How I investigate bone marrow necrosis

Abstract

Hematopathologists encounter bone marrow biopsy specimens with marrow necrosis relatively infrequently; when necrosis is seen, determining the clinical significance can be challenging. While bone marrow necrosis is not uncommon in site‐directed biopsy specimens or autopsy material, substantial necrosis is much less common in nondirected bone marrow biopsy specimens. Retrospective review showed the prevalence of bone marrow necrosis to vary between 0.3% and 2% antemortem, depending on the patient population. Numerous causes of bone marrow necrosis have been identified, including malignancy, radiation/chemotherapy, medication, infection, autoimmune disease, disseminated intravascular coagulation, antiphospholipid syndrome and other thrombotic disorders, granulocyte‐colony stimulating factor (G‐CSF) exposure, and hemoglobinopathies. Clinical findings associated with bone marrow necrosis include bone pain and fever, cytopenias, elevated LDH and ferritin, and leukoerythroblastosis. Rarely, such as in fat embolization syndrome (FES), bone marrow necrosis can be associated with thrombotic microangiopathy, neurologic dysfunction, and multiorgan failure. A thorough review of the patient's clinical record (including medical history, clinical presentation, and other laboratory findings), a thorough morphologic review of the bone marrow with appropriate ancillary stains, and an appreciation of the causes of bone marrow necrosis in different patient populations are required to determine the underlying cause of bone marrow necrosis. The purpose of this review is to present a strategy for evaluation of bone marrow necrosis found in an antemortem biopsy specimen.

Bone marrow necrosis in pediatric malignancies: 10‐Year retrospective review and review of literature

“…BMN is an exceedingly rare pathologic finding in children 1,2 . Diagnosis is made when areas of a biopsy lack normal architecture, with shadows of cells and cellular debris without connective tissue 3 . The pathophysiology is thought to be secondary to tissue hypoxia due to inadequate blood supply 13 .…”

“…Bone marrow necrosis (BMN), defined as the death of the medullary stroma with preservation of the cortical bone, is a rarely reported finding in the pediatric population 1 . There are various etiologies for BMN including medications, radiation, infection, autoimmunity, and sickle cell disease 1–8 . However, the vast majority (≈99%) are associated with malignancies 1–3,9–12 .…”

“…1 There are various etiologies for BMN including medications, radiation, infection, autoimmunity, and sickle cell disease. [1][2][3][4][5][6][7][8] However, the vast majority (≈99%) are associated with malignancies. [1][2][3][9][10][11][12] BMN is encountered more frequently in adults.…”

Bleeding in Patients with Antiphospholipid Antibodies

“…Other pathomechanisms may occasionally contribute to thrombocytopenia in aPL-positive patients. The association, albeit anecdotal, between aPL and the hemophagocytic syndrome (a hyperinflammatory disorder with pathological phagocytosis of blood cells and their precursors in the bone marrow and other tissues) and bone marrow necrosis was described [17,18]. These disorders decrease platelets via impairing megakaryopoiesis.…”

Unexpected and Deadly: Three Cases of Bone Marrow Necrosis

“…Characterized by the disruption of the reticular bone marrow pattern with preservation of cortical bone, bone marrow necrosis (BMN) is a rare pathological diagnosis that portends a poor prognosis. Although more commonly described during autopsies, 0.3% to 2% of cases are diagnosed antemortem [1,2]. It is most often associated with hematological malignancies and less commonly from metastatic solid tumors, infections, medications, sickle cell disease, chemotherapy, radiotherapy, or idiopathic causes [3,4].…”