Coagulation defects and metastatic neuroblastoma

March, 1968 T h e Journal o[ P E D I A T R I C S

347

Coagulation defects and metastatic neuroblastoma The association o[ metastatic neurobIastoma and a [atal progressive depletion o[ coagulation [actors is described in a 2-month-old male in[ant. The anemia observed may have been at least partly due to a hemolytic process. The mechanisms responsible [or the observed findings were not conclusively defined.

Campbell W. McMillan, M.D.,* Charles L. Gaudry, Jr., M.D.,** and Rudolf Holemans, M.D.*** CHAPEL

HILL,

N.

C.

D E t " L e a ' ~ O N of fibrinogen and other plasma coagulation factors, attributed to intravascular coagulation, has been observed in a variety of pathological states, including neoplastic processes? The purpose of this report is to describe progressive defects consistent with intravascular coagulation in a child with metastatic neuroblastoma. To our knowledge this is the first description of such a disorder associated with neuroblastoma.

From the Departments o[ Pediatrics and Pathology, School o[ Medicine, University o[ North Carolina. Supported by grants [rom the National Heart Institute (Grants HE-08498, HE-06350, and HE-10249), the Larry Silver Leukemia Foundation, and an institutional grant [rom the American Cancer Society. *Address, North Carolina Memorial Hospital, Chapel Hill, N. C. 27514. **Dr. Gaudly was an assistant resident in pediatrics on leave [rom the United States Naval Hospital, Portsmouth, Va. *~*Dr. Holemans was a Research Associate in the Department o[ Pathologv 1963 to 1965~ presently with the Department o[ Hematology, Albert E~nstein Medical Center, and Temple University School o] Medicine, Philadelphia, Pa.

METHODS

Measurements of bleeding time, plasma coagulation, and plasma fibrinolytic activities were performed in research laboratories of the Departments of Pediatrics and Pathology in accord with standard methods. 2' 3 A modification 4 of Todd's fibrinolysis autography technique 5 was used for study of plasminogen activator activity in frozen sections of liver (including tumor) and kidney tissue obtained freshly at the time of autopsy. Plasminogen activator content of vessel walls was assayed by a modification 6 of the method of Lieberman and Kellogg. 7 In the remaining tests cited, standard procedures were performed by service laboratories of the North Carolina Memorial Hospital. CASE REPORT

A 10-week-old Negro male infant was admitted to the North Carolina Memorial Hospital for evaluation of an abdominal mass, detected incidentally during a routine examinaVol. 72, No. 3, pp. 347-350

348

McMillan, Gaudry, and Holemans

tion. He had been delivered normally at the North Carolina Memorial Hospital following an uneventful, fullterm gestation; the birth weight was 4.46 kilograms. Physical examination was within normal limits after birth and at the time of discharge. The infant did well at home and was not seen after discharge from the hospital until the clinic visit preceding his admission. Physical examination revealed a robust Negro male infant who did not seem to be ill. Abnormal findings were moderate pallor of the mucous membranes, and a firm, nontender mass located in the upper quadrants of the abdomen. The lower border of the mass was 8 cm. below the right costal margin and 2 cm. below the left costal margin. Pertinent laboratory findings upon admission were as follows: hematocrit, 20 per cent; reticutocytes, 9.5 per cent; white blood cells, 8,900 per cubic millimeter of blood; marked variation of size and shape of the erythrocytes on smear, polychromatophilia, and adequate platelets with frequent clumps; negative direct Coombs and sickle-cell tests of the erythrocytes; negative benzidine tests on 2 separate stool specimens; normal urinalysis; blood-urea-nitrogen of 11 mg. per 100 ml. Except for a plasma prothrombin time of 31 seconds, other tests for liver function, including serum transaminase activities, were within normal limits. Roentgenograms of the skull and chest and an intravenous pyelogram were normal. On the second day of hospitalization prolonged bleeding from venipuncture and fingerprick sites was noted. Further studies at that time revealed

The lournat of Pediatrics March 1968

a hematocrit of 17 per cent, reticulocytes of 7.3 per cent, and 60,000 platelets per cubic millimeter. The uncorrected erythrocyte sedimentation rate was 1 ram. per hour. The infant was given 10 mg. of vitamin K1 intramuscularly. On the third day of hospitalization the abdomen was distended, excessive bleeding from skin puncture sites persisted, and the hematocrit was 16 per cent. The blood smear revealed 13 normoblasts per 100 leukocytes and numerous abnormally shaped erythrocytes (Fig. 1). An aspirate from the tibial bone marrow revealed relative normoblastic hyperplasia. A detailed survey of coagulation activities was also carried out (see Table I). The child was treated with 125 ml. fresh whole blood and 1.0 Gin. Factor VIII-rich fibrinogen (Fibro-antihemophilic factor, Merck). Following this therapy, prolonged bleeding from finger pricks was not observed for about 18 hours but recurred thereafter. Additional transfusions of fresh whole blood were administered on the seventh, eighth, and ninth hospital days in order to maintain the hematocrit above 15 per cent. In spite of rapid worsening of laboratory findings, the infant did not appear to be seriously ill until the ninth day of hospitalization, when tachypnea increased and feeding was more difficult. On the tenth day the child died. Postmortem findings. Necropsy was limited to examination of the abdomen. The adrenal glands were enlarged, and the medulla of each was completely replaced by tumor cells consistent with neuroblastoma. The liver was enlarged and its cut surface was composed of numerous nodules composed of tumor cells. Hepatic tissue among the nodules was markedly compressed, with multiple areas of necro3is and collapse of the reticulum. Tumor cells were not seen in the bone marrow, but were observed in blood vessels of the liver and kidney, and in lymphatic vessels of the liver and diaphragm. Present in the peritoneal cavity were 350 ml. of liquid blood. No thrombi were noted, either grossly or microscopically, in any of the organs or tissues examined.

Results of studies of coagulation and fibrinolytic activities. Coagulation studies, performed

Fig. 1. Oil immersion view of the erythrocytes on a coverslip smear, made on the child's third day of hospitalization. Note numerous abnormal forms. (Original magnification •

on the third and tenth days of hospitalization, are shown in Table I. The blood sample on the tenth day was obtained 90 minutes prior to the infant's death. Fibrinogen levels on the fifth and sixth days, following replacement therapy with fresh whole blood and fibrinogen, were 24 and 57 rag. per

Volume 72 Number 3

Coagulation defects and metastatic neuroblastoma

100 ml. respectively. A more detailed study of the response to a Factor V I I I - r i c h infused fibrinogen fraction was begun on the ninth day (See Fig. 2). Except for a transitory rise in fibrinogen and plasma Factor V I I I activity, there was a downward trend of all coagulation activities measured during this sequential study.

T a b l e I. C o m p a r i s o n of coagulation studies before a n d d u r i n g r e p l a c e m e n t therapy for a child with disordered coagulation

Coagulation tests (normal mean + S.D.)

Hospital day 3rd Day ]lOth Day

Plasma thrombin time, sec. (14 ~+2)

~60

~60

Plasma prothrombin time, see. (t3 -+ 2) Normal plasma + patient's plasma Fibrinogen fraction ~ + patient's plasma

~ 60

~60

16

15

Not done

29

Plasma partial thromboplastin ) 240 time.J" see. (48 + 6) Normal plasma + patient's 56 plasma Fibrinogen fraction~ + pa- Not done tient's plasma

) 240

Factor I (fibrinogen), mg./100 ml. plasma (283

47 101

<1

3

Factor II (prothrombin), units/100 ml. plasma (1o2 _+ 21)

36

20

Factor V (proaccelerin), units/100 ml. plasma (94 + 33)

53

3

Factor VII-X complex, units/100 ml. plasma (99 + 15)

63

18

Factor V I I I (AHF~), units/100 ml. plasma (107 +- 25)

4-4

Factor IX (Christmas factor), units/100 ml. plasma (100 + 22)

62

3 49

On the sixth day of hospitalization, no fibrinolytic activity of the plasma euglobulin fraction was measurable by the fibrin plate method at 20 hours of incubation. Antiplasmin activity was within normal limits (2.8 Loomis units per 0.2 ml. of plasma). Selected tissues were obtained at necropsy for study of plasminogen activator activity. No activity was found in tumor-containing liver sections; activities in blood vessel walls (aorta and common iliac veins) and kidney sections were comparable to those observed in sections obtained at necropsy from other children of the same age range, z, 9 DISCUSSION T h e progressive depletion of coagulation factors observed in this child was consistent with clinical a n d e x p e r i m e n t a l findings attributed to intravascular c o a g u l a t i o n ? Alt h o u g h specific mechanisms were not identified, the following interpretation, based on existing clinical a n d e x p e r i m e n t a l evidenceZ, 10, 11 is suggested: intravascular coagulation was initiated by excessive a n d sustained release of thromboplastic substances into the blood by necrotic tissue; circulating plasmlnogen activator was r e m o v e d by a d sorption onto intravascular fibrin with a net decrease in p l a s m a fibrinolytic activity; re-

-+ 88) 10005OO

/ ......................................................................

PLASMA FIBRINOGEN

mg.llOOml. 150~ (LOGIo SCALE) OBSERVED I0

/

~

EXPECTED

Platelets/cu.mm. (238,000 + 64,000)

i

4

Not done

t

~

\r

i

r

,

i

i

i

t

............. ~2:.......................9 "'-

~'~

I

24

FIBRINOGEN HOURS,POST-INFUSION INFUSION,I gm

23,000

Not dbne

*Derived from oxalated canine plasma by BaSO4-adsorption and dialysis of (NH4)2SO4-precipitate. The fraction contained measurable activity of Factors V and V I I I in addition to fibrinogen. tKaolin-activated. ++Antihemophilic factor.

PLASMA ACTIVITIES, I00 q UNITS / I00 ml. (LOG io SCALE) FACTOR 11" : : I FACTOR "V" FACTOR ~ o-.--o FACTOR " ~ - T ~,......, IJ

Fig. 2. Sequential study of coagulation response to an infusion of Factor VIII-rich fibrinogen (Fibro-antihemophilic factor, Merck). (The curve of expected response to fibrinogen replacement is based on predicted recovery in this infant weighing 6.5 kilograms and the initial half time of about 2 days observed in congenital afibrinogenemia8).

3 50

McMillan, Gaudry, and Holemans

suiting fibrinolysis may have accounted for the absence of intravascular clots at necropsy. There is increasing evidence that anticoagulant therapy is capable of controlling sustained intravascular coagulation) ~ 12 I n retrospect, heparin therapy might have sufficiently reversed the coagulation disorder to permit diagnostic surgical biopsy and institution of therapy. O n the other hand, it does not appear that drugs affecting fibrinolysis were indicated. Although a hemoperitoneum was noted at necropsy, available evidence during the child's hospitalization was more suggestive of hemolytic disease than of blood loss. The distorted erythrocytes, which were repeatedly observed, resembled those described in microangiopathic hemolytic anemia, associated with the Shwartzman reaction3 a Thus, the anemia observed in this child may have been at least partly due to a hemolytic process associated with intravascular coagulation. Although neuroblastoma is a relatively c o m m o n neoplastic disease of childhood, there are no previous reports of intravascular coagulation associated with this disease and we have not encountered this process in other cases of neuroblastoma. It is suggested that coagulation studies should be included in the investigation of any patient with thrombocytopenia and anemia, these findings generally being detected early. Children with malignant disease in general and neuroblastoma in particular are specific cases in point. SUMMARY

T h e association in a 2-month-old male infant of metastatic neuroblastoma and a fatal progressive depletion of coagulation factors has been described. T h e neoplastic process was believed to have initiated intravascular coagulation, and absence of intrav&scular clots at necropsy was attributed to secondary fibrinolysis. However, the mechanisms responsible for the observed findings

The ]ournal o[ Pediatrics March 1968

were not conclusively defined. As conventional replacement therapy in this child was ineffective, the judicious administration of heparin should be considered in similar cases. We wish to thank Drs. George D. Penick and Harold R. Roberts for their heIp in reviewing this report. REFERENCES

1. Penick, G. D., and Roberts, H. R.: Intravascular clotting: Focal and systemic, Intern. Rev. Exper. Path. 3: 269, 1964. 2. Antley, R. M., and McMillan, C. W.: Sequential coagulation studies in purpura fulminans, New England J. Med. 276: I287, 1967. 3. Holemans, R., and Roberts, H. R.: Hageman factor and in vivo activation of fibrinolysis, J. Lab. & Clin. Med. 64: 778, 1964. 4. McConnell, D., Johnson, J. G., Young, I., and Holemans, R.: Localization of plasminogen activator in kidney tissue, Lab. Invest. 15: 980, 1966. 5. Todd, A. S.: The histological localization of fibrinolysin activator, J. Path. Bact. 78: 281, 1959. 6. Holemans, R., Johnston, J. G., and McConnell, D.: Origin and stability of blood plasminogen activator, Froc. 10th Congress Europe Soc. Haematol. (Strasbourg, France, 1965), Basel and New York, 1967, S. Karger AG. In press. 7. Lieberman, J., and Kellogg, F.: Fibrinolytic activity of arterial tissues, Circulation Res. 11: 515, 1961. 8. Gitlin, D., and Borges, W. H.: Studies on the metabolism of fibrinogen in two patients with congenital afibrinogenemia, Blood 8: 679, 1953. 9. Holemans, R.: Unpublished observations. 10. Mersky, C., Johnson, A. J., Pert, J. H., and Wohl, H.: Pathogenesis of fibrinolysis in defibrination syndrome: Effect of heparin administration, Blood 24: 701, 1964. 11. Girolami~ A., Cliffton, E. E., and Agostino, D.: Hemorrhagic syndrome in dogs induced by intravenous thrombin, Thromb. Diath. Hemorrhagica, 16" 243, 1966. 12. Roberts, H. R., Penick, G. D., Webster, W. P., and Brinkhous, K. M.: The prevention of hemorrhage with anticoagulants--an exploratory study of a paradox. Ann. New York Acad. Sc. 115: 67, 1964. 13. Brain, M. C., and Hourihane, D. O.: Microangiopathic haemolytic anaemia: The occurrence of haemolysis in experimentally produced vascular disease, Brit. J. Haematol. 13: 135, 1967.