Chronic exposure to benzene results in a unique form of dysplasia

Hematotoxicity following chronic benzene exposure has been recognized for over a century, although the mechanism remains unknown. We describe a novel form of bone marrow dysplasia in 23 workers exposed to high concentrations of benzene. Distinguishing features of benzene-induced dysplasia include: marked dyserythropoiesis, eosinophilic dysplasia and abnormal cytoplasmic granulation of neutrophilic precursors. Hematophagocytosis, stromal degeneration and bone marrow hypoplasia are also seen. Severe bone marrow dysplasia is frequently accompanied by clonal T cell expansion and alterations in T lymphocyte subsets. No clonal cytogenetic abnormalities were observed. These results suggest that autoimmune-mediated bone marrow injury is an early or predisposing event in the pathogenesis of benzene-induced persistent hematopoietic disease.

[Second transplant from the same donor without conditioning for bone marrow aplasia after non-myeloablative hematopoietic stem cell transplantation for chronic myeloid leukemia]

We describe a 56-year-old woman with chronic myeloid leukemia (CML) and a past history of stroke, who underwent nonmyeloablative hematopoietic stem cell transplantation (NST) with conditioning consisting of fludarabine and cyclophosphamide. The regimen related toxicity was minimal and patient did not require transfusions of any blood products nor did she have any infections after the NST Since mixed chimerism was observed in both lymphocytes (70% were donor type) and granulocytes (none were donor type) at 56 days after NST, donor lymphocyte infusion (DLI) was performed on day 68 and then immunosuppressant therapy was discontinued. DLI resulted in graft versus leukemia (GVL) effect, causing pancytopenia and bone marrow aplasia. A second hematopoietic stem cell transplantation was performed without conditioning on day 157, and complete donor type hematopoiesis and molecular remission of CML were achieved. Although engraftment of donor hematopoietic stem cells was not obtained after the first transplantation, donor lymphocytes were engrafted by nonmyeloablative conditioning and immunosuppression. That is, the same result might have been achieved even if the patient had received transfusion of only donor lymphocyte subsets in the first step. Based on this case report, a potential cell therapy is proposed composed of the preceding donor lymphocyte infusion alone, which induces GVL effects, and subsequent donor hematopoietic stem cell transplantation.

Mutations in the reverse transcriptase component of telomerase (TERT) in patients with bone marrow failure

Human telomerase has two core components, the RNA molecule (TERC) that provides the template for telomere repeat elongation and a reverse transcriptase (TERT) that is responsible for the addition of telomere repeats at the ends of each chromosome. Mutations in TERC have been found in the autosomal-dominant form of the inherited bone marrow failure syndrome dyskeratosis congenita and in a subset of patients with aplastic anemia and myelodysplasia. These patients have short telomeres compared to age-matched controls. These observations suggest that uncharacterised cases of dyskeratosis congenita/aplastic anemia may have mutations in TERT or other molecules that associate with TERC in the telomerase complex. We have therefore screened the TERT gene for mutation by denaturing HPLC in 80 patients with inherited and acquired bone marrow failure (24 with dyskeratosis congenita, 36 with constitutional aplastic anemia, 13 with idiopathic aplastic anemia and 7 with other forms of bone marrow failure). 15 different TERT mutations have been identified. Of these, 5 are in flanking intron sequences, 6 are synonymous and 4 are non-synonymous (missense) substitutions in the coding sequence. These are the first natural mutations of TERT to be described and we highlight their possible pathogenic role in the development of bone marrow failure.

Granulomatous reactions cause symptoms or clinically imitate treatment resistance in small lymphocytic lymphoma/chronic lymphocytic leukaemia more frequently than in other non-Hodgkin lymphomas

AIMS

The electronic database of the institute of pathology, Medical University of Innsbruck, was reviewed and patient histories studied to analyse systematically the coincidence of granulomatous reactions and lymphomas in a large patient collective, and to find distinct clinicopathological correlations. Five cases of small lymphocytic lymphoma/chronic lymphocytic leukaemia (CLL) associated with granulomatous reactions in lymph nodes and bone marrow were identified, all clinically associated with signs of progressive disease.

METHODS

Cases were acquired by reviewing an electronic database comprising approximately 715,000 patients diagnosed between 1993 and 2003. Histochemical, immunohistochemical, and molecular techniques were used to verify diagnosis and associated infectious diseases. Clinical data were obtained from reviewing the charts.

RESULTS

Of 2044 bone marrow and 411 lymph node non-Hodgkin lymphoma biopsy samples, CLL was most frequently associated with bone marrow (two cases) and lymph node granulomas (three cases). These granulomas were mostly composed of epithelioid cells, with or without giant cells, and in all but one case did not show necrosis. All patients with CLL had clinical symptoms primarily caused by the granulomatous disease: two suffered from acid fast bacilli infections (Mycobacterium tuberculosis and mycobacteria other than tuberculosis) and three presented with clinical manifestations of sarcoidosis (the reason a diagnostic biopsy was performed).

CONCLUSIONS

Granulomatous reactions in patients with CLL might obscure diagnosis and imitate disease progression and Richter's transformation. Careful histological examination, exclusion of infectious agents, and a detailed clinical history are essential for correct diagnosis.

Interferon-gamma-induced gene expression in CD34 cells: identification of pathologic cytokine-specific signature profiles

Hematopoietic effects of interferon-gamma (IFN-gamma) may be responsible for certain aspects of the pathology seen in bone marrow failure syndromes, including aplastic anemia (AA), paroxysmal nocturnal hemoglobinuria (PNH), and some forms of myelodysplasia (MDS). Overexpression of and hematopoietic inhibition by IFN-gamma has been observed in all of these conditions. In vitro, IFN-gamma exhibits strong inhibitory effects on hematopoietic progenitor and stem cells. Previously, we have studied the transcriptome of CD34 cells derived from patients with bone marrow failure syndromes and identified characteristic molecular signatures common to some of these conditions. In this report, we have investigated genome-wide expression patterns after exposure of CD34 and bone marrow stroma cells derived from normal bone marrow to IFN-gamma in vitro and have detected profound changes in the transcription profile. Some of these changes were concordant in both stroma and CD34 cells, whereas others were specific to CD34 cells. In general, our results were in agreement with the previously described function of IFN-gamma in CD34 cells involving activation of apoptotic pathways and immune response genes. Comparison between the IFN-gamma transcriptome in normal CD34 cells and changes previously detected in CD34 cells from AA and PNH patients reveals the presence of many similarities that may reflect molecular signature of in vivo IFN-gamma exposure.

Bone marrow abnormalities in HIV disease

Bone marrow abnormalities are frequently observed in HIV infected individuals at all stages of the disease. The most common abnormal finding is dysplasia affecting one or more cell lines. Erythroid dysplasia is the most common type of dysplasia and is recognized in over 50% of HIV infected patients, abnormal granulocytic and megakaryocytic development is encountered in one-third of patients. Plasma cells are strikingly increased in bone marrow of HIV infected patients. It may represent a physiological response to antigenic stimulation by viruses, other infective agents or secondary to dysregulated B-cell proliferation due to HIV. Herein we present a review discussing the various bone marrow abnormalities associated with the HIV disease.

Fatty marrow conversion of the proximal femoral metaphysis in transient bone marrow edema syndrome

INTRODUCTION

In the proximal femoral metaphysis, hematopoietic marrow is predominant during the adult stage of life. The conversion of hematopoietic marrow to fatty marrow in the proximal femoral metaphysis has been suggested as an etiologic factor of ischemia in the pathogenesis of femoral head osteonecrosis. To determine whether the chronology of fatty marrow conversion of the proximal femoral metaphysis is related to transient bone marrow edema syndrome of the hip, a case control study was conducted on 10 patients with the disease.

MATERIALS AND METHODS

There were 8 men and 2 women with a mean age of 33 years (range 19-45 years). The 10 patients were matched with 20 controls for gender and age (5-year range). T1-weighted MRI scans of their hips were reviewed. Marrow of the greater trochanter becomes fatty before puberty, and thus, the greater trochanter can be used as a built-in control. The signal intensity of the proximal femoral metaphysis was compared to that of the greater trochanter.

RESULTS

In all patients, the signal intensity of the proximal femoral metaphysis was isointense (fatty marrow) relative to that of the greater trochanter. In control subjects, the signal intensity was isointense in 8 (40%) and hypointense (hematopoietic marrow) in 12 (60%) (p < 0.05).

CONCLUSION

The current study shows that the proximal femoral metaphysis is predominantly fatty in transient bone marrow edema syndrome. The conversion of hematopoietic to fatty marrow is known to correlate with decreases in intramedullary blood flow. Thus, the current study suggests that an ischemia of the proximal femur secondary to fatty marrow conversion of the proximal femoral metaphysis might be a cause of transient bone marrow edema syndrome of the hip.

Bone marrow necrosis in dogs: 34 cases (1996-2004)

OBJECTIVE

To identify the incidence, potential causes, and clinical and clinicopathologic features of bone marrow necrosis in dogs.

DESIGN

Retrospective study.

ANIMALS

34 client-owned dogs.

PROCEDURES

Reports of cytologic examinations of bone marrow specimens performed between 1996 and 2004 were reviewed. All reports that indicated the presence of necrosis, stromal disruption, phagocytic macrophages, individual cell necrosis, or myelofibrosis were evaluated further.

RESULTS

Of 609 reports of bone marrow evaluations performed during the study period, 34 (5.6%) had evidence of bone marrow necrosis. Nine dogs had no evidence of associated diseases or drug or toxin exposure, and 25 dogs had associated disease conditions or drug exposures. All 9 dogs with idiopathic bone marrow necrosis were anemic (mean Hct, 14%), but only 3 had neutropenia, and 3 had thrombocytopenia. All 9 had myelofibrosis. Of the 25 dogs with associated disease conditions or drug exposures, only 14 (56%) had anemia (mean Hct, 33%). In addition, 14 (56%) had neutropenia and 18 (72%) had thrombocytopenia. Only 10 (40%) had myelofibrosis.

CONCLUSIONS AND CLINICAL RELEVANCE

Results suggest that bone marrow necrosis may be common in dogs with hematologic disorders. In most dogs, bone marrow necrosis was associated with an underlying disease condition or drug exposure, but idiopathic bone marrow necrosis was also identified. Disease conditions that should increase suspicion of possible bone marrow necrosis include sepsis, lymphosarcoma, and systemic lupus erythematosus; drug exposures that should increase suspicion of possible bone marrow necrosis include chemotherapeutic agents, phenobarbital, carprofen, metronidazole, and mitotane.

Cuboid oedema due to peroneus longus tendinopathy: a report of four cases

OBJECTIVE

To highlight focal bone abnormality in the cuboid due to tendinopathy of the adjacent peroneus longus.

DESIGN

A retrospective review was carried out of the relevant clinical and imaging features.

PATIENTS

Two male and two female patients were studied, mean age 51.5 years (range 32-67 years), referred with foot pain and imaging showing an abnormal cuboid thought to represent either tumour or infection.

RESULTS

A long history of foot pain was usual with a maximum of 8 years. Radiographs were normal in two cases and showed erosion in two, one of which exhibited periosteal new bone formation affecting the cuboid. Bone scintigraphy was undertaken in two patients, both of whom showed increased uptake of isotope. MRI, performed in all patients, showed oedema in the cuboid adjacent to the peroneus longus tendon. The tendon and/or paratendinous tissues were abnormal in all cases, but no tendon discontinuity was identified. One patient possessed an os peroneum. Unequivocal evidence of bone erosion was seen using MRI in three patients, but with greater clarity in two cases using CT. Additional findings of tenosynovitis of tibialis posterior, oedema in the adjacent medial malleolus and synovitis of multiple joints in the foot were seen in one patient. Imaging diagnosis was made in all cases avoiding bone biopsy, but surgical exploration of the peroneal tendons was performed in two cases and biopsy of ankle synovium in one.

CONCLUSIONS

Oedema with erosion of the cuboid bone, simulating a bone lesion (cuboid "pseudotumour"), may be caused by adjacent tendinopathy of peroneus longus. It is vital to be aware of this entity to avoid unnecessary biopsy of the cuboid.

Adrenergic modulation of erythropoiesis following severe injury is mediated through bone marrow stroma

BACKGROUND

Severe trauma leads to hematopoietic failure and bone marrow (BM) dysfunction that manifests clinically as a persistent anemia and leukopenia. The impact of severe trauma and its associated hyperadrenergic state on erythropoiesis has not been described. The aim of this study was to demonstrate the effects of adrenergic agonists and antagonists on erythropoiesis, both in normal bone marrow mononuclear cells (BMNC) and stroma-depleted BM.

METHODS

Urine epinephrine (EPI) and norepinephrine (NE) excretion from severely injured patients was assessed via enzyme-linked immunoadsorbent assay (ELISA). Erythropoiesis was assessed by the growth of erythroid progenitors-erythroid burst forming units and colony forming units (BFU-E and CFU-E)-in normal human BM in the presence of adrenergic agonists and antagonists at varying concentrations. Parallel cultures, depleted of BM stroma by passage through nylon wool columns, were compared.

RESULTS

Urine NE excretion was elevated in all samples from days 1 to 10 following injury (average 139 +/- 59 mcg/day vs. control 35 +/- 9 mcg/day). In vitro doses of NE, EPI, and isoproterenol (ISO) exerted a stimulatory effect on BFU-E colony growth in BMNCs (expressed as percentage of control: 324 +/- 30, 272 +/- 16, 212 +/- 95, vs. 100%), but had no effect on stroma-depleted BM.

CONCLUSIONS

There is a substantial and persistent hyperadrenergic state seen after severe injury that may last for up to a week. Adrenergic agonists have a clear stimulatory effect on the growth of primitive erythroid precursors in normal BM. The adrenergic stimulus appears to be mediated via BM stroma.

MRI-controlled analysis of 104 patients with painful bone marrow edema in different joint localizations treated with the prostacyclin analogue iloprost

BACKGROUND

Bone marrow edema (BME) is a common cause of pain of the musculoskeletal system. The aim of the study was to assess the efficacy of iloprost in the treatment of BME of different localizations and etiologies.

PATIENTS AND METHODS

We reviewed 104 patients (54 male, 50 female) with BME. Their mean age was 52.8 +/- 14.7 years. BME was located 50 times in the knee, 19 times in the talus, 18 times in the femoral head and 17 times in other bones. Patients were allocated to three distinct etiological groups: 27 cases were estimated to have idiopathic BME, 16 post-traumatic BME and the other 61 BME secondary to activated osteoarthritis or mechanical stress. Therapy consisted of a series of five iloprost infusions with either 20, 25 or 50 microg of iloprost given over 6 hours on 5 consecutive days each.

RESULTS

At the clinical follow-up four months after therapy, the pain level of the 104 patients at rest had diminished by a mean of 73% (p<0.0001): 64% of patients reported a reduction, 34% no change and 2% an increase in pain at rest. Pain under stress decreased by a mean of 59%, (p<0.0001): 76% of patients had less pain during activity, 22% no change from baseline and 2% an increased pain level. On MRI, 65% had significant reduction of BME size or complete normalization and 20% showed no change. Worsening of the MRI pattern was found in 2%. 13% were lost to MRI follow-up. Side effects were significantly reduced by lowering the daily dose from 50 to 20 microg, without impairment of therapeutic effect.

CONCLUSION

The authors conclude that the use of parenteral iloprost might be a viable method in the treatment of BME of different etiologies.

Bone involvement in sickle cell disease

Bone involvement is the commonest clinical manifestation of sickle cell disease both in the acute setting such as painful vaso-occlusive crises, and as a source of chronic, progressive disability such as avascular necrosis. Management of these problems is often difficult because of the diagnostic imprecision of most laboratory and imaging investigations and because of the lack of evidence for most surgical procedures in sickle cell disease. This review first discusses the acute problems related to bone involvement in sickle cell disease, with particular reference to differentiating infection from infarction, and then describes the long-term effects of sickle cell disease on bone mineral density, growth, and chronic bone and joint damage.

Animal models for acquired bone marrow failure syndromes

Bone marrow failure is a disease characterized by a drastic decline in the marrow's functional ability to produce mature blood cells. Aplastic anemia, a disease in which patients have essentially empty bone marrow accompanied by severe anemia, neutropenia, and thrombocytopenia, presents a paradigm for bone marrow failure. Damage to the marrow may first result from exposure to toxic chemicals, drug overdose, radiation, and viral infection; however, it is the extended immune-mediated reaction that causes massive destruction of hematopoietic cells and leads to marrow hypoplasia and peripheral pancytopenia. In recent years, animal models of acquired bone marrow failure syndromes have helped to strengthen our understanding of the mechanisms causing bone marrow failure. In this review, animal models for bone marrow failure are summarized by two groups: 1) bone marrow failure induced by toxic chemicals and drugs such as benzene, busulfan, and chloramphenicol, and radiation, and 2) models developed by an immune-related mechanism such as viral infection or foreign lymphocyte infusion.

Prediction of myelotoxicity based on bone marrow radiation-absorbed dose: radioimmunotherapy studies using 90Y- and 177Lu-labeled J591 antibodies specific for prostate-specific membrane antigen

In radioimmunotherapy, myelotoxicity due to bone marrow radiation-absorbed dose is the predominant factor and frequently is the dose-limiting factor that determines the maximum tolerated dose (MTD). With (90)Y- and (131)I-labeled monoclonal antibodies, it has been reported that myelotoxicity cannot be predicted on the basis of the amount of radioactive dose administered or the bone marrow radiation-absorbed dose (BMrad), estimated using blood radioactivity concentration. As part of a phase I dose-escalation study in patients with prostate cancer with (90)Y-DOTA-J591 (DOTA = 1,4,7,10-tetraazacyclododecane-N,N',N'',N'''-tetraacetic acid) ((90)Y-J591) and (177)Lu-DOTA-J591 ((177)Lu-J591), we evaluated the potential value of several factors in predicting myelotoxicity.

METHODS

Seven groups of patients (n = 28) received 370-2,775 MBq/m(2) (10-75 mCi/m(2)) of (177)Lu-J591 and 5 groups of patients (n = 27) received 185-740 MBq (5-20 mCi/m(2)) of (90)Y-J591. Pharmacokinetics and imaging studies were performed for 1-2 wk after (177)Lu treatment, whereas patients receiving (90)Y had these studies performed with (111)In-DOTA-J591 ((111)In-J591) as a surrogate. The BMrad was estimated based on blood radioactivity concentration. Myelotoxicity consisting of thrombocytopenia or neutropenia was graded 1-4 based on criteria of the National Cancer Institute.

RESULTS

Blood pharmacokinetics are similar for both tracers. The radiation dose (mGy/MBq) to the bone marrow was 3 times higher with (90)Y (0.91 +/- 0.43) compared with that with (177)Lu (0.32 +/- 0.10). The MTD was 647.5 MBq/m(2) with (90)Y-J591 and 2,590 MBq/m(2) with (177)Lu-J591. The percentage of patients with myelotoxicity (grade 3-4) increased with increasing doses of (90)Y (r = 0.91) or (177)Lu (r = 0.92). There was a better correlation between the radioactive dose administered and the BMrad with (177)Lu (r = 0.91) compared with that with (90)Y (r = 0.75). In addition, with (177)Lu, the fractional decrease in platelets (FDP) correlates well with both the radioactive dose administered (r = 0.88) and the BMrad (r = 0.86). In contrast, with (90)Y, there was poor correlation between the FDP and the radioactive dose administered (r = 0.20) or the BMrad (r = 0.26). Similar results were also observed with white blood cell toxicity.

CONCLUSION

In patients with prostate cancer, myelotoxicity after treatment with (177)Lu-J591 can be predicted on the basis of the amount of radioactive dose administered or the BMrad. The lack of correlation between myelotoxicity and (90)Y-J591 BMrad may be due to several factors. (90)Y-J591 may be less stable in vivo and, as a result, higher amounts of free (90)Y may be localized in the bone. In addition, the cross-fire effect of high-energy beta(-)-particles within the bone and the marrow may deliver radiation dose nonuniformly within the marrow.

The management of necrosis-associated and idiopathic bone-marrow oedema of the proximal femur by intravenous iloprost

Bone-marrow oedema can occur both in isolation and in association with necrosis of bone, but it has not been shown whether each respond to the same methods of treatment.

We treated 16 patients with isolated oedema and 17, in which it was associated with necrosis of the proximal femur, with the prostacyclin derivative iloprost, which has been shown to be effective in the idiopathic form. The Harris hip score, the range of movement, the extent of the oedema as measured by MRI, pain on a visual analogue scale and patient satisfaction were recorded before and subsequent to treatment.

In both groups, we were able to show a significant improvement (p < 0.001) in these observations during the period of follow-up indicating that iloprost will produce clinical improvement in both circumstances.

Magnetic resonance appearance of bone marrow edema associated with hydroxyapatite deposition disease without cortical erosion

The authors report the magnetic resonance (MR) appearance of bone marrow edema associated with hydroxyapatite deposition disease without cortical erosion. Hydroxyapatite deposition disease may have bone marrow edema on MR imaging without radiographic evidence of cortical erosion, mimicking the appearance of fracture, neoplasm, or infection. Awareness of this association can prevent unnecessary additional imaging evaluation or biopsy.

Study of bone marrow abnormalities in patients with HIV disease

AIM

Present work was carried out to study the bone marrow abnormalities in patients with HIV/AIDS and to find their association with peripheral hematological abnormalities.

METHODS

Seventy four patients of HIV/AIDS were included in the study. The patients had anemia, leucopenia, thrombocytopenia or pyrexia of unknown origin (PUO) as indications for bone marrow examination. A complete blood count, relevant biochemical investigations, HIV RNA load and CD4 positive lymphocyte counts were done, besides a thorough history and clinical examination. HIV positive patients were classified as those having AIDS and those without AIDS according to NACO criteria.

RESULTS

Majority of patients (72.9%) had AIDS. Bone marrow was normocellular in 78.95% of non-AIDS and 74.55% of AIDS, hypocellular in 5.26% of non-AIDS and 7.27% of AIDS, hypercellular in 15.79% of non-AIDS and 18.18 % of AIDS patients. Myelodysplasia was present in 21.05% of non AIDS and 36.46% of AIDS and the most common series affected was granulocytic (15.79% of total in non-AIDS and 30.9% in AIDS). Dysplasia was statistically significantly associated with lower CD4 count (p = 0.031) and anemia (p = 0.013). Myelodysplasia was apparent even before patients developed anemia (16.67%). Increased plasma cells in bone marrow were observed in 57.89% of non-AIDS and 65.45% of AIDS, whereas decreased lymphoid cells were seen in 36.84% of non AIDS and 60.00% of AIDS patients.

CONCLUSIONS

Myelodysplasia is found in 32.43% of cases of HIV/AIDS and is more common in AIDS than in non AIDS patients. Granulocytic series is most commonly associated with evidence of dysplasia. Myelodysplasia is more common in patients with CD4 count < 200/microl and in patients with anemia. 54.05% of patients had decreased lymphoid cells in bone marrow and it was more commonly seen in AIDS than in non AIDS.

Granulomas in bone marrow--a study of fourteen cases

Granulomas in bone marrow are an infrequent finding and several diseases are associated with granuloma formation. Clinicopathological details of fourteen cases showing granulomas in bone marrow were studied. Fever was the commonest clinical presentation and anaemia was seen in all cases. Only one case showed epithelioid cells in the bone marrow aspirate smear while trephine biopsy was diagnostic in all cases. Granulomas were seen mainly in the paratrabecular space. Acid fast bacilli were demonstrated in five biopsies and serological test for Human Immunodeficiency virus was positive in five cases. Tuberculosis was more common in the present study as compared to others, probably due to the endemicity of tuberculosis in this region. Bone marrow biopsy is useful in the investigation of pyrexia of unknown origin as it leads to an aetiological diagnosis in most cases.

[Minor bcr/abl positive acute lymphoblastic leukemia preceded by knee joint pain due to bone marrow necrosis]

A 16-year-old male was referred to our hospital in April 2003 due to severe knee joint pain from five months previously. Lymphoblasts were identified in his peripheral blood, resulting in a diagnosis of acute lymphoblastic leukemia (ALL). Bone marrow examination revealed massive necrosis with clusters of lymphoblasts and the bcr/abl fusion gene. Magnetic resonance imaging (MRI) of the knee joint showed low signal intensity on T1-weighted images, and peripheral rim enhancement on Gd-DTPA enhanced fat suppression images, which was compatible with bone marrow necrosis. After the patient achieved complete remission (CR), the knee joint pain has disappeared. He was treated with an allogeneic bone marrow transplantation (BMT) from an HLA-identical unrelated donor and has been in CR for 26 months after the diagnosis of ALL. In the knee joint, the replacement of fatty marrow after BMT has been confirmed with MRI. Hematological malignancies including ALL should be considered in the cases of bone marrow necrosis and adequate treatment may improve necrosis.

Bone Marrow Oedema and Aseptic Osteonecrosis in Children and Adolescents with Acute Lymphoblastic Leukaemia or Non-Hodgkin-Lymphoma Treated with Hyperbaric-Oxygen-Therapy (HBO): An Approach to Cure?

BACKGROUND

There is a striking need for additional therapies of bone marrow oedema (BME) and aseptic osteonecrosis (AON) in paediatric oncology patients. Hyperbaric oxygenation (HBO) therapy used in the treatment of osteoradionecrosis is demonstrated effectiveness. Aim of this retrospective analysis was to investigate whether HBO-therapy might lead to subjective as well as objective effects in the treatment of BME and/or AON in paediatric oncology patients with acute lymphoblastic leukaemia (ALL) or Non-Hodgkin lymphoma (NHL).

PATIENTS AND METHODS

Between 11/1988 and 01/2001 27/291 (9.3 %) patients with ALL or NHL were diagnosed with a BME and/or AON in the Clinic for Paediatric Oncology, Haematology, and Immunology at University of Dusseldorf. 19/27 patients were submitted to HBO-therapy. Patients received average 45 HBO-treatments per patient (min. 13, max. 80 treatments). The affected regions were re-evaluated with MRI for radiological extent of lesions every 3 months. Pain in its intensity and localisation was serially recorded during HBO-therapy as key symptom in 11 of 19 patients.

RESULTS

27 patients (15 females, 12 males; mean age at diagnosis of malignancy 8.2 +/- 4.7 (SD) years, range 7 months to 16 years) presented with 138 lesions. 133/138 lesions were localised in the lower extremities. At diagnosis of BME and/or AON, 78/133 lesions were shown in females and 55/133 lesions in male. Girls < 10 years predominantly presented BME (33 BME vs. 6 AON), girls aged > 10 years predominantly offered AON (28 AON vs. 11 BME). BME was more often exhibited in boys < 10 years (34 BME vs. 10 AON) and rarely in boys > 10 years (4 BME vs. 6 AON). 11 patients treated with HBO-therapy were serially evaluated for pain intensity throughout their HBO-therapy courses by visual analogue scale (VAS) assessment. During the first 15 treatment courses the HBO-therapy a clear-cut reduction of pain was observed. The mean pain score before the first HBO-treatment unit was 2.4 +/- 2.7 (X +/- SD), decreased before the fifth to 1.6 +/- 1.7 and prior to the 35 (th) and 40 (th) HBO treatment to 0. Girls < 10 years treated with HBO showed an increase of BME (31 --> 46) and declining AON numbers (6 --> 2). Girls > 10 years with and without HBO-therapy showed decrease of BME lesions (7 --> 4 vs. 4 --> 0), whereas AON increased in the HBO-treated group (28 --> 29) as well as the non-treated group (0 --> 4). Males < 10 years showed an increase in BME lesion numbers despite HBO intervention (24 --> 26). The AON lesion numbers dropped in parallel (6 --> 3). Male patients not treated with HBO showed constant numbers of BME (11-->11) and a decreased numbers of AON (4 --> 2). All differences are statistically not significant.

CONCLUSIONS

Children and adolescents diagnosed with ALL or NHL have a risk for accruement of BME and/or AON irrespective of the age, with an almost exclusive involvement of the lower extremities. Lesions of pedal bones and ankle joints predominantly affect children < 10 years. Lesions of knee and hip joints predominantly affect children > 10 years. In children < 10 years of age we demonstrate declining AON numbers and conversion of AON to BME thereby implicating possible beneficial effect of HBO in such patients. HBO failed to show beneficial effect on BME whether by preventing new lesions or by improving existent lesions in children > 10 years.