Transcript Functional Pitutary Tumors - UC San Diego Neurosurgery

Plasmacytomas
By Godfrey Thuku MSIV
Outline
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Case Presentation
Types of plasma disorders
Radiosurgery treatment
Case presentation
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42yr old Hispanic female with a slowly growing right scalp cyst since
May 2009
Symptoms of left arm and fingers tingling, headaches. No systemic
signs
Cyst was approx 5cm in circumference, no erythema, tenderness to
palpation, no discharge
No history of Trauma to the site
PMH; Hypertension and hypercholesterolemia. PSH; 2 cesarean
sections. FMH; Hypertension, stroke, CAD, hypercholestrolemia.
SH; Does not smoke or drink. PE; 2 inch diameter lesion on the
right scalp. Rest of exam intact
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Neuro; Completely neurologically intact.
1st OR visit
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Aborted excision of scalp cyst
During dissection an irregular
contour was noted as well as
calcified areas.
High suspicion lesion was not a
cyst or lipoma.
Obtained skull x-rays which
demonstrated a clear defect in
the skull.
2nd OR visit
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Right frontal craniectomy
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Stereotatic surgical planning
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Resection of tumor attached to
dura
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Dura resection
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Dural reconstruction
Plasma cell disorders
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Plasma cell granulomas – monoclonal expansion of single plasma
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Plasmacytoma – a discrete solitary mass of neoplastic monoclonal
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Extramedullary plasmacytomas – localized cell neoplasms
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Solitary bone plasmactyoma – solitary lytic bone lesion
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Multiple myeloma – rarely curable systemic malignancy of plasma
cell. Its an inflammatory process
plasma cells within in either bone or tissue
arising within soft tissues
cells.
Clinical features
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Multiple Myeloma
Median age – 60-75
Gender – slight male predominance
Bone pain precipitated by movement
High levels of Monoclonal protein
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Pathology; especially to
rule out plasmagranuloma
Lab tests; CBC,
Biochemical screen
including electrolytes and
corrected sodium, serum
and urine proteins,
immunoglobulin levels, full
skeletal survey
Treatment
Radiotherapy – treatment of choice
Recommended dose – 40gy in 20 fractions for SBP of 5cm or less.
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63yr old man with Hx of successful stem cell rescue with vertex
headaches and hoarseness.
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MRI showed a mass in left clivus extending to foramen magnum.
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Tumor was unresponsive to dexamethasone for six months
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Decision made to treat it as a plasmacytoma
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Treated with fractioned cyberknife, 400 cGy for five days
Pros
 No screw-induced
numbness
 Rare cases of pin site
cellulitis with AVM’s
 Potential infections
Cons
 Can be compromised
by patient motion esp
around the skull base
No histologic confirmation of
diagnosis
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Pt had complete radiographic response within three months
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Serial head MRI for 12+ months without neurological toxicity
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70yr old female with Hx of infiltrative ductal carcinoma
had developed cavernous sinus syndrome (headache,
left side numbness and earache, double vision)
Has a solitary mass in left carvenous sinus
Probable metastases from breast, surgery done but
pathology revealed a plasmacytoma. Systemic evaluation
showed MM
Pt underwent gamma knife radiosurgery followed by
chemo.
Pros
 Tumor responded
very rapidly to
radiation
Cons
 Clinical symptoms
never resolved
 Lack of proper
diagnosis work-up
Conclusions
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Proper diagnostic work-up, including
systemic labs
Literature indicates plasmacytomas are
very radiosensitive.
Would not hesitate to use radiosugery