HEMATO-ONCOLOGY

Bone marrow metastases of solid tumors – microscopic images

 Metastaze medulare osoase în tumori solide – imagini de microscopie

First published: 31 mai 2024

Editorial Group: MEDICHUB MEDIA

DOI: 10.26416/OnHe.67.2.2024.9694

Abstract

Metastatic cancers, particularly those involving bone mar­row metastases, present significant challenges in cli­ni­cal ma­nagement. The presence of bone marrow me­tas­tases cri­ti­cally influences cancer treatment strategies, ne­ces­si­ta­ting comprehensive patient assessments. Diagnostic con­­fir­­ma­­tion involves imaging studies and bone mar­row biop­sy or aspiration, with histopathological and im­mu­no­his­to­che­mi­cal exams. The prognosis for patients with bone mar­row metastases is generally poor. Complications from mye­lo­sup­pres­sion and advanced disease stages further com­pli­cate the ma­nage­ment. This article presents two cases of solid tumors with bone marrow metastases, highlighting the diverse pre­sen­ta­tions of such metastases. These cases emphasize the importance of bone marrow evaluation in patients with solid tumors who exhibit unexplained blood ab­nor­malities, as this assessment is crucial for accurate diag­nosis, informed treat­ment decisions, and improved prognosis.
 

Keywords
bone marrow, metastasis, breast cancer, adenocarcinoma

Rezumat

Cancerele metastazate, în special cele care implică metastaze ale măduvei osoase, reprezintă o provocare în managementul clinic. Prezenţa metastazelor măduvei osoase influenţează sem­ni­fi­cativ alegerea tratamentului, necesitând evaluarea com­ple­tă a pacientului. Confirmarea diagnosticului presupune stu­dii imagistice şi biopsie sau puncţie aspirativă a măduvei osoa­se, cu examen histopatologic şi examen imunohistochimic. Prog­nos­ti­cul pentru pacienţii cu metastaze ale măduvei osoase este în general nefavorabil. Complicaţiile mielosupresiei şi sta­dii­le avansate ale bolii complică şi mai mult managementul. Acest articol prezintă două cazuri de tumori solide cu metastaze me­du­la­re, evidenţiind diferitele prezentări ale unor asemenea me­tas­ta­ze. Aceste cazuri subliniază importanţa evaluării măduvei osoa­se la pacienţii cu tumori solide care prezintă anomalii san­gui­ne inexplicabile, deoarece această evaluare este crucială pentru un diagnostic precis şi pentru decizii informate privind tra­ta­men­tul şi îmbunătăţirea prognosticului.
 

Introduction

Metastatic cancers represent a challenge to clinicians, particularly in the case of bone marrow metastasis. Most common cancers that associate medullar metastases are breast, prostate, neuroblastoma, gastric, lung, and colorectal cancers(1,2).

The management of cancer is influenced by the presence of bone marrow metastases, making it crucial to assess the patient’s status thoroughly. Bone marrow metastases should be suspected when clinical and biological changes indicate their possibility. The most frequent hematological abnormalities are anemia, leucoerythroblastic reactions, and thrombocytopenia(1). The patients often complain of bone pain, symptoms related to anemia, and weight loss(2,3). The workup for confirmation should include imaging studies and bone marrow biopsy or aspiration. To establish the origin of the abnormal cells, histopathological and immunohistochemical exams should be performed(2).

The prognosis for cancer patients with bone marrow metastases is poor, with a median survival of three months(4). However, patients eligible for systemic chemotherapy may have a slightly better outlook, with a median survival of nine months, compared to those who receive only best supportive care, which typically results in a median survival of one month(4). Due to myelosuppression, the patients are more susceptible to complications from cytopenia, and the chemotherapy doses need to be reduced. Additionally, the presence of bone marrow metastases indicates advanced disease(2).

We present the cases of two patients with solid tumors and bone marrow metastases.

Case 1

A 54-year-old woman was diagnosed with breast cancer in 2018, for which she underwent a mastectomy followed by chemotherapy, radiotherapy, and hormonal therapy. In 2023, she had a second mastectomy, with histopathological and immunohistochemical examinations returning normal results. However, a follow-up CT scan in 2024 revealed multiple bone lesions in the skull, lumbar spine and lateral ribcage, some of which interrupted the cortical bone, and others caused pathological fractures, but there were no signs of breast cancer recurrence. Her complete blood counts and biochemistry studies were normal. The bone marrow aspirate showed cohesive clusters of neoplastic cells (Figure 1).

Figure 1. Bone marrow aspirate smear – May-Grunwald Giemsa stain, 40x. Large cells with irregular cytoplasmic boundaries and hyperchromatic, unusual-shaped nuclei
Figure 1. Bone marrow aspirate smear – May-Grunwald Giemsa stain, 40x. Large cells with irregular cytoplasmic boundaries and hyperchromatic, unusual-shaped nuclei

Case 2

A 77-year-old patient was diagnosed with prostate adenocarcinoma in 2019, and subsequently received immunotherapy and radiation treatment. Four years later, he developed moderate anemia with a hemoglobin level of 8 g/dl and leukopenia with a white blood cell count of 3000/mm3. The peripheral blood smear showed an increased left shift in the differential WBC (white blood cell) count and erythroblastosis. The bone marrow biopsy revealed infiltration by neoplastic cells (Figure 2), without any signs of hematological disease.

Figure 2. Bone marrow aspirate smears – May-Grunwald Giemsa stain, 40x. Frequent islands of packed non-hematological cells characterized by large cells with large nuclei, coarse chromatin, irregular nuclear contours, basophilic and foamy cytoplasm, along with indistinct cell boundaries
Figure 2. Bone marrow aspirate smears – May-Grunwald Giemsa stain, 40x. Frequent islands of packed non-hematological cells characterized by large cells with large nuclei, coarse chromatin, irregular nuclear contours, basophilic and foamy cytoplasm, along with indistinct cell boundaries

Discussion

Bone marrow metastasis may manifest as the initial presentation of an occult cancer, occur concurrently with other tumors, or emerge during follow-up(5). Additionally, in rare instances, bone marrow metastases can serve as the sole evidence of cancer(6).

Our cases highlight the diverse presentation of bone marrow metastases. In the first case, there were no clinical or laboratory indications of bone marrow involvement, and breast cancer was in remission. The imaging studies showing bone lyses could potentially be attributed to other conditions, such as multiple myeloma. On the contrary, the second patient demonstrated a more typical presentation, with evident disease progression and cytopenia.

Conclusions

Bone marrow evaluation should be considered in patients with solid tumors and unexplained blood abnormalities. A thorough investigation is essential to establish the diagnosis, as it significantly impacts both treatment decisions and prognosis.   

 

Corresponding author: Ana-Maria Vlădăreanu E-mail: vladareanuanamaria@yahoo.com

Conflict of interest: none declared.

Financial support: none declared.

This work is permanently accessible online free of charge and published under the CC-BY licence.

Bibliografie

  1. Singh A, Rawat S, Kushwaha R, et al. Bone marrow metastasis in nonhematological malignancies: A study from tertiary care center. Ann Afr Med. 2024;23(1):91-99. 

  2. Yang H, He F, Yuan T, Xu W, Cao Z. Clinical features and treatment of bone marrow metastasis. Oncol Lett. 2023;26(2):332. 

  3. Chandra S, Chandra H, Saini S. Bone marrow metastasis by solid tumors – probable hematological indicators and comparison of bone marrow aspirate, touch imprint and trephine biopsy. Hematology. 2010;15(5):368-372. 

  4. Zhou MH, Wang ZH, Zhou HW, Liu M, Gu YJ, Sun JZ. Clinical outcome of 30 patients with bone marrow metastases. J Cancer Res Ther. 2018;14(Supplement):S512-S515. 

  5. Fan FS, Yang CF, Wang YF. Diffuse Bone Marrow Metastasis as the Initial Presentation of an Occult Breast Cancer. Case Rep Oncol Med. 2018;2018:2946409. 

  6. Wakamiya T, Tamura S, Kojima F, Kohjimoto Y, Hara I. Disseminated carcinomatosis of the bone marrow caused by prostate cancer diagnosed with only bone marrow biopsy. IJU Case Rep. 2021;4(5):303-306.

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