Extramedullary myeloid cell tumors. An immunohistochemical and morphologic study of 28 cases

Primary breast myeloid sarcoma: A case report and literature review

Myeloid sarcoma (MS) is a rare extramedullary tumor originating from immature bone marrow cells. MS of the breast is an extremely uncommon disease with non-specific clinical and radiological features. The present case report describes a distinctive case of MS of the breast, which posed diagnostic challenges due to the absence of typical imaging characteristics at the time of presentation. The patient was a 58-year-old woman who presented with a breast mass. Further examination and testing confirmed the diagnosis of MS in the right breast, with metastases to the right iliac, pubic and ischial regions. Immunohistochemical analysis identified metastatic tumors distinguished by the expression of a number of markers, including Ki-67, myeloperoxidase and cluster of differentiation 43. The patient underwent six cycles of chemotherapy with a regimen comprising etoposide, methylprednisolone, cytarabine and cisplatin, and 28 cycles (56 cGy each) of consolidation radiotherapy. Extensive examination and long-term follow-up revealed no further tumor recurrence or metastasis. Myeloid sarcomas of the breast typically manifest as palpable masses requiring diagnostic imaging. However, due to the rarity of MS of the breast without any signs of leukemia, its diagnosis and treatment are challenging. The present case report highlights the importance of maintaining high clinical, radiological and pathological standards when diagnosing this disease. Additionally, a comprehensive review of the literature on breast MS is provided. This highlights the necessity for clinicians to consider this rare diagnosis in patients presenting with a breast mass, to facilitate the appropriate treatment and prevent unnecessary procedures such as mastectomies.

Myeloid sarcoma with maxillary gingival swelling as the initial symptom: A case report and review of literature

BACKGROUND

Myeloid sarcoma (MS), also referred to as granulocytic sarcoma or chloroma, is a rare type of extramedullary malignant tumor. MS comprises primitive granulocytic precursor cells that play a key role in the early stages of white blood cell development. Notably, the occurrence of this tumor in the gingiva is rare.

CASE SUMMARY

The present study reported the case of MS with gingival swelling in the maxillary region, with aleukemic presentation in a 32-year-old male patient. Following two courses of chemotherapy, computed tomography of the region demonstrated complete clearance of the tumor. At the 12-month follow-up appointment, the patient was in a stable condition with the absence of progression. The etiology, clinical features, diagnosis, and relevant treatment of MS are discussed in the present study.

CONCLUSION

Diagnosis of MS may be confirmed following histological and immunohistochemical examinations.

Solitary eosinophilic granulocytic sarcoma in a dog

A 6-year-old male golden retriever presented with swelling of the left upper eyelid of 2 months duration, which did not improve following a course of antibiotics. Routine serum biochemistry, complete blood count and diagnostic imaging identified no clinically significant abnormalities. The mass was surgically excised, and histopathologic examination was performed. Eosinophilic granulocytic sarcoma (GS) was diagnosed based on the results of histopathology and immunohistochemistry. This is the first report of GS affecting the eyelid of a dog.

The immutable relevance of myeloid sarcomas: Clinicopathological study of fourteen cases

An extramedullary myeloid tumor or chloroma is an infrequent manifestation of a myeloid neoplasm. It is considered an equivalent to an acute myeloid leukemia. It is confirmed through biopsy, where infiltrating neoplastic myeloid cells distort the parenchyma. A total of twenty-nine cases were diagnosed as MS between 198 and 2023. Upon re-evaluation, only fourteen cases fulfilled the criteria for MS. The most common differential diagnosis were lymphomas, leukemic infiltration, and extramedullary hematopoiesis. Few were isolated cases; the rest were in the context of progression of a myeloid neoplasm. The majority had a myelomonocytic morphology and immunophenotype. The most reliable markers were CD45, HLA-DR, CD68 and CD4. The study highlights the complexity and impact of an accurate diagnosis of a myeloid sarcoma.

Extramedullary Myeloid Leukemia in the Setting of a Myeloproliferative Neoplasm

Extramedullary acute myeloid leukemia (EML), also known as myeloid sarcoma (MS), is an extramedullary solid mass derived from the proliferation of myeloblasts outside of the bone marrow. EML can present independently or concurrently with intramedullary acute myeloid leukemia (iAML). It can happen de novo or secondary to iAML, myeloproliferative neoplasm (MPN), chronic myelomonocytic leukemia (CMML), or myelodysplastic syndrome (MDS). We present a 57-year-old female with a history of Janus kinase 2 (JAK-2)-positive essential thrombocythemia (ET) evolving into EML in the setting of a persistent TP53 mutation. We discuss the essential diagnostic studies including tissue biopsy and fluorodeoxyglucose positron emission tomography/computed tomography (F-FDG PET/CT) imaging. We also investigate the significance of cytogenetics and next-generation sequencing (NGS) along with the unique pathogenesis, treatment and prognostic implications.

Target Therapy for Extramedullary Relapse of FLT3-ITD Acute Myeloid Leukemia: Emerging Data from the Field

FMS-like tyrosine kinase 3 (FLT3) is a receptor tyrosine kinase family member. Mutations in FLT3, as well known, represent the most common genomic alteration in acute myeloid leukemia (AML), identified in approximately one-third of newly diagnosed adult patients. In recent years, this has represented an important therapeutic target. Drugs such as midostaurin, gilteritinib, and sorafenib, either alone in association with conventional chemotherapy, play a pivotal role in AML therapy with the mutated FLT3 gene. A current challenge lies in treating forms of AML with extramedullary localization. Here, we describe the general features of myeloid sarcoma and the ability of a targeted drug, i.e., gilteritinib, approved for relapsed or refractory disease, to induce remission of these extramedullary leukemic localizations in AML patients with FLT3 mutation, analyzing how in the literature, there is an important development of cases describing this promising potential for care.

The Bone Marrow Microenvironment Mechanisms in Acute Myeloid Leukemia

Bone marrow (BM) is a highly complex tissue that provides important regulatory signals to orchestrate hematopoiesis. Resident and transient cells occupy and interact with some well characterized niches to produce molecular and cellular mechanisms that interfere with differentiation, migration, survival, and proliferation in this microenvironment. The acute myeloid leukemia (AML), the most common and severe hematological neoplasm in adults, arises and develop in the BM. The osteoblastic, vascular, and reticular niches provide surface co-receptors, soluble factors, cytokines, and chemokines that mediate important functions on hematopoietic cells and leukemic blasts. There are some evidences of how AML modify the architecture and function of these three BM niches, but it has been still unclear how essential those modifications are to maintain AML development. Basic studies and clinical trials have been suggesting that disturbing specific cells and molecules into the BM niches might be able to impair leukemia competencies. Either through niche-specific molecule inhibition alone or in combination with more traditional drugs, the bone marrow microenvironment is currently considered the potential target for new strategies to treat AML patients. This review describes the cellular and molecular constitution of the BM niches under healthy and AML conditions, presenting this anatomical compartment by a new perspective: as a prospective target for current and next generation therapies.

Isolated Intracranial Myeloid Sarcoma Mimicking Malignant Lymphoma: A Diagnostic Challenge and Literature Reviews

Isolated intracranial myeloid sarcoma (MS) is an unusual variant tumor with few cases reported so far in the medical literature. A 29-year-old woman was admitted to our hospital presenting progressive visual loss in the right eye and weight loss (20 kg) without a previous history of hematological disease (HD). Radiologic evaluation showed the evidence of intracranial mass. Histologically, the resected tumor was composed of a uniform population of primitive cells and primarily misdiagnosed as a T-cell non-Hodgkin’s lymphoma (NHL). Chemotherapy with cyclophosphamide, doxorubicin, vinblastine, and prednisone (CHOP) was ineffective. A biopsy and histopathological evaluation were repeated, and immunohistochemical staining revealed the positivity of immature cells to an extensive panel of myeloid markers. These findings were consistent with a diagnosis of MS and bone marrow infiltration. Literature reviews of previous cases were also undertaken.

American Registry of Pathology Expert Opinions: Evaluation of poorly differentiated malignant neoplasms on limited samples - Gastrointestinal mucosal biopsies

This review reflects a collaboration between the American Registry of Pathology (the publisher of the Armed Forces Institute of Pathology Fascicles) and Annals of Diagnostic Pathology. It is part of a series of expert recommendations on topics encountered in daily practice. The authors, three pathologists with expertise in gastrointestinal tract pathology and immunohistochemistry, met on 30 July 2019 tasked with developing expert recommendations for evaluating poorly differentiated and undifferentiated malignant neoplasms encountered on mucosal biopsies of the gastrointestinal tract. We focused on esophageal, gastric, small intestinal, colorectal, and anal (i.e., tubal gut) samples. When faced with diagnostic uncertainty on the initial H&E, it is best to begin by trying to assign the broad tumor class with screening markers such as pankeratin, S100 protein or SOX10, and CD20 or CD45. Once a broad tumor class is established, more specific differentiation markers can be pursued (e.g., lineage-restricted transcription factors for adenocarcinoma; p40 for squamous cell carcinoma; chromogranin A and synaptophysin or INSM1 for neuroendocrine neoplasms). Every small biopsy containing tumor should be considered a potential molecular pathology sample; cutting extra unstained slides with this testing in mind is strongly encouraged.

Primary bronchial myeloid sarcoma mimicking bronchogenic carcinoma: a case report

BACKGROUND

Myeloid sarcoma (MS) rarely involves the bronchus, and primary bronchial MS has almost never been reported in mainland China.

CASE PRESENTATION

A 65-year-old female patient was admitted with a 3-month history of cough. She was initially diagnosed with bronchogenic carcinoma according to chest computed tomography (CT). However, after a biopsy was taken from the endobronchial lesion by bronchoscopy and further immunohistochemical analysis was performed, the diagnosis of MS was made. Because her bone marrow was normal and she had no history of haematologic diseases, we further considered the diagnosis of primary bronchial MS. The patient received chemotherapy with HAG regimens, and the original mass completely resolved, as confirmed by chest CT scan after 3 cycles of treatment. Meanwhile, no abnormalities were found on re-examination via bronchoscopy.

CONCLUSIONS

MS should be considered in the differential diagnosis in the presence of a suspicious pulmonary mass. Immunohistochemical analysis is necessary to confirm the diagnosis. Chemotherapy can lengthen the survival time for patients.

Clinical characteristics and management of primary granulocytic sarcoma of the breast: A case report

RATIONALE

Primary granulocytic sarcoma of the breast is a rare and poor-prognosis malignancy. Clinicians do not have sufficient knowledge of this disease and often misdirect it as other soft tissue sarcomas or inflammation.

PATIENT CONCERNS

A 42-year-old female presented with a self-discovered asymptomatic growing and palpable right breast mass that had been present for 4 months.

DIAGNOSES

The patient was diagnosed as primary myeloid sarcoma.

INTERVENTIONS

The patient received modified radical mastectomy in the right breast and sentinel lymph node biopsy. Pathological diagnosis is primary granulocytic sarcoma. Then the patient accepted acute myeloid leukemia-induction chemotherapy.

OUTCOMES

The follow-up of this patient has no evidence of disease progression or spread during 1 year.

LESSONS

Granulocytic sarcoma in the breast tissue is rare. But it still should be considered in the differential diagnosis of any tumor in the breast. The present study discusses comprehensively the clinical and pathological characteristics to improve the understanding of myeloid sarcoma.

Myeloid Sarcoma

Hematological malignancies can manifest as extramedullary soft tissue masses in relatively rare cases. The rarity of it causes a diagnostic and therapeutic challenge. One of the rarest manifestations is myeloid sarcoma (MS). MS develops as part of acute myeloid leukemia, myeloproliferative neoplasm, or myelodysplastic syndrome or at relapse, especially following allogeneic hematopoietic stem cell transplant. The tumor displays high myeloperoxidase expression, hence the color green, and is called chloroma. It most commonly appears in lymph nodes, skin and soft tissues, bone, testes, gastrointestinal tract, and peritoneum. Immunohistochemistry shows CD68-KP1 as the most commonly expressed marker, then myeloperoxidase, CD117, CD99, CD68/PG-M1, lysozyme, CD34, terminal deoxynucleotidyl transferase, CD56, CD61, CD30, glycophorin A, and CD4. Different chromosomal abnormalities including MLL rearrangement, t(8; 21), monosomy 7, trisomy 8, trisomy 11, trisomy 4, inversion (16), monosomy 16,16q deletion, 5q deletion, and 20q deletion were reported. Most of the literature about MS are case reports and small retrospective studies, thus there is limited clinical knowledge of the cases and their presentation and management plans. Here, we provide a review of what has been reported in the literature about MS in the light of our experiences.

Cutaneous Leukemic Infiltrates Successfully Treated With Biomodulatory Therapy in a Rare Case of Therapy-Related High Risk MDS/AML

Cutaneous manifestations in hematologic malignancies, especially in leukemia, are not common and may be very variable. Here we report a very unusual case of a patient (female, 70 years old) who was admitted to the hospital in 2016 because of skin lesions on the face, the trunk of the body and the extremities. She had a history of breast cancer in the year 2004 (pT1b, pN0, cM0, L0, V0, R0) which had been resected and treated with adjuvant radiation and chemotherapy (cyclophosphamide, methotrexate, 5-fluorouracile) as well as psoriasis treated with methotrexate and cyclosporine. Because of mild cytopenia a bone marrow aspirate/biopsy was performed showing myelodysplastic syndrome (MDS) with multilineage dysplasia. Cytogenetic review revealed a complex aberrant karyotype denoting adverse outcome. Simultaneously, a skin biopsy could confirm leukemic skin infiltration. Consequently, a therapy with azacitidine was started. After the first cycle the patient developed severe pancytopenia with a percentage of 13% peripheral blasts (previously 0–2%) as well as fever without evidence for infection which was interpreted as progressive disease. Therefore, the therapeutic regimen was changed to a biomodulatory therapy consisting of low-dose azacitidine 75 mg/day (given sc d1-7 of 28), pioglitazone 45 mg/day per os, and all-trans-retinoic acid (ATRA) 45 mg/m2/day per os. After cycle 1 of this combined biomodulatory therapy the patient showed hematologic recovery; besides a mild anemia (hemoglobin 11.1 g/dl) she developed a normal blood count. Moreover, the cutaneous leukemic infiltrates which had been unaffected by the azacitidine ameliorated tremendously after 2 cycles resulting in a complete remission of the skin lesions after cycle 6. In conclusion, we report a very unusual case with cutaneous infiltrates being the first clinical manifestation of hematologic disease, preceding the development of acute myeloid leukemia. While azacitidine alone was ineffective, a combined biomodulatory approach resulted in a complete remission of the cutaneous manifestation.

Nonleukemic granulocytic sarcoma of orbit after blunt trauma: A case report and review of literature

RATIONALE

Granulocytic sarcoma without invasion of bone marrow or blood is very rare. The diagnosis of it is usually overlooked and the treatment has not reached a consensus. Meanwhile, the onset of this kind of disease is not clear.

PATIENT CONCERNS

Diagnose patients in early stage and help choose the right treatment strategies.

DIAGNOSES

The ultimate diagnosis was nonleukemic granulocytic sarcoma after blunt trauma.

INTERVENTIONS

Surgery was the initial treatment option. Chemotherapy including idarubicin (70 mg, D1-D3) and cytosine arabinoside (100 mg, D1-D7) and radiotherapy of total 3,060 cGy were then administered but failed to control the disease. Hematopoietic stem cell transplantation was finally administered.

OUTCOMES

No evidence of disease progression or spread according to the latest follow-up.

LESSONS

The etiology of nonleukemic granulocytic still remains unclear, though trauma seems to be a potential predisposing factor and deserves more attention for early diagnosis and timely and proper treatment. Systemic chemotherapy is more effective than radiotherapy or surgery. Hematopoietic stem cell transplantation is an alternative choice after the failure of chemotherapy.

Granulocytic Sarcomas: Difficulties in Diagnosis

Granulocytic sarcoma is an uncommon tumor composed of myeloid blasts and/or immature myeloid cells in an extramedullary site which is usually associated with acute or chronic myeloid leukemia. The tumor may also be the initial manifestation of leukemia. The histomorphological diagnosis of granulocytic sarcoma can be challenging to pathologists, especially in the absence of a known hematological disorder. In this case, differentiation of granulocytic sarcoma from malignant lymphomas and other small round cell tumors is very critical. Seven cases of granulocytic sarcoma are reported in this paper. One patient had granulocytic sarcomas at two different sites. Hematoxylin-eosin-stained sections were reexamined. Blastic, poorly differentiated, and well differentiated histopathological variants were found in two, five and one cases, respectively. Immunohistochemical studies were performed on formalin-fixed tissue from all cases using a avidin-biotin-peroxidase complex technique. The panel included antibodies against LCA, CD43, CD34, c-kit, myeloperoxidase, CD68 KP1, CD15, and CD99. All cases stained positively with LCA, CD43, CD34, myeloperoxidase, and CD68. Five cases were positive for c-kit, three cases were positive for CD15, and two cases were positive for CD99. An immunohistochemical panel including at least myeloperoxidase, CD68 and CD34 can be used for detection of myeloid differentiation. It is also important that granulocytic sarcoma be considered in the differential diagnosis of CD99-positive round cell tumors.

Initial Diagnostic Workup of Acute Leukemia: Guideline From the College of American Pathologists and the American Society of Hematology

CONTEXT

- A complete diagnosis of acute leukemia requires knowledge of clinical information combined with morphologic evaluation, immunophenotyping and karyotype analysis, and often, molecular genetic testing. Although many aspects of the workup for acute leukemia are well accepted, few guidelines have addressed the different aspects of the diagnostic evaluation of samples from patients suspected to have acute leukemia.

OBJECTIVE

- To develop a guideline for treating physicians and pathologists involved in the diagnostic and prognostic evaluation of new acute leukemia samples, including acute lymphoblastic leukemia, acute myeloid leukemia, and acute leukemias of ambiguous lineage.

DESIGN

- The College of American Pathologists and the American Society of Hematology convened a panel of experts in hematology and hematopathology to develop recommendations. A systematic evidence review was conducted to address 6 key questions. Recommendations were derived from strength of evidence, feedback received during the public comment period, and expert panel consensus.

RESULTS

- Twenty-seven guideline statements were established, which ranged from recommendations on what clinical and laboratory information should be available as part of the diagnostic and prognostic evaluation of acute leukemia samples to what types of testing should be performed routinely, with recommendations on where such testing should be performed and how the results should be reported.

CONCLUSIONS

- The guideline provides a framework for the multiple steps, including laboratory testing, in the evaluation of acute leukemia samples. Some aspects of the guideline, especially molecular genetic testing in acute leukemia, are rapidly changing with new supportive literature, which will require on-going updates for the guideline to remain relevant.

Myeloid Sarcoma: Presentation, Diagnosis, and Treatment

Myeloid sarcoma is an extramedullary tumor of immature granulocytic cells. It is a rare condition, most often associated with acute myeloid leukemia (AML), although in some rare cases it may present in nonleukemic patients. It should therefore be considered as a differential diagnosis of any atypical cellular infiltrate. It may occur at any site, leading to very varied clinical presentations. Diagnosis is challenging and relies on a high index of suspicion as well as radiology, histology, immunophenotyping, and molecular analyses, which also are essential for risk stratification and treatment planning. Systemic chemotherapy using AML-like regimens should be commenced early, even in nonleukemic disease. Surgery and/or radiotherapy may be indicated for symptomatic lesions or tumors causing local organ dysfunction or obstruction. Allogeneic hematopoietic stem cell transplantation has demonstrated promising results, particularly in patients who achieved complete remission with AML-induction protocols, and recent advances in genetic profiling may enable the development of novel targeted therapies. Prospective multicenter controlled trials are required to further refine management decisions and investigate the role of novel targeted therapies.

Granulocytic Sarcoma

Because of shared histologic and clinical features, granulocytic sarcoma (GS) may be confused with B- and T cell malignant lymphomas. Antibodies to myeloperoxidase, lysozyme, CD 15, and other determinants may correctly identify GS but are usually not part of the standard panels employed to evaluate a suspected non-Hodgkin's lym phoma. At the authors' institutions, these typically include reagents to CD20, CD43, CD45, CD45RO, and MB2. In this analysis, well-documented cases of GS and histologi cally similar lymphomas were assessed using a standard immunohistologic antibody panel employed in evaluation of putative lymphomas. In addition, antibodies to lyso zyme, myeloperoxidase, CD3, CD15, CD34, CD68, and MAC 387 were used in a second tier of analysis. The results were evaluated in a step-wise fashion. All B cell lymphomas and the majority of T cell cases were identified correctly by their reactivity for CD20 and CD45RO, respectively. Using the five standard lymphomas markers, 12 of 19 cases of GS had a phenotype that would be relatively unusual in non-Hodgkin's lymphoma—as reflected by CD43 and MB2 coexpression without CD20 or CD45RO-whereas 7 cases of GS showed a "CD43-only" phenotype and were there fore considered possible T cell lesions. All 19 GS cases were labeled by at least one second-tier marker and 18 exhibited two or more of these determinants at that level of evaluation. All T cell lymphomas failed to express CD 15, CD34, CD68, or MAC 387; however, 3 of 20 B cell tumors were focally positive for CD 15. CD3 labeled 9 of 11 cases of T cell lymphoma but also was seen in 11 of 16 cases of GS. These results indicate that, in suspected lymphoma cases, CD45-positivity, but failure to express CD20 or CD45RO, suggests the possibility of GS. Additional immunohistologic studies, in particular those for lysozyme or myeloperoxidase, can then be used to further define the tumoral lineage. Int J Surg Pathol 2(3):177-186, 1995

Myeloid Sarcoma: Presenting with Massive Cervical and Inguinal Lymphadenopathy

A 21 year old Active Duty Marine presented with acute onset of diffuse lymphadenopathy and B-symptoms. Biopsy was conducted which demonstrated myeloid sarcoma. Myeloid sarcoma is diagnostic for AML but is only present in 2-8 % of patients with AML. Our article presents a classic presentation and histologic appearance and discusses the current status of the literature.

Myeloid sarcoma derived from the gastrointestinal tract: A case report and review of the literature

Myeloid sarcoma is a type of malignant neoplasm composed of myeloblasts that locates extramedullary. The present study reports the case of a 31-year-old female who presented with upper abdominal pain, melena, vomiting and jaundice. The abdominal computed tomography revealed a mass in gastric antrum area and possible infiltration of the duodenum, gallbladder and head of the pancreas, with possible retroperitoneal lymph node metastasis. The tumor grew quickly and led to serious obstructive jaundice. New masses developed in the bilateral orbits and left breast within 2 months of admission. The pathological results of the gastroscopic biopsy and the fine-needle biopsy of the breast revealed myeloid sarcoma. Transhepatic cholangial drainage, radiotherapy and chemotherapy were administered, but the disease reoccurred and became resistant to chemotherapy, so salvage allogenetic peripheral blood stem cell transplantation was performed. The disease relapsed at 5 months post-transplantation, and chemotherapy and donor lymphocytes transfusions were then administered. The patient declined further treatment and succumbed to disease on May 19, 2015. The present study could improve the understanding of myeloid sarcoma and provide a reference for standardized and individualized treatments for this disease.

Primary intraoral granulocytic sarcoma: A rare case presenting as generalized gingival enlargement

Granulocytic sarcoma (GS) is an extremely rare condition involving infiltration of myeloblasts or immature myeloid cells in an extramedullary site. It is also known as chloroma, myeloid sarcoma or extramedullary myeloid tumor. It usually occurs concomitantly with acute myelogenous leukemia or with the onset of blastic phase of chronic myelogenous leukemia. On rare occasions, it evolves even before the onset of leukemias, and when it precedes leukemias without any overt signs, it is referred to as the primary type. Although GSs can involve any body part, localization in the oral cavity is extremely rare. The recognition of this rare primary entity is important because early aggressive chemotherapy can cause regression of the tumor and improve survival. Here, we report a rare case of GS in a nonleukemic 62-year-old female who presented with generalized gingival enlargement involving both maxilla and mandible.

Myeloid sarcomas: a clinicopathologic study of 20 cases

Objective:

Myeloid sarcoma is a tumoral mass of mature or immature myeloid blasts in extramedullary anatomic locations. It can be seen de novo or in association with acute myeloid leukemia, myeloproliferative neoplasias, or myelodysplastic syndrome. Isolated myeloid sarcoma can be seen as a relapse in cases with allogenic bone marrow transplantation. Although it may involve any tissue in the body, the most common locations are skin, soft tissues, lymph nodes, and the gastrointestinal tract. Immunohistochemically, most cases show myelomonocytic or pure monoblastic differentiation. We reviewed the clinicopathological features of 20 cases of myeloid sarcoma diagnosed in our institute in view of the literature.

Materials and Methods:

The cases diagnosed between 2005 and 2012 at the Ankara University Faculty of Medicine, Department of Pathology, were selected. Clinicopathological findings including the age and sex of the patients; symptoms; anatomic location; accompanying hematological disease; and the morphological, immunohistochemical, and cytogenetic features of the cases were noted.

Results:

Sixteen of the patients were male and 4 were female. The median age at diagnosis was 47 years. The most commonly involved locations were the lymph nodes and skin. Immunohistochemically, eleven cases were of the myelomonocytic and 7 cases were of the myeloid phenotype, whereas 2 cases showed pure monoblastic differentiation. The median follow-up period for the 18 cases with known clinical data was 33 weeks. Five patients died of the disease in an average of 36 weeks.

Conclusion:

Myeloid sarcoma is a rare presentation of leukemias, myeloproliferative neoplasias, or myelodysplastic syndrome, composed of immature myelomonocytic cells in extramedullary tissues. It may present with variable morphological and phenotypic features, always creating a challenge in pathological diagnosis.

Differential Diagnosis of Isolated Myeloid Sarcoma: A Case Report and Review of the Literature

Myeloid sarcoma (MS) is a rare disease entity identified as a variety of manifestations defined by the occurrence of extramedullary myeloid cell masses with or without bone marrow involvement. This case describes an unusual presentation of isolated MS in a 60-year-old otherwise healthy male, who initially presented to his primary care physician with vague abdominal pain. After extensive workup including three omental biopsies, umbilical core biopsy, and inguinal lymph node biopsy, he was ultimately diagnosed with isolated MS with extensive extramedullary tumor burden. Despite advanced extramedullary disease, peripheral cell counts were normal and bilateral bone marrow biopsies unremarkable with normal cellular lineages, morphology, and cytogenetics. The patient underwent induction chemotherapy and is now greater than 100 days post myeloablative unrelated donor marrow transplantation with no evidence of disease recurrence and 100% donor status with full chimerism. This case demonstrates that making a prompt diagnosis with rapid initiation of treatment in myeloid sarcoma can be challenging due to its varied clinical presentation, cytomorphology, cytochemistry, and cytogenetic overlap with other lymphoid malignancies. Once a diagnosis of MS has been made, moving quickly to induction therapy is important. Several studies have shown that improved overall survival is attained when MS is treated as acute myeloid leukemia and increased survival is noted for patients undergoing bone marrow transplantation. Further prospective studies are needed to elucidate the many remaining questions in regards to the natural history, prognosis, and optimal treatment strategies for this deadly disease.

Pan myeloid antigen-negative pediatric acute megakaryoblastic leukemia

Acute megakaryoblastic leukemia (AMKL) is a relatively common type of acute myeloid leukemia in children. We describe two unusual cases of AMKL that by flow cytometry (FC) lacked expression of any commonly evaluated myeloid antigens. One case presented as a periorbital myeloid sarcoma and clinically was thought to be a solid tumor. In both cases, the leukemic blasts were variably positive for the megakaryocytic marker CD61. Cytogenetics confirmed the presence of the t(1;22) in one case. Cytogenetics and inclusion of megakaryocytic markers in FC panels when evaluating pediatric specimens is critical for appropriate diagnosis for myeloid antigen negative AMKL.

Granulocytic sarcoma in non-leukaemic child involving maxillary sinus with long term follow up: A rare case report

Granulocytic sarcoma (GS) is a rare extramedullary malignant tumor composed of immature myeloid cells. It is strongly associated with acute myeloid leukaemia, chronic myeloproliferative diseases. Occurrence of GS in the oral cavity is extremely uncommon. Present case reported an unusual occurrence of GS without leukemia involving maxillary sinus of a child. The patient underwent chemotherapy followed by radiotherapy with complete remission. A long-term follow-up of the patient was carried without any evidence of recurrence with special focus on diagnostic difficulties. The present case highlights the perplexity in diagnosing such lesions with emphasis on the need of careful interpretation of all clinical, radiographic, histopathological and immunohistochemical details as it is one of the most frequently misdiagnosed disorder.

Report of an unusual case: testicular involvement of chronic myeloid leukemia 10 years after the complete response

Testicular extra-medullary myeloid cell tumours are rare tumours presenting in most cases with painless testicular swelling. We are representing here along of a case of 21-year-old man with painless scrotal swelling. From his medical history, he was treated by allogenic bone-marrow transplantation and chemotherapy 10 years ago because of chronic myeloid leukemia. The pathology of orchiectomy specimen revealed malign cells with blastic cell infiltration means a late relapse of chronic myeloid leukemia. The patient has been in hematological remission and no evidence of any myeloid disorders by 10 years' follow up. Although testicular involvement is a rare and an unusual event in blast crisis of chronic myeloid leukemia, extramedullary myeloid cell tumour should be considered in the diagnosis of intratesticular tumours.

Metachronous bilateral granulocytic sarcoma of the testis in a young adult: a report of an unusual entity

Granulocytic sarcomas are rare tumors composed of neoplastic blood cells, typically occurring during the course of acute nonlymphoblastic leukemia or before its onset. We present a case of a 23-year-old young adult man with metachronous granulocytic sarcoma of the testis without hematologic manifestations who was diagnosed with granulocytic sarcoma (GS). The patient was treated with right orchiectomy but relapsed with a left testicular mass 16 months later when a left orchiectomy was performed. The patient has been free of disease for 13 months following the left orchiectomy. This case highlights a rare hematologic cancer that urologists and pathologists should be aware of since it can present as a testicular mass. Only 3 cases of testicular GS without an associated hematologic disorder have been described. To the best of our knowledge, our patient is the first reported case in the English literature of metachronous GS of the testis with no evidence of hematologic disorder.

Clinical report. Primary granulocytic sarcoma: a rare presentation of an ovarian mass

Background: Primary granulocytic sarcoma (GS) only rarely presents with an ovarian mass classified as extramedullary myeloid progenitor tumor cells. Few patients with cases of primary GS survive after systemic chemotherapy.

Objective: To present a case of primary GS treated with complete course of chemotherapy. The patient is currently in complete remission.

Methods: Retrospective review of medical records and comparison with previous case reports.

Results: A 41-year-old woman presented with an ovarian mass of 6 months duration. There was no previous history of hematologic disease or presence of leukemic cells in other organs at the time of diagnosis. Immunohistochemistry confirmed the diagnosis. She received complete course of chemotherapy, after which complete remission was achieved.

Conclusion: A case of primary granulocytic sarcoma of the ovary was successfully treated with chemotherapy. This disease needs careful diagnosis and appropriate treatment for a good outcome.

Genomic aberrations in myeloid sarcoma without blood or bone marrow involvement: characterization of formalin-fixed paraffin-embedded samples by chromosomal microarrays

Myeloid sarcoma (MS) is a presentation of acute myeloid leukemia (AML) as a tumor mass outside of the bone marrow. Viable cells from MS are frequently unavailable for cytogenetic studies. We therefore investigated whether chromosomal microarray analysis (CMA) using formalin-fixed paraffin-embedded (FFPE) tissues can detect clinically important genetic abnormalities in MS. CMA successfully identified genomic aberrations in six cases of MS, and in two cases it revealed multiple abnormalities equivalent to a complex karyotype, thus predicting a poor outcome. CMA using FFPE material is therefore a feasible and clinically applicable approach for detection of prognostically significant genomic abnormalities in MS.

Granulocytic sarcoma of the breast in acute myeloid leukemia: Two case reports

Granulocytic sarcoma (GS) of the breast is extremely rare in patients with acute myeloid leukemia (AML) and therefore, is often misdiagnosed as lymphoma or other benign tumors. The current report presents two cases of GS of the breast, of which, one was considered to be a fibroma, as observed by fine-needle aspiration, and the other was misdiagnosed as lymphoma by frozen section. Previous literature that described the clinical and pathological characteristics, treatments and prognosis of GS of the breast in AML were reviewed. In addition to the treatment of mastectomy with/without radiotherapy, lumpectomy may also be received as a good treatment plan.

Orbital extra-medullary granulocytic sarcoma: clinicopathologic correlation with immunohistochemical features

Orbital granulocytic sarcoma (chloroma), a rare tumor of immature myeloid cells, has nonspecific clinical and radiological features that make it a diagnostic challenge. Light microscopy and confirmation by immunostaining aid in the diagnosis. Knowledge of this entity is important because early diagnosis and prompt treatment are associated with better prognosis. We report a series of 31 biopsy-proven orbital granulocytic sarcomas with their immunohistochemical features and review the literature.

Interdigitating dendritic cell sarcoma presenting simultaneously with acute myelomonocytic leukemia: report of a rare case and literature review

Interdigitating dendritic cell sarcoma (IDCS) is an extremely rare tumor derived from interdigitating dendritic cells. We report the first case of a 64-year-old Chinese woman who was diagnosed with simultaneous IDCS and acute myelomonocytic leukemia (AML-M4). The patient had undergone chemotherapy for breast cancer 6 years previously. Based on the laboratory results, both the IDCS and the AML-M4 in this patient were determined to be of myelogenous origination. Furthermore, a review of 62 IDCS cases (Medline database, key word: IDCS) reported to date revealed that as many as 17 % of the patients had malignant disease and received radiotherapy and/or chemotherapy prior to developing IDCS, and that this group of patients showed worse prognosis compared with counterparts. The patient in the present report showed poor response to four cycles of sequential chemotherapy, and died 6 months after the initial diagnosis.

Is acute myeloid leukemia a liquid tumor?

Extramedullary manifestations of acute myeloid leukemia (AML) were described as early as the 19th century. However, the incidence, clinical significance and pathobiology of extramedullary AML remain ill defined. We reviewed case reports, retrospective case series, pilot studies and imaging studies of extramedullary leukemia (EML) to determine its frequency, characteristics, clinical presentation and significance. EML precedes or accompanies development of AML and occurs during or following treatment, even during remission. Although imaging studies are rarely conducted and the true incidence of EML has yet to be verified, authors have reported several estimates based on retrospective and autopsy studies. The incidence of EML in patients with AML of all ages is estimated to be about 9% and EML in children with AML was detected in 40% of patients at diagnosis. The combination of positron emission tomography and computed tomography were the most sensitive and reliable techniques of detecting and monitoring EML. Based on our literature review, the frequency of EML is likely underreported. The well-documented nature of EML in patients with AML suggests that AML can manifest as a solid tumor. The extent to which EML accompanies AML and whether EML is derived from bone marrow are unknown. Furthermore, questions remain regarding the role of the microenvironment, which may or may not facilitate the survival and proliferation of EML, and the implications of these interactions with regard to minimal residual disease, tumor cell quiescence and relapse. Therefore, prospective studies of detection and characterization of EML in patients with AML are warranted.

Aleukemic granulocytic sarcoma presenting at multiple sites: ovary, breast and soft tissue

An 18 year old female presented with the history of pain in abdomen, breast engorgement, swelling over both legs and breathlessness for three month. On clinical examination diagnosis of fibroadenoma breast was made. Ultrasonography of abdomen showed bilateral ovarian mass. Bilateral salpingo-ophrectomy was done and specimen was sent for histological examination. Two lobulated solid masses of tissues the larger one measuring 13×8×5 cm and smaller one measuring 10×7×5 cm in size received. Microscopic examination showed monomorphic population of discohesive, hyperchromatic small round cells had high N:C ratio, coarse chromatin, conspicuous nucleoli and scant to moderate amount of basophilic cytoplasm, lying in sheets and separated by fibrous strands and diffusely infiltrating the ovarian stroma. Fine needle aspiration from breast lump and leg swelling showed predominant population of blast cells. Myeloperoxidase was strongly positive and diagnosis of granulocytic sarcoma was confirmed.

Eosinophilic granulocytic sarcoma in a pig

A case of granulocytic sarcoma originating from an eosinophilic lineage is described in a 5-year-old, mixed-breed, female pig. The pig had been originally sent to slaughter in a good plane of nutrition and without displaying clinical disease. At gross examination, green masses were observed in several bones, especially vertebrae, sternum, pelvis, and long bones such as femur and humerus. Similar masses were seen in skeletal muscles, lymph nodes, and kidneys. Cytology revealed large numbers of round cells with round nuclei and scant cytoplasm (myelocytes); some of these cells had a fine eosinophilic granularity to their cytoplasm (eosinophil myelocytes). Histologically, the neoplastic cells formed sheets that completely obliterated the normal architecture of subperiosteal bone marrow. The cytoplasm of the neoplastic cells stained strongly by Sirius red stain of eosinophil and was positively marked by immunohistochemistry using an anti-myeloperoxidase antibody. The association of gross examination, cytology, histology, histochemistry, and immunohistochemistry findings is consistent with a diagnosis of eosinophilic granulocytic sarcoma.

Breast leukemia: an update

BACKGROUND

Breast leukemia is extremely rare. The published data on this manifestation include predominantly case reports and do not provide any statistical information.

PURPOSE

To identify clinical signs and radiological features of breast leukemia.

MATERIAL AND METHODS

PubMed and Medline databases between 1980 and 2010 were screened using 'breast leukemia' and 'leukemia of the breast' as keywords. Secondary references were also reviewed. By this search, a total of 139 patients were identified from the literature.

RESULTS

In most patients (n = 85, 61.2%) acute myeloid leukemia was diagnosed. Acute lymphatic leukemia occurred in 35 patients (25.2%). Isolated BL before bone marrow infiltration was seen in 24 patients (17.3%). Involvement of the breast during the course of leukemia was diagnosed in 25 cases (18%). Intramammary leukemic relapse after therapy/stem cell transplantation occurred in 59 patients (42.4%). In 71 cases (51.1%) the lesions were solitary and in 57 (41%) multiple. The number of lesions was not reported in 11 patients (7.9%). There was no significant difference between the number of lesions in ML and LL. Clinically, 73% of the patients presented with palpable breast masses. Most of them were painless. Mammography was performed in 39 patients, allowing the identification of the following three mammographic patterns: breast masses (28 patients, 72%), architectural distortion (5 patients, 13%), no abnormalities (6 patients, 15%). On ultrasound, most identified masses were homogeneously hypoechoic with microlobulated or indistinct margins. On MRI, on T2-weighted images breast lesions were hyperintense. After venous administration of contrast medium, BL showed marked inhomogeneous contrast enhancement. Treatment of BL is the same as for other localizations and is based on chemotherapy and/or radiotherapy.

CONCLUSION

In the present study the clinical and radiological features of BL are described. They are non-specific. However, BL should be considered in the differential diagnosis of breast disorders, especially in patients with leukemia.

State of the art in myeloid sarcoma

INTRODUCTION

Myeloid sarcomas are extramedullary lesions composed of myeloid lineage blasts that typically form tumorous masses and may precede, follow, or occur in the absence of systemic acute myeloid leukemia. They most commonly involve the skin and soft tissues, lymph nodes, and gastrointestinal tract and are particularly challenging to diagnose in patients without an antecedent history of acute myeloid leukemia.

METHODS

We conducted a search of the English language medical literature for recent studies of interest to individuals involved in the diagnosis of myeloid sarcoma.

RESULTS

The differential diagnosis includes non-Hodgkin lymphoma, blastic plasmacytoid dendritic cell neoplasm, histiocytic sarcoma, melanoma, carcinoma, and (in children) small round blue cell tumors. The sensitivity and specificity of immunohistochemical markers must be considered when evaluating a suspected case of myeloid sarcoma. A high percentage of tested cases have cytogenetic abnormalities.

CONCLUSION

A minimal panel of immunohistochemical markers should include anti-CD43 or anti-lysozyme as a lack of immunoreactivity for either of these sensitive markers would be inconsistent with a diagnosis of myeloid sarcoma. Use of more specific markers of myeloid disease, such as CD33, myeloperoxidase, CD34 and CD117 is necessary to establish the diagnosis. Other antibodies may be added depending on the differential diagnosis. Identification of acute myeloid leukemia-associated genetic lesions may be helpful in arriving at the correct diagnosis.

How I treat extramedullary acute myeloid leukemia

Extramedullary (EM) manifestations of acute leukemia include a wide variety of clinically significant phenomena that often pose therapeutic dilemmas. Myeloid sarcoma (MS) and leukemia cutis (LC) represent 2 well-known EM manifestations with a range of clinical presentations. MS (also known as granulocytic sarcoma or chloroma) is a rare EM tumor of immature myeloid cells. LC specifically refers to the infiltration of the epidermis, dermis, or subcutis by neoplastic leukocytes (leukemia cells), resulting in clinically identifiable cutaneous lesions. The molecular mechanisms underlying EM involvement are not well defined, but recent immunophenotyping, cytogenetic, and molecular analysis are beginning to provide some understanding. Certain cytogenetic abnormalities are associated with increased risk of EM involvement, potentially through altering tissue-homing pathways. The prognostic significance of EM involvement is not fully understood. Therefore, it has been difficult to define the optimal treatment of patients with MS or LC. The timing of EM development at presentation versus relapse, involvement of the marrow, and AML risk classification help to determine our approach to treatment of EM disease.

Nonleukemic myeloid sarcoma of the liver: a case report and review of literature

Myeloid sarcoma (MS) is a neoplasm of immature granulocytes, monocytes, or both involving extramedullary sites. MS with no evidence of leukemia (nonleukemic MS) is very rare and the initial diagnosis can be difficult. This report describes an unusual case of nonleukemic MS of the liver in a 16-year-old patient presenting as debilitating hepatomegaly. A liver biopsy revealed diffuse infiltration by neoplastic cells of myeloid lineage (CD68, myeloperoxidase). A bone marrow biopsy showed no evidence of medullary involvement. The patient subsequently developed heart failure. Autopsy revealed infiltration of most organs by neoplastic cells but failed to identify abnormal myeloid cells in bone marrow.

Erythroblastic sarcoma presenting as bilateral ovarian masses in an infant with pure erythroid leukemia

Pure erythroid leukemia is a rare subtype of acute erythroid leukemia that is characterized by a predominant erythroid population, and erythroblastic sarcoma has not yet been described in the English literature. Here, we report a first case of erythroblastic sarcoma that presented as bilateral ovarian masses in a 3 ½-month-old infant girl with pure erythroid leukemia. Bone marrow aspirate and biopsy showed that the marrow was completely replaced by large-sized blasts consistent with erythroblasts. Immunophenotypically, both the tumor cells from the ovarian mass and bone marrow blasts were positive for CD117, glycophorin A, and hemoglobin A, demonstrating erythroid differentiation. Reverse transcriptase polymerase chain reaction showed that the tumor cells from ovarian mass expressed hemoglobin F and α1 spectrin, confirming their erythroid lineage. Conventional karyotype of the bone marrow aspirates revealed del(6)(q23q25) and trisomy 7 in all 21 cells examined. Fluorescence in situ hybridization of the ovarian mass demonstrated loss of c-myeloblastosis viral oncogene (C-MYB) at 6q23 locus in 41% of the cells, and deletion of chromosome 7 and 7q in 37% and 66% of cells, respectively. Taken together, we showed, for the first time, that pure erythroid leukemia presented as a myeloid sarcoma in the form of ovarian masses.

Isolated pancreatic granulocytic sarcoma: A case report and review of the literature

Granulocytic sarcoma (GS) is an extramedullary tumor mass consisting of immature myeloid cells. Isolated pancreatic granulocyte sarcoma is extremely rare. We report a very unusual pancreatic granulocytic sarcoma in a patient without acute myeloid leukemia. The patient presented with acute epigastric pain because of splenic infarction due to a mass consisting of myeloblasts in the pancreatic tail. The patients underwent splenectomy and distal pancreatectomy. Pathology and immunohistochemistry suggested a GS. Despite local surgery, an isolated tumor recurred 2 mo after operation and the patient died 3 mo after removal of the tumor. Only 7 reported cases of pancreatic GS were identified in the literature and the mass was located in the pancreatic head. This is the first report of GS in the pancreatic tail with splenic infarction.