Igd Myeloma: Immunology and Ultrastructure

IgD Myeloma: Immunology and Ultrastructure

NOEMI-JEANA IOACHIM, M.D., PATRICK J. McKENNA, M.D., IRA HALPERIN, M.D., and FREDERICK J. CHUNG

St. Vincent’s Hospital and Medical Center, New York, NY 10011

ABSTRACT

A case of multiple myeloma producing IgD-M component with light chains of lambda type is reported. It involved the skeleton and was compli cated by compression of the spinal cord and massive extension to the pleura. The urine contained lambda Bence Jones protein. Under the electron micro scope, the neoplastic plasma cells showed dissociation between nuclear and cytoplasmic maturation.

Introduction covered, only 145 cases were re ported.11,13,14,20,26 An additional case, with In 1965, Rowe and Fahey demonstrated immunologic and electron microscopic IgD, a new class of human immunoglob studies is presented here. ulins, in the serum of a patient with multi ple myeloma.23 Subsequently, the same investigators demonstrated the existence Case History of minute amounts of IgD in the normal A 65 year old white male was admitted to St. Vin serum.24 cent’s Hospital in July, 1974 with a three week history of pleuritic chest pain and thorocolumbar back pain. Of all lymphocytes with surface In addition, he had a six month history of frequency, immunoglobulins, about 18 percent have nocturia, constipation and a 22 kgms weight loss. membrane-bound IgD27 in contrast to the Physical examination revealed a cachectic white male in no acute distress. The only abnormalities small amounts of IgD in the serum. How noted were dullness to percussion and decreased ever, while membrane-associated IgD in breath sounds posteriorly over the left hemithorax. cludes mainly kappa light chains, the light Hemoglobin was 13.7 g per dl, hematocrit was 41 percent, WBC was 5,300 per mm3 with a normal chain component of normal serum IgD is differential count. BUN, creatinine, uric acid, cal of lambda type.21 The biologic activity of cium, phosphorus and alkaline phosphatase were IgD immunoglobulins is suggested by within normal limits. Roentgenographic examination of the chest showed a left pleural mass and complete their association with various pathologic destruction of the left rib, posteriorly. A skeletal sur entities including immune complex vey showed osteolytic lesions of the skull, left hu glomerulonephritis,15 systemic lupus meral head, fifth and sixth thoracic vertebrae and a large thoracic paravertebral mass. Biopsy of the latter erythematosus,30 chronic lymphocytic showed tumor tissue composed of immature plasma leukemia and Burkitt’s lymphoma.1,16 cells. A posterior iliac crest bone marrow aspiration Plasma cell myelomas with an IgD and biopsy similarly showed extensive infiltration with immature plasma cells. M-component are very rare. To date, 12 The patient was treated with melphalan, predni years after this pathologic entity was dis sone and procarbazine given intermittently at six 209 0091-7370/78/0500-0209 $01.50 © Institute for Clinical Science, Inc. 2 1 0 IOACHIM, MCKENNA, HALPERIN AND CHUNG weeks intervals for seven consecutive days. After the line on immunoelectrophoresis de first month of treatment, there was relief of pain, a veloped with IgD heavy chain and lambda decrease in the size of the thoracic mass and a de crease in the serum monoclonal protein. light chain antisera (figure 1). Electro In October 1974, the patient developed paraplegia phoresis of concentrated urine showed a after collapse of the fifth and sixth thoracic vertebrae. spike with beta mobility. Immunoelectro He was operated upon successfully; however, in the following months progressive renal failure de phoresis showed this to be lambda light veloped and the patient died in February 1975. chains (figure 2).

Methods L i g h t M ic r o s c o p y

P r o t e in S t u d ie s Sections of a pleural biopsy in the area of the fifth rib showed portions of markedly Serum and urine protein electro thickened pleura infiltrated by neoplastic phoresis was performed on cellulose ace plasma cells (figure 3). tate membranes with barbital buffer pH A bone marrow biopsy showed bony 8.6, ionic strength 0.05M. trabeculae and densely hypercellular Immunoelectrophoresis was performed bone marrow. The latter contained few on 0.9 percent agarose plates with the same residual lobules of adipose tissue and mas buffer as described and developed with ses of neoplastic plasma cells. Some were specific antisera to IgG, IgA, IgM, IgD, of mature type while others were abnor IgE, and kappa and lambda light chains.* mally large with irregularly-shaped nucle i Immunoglobulins were quantitated by ra and some were binucleated. Mitoses dial immunodiffusion.9 Cryoglobulins and were often present. Sia test were determined by standard methods. Serum viscosity was measured E l e c t r o n M ic r o s c o p y with a microcone plate viscosimeter.f Sections of the pleural mass showed E l e c t r o n M ic r o s c o p ic St u d ie s closely packed plasma cells of various sizes and phases of maturation. The cyto Tissues were fixed in 2 percent glu- plasm was fairly abundant and almost en teraldehyde in phosphate buffer pH 7.2 for tirely filled by the endoplasmic reticulum. two hours at 4° C. After washingin sucrose, The latter was well-developed with mark the tissues were post-fixed in osmium edly dilated cisternae and studded with tetraoxide for one hour. Following dehy ribosomes (figure 4). dration and embedding in Epon 812, thin The cytoplasm also included a Golgi sections were cut with an LKB microtome, complex and numerous electron dense in stained with uranyl acetate and lead citrate clusion bodies which sometimes and examined with an RCAEMU-3Gelec- coalesced resulting in bizarre shapes. On tron microscope. occasion, the whole cytoplasm was filled with inclusions displacing the nucleus to Results the periphery of the cell which appeared I m m u n o l o g ic St u d ie s degenerated. The nucleus was generally large with coarse, irregular clumps of Total proteins varied between 5.0 to 6.5 heterochromatin. In contrast to normal g per dl. Serum protein electrophoresis, plasma cells in which nucleoli are inappa- serum viscosity, IgG, IgA and IgM were rent, myeloma cells had one or two promi normal. The Sia test and the test for cryo nent nucleoli usually spherical and con globulins were negative. IgD was 65 mg densed (figure 5). Some of the nucleoli per dl. There was an abnormal precipitin were ring-shaped with coarse granules of * Hyland. chromatin-like material in their center. f Brookfield. Mitotic division of the nucleus was noted IGD MYELOMA: IMMUNOLOGY AND ULTRASTRUCTURE 2 1 1

F ig u re 1. Serum immunoelectrophoresis showing an M-component with IgD lambda identity. K

V'1 NORMAL SERA ANS

F ig u r e 2. Urine immunoelectrophoresis showing lambda Bence Jones protein. D

K 2 1 2 IOACHIM, MCKENNA, HALPER1N AND CHUNG

Figure 3. Tumor mass involving pleura. Neo plastic plasma cells with markedly pleomorphic nuclei replace fibroadi- pose tissues (Formalin fixation, H&E x 400).

in cells with well-differentiated cytoplasm homogeneous protein are needed to pro (figure 6). Binucleated cells were fre duce a spike on serum protein electro quent. Based on the general electron mi phoresis,31 an IgD M-component must in croscopic appearance of the cell matrix, crease 100 times its value before it be light and dark forms of myelomacells were comes detectable by the usual screening noted (figure 7). procedures. Similar to this patient who, at admis sion time, did not s ho w a monoclonal Discussion peak on protein electrophoresis, many IgD myeloma is an uncommon disease. cases of IgD myeloma display a modest About three percent of all myelomas are of monoclonal peak or no peak at all and are the IgD class.8,10,12,13,14 In the authors’ possibly missed although they could al hospital, of 87 cases of multiple myeloma ways be detected by immunoelectro- examined between 1970 and 1977, only phoresis. one was of the IgD type (table I). As protein abnormalities of multiple Since the normal concentration of IgD in myeloma are studied in more detail, cer the serum is 3 mg per dl and300 mg per dl of tain discrete clinical patterns are often IGD MYELOMA: IMMUNOLOGY AND ULTRASTRUCTURE 213

FIGURE 4. Cluster of tumor cells showing cytoplasm with numerous mitochondria (M), abundant vesicular endoplasmic reticulum (ER), and large nuclei (N) with clumped chromatin and prominent nucleoli (Uranyl acetate and lead citrate x 5800). found with particular classes, sub-classes hypercalcemia occurs in IgG3 myeloma,7 or light chain types of immunoglobulins. coagulation disorders are associated with Thus, hyperviscosity is most frequent in IgA myeloma28 and lambda light chain dis macroglobulinemia and IgG3 myeloma,29 ease shows a higher incidence of renal 214 IOACHIM, MCKENNA, HALPERIN AND CHUNG

F ig u r e 5. Neoplastic-plasma cell with irregularly-shaped nucleus (N), including two large compact nucleoli lacking pars amorpha. Well-developed endoplasmic reticulum (ER), mitochondria (M) and Golgia area (G). Uranyl acetate and lead citrate x 8000. failure.2 IgD myeloma appears in a tient.3,12 On occasion,10 expanding tumor younger age group, includes more often masses in the spine have compressed the extraskeletal tumors and has a shorter sur spinal cord resulting in a variety of vival time. The median age at diagnosis is neurological signs. Although the neoplas 56 years with a range from 27 to 86 tic plasma cells usually infiltrate and re years.13,14 In a review of 133 cases by Jan- place large areas of hematopoetic bone celewicz et al,14 men outnumber women marrow, they are not released in the three to one, a difference not observed for peripheral blood and only a few cases of other types of myeloma. Extra-medullary plasma cell leukemia have been reported tumors are present in two-thirds of patients associated with IgD myeloma.4,22 with IgD myeloma owing either to A hitherto unexplained structural peculi plasmocytomas developing initially in soft arity of IgD myelomas is the identity of the tissues or to invasion by skeletal tumors light chain of the M-component which has breaking through the bone as in our pa been of the lambda type in 90 percent ofthe IGD MYELOMA: IMMUNOLOGY AND ULTRASTRUCTURE 215

F ig u r e 6. Mitotic division of a neoplastic plasmacyte shows chromosomes (CHR) and dilated cistemae of rough endoplasmic reticulum. (Uranyl acetate and lead citrate x 18,000). reported cases13,14 including the present. increase in number and size with occa Almost invariably, IgD myelomas are as sional dense granules, as observed in reac sociated with lambda Bence Jones pro tive lymphoreticular cells. The well- teinuria, as in our case, and azotemia which developed endoplasmic reticulum, di is frequently the cause of fatal ending. lated cisternae and large Golgi areas were Light and electron microscopic studies of IgD myelomas do not reveal specific morphologic features as compared with T A B L E I othertypes of myelomas.17,18,19 32 The fun Class of Immunoglobulins damental abnormality of these plasma cell in 87 Patients with Multiple Myeloma neoplasms consists in the dissociation be C lass o f M No. Frequency % tween nuclear and cytoplasmic matura Component Cases Type (% It. chains) T otal tion.5,25,32 Most cells examined in our sec tions contained large, indented nuclei, IgG 58 K38 65.5 66.7 L 20 3 4 .5 with dispersed chromatin and unusually IgA 20 K 15 7 5 .0 2 3 .0 prominent nucleoli. The abnormal nuclei L 5 2 5 .0 IgD 1 -- 1.1 were in contrast with the degree of L 1 differentiation exhibited by the cytoplas Bence Jones globulin K 6 7 5 .0 9 .2 (light chain 1 d i s e a s e ) L 2 2 5 .0 mic organelles. Mitochondria showed an IOACHIM, MCKENNA, HALPERIN AND CHUNG

F ig u r e 7. Myeloma cells including parts of two dark plasma cells (D). The dense cytoplasmic matrix is packed with mitochondria. (Uranyl acetate and lead citrate x 6,000). suggestive of high secretory activity. of abnormal proteins in human serum and Mitoses were occasionally observed. Two urine is more commonly undertaken, an distinctive ultrastructural features of increasing number of IgD myelomas will myeloma cells were the large number of probably be recognized in the future, pro voluminous, irregularly-shaped, electron viding more material for the study of this dense, intracytoplasmic inclusions18 and rare neoplastic disease. the presence of dark myeloma cells6 characterized by a well-developed endo Acknowledgments plasmic reticulum and a dense, opaque Thanks are extended to Ms. Yolanda Ayala, Mr. Nelson Twiggs and Ms. Barbara Turkington for their cytoplasmic matrix. The significance of excellent technical assistance, and to Ms. Judith these features is unclear. As identification Rubin for preparation of the manuscript. IGD MYELOMA: IMMUNOLOGY AND ULTRASTRUCTURE 217

F igure 8. Myeloma plasmocytes. Note the extensive development of rough-surfaced endoplasmic reticulum (ER). One of the cells has the nucleus (N) peripheral due to accumulation of numerous dense inclusion bodies within the cytoplasm (DB). (Uranyl acetate and lead citrate x 8,000).

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