Bone marrow necrosis in acute lymphoblastic leukaemia

Role of Immunohistochemistry in Acute Leukemias with Myelonecrosis

Myelonecrosisis a rare antemortem finding most commonly seen in haematopoeitic neoplasms, especially in acute leukemia. When myelonecrosis occurs at the time of presentation, it imposes certain diagnostic issues in sub categorization of leukemias which is necessary for therapeutic as well as prognostic purposes. Flow cytometry, though is a powerful modality, has its own limitations especially when the cells are not fresh and viable; and when the specimen is not of adequate cellularity which is usual in cases of myelonecrosis. In such situations, immunocytochemistry (ICC) or immunohistochemistry (IHC) may play a major role in lineage specification in leukemias as the necrosed marrow with the ghost cells can still retain the antigenicity for certain immunomarkers. Four such interesting cases of common B acute lymphoblastic leukemia (ALL) where IHC was used for diagnosis were included. ICC and IHC done on the necrosed marrow contributed to the diagnosis of ALL in all the four cases and contributed to subsequent management. ICC and IHC if contributory can play a major role in identifying the primary cause of myelonecrosis as the ghost cells can retain the antigenicity despite being morphologically non-viable.

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

Bone marrow necrosis is a rare histopathology finding with the majority of cases occurring in the setting of a hematologic malignancy. This article reports a case of diffuse marrow necrosis in a child secondary to acute lymphoblastic leukemia and summarizes the clinical features and outcomes for children with bone marrow necrosis secondary to leukemia from 20 published reports. This review demonstrated that the most common presenting features were bone pain, fever, pancytopenia, and that outcomes were less favorable when compared with those without necrosis. However, contemporary literature suggests that outcomes are similar for children who have bone marrow necrosis secondary to leukemia when compared with overall survival rates for pediatric leukemia.

Fatal bone marrow necrosis following fludarabine administration in a patient with indolent lymphoma

We report the first known case of fulminant bone marrow necrosis (BMN) occurring after infusion of fludarabine monophosphate in a patient with recurrent low-grade non-Hodgkin's lymphoma (NHL). Extensive BMN is characterized by the development of fever, bony pain, a leukoerythroblastic peripheral blood film, variable degrees of pancytopenia and elevations in lactate dehydrogenase and alkaline phosphatase. The diagnosis of BMN is rarely entertained ante-mortem. Although the precise role chemotherapy may have played in triggering fatal BMN remains speculative, we alert clinicians to be aware of this entity as more patients with indolent lymphomas and leukemias are treated with this and other potent nucleoside analogs.

Bone marrow necrosis

Bone marrow necrosis is regarded as an uncommon entity that is associated with a poor prognosis. However, organized studies using either bone marrow biopsy specimens or autopsy material showed that bone marrow necrosis can be demonstrated in approximately one third of specimens. It is found in a large number of both malignant and nonmalignant disorders, in addition to occurring following large exposures to radiation or high dose cancer chemotherapy. In the absence of radiation or cancer chemotherapy, it probably eventuates from either vascular occlusion or blood stasis in small blood vessels. When bone marrow necrosis is prolonged, it may be associated with the development of bone marrow fibrosis, and it may serve as a predisposing etiology for idiopathic myelofibrosis. Most patients discovered with bone marrow necrosis have few symptoms, and they are eventually lost to follow-up without evident progression or development of a clinical illness. In acute disorders and in those who undergo effective therapy, recovery appears to occur without complications. This frequently overlooked finding is the subject of many case reports in the medical literature, but it has only been rarely systematically investigated. The latter is probably warranted because of the potential role of bone marrow necrosis in the pathophysiology of a number of disorders and the paucity of information for treatment of this pathological finding.

Bone marrow necrosis

Bone marrow necrosis is most frequently diagnosed at postmortem examination. Antemortem diagnosis is still uncommon. In a recent review of world literature, we have found 133 cases of bone marrow necrosis diagnosed during life. It has been observed during the course of a wide variety of diseases, most commonly in association with acute and chronic leukemia, carcinoma, malignant lymphoma, infections, and sickle cell disease. We report two intravitally diagnosed cases of bone marrow necrosis occurring in two patients with high-grade B-cell lymphoproliferative disease. These cases are unusual in that both patients had a triad of bone marrow necrosis, high-grade B-cell lymphoproliferative disease, and hypercalcemia. Despite chemotherapy, both cases ultimately proved fatal, with progressive involvement of the central nervous system.

Bone marrow histology. 3: Value of bone marrow core biopsy in acute leukaemia, myelodysplastic syndromes, and chronic myeloid leukaemia

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