Extramedullary haematopoiesis: radiological imaging features

Extramedullary haematopoiesis (EMH) is defined as the production of blood cells outside of the bone marrow, which occurs when there is inadequate production of blood cells. The most common causes of EMH are myelofibrosis, diffuse osseous metastatic disease replacing the bone marrow, leukaemia, sickle cell disease, and thalassemia. The purpose of this article is to review the common and uncommon imaging appearances of EMH by anatomical compartment. In the thorax, EMH most commonly presents as paravertebral fat-containing masses, and typically does not present a diagnostic dilemma; however, EMH in the abdomen most commonly manifests as hepatosplenomegaly with or without focal soft-tissue masses in the liver, spleen, perirenal space, and in the peritoneum. Hepatosplenomegaly, a non-specific feature, most often occurs without an associated focal mass, which makes suggestion of EMH difficult. EMH manifesting as visceral soft-tissue masses often requires biopsy as the differential diagnosis can include lymphoma, metastatic disease, and sarcoma. Many of these soft-tissue masses do not contain adipose elements, making the diagnosis of EMH difficult. Clinical history is crucial, as EMH would likely not otherwise be in the differential in patients with non-specific abdominal masses. Careful biopsy planning is necessary when EMH is a diagnostic consideration, given the propensity for haemorrhage. Understanding the typical imaging appearances of EMH based on its site of manifestation can help the radiologist when encountered with a finding that is diagnostic for EMH, and can help the radiologist suggest the need and plan appropriately for image-guided biopsy.