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A 91-year-old woman was admitted because of haematemesis and melena and impending haemodynamic impairment. Her past medical history was unremarkable; furthermore the patient was not taking any drugs on a regular basis. On rectal examination, melena was confirmed.
The initial laboratory examinations showed a haemoglobin of 7.5 g/litre (normal range 12.5–16). After adequate stabilisation with fluid replacement and red cells concentrates, intravenous omeprazole was started, and she underwent to an urgent esophagogastroduodenoscopy that revealed a gastric large fungating type submucosal polyp with central deep ulceration and with signs of recent bleeding (fig 1). Multiple biopsy specimens were taken from the lesion and histological analysis indicated the presence of a submucous infiltrate of monoclonal plasma cells. Immunofixation revealed an immunoglobulin G-k monoclonal component; Bence–Jones proteinuria was absent. Radiological study of the entire skeleton was unremarkable. A biopsy of the bone marrow revealed aggregates of polymorphic lymphocytes, accounting for 35% of the marrow cellularity (a normal reading is <10%); the aggregates stained positively for kappa light chain and negatively for lambda light chain, cytocheratins and CD34.
This pattern was compatible with the histological diagnosis of myeloma. The patient remained haemodynamically stable and was discharged after 5 days because she refused any therapy.
Extramedullary plasmacytoma is an uncommon entity that most commonly involves nasopharynx or upper respiratory tract. Involvement of the gastrointestinal tract occurs in approximated 5% of cases. The small bowel is most commonly involved followed by the stomach, colon and oesophagus. Endoscopically, gastric plasmacytomas usually present as ulcers or an ulcerated mass, occasionally as irregular thickened folds, and, rarely, as fungating type polyps or multiple small haemorrhagic friable plaques. To establish an endoscopic diagnosis is often difficult. Initial gross finding of gastric myeloma may mimic various gastric lesions, such as peptic ulcer diseases, gastric lymphoma, gastritis, amyloidosis and primary gastric carcinoma.1,2 Gastric cancers show various macroscopic appearances ranging from well defined protuberant to diffuse infiltrating tumours but histological diagnosis is usually easy using endoscopic biopsy. In contrast, gastric submucosal tumour is often difficult to diagnose histologically, the tumour surface being covered with normal mucosa. Several reports stress the impact of large biopsy forceps to reach the deeper tissues, because plasmocytoma arises in the deeper mucosal layer. Other methods to improve the diagnostic yield of endoscopic biopsy specimens is the use of immunohistochemical techniques as well as polymerase chain reaction assays. An ultrasound endoscope is useful for obtaining further information on depth of invasion and tumour localisation in the gastric wall. Ultrasound-guided biopsy has recently been developed and allows reliable histological diagnosis of gastric submucosal tumours.3
Competing interests: None.
Patient consent: Patient/guardian consent was obtained for publication.