[Pediatric acute lymphoblastic leukemia initially presenting with bone marrow necrosis]

We report on a case of pediatric acute lymphoblastic leukemia presenting with massive bone marrow necrosis. A 4-year-old boy complained of fever and leg pain. Laboratory data revealed pancytopenia, but bone marrow examination showed only necrotic materials. About one month later, repeated bone marrow examination showed leukemic cells and the necrotic marrow had disappeared. The patient was treated with standard chemotherapy and was successfully induced to complete remission. Patients with massive bone marrow necrosis should undergo bone marrow examination repeatedly to make the correct diagnosis.

Protection against radiation-induced bone marrow and intestinal injuries by Cordyceps sinensis, a Chinese herbal medicine

Bone marrow and intestinal damage limits the efficacy of radiotherapy for cancer and can result in death if the whole body is exposed to too high a dose, as might be the case in a nuclear accident or terrorist incident. Identification of an effective nontoxic biological radioprotector is therefore a matter of some urgency. In this study, we show that an orally administered hot-water extract from a Chinese herbal medicine, Cordyceps sinensis (CS), protects mice from bone marrow and intestinal injuries after total-body irradiation (TBI). CS increased the median time to death from 13 to 20 days after 8 Gy TBI and from 9 to 18 days after 10 Gy TBI. Although CS-treated mice receiving 10 Gy TBI survived intestinal injury, most died from bone marrow failure, as shown by severe marrow hypoplasia in mice dying between 18 and 24 days. At lower TBI doses of 5.5 and 6.5 Gy, CS protected against bone marrow death, an effect that was confirmed by the finding that white blood cell counts recovered more rapidly. In vitro, CS reduced the levels of free radical species (ROS) within cells, and this is one likely mechanism for the radioprotective effects of CS, although probably not the only one.

Influence of high tibial osteotomy on bone marrow edema in the knee

To determine the influence of high tibial osteotomy on subchondral bone marrow edema in medial osteoarthritis of the varus knee, full leg-length radiographs and magnetic resonance imaging were performed in 20 patients (20 knees) before surgery, 1 year postoperatively, and at a mean of 7 years postoperatively. The extent of bone marrow edema in the medial compartment was quantified with magnetic resonance imaging in two planes using the formula for a prolate ellipsoid as follows: length x width x depth x pi/6. We used the Japanese Orthopaedic Association knee score for clinical evaluation. At the last followup, all knees with valgus alignment (10/10) showed reduced edema. In contrast, bone marrow edema increased or remained unchanged in four of 10 knees with neutral or varus alignment. The percentage of satisfactory results was 100% (10/10) in valgus knees and only 30% (3/10) in neutral or varus knees. Extent of bone marrow edema at the followup correlated with the mechanical axis and knee score. Because of the prognostic value of bone marrow abnormalities in the medial compartment observed on magnetic resonance imaging, early lateral closing wedge osteotomy should be considered in patients with varus malalignment and bone marrow edema even in mild cases of medial osteoarthritis.

Bone marrow and skin granulomatosis in a patient with Bartonella infection

This report describes a case of granulomatous inflammation, involving the bone marrow and skin, due to Bartonella infection in an immunocompetent patient. The clinical presentation included prolonged fever, pancytopenia, rash and hepatitis. Bartonella infection should thus be added to the growing list of entities that produce marrow granulomas and fever.

Late-Onset Fatal Epstein-Barr Virus-Associated Hemophagocytic Syndrome following Cord Blood Cell Transplantation for Adult Acute Lymphoblastic Leukemia

A 43-year-old Japanese woman underwent unrelated cord blood transplantation (CBT) during remission for acute lymphoblastic leukemia with t(4; 11)(q21;q23). Tacrolimus was given for prophylaxis of graft-versus-host disease. The posttransplantation clinical course was mostly uneventful, and the leukemia remained in remission. Fourteen months after CBT, the patient developed pancytopenia and hepatic dysfunction with persistent high-grade fever. The bone marrow was hypocellular with increased numbers of macrophages and hemophagocytes. The numbers of Epstein-Barr virus (EBV) copies in peripheral blood samples were remarkably high. Although the patient showed complete donor-type hematopoiesis, the titer of viral capsid antigen immunoglobulin G was low, and the results of a test for EBV nuclear antigen were negative. There was no clinical response to the reduction of immunosuppressive therapy or to the administration of high-dose methylprednisolone, human immunoglobulin, or acyclovir. The patient died 466 days after CBT of massive gastrointestinal hemorrhage due to bone marrow and hepatic failures. This case demonstrates that fatal EBV-associated hemophagocytic syndrome (HPS) can occur more than 1 year after CBT. This report is the first of a case of late-onset EBV-associated HPS following CBT.

Nuclear medicine imaging and therapy of neuroendocrine tumours

Radiolabelled peptides are used for specific targeting of receptors (over-)expressed by tumour cells. Dependent on the kind of labelling and the radionuclide used, these compounds may be utilised for imaging or for therapy. A concise overview is provided on basic principles of designing and developing radiopeptides for these applications. Furthermore, clinical application of these compounds for imaging and therapy is described. Advantages of the method compared to other techniques (such as the use of radiolabelled antibodies or antibody fragments) are discussed as well as pitfalls and limitations.

Long-term toxicity of [(177)Lu-DOTA (0),Tyr (3)]octreotate in rats

PURPOSE AND METHODS

Studies on peptide receptor radionuclide therapy (PRRT) using radiolabelled somatostatin analogues have shown promising results with regard to tumour control. The efficacy of PRRT is limited by uptake and retention in the proximal tubules of the kidney, which might lead to radiation nephropathy. We investigated the long-term renal toxicity after different doses of [(177)Lu-DOTA(0),Tyr(3)]octreotate and the effects of dose fractionation and lysine co-injection in two tumour-bearing rat models.

RESULTS

Significant renal toxicity was detected beyond 100 days after start of treatment as shown by elevated serum creatinine and proteinuria. Microscopically, tubules were strongly dilated with flat epithelium, containing protein cylinders. Creatinine levels rose significantly after 555 MBq [(177)Lu-DOTA(0),Tyr(3)]octreotate, but were significantly lower after 278 MBq (single injection) or two weekly doses of 278 MBq. Renal damage scores were maximal after 555 MBq and significantly lower in the 278 and 2x278 MBq groups. Three doses of 185 MBq [(177)Lu-DOTA(0),Tyr(3)]octreotate with intervals of a day, a week or a month significantly influenced serum creatinine (469+/-18, 134+/-70 and 65+/-15 micromol/l, respectively; p<0.001). Renal histological damage scores were not significantly influenced by dose fractionation. Lysine co-administration with three weekly treatments of 185 MBq significantly lowered serum creatinine and proteinuria.

CONCLUSION

Injection of high doses of [(177)Lu-DOTA(0),Tyr(3)]octreotate resulted in severe renal damage in rats as indicated by proteinuria, elevated serum creatinine and histological damage. This damage was dose dependent and became overt between 100 and 200 days after treatment. Dose fractionation had significant beneficial effects on kidney function. Also, lysine co-injection successfully prevented functional damage.

Management of the Spectrum of Hormone Refractory Prostate Cancer

INTRODUCTION

In its advanced stages, hormone refractory prostate cancer (HRPC) is an incurable condition which consists of a spectrum of disease. This requires an integrated multidisciplinary approach by an uro-oncologic team supported by radiologists, skeletal surgeons and palliative care. Aim of this review was to critically evaluate the current and potential approaches to patients affected by HRPC.

MATERIALS AND METHODS

A comprehensive evaluation of available published data included analysis of published full-length papers that were identified with Medline and Cancerlit from January 1981 to January 2006. Official proceedings of internationally known scientific societies held in the same time period were also assessed.

RESULTS

Most men with hormone refractory prostate cancer will die of their disease in the absence of intercurrent illness, and the various conditions arising as a consequence of local and distal cancer progression commonly lead to a spectrum of morbidity requiring treatment. Recent data regarding docetaxel-based chemotherapy have shown small but significant improvements in survival and improvement in quality of life in men receiving treatment. However, this therapy may not be suitable for all patients. New agents used alone or in combination with docetaxel currently are under trial in an attempt to provide much needed improvements in outcome. Bone-targeted treatments, particularly late-generation bisphosphonates, have added to the range of options, reducing the incidence of skeletal complications in some men. Further work is needed to target their use more effectively, to explore their efficacy in combination with existing proven therapies and to develop new approaches to treat bone metastases. Complications arising as a consequence of upper and lower tract dysfunction, haematologic, neurologic and psychologic disorders are common. These complications often are amenable to effective treatment, but interventions may engender difficult clinical and ethical decisions.

CONCLUSIONS

Although HRPC is incurable, it is not untreatable, and that the clinical management embraces not just chemotherapy, but many interventional and supportive therapies. A holistic and supportive approach to patient care is vital for optimal management, and is best provided by a coordinated, multidisciplinary team including urologists and oncologists.

When physiology becomes pathology: the role of magnetic resonance imaging in evaluating bone marrow oedema in the humerus in elite tennis players with an upper limb pain syndrome

Upper limb stresses are well recognised in tennis, and the normal physiological responses of the humerus to externally applied forces are well defined. Changes to both the microscopic and macroscopic bony architecture are often not apparent on plain radiographs in the early stages of a stress reaction. Bone scintigraphy is more sensitive, but not very specific to subtle changes, as is computer aided tomography. Magnetic resonance imaging (MRI) scans are now used to assess many musculoskeletal injuries, and may allow earlier recognition of changes. This study reports on eight high level tennis players (seven professionals, one highly ranked amateur), who all presented during the course of the 2002 Australian Open and its lead up events. All had an upper limb pain syndrome centred around the elbow. Each underwent an MRI scan. A group of asymptomatic players also had scans of the same area to serve as controls. All symptomatic patients had various levels of bone marrow oedema in their distal humerus, some with periosteal reactions, although most without. No scans revealed a cortical breach. The management of these reactions is problematic in players on an international circuit, as review is sporadic and not always coordinated. The timetabling of international tournaments means it is difficult for top players to obtain adequate rest to avoid injury. Awareness of this early overuse reaction needs to be raised to allow preventive and therapeutic options to be considered to reduce the incidence of this humeral stress response producing an upper limb pain syndrome.

Pyrexia of unknown origin with neutropenia, cervical lymphadenopathy, pneumonia and marrow hypoplasia

A 56 years adult male presented with fever for 3 weeks with neutropenia and cervical lymphadenopathy with left sided pneumonitis. Histopathology of lymphnode was consistent with Kikuchi's Necrotizing Lymphadenitis. Kikuchi's disease is usually a self- limiting illness characterized by pyrexia, neutropenia and cervical lymphadenopathy in young women of Asian decent. This often leads to the misdiagnosis of lymphoma or tuberculosis. The notable feature here is an older male presented with severe neutropenia and pneumonia with hypoplastic marrow.

[Bone marrow necrosis as an initial manifestation of Philadelphia chromosome and myeloid antigens positive B acute lymphoblastic leukemia--a case report]

Many diseases cause bone marrow necrosis (BMN), especially lymphocytic leukemia. To explore the complexity of the pathogenesis and pathology of BMN and understand the multiplicity of clinical features, a case of Philadelphia chromosome positive (Ph+) B acute lymphoblastic leukemia (ALL) expressing myeloid antigens was reported. The results indicated that the clinical features of this case were complicated and multiplex, the diagnosis was confirmed by using bone marrow smear and biopsy, immunophenotype analysis, conventional cytogenetics and fluorescence in situ hybridization (FISH), the prognosis of patients improved by active treatment for primary disease. In conclusion, the Ph+ B ALL expressing myeloid antigen with BMN is very rare, its diagnosis should be confirmed by using multiple methods, and the active treatments should be performed.

Familial leukemia

Identification of genes responsible for rare familial cases of cancer provides genetic and biochemical insight into the mechanisms of carcinogenesis at work in the more common, sporadic occurrences of the corresponding malignancy. Hematopoietic malignancy is no exception, and considerable evidence substantiates the role of genetic factors in the risk for leukemia. In a few instances, leukemia runs in families as a single gene, Mendelian disorder. Only a few genes conferring heritable risk for leukemia are known, however, and most are responsible for bone marrow failure syndromes. Thus, the identification of additional genetic risk factors for leukemia represents both a challenge and an opportunity. The high frequency of leukemia and transient leukemia in Down syndrome is beginning to yield the secrets of its unique clinical properties. The apparent phenomenon of anticipation (a declining of age of onset with each passing generation) in familial forms of bone marrow failure and leukemia is now affirmed through its association with mutations in genes responsible for maintaining telomere length. And, for the majority of leukemia cases, as with other common diseases that are not under the influence of a single, major gene, but rather result from the additive interactions of complex genetic and environmental factors, common variants in metabolic enzymes, and other genes awaiting discovery, are being teased out.

Multiple constitutional aetiological factors in bone marrow failure syndrome (BMFS) patients from north India

BACKGROUND AND OBJECTIVES

A large number of patients diagnosed with bone marrow failure syndromes (BMFS), comprising aplastic anaemia (AA) and myelodysplastic syndromes (MDS), remain aetiologically uncharacterized worldover, especially in resource constrained set up. We carried out this study to identify a few constitutional causes in BMFS patients attending a tertiary care hospital in north India.

METHODS

Peripheral blood lymphocyte cultures were performed (with and without clastogens) in a cohort of 135 consecutive BMFS patients, in order to detect Fanconi anaemia (FA), Down's syndrome (+21), trisomy 8 (+8) and monosomy 7 (-7).

RESULTS

Constitutional factors were detected in 17 (12.6%) patients. FA defect was observed in 24.07 percent (13/54), 16.66 percent (1/6) and 2.85 percent (1/35) paediatric aplastic anaemia, paediatric MDS and adult MDS patients respectively. Down's syndrome was detected in 5.00 percent (2/40) adult aplastic anaemia patients. None of the patients revealed trisomy 8 or monosomy 7.

INTERPRETATION AND CONCLUSION

Presence of an underlying factor determines appropriate management, prognostication, family screening and genetic counselling of BMFS patients. Special tests required to confirm or exclude constitutional aetiological factors are not available to majority of the patients in our country. Diepoxybutane (DEB) test yielded better results than mitomycin C (MMC) test in our experience.

[Orthopedic manifestations of the antiphospholipid syndrome]

PURPOSE

The antiphospholipid syndrome (APS) is characterized by arterial and/or venous thrombosis, and pregnancy morbidity in association with antiphospholipid antibodies. Since its classical description 22 years ago, the clinical spectrum of APS has embraced the realms of obstetrics, nephrology, cardiology, neurology, gastroenterology, angiology and now, possibly orthopaedics. This is not surprising given that this disease can affect virtually any organ system and blood vessel of any size and nature. Just as venous thrombosis may affect limbs and internal organs, arterial thrombosis has been shown to affect organs such as the brain, eye, heart, kidney, liver and may also involve the skeleton.

CURRENT KNOWLEDGE AND KEY POINTS

In this review, we describe the orthopedic aspects of APS recently reported, bone metatarsal fractures, osteonecrosis and more exceptional complications, ie algodystrophy and bone marrow necrosis. We briefly discuss postulated pathogenesis and possible implications of anticoagulation.

FUTURE PROSPECTS AND PROJECTS

This data need further confirmation. They may suggest complementary physiopathologic and therapeutic implications.

Relationship Between Bone Marrow Edema and Development of Symptoms in Patients With Osteonecrosis of the Femoral Head

OBJECTIVE

The purpose of this study was to determine the significance of risk factors on MR images for predicting the outcome of patients with osteonecrosis of the femoral head.

SUBJECTS AND METHODS

Eighty-three asymptomatic or minimally symptomatic hips in 61 consecutive patients were followed up prospectively. Inclusion criteria included osteonecrosis of the femoral head identified by typical MRI findings, with no radiographic evidence of progression of collapse, and Harris hip score of 85 points or more. Every 3 months, the patients underwent clinical and radiographic examination, and MR images were obtained at 6- to 12-month intervals. Follow-up continued until worsening of hip pain with Harris hip score of less than 70 points or surgery. Asymptomatic hips were followed up for at least 24 months. The mean clinical and radiographic follow-up period after the initial diagnosis was 60 months (range, 3-168 months).

RESULTS

Thirty-six (43%) of the 83 hips were symptomatic at the last follow-up. Bone marrow edema was present in 28 hips (34%) during the follow-up period. Twenty-seven (96%) of the 28 hips were symptomatic, and bone marrow edema significantly correlated with worsening of hip pain (p < 0.0001). The necrotic volume of hips with bone marrow edema was significantly larger than those without bone marrow edema (p < 0.0001). Bone marrow edema was found to be the most significant risk factor for worsening of pain (p < 0.0001).

CONCLUSION

Bone marrow edema strongly correlated with necrotic volume and was the most significant risk factor for worsening of hip pain. A large necrotic volume of 30% or more may be the second useful indicator for predicting future worsening of hip pain.

Bone marrow edema in osteoporotic vertebral compression fractures after percutaneous vertebroplasty and relation with clinical outcome

BACKGROUND AND PURPOSE

Little is known about the evolution of bone marrow edema (BME) in osteoporotic vertebral compression fractures (VCF) after percutaneous vertebroplasty (PV) or about its relation with relief of pain. In this study, we prospectively assessed changes in BME with MR imaging at 3, 6, and 12 months after PV and related changes in BME with pain evolution and analgesic use over time.

METHODS

BME percentage was assessed in 64 patients after PV of 89 VCF with serial MR imaging follow-up at 3, 6, and 12 months. Pain was assessed before PV and at every follow-up interval by visual analog scale for pain and type of analgesic used. Relation between changes in BME and pain evolution was assessed in a subgroup of 31 patients with a single treated VCF and neither new VCF at follow-up nor pain at another untreated level.

RESULTS

BME gradually decreased over time. At 1 year after PV, 29% of treated VCF still demonstrated BME. Once BME disappeared, it did not return. Pain relief was most striking the first 3 months after PV and remained constant thereafter. There was no relation between relief of pain and extent, presence, or absence of BME after PV.

CONCLUSION

A gradual decrease of BME in osteoporotic VCF treated with PV is apparent during 12 months of MR imaging follow-up. Decrease of BME is unrelated to relief of pain.

Infiltrative myelopathy by paracoccidioidomycosis. A review and report of nine cases with emphasis on bone marrow morphology

AIMS

To report nine additional well-defined cases with infiltrative myelopathy by paracoccidioidomycosis (PCM), to describe the specific lesions and infection-related stromal abnormalities, to review the literature on this type of involvement and to introduce a new cause of granulomatous lesions of bone marrow.

METHODS AND RESULTS

Different bone marrow specimens were studied (aspirated smears, aspirated clots, biopsy imprints and biopsies) from nine patients with acute or subacute forms of PCM known to have PCM infiltrative myelopathy.

CONCLUSIONS

The biopsy specimens were the best for demonstrating bone marrow involvement by PCM. The lesions varied from compact and focal granulomas with few fungal cells to numerous disseminated fungal cells within a loose granulomatous inflammatory reaction, with a continuum between these extremes suggesting a spectrum of immune response to the fungi. Other findings such as bone marrow fibrosis, parenchymal coagulative necrosis and bone necrosis were also observed in the affected areas.

Marrow aplasia developing 13 years after HLA-identical sibling allogeneic transplantation for chronic myeloid leukaemia: successful treatment with antithymocyte globulin and peripheral blood stem cell infusion from the original donor

Secondary or late graft failure has been defined as the development of inadequate marrow function after initial engraftment has been achieved. We describe a case of profound marrow aplasia occurring 13 years after sibling allogeneic bone marrow transplantation for chronic myeloid leukaemia (CML) in first chronic phase. Although the patient remained a complete donor chimera, thereby suggesting that an unselected infusion of donor peripheral blood stem cells (PBSC) or bone marrow might be indicated, the newly acquired aplasia was thought to be immune in aetiology and some immunosuppression was therefore considered appropriate. Rapid haematological recovery was achieved after the infusion of unselected PBSC from the original donor following conditioning with anti-thymocyte globulin (ATG).

Bone marrow suppression and severe anaemia associated with persistent Plasmodium falciparum infection in African children with microscopically undetectable parasitaemia

Background

Severe anaemia can develop in the aftermath of Plasmodium falciparum malaria because of protracted bone marrow suppression, possibly due to residual subpatent parasites.

Materials and methods

Blood was collected from patients with recent malaria and negative malaria microscopy. Detection of the Plasmodium antigens, lactate dehydrogenase (Optimal^®), aldolase and histidine rich protein 2 (Now malaria^®) were used to differentiate between patients with (1) no malaria, (2) recent cleared malaria, (3) persistent P. falciparum infection. Red cell distribution width (RDW), plasma levels of soluble transferrin receptor (sTfR) and erythropoietin (EPO) were measured as markers of erythropoiesis. Interleukin (IL) 10 and tumour necrosis factor (TNF)α were used as inflammation markers.

Results

EPO was correlated with haemoglobin, irrespective of malaria (R = -0.36, P < 0.001). Persistent P. falciparum infection, but not recent malaria without residual parasites, was associated with bone marrow suppression i.e., low RDW (P < 0.001 vs. P = 0.56) and sTfR (P = 0.02 vs. P = 0.36). TNF-α and IL-10 levels were not associated with bone marrow suppression.

Conclusion

In the treatment of malaria, complete eradication of parasites may prevent subsequent development of anaemia. Severely anaemic children may benefit from antimalarial treatment if antigen tests are positive, even when no parasites can be demonstrated by microscopy.