Page 57 - Haematologica Atlas of Hematologic Cytology

CHAPTER 7 - Bone marrow necrosis
Chapter 7. BONE MARROW NECROSIS
Bone marrow necrosis is a well-described pathological entity related to the death of bone marrow stromal and hemopoietic cells. It has a 0.5-30% incidence in bone marrow biopsies, but only in 3% of cases it is severe and, very rarely, massive (Wool and Deucher, 2015). Table 1 reports the causes of this condition.
Table 1. Causes of bone marrow necrosis.
Hematologic neoplasms (leukemias, especially lymphoblas c, and lymphomas)
Adenocarcinomas
Sepsis
Disseminated intravascular coagula on
Radia on and myelotoxic agents
Chronic disorders (in ammatory, autoimmune, an phospholipid an bodies, infec ous, dysmetabolic)
Sickle cell anemia
The pathophysiology of marrow necrosis is not known. The release of either toxins or soluble mediators by malignant or inflammatory cells may be an important etiological factor. Cytokines as tumor necrosis factor (TNF) may induce expression of leukocyte adhesion receptors on endothelial cells, granulocyte activation with genera- tion and release of superoxide, and a prothrombotic effect on endothelial cells with consequent ischemia of the marrow.
The clinical picture is generally dramatic, and when bone marrow necrosis occurs at onset the diagnosis of the underlying disease may be extremely difficult. Bone pain and fever are frequently experienced and extra-medul- lary hematopoiesis may be present.
In severe cases, pancytopenia and leukoerythroblastosis are usually found. Bone marrow necrosis is more often noted in trephine sections than in aspirates. Often, only scanty amounts are obtained in marrow aspirates, and the necrotic cells, mixed with those intact ones, are often dismissed as an artefact. Trephine sections show that in necrotic areas the marrow architecture is destroyed and the supporting connective tissue is absent. All cells are scattered in a background of amorphous eosinophilic material; in several cases increased fibrosis is ob- served.
In the past, scintigraphy was typically used to evaluate the extent of marrow necrosis, but MRI is now prefer- red.
A differential diagnosis should be made with diffuse metastatic carcinoma, primary myelofibrosis and throm- botic thrombocytopenic purpura.
Reference
Wool GD, Deucher A. Bone marrow necrosis: ten-year retrospec ve review of bone marrow biopsy specimens. Am J Clin Pathol. 2015;143(2):201-213.
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