Journal of the Louisiana State Medical Society
ria included: no English abstract available, no information regarding radiologic presentation of the tumor, and lack of clarity regarding the diagnosis of solitary plasmacytoma of rib. Overall, 69 articles were identified. From these articles, a total of 15 case reports met inclusion criteria. Of these, nine articles were written in English (Table 1), 6-14 and six articles were written in another language but had abstracts written in English (Table 2). 15-20 Though reports originating in the United States were identified, 4,21,22 none of them met inclusion criteria. Namely, these reports lacked radiographic details of solitary plasmacytoma of the rib. Solitary plasmacytoma of bone is relatively rare as a cause for an isolated bone lesion. The most common site of SPBs is the vertebrate. 5,23 No studies to date have compared SPBs of the rib to SPBs located on other bones. SPBs have been reported to occur more commonly in males than fe- males, at an estimated ratio of 2:1. 3 The median age reported is 55 years. 5 In our review of the literature, SPB of the rib was reported in 12 males and three females, with age ranges of 26 to 73 years, and a median age of 45 years. 6-20 Clinical pre- sentation of SPB of the rib varies. Patients most commonly complain of pain in their chest. 3,10,13,17 Other chief complaints include limb weakness 9,20 and coughing. 13,18 However, in some cases, SPB is an incidental finding on radiographs. 8,12 In contrast to multiple myeloma, the most common type of plasma cell neoplasia, SPBs differ by the absence of elevated calcium levels, renal insufficiency, anemia, and multiple bone lesions (CRAB). 24 Corwin and colleagues 21 also note that there should be histological confirmation of plasmacytoma, and a bone marrow biopsy should reveal fewer than 10% plasma cells. In their guidelines, Soutar and colleagues 3 add that there should be absent or low serum or Figure 1: PA chest film demonstrating the absence of the right fifth rib (see arrows).
urinarymonoclonal immunoglobulin and recommend few- er than 5% plasma cells in the bone marrow for diagnosing SPB. Diagnostic studies for SPB include CT-guided biopsy or fine needle aspiration. In addition, Soutar and colleagues suggested the following investigations be performed: full blood count, biochemical screen, serum immunoglobin levels, serum and urine protein electrophoresis and im- munofixation, full skeletal survey, MRI of the thoracic and lumbar spine, and bonemarrow aspirate and trephine. They also recommend that, for some patients, additional testing may be helpful, including: MRI of the pelvis, femora and humeri, immunophenotyping andmolecular assessment of bone marrow plasma cells, and PET scanning. Radiologic examination of SPB of the rib generally re- veals lesions of the bone. 6,8-10,20 Two cases in our literature review reported a mass with destruction of the rib, 15,19 con- sistent with the current case, where the tumor presented as a missing rib on chest X-ray. In our case, the CT scan revealed a large mass, indicative of a tumor. Regarding treatment of SPB, Soutar and colleagues 3 suggest that radiotherapy is the treatment of choice for SPB, with consideration of standard chemotherapy for multiple myeoloma in patients not responding to radiotherapy. Surgical therapy is contraindicated in the absence of struc- tural instability or neurological compromise; though early referral to either an orthopedic or neurosurgical specialist is suggested for SBP involving the spine. Despite these guidelines, our review of the literature revealed that surgi- cal resection or removal of the tumor was performed in 12 cases, 6-9,11-14,16,17,19,20 whether or not surgery was performed was not reported in two cases, and only one case reported conservative treatment with radiotherapy. None of the Figure 2: CT scan of the chest showing destruction of the posterior aspect of the right fifth rib by a mass (see arrows).
64 J La State Med Soc VOL 166 March/April 2014
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