PMC9062931_01
MRI examination shows involvement of the lesion in the precentral gyrus and postcentral gyrus. The lesion shows strong diffusion restriction on diffusion-weighted imaging (a); and hypointensity on T1-weighted (b) and hyperintensity on T2-weighted imaging (c). The structural preservation of the gyri and sulci is a characteristic of this case and may reflect the pathology.
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F1
T1-weighted images, and hyperintensity on T2-weighted images [Figures 1a-c]. The epilepsy was controlled with medication, but the patient became increasingly drowsy in the days that followed.
CT images obtained before surgery show massive hemorrhage surrounding the lesion (a) with significant mass effect (b).
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F2
Repeat CT examinations revealed a hematoma and associated edematous change around the lesion and progressive expansion of the hematoma despite efforts to control blood pressure and treatment by hemostatic agents [Figures 2a and b].
Histopathologically, numerous red blood cells with fibrin and debris are present, with massive infiltration of atypical round blue cells (a: x40). The infiltrating cells are composed of clumped nuclear chromatin and eccentric eosinophilic cytoplasm (b: x200), suggesting a plasma cell origin. Immunohistochemistry study shows CD138 positivity (b; inset). In situ hybridization demonstrates uniform lambda light chain positivity and negative kappa signal, reinforcing the diagnosis of plasma cell neoplasm (c and d: x100).
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Histopathological sections revealed numerous red blood cells with fibrin and debris and massive infiltration of atypical round blue cells [Figure 3a]. Atypical cells demonstrated clumped nuclear chromatin pattern and eccentric eosinophilic cytoplasm [Figure 3b] suggesting plasma cell origin. Immunohistochemistry study showed CD138 positivity [Figure 3b; inset] and in situ hybridization demonstrated uniform lambda light chain positivity and negative kappa signal, reinforcing the diagnosis of plasma cell neoplasm [Figures 3c and d].
Postoperative CT shows evacuation of the hematoma and relaxation of the brain (a). Gadolinium-enhanced MRI demonstrates resection of the lesion, with a small amount of contrast enhancing tumor at the periphery of the cavity (b and c). Imaging obtained after intensity-modulated radiation therapy reveals a complete disappearance on gadolinium-enhanced MRI (d and e).
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F4
Although the patient was obtunded and showed severe left hemiparesis soon after the surgery, correlating with the focus of the lesion in the right central sulcus, postoperative CT revealed apparent brain decompression [Figure 4a]. Postoperative MRI demonstrated extensive near-total resection of the lesion with small residual tumor at the periphery of the cavity [Figures 4b and c]. The lesion showed an excellent response to IMRT, showing a complete disappearance on MRI [Figures 4d and e].