Bone marrow necrosis caused by metastatic colon cancer.

A 37-year-old man presented to our clinic complaining of bloody stool passage over the previous week. Colonoscopy found a mass over the sigmoid colon, and a biopsy disclosed adenocarcinoma. A hemogram revealed anemia and thrombocytopenia. Low anterior resection and transverse loop colostomy were performed after aggressive platelet transfusion. Blood clots passed from the colostomy persistently after the surgery. Laboratory data revealed elevated concentration of D-dimer (6562 ng/mL), progressive anemia, and profound thrombocytopenia (19,000/ L) 6 days after the operation. The patient complained of regional soreness and pain over the long bone area. A whole-body bone scan revealed inconclusive bony metastasis. The histological findings of a bone marrow biopsy revealed extensive marrow necrosis with few surviving cancer cells (Fig 1A). The cancer cells stained positively for p53 (Fig 1B, arrows). The patient was treated with cetuximab plus oxaliplatin, fluorouracil, and leucovorin. During the first month after the start of treatment, the passage of blood clots decreased gradually and the platelet count returned to normal. Despite treatment, the patient died of disease progression 3 months later. Bone marrow necrosis is a syndrome first reported by Wade and Stevenson in 1941. The typical findings are necrosis of myeloid tissue and medullary stroma leaving an amorphous eosinophilic background, ill-defined necrotic cells, and preserved cortical bone. The pathophysiology of bone marrow necrosis is still unclear. Failure of the microcirculation accompanied by hypoxemia causes damage to the cells. The toxicity and the release of toxins, cytokines, or vasoactive substances from the injured cells play an important role in the pathophysiology of bone marrow necrosis. The incidence of bone marrow necrosis is low. It has been reported in association with infection, sickle-cell anemia, hematological malignancy, and solid tumors. Hematological malignancy is the most common cause of the bone marrow necrosis. The prognosis in patients with bone marrow necrosis is poor. Most patients presented with symptoms of bone pain, fever, and fatigue. Laboratory tests usually disclose anemia and thrombocytopenia. Both bone x-rays and bone scans are usually normal, except in patients with metastatic disease. Colon cancer with bone marrow necrosis had rarely been reported before. Here we reported a case of colon cancer presenting with bone marrow necrosis. The patient died despite aggressive chemotherapy. To conclude, bone marrow necrosis is a rare entity and has a poor prognosis.