A 66-year-old man with a previous history of advanced prostate cancer failing complete androgen blockade, docetaxel chemotherapy, denosumab, and abiraterone acetate as judged by persistent high serum levels of prostate specific antigen presented with exertional dyspnea, normocytic anemia, and thrombocytopenia. marked bone marrow response to acute blood loss or acute hemolysis and recovery from bone marrow suppression.1 Appearance of this phenomenon has been recognized Mouse monoclonal to Flag Tag.FLAG tag Mouse mAb is part of the series of Tag antibodies, the excellent quality in the research. FLAG tag antibody is a highly sensitive and affinity PAB applicable to FLAG tagged fusion protein detection. FLAG tag antibody can detect FLAG tags in internal, C terminal, or N terminal recombinant proteins as a warning sign of bone marrow involvement by metastatic carcinoma in breast cancer.2 We like to present the dismal nature of disseminated bone marrow metastasis in a castration-resistant prostate cancer patient and call attention to the importance of immediate bone marrow examination once recognizing leukoerythroblastosis during care of such patients. Case Report A 66-year-old Taiwanese man was admitted to our medical oncology ward with the chief complaint of progressive exertional dyspnea for twenty days in December 2017. He had been diagnosed with bony metastasis from prostate cancer for 8 years and Gossypol novel inhibtior failed various kinds of treatment including luteinizing hormone-releasing hormone agonist (leuprorelin), androgen receptor antagonist (bicalutamide), denosumab and docetaxel. He was brought to our hospital after starting on dexamethasone and abiraterone acetate without improvement of serum prostate specific antigen level for two months in a medical center nearby. There Gossypol novel inhibtior Gossypol novel inhibtior was no obvious bone pain, chills or fever. He denied other major systemic disease except essential hypertension under regular medical control. His chest X-ray film disclosed Gossypol novel inhibtior right side costophrenic angle blunting and a little fluid accumulation in the minor fissure without extensive pulmonary edema. Blood chemistry showed that levels of alanine aminotransferase, gamma glutamyltransferase, bloodstream urea nitrogen and creatinine had been within normal runs. Abnormal outcomes included alkaline phosphatase of 123 iu/L (regular 32 to 91), albumin of 3.2 g/dL (regular 3.5 to 4.8) and calcium mineral of 7.7 mg/dL (regular 8.6 to 10). Serum prostate particular antigen level was 905 ng/mL (regular 0 to 4). Long term activated incomplete thromboplastin period (41.2 sec, control 31.5) and prothrombin period (international normalized proportion 1.23) were noted. Although plasma fibrinogen level was still regular (335 mg/dL, regular 200 to 400), the focus of D-dimer was incredibly high (over 20,000 ng/mL, regular significantly less than 500). Bloodstream routine test uncovered hemoglobin of 6.4 g/dL, mean corpuscular level of 89.4 fl, platelet count number of just one 1,1000/L, and white cell count number of 7,200/L with extraordinary abnormal differential matters: sections 19%, lymphocytes 35%, monocytes 1%, eosinophils 3%, rings 19%, metamyelocytes 11%, myelocytes 6%, promyelocytes 4%, blasts 1%, and atypical lymphocytes 1%. There have been 48 nucleated reddish colored cells per 100 white cells. A medical diagnosis of leukoerythroblastosis was hence established predicated on morphological proof (Body 1). Open up in another window Body 1. Leukoerythroblastosis: white and reddish colored bloodstream cell precursors in peripheral bloodstream. A) Myelocyte. B) Metamyelocyte. C) and D) Nucleated reddish colored bloodstream cells. Bone tissue marrow aspiration from correct side posterior excellent iliac crest provided a smear of full-blown metastatic carcinoma numerous clustered, dispersed or microacinar sets of epithelioid malignant cells. Bone marrow biopsy from the same area showed a picture of metastatic adenocarcinoma composed of highly pleomorphic tumor cells with hyperchromatic nuclei, prominent nucleoli, and vacuolated cytoplasm, infiltrating diffusely in the marrow with a sheeted pattern. The carcinoma cells were positive for prostate specific membrane antigen, unfavorable for cytokeratin 7 and cytokeratin 20 on immunohistochemical stains using Bond Polymer Refine Detection Kit (Leica Biosystem, Milton Keynes, UK) performed on automated Leica Bond MAX stainer (Leica Biosystem, Melbourne, Australia) with three primary antibodies (Leica Biosystem) (Physique 2). Open in a separate window Physique 2. Metastatic prostate carcinoma in bone marrow. A) Clustered and dispersed malignant cells in smear (Wright-Giemsa stain, 1000). B) Solid nests of highly pleomorphic tumor cells Gossypol novel inhibtior (hematoxylin and eosin stain, 400). C) A small locus of spindled (sarcomatoid) change of tumor cells (hematoxylin and eosin stain, 400). D) Tumor cells positive for prostate specific membrane antigen in cytoplasm (400). There were only a few small metastatic lesions over skull, manubrium, and ribs in bone scan performed two months earlier but diffuse bone marrow involvement and destruction could be seen in magnetic resonance imaging of spine done one month prior to the present hospitalization (Physique 3). The patient decided to receive palliative.