Advanced Breast Cancer First Diagnosed on Bone Marrow Biopsy

Kathleen Louden

September 25, 2013

CHICAGO — Bone marrow biopsy specimens can identify previously undiagnosed metastatic breast cancer, according to a new clinicopathologic study.

Although this situation is rare — with a frequency less than 0.2% — pathologists should be aware of the potential, said lead investigator Yaolin Zhou, MD, a third-year pathology resident at the University of Alabama at Birmingham.

All 3 of the women whose bone marrow biopsy led to an initial diagnosis of breast cancer presented with new-onset cytopenias, Dr. Zhou told Medscape Medical News.

"Despite all the medical advances today, unexplained new-onset cytopenias can be indicative of metastatic tumor," she explained. "Clinicians and pathologists should be aware of this possibility."

Dr. Zhou said her team's research is the first major North American study since the late 1970s, when 2 studies evaluating the involvement of bone marrow in solid tumors were published in Cancer (1977;39:1337-1344 and 1978;42:2373-2378).

She presented the new findings here at the American Society for Clinical Pathology 2013 Annual Meeting.

The retrospective study involved 7702 bone marrow biopsies performed at the University of Alabama.

Despite all the medical advances today, unexplained new-onset cytopenias can be indicative of metastatic tumor.

The investigators studied original pathology reports and slides stained with hematoxylin and eosin to document the extent of bone marrow involvement in breast cancer, and then correlated the findings with laboratory and clinical data.

They found 14 (0.18%) histologically confirmed cases of metastatic breast cancer.

There was no statistical correlation between the extent of bone marrow involvement and the degree or number of cytopenias or survival after biopsy, which was a median of 13.5 months.

Eleven of the 14 women (78.6%) were bicytopenic or pancytopenic, and most biopsy results showed extensive metastatic involvement of the bone marrow (median, 87.5%), the investigators note.

Three of the 14 women (21%) presented with new-onset cytopenias.

One of the women had a white blood cell count below 4000/μL indicating leukopenia, a platelet count below 150 × 10³/μL indicating thrombocytopenia, and masses in both breasts.

The second woman had fatigue, borderline anemia (hemoglobin level <11.3 g/dL), and thrombocytopenia, and was initially suspected of having leukemia or lymphoma.

The third woman had anemia and multiple lytic skeletal lesions; her physician initially thought she had multiple myeloma.

On the basis of these findings, Dr. Zhou recommends that pathologists search even routine bone marrow biopsy specimens for the presence of metastatic carcinoma.

"It's not common when you're looking at a bone marrow biopsy specimen to look for breast cancer," she said.

Saad Shaheen, MD, a pathologist at the Veterans Affairs Medical Center in Louisville, Kentucky, who was asked by Medscape Medical News to comment on the findings, said he agrees.

He noted that common indications for bone marrow biopsy include anemia of an unknown cause, cytopenia, and leukemia or lymphoma.

Of the cytopenias reported in the cases of undetected breast cancer, Dr. Shaheen said a low platelet count is probably the most meaningful warning sign of metastatic cancer to the clinician.

Dr. Shaheen added that he is unclear how a breast cancer can metastasize to the bone marrow before being diagnosed. "There could be an element of denial on the patient's part," he noted.

Dr. Zhou and Dr. Shaheen have disclosed no relevant financial relationships.

American Society for Clinical Pathology (ASCP) 2013 Annual Meeting: Scientific poster 1-59. Presented September 19, 2013.


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