Osteolytic bone lesions, hypercalcemia and paraprotein, but not a myeloma: case report and review of literature

Česká verzia

Authors: Katarína Hradská ¹; Tomáš Jelínek ¹; Juraj Ďuraš ¹; Jana Mihályová ¹; Tereza Popková ¹; Jakub Cvek ²; Kamil Bukovanský ³; Martin Havel ³; Veronika Spáčilová ⁴; Roman Hájek ¹
Authors place of work: Klinika hematoonkologie LF OU a FN Ostrava ¹; Klinika onkologická LF OU a FN Ostrava ²; Klinika nukleární medicíny LF OU a FN Ostrava ³; Interní klinika LF OU a FN Ostrava ⁴
Published in the journal: Vnitř Lék 2020; 66(5): 90-95
Category: Differential Diagnosis Column or What You Can Be Asked at a Postgraduate Certification Exam

Summary

In June 2018, 77-year-old man was referred to The Department of Haematooncology, University Hospital Ostrava, for suspicion of multiple myeloma. This was supported by laboratory findings of hypercalcemia, paraprotein IgA κ in serum and by the presence of multiple osteolytic skeletal lesions. Low number of plasma cells in bone marrow sample - cytologically (3.6 %) as well as in flow cytometry (less than 95 % clonal plasma cells out of total bone marrow plasma cells) - pointed at the direction of monoclonal gammopathy of undetermined significance (MGUS). In the course of differential diagnosis of hypercalcemia, elevated level of parathormone had been found which led to the performance of 99mTc-MIBI scintigraphy where parathyroid adenoma was discovered and later histologically verified. The final diagnosis was determined as a coincidence of MGUS and primary hyperparathyroidism. This case report also contains brief differential diagnosis of hypercalcemia and osteolytic skeletal lesions and suggestions for their diagnostic algorithms.

Keywords:

Multiple myeloma – primary hyperparathyroidism – hypercalcemia – MGUS – osteolytic lesions

Zdroje

1. Kazandjian D. Multiple myeloma epidemiology and survival: A unique malignancy. Semin Oncol 2016; 43: 676–681.

2. Maluskova D, Svobodová I, Kucerova M, et al. Epidemiology of Multiple Myeloma in the Czech Republic. Klin Onkol Cas Ceske Slov Onkol Spolecnosti 2017; 30: 35–42.

3. Jelínek T, Mihályová J, Hájek R. CD38 targeted treatment for multiple myeloma. Vnitř Lék 2018; 64: 939–948.

4. Rajkumar SV, Dimopoulos MA, Palumbo A, et al. International Myeloma Working Group updated criteria for the diagnosis of multiple myeloma. Lancet Oncol 2014; 15: e538-e548.

5. Kyle RA, Therneau TM, Rajkumar SV, et al. A long‑term study of prognosis in monoclonal gammopathy of undetermined significance. N Engl J Med 2002; 346: 564–569.

6. Jelinek T, Hajek R- Monoclonal antibodies – A new era in the treatment of multiple myeloma. Blood Rev 2016; 30: 101–110.

7. Terpos E, Ntanasis‑Stathopoulos I, Dimopoulos MA. Myeloma bone disease: from biology findings to treatment approaches. Blood 2019; 133: 1534–1539.

8. Kyle RA, Remstein ED, Therneau TM, et al. Clinical course and prognosis of smoldering (asymptomatic) multiple myeloma. N Engl J Med 2007; 356: 2582–2590.

9. Fraser WD. Hyperparathyroidism. Lancet Lond Engl 2009; 374: 145–158.

10. Adam Z, Starý K, Kubinyi J, et al. Hyperkalcemie, příznaky, diferenciální diagnostika a léčba aneb důležitost vyšetřování kalcia. Vnitř Lék 2016; 62: 370–383.

11. Adam Z, Starý K, Zajíčková K, et al. Zvýšená hladina kalcia může být prvním příznakem mnohočetného myelomu, ale může mít i jiné příčiny. Transfuze Hematol Dnes 2018; 24: 238–252.

12. David Roodman G, Silbermann R. Mechanisms of osteolytic and osteoblastic skeletal lesions. BoneKEy Rep 2015; 4: 753.

13. Hernandez RK, Wade SW, Reich A, et al. Incidence of bone metastases in patients with solid tumors: analysis of oncology electronic medical records in the United States. BMC Cancer 2018; 52: 18.

14. Jensen A, Jacobsen JB, Nørgaard, et al. Incidence of bone metastases and skeletal‑related events in breast cancer patients: A population‑based cohort study in Denmark. BMC Cancer 2011; 11: 29.

15. Califano I, Deutsch S, Löwenstein A, et al. Outcomes of patients with bone metastases from differentiated thyroid cancer. Arch Endocrinol Metab 2018; 62: 14–20.

16. Silva GT, Silva LM, Bergmann A, et al. Bone metastases and skeletal‑related events: incidence and prognosis according to histological subtype of lung cancer. Future Oncol Lond Engl 2019; 15: 485–494.

17. Chandrasekar T, Klaassen Z, Goldberg H, et al. Metastatic renal cell carcinoma: Patterns and predictors of metastases‑A contemporary population‑based series. Urol Oncol 2017; 35: 661.

18. Tsuda Y, Nakagawa T, Shinoda Y, et al. Skeletal‑related events and prognosis in urothelial cancer patients with bone metastasis. Int J Clin Oncol 2017; 22: 548–553.

19. Arvola S, Jambor I, Kuisma A, et al. Comparison of standardized uptake values between 99mTc‑HDP SPECT/CT and 18 F‑NaF PET/CT in bone metastases of breast and prostate cancer. EJNMMI Res 2019; 9: 6.

20. Reddington JA, Mendez GA, Ching A, et al. Imaging characteristic analysis of metastatic spine lesions from breast, prostate, lung, and renal cell carcinomas for surgical planning: Osteolytic versus osteoblastic. Surg Neurol Int 2016; 7: S361-S365.

21. Paulíková S, Petera J, Paulík A. Metastatické postižení kostí. Postgrad Med 2011; 13: 753–759.

22. Štěpán J, Zima T, Petruželka L. Výpověď biochemických markerů remodelace kosti při nádorovém postižení skeletu. Čas Lék Čes 2008; 147: 7–18.

23. Brunová J, Bruna J. Klinická endokrinologie a zobrazovací diagnostika endokrinopatií. Praha: Maxdorf 2009.

24. Agnihotri M, Kothari K, Naik L. Ω Brown tumor of hyperparathyroidism. Diagn Cytopathol 2017; 45: 43–44.

25. Zanocco KA, Yeh MW. Primary Hyperparathyroidism: Effects on Bone Health. Endocrinol Metab Clin North Am 2017; 46: 87–104.

26. Boccalatte LA, Higuera F, Gómez NL, et al. Usefulness of 18 F‑Fluorocholine Positron Emission Tomography‑Computed Tomography in Locating Lesions in Hyperparathyroidism: A Systematic Review. JAMA Otolaryngol – Head Neck Surg 2019.

27. Noltes ME, Kruijff S, Noordzij W, et al. Optimization of parathyroid 11C‑ choline PET protocol for localization of parathyroid adenomas in patients with primary hyperparathyroidism. EJNMMI Res 2019; 9.

28. Rossi JF, Bataille R, Chappard D, et al. B cell malignancies presenting with unusual bone involvement and mimicking multiple myeloma. Study of nine cases. Am J Med 1987; 83: 10–16.

29. Alhaj Moustafa M, Seningen JL, Jouni H. Hypercalcemia, Renal Failure, and Skull Lytic Lesions. J Investig Med High Impact Case Rep 2013; 1.

30. Mandal SK, Ganguly J, Sil K, et al. Diagnostic dilemma in a case of osteolytic lesions. BMJ Case Rep 2014; 2014.

31. WHO classification of tumours of haematopoietic and lymphoid tissues. Revised 4th edition. Lyon: International Agency for Research on Cancer; 2017.

32. Teefe E, Kim J, Lopez G, et al. Bilateral femoral osteolytic lesions in a patient with type 3 Gaucher disease. Mol Genet Metab Rep 2015; 5: 107–109.

33. Wu M, Su J, Yan F, et al. Skipped multifocal extensive spinal tuberculosis involving the whole spine. Medicine (Baltimore) 2018; 97.