Hello, I am new here. I am a healthy 42 year-old female. have been suspecting a bone / blood disorder for about 5 years. It started with severe itching (diagnosed as autoimmune sensitivity / response), bone pain (diagnosed as peripheral neuropathy), bone fractures (ankle, tail-bone, toes) and I have a permanently swollen lymph node in my neck (diagnosed as benign via ultrasound - no biopsy performed).
These have been going on for 5 years. Had bone density scan this spring and diagnosed with osteopenia (-1.4). Problem, is, all these tests were performed by various doctors and it seems as though I am the only one that has the opportunity to put it all together. Now, I went to the dermatologist for a routine body exam. A suspicious red noodle was found on my upper back and a biopsy performed. These are the results of the skin biopsy (keep in mind the above "symptoms" and diagnoses of past 5 years)
**Note; The dermatologists called me when she got the results and sent me to after-hours lab to do a CBC (it was a Friday night). She was very concerned about the plasma cells in the skin. My CBC came back beautiful! Levels were great everywhere and from what I can tell no M-proteins found.
Yesterday I signed releases to have all my records sent to a new internal medicine doctor so that I can have one central / person reviewing my medical records. I do not have an appointment yet because I want all the records to be sent and reviewed prior to my appointment.
Until then, can anyone make out the following? From what I understand, these findings are very rare/unusual and the pathologist doesn't know that I already have the diagnoses listed in the first paragraph.
My next step, regardless, is to have the lymph node biopsied. It's been there for at least 5 years. I have blown it off as a rare but normal case of a permanently swollen lymph node.
Anyway, can anyone offer up an interpretation of this pathology report from the skin biopsy?
DIAGNOSIS:
Skin, mid upper back, punch biopsy:
- Dermal fibrosis and chronic inflammation, including keratin granuloma and abundant punch cells; negative for carcinoma; see comment.
- COMMENT: The findings (see microscopic description) are most consistent with a chronically inflamed ruptured hair follicle or cyst, but the abundance of plasma cells are unusual. In Situ hybridization (ISH) stains indicate a large preponderance of kappa over lambda cells immunoglobulin light chains in plasma the plasma cells, raising the possibility of neoplastic light chain restriction. However, in an asymptomatic young patient, that possibility seems much less likely than a smoldering inflammatory process. If the patient has or develops other similar lesions, additional biopsy may be informative; if clinically relevant, the possibility of plasma cell dyscrasia could be investigated with serum protein electrophoresis.
CLINICAL NOTES: Rule out BBC
ORGAN/TISSUE SITE: Mid-upper back
GROSS DESCRIPTION: Received in a formalin-filled container labeled with the patients name is a 7x6x2 millimeter shaved biopsy of the skin. The specimen is marked with yellow ink, bisected, and submitted entirely on cassette.
MICROSCOPIC DESCRIPTION: Microscopic examination performed. The bisected shave biopsy shows dermal fibrosis with superficial and deep dense lymphohistiocytic infiltrate with sheets of plasma cells. The plasma cells lack mitotic activity, notable cytologic atypia and necrosis. Histiocytes, many of them multinucleate, make up a large proportion of the infiltrate; many have keratin or keratin-like material in their cytoplasm. The background storm is myxoid, but Alcian Blue stain does not show notably increased mucin.
Kappa and lambda immunoglobulin light chains are assessed by in situ hybridization, which highlights many times kappa plasma cells than lambda plasma cells. The significance of this finding is not obvious, as kappa-producing plasma cells normally outnumber lambda producing ones. CD3 (pan T-lymphocyte marker) and CD 20 (pan B-lymphocyte marker) each highlight a significant percentage of cells. CD68 highlights the histiocytes, as described above.
misc; KAPPA ISH DAB, LAMBDA ISH DAB
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Re: Plasma cells in the skin
Hi Bunny,
Welcome to the forum.
Have you had a serum protein electrophoresis (SPEP) and/or serum immunofixation electrophoresis (sIFE, or just IFE) tests done? These would be particularly useful for determining whether or not the source of the plasma cells in your skin is something related to multiple myeloma or another plasma cell disorder.
The SPEP and IFE tests will establish whether there is any monoclonal protein in your blood, which almost always is the result of monoclonal (myeloma-related) plasma cells being produced in your body.
If those tests turn up negative for signs of a monoclonal protein, then the source of the plasma cells is probably something else.
Another test that your doctors will probably want to run is the serum free light chain test, which measures the level of kappa and lambda free light chains in your blood. If ratio of these two levels is abnormal, that can be a sign of myeloma being present somewhere in the body.
There are other tests that may be useful to run eventually, and you also should check to see if your serum creatinine and hemoglobin levels are abnormal (I'm guessing they are not). But the SPEP, IFE, and free light chain tests are, in my mind, obvious next steps.
Good luck!
Welcome to the forum.
Have you had a serum protein electrophoresis (SPEP) and/or serum immunofixation electrophoresis (sIFE, or just IFE) tests done? These would be particularly useful for determining whether or not the source of the plasma cells in your skin is something related to multiple myeloma or another plasma cell disorder.
The SPEP and IFE tests will establish whether there is any monoclonal protein in your blood, which almost always is the result of monoclonal (myeloma-related) plasma cells being produced in your body.
If those tests turn up negative for signs of a monoclonal protein, then the source of the plasma cells is probably something else.
Another test that your doctors will probably want to run is the serum free light chain test, which measures the level of kappa and lambda free light chains in your blood. If ratio of these two levels is abnormal, that can be a sign of myeloma being present somewhere in the body.
There are other tests that may be useful to run eventually, and you also should check to see if your serum creatinine and hemoglobin levels are abnormal (I'm guessing they are not). But the SPEP, IFE, and free light chain tests are, in my mind, obvious next steps.
Good luck!
Re: Plasma cells in the skin
Hi Terry,
Thank you for your reply. They did a CBC and checked for that M protein - showed negative and the rest of my CBC was great.
"In situ hybridization (ISH) stains indicate a large preponderance of kappa over lambda cells immunoglobulin light chains in plasma the plasma cells, raising the possibility of neoplastic light chain restriction" ... and amount of kappa over lambda cells was a large preponderance ...
I don't know what to make of the "abundance" and "sheets of plasma cells" found in my skin biopsy.
Thank you for your reply. They did a CBC and checked for that M protein - showed negative and the rest of my CBC was great.
"In situ hybridization (ISH) stains indicate a large preponderance of kappa over lambda cells immunoglobulin light chains in plasma the plasma cells, raising the possibility of neoplastic light chain restriction" ... and amount of kappa over lambda cells was a large preponderance ...
I don't know what to make of the "abundance" and "sheets of plasma cells" found in my skin biopsy.
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Bunny - Name: Bunny
Re: Plasma cells in the skin
Hi Bunny,
When I read your first post, I thought to myself, “Boy! If something can go wrong, it will.” Plasma cells, for the most part, stay inside the bone marrow. That’s their home base, so to speak. So why are they under your skin?
Plasma cells do not start their life as plasma cells. Instead, they start out as lymphocytes. Due to disease processes and other factors, some lymphocytes transform into cells that become “factories” for the production of immunoglobulins. These are the cells named plasma cells.
It seems like you have a bunch of plasma cells where they are not usually found. Since the report says the “plasma cells lack mitotic activity”, it appears that they are not proliferating at any great speed. That’s good news. Also, as TerryH says, you would like to know if there is any clonality to the collection of plasma cells on your skin.
From the tone of the report, I think you should not allow yourself to get too worried. This could easily end up as a happy story for you. Keep pursuing the diagnosis and let us know how it turns out.
Joe
When I read your first post, I thought to myself, “Boy! If something can go wrong, it will.” Plasma cells, for the most part, stay inside the bone marrow. That’s their home base, so to speak. So why are they under your skin?
Plasma cells do not start their life as plasma cells. Instead, they start out as lymphocytes. Due to disease processes and other factors, some lymphocytes transform into cells that become “factories” for the production of immunoglobulins. These are the cells named plasma cells.
It seems like you have a bunch of plasma cells where they are not usually found. Since the report says the “plasma cells lack mitotic activity”, it appears that they are not proliferating at any great speed. That’s good news. Also, as TerryH says, you would like to know if there is any clonality to the collection of plasma cells on your skin.
From the tone of the report, I think you should not allow yourself to get too worried. This could easily end up as a happy story for you. Keep pursuing the diagnosis and let us know how it turns out.
Joe
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Wobbles - Name: Joe
- Who do you know with myeloma?: myself
- When were you/they diagnosed?: June 2016
- Age at diagnosis: 67
Re: Plasma cells in the skin
Joe - Thanks for taking the time to respond.
It seems as though the pathologist and the dermatologist were very concerned, but when the blood work came back normal, they ended their search right there. Normal? Normal to have plasma cells in the skin? Normal to have CD3, CD20 and CD68 markers show up and normal for the kappa to be "many times more" than the lambda?
These two (pathologist and dermatologist) are unaware that I have permanent swollen lymph node and already have osteopenia. But nothing I can really do until my new doctor gets all my records for review. I think the first thing I should ask for is to actually get that lymph node biopsied. I declined to have it biopsied a few years ago because the ultrasound showed negative for suspicious findings.
For now, I'll continue to carry on - just as I have the past 5 years
So for now, I'll continue believing I'm a healthy adult
Thanks again!
It seems as though the pathologist and the dermatologist were very concerned, but when the blood work came back normal, they ended their search right there. Normal? Normal to have plasma cells in the skin? Normal to have CD3, CD20 and CD68 markers show up and normal for the kappa to be "many times more" than the lambda?
These two (pathologist and dermatologist) are unaware that I have permanent swollen lymph node and already have osteopenia. But nothing I can really do until my new doctor gets all my records for review. I think the first thing I should ask for is to actually get that lymph node biopsied. I declined to have it biopsied a few years ago because the ultrasound showed negative for suspicious findings.
For now, I'll continue to carry on - just as I have the past 5 years
So for now, I'll continue believing I'm a healthy adult Thanks again!
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Bunny - Name: Bunny
Re: Plasma cells in the skin
Bunny,
Regarding your statement "they did a CBC and checked for that M protein - showed negative and the rest of my CBC was great", please be clear that a CBC test doesn't screen for monoclonal proteins (M-protein) whatsoever.
As Terry mentioned, you really need an IFE and an SPEP test to test for M-protein. I might also suggest testing for amyloid protein via a Congo red stain test in any follow up testing, whether that be testing a sample from an affected skin area or a swollen lymph node.
I'd also suggest working or consulting with a multiple myeloma specialist if there is any indication of monoclonal or amyloid proteins – and especially if there is cutaneous involvement that accompanies either one of these protein abnormalities.
Regarding your statement "they did a CBC and checked for that M protein - showed negative and the rest of my CBC was great", please be clear that a CBC test doesn't screen for monoclonal proteins (M-protein) whatsoever.
As Terry mentioned, you really need an IFE and an SPEP test to test for M-protein. I might also suggest testing for amyloid protein via a Congo red stain test in any follow up testing, whether that be testing a sample from an affected skin area or a swollen lymph node.
I'd also suggest working or consulting with a multiple myeloma specialist if there is any indication of monoclonal or amyloid proteins – and especially if there is cutaneous involvement that accompanies either one of these protein abnormalities.
-
Multibilly - Name: Multibilly
- Who do you know with myeloma?: Me
- When were you/they diagnosed?: Smoldering, Nov, 2012
Re: Plasma cells in the skin
Hi!
Thanks for your responses.
Let me make sure that I am understanding you all correctly. The pathologist recommended that "plasma cell dyscrasia could be investigated with serum protein electrophoresis". It was at that time that they had me go to an urgent care / after-hours lab to do a CBC, which I thought included that protein. I have copied/pasted my "CBC" results below. Did they do ANY tests that would rule out multiple myeloma or any other plasma dyscrasia? From what I understand, the correct test / tests were not done? Is there anywhere on this CBC that is another name for the "protein electrophoresis"?
My concern is that they found these abnormalities, sent me back for 1 "CBC", which showed dang near perfect and that was the end of the story. So what did they find that was so odd in the biopsy that the "CBC" ruled out definitively and that's the end of the story?
I do believe this is all too coincidental to be nothing. I'm only 42 and have bone loss (-1.4), swollen lymph node (5+years), plasma cells in skin / elevated kappa.
I'm sorry for sounding foolish and I most certainly plan on having my new doctor review these findings, but until then, i'm trying to learn what it was that the CBC showed that "over-rode" these biopsy findings.
Component Your Value Standard Range
Protein Total, Serum 7.1 g/dL 6.4 - 8.3 g/dL
Albumin (Serum) 3.9 g/dL 3.4 - 5.0 g/dL
Globulin Serum 3.2 g/dL 1.4 - 4.9 g/dL
Component Your Value Standard Range
Absolute Neutrophils 6.1 k/cmm 1.8 - 8.0 k/cmm
Absolute Lymphocytes 1.6 k/cmm 1.1 - 4.0 k/cmm
Absolute Monocytes 0.5 k/cmm 0.2 - 0.8 k/cmm
Absolute Eosinophils 0.1 k/cmm 0.0 - 0.5 k/cmm
Absolute Basophils 0.1 k/cmm 0.0 - 0.2 k/cmm
Immature Granulocytes 0.4 % 0.0 - 0.5 %
Component Your Value Standard Range
Total Protein, Serum ELP 7.1 g/dL
Albumin, Serum ELP 3.9 g/dL 3.4 - 5.0 g/dL
Alpha-1-Globulin 0.3 g/dL 0.1 - 0.4 g/dL
Alpha-2-Globulin 0.8 g/dL 0.3 - 1.1 g/dL
Beta Globulin 1.0 g/dL 0.5 - 1.2 g/dL
Gamma Globulin 1.1 g/dL 0.6 - 1.4 g/dL
S ELP Interp - See Note
Normal electrophoretic pattern. TGM
Component Your Value Standard Range
White Blood Cell Count 8.4 k/cmm 3.8 - 11.0 k/cmm
Red Blood Cell Count 4.10 m/cmm 3.70 - 5.20 m/cmm
Hemoglobin 13.7 g/dL 11.8 - 15.5 g/dL
Hematocrit 39.7 % 35.0 - 46.0 %
Mean Corpuscular Volume 96.8 fL 80.0 - 100.0 fL
RDW 13.0 % 11.0 - 15.0 %
Platelet Count 299 k/cmm 140 - 450 k/cmm
Thanks for your responses.
Let me make sure that I am understanding you all correctly. The pathologist recommended that "plasma cell dyscrasia could be investigated with serum protein electrophoresis". It was at that time that they had me go to an urgent care / after-hours lab to do a CBC, which I thought included that protein. I have copied/pasted my "CBC" results below. Did they do ANY tests that would rule out multiple myeloma or any other plasma dyscrasia? From what I understand, the correct test / tests were not done? Is there anywhere on this CBC that is another name for the "protein electrophoresis"?
My concern is that they found these abnormalities, sent me back for 1 "CBC", which showed dang near perfect and that was the end of the story. So what did they find that was so odd in the biopsy that the "CBC" ruled out definitively and that's the end of the story?
I do believe this is all too coincidental to be nothing. I'm only 42 and have bone loss (-1.4), swollen lymph node (5+years), plasma cells in skin / elevated kappa.
I'm sorry for sounding foolish and I most certainly plan on having my new doctor review these findings, but until then, i'm trying to learn what it was that the CBC showed that "over-rode" these biopsy findings.
Component Your Value Standard Range
Protein Total, Serum 7.1 g/dL 6.4 - 8.3 g/dL
Albumin (Serum) 3.9 g/dL 3.4 - 5.0 g/dL
Globulin Serum 3.2 g/dL 1.4 - 4.9 g/dL
Component Your Value Standard Range
Absolute Neutrophils 6.1 k/cmm 1.8 - 8.0 k/cmm
Absolute Lymphocytes 1.6 k/cmm 1.1 - 4.0 k/cmm
Absolute Monocytes 0.5 k/cmm 0.2 - 0.8 k/cmm
Absolute Eosinophils 0.1 k/cmm 0.0 - 0.5 k/cmm
Absolute Basophils 0.1 k/cmm 0.0 - 0.2 k/cmm
Immature Granulocytes 0.4 % 0.0 - 0.5 %
Component Your Value Standard Range
Total Protein, Serum ELP 7.1 g/dL
Albumin, Serum ELP 3.9 g/dL 3.4 - 5.0 g/dL
Alpha-1-Globulin 0.3 g/dL 0.1 - 0.4 g/dL
Alpha-2-Globulin 0.8 g/dL 0.3 - 1.1 g/dL
Beta Globulin 1.0 g/dL 0.5 - 1.2 g/dL
Gamma Globulin 1.1 g/dL 0.6 - 1.4 g/dL
S ELP Interp - See Note
Normal electrophoretic pattern. TGM
Component Your Value Standard Range
White Blood Cell Count 8.4 k/cmm 3.8 - 11.0 k/cmm
Red Blood Cell Count 4.10 m/cmm 3.70 - 5.20 m/cmm
Hemoglobin 13.7 g/dL 11.8 - 15.5 g/dL
Hematocrit 39.7 % 35.0 - 46.0 %
Mean Corpuscular Volume 96.8 fL 80.0 - 100.0 fL
RDW 13.0 % 11.0 - 15.0 %
Platelet Count 299 k/cmm 140 - 450 k/cmm
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Bunny - Name: Bunny
Re: Plasma cells in the skin
The above lab results are from a serum protein electrophoresis (SPEP) and a CBC test. The results below are the SPEP results. The rest of the results are from the CBC test.
Component Your Value Standard Range
Total Protein, Serum ELP 7.1 g/dL
Albumin, Serum ELP 3.9 g/dL 3.4 - 5.0 g/dL
Alpha-1-Globulin 0.3 g/dL 0.1 - 0.4 g/dL
Alpha-2-Globulin 0.8 g/dL 0.3 - 1.1 g/dL
Beta Globulin 1.0 g/dL 0.5 - 1.2 g/dL
Gamma Globulin 1.1 g/dL 0.6 - 1.4 g/dL
S ELP Interp - See Note
Normal electrophoretic pattern. TGM
It's a little surprising they didn't also run a serum immunofixation test, which is a bit more precise at detecting monoclonal protein than an SPEP. But the statement "Normal electrophoretic pattern" from the SPEP test is still a pretty good indicator that all is well from a monoclonal protein standpoint.
Component Your Value Standard Range
Total Protein, Serum ELP 7.1 g/dL
Albumin, Serum ELP 3.9 g/dL 3.4 - 5.0 g/dL
Alpha-1-Globulin 0.3 g/dL 0.1 - 0.4 g/dL
Alpha-2-Globulin 0.8 g/dL 0.3 - 1.1 g/dL
Beta Globulin 1.0 g/dL 0.5 - 1.2 g/dL
Gamma Globulin 1.1 g/dL 0.6 - 1.4 g/dL
S ELP Interp - See Note
Normal electrophoretic pattern. TGM
It's a little surprising they didn't also run a serum immunofixation test, which is a bit more precise at detecting monoclonal protein than an SPEP. But the statement "Normal electrophoretic pattern" from the SPEP test is still a pretty good indicator that all is well from a monoclonal protein standpoint.
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Multibilly - Name: Multibilly
- Who do you know with myeloma?: Me
- When were you/they diagnosed?: Smoldering, Nov, 2012
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