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Diagnosed with multiple myeloma, amyloidosis and severe congestive heart failure. Concerned for lump on arm

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My wife (age 74) was diagnosed with multiple myeloma based on amyloidosis based on echocardiogram and severe congestive heart failure. She has all symptoms of amyloidosis, including purpura and "raccoon eyes". The BM biopsy did not show amyloid in the bone marrow, however.

A few days ago we found a lump in the muscle of her upper right arm. It is about the shape and size of a large pecan, or a small hen egg. I saw the ultrasound in progress, and was struck by the roughly grid shaped black lines within the lump, as was the technician. Went for biopsy on Friday 4/5/13, but they could not do it because her blood pressure was 79/45, and would not go up over two hours. Scheduled again for Monday 4/8/13.

Question: I'm very worried about the lump. Is this common with multiple myeloma? Is there a most likely explanation? Can you provide a source of information on such lumps?
Additional background:

My wife was admitted to hospital on December 28, 2012 with severe congestive heart failure. She was in ICU for about 8 days of a 14 day hospital stay. The day after she was released, we saw our cardiologist. An echocardiogram was done, and the amyloidosis was diagnosed. Within a week after that diagnosis, we went my oncologist/hematologist, who suspected multiple myeloma, as well as amyloidosis. Her Lambda light chain numbers (at 226) were 10 time the high end of range.

A subsequent fat pad biopsy was reported negative, but I'm having it checked at the Amyloidosis Center of Boston University. Then a bone marrow biopsy was done, which confirmed multiple myeloma.

As noted earlier, a few days ago we found the lump in her upper right arm.

The lump scares me. She is very weak. Her blood pressure runs very low, and her heart rate very high--almost never lower than 100, and often in the 120s. Oxygen saturation usually is in mid to high 90s. She takes 60mg of Lasiks daily, but her ankles still are swollen.
Posted Sun, 28 Apr 2013 in Cancer
Answered by Dr. Indranil Ghosh 2 hours later
Thanks for your query. It appears your wife has got myleoma along with amyloidosis, which is a rare entity but well-described in literature.
The low Bp and high heart rate are due to the amyloid deposition in the heart. Though the prognosis in this scenario is quite poor, sometimes anti-myeloma therapy may show some improvement. From your query, I am not sure what therapy is she is on.
The lump in the arm is most probably due to subcutaneous deposition of amyloid. It does not require any specific therapy other than that of the primary disease. However, other causes cannot be ruled out without the biopsy, which may be plasmacytoma (collection of myeloma cells), lipoma, neurofibroma (benign tumors), organised clot, cysts or rarely, some other kind of malignant tumor.
Hope I have answered your query. I will be available to answer further follow-up queries, if any.
Above answer was peer-reviewed by
Follow-up: Diagnosed with multiple myeloma, amyloidosis and severe congestive heart failure. Concerned for lump on arm 36 minutes later
Thank you Dr. XXXXXXX

I have read a number of studies and other literature on amyloidosis, some of the best published by the Amyloidosis Center at Boston University. But of course I know very little about this terrible disease.

She took her first shot of Velcade on Thursday 4/4. She is also taking pulses of Dexamethazone four days each month. I think the Velcade may be increased soon, as my understanding is that it is normally a day 1, 4, 8 and 11 then a rest period before starting again.

Is plasmacytoma a common thing with multiple myeloma?

Is a subcutaneous deposition of amyloid common? In the reading I've done, I don't think I have encountered that. Could you recommend or send a link to literature on that?

Would it (amyloid deposition) be as large as a small hen egg? I know the biopsy is the real source of an answer, but I want to learn as much as possible about what this could be.
Would such a deposition of amyloid show a pattern of black grid-like lines inside the mass?

Thanks very much for answering these questions.
Answered by Dr. Indranil Ghosh 5 hours later

Thanks for followup.

She is getting the best treatment in velcade and dexamethasone.

Plasmacytoma is a collection of plasma cells outside the marrow and is fairly common in myeloma.

Subcutanoeus deposition of amyloid is the hallmark of amyloidosis. But you are right that such large masses are uncommon. I have posted a link for you to go through ( WWW.WWWW.WW . Have a look at Fig 13; though it is for solitary amyloidosis, similar thing can happen in systemic amyloidosis also.

I can't make much of the black-grid lines seen on ultrasound as of now. Please let me know if you get the final imaging or biopsy report.
Above answer was peer-reviewed by
Follow-up: Diagnosed with multiple myeloma, amyloidosis and severe congestive heart failure. Concerned for lump on arm 1 hour later
Thank you Dr. XXXXXXX

The link you provided is very helpful, and it makes me grateful that my wife has not suffered some of the worst of the possible effects. The only outward sign so far, unless the lump proves to be related, is the purpura. She has been having those for almost 2 years. But neither I nor our doctors related it to amyloidosis.

I am very confident in our oncologist/hematologist, but it is good that you think the treatment we are undertaking is a proper choice.

If I am able to get copies of the ultrasound images of the lump, I will upload them for you.

What is the best way to ascertain whether the amyloidosis has impacted her digestive system? She feels a drawing, hunger-like feeling often, even just after a meal. She feels full after eating only a little food...has lost 20 pounds in the last 4 months...but is not seemingly stable at about 110. She is about 5' 4" tall.

She has had many basal cell skin cancers removed over the years, but there is not history of cancer in her family.

Answered by Dr. Indranil Ghosh 20 hours later
Best way to detect gastrointestinal involvement is endoscopy. Usually it presents as weight loss, diarrhea and bleeding ( WWW.WWWW.WW . I don't think she is having significant GI involvement.
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