An unusual porta mass: Endoscopic ultrasound-guided fine needle aspiration solve the mystery

Abstract

A 60-year-old North Indian female presented with recurrent dull-aching right upper quadrant pain of a month duration. Investigations showed the presence of anemia, raised erythrocyte sedimentation rate, and azotemia (serum creatinine 2.5 mg%). Noncontract computed tomography scan demonstrated a 5 cm × 5 cm hypodense mass lesion at porta. Endoscopic ultrasonographic (EUS) examination revealed a well-defined rounded 6 cm × 6 cm hypoechoic periportal mass without any vascular invasion, fine needle aspiration (FNA) showed sheets of atypical plasma cells and plasmablasts with eccentric nuclei, 1–2 prominent nucleoli, and abundant basophilic cytoplasm; some of the cells show the characteristic pale perinuclear “hof”. Bone marrow biopsy showed hypercellular marrow with proliferation of atypical plasma cells comprising 80% of the cellularity with reduced normal hematopoietic elements. There was a sharp M band in the gamma region of 4.7 g/dl, on serum protein electrophoresis and an elevated IgG kappa-free light chain of 1590 mg/dL. All these findings were consistent with multiple myeloma with periportal plasmacytoma. Hemato-oncology Department was consulted and she received bortezomib-based therapy. On follow-up after 4 months, M band in the gamma region decreased to 0.6 g/dl and kappa-free chain decreased to 18.7 mg/dl on serum electrophoresis. Anemia improved and serum creatinine decreased to 1.3 mg/dl. Repeat EUS revealed a decreased of porta mass to 1.5 cm × 1.5 cm. This case highlights the role of EUS FNA in solving the clinical mystery and helps in reaching the final diagnosis and providing the appropriate treatment.