Presentation and outcomes for children with bone marrow necrosis and acute lymphoblastic leukemia: a literature review

Bone marrow necrosis in pediatric malignancies: 10-Year retrospective review and review of literature

Bone marrow necrosis (BMN) is a rare pathologic finding, but when encountered is most often associated with malignancy. In adults, its presence correlates with an inferior prognosis, however in children the prognostic implication is unclear. We performed a retrospective review of 3,760 bone marrow specimens in patients ≤18 years over a 10-year period. BMN was identified in less than 1% of specimens and only in patients with leukemia, lymphoma, or neuroblastoma. BMN contributed to a delay in diagnosis; however, advanced medical imaging may serve as a tool to localize nonnecrotic areas for bone marrow sampling, facilitating an expedited diagnosis.

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.

Imatinib-based therapy in adult Philadelphia chromosome-positive acute lymphoblastic leukemia: A case report and literature review

Acute lymphoblastic leukemia (ALL) has a rapid onset and rarely occurs with exclusive prodrome of general osteoporosis and vertebral compression fractures. However, Philadelphia chromosome-positive (Ph⁺) ALL has a poor prognosis, even when patients are treated with intensive chemotherapy, and the first-line effective treatment requires further elucidation. The present study focused on a 56-year-old Chinese male patient who initially presented with spontaneous bone fractures and was ultimately diagnosed as Ph⁺ ALL after 6 months, which required to preliminarily exclude a working diagnosis of myeloma. Apart from intensive chemotherapy, the patient successfully completed an imatinib-based regimen and achieved complete remission (CR) 2 weeks later. Subsequently, the patient was subjected to consolidation treatment using the same imatinib regimen combined with interferon-α 2b for 9 courses. In November 2013, the patient had achieved persistent hematological and molecular genetic normality for ~16 months after the initial CR. In conclusion, Ph⁺ ALL must be considered in the differential diagnosis of adults experiencing unexplained bone disease.

Analysis of the molecular mechanism underlying bone marrow necrosis with acute lymphoblastic leukemia

Bone marrow necrosis (BMN) is a rare phenomenon in children with malignancies, occurring most commonly in patients with acute lymphoblastic leukemia (ALL). The pathophysiology of this phenomenon has not been identified. We analyzed seven BMN cases with ALL in order to elucidate the underlying mechanism. Serum high-mobility group box 1 (HMGB1), cytochrome C, cytokines, and chemokines were measured, and real-time quantitative reverse transcription-polymerase chain reaction (RQ-RT-PCR) and immunochemistry of death-related molecules were analyzed using bone marrow samples. The serum levels of 17 of 27 cytokines and chemokines were found to be significantly elevated in patients with BMN in comparison to those in healthy volunteers; however, IFN-γ and IL-10 were not elevated. The cytokine pattern was different to that reported in hemophagocytic lymphohistiocytosis. The HMGB1 and cytochrome C levels in patients with BMN were not elevated. RQ-RT-PCR revealed significant overexpression of Fas-ligand, perforin, and granzyme B in the bone marrow of patients with ALL complicated with BMN compared with that in healthy volunteers and in patients with ALL without BMN. On immunohistochemistry, we identified leukemic cell-eliciting Fas-ligand and macrophage-eliciting TNF-α. Thus, no close relationship with massive necrosis or the intrinsic pathway of apoptosis was identified in the occurrence of BMN. These results suggest that the massive cell death phenomenon called BMN is partially induced by the extrinsic pathway of apoptosis.

Bone marrow necrosis: ten-year retrospective review of bone marrow biopsy specimens

OBJECTIVES

Bone marrow can undergo necrosis for many different causes; malignant causes are reported to be more frequent.

METHODS

We undertook a 10-year retrospective review of all bone marrow biopsy specimens with bone marrow necrosis at our institution.

RESULTS

Identified cases represented approximately 0.3% of our bone marrow cases. Most identified bone marrow cases with necrosis were involved by metastatic tumor or hematolymphoid malignancy (90% of total) in relatively equal proportions. In those cases of bone marrow necrosis with hematolymphoid malignancy, lymphoid disease predominated and the necrosis was often seen in the setting of chemotherapy. In metastatic tumor cases, necrosis seemed to enrich in prostate adenocarcinoma and Ewing sarcoma/primitive neuroectodermal tumor; neuroblastoma showed much less necrosis. Ten percent of patients with bone marrow necrosis had no underlying malignancy, and the associated causes varied.

CONCLUSIONS

The causes of bone marrow necrosis are diverse but should always prompt careful assessment for malignancy and infectious etiology.

Bone marrow necrosis in a girl with Hodgkin's disease

Bone marrow necrosis (BMN) is a rare finding in children with malignancy occurring most commonly in children with acute lymphoblastic leukemia. This article describes the first case of a girl who developed BMN during treatment for Hodgkin's disease. During the second cycle of chemotherapy, she experienced sudden profound bone pain in the lumbosacral region associated with elevated levels of lactate dehydrogenase (LDH), fibrin degradation products (D-Dimer), and alkaline phosphatase as well as pancytopenia and leukoerythroblastosis. MRI studies showed multiple confluent areas with low signal intensity and rim contrast enhancement in all vertebral bodies. Bone marrow biopsy revealed focal necrosis within hypocellular bone marrow. The patient responded quickly to symptomatic treatment with analgetics and heparin; however, elevations of LDH and D-Dimer persisted for 1.5 and 8 months, respectively. Clinicians should be aware of this rare condition to establish the diagnosis and to continue oncologic treatment as early as possible.