Teaching Case

A 61-year-old patient with documented multiple myeloma. 4 chemoterapy cycles.
In the second follow-up consultation after the 4 cycles refers an ache and "weight sensation" on the testis. Physical examination shows indurated testis. An ultrasound was requested.

At least three hypoechoic nodules were identified in the testis, with arterial flow and a systolic peak of 20.1 cm/s. Hydrocele of small volume was also identified at the right. The signs suggested secondary involvement of the testis.

The radiograph of the entire skeletal system (made on the same day) was unremarkable.

Multiple myeloma is characterised by malignant production and proliferation of a monoclonal population of plasma cells causing an increased secretion of paraprotein [1]. Is very uncommon but represents 10% of all haematologic malignancies [1, 2]. Clinically it presents as lytic bone lesions, hypercalcaemia, and renal impairment [2, 3].
Testis is uncommon for multiple myeloma extramedullary involvement.
The reported incidence of extramedullary involvement in multiple myeloma varies between 10-80 % [2, 3, 4]. The most frequent involved organs are the liver, spleen, lymph nodes, kidney and lung [4, 5].
For the diagnosis of testicular tumour to be considered the classic morphologic and immunohistochemical aspects must be taken into account.
The diagnosis of testicular tumour is histologic and must be made taking into consideration the classic morphological and immunohistochemical aspects; these are first obtained by not very aggressive techniques, such as fine needle aspiration, which will reveal the plasmocytic and malignant nature of the cells. This can be later confirmed by biopsy if necessary.
The appearance of extraosseous localisation in the course of multiple myeloma usually indicates acceleration of the malignant process. The average life expectancy upon diagnosis is 3–4 months [5, 6]. Because testicular involvement in multiple myeloma is rare, there is no uniformity in the choice of treatment yet [6].
Ultrasound findings in testicular involvement in myeloma:
-Enlarged testis;
-Hypoechoic lesions with high vascularity;
The survival rate after a testicular diagnosis with multiple myeloma is very poor [6, 7]. Bortezomib is promising in combination with chemotherapy [5, 6, 7].
There is debate whether testicular involvement is a separate entity or a a part of of MM involvement. Now it is widely accepted that testicular plasma-cell neoplasia is a local manifestation of a systemic disease process [5, 6, 7].
Our patient died 4 months later with disseminated disease. A bortezomib based chemotherapy was attempted but failed.
Take home messages
- Testicular involvement is unusual in multiple myeloma
- Most patients don’t survive more than 3 months