Sarcoidosis and agnogenic myeloid metaplasia

Abstract. Agnogenic myeloid metaplasia (AMM) was recognized 3 years after a diagnosis of sarcoidosis in a 45-year-old man. This is the second reported instance of that association, and the 15th reported case in which systemic granulomata have been associated with a myeloproliferative disorder (MPD). In the client population at risk, this connection would be expected to occur by chance once in 1700 years. Therefore, it is unlikely that the association is fortuitous. Systemic granulomata may represent an immunologic response to antigens of neoplastic origin in MPD     

Acute agnogenic myeloid metaplasia with chromosomal abnormalities.

A case of a 37-year-old woman presenting with acute agnogenic myeloid metaplasia (AAMM) is described. The disease had a stormy course and was characterized by moderate splenomegaly, persistently depressed WBC counts, extramedullary hemopoiesis and presence of a high percentage of atypical myeloblasts in the peripheral smear. Platelets were persistently low, reticulocytes significantly below normal, notwithstanding anemia. Hot tended to fall progressively to intolerably low values in the absence of transfusion. The chromosomal mapping of peripheral blood revealed the presence of a trisomy of chromosome No. 8. This abnormality already demonstrated in two previous cases of acute myelofibrosis and the clinical course of the disease suggest that acute myelofibrosis and AAMM could be the same disease while chronic myelofibrosis should be considered a separate entity. Also, it is possible that AAMM with trisomy of chromosome No. 8 and stormy clinical course may be a different entity from the acute myeloproliferative disorders associated with other chromosomal abnormalities.     

Skin manifestation of agnogenic myeloid metaplasia

Agnogenic myeloid metaplasia (AMN) with myelofibrosis is a clonal malignancy of the hematopoletic stem cell. The disease is characterized by increased endothelial cell and fibroblast proliferation, resulting in increased deposition of fibronectin, laminin, and collagen in the bone marrow. In advanced disease, extramedullary hematopoiesis (EMH) is invariably seen in the spleen and liver. The lymph nodes are also frequent sites of EMH, but other organs, especially the kidneys, arenals, lungs, pleura, ovaries, gastrointestinal tract, and dura, may also be involved. Skin manifestations are rare. They may present in several ways: erythematous plaques, nodules, diffuse or papular erythema, ulcers, and bullae. Histopathology of these lesions reveals cells from one or more myeloid lineage in the dermis, erythrold, or megakaryocytic series alone or in combination. In rare cases, all three cell lines are demonstrated. © 1994 Wiley-Liss, Inc.     

Left ventricular thrombus in agnogenic myeloid metaplasia

A 40-year-old white male with agnogenic myeloid metaplasia presented to our institution with symptoms of fever, rash and pleuropericardial pain. A two-dimensional echocardiogram revealed a pedunculated left ventricular mass which simulated a left ventricular myxoma. Left ventricular wall motion and coronary arteries were normal on preoperative angiography. The mass was surgically removed and found to be fibrin thrombus. A mild chronic inflammatory infiltrate was present in the base of the thrombus. The formation of thrombus in the left ventricle was ascribed to spontaneous aggregation of platelets and myocarditis of unknown cause.     

Spontaneous hematologic remission in agnogenic myeloid metaplasia

A 60 year old man had well documented agnogenic myeloid metaplasia with pancytopenia. Frequent red cell transfusions were required for two and a half years. Androgen therapy was not beneficial and was discontinued 26 months before a spontaneous hematologic remission occurred. The remission was documented by bone marrow biopsy and reticuloendothelial scanning of the marrow. Hepatosplenomegaly, poikilocytosis and expansion of the marrow space have persisted despite hematologic remission.     

Splenectomy in agnogenic myeloid metaplasia and postpolycythemic myeloid metaplasia. A study of 34 cases

A retrospective analysis of 34 successive splenectomies in 137 patients with myelofibrosis was carried out. Indications, complications, and response to splenectomy were compared between 22 patients with agnogenic myeloid metaplasia (AMM) and 12 patients with postpolycythemic myeloid metaplasia (PPMM). Painful splenomegaly, refractory hemolytic anemia, and refractory thrombocytopenia were the common indications for surgery. The best results were obtained for painful splenomegaly. For the other indications, half to three fourths of the patients improved with splenectomy. An increased incidence of excessive hemorrhage, infected hematoma, and early mortality was more common in the PPMM group and was found to be connected with large spleens, prolonged bleeding time, and prominent thrombocytopenia. Persistent thrombocytosis after surgery was more common in the AMM group. Leukemic transformation seemed to be related to thrombocytosis and to prior therapy with alkylating agents. Median survival following splenectomy was 43 months in the AMM group and 32 months in the PPMM group. We conclude that splenectomy has a role in improving the quality of life by ameliorating mechanical discomfort and decreasing transfusion requirement in the late phase of AMM. However, in patients with PPMM, because of the high complication rate, splenectomy should be carefully considered for specific indications on an individual basis.     

Allogeneic bone marrow transplantation for agnogenic myeloid metaplasia

Agnogenic myeloid metaplasia is a rare indication for allogeneic bone marrow transplantation (BMT). We have retrospectively studied 12 patients allografted for this disease within the French BMT group. Prior to BMT, the mean age was 40 years (range 14–49). Diagnosis was based on the Polycythaemia Vera Study Group criteria. Before BMT, 10 patients had been splenectomized, eight required transfusions, and four had received at least two lines of chemotherapy. Cyclophosphamide and total body irradiation was the main conditioning regimen used ( n= 8). The donor was an HLA-identical sibling except in one case where there was one HLA-DR mismatch. Acute graft-versus-host disease (GVHD) prophylaxis consisted of methotrexate and cyclosporine A. 11 patients engrafted with median times to achieve absolute neutrophil count > 0.5 × 10⁹/l and platelet count > 50 × 10⁹/l of 17 (range 12–44) and 29 (range 12–196) days respectively. One primary graft failure occurred. 10 patients developed grade II–IV acute GVHD, four developed extensive chronic GVHD. One patient relapsed 16 months post-BMT and was untreated and well 14 months later. Three patients died from the BMT procedure. In May 1996 the median follow-up was 25 months and the 4-year overall and event-free survivals were 71% and 59%, respectively. Thus, we conclude that extensive myelofibrosis is not associated with delayed engraftment, and that HLA-identical sibling allogeneic BMT can be considered in a small proportion of patients with agnogenic myeloid metaplasia.     

The choice between splenectomy and medical treatment in patients with advanced agnogenic myeloid metaplasia.

The objective of the study was to explore the risks and benefits of splenectomy in advanced agnogenic myeloid metaplasia (AMM). We searched the literature (Medline, 1970-1987) for studies of postoperative survival, operative mortality and effects of splenectomy on painful splenomegaly, and portal hypertension or transfusion requirements in patients with AMM. We employed formal decision analysis to determine the relative value of medical and surgical treatment of advanced AMM. Results of data synthesis showed that splenectomy in AMM is associated with an operative mortality of 13.4% (95% confidence intervals (CI): 9.5-17.2%), an early morbidity of 45.3% (CI: 39.6-51.1%), and a late morbidity of 16.3% (CI: 9.9-22.5%). Almost all patients with portal hypertension and painful splenomegaly, but only about half of those with thrombopenia and anemia were reported to have experienced relief in their symptoms or signs after splenectomy. We found no evidence that splenectomy affects survival in AMM. We concluded that splenectomy in advanced AMM is a palliative procedure that carries a substantial risk. It may be considered for symptomatic patients after they have been informed about the operative mortality, morbidity, and chances of palliation. Decisions about treatment of advanced AMM should be guided predominantly by the patient's preferences.     

Influence of splenectomy on hemostasis in agnogenic myeloid metaplasia

The effect of splenectomy on hemostatic tests was studied in 10 patients with agnogenic myeloid metaplasia. Prolonged partial thromboplastin time and abnormal prothrombin consumption were found before splenectomy and were normalized postoperatively in the majority of patients. Prolonged bleeding time and prothrombin time were normalized in some patients. While platelet counts and fibrinogen levels rose significantly following splenectomy, platelet aggregation remained impaired. Thrombocytosis and increased fibrinogen level after splenectomy in patients with agnogenic myeloid metaplasia can enhance a thromboembolic tendency.     

Whole-pulmonary low-dose radiation therapy in agnogenic myeloid metaplasia with diffuse lung involvement

Agnogenic myeloid metaplasia is a hematologic disorder accompanied by extramedullary hematopoiesis (EMH) affecting various organs. Lung involvement however is rare. We present the case of a 76-year-old woman with myelofibrosis, recurrent pleural effusions, pulmonary hypertension, and serious right cardiac failure. An open lung biopsy confirmed pulmonary EMH. She underwent low-dose (200 cGy) whole-lung radiotherapy in 4 fractions of 50 cGy each. Her clinical and hemodynamic parameters improved. We conclude that low-dose whole-lung radiation may be efficacious for the palliative treatment of pulmonary EMH.     

Immune disorders in agnogenic myeloid metaplasia: relations to myelofibrosis

S ummary . Tests for a dysimmune state were done in an unselected group of 67 patients with agnogenic myeloid metaplasia (AMM). The results were compared to those of 56 patients with polycythaemia vera (PV). 75% of AMM patients versus 32% of PV patients had various abnormalities. The most frequent disorders among AMM patients were serum antinuclear and anti smooth muscle autoantibodies (10 3% each), a positive test for rheumatoid factor (21 7%), a polyclonal increase in serum immunoglobulin levels (46 8%) or a serum monoclonal component (9 7%), a positive direct Coombs'test (19%), an anti I autoantibody (30%). In AMM patients there was no relationship between age, sex, importance of splenic enlargement, time from diagnosis or treatment and the present of a dysimmunity.
Furthermore, in AMM patients, but also in PV patients, it seems that the more frequent and numerous these abnormalities the more severe is the myelofibrosis. Like other previous studies, these results suggest a lymphoid cell involvement in AMM and a role for these immune disorders in the pathogenesis of myelofibrosis.     

Clonal granulocytes and bone marrow cells in the cellular phase of agnogenic myeloid metaplasia.

Myelofibrosis with myeloid metaplasia (MMM) belongs to the group of myeloproliferative syndromes. It is characterized by a sustained proliferation of megakaryocytes and increased medullary reticulin fibers. Until now the cellular phase at onset of the disease has not been analyzed for clonality of the hematopoietic cells. In this study we used X-linked restriction length polymorphism (RFLP) analysis to investigate the clonality of granulocytes and bone marrow cells from the cellular phase and advanced stages of the disease. In each of 12 heterozygous females, monoclonality of granulocytes or total bone marrow cells could be demonstrated. These results show that the cellular phase represents a monoclonal, and hence a probably neoplastic, proliferation of a pluripotent stem cell. The monoclonality of granulocytes present at the onset of disease should allow analysis of DNA of these easily accessible peripheral cells for the detection of specific clonal aberrations.