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ORIGINAL ARTICLE
Year : 2018  |  Volume : 14  |  Issue : 9  |  Page : 512-515

Clinical outcome of 30 patients with bone marrow metastases


Department of Hematology and Oncology, The First Affiliated Hospital of The People's Liberation Army General Hospital, Beijing 100048,PR China, P.R. China

Date of Web Publication29-Jun-2018

Correspondence Address:
Jun Zhong Sun
Department of Hematology and Oncology, The First Affiliated Hospital of The People's Liberation Army General Hospital, 51 Fucheng Road, Beijing 100048
P.R. China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.172717

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 > Abstract 

Objective: Cancer patients with bone marrow metastases are rare and dismal. The study was to identify the clinical features and prognostic factors in cancer patients with bone marrow metastases.
Patients and Methods: A total of 30 patients with bone marrow metastases were reviewed between September 2007 and September 2013. Bone marrow metastases were identified by bone marrow aspiration.
Results: The median age was 56.5 years (range, 8–85 years). The two most common primary tumor sites were the stomach (7, 23.3%), breast (5, 16.7%). Bone metastases (27, 90.0%) were the most common concurrent metastases. The most common cause for bone marrow aspiration was anemia and thrombocytopenia (10, 33.3%). The median survival time was 3 months (range, 0.5–82 months). Patients with good performance status (n = 19) had a longer median survival time than patients with poor performance status (n = 11) (8 months vs. 1 months, P = 0.041). Patients with primary unknown origin (n = 5) had a significantly shorter overall survival time than patients with known origin (n = 25) (1 month vs. 6 months = 0.010). The median survival time was 9 months in the systemic therapy group (n = 21) and 1 month in the best supportive care group (n = 9) (P = 0.000).
Conclusion: To make primary origin clear and start systemic antitumor therapy is beneficial for patients with bone marrow metastases.

Keywords: Antitumor therapy, bone marrow metastases, cancer


How to cite this article:
Zhou MH, Wang ZH, Zhou HW, Liu M, Gu YJ, Sun JZ. Clinical outcome of 30 patients with bone marrow metastases. J Can Res Ther 2018;14, Suppl S2:512-5

How to cite this URL:
Zhou MH, Wang ZH, Zhou HW, Liu M, Gu YJ, Sun JZ. Clinical outcome of 30 patients with bone marrow metastases. J Can Res Ther [serial online] 2018 [cited 2019 Jul 17];14:512-5. Available from: http://www.cancerjournal.net/text.asp?2018/14/9/512/172717


 > Introduction Top


Metastatic cancer is a therapeutic challenge to clinicians, especially for patients with bone marrow metastases. The incidence of cancer patients with bone marrow metastases is rare.[1],[2] The most primary sites of cancer patients with bone marrow metastases are breast, prostate, stomach, and lungs.[3],[4] Reports on the clinical features and outcomes of patients with bone marrow metastases are limited. Bone marrow aspiration is not a routine examination in cancer patients, which makes the early diagnosis and systemic therapy of bone marrow metastases difficult. It may be carried out in cancer patients with bone pain or cytopenia.[5],[6] Patients with bone marrow metastases have a dismal prognosis due to a rapid disease progression and a poor response to treatment.[7],[8] The prognostic factors of patients with bone marrow metastases were reported to be the primary tumor site, performance status, platelet count, and therapeutic regimens.[9],[10] No standard treatment of patients with bone marrow metastases is recommended.[11] Many patients with bone marrow metastases receive only supportive care because all possible therapeutic regimens have been tried or because they are too weak to be given any antitumor therapy. It is difficult for clinicians to decide whether patients with bone marrow metastases should receive systemic antitumor therapy or best supportive care. The present analysis was performed retrospectively to study the clinical outcomes and prognostic factors in cancer patients with bone marrow metastases.


 > Patients and Methods Top


A retrospective study was conducted on the patients with bone marrow metastases who were treated in our hospital between September 2007 and September 2013. All diagnoses of bone marrow metastases were identified by bone marrow aspiration. Patients with hematologic malignancies were excluded from the study. Data on patient demographics, primary tumor, Eastern Cooperative Oncology Group performance status (ECOG PS), sites of involvement when bone marrow metastases were detected, the use of systemic antitumor therapy, time of bone marrow metastases from the diagnosis, predominant abnormality that suggested a bone marrow aspiration should be carried out, and survival times, were collected. Synchronous bone marrow metastases were defined before or within 2 weeks after the initial or relapsed cancer diagnosis. Cytotoxic chemotherapy, targeted therapy, or hormone therapy for prostate or breast cancer was regarded as systemic antitumor therapy. The study was approved by the ethics committee of the institute.

Statistics

The basic data were summarized as n (%) for categorical variables and median with range for continuous variables. Overall survival (OS) was the primary endpoint of the study, which was calculated using the Kaplan–Meier method by SPSS 17.0 statistics software (SPSS Inc., Chicago, USA). OS was defined as the time from the date of the bone marrow metastases to the date of death or the end of the study (June 2015). Comparison of survival was performed using the log-rank test. A P <0.05 was considered statistically significant.


 > Results Top


Patient characteristics

A total of 30 patients with bone marrow metastases were included. The clinical characteristics of the patients are shown in [Table 1]. The median age of the patients was 56.5 years (range, 8–85 years). Sixteen (53.3%) patients were male and 14 (46.7%) patients were female. In the 30 patients with bone marrow metastases, 7 (23.3%) patients were diagnosed with gastric cancer, 5 (16.7%) patients with breast cancer, 5 (16.7%) patients with primary cancers of unknown origin, 3 (10.0%) patients with lung cancer, 3 (10.0%) patients with prostatic cancer, 2 patients with neuroblastoma, 1 patient with liver cancer, 1 patient with osteosarcoma, 1 patient with nasopharynx cancer, 1 patient with parotid gland carcinoma, and 1 patient with ovarian cancer. The most common site of concurrent metastases was bone (27, 90.0%), followed by liver (5, 16.7%), lymph nodes (5, 16.7%), brain (3, 10.0%), and ovary (2, 6.7%). The most common cause for bone marrow aspiration was anemia and thrombocytopenia (10, 33.3%), followed by thrombocytopenia (8, 26.7%), anemia (6, 20.0%), hot uptake in bone scan (3, 10.0%), and hot uptake in positron emission tomography-computed tomography (PET/CT) (2, 6.7%). Bone marrow metastases were present in 14 patients at primary cancer or relapsed cancer diagnosis, including 5 patients with unknown primary origin. In the other 16 patients, the median time from the primary or relapsed cancer to the diagnosis of bone marrow metastases was 2.5 months (range, 1–9 months).
Table 1: Patient characteristics

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Survival after bone marrow metastases

The median survival time of the 30 patients with bone marrow metastases was 3 months (range, 0.5–82 months) [Figure 1]. Nineteen (73.3%) patients had an ECOG PS of 0 or 1 (good performance status), whereas 11 (26.7%) patients had an ECOG PS of 2 or 3 (poor performance status). The median survival time was 8 months in the patients with ECOG PS of 0 or 1 (range, 1–82 months) and 1 months (range, 0.5–15 months) in the patients with ECOG PS of 2 or 3 (P = 0.041, [Figure 2]). Five patients with primary cancers of unknown origin survived significantly shorter than the other 25 patients with the known origin (1 months, range 0.5–3 months, vs. 6 months, range 0.5–82 months, P = 0.010, [Figure 3]). Twenty-one patients (70.0%) received systemic antitumor therapy, and nine patients (30.0%) received best supportive care. The median survival time was 9 months (range, 1–82 months) and 1 month (range, 0.5–3 months) in the systemic therapy and best supportive care cohorts, respectively (P = 0.000, [Figure 4]).
Figure 1: Overall survival of all patients

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Figure 2: Overall survival of patients: Good performance status group versus poor performance status group

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Figure 3: Overall survival of patients: Primary unknown origin group versus primary known origin

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Figure 4: Overall survival of patients: Systemic antitumor therapy group versus best supportive care group

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 > Discussion Top


The incidence of cancer patients with bone marrow metastases is low. These patients were not enrolled in clinical trials because of advanced stage, poor performance status, or abnormal laboratory results. Therefore, the clinical features and prognostic factors of these patients remain an issue. The current study was aimed to identify the clinical features and prognostic factors in cancer patients with bone marrow metastases.

Primary tumors in the breast, prostate, stomach, and lungs are the most common cancers with bone marrow metastases. A total of 11 tumor sites were found in our 30 patients cohorts. The top was gastric cancer, followed by breast cancer, cancer with unknown origin, lung cancer, prostatic cancer, etc.; therefore, compared with previous reports,[3],[4] the present study had a comparable constitution of cancer patients with bone marrow metastases.

All patients with bone marrow metastases had evident bone metastases in the study of Kopp et al.[12] A close relationship between bone marrow metastases and bone involvement was also shown in our study. Ninety percent of the patients with bone marrow metastases showed apparent bone metastases. A total of 15 extraosseous organ involvements were confirmed in our series, including five liver metastases, five lymph node metastases, three brain metastases, and two ovary metastases.

In the present study, patients with bone marrow metastases were confirmed by bone marrow aspiration. The actual cases may be underestimated because bone marrow aspiration was able to identify metastases in most patients but not all.[13],[14] Bone marrow biopsy had higher sensitivity than aspiration in finding cancer, and appropriate immunohistochemistry according to the morphology of cancer played a great role in ascertaining origin in patients with primary unknown origin.[15] In line with previous reports,[4],[16] anemia and/or thrombocytopenia were the most common reasons to indicate that bone marrow aspiration should be carried out. In addition, with the improvement of technical procedures, hot uptake in bone scan, or PET/CT was playing an increasingly important role in the diagnosis of bone marrow metastases. In our series, five patients presented with hot uptake in bone scan or PET/CT and without cytopenia were confirmed bone marrow metastases by bone marrow aspiration.

Performance status is a crucial prognostic factor for cancer patients as well as in cancer patients with bone marrow metastases.[10],[17] In our study, patients with poor ECOG PS had a shorter median survival time than patients with good ECOG PS (1 month vs. 8 months, P = 0.041). High tumor burden, severe complications, and intolerance to antitumor therapy may account for the dismal prognosis.

No significant difference of the median OS time was found between patients with primary known and unknown tumor in Kucukzeybek et al. study.[16] In contrast, in the present study, patients with primary unknown origin had a significantly shorter OS time than patients with known origin (P = 0.010). A possible explanation for the difference was that the previous study had a greater percentage of patients with primary unknown origin (32.8% vs. 16.7%) and no specific antitumor therapy could be given.

The median survival time for the entire 30 patients was 3 months (range, 0.5–82 months). The median survival time was 9 months in the systemic therapy group (range, 1–82 months) and 1 month (range, 0.5–3 months) in the best supportive care group (P = 0.000). Accordingly, the prognosis of patients with bone marrow metastases is poor, especially for patients with best supportive care. Hung et al. studied 83 patients with bone marrow metastases;[10] the median survival time was 87 days (95% CI, 2.7–171 days) in the antitumor therapy group (n = 50) and 21 days (95% CI, 13–29 days) in the supportive group (P < 0.000). Similarly, Kucukzeybek et al. studied 39 patients with a known primary origin;[16] the median survival time was 28 days in the best supportive group, and 418 days in the antitumor therapy group (P < 0.005). In spite of the small sample size and retrospective analysis of the study, patients treated with systemic therapy had a much longer survival time than patients with no antitumor therapy. Thus, systemic antitumor therapy should be preferred to choose in cancer patients with bone marrow metastases.


 > Conclusion Top


The positive prognostic factors for patients with bone marrow metastases were good performance status, primary known origin and systemic antitumor therapy. To make primary origin clear and start systemic antitumor therapy is beneficial for patients with bone marrow metastases.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
 > References Top

1.
Kim HS, Yi SY, Jun HJ, Lee J, Park JO, Park YS, et al. Clinical outcome of gastric cancer patients with bone marrow metastases. Oncology 2007;73:192-7.  Back to cited text no. 1
    
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Hung YS, Chou WC, Chen TD, Chen TC, Wang PN, Chang H, et al. Prognostic factors in adult patients with solid cancers and bone marrow metastases. Asian Pac J Cancer Prev 2014;15:61-7.  Back to cited text no. 10
    
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Kusumoto H, Haraguchi M, Nozuka Y, Oda Y, Tsuneyoshi M, Iguchi H. Characteristic features of disseminated carcinomatosis of the bone marrow due to gastric cancer: The pathogenesis of bone destruction. Oncol Rep 2006;16:735-40.  Back to cited text no. 11
    
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Kopp HG, Krauss K, Fehm T, Staebler A, Zahm J, Vogel W, et al. Symptomatic bone marrow involvement in breast cancer – Clinical presentation, treatment, and prognosis: A single institution review of 22 cases. Anticancer Res 2011;31:4025-30.  Back to cited text no. 12
    
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Nanda A, Basu S, Marwaha N. Bone marrow trephine biopsy as an adjunct to bone marrow aspiration. J Assoc Physicians India 2002;50:893-5.  Back to cited text no. 14
    
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Mishra P, Das S, Kar R, Jacob SE, Basu D. Non-haematopoietic malignancies metastasing to the bone marrow: A 5 year record-based descriptive study from a tertiary care centre in South India. Indian J Cancer 2014;51:30-4.  Back to cited text no. 15
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Kucukzeybek BB, Calli AO, Kucukzeybek Y, Bener S, Dere Y, Dirican A, et al. The prognostic significance of bone marrow metastases: Evaluation of 58 cases. Indian J Pathol Microbiol 2014;57:396-9.  Back to cited text no. 16
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Chou WC, Yeh KY, Peng MT, Chen JS, Wang HM, Lin YC, et al. Development and validation of a prognostic score to predict survival in adult patients with solid tumors and bone marrow metastases. Medicine (Baltimore) 2015;94:e966.  Back to cited text no. 17
    


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