Comparison of bone marrow sections, smears and immunohistological staining for immunoglobulin light chains in the diagnosis of benign and malignant plasma cell proliferations

Bone marrow specimens from 118 patients with clinical suspicion of multiple myeloma were studied to assess the diagnostic reliability of histological and cytological criteria. Plasma cell clonality was assessed by demonstrating light chain restriction. In most cases of multiple myeloma, the classical cytological and histological criteria were found. In eight cases in which the marrow contained less than 10% of plasma cells, there was discordance between the light microscopic and immunohistochemical findings. In six cases without evidence of multiple myeloma and with polyclonal plasma cells in bone marrow, abnormal plasma cells resembling a malignant proliferation were found. These findings indicate that comparison of histological and cytological results with immunohistological studies for immunoglobulin light chains in bone marrow biopsy sections can be helpful in the evaluation of patients with a susicion of multiple myeloma and when the marrow contains less than 10% of plasma cells.     

Multiple myeloma in association with sarcoidosis

The association of sarcoidosis with Hodgkin disease and non-Hodgkin lymphoma is well known. However, multiple myeloma also can occur rarely in association with sarcoidosis. We describe a patient with sarcoidosis who subsequently developed multiple myeloma. The patient was a 49-year-old woman with a 4-year history of severe, chronic, active sarcoidosis involving her lungs, lymph nodes, eyes, and bone marrow. During the initial clinical workup, a serum monoclonal paraprotein was detected and bone marrow examination revealed a slight increase in plasma cells (4%), in addition to noncaseating granulomas. Thus, the diagnoses of monoclonal gammopathy of undetermined significance and sarcoidosis were established simultaneously. She sought medical attention for her current illness when she developed low back pain and weakness of her lower extremities. Serum protein electrophoresis and immunofixation revealed a monoclonal paraprotein, immunoglobulin (Ig) G kappa type, and quantification revealed an IgG level of 46.67 g/L (normal, 5.88--15.73 g/L). Bone marrow aspiration and biopsy revealed multiple myeloma and sarcoidosis. Including this patient, 11 cases of sarcoidosis and multiple myeloma have been reported to date, including 3 patients with monoclonal gammopathy of undetermined significance preceding the onset of multiple myeloma. In this case, as in most of the cases reported previously, sarcoidosis preceded the development of multiple myeloma.     

Studies on the origin of the precursor cells in multiple myeloma, Waldenström's macroglobulinaemia and benign monoclonal gammopathy. I. Cytoplasmic isotype and idiotype distribution in peripheral blood and bone marrow.

Lymphocytes and plasma cells in the peripheral blood and bone marrow of patients with multiple myeloma, benign monoclonal gammopathy and Waldenström's macroglobulinaemia were investigated for their cytoplasmic immunoglobulin distribution. Anti-idiotypic sera were used as markers for monoclonality. Double-wavelength fluorescence microscopy made it possible simultaneously to use anti-isotype and anti-idiotype sera with different fluorochromes. It was concluded that, in the bone marrow, the monoclonal event starts at the level of a lymphoid cell which has already been committed to its final isotype. The size of the monoclonal expansion in the bone marrow and the cell types involved in the proliferation may determine whether spread occurs. Polyclonal lymphoid cells containing cytoplasmic immunoglobulins were decreased in the peripheral blood and exhibited a reversed kappa/lambda ratio when compared to the immunoglobulin-containing cells in the bone marrow. This finding suggests a light chain-type related depression of polyclonal B cell precursors.     

Newly developed multiple myeloma in a patient with primary T-cell lymphoma of bone

Primary non-Hodgkin's lymphoma of bone (PLB) is rare, and generally presents as a single extensive and destructive bone lesion. Histopathologically, most cases present as diffuse large B-cell lymphoma, and T-cell lymphoma is rare. By contrast, multiple myeloma is a disease defined as the neoplastic proliferation of a single clone of plasma cells producing a monoclonal immunoglobulin. We report a case of multiple myeloma that developed during treatment of PLB in a type of T-cell. A 48-yr-old man was diagnosed as T-cell PLB, stage IE, 18 months ago. The patient received the chemoradiotherapy and salvage chemotherapy for PLB. However, the lymphoma progressed with generalized bone pain, and laboratory findings showed bicytopenia and acute renal failure. On bone marrow biopsy, the patient was diagnosed as having multiple myeloma newly developed with primary T-cell lymphoma of bone. In spite of chemotherapy, the patient died of renal failure.     

Plasma cell tumors with neurologic symptoms: cytological findings

Plasma cell neoplasms (plasma cell dyscrasias) are a group of entities characterized by the neoplastic proliferation of a single clone of plasma cells, typically producing a monoclonal immunoglobulin. These tumors can manifest as multiple myeloma, monoclonal gammopathy of undetermined significance, plasma cell myeloma, or plasmacytoma. We report two plasma cell tumors, one of them presented with headache and diplopia, and the second one complained from low back pain. The aspirate exhibited numerous plasma cells in various stage of maturation and was initially diagnosed as extra-skeletal solitary plasmacytoma on fine-needle aspiration cytology (FNAC). Immunohistochemistry demonstrated monoclonal expression of light immunoglobulin chains together with demonstration of CD 38 positivity. Systematic approach such as bone marrow examination, serum protein electrophoresis, skeletal imaging, and urine examination for Bence-Jones proteins were performed for patients. With these investigations, one case was labeled as multiple myeloma with secondary solitary plasmacytoma in pituitary gland and soft tissue and another one as primary extra-skeletal solitary plasmacytoma. Although fine-needle aspiration is a reliable and rapid technique for initial diagnosis, further work-up and clinical follow-up of these patients is necessary to rule out multiple myeloma. Because of cytomorphological similarity between plasma cells and endocrine cells, EMP of sellar region may be confused with pituitary adenoma especially at the time of intraoperative consultation.     

Immunoglobulin gene rearrangement in multiple myeloma: limitations of Southern blot analysis.

Thirty-six patients with early and advanced multiple myeloma were investigated with Southern blot analysis to determine the presence of immunoglobulin gene rearrangement as evidence of clonality. Rearrangements were not uniformly found, being detected in only 14 of 19 patients with newly diagnosed myeloma and in 15 of 17 cases of clinically advanced myeloma. A correlation between percentage of bone marrow plasma cells and detection of immunoglobulin gene rearrangement was noted; however, in four cases of early myeloma with > 10% marrow plasma cells, no rearrangement was found. These results suggest that Southern blot analysis may not be an optimal method for the determination of clonality in plasma cell dyscrasias or, alternatively, that a proportion of the plasma cells found on bone marrow examination in some patients with early myeloma may not be monoclonal.     

The Effect of Anti-Ia Antibody on Immunoglobulin-secreting Cells from Healthy Individuals and Myeloma Patients

Immunoglobulin-secreting cells (ISC) in the peripheral blood of healthy individuals and in the bone marrow, peripheral blood, or plasmacytomas of patients with multiple myeloma were enumerated by a protein-A plaque-forming cell assay after treatment with anti-Ia antibody and complement. Rabbit anti-human B-cell antisera and monoclonal anti-Ia antibody (OKIal) were used. By this treatment, the number of ISC in the peripheral blood of healthy individuals decreased to half, and that of M-protein-secreting cells from some patients with multiple myeloma also decreased markedly. In one patient, the number of M-protein-secreting cells in the bone marrow were markedly reduced by this treatment, but this was not the case after 6 months of chemotherapy, suggesting that the chemotherapy reduced chiefly the Ia-positive myeloma cells rather than Ia-negative myeloma cells.     

Restricted Expression of Immunoglobulin Light Chain mRNA and of the Adhesion Molecule CD11b on Circulating Monoclonal B Lineage Cells in Peripheral Blood of Myeloma Patients

Circulating monoclonal B cells in peripheral blood from patients with multiple myeloma or with monoclonal gammopathy of undetermined significance (MGUS) have previously been shown to express CD19, CD20, and PCA-1 and are predominantly CD45R0+, characterizing them as very late stage B cells. This work shows that the abnormal B cells are monoclonal as defined by their exclusive expression of either kappa or lambda light chain mRNA, and that the same type of light chain mRNA is expressed in both bone marrow plasma cells and blood B cells. These abnormal tumour-related circulating B cells express high densities of CD11b, a beta 2-integrin, which is expressed in a conformationally active state as defined by reactivity with monoclonal antibody 7E3. Normal peripheral blood B cells which do not bear CD11b acquire a high density after stimulation with pokeweed mitogen (PWM). At day 4 of culture, the expression of CD11b on normal CD19+ B cells was nearly comparable to that of the circulating myeloma late stage B cells. After PWM stimulation of circulating myeloma B cells the expression of CD11b was gradually lost during 4 days of culture, suggesting that its expression is dynamically regulated. Two patients with no phenotypically abnormal B cells in their blood at diagnosis acquired a large subset of CD11b+ B cells 4 weeks after initiation of chemotherapy. In most patients, a subset of the circulating myeloma B cells express a low density of CD5. The proportion of CD19+ B cells in the bone marrow expressing CD11b was much reduced compared with peripheral blood B cells, and CD11b was not detectable on plasma cells in the bone marrow, suggesting a sequential relationship of the B-cell subsets detected in our population of patients, involving gradual loss of CD11b concurrent with the loss of CD19 during B lineage differentiation. These cells appear to represent a continuously differentiating monoclonal B lineage culminating in the CD11b- plasma cell entrenched in the bone marrow. We speculate that the expression of conformationally active CD11b on the abnormal B cells in peripheral blood mononuclear cells of myeloma patients facilitates transendothelial migration of circulating myeloma B cells to the bone marrow.     

Flow cytometric DNA analysis and clinical correlations in multiple myeloma.

DNA content of both bone marrow and peripheral blood mononuclear cells was measured by flow cytometric analysis in 46 patients with untreated multiple myeloma and 15 patients with benign monoclonal gammopathy to clarify further the incidence and clinical correlations of DNA aneuploidy. Aneuploidy was detected in the bone marrow of 25 multiple myeloma patients (54%) but in only one benign monoclonal gammopathy patient (7%), who developed multiple myeloma 34 months later. Thus DNA aneuploidy is considered rare in benign monoclonal gammopathy. In two multiple myeloma patients, DNA aneuploidy was detected also in blood, indicating circulating myeloma cells. The light chain of the M component was more frequently lambda in the diploid and kappa in the aneuploid group. Most of the patients with only light chain secretion were DNA aneuploid. Multiple myeloma patients with DNA hypodiploidy (7%), biclonal aneuploidy (4%), or DNA aneuploidy detectable in blood (4%) did not respond to therapy with melphalan and prednisone. Survival was not influenced by DNA content. No DNA aneuploidy was detected in the bone marrow or the peripheral blood of 26 patients with chronic lymphocytic leukemia or two patients with Waldenstr?m's macroglobulinemia.     

IgM myeloma, a distinct entity in the spectrum of B-cell neoplasia

The distinction between multiple myeloma and Waldenstr?m's macroglobulinemia can usually be made on the basis of clinical, histologic, and immunologic findings. However, some patients have features of both diseases. Two patients who had IgM monoclonal gammopathies and plasma cell neoplasia are presented. Both had bone lesions, monoclonal IgMk, and bone marrow infiltration with plasma cells. The presence of plasma cells was verified by electron microscopy. Immunoperoxidase studies in both cases showed positive staining with mu and kappa antisera only, suggesting that these plasma cells were the source of the IgMk protein. Using the criteria of monoclonal IgM, plasma cell neoplasia, and bone lesions, 28 similar cases were found. The analysis of clinical data revealed an increased incidence of lytic bone lesions, decreased IgG and IgA, renal failure, hypercalcemia, and Bence-Jones proteinuria, as are commonly seen in multiple myeloma. It also demonstrated an increased incidence of hyperviscosity symptoms, lymphadenopathy, hepatosplenomegaly, and mucous membrane bleeding, as are often seen in Waldenstr?m's macroglobulinemia. Other common findings were anemia and plasma cell leukemia. These data suggest that, although rare, IgM myeloma should be considered a distinct clinical entity in the spectrum of B-cell malignancies with characteristics of both multiple myeloma and Waldenstr?m's macroglobulinemia.     

Immunoglobulin synthesis in primary and myeloma amyloidosis.

Bone marrow cells from 14 patients with primary amyloidosis and two patients with myeloma amyloidosis were studied by immunofluorescence and biosynthesis experiments after incorporation of radioactive amino acids. Cells from four patients affected with non-myeloma secondary amyloidosis were also studied as controls. In primary amyloidosis, monoclonal plasma cell populations were demonstrated by immunofluorescence in virtually every case, even in patients without serum and urine monoclonal immunoglobulin and with a normal percentage of bone marrow plasma cells. Biosynthesis experiments showed the secretion of large amounts of free light chains, most often of the lambda type, in every primary or myeloma amyloidosis case and the presence of light chain fragments in almost all cases. Special features in certain patients were the synthesis of short gamma chains (two cases), assembly block at the HL half molecule level of a monoclonal IgA (one case) and secretion of decameric abnormally large kappa chains (one case). This is in contrast with non-myelomatous secondary amyloidosis where the distribution of bone marrow plasma cells was normal by immunofluorescence and where normal sized immunoglobulins were synthesized, without free light chain secretion and fragments. These data confirm that primary amyloidosis belongs to plasma cell dyscrasias and emphasize the role of free light chains and light chain fragments in the pathogenesis of amyloid deposition.     

Peanut agglutinin (lectin from Arachis hypogaea) binding to hemopoietic cells: an immunophenotypic study using a biotin streptavidin technique.

The lectin peanut agglutinin (PNA) was used to study the surface carbohydrate expression of galactose beta 1, 3, N-acetylgalactosamine by normal and malignant hemopoietic cells. Immunostaining was performed using biotinylated PNA and a streptavidin-alkaline phosphatase staining technique on 78 patients. The study was undertaken to enlarge on previous reports of lectin binding to cells of hemopoietic origin and to establish the potential role of biotinylated PNA as a component of an immunotoxin for in vitro purging of bone marrow in patients with multiple myeloma. In normals only monocytes, macrophages, centroblasts and plasma cells showed reactivity. Of the hematological malignancies, all cases of multiple myeloma were positive and non-Hodgkin's lymphoma cases with a large cell component had positive centroblasts. Two of 5 cases of acute myelomonocytic leukemia, one case of chronic myelomonocytic leukemia and one case of pleomorphic T cell non-Hodgkin's lymphoma showed PNA positive neoplastic cells. The reactivity of biotinylated PNA with centroblasts and plasma cells suggests that it may be of potential value when linked to a streptavidin-ricin conjugate in the in vitro purging of bone marrow of patients with multiple myeloma prior to autologous bone marrow transplantation.     

IgG-kappa type multiple myeloma in alcoholic cirrhosis--a case report

Transition from polyclonal to monoclonal gammopathy resulted in myeloma in the course of cirrhosis is rare but of interest. We treated such a case of multiple myeloma of IgG-kappa type associated with alcoholic cirrhosis. The case was a 72-year-old Japanese male patient who was admitted because of ascites and edema. Physical examination and laboratory findings including liver histology were compatible with alcoholic cirrhosis. Serum electrophoresis revealed monoclonal hypergammaglobulinemia of IgG-kappa. Bence Jones protein in urine was positive. Bone scintigraphy and roentgenography revealed small punched out lesions in the skull. A bone marrow clot section showed marked infiltration of atypical plasma cells. From these findings multiple myeloma associated with alcoholic cirrhosis was diagnosed. On the basis of a review of the reported cases, the possible relationship between monoclonal gammopathy and chronic liver diseases was discussed.     

Bone marrow biopsy in monoclonal gammopathies: correlations between pathological findings and clinical data. The Cooperative Group for Study and Treatment of Multiple Myeloma.

Between January 1987 and October 1989, 561 consecutive untreated patients with monoclonal gammopathy of undetermined clinical importance (MGUS) (n = 295) or with multiple myeloma (n = 266) were evaluated in a multicentre trial. Both bone marrow biopsy and aspiration (performed at different anatomical sites) were required at presentation. Bone marrow biopsy data indicated that changes in bone marrow composition from MGUS to early multiple myeloma and to advanced multiple myeloma followed a precise pattern, including an increased percentage of bone marrow plasma cells (BMPC%), a shift from plasmocytic to plasmoblastic cytology, an increase in bone marrow cellularity and fibrosis, a change in bone marrow infiltration (becoming diffuse rather than interstitial), a decrease in residual haemopoiesis and an increase in osteoclasts. In multiple myeloma the BMPC% of biopsy specimens and aspirate were closely related, although in 5% of cases the difference between the two values was greater than 20%. Some histological features were remarkably associated with each other. For example, BMPC% was higher in cases with plasmoblastic cytology, heavy fibrosis, or reduced residual haemopoiesis. Anaemia was the clinical characteristic most influenced by bone marrow histology. The BMPC% was the only histological variable which affected the greatest number of clinical and laboratory characteristics, including, besides haemoglobin concentration, erythrocyte sedimentation rate, radiographic skeletal bone disease, and serum concentrations of monoclonal component, calcium, beta 2-microglobulin and thymidine kinase activity. These data indicate that comparative bone marrow histology in monoclonal gammopathies has clinical importance.     

Neural cell adhesion molecule expression in plasma cells in bone marrow biopsies and aspirates allows discrimination between multiple myeloma, monoclonal gammopathy of uncertain significance and polyclonal plasmacytosis

AIMS: Differential diagnosis between multiple myeloma (MM), monoclonal gammopathy of uncertain significance (MGUS), and polyclonal plasmacytosis may be difficult in cases with not much bone marrow infiltration. Normal plasma cells express the antigens CD138, CD38, CD19, CD10 and D-related human leucocyte antigen (HLA-DR). Myelomatous plasma cells lack B lymphoid-associated markers and may express cell surface antigens associated with other haematopoietic lineages such as NCAM/CD56 (neural cell adhesion molecule). Recently, a monoclonal antibody, anti-CD56, has become available that can be used in fixed tissues embedded in paraffin, and it has been reported that osteoblastic cells of trabecular bone strongly express NCAM/CD56. METHODS AND RESULTS: We analysed NCAM molecule expression in 35 samples from patients with plasma cell disorders: 14 cases of MM, 16 cases of MGUS, and five cases of polyclonal plasmacytosis using immunohistochemistry in parallel in bone marrow core biopsies processed routinely and in bone marrow smears from the same patients. Of the MM samples 78% were CD56+ in smears and 92% positive in biopsies. We did not find strong CD56 expression in MGUS samples. One of five samples of polyclonal plasmacytosis was CD56+. A case was considered to be positive for CD56 expression if >50% of the CD138+ plasma cells expressed NCAM with an intensity on a par with that of the osteoblasts. CONCLUSION: We conclude that CD56 antibody is a very useful marker in the study of plasma cell proliferation in bone marrow biopsies and in bone marrow aspirates and is a great help in discriminating between MM, MGUS, and polyclonal plasmacytosis, especially in those cases with low infiltration.     

Usefulness and reproducibility of cytomorphologic evaluations to differentiate myeloma from monoclonal gammopathies of unknown significance

We attempted to differentiate monoclonal gammopathies of unknown significance (MGUS) and multiple myeloma (MM) on morphologic grounds and to determine interobserver reproducibility of the differentiation. Cytologists blindly evaluated bone marrow smears from 154 patients with bone marrow plasmacytosis for the proportion of plasma cells with predefined cellular atypias. The single morphologic characteristic that most strongly differentiated MM from MGUS was the presence of nucleoli. The percentage of plasma cells, cytoplasmic contour irregularities, and anisocytosis also predicted a diagnosis of myeloma in multivariate analysis. Six cytologists independently evaluated 68 consecutive cases to determine sensitivity and specificity of these cytomorphologic features. The interobserver coefficient of variation for the plasma cell count was 33%. On consideration of the diagnosis, 36 of 41 MGUS cases and all 24 cases of myeloma were classified correctly. The use of a predesigned score system did not present such a bias, although it did not improve overall efficiency. The plasma cell count is the most predictive characteristic of myeloma from a cytologic viewpoint, but the interobserver variability is high. Interobserver variability is also high in the assessment of morphologic atypia, and atypical traits are not uncommon in plasma cells in MGUS.     

Paraproteinaemia: use of idiotypic determinants as specific markers for tumour activity

Five patients with paraproteinaemia were investigated using anti-idiotype antibodies specific for their paraproteins. Sensitive assays were used to detect soluble paraprotein either in serum or in supernatants from cultures of peripheral blood mononuclear cells (PBMC) and bone marrow cells. It was found that (i) measurement of serum paraprotein by specific radioimmunoassay is a sensitive method of monitoring the course of multiple and solitary myeloma, (ii) morphologically normal bone marrow from a multiple myeloma patient contained paraprotein-secreting plasma cells, (iii) a patient with benign monoclonal gammopathy had at least one stage in her disease where pre-plasmacytic tumour cells were present in the peripheral blood, (iv) the PBMC of the patients with active myeloma contained suppressor monocytes, and (v) PBMC from treated myeloma patients (both those with still active disease and those in apparently complete remission) would not secrete paraprotein in culture under a variety of different culture conditions including partial monocyte depletion.     

A case of aggressive multiple myeloma with cleaved, multilobated, and monocytoid nuclei, and no serum monoclonal gammopathy

Multiple myeloma is a B-cell malignancy characterized by proliferation of neoplastic plasma cells. A few cases have been reported identifying variant forms of neoplastic plasma cells with atypical nuclei that secrete myeloma protein. We report a highly unusual case of plasma cell myeloma that presented with cleaved, multilobated, and monocytoid nuclei, without detectable myeloma protein in the serum or urine. The bone marrow contained sheets of plasma cells exhibiting pleomorphic nuclei with cleaved, multilobated, and monocytoid features that were negative for myeloperoxidase and dual esterase. Flow cytometric analysis revealed CD38high/CD45low cells expressing cytoplasmic kappa light chain, without evidence of myeloid or lymphoid differentiation. Following chemotherapy, the patient developed secondary plasma cell leukemia. A high plasma cell labeling index was obtained from bone marrow and peripheral blood, indicating a poor prognosis. In addition to quantitative immunoglobulins, serum protein electrophoresis, and immunofixation electrophoresis of serum and urine, we recommend cytochemical and flow cytometric studies for evaluation of suspected plasma cell myeloma with atypical cellular features.     

Thrombocythaemia and multiple myeloma. A report on two cases

A report is presented on two patients with the very rare combination of thrombocythaemia and multiple myeloma. Both patients displayed an increase in monoclonal immunoglobulin in the serum, an increased amount of plasma cells in the bone marrow, and multiple osteolytic lesions in the skeleton, along with a platelet count exceeding 1 mill./mm3, haemorrhagic diathesis, and thromboembolic complications. In case 1, both diseases reacted favourably to treatment with melphalan during a 36-month follow-up. In case 2, the thrombocythaemia had been brought under control with busulphan prior to the diagnosis of myeloma. The latter patient died before initiation of treatment of the myeloma. The signifacance of the combination is discussed.     

Monoclonal gammopathy of undetermined significance: a morphologic and immunophenotypic study of the bone marrow.

A monoclonal paraprotein in the serum or urine raises the possibility of myeloma. However, in a significant proportion of individuals with serum paraproteins, particularly those with low levels of paraprotein, clinical and routine bone marrow evaluation is not diagnostic of an underlying neoplasm. The purpose of this study was to define the pathologic basis for monoclonal gammopathy in patients whose bone marrow biopsies showed no evidence of myeloma. We used immunofluorescence microscopy and flow cytometry of cell suspensions prepared from aspirated marrow, as well as immunohistochemistry of core biopsies, to perform immunopathologic evaluations of the bone marrow from 26 such patients. Eighteen patients with myeloma and seven without a serum paraprotein or evidence of myeloma were similarly studied. The data indicate that 17 of the 26 patients with monoclonal paraproteins whose routine bone marrow biopsies were normal or nondiagnostic had, in fact, a dispersed monotypic plasma cell population of concordant immunoglobulin heavy and light chain type in the bone marrow demonstrable by at least one of the three analytic methods. Among these, immunofluorescence microscopy of isolated bone marrow mononuclear cells was the most sensitive assay. Immunophenotypic evaluation of the bone marrow is useful for documenting and quantifying a monoclonal plasma cell population in patients with monoclonal gammopathy of undetermined significance.