Journal of the Royal Society of Medicine Volume 85 May 1992
Bone marrow necrosis and disseminated intravascular coagulation in disseminated carcinoma
anaemia and DIC were found (Table 1). The cytologic and histologic examination of the bone mnarrow showed BMN, the cwTc-sulphur ininicolloid bone marrow scan failed to-identify functioning bone marrow in the axial skejetin, together with a- shift of the non ihomogenous uptake predominantly into the tibias, femorpj bones and wi.eri. A 4-week treatment with heparin (15 000 iu/day),
V Acudla MD' J Dugek MD2 Y Hrckova MD3 M §udlovaMDa Z Fry§Ak MD3 'Third Department of Medicine, 2Department of Pathology and 3First Department of Medicine, University Hospital, IP Pavlova Street 6, 775 20 Olomouc, Czechoslovakia
fresh
frozen
plasma and platelet transfusions
led
to
a temporary disappearance of the bleeding, to an improvement of some coagulation tests, and to a decrease in
Keywords: bone marrow necrosis; disseminated intravascular coagulation; disseminated carcinoma
The simultaneous presence of disseminated intravascular coagulation (DIC) and bone marrow necrosis (BMN) has been only sporadically reported farA1-. We discuss two patients in whom such an association of DIC and BMN was observed in generalized carcinoma with massive metastatic bone marrow involvement. so
Case reports Case 1 A 39-year-old woman suffered from intense pain in the lumbar spine, weakness and spontaneous skin-bleeding. Microangiopathic haemolytic anemia and DIC were diloed (Table 1). The occurrence of neoplastic cela in the bone marrow and in the left gupraclavicular lymph node and X-ray signs of pulmonal tumorous dissemination cqnflrme the presence of a genkeralized neoplastic process. The condition of the patient deteriorated rapidly. Left sided hemiplegia and renal failure deqloped,and the patien died 6 days after admission. Necropsy showed an extensively disseminated low differentiated gastric carcinoma, and extensive BMN with numerous fibrin thrombi and plugs of tumour cells in the bone marrow and in the CNS microcirculation. Furthermore, renal tubular necrosis and a subarachnoidal haematoma were found. Case 2 A 48-year-old man had severe pain in the lumbar spine, high temperature and diffuse petechial haemorrhages and mucous membrane bleeding. Microangiopathic haemolytic
the intensity of haemolysis (Table 1). The suspected disseminated neoplastic process was confirmed by finding focal lesions in the vertebra,- in the claviculas an'd humeri on 9'Tc scintigraphy and X-ray examination of the skeleton. Two cycles of COP chemotherapy (cyclophosphamide, oncovine, prednisone) resulted in a temporary disappearance of temperature and bone pain. Serious skin-bleeding "and gastroint inali hemorrhage with' intractable anaemia (Hb 2.2 g/dl) wereobbserved, and the patient died 8 weeks after the diagnosis of BMN. Necropsy showed a disseminated muciparous carcinoma of an unknown primary source (possibly ventricle), with marked catcinonrsts microangiopathy. Extensive BMN with focal reparatory fibrosis was associated with the presence of' extram6dullary haemopoiesis in the liver and the spleen.
Discussion There are several papers dealing with BMN5-5 but, until now, only a few observations'5 of concomitant BMN and DIC have been published. Rosel observed thLs connection during postpartum sepsis. Harigaya et al.2 describe the presence of ischaemic infarcts with BMN and DIC. Ritter et al.' obsetved this situation- in' ANLL. Si'milar to Ridci et al.' and Laso et al.5, we ftuiind BMN and DIC in two cases of genetalized carcinomna. In the bone marrow and of DIC of patient 1, carcinoaMtous microaigiopathy was associated with the obliteration of-the marrow microcirculation with the numerous fibrini microthrombi. The treatmetif afDIC with heparin under the condition of BMN and carcinomatous micmoangiopathyo showed only limited effect: 'According to Knupp-et' aL9, the tumour necrosis factor 'ativft in plasma probably 'played a 'potential role in the development of BMN in patients with disseminated cancer. In view of the fact that subclinical, frequently unrecognized, DICG oecurs often in most of the diseases which are occasionally also complicated with BMN, it is necessary to pay morel attention to such association of these two processes.
Table 1. Laboratory parameters of the patients Case 1 (female, 39 years):. disseminad gastric carcinoma
Case 2 (ma7e, 48 years): disseminated carcinoma of unknown primary source
At, the time of BMN ,dignosis
At the time of
Haemoglobin (g/l) Reticulocyte (0.005-0.020) WBC count (x109/l) Platelet count (x109/l) Leucoerythroblastic picture Indirect bilirubin (
Bone marrow necrosis and disseminated intravascular coagulation in disseminated carcinoma
anaemia and DIC were found (Table 1). The cytologic and histologic examination of the bone mnarrow showed BMN, the cwTc-sulphur ininicolloid bone marrow scan failed to-identify functioning bone marrow in the axial skejetin, together with a- shift of the non ihomogenous uptake predominantly into the tibias, femorpj bones and wi.eri. A 4-week treatment with heparin (15 000 iu/day),
V Acudla MD' J Dugek MD2 Y Hrckova MD3 M §udlovaMDa Z Fry§Ak MD3 'Third Department of Medicine, 2Department of Pathology and 3First Department of Medicine, University Hospital, IP Pavlova Street 6, 775 20 Olomouc, Czechoslovakia
fresh
frozen
plasma and platelet transfusions
led
to
a temporary disappearance of the bleeding, to an improvement of some coagulation tests, and to a decrease in
Keywords: bone marrow necrosis; disseminated intravascular coagulation; disseminated carcinoma
The simultaneous presence of disseminated intravascular coagulation (DIC) and bone marrow necrosis (BMN) has been only sporadically reported farA1-. We discuss two patients in whom such an association of DIC and BMN was observed in generalized carcinoma with massive metastatic bone marrow involvement. so
Case reports Case 1 A 39-year-old woman suffered from intense pain in the lumbar spine, weakness and spontaneous skin-bleeding. Microangiopathic haemolytic anemia and DIC were diloed (Table 1). The occurrence of neoplastic cela in the bone marrow and in the left gupraclavicular lymph node and X-ray signs of pulmonal tumorous dissemination cqnflrme the presence of a genkeralized neoplastic process. The condition of the patient deteriorated rapidly. Left sided hemiplegia and renal failure deqloped,and the patien died 6 days after admission. Necropsy showed an extensively disseminated low differentiated gastric carcinoma, and extensive BMN with numerous fibrin thrombi and plugs of tumour cells in the bone marrow and in the CNS microcirculation. Furthermore, renal tubular necrosis and a subarachnoidal haematoma were found. Case 2 A 48-year-old man had severe pain in the lumbar spine, high temperature and diffuse petechial haemorrhages and mucous membrane bleeding. Microangiopathic haemolytic
the intensity of haemolysis (Table 1). The suspected disseminated neoplastic process was confirmed by finding focal lesions in the vertebra,- in the claviculas an'd humeri on 9'Tc scintigraphy and X-ray examination of the skeleton. Two cycles of COP chemotherapy (cyclophosphamide, oncovine, prednisone) resulted in a temporary disappearance of temperature and bone pain. Serious skin-bleeding "and gastroint inali hemorrhage with' intractable anaemia (Hb 2.2 g/dl) wereobbserved, and the patient died 8 weeks after the diagnosis of BMN. Necropsy showed a disseminated muciparous carcinoma of an unknown primary source (possibly ventricle), with marked catcinonrsts microangiopathy. Extensive BMN with focal reparatory fibrosis was associated with the presence of' extram6dullary haemopoiesis in the liver and the spleen.
Discussion There are several papers dealing with BMN5-5 but, until now, only a few observations'5 of concomitant BMN and DIC have been published. Rosel observed thLs connection during postpartum sepsis. Harigaya et al.2 describe the presence of ischaemic infarcts with BMN and DIC. Ritter et al.' obsetved this situation- in' ANLL. Si'milar to Ridci et al.' and Laso et al.5, we ftuiind BMN and DIC in two cases of genetalized carcinomna. In the bone marrow and of DIC of patient 1, carcinoaMtous microaigiopathy was associated with the obliteration of-the marrow microcirculation with the numerous fibrini microthrombi. The treatmetif afDIC with heparin under the condition of BMN and carcinomatous micmoangiopathyo showed only limited effect: 'According to Knupp-et' aL9, the tumour necrosis factor 'ativft in plasma probably 'played a 'potential role in the development of BMN in patients with disseminated cancer. In view of the fact that subclinical, frequently unrecognized, DICG oecurs often in most of the diseases which are occasionally also complicated with BMN, it is necessary to pay morel attention to such association of these two processes.
Table 1. Laboratory parameters of the patients Case 1 (female, 39 years):. disseminad gastric carcinoma
Case 2 (ma7e, 48 years): disseminated carcinoma of unknown primary source
At, the time of BMN ,dignosis
At the time of
Haemoglobin (g/l) Reticulocyte (0.005-0.020) WBC count (x109/l) Platelet count (x109/l) Leucoerythroblastic picture Indirect bilirubin (
