BONE MARROW METASTASES

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Clinical Course

The clinical course of cancer patients with marrow metastases depends upon the other sites of metastatic disease. When bone marrow isthe predominant site of metastasis, patients who are untreated or who become refractory to therapy typically develop progressive pancytopenia. In that setting morbidity and mortality are most often due to myelosuppression-induced infection or bleeding or both.

Correlation Between Marrow Metastases and Clinical Outcome in the Standard Therapy Setting

Several clinical breast cancer studies have shown that patients with occult disease in the marrow have a

Routine Detection Methods

In addition to bone marrow aspirates and biopsies, the tests most widely used to detect or confirm marrow metastases in cancer patients include complete blood counts (CBC), radionuclide bone scans, and skeletal radiographs.

METHODS FOR ERADICATING CANCER CELLS FROM MARROW

High-dose therapy with autologous bone marrow support (ABMS) or, more recently, peripheral blood progenitor cell (PBPC) support, has become the treatment of choice for selected high-risk cancer patients. 23, 35, 41, 75 Autologous marrow may contain clonogenic tumor cells that could contribute to relapse of cancer if reinfused into the patient. 58 Marrow-supported intensive treatments are being employed with increasing frequency earlier in the course and stage of malignant disease. In this

Acute Myelogenous Leukemia (AML)

Many clinical studies suggest that marrow purging may benefit certain patients. Gorin et al 34 reported a higher disease-free survival rate in recipients of pharmacologically purged grafts when compared with unpurged autografts for AML patients in first complete remission. Using pharmacologically and immunologically purged marrow respectively, Yeager et al 79 and Ball et al 2 have reported disease-free survival rates for AML patients in second or third complete remission that appear to be

CONCLUSION

The question of whether bone marrow purging or purification is clinically necessary remains unanswered. A randomized trial comparing purged with unpurged marrow support is desirable to validate the importance of purging, Such trials have been very difficult to organize. Patient refusal, the large numbers of patients who would be required, the lack of agreement on the optimal purging regimen, and even the lack of agreement on the need to purge at all are obstacles that have thus far prevented

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    Address reprint requests to Elizabeth J. Shpall, MD University of Colorado Health Sciences Center Campus Box B190 4200 East Ninth Avenue Denver, CO 80262

    *

    From the Bone Marrow Transplant Program (EJS, CH, PC, UG, LH, SIB, MR, RBJ) and the Department of Pathology (WF), University of Colorado, Denver, Colorado; and the Division of Transplantation Medicine, Richland Memorial Hospital and the University of South Carolina, Columbia, South Carolina (APG)

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