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Leukemoid Reaction in Association with Bone Marrow Necrosis Due to Metastatic Prostate Cancer

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Leukemoid Reaction in Association with Bone Marrow Necrosis Due to Metastatic Prostate Cancer □ CASE REPORT □ Leukemoid Reaction in Association with Bone Marrow Necrosis due to Metastatic Prostate Cancer Taichi AZUMA, Ikuya SAKAI,Takuya MATSUMOTO, Akira OZAWA*, Nozomu TANJI*, Akito WATANABE**, Naoyuki UCHIDA, Hirosi NARUMI, Yoshihiro YAKUSHIJIN, Takaaki HATO***, Masaki YASUKAWA and Shigeru FUJITA Abstract While immature neutrophils such as chronic myeloid leuke- mia (CML) have decreased LAP, stimulated neutrophils such An 80-year-old man presented to the internist with as in a leukemoid reaction or infection have increased LAP fever, fatigue and leukocytosis up to 66.8×103 /l. Al- scores. We report here a case of marked leukocytosis with though a chronic myelogenous leukemia was initially sus- bone marrow necrosis in a patient with prostate cancer, who pected, he was diagnosed as metastatic bone marrow was initially suspected as CML because of a decreased LAP tumor with bone marrow necrosis from primary prostate score. cancer on the basis of the clinical and pathological find- ings. The serum concentrations of IL-6 and TNF-were Case Report mildly elevated to 65.0 pg/ml and, 54.0 pg/ml respec- tively. It is probable that these humoral factors were par- An 80-year-old man with fever, anorexia, and general fa- tially responsible for the leukemoid reaction although tigue had a medical examination at a regional hospital. CML other factors induced by the bone marrow necrosis with was suspected because of marked leukocytosis. He was re- bone marrow metastasis of prostate cancer are also likely ferred to our hospital for additional investigation and treat- involved. ment. On admission, physical examination showed mild (Internal Medicine 44: 1093–1096, 2005) swelling of prostate with digital rectal examination. No lymphadenopathy or hepatosplenomegaly was detected. Key words: leukocytosis, LAP score, TNF-,IL-6 Hematological findings were as follows: white blood cells, 66,800/l (1.5% myeloblasts, 24.5% myelocytes, 4.5% meta- myelocytes, 54% neutrophils, 2% eosinophils, 4% basophils, 3% monocytes, 6% lymphocytes, 0.5% atypical lympho- Introduction cytes); hemoglobin, 10.4 g/dl; platelets, 32.4×104/l. In addi- tion, 1.5 erythroblasts per 100 white cells were counted on Leukemoid reaction is defined as a reactive leukocytosis smears of the peripheral blood. Coagulation test revealed ele- in excess of 7.5×103/l. It is caused by an exaggerated mye- vated fibrin degradation products and D-dimer. Lactate loid response to several stimuli including infections, aller- dehydrogenase (LDH) level and alkaline phosphatase (ALP) gies, burns, intoxications, acute hemorrhage, malignant level was 1,028 IU/ml (normal: 85–253) and 965 IU/ml (nor- neoplasms and certain drugs including corticosteroids and mal: 104–338), respectively. LAP score was 130.0 (normal: lithium. In the absence of lymphadenopathy, organomegaly, 169.5–335.0). A bone marrow aspirate from the sternum basophilia, or eosinophilia, a high leukocyte alkaline showed myeloid hyperplasia without abnormal morphologi- phosphatase (LAP) score initially favored the diagnosis of a cal appearance. Neither excess of blasts nor abnormal cells leukemoid reaction. LAP is an enzyme present in the cyto- was found. Cytogenetic studies were normal karyotype and plasmic microsomes of neutrophils, bands, metamyelocytes bcr/abl fusion transcript was not observed by reverse trans- and myelocytes but not of lymphocytes or monocytes. A cription-polymerase chain reaction. Diagnosis of a leuke- LAP score is usually requested in cases of neutrophilia (1). moid reaction was established. In the absence of infection, a From the First Department of Internal Medicine, *the Department of Urology, Ehime University School of Medicine, Ehime, **Ehime Prefectural Imabari Hospital, Ehime and ***the Division of Blood Transfusion, Ehime University School of Medicine, Ehime Received for publication February 16, 2005; Accepted for publication June 18, 2005 Reprint requests should be addressed to Dr. Taichi Azuma, the First Department of Internal Medicine, Ehime University School of Medicine, Shitsukawa, Toon, Ehime 791-0295 Internal Medicine Vol. 44, No. 10 (October 2005) 1093 AZUMA et al Ａ Figure 1. Bone marrow aspiration from the posterior iliac crest shows bone marrow necrosis (May-Grünwald-Giemsa staining, ×100). search for an occult malignancy was mandatory. The serum level of prostate-specific antigen (PSA) was elevated to 330.2 ng/ml (normal: less than 4 ng/ml). A bone scintigraphy showed multiple uptakes, which suggested bone metastases. A bone marrow aspiration and biopsy from the posterior iliac crest showed bone marrow necrosis (Fig. 1) and invasion by a small round tumor, positive for PSA staining, respectively (Fig. 2). On the basis of these clinical and pathological find- ings, we diagnosed the case as metastatic bone marrow tumor with bone marrow necrosis from primary prostate can- cer. To examine the cause of leukocytosis, multiple cytokine levels in serum were measured. The serum concentrations of cytokines, including interleukin (IL)-1, IL-1, IL-3, Ｂ granulocyte colony-stimulating factor (G-CSF), and granulo- Figure 2. Histopathologic features of bone marrow biopsy cyte-macrophage colony-stimulating factor (GM-CSF), were specimen. (A) Small round tumor cells are localized in the bone unremarkable. In contrast, the serum concentrations of IL-6 marrow tissues (HE stain, ×100). (B) Immunohisto-chemical and tumor necrosis factor (TNF)-were elevated to 65.0 staining with PSA antibody (×400). pg/ml (normal level, 8.0 pg/ml) and, 54.0 pg/ml (normal level, 5.0 pg/ml), respectively. Antiandrogenic therapy with oral chlormadinone acetate following subcutaneous injection the range of 12–30×103/l, although levels as high as 100× of goserelin acetate as luteinizing hormone releasing hor- 103/l have been reported (10). It is likely that such leuke- mone (LH-RH) analogue was started. The clinical course is moid reactions are mediated by tumor-related cytokines, in- shown in Fig. 3. After the above hormone therapies were ad- cluding GM-CSF, IL-1, IL-6 and G-CSF (11–14). ministered, he was afebrile and progressed faborably. Nevertheless, the fact that no detectable cytokines can be Leukocyte count of peripheral blood and PSA level declined found in other cases suggests that carcinoma-related neutro- to the normal range immediately and remained stable over phil leukocytosis may be induced by mechanisms other than the subsequent 4 months. those described above. Typically, tumor-associated leuke- moid reactions reflect an aggressive underlying clinical Discussion course and both diagnoses are often established simultane- ously (15). Neutrophilia is frequently seen in large cell lung cancer Bone marrow necrosis is defined as the destruction of (2), although it has been reported in association with a vari- hematopoietic tissue and marrow stroma with preservation of ety of tumors (3–7), particularly in the presence of marrow bone (16, 17). Most frequently, it is caused by failure of involvement (8, 9). The leukocytosis is usually modest, in bone marrow microcirculation. It is a complication in a wide 1094 Internal Medicine Vol. 44, No. 10 (October 2005) Leukocytosis in a Patient with Prostate Cancer Figure 3. Clinical course. WBC: white blood cells, Hb: hemoglobin, PLT: platelets, PSA: prostate-specific antigen. spectrum of diseases, most frequently of malignancies, and is that the low LAP activity reflects incomplete maturation of only rarely diagnosed ante mortem. Clinically, it is charac- granulocytes, which is related to serum G-CSF levels (25). A terized by fever and bone pain usually located in the lower negative feedback mechanism exists between peripheral back. A leukoerythoblastic picture in peripheral blood, neutrophils and serum G-CSF levels in the chronic phase of pancytopenia and increased levels of LDH and ALP are the CML, and that low levels of G-CSF in the chronic phase of most frequent laboratory signs. Bone marrow necrosis is a CML might be an important factor in the low LAP score rare event and is associated mainly with a neoplastic process (26). In accordance with this notion, the LAP activity in involving the bone marrow. Hematologic malignancies are polymorphonuclear leukocytes from patients with CML is the neoplasms most commonly related to bone marrow ne- enhanced by the addition of G-CSF in vitro (27). Generally, crosis (18). As for non-hematologic malignancies, tumors of the LAP activity in cancer patient is varied in the various dis- the stomach are the most often described, excluding tumors ease states (28, 29). In the present patient, the low LAP score of unknown origin (19). seems to be caused by the low level of serum G-CSF (14 In the present case, the serum concentrations of IL-1, IL- pg/ml) in comparison with neutrophil counts as well as in 1, IL-3, G-CSF, and GM-CSF, were unremarkable. In con- CML. To our knowledge, this is the first case of leukemoid trast, the serum concentrations of IL-6 and TNF- were reaction with bone marrow necrosis in a patient with prostate mildly elevated. TNF, a macrophage secretory protein pro- cancer. duced by peripheral blood monocytes from patients with cancer, has been shown to possess cytotoxicity toward tumor References cells in vitro (20). The correlation between bone marrow ne- crosis in patients with cancer and TNF in plasma has been 1) Bendix-Hansen K, Bergmann OJ. Evaluation of neutrophil alkaline reported (21, 22). On the other hand, it was reported that IL- phosphatase (NAP) activity in untreated myeloproliferative syndromes 6 caused leukocytosis related to several malignancies. and in leukaemoid reactions. Scand J Haematol 35: 219–224, 1985. 2) Ascensao JL, Oken MM, Ewing SL, Goldberg RJ, Kaplan ME. Leukocytosis is considered the result of elevated IL-6 in con- Leukocytosis and large cell lung cancer. A frequent association. Cancer nection with parathyroid hormone-related protein secreted 60: 903–905, 1987. primary tumor or with necrotic tissue involved tumor cells 3) de Wolff JF, Planken EV, den Ottolander GJ. Extreme leucocytosis and (23).
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