Skip to main content Accessibility help

We use cookies to distinguish you from other users and to provide you with a better experience on our websites. Close this message to accept cookies or find out how to manage your cookie settings.

Close cookie message
×
Hostname: page-component-8448b6f56d-c47g7 Total loading time: 0 Render date: 2024-04-23T21:42:56.349Z Has data issue: false hasContentIssue false

12 - DIAGNOSIS, RISK-STRATIFICATION, AND MANAGEMENT OF SOLITARY PLASMACYTOMA

Published online by Cambridge University Press:  11 July 2009

By
Meletios A. Dimopoulos  and
Efstathios Kastritis
Edited by
S. Vincent Rajkumar  and
Robert A. Kyle
S. Vincent Rajkumar
Affiliation:
Mayo Clinic, Minnesota
Robert A. Kyle
Affiliation:
Mayo Clinic, Minnesota
Get access

Summary

INTRODUCTION

Plasma cell dyscrasias include a wide variety of diseases characterized by the abnormal accumulation of plasma cells resulting in various systemic symptoms and signs. Plasma cells are usually widespread throughout the bone marrow; however, in a minority of patients malignant plasma cells may form a single lesion. These lesions are usually confined to the bone and, less frequently, in extramedullary sites. They are composed of monoclonal plasma cells that are otherwise identical to plasma cells found in myeloma. However, these patients do not have evidence of systemic multiple myeloma (MM), and an extensive work up shows no other foci of disease. When this solitary lesion is confined to bone it is characterized as a solitary bone plasmacytoma (SBP) while when this lesion is confined to extraosseous sites it is characterized as a solitary extramedullary plasmacytoma (SEP).

DEFINITIONS

According to criteria reported by the International Myeloma Working Group, diagnosis of solitary plasmacytoma of bone is based on histological evidence of a tumor consisting of monoclonal plasma cells identical to those seen in MM (Table 12.1). In addition, complete skeletal radiographs must show no other lesions of MM. Magnetic resonance imaging (MRI) has significantly increased sensitivity over conventional radiographs, especially in the imaging of the axial skeleton, and an MRI of the spine and pelvis may show unsuspected and asymptomatic skeletal lesions. Patients with multiple lesions in MRI should be considered as having myeloma and not SBP even if conventional radiographs show no other evidence of skeletal involvement.

Type
Chapter
Information
Treatment of Multiple Myeloma and Related Disorders , pp. 150 - 163
Publisher: Cambridge University Press
Print publication year: 2008

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

,International Myeloma Working Group. Criteria for the classification of monoclonal gammopathies, multiple myeloma and related disorders.. Br J Haematol 2003;121(5):749–57.CrossRefGoogle Scholar
Dimopoulos, MA, Moulopoulos, , Maniatis, A, Alexanian, R. Solitary plasmacytoma of bone and asymptomatic multiple myeloma. Blood 2000;96(6):2037–44.Google ScholarPubMed
Nanni, C, Zamagni, E, Farsad, M, Franchi, R, Franti, S.Role of 18F-FDG PET/CT in the assessment of bone involvement in newly diagnosed multiple myeloma: preliminary results. Eur J Nucl Med Mol Imaging 2006;33(5):525–31.CrossRefGoogle ScholarPubMed
Zamagni, E, Nanni, C, Patriarca, F, et al. A prospective comparison of 18F-fluorodeoxyglucose positron emission tomography-computed tomography, magnetic resonance imaging and whole-body planar radiographs in the assessment of bone disease in newly diagnosed multiple myeloma. Haematologica 2007;92(1):50–5.CrossRefGoogle ScholarPubMed
Hill, QA, Tute, RM, Child, JA, Tute, RM, Owen, RG. Neoplastic plasma cells are demonstrable at bone marrow sites distant to solitary plasmacytoma of bone and predict for progression to multiple myeloma. ASH Annual Meeting Abstracts 2006;108(11):3512-.
Mclain, RF, Weinstein, JN.Solitary plasmacytomas of the spine: a review of 84 cases. J Spinal Disord 1989;2(2):69–74.CrossRefGoogle ScholarPubMed
Alexander, MP, Goodkin, , Poser, CM.Solitary plasmacytoma producing cranial neuropathy. Arch Neurol 1975;32(11):777–8.CrossRefGoogle ScholarPubMed
Prasad, ML, Mahapatra, AK, Kumar, L, et al. Solitary intracranial plasmacytoma of the skull base. Indian J Cancer 1994;31(3):174–9.Google ScholarPubMed
Higurashi, M, Yagishita, S, Fujitsu, K, Kitsuta, Y, Yakemoto, Y, Osano, S.Plasma cell myeloma of the skull base: report of two cases. Brain Tumor Pathol 2004;21(3):135–41.CrossRefGoogle ScholarPubMed
Pambuccian, SE, Horyd, ID, Cawte, T, Huvos, AG.Amyloidoma of bone, a plasma cell/plasmacytoid neoplasm. Report of three cases and review of the literature. Am J Surg Pathol 1997;21(2):179–86.CrossRefGoogle ScholarPubMed
Rawlings, NG, Brownstein, S, Robinson, JW, Jordan, DR.Solitary osseous plasmacytoma of the orbit with amyloidosis. Ophthal Plast Reconstr Surg 2007;23(1):79–80.CrossRefGoogle ScholarPubMed
Cooper, JH, Rootman, J, Ramsey, MS.Extramedullary plasmacytoma (amyloid tumour) of the caruncle. Can J Ophthalmol 1989;24(4):166–8.Google ScholarPubMed
Nagasaka, T, Lai, R, Kuno, K, Nakashima, T, Nakashima, N.Localized amyloidosis and extramedullary plasmacytoma involving the larynx of a child. Hum Pathol 2001;32(1):132–4.CrossRefGoogle Scholar
Dispenzieri, A, Kyle, RA, Lacy, MQ, et al. POEMS syndrome: definitions and long-term outcome. Blood 2003;101(7):2496–506.CrossRef
Moulopoulos, , Dimopoulos, MA, Weber, D, Fuller, L, Libshitz, HI, Alexanian, R.Magnetic resonance imaging in the staging of solitary plasmacytoma of bone. J Clin Oncol 1993;11(7):1311–5.CrossRefGoogle ScholarPubMed
Wilder, RB, Ha, CS, Cox, JD, Weber, D, Delasalle, K, Alexanian, R.Persistence of myeloma protein for more than one year after radiotherapy is an adverse prognostic factor in solitary plasmacytoma of bone. Cancer 2002;94(5):1532–7.CrossRefGoogle ScholarPubMed
Moulopoulos, , Dimopoulos, MA.Magnetic resonance imaging of the bone marrow in hematologic malignancies. Blood 1997;90(6):2127–47.Google ScholarPubMed
Liebross, RH, Ha, CS, Cox, JD, Weber, D, Delasalle, K, Alexanian, R.Solitary bone plasmacytoma: outcome and prognostic factors following radiotherapy. Int J Radiat Oncol Biol Phys 1998;41(5):1063–7.CrossRefGoogle ScholarPubMed
Schirrmeister, H, Buck, AK, Bergmann, L, et al. Positron emission tomography (PET) for staging of solitary plasmacytoma. Cancer Biother Radiopharm 2003;18(5):841–5.CrossRefGoogle ScholarPubMed
Dimopoulos, MA, Pouli, A, Anagnostopoulos, A, et al. Macrofocal multiple myeloma in young patients: a distinct entity with favorable prognosis. Leuk Lymphoma 2006;47(8):1553–6.CrossRefGoogle ScholarPubMed
Dingli, D, Kyle, RA, Rajkumar, SV, et al. Immunoglobulin free light chains and solitary plasmacytoma of bone. Blood 2006;108(6):1979–83.CrossRefGoogle ScholarPubMed
Soutar, R, Lucraft, H, Jackson, G, et al. Guidelines on the diagnosis and management of solitary plasmacytoma of bone and solitary extramedullary plasmacytoma. Br J Haematol 2004;124(6):717–26.CrossRefGoogle ScholarPubMed
Barosi, G, Boccadoro, M, Cavo, M, et al. Management of multiple myeloma and related-disorders: guidelines from the Italian Society of Hematology (SIE), Italian Society of Experimental Hematology (SIES) and Italian Group for Bone Marrow Transplantation (GITMO). Haematologica 2004;89(6):717–41.Google Scholar
Knobel, D, Zouhair, A, Tsang, RW, et al. Prognostic factors in solitary plasmacytoma of the bone: a multicenter Rare Cancer Network study. BMC Cancer 2006;6:118.CrossRefGoogle Scholar
Mill, WB, Griffith R. The role of radiation therapy in the management of plasma cell tumors. Cancer 1980;45(4):647–52.3.0.CO;2-E>CrossRefGoogle ScholarPubMed
Chak, LY, Cox, RS, Bostwick, DG, et al. Solitary plasmacytoma of bone: treatment, progression, and survival. J Clin Oncol 1987;5(11):1811–5.CrossRefGoogle Scholar
Delauche-Cavallier, MC, Laredo, JD, Wybier, M, et al. Solitary plasmacytoma of the spine. Long-term clinical course. Cancer 1988;61(8):1707–14.3.0.CO;2-N>CrossRefGoogle ScholarPubMed
Frassica, DA, Frassica, FJ, Schray, MF, et al. Solitary plasmacytoma of bone: Mayo Clinic experience. Int J Radiat Oncol Biol Phys 1989;16(1):43–8.CrossRefGoogle ScholarPubMed
Mayr, NA, Wen, BC, Hussey, DH, et al. The role of radiation therapy in the treatment of solitary plasmacytomas. Radiother Oncol 1990;17(4):293–303.CrossRefGoogle ScholarPubMed
Holland, J, Trenkner, DA, Wasserman, TH, et al. Plasmacytoma. Treatment results and conversion to myeloma. Cancer 1992;69(6):1513–7.3.0.CO;2-X>CrossRefGoogle ScholarPubMed
Aviles, A, Huerta-Guzman, J, Delgado, S, et al. Improved outcome in solitary bone plasmacytomata with combined therapy. Hematol Oncol 1996;14(3):111–7.3.0.CO;2-G>CrossRefGoogle ScholarPubMed
Bolek, TW, Marcus, RB, Mendenhall, NP.Solitary plasmacytoma of bone and soft tissue. Int J Radiat Oncol Biol Phys 1996;36(2):329–33.CrossRefGoogle ScholarPubMed
Jyothirmayi, R, Gangadharan, VP, Nair, MK, et al. Radiotherapy in the treatment of solitary plasmacytoma. Br J Radiol 1997;70(833):511–6.CrossRefGoogle ScholarPubMed
Tsang, RW, Gospodarowicz, MK, Pintilie, M, et al. Solitary plasmacytoma treated with radiotherapy: impact of tumorsize on outcome. Int J Radiat Oncol Biol Phys 2001;50(1):113–20.CrossRefGoogle Scholar
Ozsahin, M, Tsang, RW, Poortmans, P, et al. Outcomes and patterns of failure in solitary plasmacytoma: a multicenter Rare Cancer Network study of 258 patients. Int J Radiat Oncol Biol Phys 2006;64(1):210–7.CrossRefGoogle ScholarPubMed
Knowling, MA, Harwood, AR, Bergsagel, DE.Comparison of extramedullary plasmacytomas with solitary and multiple plasma cell tumors of bone. J Clin Oncol 1983;1(4):255–62.CrossRefGoogle Scholar
Mendenhall, CM, Thar, TL, Million, RR.Solitary plasmacytoma of bone and soft tissue. Int J Radiat Oncol Biol Phys 1980;6(11):1497–501.CrossRefGoogle ScholarPubMed
Bataille, R, Sany, J.Solitary myeloma: clinical and prognostic features of a review of 114 cases. Cancer 1981;48(3):845–51.3.0.CO;2-E>CrossRefGoogle ScholarPubMed
Weber, DM.Solitary bone and extramedullary plasmacytoma. Hematology Am Soc Hematol Educ Program 2005:373–6.Google ScholarPubMed
Alexanian, R.Localized and indolent myeloma. Blood 1980;56(3):521–5.Google ScholarPubMed
Alexiou, C, Kau, RJ, Dietzfelbinger, H, et al. Extramedullary plasmacytoma: tumor occurrence and therapeutic concepts. Cancer 1999;85(11):2305–14.3.0.CO;2-3>CrossRefGoogle ScholarPubMed
Durr, HR, Kuhne, JH, Hagena, FW, et al. Surgical treatment for myeloma of the bone. A retrospective analysis of 22 cases. Arch Orthop Trauma Surg 1997;116(8):463–9.CrossRefGoogle Scholar
Burt, M, Karpeh, M, Ukoha, O, et al. Medical tumors of the chest wall. Solitary plasmacytoma and Ewing's sarcoma. J Thorac Cardiovasc Surg 1993;105(1):89–96.Google ScholarPubMed
Chang, MY, Shih, LY, Dunn, P, et al. Solitary plasmacytoma of bone. J Formos Med Assoc 1994;93(5):397–402.Google ScholarPubMed
Shih, LY, Dunn, P, Leung, WM, et al. Localised plasmacytomas in Taiwan: comparison between extramedullary plasmacytoma and solitary plasmacytoma of bone. Br J Cancer 1995;71(1):128–33.CrossRefGoogle ScholarPubMed
Galieni, P, Cavo, M, Avvisati, G, et al. Solitary plasmacytoma of bone and extramedullary plasmacytoma: two different entities? Ann Oncol 1995;6(7):687–91.CrossRefGoogle ScholarPubMed
Dimopoulos, MA, Kiamouris, C, Moulopoulos, LA.Solitary plasmacytoma of bone and extramedullary plasmacytoma. Hematol Oncol Clin North Am 1999;13(6):1249–57.CrossRefGoogle ScholarPubMed
Dimopoulos, MA, Moulopoulos, A, Delasalle, K, et al. Solitary plasmacytoma of bone and asymptomatic multiple myeloma. Hematol Oncol Clin North Am 1992;6(2):359–69.CrossRefGoogle ScholarPubMed
Dimopoulos, MA, Goldstein, J, Fuller, L, et al. Curability of solitary bone plasmacytoma. J Clin Oncol 1992;10(4):587–90.CrossRefGoogle ScholarPubMed
Kumar, S, Fonseca, R, Dispenzieri, A, et al. Prognostic value of angiogenesis in solitary bone plasmacytoma. Blood 2003;101(5):1715–7.CrossRefGoogle ScholarPubMed
Morgan, TK, Zhao, S, Chang, KL, et al. Low CD27 expression in plasma cell dyscrasias correlates with high-risk disease: an immunohistochemical analysis. Am J Clin Pathol 2006;126(4):545–51.CrossRefGoogle ScholarPubMed
Galieni, P, Cavo, M, Pulsoni, A, et al. Clinical outcome of extramedullary plasmacytoma. Haematologica 2000;85(1):47–51.Google ScholarPubMed
Susnerwala, SS, Shanks, JH, Banerjee, SS, et al. Extramedullary plasmacytoma of the head and neck region: clinicopathological correlation in 25 cases. Br J Cancer 1997;75(6):921–7.CrossRefGoogle ScholarPubMed
Webb, HE, Harrison, EG, Masson, JK, et al. Solitary extramedullary myeloma (plasmacytoma) of the upper part of the respiratory tract and oropharynx. Cancer 1962;15: 1142–55.3.0.CO;2-5>CrossRefGoogle Scholar
Helmus, C.Extramedullary plasmacytoma of the head and neck. Laryngoscope 1964;74: 553–9.CrossRefGoogle Scholar
Kotner, LM, Wang, CC.Plasmacytoma of the upper air and food passages. Cancer 1972;30(2):414–8.3.0.CO;2-Z>CrossRefGoogle ScholarPubMed
Medini, E, Rao, Y, Levitt, SH.Solitary extramedullary plasmacytoma of the upper respiratory and digestive tracts. Cancer 1980;45(11):2893–6.3.0.CO;2-9>CrossRefGoogle ScholarPubMed
Segas, J, Skoulakis, H, Katrinakis, G, et al. Solitary extramedullary plasmacytoma of the oropharynx: a rare location. Ear Nose Throat J 1993;72(11):743–5.Google ScholarPubMed
Remigio, PA, Klaum, A.Extramedullary plasmacytoma of stomach. Cancer 1971;27(3):562–8.3.0.CO;2-S>CrossRefGoogle ScholarPubMed
Preud'Homme, JL, Galian, A, Danon, F, et al. Extramedullary plasmacytoma with gastric and lymph node involvement: an immunological study. Cancer 1980;46(8):1753–8.3.0.CO;2-Z>CrossRefGoogle ScholarPubMed
Chim, CS, Wong, WM, Nicholls, J, et al. Extramedullary sites of involvement in hematologic malignancies: case 3. Hemorrhagic gastric plasmacytoma as the primary presentation in multiple myeloma. J Clin Oncol 2002;20(1):344–7.CrossRefGoogle ScholarPubMed
Amin, R.Extramedullary plasmacytoma of the lung. Cancer 1985;56(1):152–6.3.0.CO;2-E>CrossRefGoogle ScholarPubMed
Chen, KY, Wu, HD, Chang, YL, et al. Primary pulmonary plasmacytoma with lobar consolidation: an unusual presentation. J Formos Med Assoc 1998;97(7):507–10.Google Scholar
Joseph, G, Pandit, M, Korfhage, L.Primary pulmonary plasmacytoma. Cancer 1993;71(3):721–4.3.0.CO;2-U>CrossRefGoogle ScholarPubMed
Shin, MS, Carcelen, MF, Ho, KJ.Diverse roentgenographic manifestations of the rare pulmonary involvement in myeloma. Chest 1992;102(3):946–8.CrossRefGoogle Scholar
Takahashi, R, Nakano, S, Namura, K, et al. Plasmacytoma of the urinary bladder in a renal transplant recipient. Int J Hematol 2005;81(3):255–7.CrossRefGoogle Scholar
Yang, C, Motteram, R, Sandeman, TF.Extramedullary plasmacytoma of the bladder: a case report and review of literature. Cancer 1982;50(1):146–9.3.0.CO;2-X>CrossRefGoogle ScholarPubMed
More, JR, Dawson, DW, Ralston, AJ, et al. Plasmacytoma of the thyroid. J Clin Pathol 1968;21(5):661–7.CrossRefGoogle ScholarPubMed
Salazar, JE, Nelson, JF, Winer-Muram, HT.Extramedullary plasmacytoma of the thyroid. Can Assoc Radiol J 1987;38(2): 136–8.Google ScholarPubMed
Bourtsos, EP, Bedrossian, CW, Frias, DV, et al. Thyroid plasmacytoma mimicking medullary carcinoma: a potential pitfall in aspiration cytology. Diagn Cytopathol 2000;23(5):354–8.3.0.CO;2-7>CrossRefGoogle ScholarPubMed
Iizumi, T, Shinohara, S, Amemiya, H, et al. Plasmacytoma of the testis. Urol Int 1995;55(4):218–21.CrossRefGoogle ScholarPubMed
Proctor, NS, Rippey, JJ, Shulman, G, et al. Extramedullary plasmacytoma of the breast. J Pathol 1975;116(2):97–100.CrossRefGoogle ScholarPubMed
Kirshenbaum, G, Rhone, DP.Solitary extramedullary plasmacytoma of the breast with serum monoclonal protein: a case report and review of the literature. Am J Clin Pathol 1985;83(2):230–2.CrossRefGoogle ScholarPubMed
Alhan, E, Calik, A, Kucuktulu, U, et al. Solitary extramedullary plasmocytoma of the breast with kappa monoclonal gammopathy. Pathologica 1995;87(1):71–3.Google ScholarPubMed
Cangiarella, J, Waisman, J, Cohen, JM, et al. Plasmacytoma of the breast. A report of two cases diagnosed by aspiration biopsy. Acta Cytol 2000;44(1):91–4.CrossRefGoogle ScholarPubMed
Chiara, A, Losito, S, Terracciano, L, et al. Primary plasmacytoma of the breast. Arch Pathol Lab Med 2001;125(8):1078–80.Google ScholarPubMed
Ferlito, A, Polidoro, F, Recher, G.Extramedullary plasmacytoma of the parotid gland. Laryngoscope 1980;90(3):486–93.CrossRefGoogle ScholarPubMed
Simi, U, Marchetti, G, Bruno, R, et al. Plasmacytoma of the parotid gland. Report of a case and review of the world literature. Acta Otorhinolaryngol Belg 1988;42(1):93–6.Google ScholarPubMed
Gonzalez-Garcia, J, Ghufoor, K, Sandhu, G, et al. Primary extramedullary plasmacytoma of the parotid gland: a case report and review of the literature. J Laryngol Otol 1998;112(2):179–81.CrossRefGoogle ScholarPubMed
Liebross, RH, Ha, CS, Cox, JD, et al. Clinical course of solitary extramedullary plasmacytoma. Radiother Oncol 1999;52(3):245–9.CrossRefGoogle ScholarPubMed
Hari, CK, Roblin, DG.Solitary plasmacytoma of the parotid gland. Int J Clin Pract 2000;54(3):197–8.Google ScholarPubMed
Kanthan, R, Torkian, B.Solitary plasmacytoma of the parotid gGland with crystalline inclusions: a case report. World J Surg Oncol 2003;1(1):12.CrossRefGoogle ScholarPubMed
Lin, BT, Weiss, LM.Primary plasmacytoma of lymph nodes. Hum Pathol 1997;28(9):1083–90.CrossRefGoogle ScholarPubMed
Lim, YH, Park, SK, Oh, HS, et al. A case of primary plasmacytoma of lymph nodes. Korean J Intern Med 2005;20(2):183–6.CrossRefGoogle ScholarPubMed
Inbasekaran, V, Vijayarathinam, P, Arumugam, S.Solitary intracerebral plasmacytoma. J Indian Med Assoc 1991;89(1):16–7.Google ScholarPubMed
Dimopoulos, MA, Hamilos, G.Solitary bone plasmacytoma and extramedullary plasmacytoma. Curr Treat Options Oncol 2002;3(3):255–9.CrossRefGoogle ScholarPubMed
Bartl, R, Frisch, B, Fateh-Moghadam, A, et al. Histologic classification and staging of multiple myeloma. A retrospectiveand prospective study of 674 cases. Am J Clin Pathol 1987;87(3):342–55.CrossRefGoogle Scholar
Kremer, M, Ott, G, Nathrath, M, et al. Primary extramedullary plasmacytoma and multiple myeloma: phenotypic differences revealed by immunohistochemical analysis. J Pathol 2005;205(1):92–101.CrossRefGoogle ScholarPubMed
Hotz, MA, Schwaab, G, Bosq, J, et al. Extramedullary solitary plasmacytoma of the head and neck. A clinicopathological study. Ann Otol Rhinol Laryngol 1999;108(5):495–500.CrossRefGoogle ScholarPubMed
Hussong, JW, Perkins, SL, Schnitzer, B, et al. Extramedullary plasmacytoma. A form of marginal zone cell lymphoma? Am J Clin Pathol 1999;111(1):111–6.CrossRefGoogle ScholarPubMed
Wiltshaw, E.The natural history of extramedullary plasmacytoma and its relation to solitary myeloma of bone and myelomatosis. Medicine (Baltimore) 1976;55(3):217–38.CrossRefGoogle ScholarPubMed
Harwood, AR, Knowling, MA, Bergsagel, DE.Radiotherapy of extramedullary plasmacytoma of the head and neck. Clin Radiol 1981;32(1):31–6.CrossRefGoogle ScholarPubMed
Koss, MN, Hochholzer, L, Moran, CA, et al. Pulmonary plasmacytomas: a clinicopathologic and immunohistochemical study of five cases. Ann Diagn Pathol 1998;2(1):1–11.CrossRefGoogle ScholarPubMed
Brinch, L, Hannisdal, E, Abrahamsen, AF, et al. Extramedullary plasmacytomas and solitary plasma cell tumours of bone. Eur J Haematol 1990;44(2):132–5.CrossRefGoogle Scholar
Jackson, A, Scarffe, JH.Prognostic significance of osteopenia and immunoparesis at presentation in patients with solitary myeloma of bone. Eur J Cancer 1990;26(3):363–71Google Scholar

Save book to Kindle

To save this book to your Kindle, first ensure coreplatform@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about saving to your Kindle.

Note you can select to save to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

Find out more about the Kindle Personal Document Service.

Available formats
×

Save book to Dropbox

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Dropbox.

Available formats
×

Save book to Google Drive

To save content items to your account, please confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your account. Find out more about saving content to Google Drive.

Available formats
×