low signal on both T1WI and T2WI
1 56/M Sacrum Multilocular change I
Heterogeneous enhancement
Low signal on T1WI
High signal with linear low signal inside on T2WI and DWI
2 57/F Sacrum Multilocular change I
Marked homogeneous enhancement
After radiotherapy: low signal on both T1WI and T2WI
Low signal on T1WI
Partial multilocular change
3 52/M Ilium High signal with linear low signal inside on T2WI II
Marked homogeneous enhancement
Marked homogeneous enhancement
Low signal on T1WI
Partial multilocular change
4 58/M Ilium High signal with linear low signal inside on T2WI II
Marked homogeneous enhancement
Marked homogeneous enhancement
Partial multilocular change
5 35/M Ischium No MRI obtained II
Homogeneous enhancement
Unilocular change
6 58/F Sacrum Perilesional osteosclerosis No MRI obtained I
Marked homogeneous enhancement
Low signal on T1WI
Unilocular change
7 45/F Sacrum High signal on T2WI and DWI II
Marked homogeneous enhancement
Marked homogeneous enhancement
Heterogeneous low signal on T1WI
Complete osteolytic destruction
8 44/M Ilium Heterogeneous high signal on T2WI III
Huge soft tissue mass
Slight heterogeneous enhancement
Low signal on T1WI
Complete osteolytic destruction
9 75/F Ilium High signal on T2WI III
Soft tissue mass
Heterogeneous enhancement
Complete osteolytic destruction Low signal on T1WI
10 75/M Ilium Round soft tissue mass High signal on T2WI and DWI III
Marked homogeneous enhancement Marked homogeneous enhancement
Note.— DWI = diffusion weighted imaging, T1WI = T1-weighted imaging, T2WI = T2-weighted imaging

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Wang et al.

osteolytic lesion with marked enhancement on CT or MRI. marked homogeneous enhancement on MR images may be
Kosaka et al. (9) reported that 3 cases of sacral solitary helpful for the diagnosis of pelvic solitary plasmacytoma.
plasmacytoma showed relatively low signal intensity on T2- Furthermore, DWI of pelvic solitary plasmacytoma has
weighted images. Our study provided a somewhat different not been reported previously. We found that the pelvic
but interesting insight on the subject. solitary plasmacytoma masses showed high signal on
The CT features of pelvic solitary plasmacytoma can be DWI. We believe that this feature is helpful for diagnosis;
summarized as 3 types: multilocular type, unilocular type furthermore, it may be triggered by plasma cell aggregation,
and complete osteolytic destruction type. The multilocular causing limited diffusion. Given the low number of cases
type includes complete multilocular change and partial on DWI, further studies are clearly needed. Moreover, MRI
multilocular change. The former is seen in the sacrum, is more suitable for reexamination after radiotherapy to
consisting of the mass itself and the remaining sacrum; the show a curative effect that includes size and signal change.
lesion consists of the expansion and destruction of the bone Two cases after radiotherapy in our groups showed low
cortex, sometimes with a thinning bone ridging around the signal intensity on T2-weighted images and heterogeneous
periphery, creating a “soap bubble” appearance. The latter enhancement on MRI. We inferred that the low signal
is seen in the ilium or the ischium, similar to the “mini intensity on T2-weighted images might be related to
brain” described in a spinal solitary plasmacytoma (16). post-radiotherapy fibrous tissue hyperplasia, while the
This multilocular change has not been described for pelvic heterogeneous enhancement may have resulted from
solitary plasmacytoma in previous literature, nor has it ever necrosis or degeneration within the masses (18).
been seen in other tumors like osteosarcoma, lymphoma and The relationship between imaging features and
chordoma, during our long-term clinical work. Therefore, pathological grading of pelvic solitary plasmacytoma has
we believe that this change has particular importance not been reported previously. We found that distinctive
for the diagnosis of pelvic solitary plasmacytoma. The CT imaging appearances of pelvic solitary plasmacytoma
unilocular type is seen in the sacrum and is compatible are closely correlated to its pathologic grades. Features
with the previous literature (9). This type demonstrates such as multilocular change, slight expansion, local bone
slight expansion with soft tissue mass showing marked cortex disruptions, perilesional osteosclerosis, masses
homogeneous enhancement on the enhanced CT. The inside bone destruction, often suggest a low-grade solitary
complete osteolytic destruction type is seen in the ilium, plasmacytoma of the bone. A more obvious and distinct
showing slight expansion but with huge soft tissue mass multilocular change indicates a lower pathologic grade.
extending outside the bone structure, which in fact is not While advanced solitary plasmacytoma of the bone often
compatible with findings in the previous literature. We has complete osteolytic destruction with little or no local
believe that this manifestation may be related to their multilocular change, there are also large soft tissue masses,
higher degree of malignancy. obvious bone cortex disruptions, and osseous defects.
MRI is less advantageous compared to CT in displaying However, the enhancement degree of the mass may not be
the imaging features of bone destruction, like multilocular related to its pathologic grades.
or unilocular change, expansion lesions or punched-out The MR imaging findings of pelvic solitary plasmacytoma
defects. It can only demonstrate some linear low signal also correlated to its pathologic grades, especially to
intensity inside the soft tissue mass or the dark signal the manifestation of soft tissue mass. The mass is often
bone cortex around the mass. Nevertheless, MRI still confused with a low pathologic grade, and vice versa, since
has its particular imaging features and specific values, it is similar to primary bone formation or within the bone
which makes it indispensable to imaging technology. destruction, and has homogeneous or some linear low
The solitary plasmacytoma of the bone lesions before signal intensity within, or perilesional dark rim (remaining
treatment often show homogeneous low signal intensity bone). The signal intensity on both T1-weighted images
on T1-weighted images and high signal on T2-weighted and T2-weighted images is thought to be unrelated to the
images. None of our cases showed low signal intensity pathologic grades.
on T2-weighted images, which was contrary to published Imaging studies showed that pelvic solitary plasmacytoma
findings (9). However, MRI is more advantageous than CT has obvious malignant tumor characteristics, and therefore
in displaying the enhancement features of the mass. The pelvic solitary plasmacytoma should be considered in

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Pelvic Solitary Plasmacytoma: Imaging Findings with Histopathologic Correlation

the differential diagnosis of many primary bone tumors involving young individuals, is there a role for preceding
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