Bone Marrow Necrosis in Newly Diagnosed Acute Leukemia: Two Case Reports and Review of the Literature

Atypical BCR-ABL1 transcript in mixed phenotype acute leukemia with bone marrow necrosis

Mixed phenotype acute leukemia (MPAL) is a type of acute leukemia in which encompasses mixed features of myeloid, T-lymphoid, and/or B-lymphoid differentiation. Philadelphia chromosome-positive (Ph+) MPAL is a rare subgroup with a poor prognosis and accounts for ＜1% of adult acute leukemia. Until now, there is still no consensus on how to best treat Ph+ MPAL. Here, we report a 62-year-old male with Ph+ (atypical e13a2 BCR-ABL1 fusion protein) MPAL. This patient presented with recurrent and intense bone pain due to bone marrow necrosis (BMN). Besides, he did not achieve a complete remission for the first two chemotherapies, until he received flumatinib combined with hyper-CVAD (B) (a dose-intensive regimen include methotrexate and cytarabine). To our knowledge, this is the first report to describe the coexistence of BMN and atypical e13a2 BCR-ABL1 transcripts in patients with MPAL. This finding will bring new understandings in the diagnosis and treatment of Ph+ MPAL.

Bone marrow necrosis: Facts, controversies, and perspective

Bone marrow necrosis (BMN) is a clinically and pathologically poorly-defined and readily-overlooked entity. The current facts and guidelines pertaining to this entity are scarce, and there exist controversies. Upon reviewing the literature, we present the facts, analyze these controversies, and discourse on future prospects.

Numb chin syndrome as a presentation for acute myeloid leukemia relapse post-hematopoietic cell transplant: Case report and review of literature

NCS is defined as reduced or absent sensation in the chin and lower lip within the distribution of the mental or inferior alveolar nerves. Although commonly associated with local trauma, NCS can indicate an underlying malignancy or can be the presenting symptom of cancer recurrence. We describe a 6-year-old female patient with AML and t(8,21) who underwent allogeneic HCT. Five months post-HCT, the patient presented with right-sided facial pain and numbness in her chin and lower lip consistent with NCS. Two weeks later, the patient had bone marrow relapse indicating AML recurrence. Although NCS remains a rare diagnosis especially in children, in the context of leukemia, it usually indicates an advanced disease or could be a sign of recurrence, and is commonly associated with grim prognosis. Further research is needed to study the link between NCS and specific cytogenetic abnormalities.

Bone Marrow Necrosis in a Patient Following Blinatumomab Therapy

Bone marrow necrosis (BMN) is an extremely rare condition characterized by necrosis of the myeloid tissue and medullary stroma leaving an amorphous eosinophilic background and ill-defined necrotic cells in the hematopoietic bone marrow. Several conditions are associated with BMN, including sickle cell disease, metastatic carcinoma, and hematologic malignancies. It is also associated with the use of antineoplastic drugs, such as fludarabine, interferon alpha, and imatinib. Blinatumomab is a CD19/CD3 bispecific T-cell engager antibody which redirects autologous CD3-positive T cells to CD19-positive lymphoblasts creating a cytolytic synapse leading to blastic cells. Cytokine release syndrome, cerebral nervous system toxicities, and febrile neutropenia are the most frequent adverse effects of blinatumomab. Here, we report an adolescent boy with relapse/resistant acute lymphoblastic leukemia developing BMN following blinatumomab therapy. To our knowledge, this is the first case report on BMN following blinatumomab treatment.

Acute Myeloid Leukemia Presenting with Numb Chin Syndrome: A Case Report and Review of Literature

BACKGROUND Numb chin syndrome is a rare and under diagnosed neuropathy of the inferior alveolar branch of the trigeminal nerve usually causing a lower lip and chin anesthesia or paresthesia. The syndrome is commonly associated with broad-spectrum malignant and non-malignant conditions. CASE REPORT Here we report a case of a 30-year-old male who presented with numb chin syndrome in the form of jaw pain, paresthesia, and hypoesthesia of the mental area as the presenting symptoms of acute of myeloid leukemia with t(8;21) treated with (3+7) protocol (3 days anthracycline+7 days cytarabine). The pain and paresthesia improved but hypothesia persisted. CONCLUSIONS Acute myeloid leukemia is one of the most serious causes of numb chin syndrome which should not be overlooked.

Clinicopathologic Findings of Spontaneous Leukemia in 9 Pet African Hedgehogs (Atelerix Albiventris)

Previous reports of leukemia in hedgehogs are limited. We describe clinicopathologic features of leukemia in 9 hedgehogs, including eosinophilic leukemia (n = 3) and acute leukemia/leukemic phase of lymphoma (n = 6). All 3 hedgehogs with eosinophilic leukemia were older than 2 years of age; in contrast, 4 of 6 cases of acute leukemia/lymphoma were <2 years old. Hedgehogs presented for non-specific clinical signs of anorexia and lethargy. On hematologic testing, hedgehogs with eosinophilic leukemia had a marked leukocytosis, consisting mostly of eosinophilic precursors with fewer mature eosinophils, whereas there were 43–97% immature cells (blasts) in the blood of hedgehogs with acute leukemia/lymphoma. Anemia (n = 6) and/or thrombocytopenia (n = 6) were concurrent findings. Increased liver enzyme activities (alanine aminotransferase, alkaline phosphatase) and hypoalbuminemia were the common findings on biochemical panels. All cases of eosinophilic leukemia and 4 cases of acute leukemia/lymphoma died shortly after diagnosis (median 7 days, range 0–41 days), whereas 2 cases of acute leukemia/lymphoma lived for 94 or 101 days. Postmortem examination in 5 cases (1 eosinophilic leukemia, 4 acute leukemia/lymphoma) showed bone marrow infiltrates, confirming eosinophilic leukemia and acute leukemia in 1 and 3 cases, and bone marrow necrosis in 1 animal with acute leukemia/lymphoma. Immunohistochemical staining of bone marrow sections confirmed a T-cell acute leukemia in 1 case. Several hedgehogs had concurrent carcinomas. Hedgehogs suffer from eosinophilic leukemia and acute leukemia/lymphoma. However, classification of acute leukemia by lineage was not possible due to lack of hedgehog cross-reactive or species-specific reagents.

Bone marrow necrosis in neuroendocrine tumor of the thymus

The prognosis of patients with marrow necrosis secondary to neoplastic disease (often gastric adenocarcinoma) was found to be extremely poor with a median overall survival (OS) of few months. This case confirms the very poor prognosis and shows an association with a neural endocrine adenocarcinoma of the thymus.

Unexplained pancytopenia in acute myeloid leukemia treatment

Certain histopathological findings have been described in acute myeloid leukemia (AML) patients during treatment that define the hematologic outcomes. Such entities as bone marrow necrosis and hemophagocytic lymphohistiocytosis have been reported. These often result in severe pancytopenia.