Introduction

Bone marrow biopsies are frequently done for histologically documented malignancies for staging and also in suspected malignancies Bone marrow involvement by solid tumor implicates advanced disease and bad prognosis [1 ]. The tumours most frequently detected in bone marrow biopsies in adults are carcinoma of the breast, lung, prostate stomach colon, kidney and thyroid gland.[2],[3]. Among adult solid tumours, involving bone marrow, breast carcinoma is common in women and prostatic carcinoma in men [3],[4]. The Metastases of solid tumours in the bone marrow are rarely reported, and laboratory findings and clinical presentations are not characteristic [4].

Marrow involvement by Sarcomas is relatively low and tumour cells are invariably seen in groups or clusters. They are generally sharply demarcated, and look alien to the marrow environment [3], [5]. Sometimes marrow involvement is focal and the yield of marrow biopsies is increased by the amount of tissue obtained. [4]

The final step in cancer progression is metastasis and most cancer patients die from metastasis and not from primary disease. [5],[6],[7]. In this study, we attempted to study the haematological picture and clinical picture morphological /IHC in patients with metastasis. This is the study of solid tumors, and metastasis to bone marrow, The period of study was 7 years (2006-2013), from a regional cancer center in India.

Materials and Methods

We at Kidwai Cancer Center retrospectively analysed, medical records of patients with bone marrow metastasis suspected to have non-haematological malignancies and were referred to the Department of Pathology between January 2006 to January 2013, patients records included history, general physical examination, laboratory and radiological data blood and BMA /Biopsy as well as IHC staining. Also, haematological malignancies, lymphoma, and SRCT were excluded in this study. Haemogram details were reviewed. Bone marrow was obtained from the posterior iliac crest by Jamshidi needle. Bone marrow smears and peripheral smears and stained by Romanowsky stains, Bone marrow biopsies were stained with hematoxylin and eosin.

Figure 1: On H&E 20x Bone Marrow smears showing Metastatic carcinoma breast

Figure 2: On H&E 20x Bone Marrow smears showing metastatic prostatic carcinoma

We didn’t have any dry tap, carcinoma breast metastatic to marrow had fibrosis. , was a very difficult differential diagnosis of myelofibrosis. There could be difficulty in a few cases which resemble hematopoietic origin because of the giant cells, resembling megakaryocytes.

Figure 3: Metastatic Carcinoma prostate cells in High power

Figure 4: Metastatic Carcinoma prostate cells in low-power, glandular pattern

In the current study, marrow was said to be involved in any one of these had showed metastatic cells. The clinical and prognostic significance of leucoerythroblastic anemia in patients with metastatic prostatic cancer and general patients with disseminated solid tumors is not understood clearly. Leucoerythroblastic anemia has greater transfusion requirements .breast carcinoma involving marrow, the majority were infiltrating duct carcinoma, and bone marrow metastasis in gastric cancers are generally seen in younger patients and poorly differentiated tumours. The prognosis is worsened with poor histology and pancytopenia. Among adult solid tumors, involving bone marrow, the breast is common in women and prostatic carcinoma in men. Many cancers especially carcinoma breast and carcinoma prostate are associated with marked desmoplastic reaction, the reason for dry tap in a few cases. Also is a very difficult differential diagnosis from myelofibrosis. Some cases marked osteosclerosis.[3],[14 ]

Immunohistochemistry may be useful in recognizing some tumors in the marrow .routine IHC is not necessary for detecting marrow involvement. However, IHC may be required when individual tumour cells are scattered in the marrow, especially in invasive lobular carcinoma. [14],[15]. In the current study, all the cases of carcinoma breast were infiltrating duct carcinoma. It's always better to compare the H&E if the foci of metastasis are very small with the IHC reaction.[14] Many studies have confirmed that Molecular markers increase the detection rate of metastasis [16 ] our study lacked the molecular techniques. Immunological quantification of the metastatic cells in bone marrow also is being done. The coexistence of solid tumors and bone marrow metastasis is associated with a deteriorating clinical course and poor prognosis.[3], [4]. The approach to unknown primary lesions should be the same as metastatic lesion analysis in other sites. [8],[14],[15],[16], due to financial constraints our study couldn’t use extensive IHC panels, however, the possibility of neuroendocrine, carcinoma, breast carcinomas, and cancer prostate was suggested in the limited IHC panel.

Immunohistochemistry was done and it showed Synaptophysin and chromogranin expression. In Neuroendocrine carcinomas, breast carcinoma involving marrow showed CK and ER positivity, and prostatic carcinomas showed positivity for CK and positivity for PSA in a case.