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Extramedullary Plasmacytoma of the Thyroid Gland Producing Gamma Heavy Chain

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Extramedullary Plasmacytoma of the Thyroid Gland Producing Gamma Heavy Chain Endocrinol. Japon. 1985, 32 (3), 427-433 Extramedullary Plasmacytoma of the Thyroid Gland Producing Gamma Heavy Chain SUNAO MATSUBAYASHI, HAJIME TAMAI, TOSHIMITSU SUZUKI*, Fumio MATSUZUKA**, AKIRA MIYAUCHI**, NOBUYUKI KOBAYASHI, SHUJI FUKATA, KANJI KUMA**, NOBORU YANAIHARA***, AND SHIGENOBU NAGATAKI**** Department of Psychosomatic Medicine, Kyushu University School of Medicine, Fukuoka 812. *Deprtment of Pathology, Niigata University School of Medicine, Niigata 951. **Department of Surgery, Kuma Hospital, Kobe 650. ***Laboratory of Bioorganic Chemistry, Shizuoka College of Pharmacy, Shizu- oka 422. ****Department of Internal Medicine, Nagasaki University School of Medicine, Nagasaki 852. Abstract We encountered a 65-year-old man with gamma heavy chain disease asso- ciated with extramedullary plasmacytoma of the thyroid gland. Serum electro- phoresis revealed an abnormal fast gamma band that cross-reacted with anti- IgG (FcƒÁ) sera immunoelectrophoretically. Intracytoplasmic monoclonal immunoglobulin, IgG (FcƒÁ), was demonstrated in thyroid tissue sections using an indirect immunofluorescence method. After surgery, the serum abnormal fast gamma band disappeared. At the time of writing, the patient has survived 18 months post-surgery. Gamma heavy chain disease is regarded only after exclusion of skeletal myeloma on as a lymphoproliferative disorder charac- a long-term follow-up. Recently, Seligmann terized by the heavy chain fragment of IgG. et al. (1979) and Kyle et al. (1981) reported About 60 patients with this disorder have gamma heavy chain disease associated with been described since the first report by plasmacytoma of the thyroid gland, but not Franklin et al. (1964). Its course is usually in detail. fatal (Kyle et al., 1981). Extramedullary We had an opportunity to observe plasmacytoma of the thyroid gland is even another patient with gamma heavy chain rarer. Voegt (1938) reported the first case. disease associated with extramedullary The diagnosis of extramedullary plasmacy- plasmacytoma of the thyroid gland. We toma of the thyroid gland can be made present here the clinical and immunohisto- chemical findings in our patient. Received February 6, 1985 Endocrinol Japon. 428 MATSUBAYASHI et al. June 1985 %) and thyroid scintinogram with radi- Case Report ioiodine revealed a cold region in a marginal part of the goiter. Total protein was 8.5 A 65-year-old man with an 11 month g/dl with 57.1% albumin and 42.9% globulin. history of goiter was admitted to Kuma Serum immunoglobulin levels were 3280mg/ Hospital in March 1983. No other local dl for IgG, 150mg/dl for IgA and 137mg/ or systemic symptoms were present. A dl for IgM. Serum electrophoresis revealed thyroid mass had not been noted in 1978 an abnormal fast gamma band (11.7% of total when the patient had undergone an exami- protein) (Figure 1a), which was also detected nation for cholecystitis. There was no in the concentrated urine electrophoretically. family history of thyroid illness. The production of gamma globulin excluding Physical examination revealed non-tender, abnormal protein (M-protein) was suppressed. firm, mobile, and diffusely enlarged bilateral Upon immunoelectrophoresis of the serum, lobes of the thyroid gland measuring 11.5 M-protein was proven to be IgG (FcƒÁ). Bone cm in maximum diameter. Bone tenderness, marrow examination showed 3.2% plasma lymphoadenopathy and hepatosplenomegaly cells (within normal limits), which were not were absent. monoclonal, using the immunofluorescence method. Laboratory data The RBC count was 431×104/cumm, Surgery and Pathology Hb 11.8g/dl, Hct 35.5%. The WBC count A total thyroidectomy was performed on was 4300/cumm with 69% neutrophils, 2% June 1, 1983. The thyroid gland was hard, eosinophils, 21% lymphocytes and 8% enlarged and weighed 155 g. The cut sur- monocytes. The erythrocyte sedimentation face of the thyroid gland was yellow-green ratio was 24mm/1hr. Resin T3 uptake in color. Histologically, diffuse cellular was 29.7% (norma1, 23.0-34.0%). Thyro- infiltration of plasma cells with nuclei of xine was 7.0μg/d1 (norma1, 4.5-13.0μg/dl). various size almost totally replaced the Thyrotropin-stimulating hormone was 12.3 thyroid tissue (Figure 2) and infiltrated the μU/m1 (normal<5μU/ml). Anti-thyroglo- capsule. Not a germinal center nor an bulin antibody titer was 28×102(norma1< amyloid deposition was observed. Thyroid 200) and anti-microsomal antibody titer was. follicular epithelial cells were degenerative 29×102 (norma1<200). Thyroid radioiodine and atrophic. There were no lymph nodes uptake at 24hr was 30.0% (normal,10-40 involved with tumor cells. a b c Fig. 1. Serum electrophoresis was performed and expressed using densitometry on a) May 30, 1983, b) June 10, 1983, and c) August 17, 1983. Total thyroidectomy was performed on June 1, 1983. The arrow indicates monoclonal protein (M-protein). Vol.32, No.3 PLASMACYTOMA OF THE THYROID GLAND 429 metastatic tumors. Materials and Methods Regents Goat antisera to human immunoglobulins, IgG, IgA and IgM were obtained from the Medical Biological Laboratory (Nagoya, Japan), and rabbit antisera to human IgD and IgE came from Hyland (Illinois, USA). Rabbit antisera to human immunoglobulin fragments, IgG (Fab), IgG (Fc), heavy chains (ƒÁ, ƒ¿, ƒÊ, ƒÂ, ƒÃ) and light chains (ƒÉ, ƒÈ) were purchased from Hoechst Japan Inc. (Tokyo, Japan). Human IgG and its frag- ments, Fab and Fc were also obtained from Green Cross Corp. (Osaka, Japan). Anti-rabbit IgG labelled with fluoresecin isothiocyanate (FITC) was obtained from Miles (Indiana, USA). FA mountain fluid was purchased from Difco (Michigan, USA). Immunoelectrophoresis Immunoelectrophoresis of the serum was performed according to the conventional method (Doe et al., 1979). Immunohistochemistry Fig. 2. Section of thyroid tissue, with diffuse A portion of the thyroid gland was fixed with infiltration by plasma cells with nuclei of 10% formalin solution and embedded in para- various size (Hematoxylin-eosin staining, original magnification•~200). ffin wax. For an indirect immunofluorescence method, sections were dewaxed, stained with the diluted primary antisera (1: 50) with 0.01M Treatment and Follow-up phosphate buffered saline (PBS) pH7.4 for 1hr Postoperative radiation (4,000 rad) was at room temperature, washed with PBS, and reacted with secondary antiserum for 1hr at room administrated to the thyroid region and the temperature. After washing with PBS, the slides upper mediastinum. were mounted using FA mounting fluid and Serum electrophoresis was performed at photographed under an Olympus fluorescence intervals of one week to two weeks. Ten microscope (Model BHF, Tokyo, Japan). days after surgery, the abnormal fast gamma For every test section stained with antiserum, band rapidly decreased (6.1% of total a set of controls was also examined. protein) (Figure 1b): 80 days after surgery, it disappeared (Figure 1c), nor at that time, could it be detected immunoelectophoreti- Result cally. Anti-thyroglobulin and anti-micro- somal antibody titers were reduced, 24•~102 An abnormally fast gamma band, which and 25•~102 respectively. was detected by serum electrophoresis on At the time of this report, the patient cellulose acetate membrane, appeared as has survived 18 months after surgery. There abnormal precipitation which cross-reacted are no recurrent local tumors nor systemic with anti-IgG (Fe) and anti-gamma heavy Endocrinol Japon. 430 MATSUBAYASHI et al. June 1985 Fig. 3. Serum irnmunoelectrophores's using anti-human immunoglobulin antisera. The patient's serum reacted with anti-IgG (Fc) sera. Table 1. Immunohistochemistry of plasmacytoma of the thyroid gland. *; Immunohistochemistry after indirect immunofluorescence method . **; not detectable . Vol.32, No.3 PLASMACYTOMA OF THE THYROID GLAND 431 Discussion Extramedullary plasmacytoma of the thyroid gland is a very rare disorder. It is classified as one of the malignant lympho- mas of the thyroid gland (Devine et al., 1981), with a frequency ranging from 0% to 3.5% (Burke et al., 1977; Devine et al., 1981). The diagnosis of extramedullary plasmacy- toma of the thyroid gland can be made only after exclusion of multiple myeloma. In order to categorize the case as an ex- tramedullary plasmacytoma, bone marrow plasma cells must not be monoclonal. To date, only 18 cases of extramedullary plasmacytoma of the thyroid gland have been reported (Voegt, 1938; Shaw and Smith, 1940; Barton and Farmer, 1949; Hazard and Schidecker, 1949; More et al., 1968; Shimaoka et al., 1978; Corwin and Lind- berg, 1979; Seligmann et al., 1979; Buss et al., 1980; Bevilacqua, 1981; Devine et al., 1981; Kyle et al., 1981; Macpherson et al., 1981; Kapadia et al., 1982; Koyama et al., 1983). Gamma heavy chain diseases associated with Fig. 4. Immunostaining of thyroid tissue, con- extramedullary plasmacytoma of the thyroid sective slide shown in Figure 2. Almost all gland have been described by Seligmann etal., of thyroid tumor cells (plasma cells) in the (1979) and Kyle et al. (1981) only, the strorra were stained positively with anti-IgG frequency ranging from 9.0% to 14.3% of (Fe) sera (indirect immunofluorescence method, original magnification•~200). gamma heavy chain diseases (Seligmann et al., 1979; Kyle et al., 1981). However, they did not report these cases in detail. chain antisera, but did not react with other Generally, gamma heavy chain diseases are antisera (Figure 3). fatal (Kyle et al., 1981). Most of those tumor cells which proli- At first, it was thought that our case ferated in the stroma of the
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