IMAGES IN CYTOLOGY Section Editor: Stephan Pambuccian, MD
Black Bone Marrow Variable Cytoplasmic Melanin Content in Malignant Melanoma Cells in Bone Marrow Aspirate ~oz, M.D.,1* Cristina Caldero n-Cabrera, M.D.,1 M. Angeles Domınguez-Mun 1 Rosario M. Morales, M.D., Ph.D., Concepcion Prats, M.D.,1 n, M.D.,2 Ricardo Bernal, M.D., Ph.D.,1 Marta Ruiz, M.D.,1 Inmaculada Tallo Antonio Pe rez-Simo n, M.D., Ph.D.,1 Jose
Melanoma rarely infiltrates bone marrow and, just in case of disseminated disease, it reaches 5–7%, being often amelanotic. Involvement of bone marrow increases to 45% of cases when autopsy is performed.1 It is extremely infrequent that a trephine biopsy reflects in its coloration the melanin content, although pigment-loaded cells in the aspirate are present.2
Case Report A 69-year-old male was diagnosed with polypoid nodular melanoma in the left lumbar region categorized as Clark’s level 5, stage V with Breslow’s depth of 6 mm. The lesion was surgically resected without further therapy because of the advanced age of the patient. Seven years later, the patient returned to consultation due to asthenia, dyspnea, and weight loss of 10 kg. The blood count showed hemoglobin 83 g/L, mean corpuscular volume 88.2 fL, mean corpuscular hemoglobin 25.9 pg, mean corpuscular hemoglobin concentration 293 g/L, leucocytes 6.41 3 109/L (neutrophils 2.89 3 109/L), and pla1 Department of Hematology, Instituto de Biomedicina de Sevilla (IBIS), Hospital Universitario Virgen del Rocıo/CSIC/Universidad de Sevilla, Sevilla, Spain 2 Department of Hematology, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain. *Correspondence to: M Angeles Domınguez-Mu~ noz, M.D., Department of Hematology, Instituto de Biomedicina de Sevilla (IBIS) Hospital Universitario Virgen del Rocıo/CSIC/Universidad de Sevilla, Sevilla, Spain. E-mail: [email protected] Received 9 January 2014; revised 19 June 2014; Accepted 17 July 2014 DOI: 10.1002/dc.23203 Published online 1 August 2014 in Wiley Online Library (wileyonlinelibrary.com).
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telets 70 3 109/L. Peripheral blood examination showed segmented neutrophils 37%, bands 16%, metamyelocytes 7%, myelocytes 7%, blasts 1%, lymphocytes 27%, monocytes 3%, eosinophils 1%, basophils 1%, and 22 erythroblasts/100 leucocytes. Biochemical investigations showed alanine aminotransferase 80 UI/L, aspartate aminotransferase 67 UI/L, alkaline phosphatase 371 IU/L, and lactate dehydrogenase 627 IU/L. Abdominal ultrasound showed focal liver lesions suggestive of metastatic involvement. Radiological imaging tests showed no osteolytic lesions. The presence of anemia, thrombocytopenia, and leukoerythroblastic reaction led to a bone marrow study. A completely black 12-mm-long trephine biopsy (Fig. 1) was obtained, histologically confirming diffuse neoplastic infiltration with abundant melanin content (Fig. 2A) and typical prominent inclusion-like nucleoli (Fig. 2B) associated with reticculinic fibrosis. The absence of hematopoietic and adipose tissue was evident. Bone marrow aspirate was very difficult and little material of normal hematic coloration, in accordance with the previously described fibrosis in trephine biopsy. The May-Gr€unwald-Giemsa (MGG) at pH 6.4 showed a hypocellular bone marrow with prominent infiltration of undifferentiated non hematopoietic cells, with the appearance of malignancy, usually pleomorphic and sometimes forming nests (Figs. 3A–C). The tumor cells generally had a single nucleus with large cytoplasm, which was predominantly agranular; only 5% of the cells showed greenish brown cytoplasmic granulation (Figs. 4A–C). In some tumor cells, prominent inclusion-like nucleoli were clearly distinguished (Figs. 5A and B). C 2014 WILEY PERIODICALS, INC. V
Diagnostic Cytopathology DOI 10.1002/dc
BONE MARROW INFILTRATION OF MELANOMA
Fragmented or cell debris often appeared. Hematopoiesis was virtually absent. A total of 1.5% of histiocytic cells overloaded with melanin pigment (melanophages) in thick aggregates, identifiable by their smaller and partially
covered nucleus, and large cell size were found (Figs. 6A and B). The background showed numerous dispersed extracellular black granular pigment. The patient presented with progressive deterioration, requiring multiple red blood cells and platelet transfusions, and subsequently died two months later after diagnosis of metastasis due to upper gastrointestinal bleeding.
Discussion Fig. 1. A 12-mm-long trephine biopsy. Uniform black color.
Melanoma infiltrating bone marrow is a very unusual event of established poor prognosis.1 It is a well known
Fig. 2. A and B. Trephine biopsy, diffuse infiltration of melanoma cells. Hematopoietic tissue replaced by tumor tissue with abundant melanin pigment (A, H&E, 3250). Nests of neoplastic cells: Image of prominent inclusion-like nucleoli in the center (arrow; B, H&E, 3400).
Fig. 3. A–C: Bone marrow aspirate, tumor cells without or minimum evidence of melanin content. Metastatic nest without melanin panoramic view (A, MGG, 3100) and increased in size (B, MGG, 31000). Group of fusiform malignant melanocytes with faintly granular pigmentation (C, MGG, 31000). Diagnostic Cytopathology, Vol. 43, No 6
479
Diagnostic Cytopathology DOI 10.1002/dc
~ DOMINGUEZ-MUNOZ ET AL.
Fig. 4. A–C: Bone marrow aspirate, tumor cells with melanin pigment appreciated as greenish brown granulation (A–C, MGG, 31000).
Fig. 5. A and B: Bone marrow aspirate. Prominent inclusion-like nucleoli in the nucleus (MGG, 31000).
fact that cytologic samples obtained from fine needle or aspiration of biological fluids affected by metastatic melanomas may show a blackish appearance.3 Differential diagnosis of black pigmentation in bone marrow includes, in addition to melanoma metastases,4 rare entities such as bone marrow anthracosis5,6 or the presence of metallic wear debris in bone marrow coming from the site of a severely worn joint implant.7 The present case shows a red bone marrow aspirate, in contrast to a dark appearance reported by other 480
Diagnostic Cytopathology, Vol. 43, No 6
authors.8–10 However, the color of trephine biopsy was intensely black, which represents an exceptional finding, raising the possible diagnosis of metastatic melanoma, based on the presence of melanin loaded areas. A notable finding in the aspirate was the predominance of tumor cells with apparent lack of melanin content, with greenish brown granules appreciated in just 5% of the tumor cells. This was in contrast to the high pigment content present in melanophages, consisting of black, dense material, and large blocks of pigment.
Diagnostic Cytopathology DOI 10.1002/dc
BONE MARROW INFILTRATION OF MELANOMA
Fig. 6. A and B: Bone marrow aspirate. Large histiocyte overloaded with melanin pigment (A, MGG, 31000). Melanophage surrounded by tumor cells without clear evidence of pigmentation (B, MGG, 31000).
The different color observed between trephine biopsy and aspirated material was related to the way the aspirate was obtained from an area of less melanin content of the biopsy, adding that fibrosis may have contributed to poor cellularity aspiration, which was also probably diluted with bone marrow vascularization and masked the blackish color. Likewise, we cannot dismiss that the processing method had any influence in the discrepant histologic sections and aspirate smears and even the fact that the gross nature of the biopsy does not match 100% with the extent of pigment (which looks less) in the sections. Macroscopic observation of samples of bone marrow aspirate and biopsy, characteristically of blackish tonality, suggests the likely diagnostic possibility of metastatic melanoma, although a discrepancy in the coloration of both is feasible.
References 1. Stewart WR, Gelberman RH, Harrelson JM, Seigler HF. Skeletal metastases of melanoma. J Bone Joint Surg Am 1978;60: 645–649.
2. Bhandari S, Jack F, Hussain K, Bell A. Metastatic melanoma in the marrow: A black and white diagnosis. Br J Haematol 2009;147:1. 3. Siddaraju N. Clinical cytology in the diagnosis and management of melanoma. In: Cao MY, editor. Current Management of Malignant Melanoma. InTech; 2011. Available at: http://www.intechopen.com/ books/current-management-of-malignant-melanoma/clinical-cytologyin-the-diagnosis-and-management-of-melanoma. 4. Velasco-Rodrıguez D, Castellanos-Gonzalez M, Alonso-Domınguez JM, Martın-Gonzalez M, Villarubia J. Metastatic malignant melanoma detected on bone marrow aspiration. Br J Haematol 2013; 162:432. 5. Miller D. Observations on a case of probable bone marrow anthracosis. Blood 1959;14:1350–1353. 6. Pelstring RJ, Kim CK, Lower EE, Swerdlow SH. Marrow granulomas in coal workers’ pneumoconiosis. A histologic study with elemental analysis. Am J Clin Pathol 1988;89:553–556. 7. Engh CA, Jr, Moore KD, Vinh TN, Engh GA. Titanium prosthetic wear debris in remote bone marrow. A report of two cases. J Bone Joint Surg Am 1997;79:1721–1725. 8. Serrier C, Lesesve JF. Metastatic malignant melanoma in the bone marrow. Blood 2013;121:721. 9. Mirfazaelian H, Rezvani A, Daneshbod Y. Black bone marrow aspirate. J Postgrad Med 2013;59:246–248. 10. Franklin JW, Zavala DC, Radcliffe CE. The detection of malignant melanoma by bone marrow aspiration; a report of two cases. Blood 1952;7:934–941.
Diagnostic Cytopathology, Vol. 43, No 6
481
Black Bone Marrow Variable Cytoplasmic Melanin Content in Malignant Melanoma Cells in Bone Marrow Aspirate ~oz, M.D.,1* Cristina Caldero n-Cabrera, M.D.,1 M. Angeles Domınguez-Mun 1 Rosario M. Morales, M.D., Ph.D., Concepcion Prats, M.D.,1 n, M.D.,2 Ricardo Bernal, M.D., Ph.D.,1 Marta Ruiz, M.D.,1 Inmaculada Tallo Antonio Pe rez-Simo n, M.D., Ph.D.,1 Jose
Melanoma rarely infiltrates bone marrow and, just in case of disseminated disease, it reaches 5–7%, being often amelanotic. Involvement of bone marrow increases to 45% of cases when autopsy is performed.1 It is extremely infrequent that a trephine biopsy reflects in its coloration the melanin content, although pigment-loaded cells in the aspirate are present.2
Case Report A 69-year-old male was diagnosed with polypoid nodular melanoma in the left lumbar region categorized as Clark’s level 5, stage V with Breslow’s depth of 6 mm. The lesion was surgically resected without further therapy because of the advanced age of the patient. Seven years later, the patient returned to consultation due to asthenia, dyspnea, and weight loss of 10 kg. The blood count showed hemoglobin 83 g/L, mean corpuscular volume 88.2 fL, mean corpuscular hemoglobin 25.9 pg, mean corpuscular hemoglobin concentration 293 g/L, leucocytes 6.41 3 109/L (neutrophils 2.89 3 109/L), and pla1 Department of Hematology, Instituto de Biomedicina de Sevilla (IBIS), Hospital Universitario Virgen del Rocıo/CSIC/Universidad de Sevilla, Sevilla, Spain 2 Department of Hematology, Hospital General Universitario de Ciudad Real, Ciudad Real, Spain. *Correspondence to: M Angeles Domınguez-Mu~ noz, M.D., Department of Hematology, Instituto de Biomedicina de Sevilla (IBIS) Hospital Universitario Virgen del Rocıo/CSIC/Universidad de Sevilla, Sevilla, Spain. E-mail: [email protected] Received 9 January 2014; revised 19 June 2014; Accepted 17 July 2014 DOI: 10.1002/dc.23203 Published online 1 August 2014 in Wiley Online Library (wileyonlinelibrary.com).
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Diagnostic Cytopathology, Vol. 43, No 6
telets 70 3 109/L. Peripheral blood examination showed segmented neutrophils 37%, bands 16%, metamyelocytes 7%, myelocytes 7%, blasts 1%, lymphocytes 27%, monocytes 3%, eosinophils 1%, basophils 1%, and 22 erythroblasts/100 leucocytes. Biochemical investigations showed alanine aminotransferase 80 UI/L, aspartate aminotransferase 67 UI/L, alkaline phosphatase 371 IU/L, and lactate dehydrogenase 627 IU/L. Abdominal ultrasound showed focal liver lesions suggestive of metastatic involvement. Radiological imaging tests showed no osteolytic lesions. The presence of anemia, thrombocytopenia, and leukoerythroblastic reaction led to a bone marrow study. A completely black 12-mm-long trephine biopsy (Fig. 1) was obtained, histologically confirming diffuse neoplastic infiltration with abundant melanin content (Fig. 2A) and typical prominent inclusion-like nucleoli (Fig. 2B) associated with reticculinic fibrosis. The absence of hematopoietic and adipose tissue was evident. Bone marrow aspirate was very difficult and little material of normal hematic coloration, in accordance with the previously described fibrosis in trephine biopsy. The May-Gr€unwald-Giemsa (MGG) at pH 6.4 showed a hypocellular bone marrow with prominent infiltration of undifferentiated non hematopoietic cells, with the appearance of malignancy, usually pleomorphic and sometimes forming nests (Figs. 3A–C). The tumor cells generally had a single nucleus with large cytoplasm, which was predominantly agranular; only 5% of the cells showed greenish brown cytoplasmic granulation (Figs. 4A–C). In some tumor cells, prominent inclusion-like nucleoli were clearly distinguished (Figs. 5A and B). C 2014 WILEY PERIODICALS, INC. V
Diagnostic Cytopathology DOI 10.1002/dc
BONE MARROW INFILTRATION OF MELANOMA
Fragmented or cell debris often appeared. Hematopoiesis was virtually absent. A total of 1.5% of histiocytic cells overloaded with melanin pigment (melanophages) in thick aggregates, identifiable by their smaller and partially
covered nucleus, and large cell size were found (Figs. 6A and B). The background showed numerous dispersed extracellular black granular pigment. The patient presented with progressive deterioration, requiring multiple red blood cells and platelet transfusions, and subsequently died two months later after diagnosis of metastasis due to upper gastrointestinal bleeding.
Discussion Fig. 1. A 12-mm-long trephine biopsy. Uniform black color.
Melanoma infiltrating bone marrow is a very unusual event of established poor prognosis.1 It is a well known
Fig. 2. A and B. Trephine biopsy, diffuse infiltration of melanoma cells. Hematopoietic tissue replaced by tumor tissue with abundant melanin pigment (A, H&E, 3250). Nests of neoplastic cells: Image of prominent inclusion-like nucleoli in the center (arrow; B, H&E, 3400).
Fig. 3. A–C: Bone marrow aspirate, tumor cells without or minimum evidence of melanin content. Metastatic nest without melanin panoramic view (A, MGG, 3100) and increased in size (B, MGG, 31000). Group of fusiform malignant melanocytes with faintly granular pigmentation (C, MGG, 31000). Diagnostic Cytopathology, Vol. 43, No 6
479
Diagnostic Cytopathology DOI 10.1002/dc
~ DOMINGUEZ-MUNOZ ET AL.
Fig. 4. A–C: Bone marrow aspirate, tumor cells with melanin pigment appreciated as greenish brown granulation (A–C, MGG, 31000).
Fig. 5. A and B: Bone marrow aspirate. Prominent inclusion-like nucleoli in the nucleus (MGG, 31000).
fact that cytologic samples obtained from fine needle or aspiration of biological fluids affected by metastatic melanomas may show a blackish appearance.3 Differential diagnosis of black pigmentation in bone marrow includes, in addition to melanoma metastases,4 rare entities such as bone marrow anthracosis5,6 or the presence of metallic wear debris in bone marrow coming from the site of a severely worn joint implant.7 The present case shows a red bone marrow aspirate, in contrast to a dark appearance reported by other 480
Diagnostic Cytopathology, Vol. 43, No 6
authors.8–10 However, the color of trephine biopsy was intensely black, which represents an exceptional finding, raising the possible diagnosis of metastatic melanoma, based on the presence of melanin loaded areas. A notable finding in the aspirate was the predominance of tumor cells with apparent lack of melanin content, with greenish brown granules appreciated in just 5% of the tumor cells. This was in contrast to the high pigment content present in melanophages, consisting of black, dense material, and large blocks of pigment.
Diagnostic Cytopathology DOI 10.1002/dc
BONE MARROW INFILTRATION OF MELANOMA
Fig. 6. A and B: Bone marrow aspirate. Large histiocyte overloaded with melanin pigment (A, MGG, 31000). Melanophage surrounded by tumor cells without clear evidence of pigmentation (B, MGG, 31000).
The different color observed between trephine biopsy and aspirated material was related to the way the aspirate was obtained from an area of less melanin content of the biopsy, adding that fibrosis may have contributed to poor cellularity aspiration, which was also probably diluted with bone marrow vascularization and masked the blackish color. Likewise, we cannot dismiss that the processing method had any influence in the discrepant histologic sections and aspirate smears and even the fact that the gross nature of the biopsy does not match 100% with the extent of pigment (which looks less) in the sections. Macroscopic observation of samples of bone marrow aspirate and biopsy, characteristically of blackish tonality, suggests the likely diagnostic possibility of metastatic melanoma, although a discrepancy in the coloration of both is feasible.
References 1. Stewart WR, Gelberman RH, Harrelson JM, Seigler HF. Skeletal metastases of melanoma. J Bone Joint Surg Am 1978;60: 645–649.
2. Bhandari S, Jack F, Hussain K, Bell A. Metastatic melanoma in the marrow: A black and white diagnosis. Br J Haematol 2009;147:1. 3. Siddaraju N. Clinical cytology in the diagnosis and management of melanoma. In: Cao MY, editor. Current Management of Malignant Melanoma. InTech; 2011. Available at: http://www.intechopen.com/ books/current-management-of-malignant-melanoma/clinical-cytologyin-the-diagnosis-and-management-of-melanoma. 4. Velasco-Rodrıguez D, Castellanos-Gonzalez M, Alonso-Domınguez JM, Martın-Gonzalez M, Villarubia J. Metastatic malignant melanoma detected on bone marrow aspiration. Br J Haematol 2013; 162:432. 5. Miller D. Observations on a case of probable bone marrow anthracosis. Blood 1959;14:1350–1353. 6. Pelstring RJ, Kim CK, Lower EE, Swerdlow SH. Marrow granulomas in coal workers’ pneumoconiosis. A histologic study with elemental analysis. Am J Clin Pathol 1988;89:553–556. 7. Engh CA, Jr, Moore KD, Vinh TN, Engh GA. Titanium prosthetic wear debris in remote bone marrow. A report of two cases. J Bone Joint Surg Am 1997;79:1721–1725. 8. Serrier C, Lesesve JF. Metastatic malignant melanoma in the bone marrow. Blood 2013;121:721. 9. Mirfazaelian H, Rezvani A, Daneshbod Y. Black bone marrow aspirate. J Postgrad Med 2013;59:246–248. 10. Franklin JW, Zavala DC, Radcliffe CE. The detection of malignant melanoma by bone marrow aspiration; a report of two cases. Blood 1952;7:934–941.
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