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Chernak BJ, Rampal RK. Extramedullary hematopoiesis in myeloproliferative neoplasms: Pathophysiology and treatment strategies. INTERNATIONAL REVIEW OF CELL AND MOLECULAR BIOLOGY 2021; 365:97-116. [PMID: 34756246 DOI: 10.1016/bs.ircmb.2021.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
Extramedullary hematopoiesis (EMH) is often a physiologic response to ineffective marrow production of hematologic cells. While this can be found incidentally in various physiologic and pathophysiologic states, the myeloproliferative neoplasms (MPNs) are some of the most common underlying conditions found in patients with EMH. Although this process can assist with hematologic production in defective states, the burden of EMH can lead to symptomatic discomfort and mechanical obstructive complications, most commonly in the spleen and liver. Here we describe the pathophysiology of EMH, treatment options, including medical, surgical and radiation-based approaches.
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Affiliation(s)
- Brian J Chernak
- Department of Leukemia, Memorial Sloan Kettering Cancer Center, New York, NY, United States; Department of Medicine, NewYork-Presbyterian Weill Cornell Medical Center, New York, NY, United States
| | - Raajit K Rampal
- Department of Leukemia, Memorial Sloan Kettering Cancer Center, New York, NY, United States.
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2
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Abstract
Mesenteries are extensions of the visceral and parietal peritoneum consisting of fat, vessels, nerves, and lymphatics. Mesenteric masses have a wide differential diagnosis with neoplastic, infectious, or inflammatory etiologies and can either be solid or cystic. Imaging features are critical for the diagnosis. We review the epidemiology, imaging spectrum, and differentiating features and treatment of mesenteric masses.
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Panda A, Chandrashekhara SH, Nambirajan A, Mishra P. Idiopathic myelofibrosis with disseminated hepatosplenic, mesenteric, renal and pulmonary extramedullary haematopoeisis, portal hypertension and tuberculosis: initial presentation and 2 years follow-up. BMJ Case Rep 2016; 2016:bcr-2016-217854. [PMID: 28011890 DOI: 10.1136/bcr-2016-217854] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 35-year-old man with a 12-year history of idiopathic myelofibrosis (IMF) presented in 2014 with fatigue and abdominal distension. CT scan revealed massive hepatosplenomegaly with focal splenic lesions, soft tissue around renal pelvis, mesenteric masses compressing bowel loops and perilymphatic nodules in lungs. There was portal hypertension, ascites, pleural effusion, bilateral psoas abscesses and necrotic retroperitoneal lymphadenopathy. MRI additionally revealed hypointense periportal infiltrative lesions in liver, not seen on CT scan. None of these lesions showed diffusion restriction. Biopsy from mesenteric masses revealed extramedullary haematopoeisis. Aspiration from psoas abscess confirmed tuberculosis. Follow-up after 6 weeks of ruxolitinib (JAK2 tyrosine kinase inhibitor) and 9 months of antitubercular therapy revealed resolution of psoas abscesses and lymph nodes. Mild reduction was noted in mesenteric masses and ascites while perirenal soft tissue had increased. Follow-up imaging after another 1 year of ruloxitinib showed new-onset bilateral paravertebral and presacral foci of extramedullary haematopoeisis.
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Affiliation(s)
- Ananya Panda
- All India Institute of Medical Science, New Delhi, India
| | | | - Aruna Nambirajan
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - Pravas Mishra
- Department of Hematology, All India Institute of Medical Science, New Delhi, India
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Appelmann I, Kreher S, Parmentier S, Wolf HH, Bisping G, Kirschner M, Bergmann F, Schilling K, Brümmendorf TH, Petrides PE, Tiede A, Matzdorff A, Griesshammer M, Riess H, Koschmieder S. Diagnosis, prevention, and management of bleeding episodes in Philadelphia-negative myeloproliferative neoplasms: recommendations by the Hemostasis Working Party of the German Society of Hematology and Medical Oncology (DGHO) and the Society of Thrombosis and Hemostasis Research (GTH). Ann Hematol 2016; 95:707-18. [PMID: 26916570 DOI: 10.1007/s00277-016-2621-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Accepted: 02/15/2016] [Indexed: 12/31/2022]
Abstract
Philadelphia-negative myeloproliferative neoplasms (Ph-negative MPN) comprise a heterogeneous group of chronic hematologic malignancies. The quality of life, morbidity, and mortality of patients with MPN are primarily affected by disease-related symptoms, thromboembolic and hemorrhagic complications, and progression to myelofibrosis and acute leukemia. Major bleeding represents a common and important complication in MPN, and the incidence of such bleeding events will become even more relevant in the future due to the increasing disease prevalence and survival of MPN patients. This review discusses the causes, differential diagnoses, prevention, and management of bleeding episodes in patients with MPN, aiming at defining updated standards of care in these often challenging situations.
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Affiliation(s)
- Iris Appelmann
- Department of Hematology, Oncology, Hemostaseology, and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University, 52074, Aachen, Germany
| | - Stephan Kreher
- Department of Hematology and Oncology, Charite Berlin, Berlin, Germany
| | - Stefani Parmentier
- Department of Hematology, Oncology, and Palliative Medicine, Rems-Murr-Klinikum Winnenden, Winnenden, Germany
| | - Hans-Heinrich Wolf
- Department of Internal Medicine IV, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Guido Bisping
- Department of Medicine I, Mathias Spital Rheine, Rheine, Germany
| | - Martin Kirschner
- Department of Hematology, Oncology, Hemostaseology, and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University, 52074, Aachen, Germany
| | - Frauke Bergmann
- Medizinisches Versorgungszentrum Wagnerstibbe, Hannover, Germany
| | - Kristina Schilling
- Department of Hematology and Oncology, University Hospital Jena, Jena, Germany
| | - Tim H Brümmendorf
- Department of Hematology, Oncology, Hemostaseology, and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University, 52074, Aachen, Germany
| | - Petro E Petrides
- Hematology Oncology Centre, Ludwig Maximilians University of Munich Medical School, Munich, Germany
| | - Andreas Tiede
- Department of Haematology, Haemostasis, Oncology and Stem-Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Axel Matzdorff
- Clinic for Internal Medicine II, Dept. of Hematology, Oncology, Asklepios Clinic Uckermark, Schwedt/Oder, Germany
| | | | - Hanno Riess
- Department of Hematology and Oncology, Charite Berlin, Berlin, Germany
| | - Steffen Koschmieder
- Department of Hematology, Oncology, Hemostaseology, and Stem Cell Transplantation, Faculty of Medicine, RWTH Aachen University, 52074, Aachen, Germany.
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Koch M, Kurian EM. Pleural fluid extramedullary hematopoiesis case report with review of the literature. Diagn Cytopathol 2015; 44:41-4. [PMID: 26592973 DOI: 10.1002/dc.23390] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2015] [Revised: 09/28/2015] [Accepted: 11/09/2015] [Indexed: 11/07/2022]
Abstract
Extramedullary hematopoiesis (EMH) is the trilineage formation of normal blood cells outside of the bone marrow. While predominantly seen in the spleen and liver, EMH rarely occurs in serous effusions. Accurate diagnosis requires recognition of megakaryocytes and other precursor hematopoietic elements. We present a case of pleural fluid EMH in a patient with primary myelofibrosis and developing leukemia, with a review of the literature, prognostic implications and diagnostic challenges.
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Affiliation(s)
- Meghan Koch
- Department of Anatomic Pathology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Elizabeth M Kurian
- Department of Anatomic Pathology, University of Texas Southwestern Medical Center, Dallas, Texas
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Henriquez-Camacho C, Martinez-Barranco P, Velasco M, Villafuerte-Gutierrez P, Losa J. Nontuberculous mycobacterial infection in a patient with myelofibrosis: case report and concise review. Clin Case Rep 2015; 3:438-41. [PMID: 26185644 PMCID: PMC4498858 DOI: 10.1002/ccr3.268] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Revised: 11/21/2014] [Accepted: 03/03/2015] [Indexed: 11/09/2022] Open
Abstract
A 70-year-old patient having massive refractory ascites in the course of idiopathic myelofibrosis was diagnosed of peritoneal extramedullary hematopoiesis and developed an overwhelming nontuberculous mycobacterial infection. The case describes this unusual infection and highlights the need for additional studies to confirm the etiology of ascites in primary myelofibrosis.
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Affiliation(s)
- Cesar Henriquez-Camacho
- Infectious Disease Section, Internal Medicine Unit, Hospital Universitario Fundacion Alcorcon Madrid, Spain
| | | | - Maria Velasco
- Infectious Disease Section, Internal Medicine Unit, Hospital Universitario Fundacion Alcorcon Madrid, Spain
| | | | - Juan Losa
- Infectious Disease Section, Internal Medicine Unit, Hospital Universitario Fundacion Alcorcon Madrid, Spain
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Murakami J, Shimizu Y. Hepatic manifestations in hematological disorders. Int J Hepatol 2013; 2013:484903. [PMID: 23606974 PMCID: PMC3626309 DOI: 10.1155/2013/484903] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2012] [Revised: 02/11/2013] [Accepted: 02/11/2013] [Indexed: 12/17/2022] Open
Abstract
Liver involvement is often observed in several hematological disorders, resulting in abnormal liver function tests, abnormalities in liver imaging studies, or clinical symptoms presenting with hepatic manifestations. In hemolytic anemia, jaundice and hepatosplenomegaly are often seen mimicking liver diseases. In hematologic malignancies, malignant cells often infiltrate the liver and may demonstrate abnormal liver function test results accompanied by hepatosplenomegaly or formation of multiple nodules in the liver and/or spleen. These cases may further evolve into fulminant hepatic failure.
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Affiliation(s)
- Jun Murakami
- The Third Department of Internal Medicine, Faculty of Medicine, University of Toyama, Toyama 930-0194, Japan
| | - Yukihiro Shimizu
- Gastroenterology Unit, Takaoka City Hospital, Toyama 933-8550, Japan
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Patra B, Maheshwari A, Chandra J, Aneja S, Agarwal S, Nangia A, Seth A. Chronic idiopathic myelofibrosis with myeloid metaplasia presenting as refractory ascites. Pediatr Blood Cancer 2010; 54:151-3. [PMID: 19785025 DOI: 10.1002/pbc.22274] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Chronic idiopathic myelofibrosis (CIM) with myeloid metaplasia is a myeloproliferative disorder characterized by leukoerythroblastosis, tear drop erythrocytes, extra-medullary hematopoesis (EMH), and varying degree of myelofibrosis. CIM, presenting as refractory ascites secondary to peritoneal hematopoesis, is extremely rare with only six adult cases reported in literature. This is a report of a child with CIM presenting as refractory ascites as a consequence of EMH in the peritoneum. The patient was treated with intermittent hydroxyurea with favorable response over 3 weeks. The patient was thereafter lost to follow up.
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Affiliation(s)
- Bijoy Patra
- Department of Pediatrics, Lady Hardinge Medical College, New Delhi, India
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Extramedullary erythropoiesis in the adult liver requires BMP-4/Smad5-dependent signaling. Exp Hematol 2009; 37:549-58. [PMID: 19375646 DOI: 10.1016/j.exphem.2009.01.004] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2008] [Revised: 01/12/2009] [Accepted: 01/13/2009] [Indexed: 11/21/2022]
Abstract
OBJECTIVE In mice, homeostatic erythropoiesis occurs primarily in the bone marrow. However, in response to acute anemia, bone morphogenetic proteins 4 (BMP-4)-dependent stress erythropoiesis occurs in the adult spleen. BMP-4 can also regulate stress erythropoiesis in the fetal liver. In humans, erythropoiesis occurs in the bone marrow. However, in certain pathological conditions, extramedullary erythropoiesis is observed, where it can occur in several organs, including the liver. Given these observations, we propose to investigate whether the BMP-4-dependent stress erythropoiesis pathway can regulate extramedullary erythropoiesis in the livers of splenectomized mice. MATERIALS AND METHODS Using splenectomized wild-type and flexed-tail (f) mice, which have a defect in BMP-4 signaling, we compared their recovery from phenylhydrazine-induced hemolytic anemia and characterized the expansion of stress burst-forming unit-erythroid in the livers of these mice during the recovery period. RESULTS Our analysis indicates that in the absence of a spleen, stress erythropoiesis occurs in the murine liver. During the recovery, stress burst-forming unit-erythroid are expanded in the livers of splenectomized mice in response to BMP-4 expressed in the liver. f/f mice, which exhibit a defect in splenic stress erythropoiesis do not compensate for this defect by upregulating liver stress erythropoiesis. Furthermore, splenectomized f/f mice exhibit a defect in liver stress erythropoiesis, which demonstrates a role for the BMP-4-dependent stress erythropoiesis pathway in extramedullary erythropoiesis in the adult liver. CONCLUSIONS Our data indicate that the BMP-4-dependent stress erythropoiesis pathway regulates extramedullary stress erythropoiesis, which occurs primarily in the murine spleen or in the case of splenectomized mice, in the adult liver.
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Kim SJ, Lee Y, Kim SH, Kim H, Park KU, Bang SM, Lee JS. Extramedullary peritoneal hematopoiesis combined with tuberculosis in a patient with primary myelofibrosis. Med Oncol 2008; 26:238-41. [PMID: 18850308 DOI: 10.1007/s12032-008-9099-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2008] [Accepted: 09/24/2008] [Indexed: 01/30/2023]
Abstract
Primary myelofibrosis (PMF) is a myeloproliferative disorder characterized by bone marrow fibrosis or dysmegakaryocytes, extramedullary hematopoiesis, and the presence of JAK2 mutations. We present a 73-year-old man with PMF that had a fulminant clinical course. Peritoneal extramedullary hematopoiesis combined with tuberculosis was found 4 months after the diagnosis. This combination of complications has not been previously reported. These events were followed by rapid leukemic transformation and the patient's death.
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Affiliation(s)
- Su-Jung Kim
- Department of Internal Medicine, College of Medicine, Seoul National University, Seoul, Korea
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Riesterer O, Gmür J, Lütolf U. Repeated and Preemptive Palliative Radiotherapy of Symptomatic Hepatomegaly in a Patient with Advanced Myelofibrosis. ACTA ACUST UNITED AC 2008; 31:325-7. [DOI: 10.1159/000127399] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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12
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Abstract
The hemopoietic cell elements in body fluids is a rare encounterance. From among the normal bone marrow inhabitants, only megakaryocytes are occasionally seen in pleural and peritoneal fluids due to extramedullary hemopoiesis as a result of myeloproliferative disorders. The finding of isolated normoblasts in body fluids with no other marrow elements is described here for the first time in pleural fluid from two patients. The normoblasts which have a close resemblance morphologically to mesothelial cells, need to be differentiated from one another. A supravital stain is of help when in doubt. Because of their close resemblance, normoblasts may get missed during evaluation. This report highlights the need for a larger number of positive cases with emphasis on their course details to understand the significance of normoblasts in body fluids.
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Affiliation(s)
- Usha Kini
- Department of Pathology, St. John's Medical College and Hospital, Koramangala, Bangalore, India.
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Holden C, Hennessy O, Lee WK. Diffuse Mesenteric Extramedullary Hematopoiesis with Ascites: Sonography, CT, and MRI Findings. AJR Am J Roentgenol 2006; 186:507-9. [PMID: 16423960 DOI: 10.2214/ajr.04.1788] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Christopher Holden
- Department of Medical Imaging, St. Vincent's Hospital, University of Melbourne, 41 Victoria Parade, Fitzroy, Victoria 3065, Australia
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14
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Wright JR, Van den Hof MC, Macken MB. Prenatal infantile cortical hyperostosis (Caffey's disease): a 'hepatic myeloid hyperplasia-pulmonary hypoplasia sequence' can explain the lethality of early onset cases. Prenat Diagn 2005; 25:939-44. [PMID: 16193456 DOI: 10.1002/pd.1235] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Infantile cortical hyperostosis (ICH) is benign and self-limiting when it presents near or after birth but is usually lethal when it presents earlier. METHODS We present the clinical, ultrasonic, radiographic and pathologic findings in an instructive case of early onset prenatal ICH. RESULTS A 40-year-old G2P1 woman delivered spontaneously at 22 weeks' gestation. Prenatal ultrasounds showed rib and mandibular abnormalities as well as short humeri. Post-mortem radiographs showed asymmetric hyperostosis in long bones, mandible, scapulae and pelvis with sparing of spine, hands, feet and skull. The affected skeleton showed marked bony sclerosis and ballooning of the diaphyses of the long bones with periosteal sclerosis. A complete autopsy showed characteristic histologic findings in affected bones. Previous reports at 20+ weeks have described anasarca, fetal hydrops, hepatomegaly, and pulmonary hypoplasia. In our case, there was no hydrops/anasarca; hepatomegaly, due to massive extramedullary hematopoiesis with marked myeloid hyperplasia, combined with ribcage abnormalities, caused mild pulmonary hypoplasia. CONCLUSION We hypothesize that early onset fetal ICH is usually lethal because massive hepatic myeloid hyperplasia sequentially causes: (1) hepatomegaly and, in conjunction with rib abnormalities, mild pulmonary hypoplasia, (2) sinusoidal and pre-sinusoidal portal hypertension followed by ascites/hydrops, and (3) ascites/hydrops-induced severe pulmonary hypoplasia.
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Affiliation(s)
- James R Wright
- Department of Pathology and Laboratory Medicine, Alberta Children's Hospital (Calgary Laboratory Services), Calgary, Canada.
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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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NAKANISHI SEIJI, MIYATA TOMOSHI, MURATA YOSUKE, OHNO YOSHINORI, HATAKEYAMA YUKO, KUMAGI TERU, ABE MASANORI, MATSUI HIDETAKA, IUCHI HIDEHITO, MICHITAKA KOJIRO, HORIIKE NORIO, ONJI MORIKAZU. PELIOSIS HEPATIS: IMPROVEMENT OF ESOPHAGEAL VARICES AFTER THE SURGICAL TREATMENT OF PLACENTAL SITE TROPHOBLASTIC TUMOR OF THE UTERUS. Dig Endosc 2003. [DOI: 10.1046/j.1443-1661.2003.00218.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Affiliation(s)
- SEIJI NAKANISHI
- Third Department of Internal Medicine, Ehime University School of Medicine, Shigenobu‐Cho, Ehime, Japan
| | - TOMOSHI MIYATA
- Third Department of Internal Medicine, Ehime University School of Medicine, Shigenobu‐Cho, Ehime, Japan
| | - YOSUKE MURATA
- Third Department of Internal Medicine, Ehime University School of Medicine, Shigenobu‐Cho, Ehime, Japan
| | - YOSHINORI OHNO
- Third Department of Internal Medicine, Ehime University School of Medicine, Shigenobu‐Cho, Ehime, Japan
| | - YUKO HATAKEYAMA
- Third Department of Internal Medicine, Ehime University School of Medicine, Shigenobu‐Cho, Ehime, Japan
| | - TERU KUMAGI
- Third Department of Internal Medicine, Ehime University School of Medicine, Shigenobu‐Cho, Ehime, Japan
| | - MASANORI ABE
- Third Department of Internal Medicine, Ehime University School of Medicine, Shigenobu‐Cho, Ehime, Japan
| | - HIDETAKA MATSUI
- Third Department of Internal Medicine, Ehime University School of Medicine, Shigenobu‐Cho, Ehime, Japan
| | - HIDEHITO IUCHI
- Third Department of Internal Medicine, Ehime University School of Medicine, Shigenobu‐Cho, Ehime, Japan
| | - KOJIRO MICHITAKA
- Third Department of Internal Medicine, Ehime University School of Medicine, Shigenobu‐Cho, Ehime, Japan
| | - NORIO HORIIKE
- Third Department of Internal Medicine, Ehime University School of Medicine, Shigenobu‐Cho, Ehime, Japan
| | - MORIKAZU ONJI
- Third Department of Internal Medicine, Ehime University School of Medicine, Shigenobu‐Cho, Ehime, Japan
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Weinschenker P, Kutner JM, Salvajoli JV, Hanriot RM, Ribeiro AF, Capelozzi VL, Del Giglio A. Whole-pulmonary low-dose radiation therapy in agnogenic myeloid metaplasia with diffuse lung involvement. Am J Hematol 2002; 69:277-80. [PMID: 11921022 DOI: 10.1002/ajh.10075] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Agnogenic myeloid metaplasia is a hematologic disorder accompanied by extramedullary hematopoiesis (EMH) affecting various organs. Lung involvement however is rare. We present the case of a 76-year-old woman with myelofibrosis, recurrent pleural effusions, pulmonary hypertension, and serious right cardiac failure. An open lung biopsy confirmed pulmonary EMH. She underwent low-dose (200 cGy) whole-lung radiotherapy in 4 fractions of 50 cGy each. Her clinical and hemodynamic parameters improved. We conclude that low-dose whole-lung radiation may be efficacious for the palliative treatment of pulmonary EMH.
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Affiliation(s)
- Patrícia Weinschenker
- Division of Hematology and Oncology, ABC Foundation School of Medicine, São Paulo, Brazil
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18
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Tefferi A, Jiménez T, Gray LA, Mesa RA, Chen MG. Radiation therapy for symptomatic hepatomegaly in myelofibrosis with myeloid metaplasia. Eur J Haematol 2001; 66:37-42. [PMID: 11168506 DOI: 10.1034/j.1600-0609.2001.00342.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To describe the experience with liver irradiation in advanced cases of myelofibrosis with myeloid metaplasia (MMM). METHODS Over a 20-yr period, 14 patients with MMM were treated with a total of 25 courses of liver, abdominal, or abdominal and pelvic irradiation for symptomatic hepatomegaly with (5 patients) or without (9 patients) ascites. All 14 patients had advanced disease and 11 (79%) had previous splenectomy. The median radiation therapy (RT) dose per course was 150 cGy (range 50-1000) administered at a median of six fractions. Four patients received two to six courses. RESULTS Twelve of the 14 patients (86%) had a transient (median 3 months) subjective response from RT. However, in only 35% of these was there a transient (median 3 months) decrease in palpable liver size. Four of the five patients with ascites experienced a short-term response from RT. Eight of the 13 patients suitable for evaluation (62%) had treatment-associated cytopenia, often in the form of anemia and/or thrombocytopenia. At last follow-up, 10 patients (71%) had died after a median of 7 months (range 0.1-23) and 4 were alive at 3, 20, 33, and 57 months after RT. CONCLUSIONS Low-dose abdominal RT for symptomatic hepatomegaly or ascites associated with advanced-stage MMM is myelosuppressive and provides only temporary and mainly subjective and short-lived relief.
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Affiliation(s)
- A Tefferi
- Division of Hematology and Internal Medicine and Mayo Clinic and Mayo Foundation, Rochester, Minnesota 55905, USA
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19
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Oren I, Goldman A, Haddad N, Azzam Z, Krivoy N, Alroy G. Ascites and pleural effusion secondary to extramedullary hematopoiesis. Am J Med Sci 1999; 318:286-8. [PMID: 10522557 DOI: 10.1097/00000441-199910000-00009] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Extramedullary hematopoiesis in the pleura and peritoneum is rare. It is usually asymptomatic and generally is diagnosed on post mortem examination. Herein we describe a 33-year-old woman with long-standing myelofibrosis who presented with symptomatic ascites and pleural effusion. After complete evaluation, these were found to have been caused by extramedullary hematopoietic implants to the pleura and peritoneum. The pleural effusion responded to low-dose radiotherapy.
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Affiliation(s)
- I Oren
- Department of Medicine A and Hematology, Rambam Medical Center and School of Medicine, Technion, Haifa, Israel
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Oren I, Goldman A, Haddad N, Azzam Z, Krivoy N, Alroy G. Ascites and Pleural Effusion Secondary to Extramedullary Hematopoiesis. Am J Med Sci 1999. [DOI: 10.1016/s0002-9629(15)40633-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Hung SC, Huang ML, Liu SM, Hsu HC. Massive ascites caused by peritoneal extramedullary hematopoiesis as the initial manifestation of myelofibrosis. Am J Med Sci 1999; 318:198-200. [PMID: 10487412 DOI: 10.1097/00000441-199909000-00017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
An 83-year-old man presented with massive ascites. Cytological examination of the ascites revealed primitive hematopoietic cells. The specimen of bone marrow biopsy disclosed diffuse fibrosis, which suggested myelofibrosis with extramedullary hematopoiesis as the cause of ascites. His symptoms resolved dramatically after administration of hydroxyurea. Ascites formation in myelofibrosis is often attributed to presinusoidal portal hypertension and occurs in the context of well-established disease. This case demonstrates that myelofibrosis may manifest as massive ascites caused by peritoneal implants of myeloid tissues. Extramedullary hematopoiesis should be included in the differential diagnosis of ascites.
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Affiliation(s)
- S C Hung
- Department of Medicine, Veterans General Hospital-Taipei, Taiwan, ROC
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Massive Ascites Caused by Peritoneal Extramedullary Hematopoiesis as the Initial Manifestation of Myelofibrosis. Am J Med Sci 1999. [DOI: 10.1016/s0002-9629(15)40614-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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Shibata K, Nakano S, Watanabe M, Yano H, Matsuzaki M, Sano M. Acute megakaryocytic leukaemia (AML-M7) with myelofibrosis terminating in AML-MO with concurrent liver fibrosis. Eur J Haematol Suppl 1998; 60:310-2. [PMID: 9654161 DOI: 10.1111/j.1600-0609.1998.tb01045.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Stahl RL, Hoppstein L, Davidson TG. Intraperitoneal chemotherapy with cytosine arabinoside in agnogenic myelofibrosis with myeloid metaplasia and ascites due to peritoneal extramedullary hematopoiesis. Am J Hematol 1993; 43:156-7. [PMID: 8342549 DOI: 10.1002/ajh.2830430222] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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Abstract
Polycythemia vera (PV) is one of the myeloproliferative diseases, and, as such, is an example of clonal hematopoiesis. The progeny of a single, abnormal, hematopoietic stem cell gain a growth advantage over their normal counterparts resulting in overproduction of red cells generally accompanied by overproduction of granulocytes and platelets as well. There are a variety of nonspecific symptoms at onset related to the increased red cell mass and hematocrit accompanied by the more specific manifestations of pruritus, erythromelalgia, and hepatic, portal, and mesenteric vein thrombosis. Splenomegaly and hypertension are common. The laboratory hallmark is an increased red cell mass. There is also often an increase in white cell count, platelet count, and leukocyte alkaline phosphatase along with other findings reflecting the increased rate of turnover of hematopoietic cells. The bone marrow biopsy generally displays hypercellularity involving all three cell lines and absent iron stores. The diagnosis of PV depends on excluding spurious polycythemia in which there is a high hematocrit but a normal red cell mass and secondary polycythemia in which there is an increased red cell mass in response to tissue hypoxia or the inappropriate production of erythropoietin, generally by a tumor. In addition, one should try to establish the diagnosis in a positive fashion by a combination of studies of the blood and bone marrow. Phlebotomy and occasionally plateletpheresis should be used as acute therapy. Chronic therapy is guided by the knowledge that patients treated with phlebotomy alone have an increased rate of thrombotic complications particularly in older patients and those with previous thrombotic disease. Myelosuppressive therapy can reduce the incidence of these complications, but is commonly associated with an increased incidence of second malignancies, particularly acute leukemia. At present, hydroxyurea is the myelosuppressive agent of choice. Antiplatelet agents have a limited role except in the palliation of the syndrome of erythromelalgia. Median survival is approximately 10 years. As implied above, the causes of morbidity and mortality vary with the mode of chronic therapy which has been employed, leukemia being more common after myelosuppressive therapy and thrombotic complications being more common after therapy with phlebotomy alone. Ten percent to 50% of patients move into a spent phase followed by postpolycythemic myeloid metaplasia, irrespective of previous therapy employed. Eventually, the major problems may be cytopenias and massive splenomegaly.
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Affiliation(s)
- S Murphy
- Jefferson Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
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