PMC4627100_01
(a) Cutaneous dome shaped nodules peripherally located on the full thickness skin graft, three weeks after excision of squamous cell carcinoma (b) 7 days later, rapid growth and ulceration of the lesions expanding beyond the graft site.
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However, 2 weeks later, he re-presented with multiple red dome-shaped cutaneous nodules on the FTSG located on the forehead (Figure 1), surgical excision site on the right arm and the graft donor site. S100 and MELAN A, excluding possible recurrence of melanoma. Seven days later, the nodules dramatically increased in size with associated ulceration (Figure 1).
(a) Immature plasma cells, with large eccentric nuclei and scattered mitosis (H&E x40). (b) Intense staining of CD138 (x10). (c) Positive staining for Ki67 (high proliferation index >80%) (x10).
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Histology from a formal excision demonstrated complete replacement of the dermis and subcutaneous fat by sheets of immature plasma cells (Figure 2). Immunohistochemistry was strongly positive for CD138, with a very high proliferation fraction >80% (Figure 2).
Computed tomography showing destruction of the proximal humerus by a large osteolytic lesion. There is soft tissue plasmacytoma located on the anterior chest wall and partial destruction of the sternum.
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Radiological imaging illustrated multiple osteolytic lesions throughout the skeletal system, particularly with considerable destruction of the right humeral head (Figure 3).
(a) Tumour cells expressing surface IgA. (x40) (b & c) Kappa and lambda light chains, (c) plasma cells showing restriction of immunoglobulin lambda-chain expression (x10).
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Serum protein electrophoresis confirmed monoclonal IgA gammopathy and plasma cell tumour markers demonstrated surface IgA with lambda light chain restricted (Figure 4), resulting in a diagnosed of IgA lambda MM (Stage III).