Bone Marrow Involvementas the Initial Presentation of Breast Cancer

Narjust Duma MD^1, , Zhen Wang MD¹ and Claudia Miranda MD¹

¹Internal Medicine Department, Rutgers-New Jersey Medical School, Newark, New Jersey, United States

Cite this paper

Narjust Duma MD, Zhen Wang MD and Claudia Miranda MD. Bone Marrow Involvementas the Initial Presentation of Breast Cancer. American Journal of Medical Case Reports. 2015; 3(6):177-180. doi: 10.12691/AJMCR-3-6-8

Abstract

Breast cancer has a predilection for spreading to the bone, brain, liver and lung, however metastasis to bone marrow resulting in bone marrow failure is considered rare. Here, we discuss a case of breast cancer presenting with bone marrow involvement and diffuse bone lytic lesions. The patient was an81 year old female presenting with back pain in the lumbar region for four months, progressively worsening despite physical therapy and oral analgesics. She was referred for magnetic resonance image which revealed diffuse bone lytic lesions. Follow up computed tomography of chest, abdomen and pelvis confirmed bone lesions but was negative for any primary malignancy. Peripheral blood studies showed white blood cell count of 4.5x 10³/µL, hemoglobin of 6.6g/dL, hematocrit of 21% and platelet count of 120.000/µL. She also had renal dysfunction with creatinine of 1.41mg/dL and calcium of 9.8mg/dL. Due to concern for a plasma cell neoplasia, the patient was referred to our oncology clinic. Physical examination was unremarkable and peripheral blood studies revealed IgG 1411mg/dL, IgA 292mg/dL, IgM 122mg/dL with undetectable serum and urine M spikes. She underwent a bone marrow biopsy which was negative for multiple myeloma but showed a neoplastic component in the marrow (approximately 5%) positive for Pan-Keratin, GATA3, ER and Cyclin D1, consistent with mammary carcinoma. During further questioning, she reported a normal screening mammogram one year prior to the onset of symptoms. Positron emission tomography (PET)was remarkable for extensive bony metastatic disease and a heterogeneous hyper-metabolic adrenal mass concerning for metastasis. She was started on endocrine therapy with a daily aromatase inhibitor and monthly Denosumab for bone metastasis. At her six month follow up, PET-scan showed stable disease. Currently, she remains on the same hormonal regimen with monthly follow up at the oncology clinic.

Keywords

metastatic breast cancer, bone marrow involvement, plasma cell neoplasm, cytopenias

Copyright

This work is licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/

References

[1]	Cancer statistics, J Natl Cancer Inst 2011 May 4; 103(9): 714.
[2]	Kopp, Hans-Georg, et al. "Symptomatic bone marrow involvement in breast cancer–clinical presentation, treatment, and prognosis: a single institution review of 22 cases." Anticancer research 31.11 (2011): 4025-4030.
[3]	Delsol G, Guiu-Godfrin B, Guiu M, Pris J, Corberand J, Fabre J: Leukoerythroblastosis and cancer frequency, prognosis, and physiopathology significance. Cancer 44: 1009-1013, 1979.
[4]	Braun S, Pantel K, Muller P, Janni W, Hepp F, Kentenich CR, Gastroph S, Wischnik A, Dimpfl T, Kindermann G, Riethmuller G and Schlimok G: Cytokeratin-positive cells in the bone marrow and survival of patients with stage I, II, or III breast cancer. N Engl J Med 342: 525-533, 2000.
[5]	Freyer, Gilles, BlandineLigneau, and VéroniqueTrillet-Lenoir. "Palliative hormone therapy, low-dose chemotherapy, and bisphosphonate in breast cancer patients with bone marrow involvement and pancytopenia: report of a pilot experience." European journal of internal medicine 11.6 (2000): 329-333.
[6]	Rubins JM: The role of myelofibrosis in malignant leukoerythroblastosis. Cancer 51: 308-311, 1983.
[7]	ShamdasGJ, Ahmann FR, Matzner MB and Ritchie JM: Leukoerythroblastic anemia in metastatic prostate cancer.Clinical and prognostic significance in patients with hormonerefractory disease. Cancer 71: 3594-3600, 1993.
[8]	Lewanski, Conrad R., et al. "Bone marrow involvement in breast cancer detected by positron emission tomography." Journal of the Royal Society of Medicine 92.4 (1999): 193.
[9]	Zhao, Jian, et al. "MRI of the spine: image quality and normal–neoplastic bone marrow contrast at 3 T versus 1.5 T." American Journal of Roentgenology 192.4 (2009): 873-880.
[10]	Hanrahan, Christopher J., and Lubdha M. Shah. "MRI of spinal bone marrow: part 2, T1-weighted imaging-based differential diagnosis." American Journal of Roentgenology 197.6 (2011): 1309-1321.
[11]	J.N. Ingle, D.C. Tormey, J.M. Bull, et al. Bone marrow involvement in breast cancer: effect on response and tolerance to combination chemotherapy Cancer, 39 (1977), pp. 250-257.
[12]	R. Rodriguez-Kraul, G.N. Hortobagyi, A.U. Buzdar, et al. Combination chemotherapy for breast cancer metastatic to bone marrow Cancer, 48 (1981), pp. 227-238.
[13]	Ardavanis, A., et al. "Low-dose Capecitabine in Breast Cancer Patients with Symptomatic Bone Marrow Infiltration: A Case Study." Anticancer research28.1B (2008): 539-541.
[14]	G.N. Hortobagyi, T.L. Smith, S.S. Legha, et al. Multivariate analysis of prognostic factors in advanced breast cancer J ClinOncol, 1 (1983), pp. 1776-1782.
[15]	Gebauer G, Fehm T, Merkle E, Beck EP, Lang N and Jager W: Epithelial cells in bone marrow of breast cancer patients at time of primary surgery: clinical outcome during long-term follow up. J ClinOncol 19: 3669-3674, 2001.