A 52-year-old woman with a history of carcinoma of the breast and progressive bone pain is admitted to the hospital. 

Q4. What further tests are indicated? 

Q5. What is the diagnosis? 

A1. The blood film shows immature red and white blood cell forms and is thus leucoerythroblastic. 

Possible causes are bone marrow infiltration, acute hemolysis, and overwhelming sepsis or bleeding – that is, situations in which the marrow is either replaced by abnormal cells (including fibrous tissue) or responding to an acute and overwhelming systemic illness. 

A2. The marrow is infiltrated by abnormal, non-myeloid cells. 

A3. Trephine biopsy confirms marrow infiltration. 

A4. A bone scan will confirm secondary deposits. 

This patient may have hypercalcemia (which can lead to renal failure) and the alkaline phosphatase (bone isoenzyme) may be raised.

Immunocytochemistry and flow cytometry may be used to confirm the origin of the infiltrating cells, for example, epithelial cells are usually positive for cytokeratin. 

A5. Carcinoma of the breast with bone marrow secondaries. 

Other tumors that frequently affect the marrow include tumors of the bronchus (Figure a), prostate, renal and thyroid, and neuroblastoma in childhood (Figure b). 

                Figure a