Use of endoscopic ultrasound in diagnosing plasmacytoma of the pancreas.

CONTEXT: An extramedullary plasmacytoma is a discrete collection of monoclonal plasmocytes arising in tissues other than the bone. Gastrointestinal involvement has been reported in approximately 10% of cases and usually involves the liver; however, there have been a number of cases involving the pancreas.

DISCUSSION: Although helical CT can be used to diagnose pancreatic plasmacytomas based on a typical radiological appearance, there are a number of pitfalls with CT including similar radiologic appearances of other pancreatic tumors, malignant seeding induced by CT biopsy, and creation of multiple secondary plasmacytomas precipitated by CT biopsy. Tissue diagnosis is critical to management in pancreatic lesions as the decision to pursue surgery (pancreatic adenocarcinoma) versus chemotherapy (lymphoma) or radiation (extramedullary plasmacytoma) is dependent on a correct tissue diagnosis. Tissue diagnosis can change morbidity and mortality with respect to specific treatment of pancreatic lesions in the milieu of pancreatic tumor variance. In the confirmed tissue diagnosis of pancreatic plasmacytoma, radiation and chemotherapy can be preferentially chosen over high risk surgery. EUS-FNA has a lower risk of malignant seeding, complications, and a high sensitivity in the diagnosis of pancreatic plasmacytomas, especially with an increased number of passes and bedside cytopathologists.

CONCLUSION: It is important for physicians to have a high index of suspicion for diagnosing pancreatic plasmacytomas in the appropriate clinical setting (i.e., a previously diagnosed multiple myeloma, extramedullary plasmacytoma or any other plasma cell neoplasm). EUS-FNA is now an indispensable imaging modality to achieve the diagnosis of pancreatic extramedullary plasmacytomas with an inherently lower rate of complications, and should be the first choice for tissue evaluation.