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JAMA Oncology Clinical Challenge
October 2017

New Painful Nodules in a Patient With Multiple Myeloma

Author Affiliations
  • 1Department of Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
  • 2Norris Cotton Cancer Center, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire
JAMA Oncol. 2017;3(10):1423-1424. doi:10.1001/jamaoncol.2017.2112

A woman in her 60s presented for evaluation of multiple painful cutaneous nodules that had developed over the previous 2 months. The patient had a history of IgGκ multiple myeloma, diagnosed approximately 6 months earlier. At that time, flow cytometry showed a κ-restricted plasma cell population positive for CD38 and CD138 but negative for CD3, CD20, and CD45 expression. Cytogenetic analysis with fluorescent in situ hybridization did not reveal high-risk genetic markers. The patient demonstrated no evidence of end organ disease, and her myeloma was classified as stage II. Since her initial diagnosis, she had completed 4 cycles of lenalidomide, bortezomib, and dexamethasone (RVD) therapy in addition to irradiation for lytic lesions of the thoracic and lumbar spine. Physical examination revealed scattered red-violaceous nodules, with the largest measuring approximately 6.0 × 5.5 × 2.5 cm (Figure, A). They were found in the mouth, the trunk, and on all 4 extremities. The lesions were nonulcerated, round with a smooth surface, fixed, and firm and tender to touch. Serum protein levels were normal. An ultrasound-guided needle biopsy and immunohistochemical analysis of the largest lesion on the patient’s right shoulder were performed (Figure, B and C).

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