VCOM Research Day Program Book 2023

Medical Resident Research Case Reports

02 Multiple Myeloma (MM) in a Young Male Adult, a Rare Phenomenon: Single Case Presentation

David M. Johnson, DO, Crystal B. Lafleur, DO, Tanner Bazemore, BS, Heather Brooks, MD Corresponding author:

LewisGale Hospital Montgomery Internal Medicine Residency Program

stepping into a hole at work. Physical exam revealed mild mid-thoracic tenderness on palpation and was unremarkable for any neurological deficits. CT scans revealed multiple spinal lesions concerning for malignancy. MRI of the cervical and thoracic an infiltrative lesion at T5 with paraspinal soft tissue extension, and additional enhancing lesions at T10, T11, and involving the left fifth. MRI of the lumbar spine showed multiple round enhancing bone marrow lesions in the L4 vertebral body, sacrum, and visualized iliac bones consistent with diffuse osseous metastatic disease. CBC and CMP were within normal limits. Serum and urine protein electrophoresis with immunofixation and serum free light chain analysis was performed. These revealed a serum M-spike of 0.6 (units) and a free kappa/ lambda ratio 2.83 (units). CT-guided biopsy of the T5 bone lesion was performed and revealed plasma cell dyscrasia. Bone marrow biopsy and aspirate revealed plasma cell myeloma, kappa light chain restricted, however, most of the marrow did not show significant plasma cell infiltrate. The plasma cells accounted for about 10% of the overall cellularity. Flow cytometry detected only 0.8% monoclonal plasma

cells. FISH revealed monosomy 17 (along with other cytogenic abnormalities) which is associated with a poor prognosis. The presence of significant skeletal involvement without significant serum involvement suggested that this patient’s disease had characteristics more consistent with macrofocal MM compared to typical MM. Outcomes: Repeat CT scan four days after biopsy showed progressive collapse of the T5 vertebral body. Subsequently, a successful T5 corpectomy with posterior thoracic fixation/fusion from T2 to T8. The biopsy was positive for plasma cell myeloma with kappa light chain restricted. Based on the revised guidelines for staging MM due to the del(17p) deletion, but lack of elevated globulins the patient was classified as stage II. Patient was started on induction treatment with bortezomib, lenalidomide and dexamethasone. After 4 months of treatment, repeat PET/CT showed no evidence of bony lesions. Overall plan included collection of stem cells and proceeding to autologous stem cell transplant, but patient has unfortunately been inconsistent with follow-up.

Introduction: MM is a malignancy involving plasma cell proliferation in the bone marrow which can lead to displacement of other hematopoietic cell lines. Accumulation of proliferated plasma cells in extramedullary or axial skeleton locations can also lead to the development of plasmacytomas. Macrofocal MM is defined by the presence of bone lesions without diffuse bone marrow infiltration. It has been shown that patients diagnosed with MM at a young age are more likely to have a macrofocal MM subtype. The infrequency with which MM is found in patients under the age of 40 leads to intimidating diagnostic and management challenges especially when the patient does not have regular primary care. Early detection is critical to improved overall survival. If caught in an earlier stage overall survival rate at 5-years is 83% for those ≤ 40 years and 53% for those ≥ 40 years old. The 5-year survival rate decreases to 54% if caught in the later stage once the cancer has spread to distant parts of the body. Clinical Findings: A 36-year-old male presented with a five-month history of progressively worsening mid-upper back pain that started after



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