University of Miami/Jackson Medical Hospital Miami, FL
Manuela Araque, MD, MPH1, Shyam Vedantam, DO2, Manuel Lora Gonzalez, MD3, Jordan Orr, MD3, Jodie A. Barkin, MD, FACG3, Daniel A. Sussman, MD3 1University of Miami/Jackson Medical Hospital, Miami, FL; 2University of Miami, Miami, FL; 3University of Miami Miller School of Medicine, Miami, FL Introduction: Metastatic tumors to the pancreas primarily include breast, lung, ovarian, and renal cell carcinoma. Extramedullary involvement in hematologic plasma cell malignancies is rare and indicates a poor prognosis. We describe a rare case of extramedullary relapsing IgG Kappa multiple myeloma metastatic to the pancreatic body.
Case Description/
Methods: A 57-year-old man with IgG Kappa multiple myeloma (diagnosed 5 years prior, status post autologous stem cell transplant complicated by relapse of the disease 4 years later) presented to the emergency department due to a 3-day history of worsening left-sided abdominal and back pain. Relapsing disease was diagnosed in 2024 via a pathologic right humerus fracture while on lenalidomide maintenance therapy. He received four cycles of iberdomide, daratumumab, carfilzomib, and dexamethasone (Iber-KDd) as part of a clinical trial prior to his ED visit.
On admission, his labs were notable for hemoglobin 11.8, platelets 409, lactate 2.7, and lipase 71, with a normal bilirubin of 0.5 and alkaline phosphatase of 71. Two days prior, he underwent a PET scan to evaluate a palpable mass in the left mid-back, which showed new fluorodeoxyglucose (FDG) avid abdominopelvic lymph nodes/implants and a new FDG avid pancreatic body lesion. In the ED, an abdominal CT scan demonstrated a homogenous density in the pancreas without focal lesions or main ductal dilatation.
Endoscopic ultrasound (EUS) found an 18x17mm hypoechoic, heterogenous mass in the pancreatic body with ill-defined borders (Figure 1). Fine needle biopsy (FNB) results demonstrated a kappa-restricted plasma cell neoplasm involving pancreas parenchyma (Figure 2). Prior to discharge, he started dexamethasone, cyclophosphamide, etoposide, and cisplatin (DCEP) with the plan to bridge to CAR-T therapy and to start palliative radiation therapy as an outpatient. Discussion: This case demonstrates extramedullary involvement of relapsing multiple myeloma in the pancreatic body without physical signs or laboratory findings of obstructive jaundice. In our literature review, pancreatic involvement in multiple myeloma is considered a rare entity that presents typically with signs of obstructive jaundice and indicates a poor prognosis, remaining a unique subtype of metastatic tumors to the pancreas. We highlight the diagnostic utility of an EUS-guided FNB when evaluating FDG-avid lesions on PET-CT with the possibility of appropriate diagnosis to minimize delays in care and reduce morbidity and mortality.
Figure: Figure 1: CTAP, PET, and EUS findings demonstrating a pancreatic body lesion, raising concern for malignancy.
Figure: Figure 2: The cell block sections show a hypercellular specimen composed predominantly of a monotonous population of atypical plasmacytoid cells arranged in loosely cohesive clusters and dispersed singly. The neoplastic cells are medium to large in size with eccentrically placed nuclei, coarse "clock-face" chromatin, and inconspicuous to prominent nucleoli. The cytoplasm is moderate in amount, eosinophilic, and finely granular, with some cells exhibiting perinuclear clearing (hof), characteristic of plasma cell differentiation. The cytomorphology raises concern for extramedullary involvement by a plasma cell neoplasm, such as multiple myeloma.
Disclosures: Manuela Araque indicated no relevant financial relationships. Shyam Vedantam indicated no relevant financial relationships. Manuel Lora Gonzalez indicated no relevant financial relationships. Jordan Orr indicated no relevant financial relationships. Jodie Barkin: AbbVie – Advisor or Review Panel Member. Aimmune Therapeutics – Advisor or Review Panel Member. Amgen – Consultant. CorEvitas – Consultant. Iterative Health – Consultant. Medtronic – Consultant. MotusGI – Consultant. Daniel Sussman indicated no relevant financial relationships.
Manuela Araque, MD, MPH1, Shyam Vedantam, DO2, Manuel Lora Gonzalez, MD3, Jordan Orr, MD3, Jodie A. Barkin, MD, FACG3, Daniel A. Sussman, MD3. P0242 - Not Just Bone Deep: A Pancreatic Presentation of Myeloma – A Case Report and Review of the Literature, ACG 2025 Annual Scientific Meeting Abstracts. Phoenix, AZ: American College of Gastroenterology.
