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Anemia in malignant tumors and their multiple metastases in the bone marrow
The cause of the anemic condition in malignant tumors can be the following factors: 1) the toxic effect of the malignant tumor on erythropoiesis; 2) bleeding due to decay of the tumor and rupture of blood vessels; 3) secondary joining infection; 4) an erythropoiesis disorder due to bone marrow metastases; 5) achilia (with cancer of the stomach) and the associated violation of the assimilation of antianemic substances and iron; 6) liver damage (with metastases or with primary liver cancer).
Particular consideration is required for anemia in cancerous bone marrow metastases.
Most often, cancer of the prostate, breast, stomach, lungs, thyroid gland, kidneys (hypernephroma) metastases in the bone. When a malignant tumor is metastasized to the bone marrow, anemic syndrome occupies a major place in the clinical picture of the disease. The initial focus of the process - the tumor that caused the dissemination of cancer through the bones, is often so small that it remains as if in the shade and is not determined by any research methods. Distinctive features of this anemia are an unusually pronounced erythro- (normo) blastosis and a leukemoid blood picture. However, in 1/3 of cases, even with the enormous spread of bone metastases, a leukemoid reaction may be absent.
Not always with cancerous metastases in the bone marrow, the blood picture is so characteristic. We observed extensive cancer metastases in the bone marrow with minor changes in peripheral blood. There is no doubt that the blood picture for cancer metastases in the bone marrow depends not only on the invasive factor - implantation of cancer cells in the bone marrow, but also on the reactivity of the bone marrow. There is no connection between the type of tumor and the nature of the reaction of the bone marrow.
The following types of reactions of the hematopoietic system to cancerous metastases in the bone marrow are distinguished (Dustin).
1. Myeloid reaction (myeloma), characterized by the presence in the blood of young cells of the granulo-and erythropoietic series. Myelia can be observed without severe anemia.
2. Erythroblastic reaction, usually with pronounced anemia. However, in some cases, there is a disproportion between high erythroblastosis and a slight degree of anemia.
3. A leukemoid reaction characterized by high leukocytosis, sometimes with a large number of myelocytes.
4. Pan-hemocytopenic reaction, manifested in a decrease in the number of all blood elements - red blood cells, white blood cells and blood platelets. Similar blood carotene imitates the blood picture in panmyelopathies (aplastic anemia, panmyelophthis).
5. Anemic reaction without the appearance in the peripheral blood of young (immature) elements.
According to our observations, two more must be added to these forms: 1) hemorrhagic and 2) hemolytic.
The pathogenesis of each of these forms is complex.
The hemorrhagic form of bone marrow carcinosis is primarily associated with thrombocytopenia and associated with the latter hemogenic syndrome (impaired retraction of a blood clot, prolonged duration of bleeding). G.A. Dashtayants leads 7 cases of carcinosis to the bone marrow, which imitated Werlhof's symptom complex. In the case described by us (1953), in a patient with diffuse bone marrow carcinosis due to metastases of gallbladder cancer, hemorrhagic syndrome proceeded according to the hemophilic type, with reduced blood coagulation.
The hemolytic form of bone marrow carcinosis proceeds as acquired hemolytic anemia and jaundice with predominantly intracellular hemolysis, but without a pronounced enlargement of the spleen.
In the case we observed, a decreased resistance of red blood cells with spherocytosis was observed with a negative Coombs reaction. The literature describes cases that occurred as Markiathav syndrome - with intravascular hemolysis, hemoglobinuria and hemosiderinuria, but with a positive Coombs reaction.
Osteolytic and osteoplastic forms of bone marrow carcinosis are distinguished by the nature of the reaction of the surrounding bone tissue to cancer metastases.
Sometimes there is a significant difficulty or inability to puncture the sternum in case of cancerous osteosclerosis. Sometimes punctate is obtained without an impurity of blood, which makes it difficult to make smears (you have to resort to crushing the resulting piece of tissue between two glasses). The search for cancer cells should be carried out at low magnification; found groups of cells are identified under the immersion system. Most often, osteoplastic forms of carcinosis are found in metastases of gastric cancer.
The cytological diagnosis of cancer cells in sternal punctate is not particularly difficult. The most important sign of cancer cells is their atypia in relation to the surrounding myeloid tissue. In general, cancerous metastasis to the bone marrow is recognized not only on the basis of the study of individual cells (because the morphology of cancer cells is very diverse and depends on the type of neoplasm), but also on the basis of findings of cell clusters or cords consisting of atypical, i.e., non-bone marrow tissue . Along with atypical cells uncharacteristic of bone marrow, whose membership in metastases is not in doubt, neoplastic cells are found in bone marrow punctate, which undergo some kind of metaplasia in the bone marrow, acquiring some properties of myeloid elements, in particular, azurophilic granularity. In some cases, a single cancer cell may resemble either a giant reticular cell (such as a Sternberg cell) or macroscopic hemocytoblast.
With diffuse bone marrow metaplasia with foreign tissue, the blood picture may approach that observed in acute myelogenous leukemia. This was the case with the patient we observed, in which lung cancer was accompanied by diffuse metastasis to all bones: in the blood there were many undifferentiated cells such as micromyeloblasts, and bone marrow puncture was made up of elements of small cell cancer. In general, the differential diagnosis of bone marrow carcinosis with systemic lesions, especially in the presence of a leukemoid blood picture, presents significant difficulties. The diagnosis becomes even more difficult in cases of hemorrhagic or hemolytic syndrome, as well as in the presence of an enlarged spleen. The latter is observed with carcinosis or due to metastases in the spleen (which is relatively rare), or due to the development of vicarious blood formation in it, especially with osteoplastic carcinomas. In these cases, the similarity of the disease with systemic lesions of blood formation becomes even more pronounced.
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Anemia in malignant tumors and their multiple metastases in the bone marrow
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