Extramedullary Plasmacytomas(EMP) are rare tumors accounting for 0.4% of all head and neck malignancies and 4% of all nonepithelial tumors of nasal cavity. The absence of multiple myeloma must be confirmed with bone marrow examination and skeletal surveys, before arriving at a diagnosis of EMP. We report a case of extramedullary plasmacytoma of the nasal cavity in a 60 year old female, who was a chronic tobacco sniffer. The case demonstrates the multidisciplinary approach required for the optimal diagnosis and management of such tumors and proposes chronic irritation of the nasal mucosa as one of the etiological factors for EMP. Introduction Extramedullary Plasmacytomas(EMP) are rare tumors accounting for 0.4% of all head and neck malignancies and 4% of all nonepithelial tumors of nasal cavity.1 About 80% of the extramedullary plasmacytomas are localized in the submucosa of the upper respiratory tract, with a large proportion occurring in the sinonasalasopharyngeal area.1-3 The absence of multiple myeloma must be confirmed with bone marrow examination and skeletal surveys ,before arriving at a diagnosis of EMP. The therapy consists of combined surgery and radiotherapy. The main prognostic indicator for EMP is progression to multiple myeloma.10-32% of all patients develop multiple myeloma which reduces the mean survival time from 8.3 years to 20 months .1,4 We report a case of EMP of the nasal cavity in a 60 year old female who was a chronic tobacco sniffer. The patient was managed by endoscopic removal of the tumor followed by radiotherapy. A 6 month follow up of the patient revealed neither recurrence of the tumor nor a progression to multiple myeloma. Case Report A 60 year old female, with unremarkable past medical history, presented with right sided nasal obstruction, mucoid nasal discharge and intermittent epistaxis for the past 5 months. There was history of occasional headaches .The patient had been sniffing tobacco for the past 35 years. The general physical examination did not reveal any abnormality, nor was there any evidence of lymphadenopathy. Anterior rhinoscopy revealed a pinkish, fleshy mass in the right nasal cavity which was firm in consistency, bled easily and was insensitive to probing. Endoscopic examination confirmed the presence of a dark red sub mucosal lesion with a smooth surface. The CT scan of the patient revealed a hypodense mass localized to the right nasal cavity showing contrast enhancement with no bony erosion (figure 1 ).A nasal biopsy was subsequently taken which revealed a dense infiltrate of plasma cells ( figure 2 ). A histological diagnosis of plasmacytoma was made. Routine blood tests and serum biochemistry including calcium, phosphorus, blood urea nitrogen, urea, uric acid and creatinine were all within reference range. Both serum myeloma proteins and urine Bence- Jones proteins were negative. Serum and urine electrophoresis did not reveal M component. Bone marrow biopsy revealed a plasma cell infiltrate of less than 3% of all nucleated cells .Chest radiograph, total body skeletal survey and Tc99 scintigram, showed no systemic lesion. The finding confirmed a diagnosis of stage 1 extramedullary plasmacytoma. The patient underwent complete surgical removal of the tumor endoscopically. This was followed by radiotherapy of 5000 cGy, delivered over a period of 6 weeks. A 6 month follow- up of the patient did not reveal any recurrence.
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