Post traumatic Sternal Mass leading to Multiple Myeloma: Is There a Link?
Naima Ait mouddene*, Wiaam Elkhattabi, Salma Msika, Hajar Bamha, Nabil Bougteb, Hajar Arfaoui, Hicham Afif
Department of Pulmonology and Respiratory Disease, 20 Aout 1953 Hospital, University Hospital Center of Casablanca-Morocco
*Corresponding author
Naima Ait mouddene, Department of Pulmonology and Respiratory Disease, 20 Aout 1953 Hospital, University Hospital Center of CasablancaMorocco
DOI: 10.55920/JCRMHS.2025.11.001487
Figure 1: Sternal and parasternal mass at the site of an scar (8cm).
Figure 2: Lateral chest X-ray showing a well-defined, rounded radiolucent formation projected over the manubrio-sternal region, surrounded by a thin opaque rim with cortical thinning
Figure 3: Frontal chest X-ray showing a hyperlucent, slightly overdistended lung with blunting of the right cardiophrenic angle.
Figure 4: Skull X-ray showing punched-out osteolytic lesions.
Figure 5: X-ray of the thoracolumbar spine showing osteolytic lesions with some vertebral compressions
Figure 6: Thoracic CT scan showing an osteolytic mass at the sternum extending into the anterior mediastinum
Figure 7: Multiple myeloma cells observed on a histological section (Ref. Firth J. Haematology: multiple myeloma. Clin Med. Jan 2019;19(1):58 60)..
Figure 8: Regression of the sternal mass after chemotherapy, reduced by 3 cm
Figure 9: Chest CT scan showing the regression of the parietal mass and the anterior mediastinal mass after chemotherapy.
History of PresentIllness: The diseasebegan six monthsagowith the progressive appearance of a thoracic mass at the sternal scar site, associatedwithincreasingdyspnea, whichrapidlyprogressed to mMRC stage II. Twomonthslater, the patient developedmildhemoptysis (<50 cc). At that time, healsoreported postprandial vomiting, oliguria, feverish sensations, and rapiddeterioration of generalhealthstatus.
Examination on Admission: The patient wasadmitted in poorgeneral condition (PS = 3), anxious, pale, and underweight (BMI = 15.4 kg/m²) without digital clubbing or lowerlimbedema. He wasafebrile, eupneic (20 breaths/min), had an oxygen saturation of 95% on room air, normal blood pressure (110/88 mmHg), and a heart rate of 90 bpm.
Pleuro-pulmonaryexaminationrevealed an 8 cm x 8 cm anteriorthoracic mass at the manubrio-sternal junction, corresponding to a horizontal scar. The mass was hard at the center, painless, fixed to bothunderlying and overlying planes, and showed no inflammatorysigns. Pulmonary auscultation revealed no audible rales. Osteoarticularexaminationfound no bonetenderness, and the rest of the physicalexaminationwasunremarkable.
Radiological and Biological Workup Imaging Studies: A chest X-ray (frontal and lateralviews) showed a well-demarcated, grosslyroundedlesionprojected over the manubrio-sternal region, with a clear content surrounded by a thin opaque rim and cortical thinning, suggestive of a probable bone mass (Figure 2). Pulmonaryparenchymalanalysisrevealedhyperlucent, slightlyoverdistendedlungswithdiaphragmaticflattening and blunting of the right cardiophrenic angle (Figure 3).
Biological Workup: Blood count showednormochromicnormocyticanemia (Hb = 9 g/dL) withoutleukocytosis or lymphopenia. C-reactiveproteinwaselevated (51.9 mg/L), with an acceleratederythrocytesedimentation rate (ESR = 110 mm/h). Electrolyte panel showedhyponatremia (128 mEq/L) and hypercalcemia (correctedCa²⁺: 133 mg/L). Serumcreatininewaselevated (21.5 mg/L) withlow urine output (350 mL/24h). Serumproteinanalysisshowedhyperproteinemia (139 g/L) withseverelydecreasedalbuminlevels (16 g/L). Giventhesefindings, serumproteinelectrophoresis (SPE) wasperformed, revealing a monoclonal gamma peak, raising suspicion of multiple myeloma or plasmacytoma.
Multiple Myeloma Workup: Skull X-ray revealedpunched-out osteolyticlesions (Figure 4), whilethoracolumbarspine X-ray showedosteolyticlesionswithvertebral compression fractures (Figure 5). However, pelvic and long bone X-rays wereunremarkable. A thoracic CT scan showed an osteolytic sternal mass extendingdeeplyinto the anteriormediastinum, without calcification or evidence of pulmonaryparenchymal invasion (Figure 6). Bronchoscopyrevealed a diffuse inflammation of the tracheobronchialtree . Bronchial biopsies showed non-specificfibro-inflammatory changes with no malignancy.
Biological Investigations: Immunofixation of serumproteinsconfirmed monoclonal IgG lambda. Bone marrow aspiration revealed 53-55% dystrophic plasma cells and rouleaux formation of redbloodcell, suggestive of multiple myeloma (Figure 7). A 24-hour urine studyshowedoliguria (350 mL) withproteinuria (0.32 g/24h). Urine proteinelectrophoresisdetectedelevated free kappa light chains (22.31 mg/L). Cytogeneticanalysis of bonemarrowcellsshowed a hypodiploid clone (44 chromosomes) withnumerical and structural abnormalities. Beta-2 microglobulinwaselevated (13.95 mg/L) (Table 1).
Table 1: Biological assessment during multiple myeloma
Table 2: Follow-up biological assessment after chemotherapy treatment
Final Diagnosis : Based on clinical, radiological, and biological findings, along with bone marrow results, a diagnosis of kappa light chain multiple myeloma was confirmed, presenting as a sternal mass at the site of prior trauma.
Treatment: The patient received symptomatic treatment, including rehydration, electrolyte correction, and a high-protein diet. Etiologic treatment was initiated in collaboration with hematologists, comprising VTD (bortezomib, thalidomide, and dexamethasone). Additionally, hospitalizationwasused as an opportunity to offer smoking cessation counseling.
Evolution and Prognosis: After four months of treatment and six chemotherapy cycles, the patient's condition significantly improved, with a PS of 0 (vs. 3), a weight gain of 12 kg, resolution of dyspnea, and regression of the sternal mass (3 cm vs. 8 cm) (Figure 8). Biological parameters (Table 2) and CT findings (Figure 9) showed marked improvement. Prognostic assessment using the Durie and Salmon classification placed the patient at Stage III, with an estimated survival of 23 months.