Hodgkin's disease presenting as myelofibrosis

Successful treatment of primary bone marrow Hodgkin lymphoma with brentuximab vedotin: a case report and review of the literature

Background

Hodgkin lymphoma usually presents with sequential enlargement of peripheral lymph nodes, and bone marrow invasion rarely occurs (approximately 3–5%). However, several cases have been reported as “primary” bone marrow Hodgkin lymphoma, especially among patients with human immunodeficiency virus and the elderly. This type of Hodgkin lymphoma is characterized by no peripheral lymphadenopathies and has been reported to have poorer prognosis.

Case presentation

A 38-year-old Japanese man was admitted to our hospital because of fever of unknown origin and pancytopenia without lymphadenopathies. Bone marrow examination revealed Hodgkin cells mimicking abnormal cells. These were positive for CD30, EBER-1, CD15, PAX-5, and Bob-1 and negative for Oct-2, CD3, CD20, surface immunoglobulin, CD56. On the basis of systemic evaluation and bone marrow examination, he was diagnosed with primary bone marrow Hodgkin lymphoma. We initiated therapy with DeVIC (dexamethasone, etoposide, ifosfamide, and carboplatin) therapy, but remission was not achieved. Then, the patient was treated with brentuximab vedotin combined with systemic chemotherapy (Adriamycin, vinblastine and dacarbazine), which was effective.

Conclusions

There is no established treatment strategy for Hodgkin lymphoma, and therapeutic outcomes using ABVD (Adriamycin, bleomycin, vinblastine and dacarbazine)-like or CHOP (cyclophosphamide, Adriamycin, vincristine, and prednisone)-like regimens are reportedly poor. Only a few patients have been reported to achieve long-term remission. Through this case report, we suggest an alternative therapeutic option for primary bone marrow Hodgkin lymphoma.

Hodgkin's lymphoma associated with myelofibrosis: A case report

In the present study, the case of a patient with nodular sclerosing Hodgkin's lymphoma (NSHL) presenting with diffuse fibrosis of the bone marrow (BM) was reported. A 30-year-old male complained of fever for 1 year, as well as lumbago, lymph node swelling and night sweats for 3 months. A biopsy of the lymph nodes established a diagnosis of NSHL. Aspiration of BM was a dry tap, and the BM biopsy demonstrated marked myelofibrosis with increased proliferation of reticulin fiber. Multiple skeletal lesions were detected in the patient's vertebra, pelvis, sternum and bilateral femur by magnetic resonance imaging and computed tomography. Following numerous courses of chemotherapy and radiotherapy, remission of the lymphoma was achieved. Subsequently, the BM aspiration became possible, and BM biopsy demonstrated a reduction in fibrosis.

The differential diagnosis and bone marrow evaluation of new-onset pancytopenia

New-onset pancytopenia can be caused by a wide variety of etiologies, leading to a diagnostic dilemma. These etiologies range from congenital bone marrow failure to marrow space-occupying lesions, infection, and peripheral destruction, to name a few. Bone marrow examination, in addition to a detailed clinical history, is often required for an accurate diagnosis. The purpose of this review is to provide a brief overview of many of the causes of new-onset pancytopenia in adults and children, with emphasis on bone marrow findings and recommendations of additional testing and clinical evaluation when needed, with the overall aim of aiding the pathologist's role as a consultant to the patient's treating physician.

Hereditary and familial syndromes of bone and blood. Genetic pathways, diagnostic pitfalls

Numerous metabolic disorders, teratogenic agents, and in utero infections lead to congenital bone disease and malformation. This review focuses on hereditary and familial disorders of bone with particular emphasis on impaired hematopoiesis, myelofibrosis, pathologic fractures, and dysmorphology of the forearm and craniofacial structures. The severity of bone disease and marrow dysfunction of any given disorder may vary considerably from one affected individual to the next, and intrapersonal variability over time may be substantial as well. Both can impart difficulty to the appropriate evaluation and delay the correct diagnosis. Many of these disorders are phenotypically quite similar but require very different therapeutic intervention.

bcr/abl-negative, classic myeloproliferative disorders: diagnosis and treatment

Essential thrombocythemia, polycythemia vera, and myelofibrosis with myeloid metaplasia constitute the "classic" bcr/abl-negative myeloproliferative disorders (MPDs). Each of these MPDs represents a stem cell-derived clonal myeloproliferation with the respective features of thrombocytosis, erythrocytosis, and bone marrow fibrosis. Unlike with cases of chronic myeloid leukemia, in which the bcr/abl mutation is invariably detected, current diagnosis of essential thrombocythemia, polycythemia vera, and myelofibrosis with myeloid metaplasia is based on a consensus-driven set of clinical and laboratory criteria that have undergone substantial modification in recent times. The recent discovery of a recurrent activating Janus tyrosine kinase (JAK2) mutation (JAK2VG17F) in all 3 classic MPDs offers another opportunity for refining current diagnoses and disease classifications. In this article, we outline contemporary diagnostic algorithms for each of these disorders and provide an evidence-based approach to management.

Role of staging bone marrow examination in children with Hodgkin disease

PURPOSE

To determine the value of bone marrow trephine biopsy as part of the clinical staging for children presenting with Hodgkin disease.

PATIENTS AND METHODS

A retrospective study of pre-treatment bone marrow examinations was undertaken to examine the value of bone marrow staging in children with Hodgkin disease. The records of 122 children, diagnosed with Hodgkin disease at Texas Children's Hospital between February 1960 and July 1996 were reviewed. Age, sex, complete blood counts (CBC), pathology, and clinical and pathological staging results were tabulated.

RESULTS

Information was complete for analysis in 110 patients. Bone marrow trephine biopsies identified Hodgkin disease in 2/110 patients (1.8%). The patients with bone marrow disease had clinical stage IIIB disease prebiopsy. Positive bone marrow biopsy results did not effect a change in therapy, and the small number of positive cases do not allow any prediction as to prognosis.

CONCLUSION

There is no role for bone marrow trephine examination in children with clinical stage I-IIIA Hodgkin disease.

Extramedullary megakaryoblastic tumors following an indolent phase of myelofibrosis

A 59-year-old man developed multiple subcutaneous and bone tumors after 2 years' duration of indolent myelofibrosis. These tumors exhibited a diffuse proliferation of pleomorphic blast cells. The skeletal x-rays showed disseminated osteolysis and osteosclerosis. Blast cells obtained from the pleural effusion did not react with myeloperoxidase, sudan black B or non-specific esterase. Genotypic analysis of DNA samples at autopsy did not demonstrate rearrangements of T-cell receptor beta-chain or immunoglobulin heavy-chain genes. Frozen-section immunohistochemical studies revealed that the neoplastic cells were derived from megakaryocytic lineage. The present case represents a novel and unusual subtype of megakaryocytic neoplasm.

Idiopathic myelofibrosis--an update with particular reference to clinical aspects and prognosis

Idiopathic myelofibrosis (IMF) is characterized by excessive accumulation of connective tissue in the bone marrow as part of a clinical syndrome which in its classical form is featured by leukoerythroblastic anemia and huge splenomegaly at the time of diagnosis. An acute variant of the disease exists being featured by pancytopenia, nor or minimal splenomegaly and a rapidly fatal clinical course. This review describes the relationship of IMF to other chronic myeloproliferative disorders and highlights current concepts of the pathogenesis of bone marrow fibrosis, implicating the intramedullary release of various growth factors, including platelet-derived growth factor beta. In a subgroup of patients bone marrow fibrosis may develop consequent to autoimmune bone marrow damage. The clinical and laboratory findings in some of the larger series of patients are presented and the reasons for the highly variable clinical presentation and prognosis are critically discussed. It is proposed that studies on prognosis in IMF are based upon simple prognostic staging systems, which should include the Hb-concentration, platelet count, spleen size and the presence/absence of osteomyelosclerosis on X-ray. Using these parameters the patients are easily categorized into three prognostic groups with highly different survival times.

Hodgkin's disease diagnosed post mortem: a population based study

All cases of Hodgkin's disease (HD) notified to the Danish Cancer Registry from 1976 through 1987 in patients less than 70 years old were reviewed in order to identify patients in whom a correct diagnosis was established only post mortem. The case records of such patients were reviewed in a search for clinical features that could have ensured a correct pre mortem diagnosis. HD was diagnosed after death in 31 patients in this unselected population based study and thus constituting only 2.4% of all patients less than 70 years with HD, but 14.1% of the group aged 65-69 years. Most patients were identified during the first part of the study period, which may reflect a decreasing autopsy rate. HD was considered to be a coincidental finding in four patients and the primary cause of death in 27 patients. Among the later 27 patients a number of unfavourable prognostic factors were a common finding: persistent unexplained fever and weight loss, pancytopenia, hepatic involvement, bone marrow involvement, advanced stage disease, and lymphocytic depletion histology. However, most of the patients had no concurrent diseases and may have benefitted from a correct diagnosis and a potentially curative treatment. The many uncommon features of HD together with the frequent findings of falsely negative chest X-ray, bone marrow examination, liver biopsy, and ultrasound contributed to the difficulty in diagnosis. In about 1/3 of the patients clinical findings suggestive of lymphoma did not result in relevant diagnostic procedures.

Transient reversal of bone marrow aplasia associated with lymphocyte depleted Hodgkin's disease after combination chemotherapy

This report describes a patient with lymphocyte depleted Hodgkin's disease who presented with bone marrow aplasia. The aplastic marrow reverted to normal after initiation of MOPP chemotherapy; however, 4 months after completion of therapy, bone marrow aplasia recurred in the absence of recurrent Hodgkin's disease. The patient remains free of Hodgkin's disease 34 months after completion of chemotherapy. Bone marrow abnormalities in Hodgkin's disease are reviewed and the current understanding of the pathological mechanisms leading to aplastic anemia is discussed.

Hodgkin's disease associated with systemic lupus erythematosus

We report on the rare association of Hodgkin's disease with systemic lupus erythematosus. Two years after the diagnosis of systemic lupus erythematosus, the patient developed upper abdominal pain, jaundice, splenomegaly, and fever of unknown origin. He had a rapidly fatal clinical course, despite being treated for systemic lupus erythematosus, cholecystitis, and possible sepsis. Autopsy revealed Hodgkin's disease, lymphocyte-depletion type, involving lymph nodes, liver, spleen, and bone marrow. The awareness of the association of Hodgkin's disease with systemic lupus erythematosus and its modes of presentation will help in the early diagnosis and management of such patients.