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Reilly JT, McMullin MF, Beer PA, Butt N, Conneally E, Duncombe A, Green AR, Michaeel NG, Gilleece MH, Hall GW, Knapper S, Mead A, Mesa RA, Sekhar M, Wilkins B, Harrison CN. Guideline for the diagnosis and management of myelofibrosis. Br J Haematol 2012; 158:453-71. [DOI: 10.1111/j.1365-2141.2012.09179.x] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2012] [Accepted: 05/02/2012] [Indexed: 01/09/2023]
Affiliation(s)
- John T. Reilly
- Sheffield Teaching Hospitals NHS Foundation Trust; Sheffield; UK
| | | | - Philip A. Beer
- Terry Fox Laboratory; BC Cancer Agency; Vancouver; BC; Canada
| | - Nauman Butt
- Wirral University Teaching Hospital; Wirral; UK
| | | | - Andrew Duncombe
- University Hospital Southampton NHS Foundation Trust; Southampton; UK
| | | | | | | | | | | | - Adam Mead
- Oxford University Hospitals NHS Trust; Oxford; UK
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Zherebitskiy V, Morales C, Del Bigio MR. Extramedullary hematopoiesis involving the central nervous system and surrounding structures. Hum Pathol 2011; 42:1524-30. [DOI: 10.1016/j.humpath.2011.01.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2010] [Revised: 01/17/2011] [Accepted: 01/21/2011] [Indexed: 11/26/2022]
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Abstract
Extramedullary hematopoiesis (EMH), defined as the presence of hematopoiesis outside bone marrow and peripheral blood, occurs asa compensatory phenomenon in several hematologic disorders and bone marrow dysfunction. EMH predominantly affects reticuloendothelial system including the spleen, liver and lymph nodes. Here,we report a rare case of multiple intracranial meningeal EMH. A37-year-old woman was anemic with gradually worsening vision for 8 months. Multiple extra-axial masses were found on imaging and the patient underwent the biopsy for the left frontotemporal lesion.Final diagnosis was multiple intracranial meningeal EMH. Treatment of fractionated external beam radiotherapy resulted in marked symptomatic improvement. This case indicates that although the diagnosis of meningeal EMH is difficult, there is a need to consider EMHin the differential diagnosis of anemic patients with tumor-like mass lesions in extramedullary sites.
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Affiliation(s)
- Wen-Xia Jiang
- Department of Pathology, Tongji University School of Medicine, Shanghai, China
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Seddighi AS, Seddighi A. Extramedullary hematopoiesis presenting as a compressive cord and cerebral lesion in a patient without a significant hematologic disorder: a case report. J Med Case Rep 2010; 4:319. [PMID: 20939863 PMCID: PMC2972301 DOI: 10.1186/1752-1947-4-319] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2009] [Accepted: 10/12/2010] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Intracranial or spinal compressive lesions due to extramedullary hematopoiesis have been reported in the medical literature. Most of the reported cases are extradural lesions or, on rare occasions, foci within another neoplasm such as hemangioblastoma, meningioma or pilocytic astrocytoma. Often these cases occur in patients with an underlying hematological disorder such as acute myelogenic leukemia, myelofibrosis, or other myelodysplastic syndromes. Such lesions have also been reported in thalassemia major. CASE PRESENTATION We report the case of a 43-year-old Iranian woman in whom extramedullary hematopoiesis presented as a compressive cord lesion and then later as an intracranial lesion. CONCLUSIONS To the best of our knowledge, we document the first reported case of sacral, lumbar, thoracic and cranial involvement in the same patient with extramedullary hematopoiesis, which seems both rare and remarkable.
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Affiliation(s)
- Amir Saied Seddighi
- Shohada Tajrish Hospital, Beheshti University of Medical Sciences, Tehran, Iran.
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5
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Meningeal extramedullary haematopoiesis mimicking subdural hematoma. J Clin Neurosci 2008; 15:208-10. [PMID: 18068988 DOI: 10.1016/j.jocn.2006.06.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2006] [Revised: 06/21/2006] [Accepted: 06/25/2006] [Indexed: 11/21/2022]
Abstract
Extramedullary haematopoiesis is a compensatory phenomenon in diseases where erythrocyte production is diminished or destruction is accelerated. The authors describe a rare case of meningeal extramedullary haematopoiesis mimicking subdural hematoma. CT scan revealed a hyperdense subdural lesion at the right frontal region following head injury. The patient was operated on and the pathological examination of the subdural lesion showed extramedullary haematopoiesis.
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Almoznino-Sarafian D, Dotan E, Sandbank J, Gorelik O, Chachashvily S, Shteinshnaider M, Cohen N. Unusual manifestations of myelofibrosis in a patient with congenital asplenia. Acta Haematol 2007; 118:226-30. [PMID: 18073460 DOI: 10.1159/000112308] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2007] [Accepted: 07/18/2007] [Indexed: 11/19/2022]
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Zona G, Spena G, Sbaffi PF, Spaziante R. A meningioma with islets of extramedullary myeloid metaplasia: case report. Neurosurgery 2007; 61:E418-9; discussion E419. [PMID: 17762725 DOI: 10.1227/01.neu.0000255520.04462.5a] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE Idiopathic myelofibrosis is a clonal stem cell disorder that leads to ineffective erythropoiesis accompanied by reactive myelofibrosis (bone marrow fibrosis). As a consequence, extramedullary hematopoiesis characteristically develops. The central nervous system is rarely affected; the spinal canal and the cranial meninges are generally the preferred locations. Extramedullary hematopoiesis within central nervous system primary tumors have already been reported but, to our knowledge, never before in a patient with evidence of idiopathic myelofibrosis. CLINICAL PRESENTATION A patient experiencing generalized idiopathic myelofibrosis developed a hemorrhagic intracranial meningioma containing islets of extramedullary myeloid metaplasia. INTERVENTION The tumor was radically removed through a right frontal craniotomy. After surgery, the patient recovered completely and was discharged with a normal neurological status. After 6 years, the patient is in excellent condition with no sign of recurrence on magnetic resonance imaging scans. CONCLUSION The reasons for this uncommon association are uncertain, but we hypothesize that myeloid islets may be involved in the origin of the tumor as well as in its acute hemorrhagic onset. Moreover, we suggest that in the presence of proven idiopathic myelofibrosis intracranial myeloid metaplasia should be ruled out by appropriate neuroimaging and considered as a potential diagnosis in the presence of brain lesions.
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Affiliation(s)
- Gianluigi Zona
- Department of Neurosurgery, San Martino University Hospital, Genoa, Italy.
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Kaya H, Cerci SS. Tc-99m nanocolloid scintigraphic imaging of intracranial meningeal extramedullary hematopoiesis in a patient with idiopathic myelofibrosis. Ann Nucl Med 2006; 20:565-8. [PMID: 17134026 DOI: 10.1007/bf03026823] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Meningeal extramedullary hematopoiesis (EMH) is a rare finding in idiopathic myelofibrosis. Intracranial EMH is typically asymptomatic and sites are usually found by chance. Diagnosis of EMH is difficult, based on clinical circumstances and the use of different diagnostic imaging modalities, such as CT, MRI or radionuclide imaging. We present a case with intracranial medullary hematopoiesis due to idiopathic myelofibrosis diagnosed with Tc-99m nanocolloid scintigraphy. Cranium SPECT images that were performed with Tc-99m nanocolloid showed increased radiotracer uptake in the bilateral parietal, bilateral frontal and left occipital bones and especially in falx cerebri of sinus sagittalis superior. In Tc-99m MDP bone scintigraphy, increased osteoblastic activity in the left frontal and parietal bones, in shoulders, knee and ankle joints, and in both metatarsal bones were seen. After gadodiamid injection, Tl weighted MRI showed diffuse contrast increased in the meningeal areas surrounding the brain. A biopsy of the mass revealed extramedullary hematopoiesis composed of erythroblasts, mature and immature myeloid cells, and megakaryocytes. It was deduced that these described foci of EMH.
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Affiliation(s)
- Halil Kaya
- Department of Nuclear Medicine, Dicle University, School of Medicine, Diyarbakir, Turkey
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Abstract
Idiopathic myelofibrosis (IMF) is the least common of the chronic myeloproliferative disorders and carries the worst prognosis with a median survival of 4 years. It is a clonal haematopoietic stem-cell disorder and, although the pathogenesis remains unclear, approximately 50% of cases are known to possess an activating JAK2 V617F mutation. In contrast, the characteristic stromal proliferation is a reactive, or secondary, event that results from the aberrant release of a variety of growth factors from megakaryocytes and monocytes. Treatment for most cases is supportive, although androgens, recombinant erythropoietin, steroids and thalidomide are effective modalities for the amelioration of anaemia. Myelosuppression, splenectomy and irradiation are valuable therapeutic modalities for specific clinical situations. Prognostic scores are available to aid the identification of cases for whom bone marrow transplantation should be considered. Recently, the use of reduced intensity conditioning has resulted in prolonged survival and lower transplant-related mortality. This review summarises the recent advances in the disease's pathogenesis and discusses the role of the various therapeutic options.
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Affiliation(s)
- John T Reilly
- Academic Unit of Haematology, Division of Genomic Medicine, Royal Hallamshire Hospital, Sheffield, UK.
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Haidar S, Ortiz-Neira C, Shroff M, Gilday D, Blaser S. Intracranial involvement in extramedullary hematopoiesis: case report and review of the literature. Pediatr Radiol 2005; 35:630-4. [PMID: 15580341 DOI: 10.1007/s00247-004-1361-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2004] [Revised: 09/02/2004] [Accepted: 10/04/2004] [Indexed: 10/26/2022]
Abstract
Intracranial involvement in extramedullary hematopoiesis (EMH) is rare, but it should be suspected in patients with myelofibrosis presenting with chronic severe headache. We present a 9-year-old girl with known myelofibrosis whose headaches were unresponsive to routine treatment. CT and MRI studies of the brain showed diffuse pachymeningeal thickening. CT examinations of the chest and abdomen had demonstrated bilateral thoracic paraspinal masses caused by EMH, suggesting the possibility that the intracranial involvement might also be related to EMH. The diagnosis was confirmed by sulfur colloid isotope scan.
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Affiliation(s)
- Salwa Haidar
- Department of Diagnostic Imaging, Hospital for Sick Children, 555 University Avenue, Toronto, ON M5G 1X8, Canada.
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Ayyildiz O, Isikdogan A, Celik M, Muftuoglu E. Intracranial meningeal extramedullary hematopoiesis inducing serious headache in a patient with idiopathic myelofibrosis. J Pediatr Hematol Oncol 2004; 26:28-9. [PMID: 14707708 DOI: 10.1097/00043426-200401000-00009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Beckner ME, Lee JYK, Schochet SS, Chu CT. Intracranial extramedullary hematopoiesis associated with pilocytic astrocytoma: a case report. Acta Neuropathol 2003; 106:584-7. [PMID: 14520481 DOI: 10.1007/s00401-003-0767-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2003] [Revised: 08/04/2003] [Accepted: 08/04/2003] [Indexed: 10/26/2022]
Abstract
Intracranial EMH is only occasionally found in primary brain tumors (mostly hemangioblastomas) and, to our knowledge, this is the first case of EMH associated with an astrocytoma. Intracranial extramedullary hematopoiesis (EMH) is described in a 29-year-old man with a recurrent pilocytic astrocytoma in the tectal region. Special stains confirmed the identities of erythroid, myeloid and megakaryocytic cells. The patient had no evidence of a predisposing bone marrow disorder or systemic EMH. Although the presence of multinucleated and blastic cells associated with a low-grade brain neoplasm is unusual, recognition of hematopoietic lineages allows EMH to be readily identified. Another tumor resection after a year of follow-up confirmed the absence of malignant progression in this recurrent astrocytoma. The small number of cases describing intracranial EMH in the absence of systemic hematologic abnormalities are correlated with the findings in this case. The low incidence of intracranial EMH indicates that cells with hematopoietic potential are seldom exposed to a supportive microenvironment within the central nervous system. However, intracranial EMH should be included as a potential, ancillary diagnosis when considering brain lesions. This may be particularly true if medical therapies involving growth factors or stem cells are found to promote hematopoiesis.
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Affiliation(s)
- Marie E Beckner
- Department of Pathology, University of Pittsburgh School of Medicine, 200 Lothrop Street, Rm. A-515, Pittsburgh, PA 15213, USA.
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Koch CA, Li CY, Mesa RA, Tefferi A. Nonhepatosplenic extramedullary hematopoiesis: associated diseases, pathology, clinical course, and treatment. Mayo Clin Proc 2003; 78:1223-33. [PMID: 14531481 DOI: 10.4065/78.10.1223] [Citation(s) in RCA: 203] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To define associated clinical conditions, pathology, natural history, and treatment outcome of nonhepatosplenic extramedullary hematopoiesis (NHS-EMH). PATIENTS AND METHODS We retrospectively reviewed the medical charts of all patients identified as having NHS-EMH from 1975 to 2002. Diagnosis was made by tissue biopsy, fine-needle aspiration biopsy, or radionuclide bone marrow scanning. RESULTS We identified 27 patients with antemortem diagnosis of NHS-EMH. The most common associated condition and disease site were myelofibrosis with myeloid metaplasia (MMM) (in 18 patients [67%]) and the vertebral column (in 7 patients [26%]; all involving the thoracic region), respectively. At the time of diagnosis of NHS-EMH, concurrent splenic EMH (in 22 patients [82%]; 15 [56%] had undergone splenectomy) and red blood cell transfusion dependency (in 12 patients [44%]) were prevalent. Of the 27 patients, 9 (33%) required no specific therapy. Specific therapy was radiation (in 7 patients with a 71% response rate) and surgical excision (in 6 patients with a 67% response). Treatment-associated complications were limited to surgery. Radiation therapy was not used in the non-MMM group, but low-dose radiation therapy was used in the MMM group for paraspinal or intraspinal EMH (median dose, 1 Gy; range, 1-10 Gy), pleural or pulmonary disease (median dose, 1.25 Gy; range, 1.00-1.50 Gy), and abdominal or pelvic disease (median dose, 2.02 Gy; range, 150-4.50 Gy). Median survival after the diagnosis of NHS-EMH was 13 months in the MMM group and 21 months in the non-MMM group. CONCLUSIONS This retrospective study suggests that NHS-EMH is rare, is often associated with MMM, and preferentially affects the thoracic spinal region. Asymptomatic disease may require no specific treatment, whereas symptomatic disease is best managed with low-dose radiation therapy.
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Affiliation(s)
- Cody A Koch
- Mayo Medical School, Mayo Clinic, Rochester, Minn 55905, USA
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Pless M, Rizzo JF, Shang J. Orbital apex syndrome: a rare presentation of extramedullary hematopoiesis: case report and review of literature. J Neurooncol 2002; 57:37-40. [PMID: 12125965 DOI: 10.1023/a:1015789630250] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
We describe a case of compressive neuropathy in the orbital apex due to extramedullary hematopoiesis (EMH). A 64-year-old man with Polycythemia Rubra Vera developed unilateral visual loss, proptosis, complete ophthalmoplegia, and facial paresis. Bone marrow biopsy showed myelofibrosis. Magnetic resonance imaging demonstrated enhancement at the orbital apex and subtle optic canal narrowing. Decompression of the optic nerve with biopsy of surrounding bone showed EMH. The patient received a course of radiation without benefit. We suggest including the diagnosis of EMH of the orbital apex bones in the differential diagnosis of patients with myeloproliferative disorders who develop an orbital apex syndrome.
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Affiliation(s)
- Misha Pless
- Division of Neuro-Ophthalmology, University of Pittsburgh Medical Center, PA 15213, USA
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Mak YK, Chan CH, So CC, Chan MK, Chu YC. Idiopathic myelofibrosis with extramedullary haemopoiesis involving the urinary bladder in a Chinese lady. CLINICAL AND LABORATORY HAEMATOLOGY 2002; 24:55-9. [PMID: 11843900 DOI: 10.1046/j.1365-2257.2002.00424.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Extramedullary haemopoiesis (EMH) associated with idiopathic myelofibrosis most commonly involves the reticuloendothelial organs, such as the spleen and liver, although ectopic haemopoietic tissue has also been described rarely in the lymph nodes, skin, gastrointestinal tract, pleura, peritoneum, central nervous system, and genital and urinary tracts. We report on a 54-year-old Chinese lady with a long history of idiopathic myelofibrosis who presented with gross haematuria and left hydronephrosis due to EMH in the bladder trigone. Cystoscopic examination revealed a sessile necrotic papillary growth at the trigone, obstructing the left ureteric orifice. Transurethral resection of the bladder tumour was performed, and microscopic examination of the tumour chips demonstrated atypical megakaryocytes, immature granulocytes and normoblasts, confirming the presence of EMH. The residual bladder tumour responded well to low dose radiotherapy, with subsequent disappearance of haematuria and normalization of ultrasonogram findings.
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Affiliation(s)
- Y K Mak
- Department of Medicine, Queen Elizabeth Hospital, Kowloon, China
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Ohtsubo M, Hayashi K, Fukushima T, Chiyoda S, Takahara O. Case report: intracranial extramedullary haematopoiesis in postpolycythemic myelofibrosis. Br J Radiol 1994; 67:299-302. [PMID: 8131005 DOI: 10.1259/0007-1285-67-795-299] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Extramedullary haematopoiesis (EMH), which may occur in various types of haemodyscrasia and dyshaematopoiesis, is generally seen in the spleen, liver and lymph nodes, but rarely within the cranium. This is a case of intracranial EMH in a patient with secondary myelofibrosis which developed after the treatment of polycythaemia rubra vera.
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Affiliation(s)
- M Ohtsubo
- Department of Radiology, Japanese Red Cross Nagasaki Atomic Bomb Hospital
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Bureau N, Ethier S, Bourdon F, Schurch W. Myeloid metaplasia complicating polycythemia vera: ultrasonographic findings in the stomach. JOURNAL OF CLINICAL ULTRASOUND : JCU 1993; 21:631-635. [PMID: 8227393 DOI: 10.1002/jcu.1870210910] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Affiliation(s)
- N Bureau
- Department of Radiology, Hôtel-Dieu de Montréal, Québec, Canada
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Oesterling JE, Keating JP, Leroy AJ, Earle JD, Farrow GM, McCarthy JT, Silverstein MN. Idiopathic myelofibrosis with myeloid metaplasia involving the renal pelves, ureters and bladder. J Urol 1992; 147:1360-2. [PMID: 1569685 DOI: 10.1016/s0022-5347(17)37566-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Myeloid metaplasia associated with idiopathic myelofibrosis most commonly involves the reticuloendothelial organs, such as the spleen, liver and retroperitoneal lymph nodes. We report on a patient with myeloid metaplasia (extramedullary hematopoiesis) of the renal pelves, ureters and bladder. The pathogenesis, clinical characteristics, treatment and prognosis of this condition are discussed.
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Affiliation(s)
- J E Oesterling
- Department of Urology, Mayo Clinic, Rochester, Minnesota 55905
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Cohn SL, Cohn RA, Chou P, Donaldson JS, Langman CB. Infantile myelofibrosis with nephromegaly secondary to myeloid metaplasia. Clin Pediatr (Phila) 1991; 30:59-61. [PMID: 1995204 DOI: 10.1177/000992289103000111] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- S L Cohn
- Division of Hematology, Northwestern University Medical School, Chicago, IL
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