1
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Hu S, Xiao F, Zhang Z, Jiang Y, Mao D, Wang J, He X. Solitary eosinophilic granulocytic sarcoma in a dog. Vet Med Sci 2024; 10:e1465. [PMID: 38709141 PMCID: PMC11072188 DOI: 10.1002/vms3.1465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 03/05/2024] [Accepted: 04/12/2024] [Indexed: 05/07/2024] Open
Abstract
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.
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Affiliation(s)
- Shou‐Ping Hu
- State Key Laboratory for Animal Disease Control and PreventionHarbin Veterinary Research InstituteChinese Academy of Agricultural SciencesHarbinPeople's Republic of China
| | - Fei Xiao
- State Key Laboratory for Animal Disease Control and PreventionHarbin Veterinary Research InstituteChinese Academy of Agricultural SciencesHarbinPeople's Republic of China
| | - Zhuo Zhang
- State Key Laboratory for Animal Disease Control and PreventionHarbin Veterinary Research InstituteChinese Academy of Agricultural SciencesHarbinPeople's Republic of China
| | - Yan Jiang
- State Key Laboratory for Animal Disease Control and PreventionHarbin Veterinary Research InstituteChinese Academy of Agricultural SciencesHarbinPeople's Republic of China
| | - Dong‐Sheng Mao
- State Key Laboratory for Animal Disease Control and PreventionHarbin Veterinary Research InstituteChinese Academy of Agricultural SciencesHarbinPeople's Republic of China
| | - Jing‐Fei Wang
- State Key Laboratory for Animal Disease Control and PreventionHarbin Veterinary Research InstituteChinese Academy of Agricultural SciencesHarbinPeople's Republic of China
| | - Xi‐Jun He
- State Key Laboratory for Animal Disease Control and PreventionHarbin Veterinary Research InstituteChinese Academy of Agricultural SciencesHarbinPeople's Republic of China
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2
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Jebrini N, Sarahneh H, Jaber M, Natsheh M, Abu Ayyash A, Bannoura S, Razem R. Gastric myeloid sarcoma mimicking pseudoachalasia in non-leukemic context: a singular case report. Ann Med Surg (Lond) 2024; 86:2281-2285. [PMID: 38576939 PMCID: PMC10990304 DOI: 10.1097/ms9.0000000000001830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 02/04/2024] [Indexed: 04/06/2024] Open
Abstract
Introduction and importance Myeloid sarcoma (MS) is a rare tumour associated with acute myeloid leukaemia (AML) and occasionally occurs independently. It typically affects skin, bone, lymph nodes, and rarely the gastrointestinal tract, with gastric cases being extremely rare. Notably, no reported instances associate pseudoachalasia with gastric myeloid sarcoma. Case presentation A 20-year-old male presented with severe dysphagia, refractory vomiting, and weight loss. Diagnosed with type III achalasia via oesophageal tests, subsequent gastroscopy revealed a large gastric mass, later identified as gastric myeloid sarcoma through histopathology. Clinical discussion MS, characterized by immature blast cells, poses diagnostic challenges without typical leukaemia symptoms. Diagnosis involves immunohistochemistry, employing markers like CD33, CD34, and CD43. Optimal treatments, such as chemotherapy or stem cell transplantation, aim to delay leukaemia progression. Gastric primary de-novo myeloid sarcoma is exceedingly rare, emphasizing the need for tailored treatment strategies. Conclusion Gastric myeloid sarcoma is an exceptionally rare tumour, especially without concurrent acute myeloid leukaemia (AML), complicating its diagnosis. This case represents the first globally documented instance of gastric myeloid sarcoma causing pseudoachalasia. Documenting this unique clinical presentation is crucial for a better grasp of gastric myeloid sarcoma's diverse manifestations.
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Affiliation(s)
- Nidal Jebrini
- Faculty of Medicine, Palestine Polytechnic University, Hebron, Palestine
- Al-Ahli Hospital, Doha, Qatar
| | - Husein Sarahneh
- Faculty of Medicine, Palestine Polytechnic University, Hebron, Palestine
| | - Mohanad Jaber
- Faculty of Medicine, Palestine Polytechnic University, Hebron, Palestine
- Al-Ahli Hospital, Doha, Qatar
- Forensic Pathology
| | | | | | | | - Raghad Razem
- Faculty of Medicine, Palestine Polytechnic University, Hebron, Palestine
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3
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Pervaiz A, Brimioulle M, Qureishi A, Royston D. Nasopharyngeal myeloid sarcoma as a manifestation of acute monomyelocytic leukaemia. BMJ Case Rep 2023; 16:e251681. [PMID: 38123315 DOI: 10.1136/bcr-2022-251681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023] Open
Abstract
This case report describes the case of a man in his seventies presenting with a nasopharyngeal deposit of myeloid sarcoma associated with acute monomyelocytic leukaemia. He presented with right nasal obstruction associated with unilateral pulsatile tinnitus. CT and MRI scans of sinuses identified a moderately restricting mucosal swelling of the right torus tubarius, and a biopsy of the lesion diagnosed a nasal deposit of myeloid sarcoma.
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Affiliation(s)
| | | | - Ali Qureishi
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Daniel Royston
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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4
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Hawthorne J, Cubro H, Farabee E, Al-Quran SZ, Al-Kawaaz M, Vranic S, Goldsberry W, Metzinger D, Todd S. Bilateral adnexal masses: A case report of acute myeloid leukemia presenting with myeloid sarcoma of the ovary and review of literature. Gynecol Oncol Rep 2023; 47:101202. [PMID: 37251785 PMCID: PMC10209116 DOI: 10.1016/j.gore.2023.101202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 05/04/2023] [Accepted: 05/13/2023] [Indexed: 05/31/2023] Open
Abstract
•We report a case of a patient with acute myeloid leukemia (AML) presenting as myeloid sarcoma.•This patient with bilateral adnexal masses was managed via total robotic hysterectomy with bilateral salpingo-oophorectomy.•There are a limited number of reports of bilateral ovarian occurrences that exist in the literature.•Myeloid sarcoma of the ovaries may present with vaginal bleeding to dysmenorrhea, dysuria, and palpable abdominal mass.
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Affiliation(s)
- Jenci Hawthorne
- Department of Gynecology Oncology, University of Louisville, Department of Obstetrics, Gynecology, and Women’s Health, 550 South Jackson Street, Ambulatory Care Building, Second Floor, Louisville, KY 40202, United States
| | - Hajrunisa Cubro
- Department of Gynecology Oncology, University of Louisville, Department of Obstetrics, Gynecology, and Women’s Health, 550 South Jackson Street, Ambulatory Care Building, Second Floor, Louisville, KY 40202, United States
| | - Elizabeth Farabee
- Department of Gynecology Oncology, University of Louisville, Department of Obstetrics, Gynecology, and Women’s Health, 550 South Jackson Street, Ambulatory Care Building, Second Floor, Louisville, KY 40202, United States
| | - Samer Z. Al-Quran
- University of Louisville, Department of Pathology, Abell Administration Building, 323 East Chestnut Street, Louisville, KY 40202, United States
| | - Mustafa Al-Kawaaz
- University of Louisville, Department of Pathology, Abell Administration Building, 323 East Chestnut Street, Louisville, KY 40202, United States
| | - Semir Vranic
- College of Medicine, QU Health, Qatar University, 2713 Doha, Qatar
| | - Whitney Goldsberry
- Department of Gynecology Oncology, University of Louisville, Department of Obstetrics, Gynecology, and Women’s Health, 550 South Jackson Street, Ambulatory Care Building, Second Floor, Louisville, KY 40202, United States
| | - Daniel Metzinger
- Department of Gynecology Oncology, University of Louisville, Department of Obstetrics, Gynecology, and Women’s Health, 550 South Jackson Street, Ambulatory Care Building, Second Floor, Louisville, KY 40202, United States
| | - Sarah Todd
- Department of Gynecology Oncology, University of Louisville, Department of Obstetrics, Gynecology, and Women’s Health, 550 South Jackson Street, Ambulatory Care Building, Second Floor, Louisville, KY 40202, United States
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5
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Ramia de Cap M, Chen W. Myeloid sarcoma: An overview. Semin Diagn Pathol 2023; 40:129-139. [PMID: 37149396 DOI: 10.1053/j.semdp.2023.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 04/12/2023] [Accepted: 04/12/2023] [Indexed: 05/08/2023]
Abstract
Myeloid Sarcoma (MS) is a high grade, hematological malignancy defined as an extramedullary tumor mass of myeloid blasts with or without maturation that effaces tissue architecture. It is a highly heterogenous condition that represents a variety of myeloid neoplasms. This heterogeneity of MS, together with its rarity, have greatly hampered our understanding of the condition. Diagnosis requires tumor biopsy, which should be accompanied by bone marrow evaluation for medullary disease. It is presently recommended that MS be treated similar to AML. Additionally, ablative radiotherapy and novel targeted therapies may also be beneficial. Genetic profiling has identified recurrent genetic abnormalities including gene mutations associated with MS, supporting its etiology similar to AML. However, the mechanisms by which MS homes to specific organs is unclear. This review provides an overview of pathogenesis, pathological and genetic findings, treatment, and prognosis. Improving the management and outcomes of MS patients requires a better understanding of its pathogenesis and its response to various therapeutic approaches.
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Affiliation(s)
- Maximiliano Ramia de Cap
- North Bristol NHS Trust, Southmead Hospital, Pathology Sciences Building, Westbury on Trym, Bristol BS10 5NB, UK.
| | - Weina Chen
- UT Southwestern Medical Center, Dallas, TX, USA
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6
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Wang C, Zhu L, Liu S, He C, Yi S, Wang Y, Meng F, Xiao M, Zhang Y, Mao X. Isolated meningeal myeloid sarcoma with recurrent MLL-AF6 translocation: a case report. J Int Med Res 2023; 51:03000605231159310. [PMCID: PMC10009040 DOI: 10.1177/03000605231159310] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 02/06/2023] [Indexed: 06/12/2023] Open
Abstract
This study aimed to help improve the diagnosis and treatment of isolated myeloid sarcoma. We report the case of a female adolescent patient with isolated meningeal myeloid sarcoma. She was admitted to our department because of vomiting, headache and hearing loss. Positron emission tomography-computed tomography and brain magnetic resonance imaging showed multiple intracranial space-occupying lesions. A complete examination, including morphology, cytology, immunophenotyping, cytogenetics and molecular biology tests of cerebrospinal fluid and bone marrow, was conducted. The diagnosis of primary myeloid sarcoma of the central nervous system with mixed lineage leukemia gene rearrangement with AF6 was established. The patient underwent systemic chemotherapy and intrathecal treatment followed by whole-brain radiotherapy. She achieved complete remission for 84 months and has not developed bone marrow involvement during follow-up. The combination of morphology, cytology, flow cytometry, cytogenetics and molecular analysis can improve the definite diagnosis of isolated myeloid sarcoma.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Xia Mao
- Xia Mao, Department of Hematology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, No. 1095 Jiefang Road, Wuhan 430000, China.
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7
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Patterson M, Wu Y, Niazi M. Myeloid Sarcoma Presenting as Obstructive Jaundice. Case Rep Gastroenterol 2021; 15:695-702. [PMID: 34594168 PMCID: PMC8436724 DOI: 10.1159/000514528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Accepted: 01/12/2021] [Indexed: 11/25/2022] Open
Abstract
Myeloid sarcoma (MS) is a rare solid neoplasm that consists of extramedullary myeloid precursor cells. Generally, it is associated with underlying acute myeloid leukemia (AML) or AML yet to manifest clinically. It can present as isolated, also known as primary MS without evidence of AML or other myeloproliferative neoplasms. We present the case of a previously healthy 36-year-old male, who was admitted to hospital with new-onset painful obstructive jaundice and final diagnosis of isolated MS was made after through investigations. We are pleased to report that he had favorable response to the treatment and remains well.
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Affiliation(s)
- Matthew Patterson
- Department of Internal Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Yue Wu
- Department of Pathology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Mina Niazi
- Department of Gastroenterology and Hepatology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
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8
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Weyrich A, Becker S, Vienenkötter J, Reiner G, Herden C. A rare case of multicentric eosinophilic granulocytic sarcoma as cause of hindlimb weakness and non‐regenerative anaemia in a minipig. VETERINARY RECORD CASE REPORTS 2021. [DOI: 10.1002/vrc2.133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Angelika Weyrich
- Institute of Veterinary Pathology Justus‐Liebig‐University Giessen Germany
| | - Sabrina Becker
- Department of Veterinary Clinical Sciences, Swine Diseases Justus‐Liebig‐University Giessen Germany
| | - Julia Vienenkötter
- Institute of Veterinary Pathology Justus‐Liebig‐University Giessen Germany
| | - Gerald Reiner
- Department of Veterinary Clinical Sciences, Swine Diseases Justus‐Liebig‐University Giessen Germany
| | - Christiane Herden
- Institute of Veterinary Pathology Justus‐Liebig‐University Giessen Germany
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9
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Granulocytic sarcoma: Extramedullary manifestation of chronic myeloproliferative neoplasm in a young African woman. HUMAN PATHOLOGY: CASE REPORTS 2021. [DOI: 10.1016/j.ehpc.2020.200462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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10
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Bai CR, Li X, Wang JS, Li JJ, Liu N, Fei Q, Li D, Yang Y. Diagnosis and surgical treatment of primary isolated aggressive lumbar myeloid sarcoma: a rare case report and review of the literatures. BMC Musculoskelet Disord 2021; 22:220. [PMID: 33627110 PMCID: PMC7905608 DOI: 10.1186/s12891-021-04066-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 02/09/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Myeloid sarcoma is a rare, extramedullary, solid tumor derived from immature myeloid cell precursors. It is most frequently accompanied by acute myelogenous leukemia, though infrequently found in non-acute myelogenous leukemia patients. The tumor may involve any part of the body, but the lumbar spine is seldom involved. The present case study aims to understand the diagnosis and surgical treatment of a rare primary isolated myeloid sarcoma of the lumbar spine causing aggressive spinal cord compression in a non-acute myelogenous leukemia patient. CASE PRESENTATION A 29-year-old man complained of an aggressive radiating pain to the lower extremities and moderate dysuria with a Visual Analogue Scale score that gradually increased from 3 to 8. Lumbar enhanced magnetic resonance imaging and computed tomography revealed a lumbar canal lesion at lumbar spine L2 to L4 with spinal cord compression. A whole body bone scan with fused single photon emission computed tomography/computed tomography demonstrated abnormal 99mTc-methylene diphosphonate accumulation in the L3 lamina and spinous process. No evidence of infection or hematology disease was observed in laboratory tests. Due to rapid progression of the symptoms and lack of a clear diagnosis, decompression surgery was performed immediately. During the operation, an approximately 6.0 × 2.5 × 1.2 cm monolithic, fusiform, soft mass in the epidural space and associated lesion tissues were completely resected. The radiating pain was relieved immediately and the dysuria disappeared within 1 week. Intraoperative pathological frozen section analysis revealed a hematopoietic malignant tumor and postoperative immunohistochemistry examination confirmed the diagnosis of myeloid sarcoma. CONCLUSIONS The primary isolated aggressive lumbar myeloid sarcoma is rarely seen, the specific symptoms and related medical history are unclear. Surgery and hematological treatment are effective for understanding and recognizing this rare tumor.
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Affiliation(s)
- Cheng-Rui Bai
- Department of Orthopedics, Beijing Friendship Hospital Affiliated of Capital Medical University, 95 Yong An Rd, Beijing, 100050, China
| | - Xiang Li
- Department of Orthopedics, Beijing Friendship Hospital Affiliated of Capital Medical University, 95 Yong An Rd, Beijing, 100050, China
| | - Jing-Shi Wang
- Department of Hematology, Beijing Friendship Hospital Affiliated of Capital Medical University, 95 Yong An Rd, Beijing, 100050, China
| | - Jin-Jun Li
- Department of Orthopedics, Beijing Friendship Hospital Affiliated of Capital Medical University, 95 Yong An Rd, Beijing, 100050, China
| | - Ning Liu
- Department of Orthopedics, Beijing Friendship Hospital Affiliated of Capital Medical University, 95 Yong An Rd, Beijing, 100050, China
| | - Qi Fei
- Department of Orthopedics, Beijing Friendship Hospital Affiliated of Capital Medical University, 95 Yong An Rd, Beijing, 100050, China
| | - Dong Li
- Department of Orthopedics, Beijing Friendship Hospital Affiliated of Capital Medical University, 95 Yong An Rd, Beijing, 100050, China
| | - Yong Yang
- Department of Orthopedics, Beijing Friendship Hospital Affiliated of Capital Medical University, 95 Yong An Rd, Beijing, 100050, China.
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11
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Zotzmann V, Wengenmayer T, Lang CN, Staudacher DL, Mueller-Peltzer K, Bamberg F, Marks R, Bode C, Wäsch R. Case Report: Refusal of an Veno-Arterial Extracorporeal Membrane Oxygenation Due to Malignant Disease? - An Extremely Rare Form of Cardiac Involvement in Acute Myeloid Leukemia. Front Med (Lausanne) 2021; 8:584507. [PMID: 33708776 PMCID: PMC7940367 DOI: 10.3389/fmed.2021.584507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 02/04/2021] [Indexed: 11/20/2022] Open
Abstract
We report here on a 61-year-old patient with acute right heart failure of unclear etiology. Echocardiography revealed a myocardial mass infiltrating the heart, though, we assumed a cardiac lymphoma. A VA-ECMO was implanted as bridging for diagnosis and therapy. Our patient received chemotherapy, under which the tumor (of unknown etiology at this point) reached a partial remission. Nine months after first admission the patient developed acute myeloid leukemia with DNMT3a and TET2 mutations. Retrospective analysis of the cardiac biopsy revealed the identical mutations and matched with the diagnosis of an extremely rare primary extramedullary manifestation of an AML (myelosarcoma). The patient received induction-chemotherapy and was planned for consolidating allogeneic stem cell transplantation. From this case, we conclude that an extracorporeal therapy should be discussed in selected patients even in case of an initially fatal appearing prognosis. In selected cases, extracorporeal support can generate enough time for diagnosis and therapy. However, transparent planning, including discussion of best supportive care strategies involving the patient's family are indispensable requirements for starting ECMO in such patients.
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Affiliation(s)
- Viviane Zotzmann
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany.,Department of Cardiology and Angiology I, University Heart Center Freiburg, Bad Krozingen, Germany
| | - Tobias Wengenmayer
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany.,Department of Cardiology and Angiology I, University Heart Center Freiburg, Bad Krozingen, Germany
| | - Corinna N Lang
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany.,Department of Cardiology and Angiology I, University Heart Center Freiburg, Bad Krozingen, Germany
| | - Dawid L Staudacher
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany.,Department of Cardiology and Angiology I, University Heart Center Freiburg, Bad Krozingen, Germany
| | - Katharina Mueller-Peltzer
- Department of Diagnostic and Interventional Radiology, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Fabian Bamberg
- Department of Diagnostic and Interventional Radiology, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Reinhard Marks
- Department of Medicine I (Hematology, Oncology, and Stem-Cell Transplantation), Faculty of Medicine, Medical Center, Freiburg im Breisgau, Germany
| | - Christoph Bode
- Department of Medicine III (Interdisciplinary Medical Intensive Care), Medical Center, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany.,Department of Cardiology and Angiology I, University Heart Center Freiburg, Bad Krozingen, Germany
| | - Ralph Wäsch
- Department of Medicine I (Hematology, Oncology, and Stem-Cell Transplantation), Faculty of Medicine, Medical Center, Freiburg im Breisgau, Germany
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12
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Affiliation(s)
- H. Takeh
- Department of Surgery, Centre Hospitalier Molière-Longchamp, Brussels, Belgium
| | - M. Farran
- Department of Surgery, Centre Hospitalier Molière-Longchamp, Brussels, Belgium
| | - J. P. Debaize
- Department of Surgery, Centre Hospitalier Molière-Longchamp, Brussels, Belgium
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13
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Shallis RM, Gale RP, Lazarus HM, Roberts KB, Xu ML, Seropian SE, Gore SD, Podoltsev NA. Myeloid sarcoma, chloroma, or extramedullary acute myeloid leukemia tumor: A tale of misnomers, controversy and the unresolved. Blood Rev 2020; 47:100773. [PMID: 33213985 DOI: 10.1016/j.blre.2020.100773] [Citation(s) in RCA: 63] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 09/01/2020] [Accepted: 10/02/2020] [Indexed: 02/06/2023]
Abstract
The World Health Organization classification and definition of "myeloid sarcoma" is imprecise and misleading. A more accurate term is "extramedullary acute myeloid leukemia tumor (eAML)." The pathogenesis of eAML has been associated with aberrancy of cellular adhesion molecules, chemokine receptors/ligands and RAS-MAPK/ERK signaling. eAML can present with or without synchronous or metachronous intramedullary acute myeloid leukemia (AML) so a bone marrow evaluation is always recommended. Accurate diagnosis of eAML requires tissue biopsy. eAML confined to one or a few sites is frequently treated with local therapy such as radiotherapy. About 75-90% of patients with isolated eAML will develop metachronous intramedullary AML with a median latency period ranging from 4 to 12 months; thus, patients with isolated eAML may also be treated with systemic anti-leukemia therapy. eAML does not appear to have an independent prognostic impact; selection of post-remission therapy including allogeneic hematopoietic cell transplant (alloHCT) is typically guided by intramedullary disease risk. Management of isolated eAML should be individualized based on patient characteristics as well as eAML location and cytogenetic/molecular features. The role of PET/CT in eAML is also currently being elucidated. Improving outcomes of patients with eAML requires further knowledge of its etiology and mechanism(s) as well as therapeutic approaches beyond conventional chemotherapy, ideally in the context of controlled trials.
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Affiliation(s)
- Rory M Shallis
- Section of Hematology, Department of Medicine, Yale University School of Medicine and Yale Cancer Center, New Haven, USA
| | - Robert P Gale
- Haematology Section, Division of Experimental Medicine, Department of Medicine, Imperial College London, London, UK
| | - Hillard M Lazarus
- Department of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Kenneth B Roberts
- Department of Radiation Oncology, Yale University School of Medicine, New Haven, USA
| | - Mina L Xu
- Department of Pathology, Yale University School of Medicine, New Haven, USA
| | - Stuart E Seropian
- Section of Hematology, Department of Medicine, Yale University School of Medicine and Yale Cancer Center, New Haven, USA
| | - Steven D Gore
- Section of Hematology, Department of Medicine, Yale University School of Medicine and Yale Cancer Center, New Haven, USA
| | - Nikolai A Podoltsev
- Section of Hematology, Department of Medicine, Yale University School of Medicine and Yale Cancer Center, New Haven, USA.
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14
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Engel NW, Reinert J, Borchert NM, Panagiota V, Gabdoulline R, Thol F, Heuser M, Fiedler W. Newly diagnosed isolated myeloid sarcoma-paired NGS panel analysis of extramedullary tumor and bone marrow. Ann Hematol 2020; 100:499-503. [PMID: 33108522 PMCID: PMC7817572 DOI: 10.1007/s00277-020-04313-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 10/15/2020] [Indexed: 11/15/2022]
Abstract
Isolated myeloid sarcoma (MS) is a rare malignancy in which myeloid blast forms tumors at various locations while the bone marrow (BM) remains cytomorphologically free from disease. We analyzed isolated MS from four patients and their BMs at initial diagnosis and follow-up, using a custom next-generation sequencing (NGS) panel. We observed possible clonal evolution and a clonal hematopoiesis of indeterminate potential (CHIP)-like finding in the BM of one of three cases with detectable mutations. Clinical presentation of one patient suggested extramedullary confined homing of blasts to distal sites in the relapse situation still sparing the BM. In summary, our findings shall motivate future work regarding signals of extramedullary blast trafficking and clonal evolution in MS.
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Affiliation(s)
- Nils W Engel
- Department of Oncology, Haematology and Bone Marrow Transplantation with Section Pneumology, Hubertus Wald Tumorzentrum, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Jochim Reinert
- Department of Oncology, Haematology and Bone Marrow Transplantation with Section Pneumology, Hubertus Wald Tumorzentrum, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Nora M Borchert
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Victoria Panagiota
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Razif Gabdoulline
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Felicitas Thol
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Michael Heuser
- Department of Hematology, Hemostasis, Oncology, and Stem Cell Transplantation, Hannover Medical School, Hannover, Germany
| | - Walter Fiedler
- Department of Oncology, Haematology and Bone Marrow Transplantation with Section Pneumology, Hubertus Wald Tumorzentrum, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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15
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Xu G, Zhang H, Nong W, Li C, Meng L, Liu C, Li F. Isolated Intracranial Myeloid Sarcoma Mimicking Malignant Lymphoma: A Diagnostic Challenge and Literature Reviews. Onco Targets Ther 2020; 13:6085-6092. [PMID: 32612369 PMCID: PMC7323804 DOI: 10.2147/ott.s245828] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Accepted: 05/18/2020] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- Guixuan Xu
- Department of Pathology and Key Laboratories for Xinjiang Endemic and Ethnic Diseases, The First Affiliated Hospital, Shihezi University of Medical, Shihezi, 832002, People's Republic of China
| | - Haijun Zhang
- Department of Pathology and Key Laboratories for Xinjiang Endemic and Ethnic Diseases, The First Affiliated Hospital, Shihezi University of Medical, Shihezi, 832002, People's Republic of China
| | - Weixia Nong
- Department of Hematology, The First Affiliated Hospital of Medical College of Shihezi University, Shihezi 832002, People's Republic of China
| | - Chunsen Li
- Department of Pathology and Key Laboratories for Xinjiang Endemic and Ethnic Diseases, The First Affiliated Hospital, Shihezi University of Medical, Shihezi, 832002, People's Republic of China
| | - Lian Meng
- Department of Pathology and Key Laboratories for Xinjiang Endemic and Ethnic Diseases, The First Affiliated Hospital, Shihezi University of Medical, Shihezi, 832002, People's Republic of China
| | - Chunxia Liu
- Department of Pathology and Key Laboratories for Xinjiang Endemic and Ethnic Diseases, The First Affiliated Hospital, Shihezi University of Medical, Shihezi, 832002, People's Republic of China
| | - Feng Li
- Department of Pathology and Key Laboratories for Xinjiang Endemic and Ethnic Diseases, The First Affiliated Hospital, Shihezi University of Medical, Shihezi, 832002, People's Republic of China.,Department of Pathology and Medical Research Center, Beijing Chaoyang Hospital, Capital Medical University, Beijing 100020, People's Republic of China
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16
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Bakst R, Powers A, Yahalom J. Diagnostic and Therapeutic Considerations for Extramedullary Leukemia. Curr Oncol Rep 2020; 22:75. [PMID: 32577912 DOI: 10.1007/s11912-020-00919-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to summarize the current literature on the presentation, diagnosis, and treatment options available for extramedullary (EM) manifestations of leukemia including myeloid sarcoma (MS) and leukemia cutis (LC). RECENT FINDINGS Advanced imaging using 18FDG-PET/CT is an effective screening tool for EM manifestations of leukemia. The role of radiation therapy has been more clearly delineated in the treatment of both MS and LC. FDA-approved targeted agents have improved outcomes in patients with AML but have not demonstrated improvements specifically for EM; however, a checkpoint inhibitor, Ipilimumab, holds promise in impacting local control for the treatment of AML-related EM. EM manifestations of leukemia pose significant therapeutic challenges. Treatment of EM is predicated on multiple factors including the presence of concomitant bone marrow involvement, AML-risk classification, and timing of presentation at initial diagnosis or relapse following systemic therapy.
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Affiliation(s)
- Richard Bakst
- Department of Radiation Oncology, Icahn School of Medicine at Mount Sinai, 1184 Fifth Avenue, New York, NY, 10029, USA.
| | - Ann Powers
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Joachim Yahalom
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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17
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Abstract
PURPOSE OF REVIEW Myeloid sarcoma; also known as granulocytic sarcoma and chloroma, often occurs concomitantly with AML, and rarely without bone marrow involvement. In this article, we review the recent literature on myeloid sarcoma, focusing on treatment approach for this rare disease, and addressing the prognostic and therapeutic role of molecular and cytogenetic aberrations. RECENT FINDINGS Molecular testing and cytogenetics are important adjunct to conventional diagnostic methods. The significance of cytogenetic and molecular abnormalities in myeloid sarcoma is not completely established, but testing for targetable mutations on myeloid sarcoma cells is feasible, imperative, and may guide treatment decisions. Outcomes in myeloid sarcoma largely depend on the background of its development. Almost all patients with myeloid sarcoma eventually develop AML typically in a short period after its diagnosis; therefore, remission induction treatment using AML type chemotherapy has been the standard of care. Postremission therapy is controversial; allogenic SCT, radiotherapy or consolidation chemotherapy should be considered according to patient risk. SUMMARY Further research is required to understand the nature of myeloid sarcoma, and inclusion of patients with this condition in clinical trials should be considered to better identify the best diagnostic, prognostic, and therapeutic approach in managing this rare disease.
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18
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Slusarenko da Silva Y, Naclério-Homem MDG. Myeloid sarcoma on the temporal region before the onset of the acute myeloid leukemia: an extremely rare case report. Oral Maxillofac Surg 2020; 24:251-254. [PMID: 31970569 DOI: 10.1007/s10006-020-00833-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 01/10/2020] [Indexed: 06/10/2023]
Abstract
PURPOSE Myeloid sarcoma (MS) is a rare malignant tumor that arises outside the bone marrow and usually occurs concomitantly or after the acute myeloid leukemia (AML). The aim of the present study is to report an extremely rare case of a patient with an MS arising in the maxillofacial region before the onset of AML to serve as a guide on how to conduct the initial assessment and diagnosis of similar cases. MATERIALS AND METHODS A 29-year-old healthy man complained of a "swelling on the head," which was rapidly increasing. He was asymptomatic and never had a previous AML. RESULTS The patient presented a large mass on the left temporal region. The computed tomography showed a well-delimited lesion extending from the lateral pterygoid muscle and involving the zygomatic arch and lateral orbital rim. The mass was diagnosed as an MS arising before the onset of the AML. CONCLUSION Masses of a rapid increase in the maxillofacial region should always raise suspicion of being an MS even in asymptomatic patients. Following a protocol of initial assessment and diagnosis will decrease the period between the initial appearance of the MS and effective treatment aimed to prevent or delay the manifestation of leukemia, improving the prognosis and survival of these patients.
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Affiliation(s)
- Yuri Slusarenko da Silva
- Department of Oral & Maxillofacial Surgery, Traumatology and Prosthesis, Faculty of Dentistry, University of São Paulo, Av Prof. Lineu Prestes 2227 Butantã, São Paulo, State of São Paulo, 05508-000, Brazil.
| | - Maria da Graça Naclério-Homem
- Department of Oral & Maxillofacial Surgery, Traumatology and Prosthesis, Faculty of Dentistry, University of São Paulo, Av Prof. Lineu Prestes 2227 Butantã, São Paulo, State of São Paulo, 05508-000, Brazil
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19
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Slouma M, Rahmouni S, Dhahri R, Khayati Y, Zriba S, Amorri W, Gharsallah I, Metoui L, Louzir B. Epidural myeloid sarcoma as the presenting symptom of chronic myeloid leukemia blast crisis. Clin Rheumatol 2020; 39:2453-2459. [PMID: 32458246 DOI: 10.1007/s10067-020-05167-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 05/05/2020] [Accepted: 05/11/2020] [Indexed: 02/03/2023]
Abstract
Epidural myeloid sarcoma revealing chronic myeloid leukemia is scarce. Herein, we describe a patient that presented with back pain and bilateral sciatica secondary to root compression due to epidural deposition of leukemic cells. The magnetic resonance imaging showed epidural masses, causing a slight restriction of the spinal canal with bilateral L5 root compression. Laboratory examinations showed hyperleukocytosis (white blood cell count: 83 × 109/L, absolute neutrophil count: 60 × 109/L). The bone marrow cytology and immunophenotypic findings confirmed the diagnosis of myeloid leukemia. The diagnosis of spinal myeloid sarcoma revealing chronic myeloid leukemia during the blast phase was established. The patient underwent induction chemotherapy. Then, bone marrow cytology revealed less than 3% of blasts, which correspond to cytological remission. Three months later, MRI showed complete disappearance of the epidural masses. A literature review was conducted by searching PubMed using these terms: "Leukemia, Myeloid" AND "Spine" AND "Sarcoma, Myeloid". We emphasize clinical and radiological findings of spinal myeloid sarcoma. This diagnosis should be considered when the MRI reveals epidural mass lesion. The early management of this disease is necessary, and the treatment of myeloid sarcoma is not codified. Our case highlighted that chemotherapy treatment could be sufficient to lead to the disappearance of myeloid sarcoma and the remission of leukemia.
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Affiliation(s)
- Maroua Slouma
- Department of Internal Medicine, Military Hospital, Tunis El Manar University, Tunis, Tunisia.
| | - Safa Rahmouni
- Department of Internal Medicine, Military Hospital, Tunis El Manar University, Tunis, Tunisia
| | - Rim Dhahri
- Department of Internal Medicine, Military Hospital, Tunis El Manar University, Tunis, Tunisia
| | - Yasmine Khayati
- Department of Internal Medicine, Military Hospital, Tunis El Manar University, Tunis, Tunisia
| | - Samy Zriba
- Department of Hematology, Military Hospital, Tunis El Manar University, Tunis, Tunisia
| | - Wajdi Amorri
- Department of Radiology, Military Hospital, Tunis El Manar University, Tunis, Tunisia
| | - Imen Gharsallah
- Department of Internal Medicine, Military Hospital, Tunis El Manar University, Tunis, Tunisia
| | - Leila Metoui
- Department of Internal Medicine, Military Hospital, Tunis El Manar University, Tunis, Tunisia
| | - Bassem Louzir
- Department of Internal Medicine, Military Hospital, Tunis El Manar University, Tunis, Tunisia
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20
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The first case of acute myeloid leukaemia/myeloid sarcoma with cytokeratin expression on blasts diagnosed on urine specimen. Hematol Oncol Stem Cell Ther 2020; 14:343-347. [DOI: 10.1016/j.hemonc.2020.02.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Revised: 02/04/2020] [Accepted: 02/21/2020] [Indexed: 12/30/2022] Open
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21
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Mitra AD, Ku NK, Betts EV. Educational Case: Myeloid Sarcoma: A Subtype of Acute Myeloid Leukemia. Acad Pathol 2020; 7:2374289520956361. [PMID: 35243000 PMCID: PMC8856724 DOI: 10.1177/2374289520956361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 07/27/2020] [Accepted: 08/05/2020] [Indexed: 11/16/2022] Open
Abstract
The following fictional case is intended as a learning tool within the Pathology Competencies for Medical Education (PCME), a set of national standards for teaching pathology. These are divided into three basic competencies: Disease Mechanisms and Processes, Organ System Pathology, and Diagnostic Medicine and Therapeutic Pathology. For additional information, and a full list of learning objectives for all three competencies, seehttp://journals.sagepub.com/doi/10.1177/2374289517715040.1
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Affiliation(s)
- Ananya Datta Mitra
- Department of Pathology and Laboratory Medicine, University of California Davis Medical Center, Sacramento, CA, USA
| | - Nam Kyun Ku
- Department of Pathology and Laboratory Medicine, University of California, Sacramento, CA, USA
| | - Elham Vali Betts
- Department of Pathology and Laboratory Medicine, University of California Davis Medical Center, Sacramento, CA, USA
- Elham Vali Betts, Department of Pathology and Laboratory Medicine, University of California, Davis Medical Center, 4400 V Street, Sacramento, CA 95817, USA.
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22
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Acute Myeloid Leukemia Presenting as Myeloid Sarcoma with a Predisposition to the Gynecologic Tract. Case Rep Oncol Med 2019; 2019:4189275. [PMID: 31976102 PMCID: PMC6955122 DOI: 10.1155/2019/4189275] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 12/12/2019] [Indexed: 11/17/2022] Open
Abstract
Myeloid sarcoma (MS) is a rare, extramedullary tumor consisting of immature white blood cells of myeloid lineage. MS is usually associated with the concurrent diagnosis of acute myeloid leukemia (AML) but can also present in the absence of bone marrow disease or at relapse of AML. MS of the gynecologic tract is exceedingly rare; however, it is hypothesized that it is likely more prevalent than previously understood given postmortem findings and persistence in preserved ovarian tissue. There is minimal literature surrounding MS and extramedullary relapse with no clear guidelines. This is a case report of a 48-year-old woman with MS involving the uterine corpus, fallopian tubes, and left ovary followed by a literature review. The overall aim is to review data regarding leukemic immune evasion and sanctuary sites in order to raise awareness as this represents an important and underrecognized hematologic malignancy in an often misdiagnosed, underrecognized site.
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23
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Zhang X, Huang P, Chen Z, Bi X, Wang Y, Wu J. Vulvar myeloid sarcoma as the presenting symptom of acute myeloid leukemia: a case report and literature review of Chinese patients, 1999-2018. Diagn Pathol 2019; 14:126. [PMID: 31699112 PMCID: PMC6839179 DOI: 10.1186/s13000-019-0892-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 09/18/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Myeloid sarcoma (MS), which represents a rare malignancy that comprises of myeloid blasts occurring at extra-medullary sites, closely correlates with the onset and relapse of acute myeloid leukemia (AML) and other hemopoietic neoplasm. Female genital system is an uncommon location of MS, with the vulvar MS being even rarer that only eight cases have been reported in English-written literature. CASE PRESENTATION A 47-year-old woman presented with chronic ulceration on her vulva for one and a half month. Microscopic examination of incisional biopsy revealed dermal infiltration of myeloid precursor cells, which were positive for MPO, lysozyme, CD43, CD68, CD38 and CD117. Bone marrow flowcytometric analysis showed myeloblast count of 74%, which expressed CD13, CD33, CD117 and HLA-DR. A diagnosis of AML (M2 type) was made and vulvar MS was the earliest symptom. The patient achieved complete remission after chemotherapy with no evidence of recurrence in a 27-month follow-up. We reviewed the literature and identified 54 cases of Chinese patients with gynecological MS between 1999 and 2018, and discovered that in Chinese population, MS most frequently involved uterine cervix followed by the ovary and vulva, and ovarian MS onset much earlier than other sites. Remarkably, vulvar MS exhibited a high rate of concurrent AML and secondary myeloid leukemia within a short time of its occurrence. Despite its limited distribution, MS should be tackled aggressively with chemotherapy followed by allogeneic hematopoietic stem cell transplantation if the appropriate donor is available. CONCLUSIONS Female genital MS, especially vulvar MS, should be included in the differential diagnosis of gynecological neoplasm, which will facilitate its early diagnosis and prompt management.
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Affiliation(s)
- Xilin Zhang
- Department of Dermatology, Changhai Hospital, Second Military Medical University, Shanghai, 200433, China
- Department of Dermatology, Shanghai Skin Disease Hospital, Shanghai, 200433, China
| | - Peichen Huang
- Department of Dermatology, Changhai Hospital, Second Military Medical University, Shanghai, 200433, China
| | - Zhuo Chen
- Department of Dermatology, Shanghai Children's Medical Central, Shanghai Jiao Tong University School of Medicine, Shanghai, 200127, China
| | - Xinling Bi
- Department of Dermatology, Changhai Hospital, Second Military Medical University, Shanghai, 200433, China
| | - Ying Wang
- Department of Dermatology, Changhai Hospital, Second Military Medical University, Shanghai, 200433, China.
| | - Jianhua Wu
- Department of Dermatology, Changhai Hospital, Second Military Medical University, Shanghai, 200433, China.
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24
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Almalki AMJ, Alotaibi FA, Jabr HF, Mastan AR. Unilateral Proptosis As An Initial Sign Of Acute Myeloid Leukemia In A Child: A Case Report. Int Med Case Rep J 2019; 12:319-323. [PMID: 31695517 PMCID: PMC6817491 DOI: 10.2147/imcrj.s206596] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Accepted: 08/05/2019] [Indexed: 12/21/2022] Open
Abstract
Granulocytic sarcoma (chloroma) is a rare malignant solid tumor representing an extramedullary manifestation of acute myeloid leukemia (AML). Rarely, a chloroma can develop as the sole manifestation and its appearance may precede the systemic manifestations of acute myelocytic leukemia by months to years. We report a rare case of unilateral orbital mass presenting with progressive proptosis involving left globe in an otherwise healthy child, and give a brief overview of the literature about this unusual presentation. Leukemic infiltration should be considered in the differential diagnosis of orbital masses and proptosis even in the absence of systemic manifestations of AML. Early detection and management are crucial to preserve vision and prevent complications.
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Affiliation(s)
| | - Faisal Ali Alotaibi
- Ophthalmology Department, King Abdulaziz Specialist Hospital, Taif, Kingdom of Saudi Arabia
| | - Hatim Fawzi Jabr
- Ophthalmology Department, King Abdulaziz Specialist Hospital, Taif, Kingdom of Saudi Arabia
| | - Abdul Rehman Mastan
- ENT Department, King Abdulaziz Specialist Hospital, Taif, Kingdom of Saudi Arabia
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25
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Wu HY, Liu L, Gu L, Luo YH. Clinical characteristics and management of primary granulocytic sarcoma of the breast: A case report. Medicine (Baltimore) 2019; 98:e16648. [PMID: 31464900 PMCID: PMC6736367 DOI: 10.1097/md.0000000000016648] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
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.
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26
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Castro E, Morales L, Zreik R, Donner LR. A Focus of Differentiated Myeloid Sarcoma in a Ligation Specimen of the Fallopian Tube: No Evidence of Hematologic Abnormality in 18 Years of Follow-up Despite Absence of Treatment. Int J Surg Pathol 2019; 28:99-101. [PMID: 31342805 DOI: 10.1177/1066896919864167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A 0.2-cm intramural focus composed predominantly of myelocytes and metamyelocytes, many CD3+, CD43+ T-lymphocytes, scanty CD20+ B-lymphocytes, rare mast cells, but no eosinophils or myeloblasts was incidentally found in a ligation specimen of the left fallopian tube. The myeloid cells were positive for chloroacetate esterase, myeloperoxidase, myeloid marker BM2, and CD43, and they were negative for CD30, CD34, CD117, ERG, and TDT. The findings in the left fallopian tube were consistent with the diagnosis of differentiated myeloid sarcoma. The right fallopian tube was normal. No hematologic abnormalities were found elsewhere in the body. Curiously, the patient remains free of any hematologic abnormality for 18 years despite absence of treatment.
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Affiliation(s)
- Eduardo Castro
- Baylor Scott & White Medical Center, Temple, TX, USA.,Texas A&M University College of Medicine, Temple, TX, USA
| | - Linden Morales
- Baylor Scott & White Medical Center, Temple, TX, USA.,Texas A&M University College of Medicine, Temple, TX, USA
| | - Riyam Zreik
- Baylor Scott & White Medical Center, Temple, TX, USA.,Texas A&M University College of Medicine, Temple, TX, USA
| | - Ludvik R Donner
- Baylor Scott & White Medical Center, Temple, TX, USA.,Texas A&M University College of Medicine, Temple, TX, USA
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27
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Magdy M, Abdel Karim N, Eldessouki I, Gaber O, Rahouma M, Ghareeb M. Myeloid Sarcoma. Oncol Res Treat 2019; 42:224-229. [PMID: 30840960 DOI: 10.1159/000497210] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Accepted: 01/23/2019] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Mohamed Magdy
- Department of Pediatric Oncology, Pediatric Hospital, Cairo, Egypt
| | - Nagla Abdel Karim
- Department of Internal Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Ihab Eldessouki
- Department of Internal Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Ola Gaber
- Department of Internal Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Mohamed Rahouma
- Department of Surgical Oncology, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Mohamed Ghareeb
- Department of Medical Oncology, National Cancer Institute, Cairo University, Cairo, Egypt
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28
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Suzuki J, Harazaki Y, Morita S, Kaga Y, Nomura K, Sugawara M, Katori Y. Myeloid Sarcoma of the Paranasal Sinuses in a Patient with Acute Myeloid Leukemia. TOHOKU J EXP MED 2018; 246:141-146. [PMID: 30369515 DOI: 10.1620/tjem.246.141] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Myeloid sarcoma (MS) is an uncommon extramedullary malignant tumor, and often represents a subgroup of acute myeloid leukemia (AML). MS of paranasal sinus origin is extremely rare. We report an uncommon case of sinonasal MS associated with AML, who was successfully treated with hematopoietic stem-cell transplantation. A 39-year-old male was admitted with complaints of left nasal obstruction and proptosis. Computed tomography and magnetic resonance imaging identified a left ethmoidal mass involving the maxillary sinus, the orbit, and the skull base. Nasal endoscopic examination detected a whitish homogeneous mass occupying the left nasal cavity. Although accumulation of atypical lymphocytes was suspected based on initial pathological inspection, immunohistochemical analysis showed myeloperoxidase-positive myeloid cells. Together with concomitant leukocytosis (149,000/µL) composed of myeloid blast cells and excess of myeloblasts in the bone marrow, the patient was diagnosed as sinonasal MS with AML with maturation (French-American-British Classification M2). The patient was treated by chemotherapy (remission induction therapy with daunorubicin and cytarabine; salvage chemotherapy with high-dose cytarabine), radiotherapy (30 Gy in 10 fractions) and allogeneic hematopoietic stem-cell transplantation, and followed up for 12 months with no recurrence. Early diagnosis is critical for the best improvement of MS. MS of the paranasal sinuses may easily be misdiagnosed as malignant lymphoma or poorly differentiated carcinoma. Prompt hematological and immunohistological investigations with suspicion of MS are essential for correct diagnosis. Furthermore, we concisely review nine previously reported patients with MS and indicate the importance of hematopoietic stem-cell transplantation for good prognosis.
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Affiliation(s)
- Jun Suzuki
- Department of Otolaryngology-Head and Neck Surgery, Tohoku University School of Medicine.,Department of Otolaryngology, Tohoku Kosai Hospital
| | | | | | - Yoshiko Kaga
- Department of Clinical Lavoratory, Miyagi Cancer Center
| | | | | | - Yukio Katori
- Department of Otolaryngology-Head and Neck Surgery, Tohoku University School of Medicine
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29
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Cunningham I, Worthley D. Leukemia in gastrointestinal organs as cause of treatment failure: 378 cases analyzed. Am J Hematol 2018; 93:1327-1336. [PMID: 30105897 DOI: 10.1002/ajh.25250] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 07/31/2018] [Accepted: 08/06/2018] [Indexed: 12/19/2022]
Abstract
Leukemia growing as tumors in gastrointestinal organs is an under-investigated cause of treatment failure and death. These present with symptoms often mistaken for common toxicities but may grow large before symptoms. To synthesize experience available only in case reports, 378 were analyzed. Invasive and metastatic behavior typical of solid GI tumors was revealed even when marrow was uninvolved. Within 3 months of diagnosis, 33% had died, 47% within 1 year. Survivals of 4 to 18 years after involvement suggest cure is possible. Evidence is presented that combined local and systemic therapy has successfully treated GI leukemic tumors when identified early.
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Affiliation(s)
- Isabel Cunningham
- Columbia University College of Physicians and Surgeons, New York, New York
| | - Daniel Worthley
- Cancer Theme, South Australian Health and Medical Research Institute, Adelaide, Australia
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30
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Rose A, Brayer J. Connecting the Dots: A Case of Myeloid Sarcoma. Am J Med 2018; 131:e357-e359. [PMID: 29729239 DOI: 10.1016/j.amjmed.2018.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Revised: 04/01/2018] [Accepted: 04/02/2018] [Indexed: 10/17/2022]
Affiliation(s)
- Ashley Rose
- Department of Internal Medicine, University of South Florida Morsani College of Medicine, Tampa.
| | - Jason Brayer
- Department of Malignant Hematology, H. Lee Moffitt Cancer Center, Tampa, Fla
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31
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Oravcova I, Mikuskova E, Leitnerova M, Gyarfas J, Mlcakova A, Szepe P, Plank L, Demitrovicova L, Mikudova V, Cingelova S, Mego M, Drgona L. A unique clinical presentation of de novo acute promyelocytic leukemia as a myeloid sarcoma of the breast. Int J Hematol 2018; 108:550-553. [PMID: 29931624 DOI: 10.1007/s12185-018-2479-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 06/04/2018] [Accepted: 06/14/2018] [Indexed: 11/26/2022]
Abstract
Myeloid sarcoma is a rare presentation of acute leukemia as a solid tumor at various extramedullary sites. It may present concurrently, before or after the onset of systemic bone marrow leukemia. Unusual clinical localization may lead to misdiagnosis, or delayed diagnosis and treatment. We describe the first case, to our knowledge, of de novo myeloid sarcoma of the breast confirmed as acute promyelocytic leukemia. Immunohistochemical analysis, flow cytometry, fluorescent in situ hybridization analysis and molecular analysis using RQ-PCR of tissue samples should be routine in determining the correct diagnosis in this setting.
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MESH Headings
- Adult
- Antineoplastic Combined Chemotherapy Protocols/therapeutic use
- Biopsy
- Bone Marrow/pathology
- Breast Neoplasms/diagnosis
- Breast Neoplasms/genetics
- Breast Neoplasms/metabolism
- Diagnosis, Differential
- Female
- Flow Cytometry
- Humans
- Immunohistochemistry
- In Situ Hybridization, Fluorescence
- Leukemia, Promyelocytic, Acute/diagnosis
- Leukemia, Promyelocytic, Acute/genetics
- Leukemia, Promyelocytic, Acute/metabolism
- Magnetic Resonance Imaging
- Mammography
- Sarcoma, Myeloid/diagnosis
- Sarcoma, Myeloid/genetics
- Sarcoma, Myeloid/metabolism
- Treatment Outcome
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Affiliation(s)
- Iveta Oravcova
- Department of Oncohematology II, National Cancer Institute, Klenová 1, 83310, Bratislava, Slovakia.
- Oncohematology Clinic, Faculty of Medicine, Comenius University and National Cancer Institute, Bratislava, Slovakia.
| | - Eva Mikuskova
- Department of Oncohematology II, National Cancer Institute, Klenová 1, 83310, Bratislava, Slovakia
| | - Michaela Leitnerova
- Department of Medical Genetics, National Cancer Institute, Bratislava, Slovakia
| | - Jan Gyarfas
- Department of Laboratory Hematology, National Cancer Institute, Bratislava, Slovakia
| | - Andrea Mlcakova
- Department of Laboratory Hematology, National Cancer Institute, Bratislava, Slovakia
| | - Peter Szepe
- Department of Pathology, Jessenius Faculty of Medicine, The Comenius University, Martin, Slovakia
| | - Lukas Plank
- Department of Pathology, Jessenius Faculty of Medicine, The Comenius University, Martin, Slovakia
| | - Ludmila Demitrovicova
- Department of Oncohematology II, National Cancer Institute, Klenová 1, 83310, Bratislava, Slovakia
| | - Vanda Mikudova
- Department of Oncohematology II, National Cancer Institute, Klenová 1, 83310, Bratislava, Slovakia
| | - Silvia Cingelova
- Department of Oncohematology II, National Cancer Institute, Klenová 1, 83310, Bratislava, Slovakia
| | - Michal Mego
- 2nd Department of Oncology, Faculty of Medicine, Comenius University and National Cancer Institute, Bratislava, Slovakia
| | - Lubos Drgona
- Oncohematology Clinic, Faculty of Medicine, Comenius University and National Cancer Institute, Bratislava, Slovakia
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Primary Myeloid Sarcoma of the Prostate: A Case Report and Literature Review. Case Rep Hematol 2018; 2018:3604298. [PMID: 29854498 PMCID: PMC5949173 DOI: 10.1155/2018/3604298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 04/10/2018] [Indexed: 11/20/2022] Open
Abstract
We report the case of a 73-year-old male with primary myeloid sarcoma (MS) of the prostate. He underwent remission-induction chemotherapy followed by conventional consolidation for acute myeloid leukemia (AML). One year after initial diagnosis, he was without evidence of AML, the longest reported period of time in the literature for a case of primary MS of the prostate. From 1985 to 2017, fifteen other cases of MS of the prostate have been reported and are reviewed here. Five cases occurred as primary MS, without evidence of AML on bone marrow examination or prior history of hematologic disorders, and progressed to AML within a range of three weeks to seven months. None of these cases were started on conventional chemotherapy for AML prior to progression. Due to its rarity, primary MS of the prostate is often diagnosed incidentally, but prompt AML-targeted treatment is crucial to delaying the progression to AML.
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Dufour C, Garaventa A, Brisigotti M, Rosanda C, Mori PG. Massively Diffuse Multifocal Granulocytic Sarcoma in a Child with Acute Myeloid Leukemia. TUMORI JOURNAL 2018; 81:222-4. [PMID: 7571035 DOI: 10.1177/030089169508100316] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
A case of granulocytic sarcoma in an 8-year-old boy with acute myeloid leukemia and t (8; 21) is reported. The case is of interest due to massive extension of the tumor, which may raise different diagnostic difficulties with other solid tumors such as lymphoma, Ewing sarcoma, and soft tissue sarcoma. Furthermore, the tumor was localized in some sites, such as the parotid region and peripheral nerves, which are not usually involved in granulocytic sarcoma. The case points out the diagnostic difficulties with this kind of tumor and appears to contribute to the identification of a subgroup of acute myeloid leukemia with peculiar features, such as M2 morphology with Auer rods, t (8; 21), granulocytic sarcoma and a poor prognosis.
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Affiliation(s)
- C Dufour
- Department of Pediatric Hematology/Oncology, Giannina Gaslini Children's Research Hospital, Genova, Italy
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Abstract
A granulocytic sarcoma with myxoid features simulating a chondrosarcoma was detected in the left arm of a 59 years old man. It is suggested that extramedullary hematopoietic neoplasms such as granulocytic sarcoma may display, similarly to malignant lymphomas, non-specific sarcoma-like features that obscure the usual diagnostic characteristics.
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Affiliation(s)
- S Di Palma
- Divisione di Anatomia Patologica e Citologia, Milan, Italy
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35
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Claerhout H, Van Aelst S, Melis C, Tousseyn T, Gheysens O, Vandenberghe P, Dierickx D, Boeckx N. Clinicopathological characteristics of de novo and secondary myeloid sarcoma: A monocentric retrospective study. Eur J Haematol 2018. [DOI: 10.1111/ejh.13056] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Helena Claerhout
- Department of Laboratory Medicine; University Hospitals Leuven; Leuven Belgium
| | - Sophie Van Aelst
- Department of Laboratory Medicine; University Hospitals Leuven; Leuven Belgium
| | - Celine Melis
- Department of Pathology; University Hospitals Leuven; Leuven Belgium
| | - Thomas Tousseyn
- Department of Pathology; University Hospitals Leuven; Leuven Belgium
- Translational Cell and Tissue Research; KU Leuven; Leuven Belgium
| | - Olivier Gheysens
- Department of Nuclear Medicine; University Hospitals Leuven; Leuven Belgium
| | - Peter Vandenberghe
- Department of Hematology; University Hospitals Leuven; Leuven Belgium
- Center for Human Genetics; KU Leuven; Leuven Belgium
| | - Daan Dierickx
- Department of Hematology; University Hospitals Leuven; Leuven Belgium
- Department of Oncology; KU Leuven; Leuven Belgium
| | - Nancy Boeckx
- Department of Laboratory Medicine; University Hospitals Leuven; Leuven Belgium
- Department of Oncology; KU Leuven; Leuven Belgium
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36
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Cheng Y, Yu C, Zhu S, Guo L, Zhang Y, Zhang Y, Ma X. Nonleukemic granulocytic sarcoma of orbit after blunt trauma: A case report and review of literature. Medicine (Baltimore) 2018; 97:e0373. [PMID: 29642189 PMCID: PMC5908642 DOI: 10.1097/md.0000000000010373] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
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.
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Gaal A, Chisholm KM, Egbert M. How Rare Is an Oral Presentation of Myeloid Sarcoma in the Infant? J Oral Maxillofac Surg 2018; 76:561-568. [DOI: 10.1016/j.joms.2017.08.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Revised: 08/26/2017] [Accepted: 08/26/2017] [Indexed: 10/18/2022]
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Tokunaga K, Yamamura A, Ueno S, Kikukawa Y, Yamaguchi S, Hidaka M, Matsuno N, Kawaguchi T, Matsuoka M, Okuno Y. Isolated Pancreatic Myeloid Sarcoma Associated with t(8;21)/RUNX1-RUNX1T1 Rearrangement. Intern Med 2018; 57:563-568. [PMID: 29151502 PMCID: PMC5849554 DOI: 10.2169/internalmedicine.8912-17] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
No valid treatment for isolated myeloid sarcoma (IMS) has yet been established, and no thorough genetic examinations have been performed because of its low incidence and unique manner of development. We herein report a 34-year-old man with pancreatic IMS with t(8;21)/RUNX1-RUNX1T1 rearrangement. He was treated with high-dose cytarabine followed by allogeneic hematopoietic stem cell transplantation (allo-HSCT). This is the first report of pancreatic IMS with t(8;21). Positron emission tomography/computed tomography and genetic study are useful for the diagnosis, and allo-HSCT achieved complete remission in this patient.
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Affiliation(s)
- Kenji Tokunaga
- Department of Hematology, Rheumatology, and Infectious Diseases, Faculty of Life Sciences, Kumamoto University, Japan
| | - Ayako Yamamura
- Department of Hematology, Rheumatology, and Infectious Diseases, Faculty of Life Sciences, Kumamoto University, Japan
| | - Shikiko Ueno
- Department of Hematology, Rheumatology, and Infectious Diseases, Faculty of Life Sciences, Kumamoto University, Japan
| | - Yoshitaka Kikukawa
- Department of Hematology, Rheumatology, and Infectious Diseases, Faculty of Life Sciences, Kumamoto University, Japan
| | - Shunichiro Yamaguchi
- Department of Hematology, National Hospital Organization Kumamoto Medical Center, Japan
| | - Michihiro Hidaka
- Department of Hematology, National Hospital Organization Kumamoto Medical Center, Japan
| | - Naofumi Matsuno
- Department of Hematology, Rheumatology, and Infectious Diseases, Faculty of Life Sciences, Kumamoto University, Japan
| | - Tatsuya Kawaguchi
- Department of Hematology, Rheumatology, and Infectious Diseases, Faculty of Life Sciences, Kumamoto University, Japan
| | - Masao Matsuoka
- Department of Hematology, Rheumatology, and Infectious Diseases, Faculty of Life Sciences, Kumamoto University, Japan
| | - Yutaka Okuno
- Department of Hematology, Rheumatology, and Infectious Diseases, Faculty of Life Sciences, Kumamoto University, Japan
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Markoc F, Bozdogan N, Yükrük FA, Gumuc EB, Akdur NC. Granulocytic Sarcomas: Difficulties in Diagnosis. TUMORI JOURNAL 2018; 96:149-53. [DOI: 10.1177/030089161009600124] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
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Affiliation(s)
- Fatma Markoc
- Department of Pathology, Ankara Abdurrahman Yurtarslan Oncology Training and Research Hospital, Ankara, Turkey
| | - Nazan Bozdogan
- Department of Pathology, Ankara Abdurrahman Yurtarslan Oncology Training and Research Hospital, Ankara, Turkey
| | - Fisun Ardic Yükrük
- Department of Pathology, Ankara Abdurrahman Yurtarslan Oncology Training and Research Hospital, Ankara, Turkey
| | | | - Noyan Can Akdur
- Department of Pathology, Ankara Training and Research Hospital, Ankara, Turkey
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40
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Dominguez Rullán JA, Fernández Lizarbe E, Capuz B, Piris M, Sancho García S. Radiotherapy for isolated granulocytic sarcoma: Case report and review of literature. Clin Transl Radiat Oncol 2018; 8:1-3. [PMID: 29594235 PMCID: PMC5862674 DOI: 10.1016/j.ctro.2017.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2017] [Revised: 10/31/2017] [Accepted: 11/01/2017] [Indexed: 11/23/2022] Open
Abstract
Isolated chloroma should be considered as a systemic disease. Consolidation radiotherapy has been related with prolonged failure free survival. Excellent local control of chloroma is achieved with low-dose radiotherapy.
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41
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Isolated myelosarcoma is characterized by recurrent NFE2 mutations and concurrent preleukemic clones in the bone marrow. Blood 2017; 131:577-581. [PMID: 29191917 DOI: 10.1182/blood-2017-07-793620] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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42
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Radiotherapy for extramedullary leukaemic manifestation (Chloroma). Strahlenther Onkol 2017; 194:164-173. [DOI: 10.1007/s00066-017-1236-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Accepted: 10/26/2017] [Indexed: 01/19/2023]
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43
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Hou X, Du L, Yu H, Zhang X. Use of magnetic resonance imaging for diagnosis and after treatment of patients with myeloid sarcoma of the brain. Oncotarget 2017; 8:102581-102589. [PMID: 29254273 PMCID: PMC5731983 DOI: 10.18632/oncotarget.21905] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Accepted: 09/20/2017] [Indexed: 12/11/2022] Open
Abstract
The purpose of this retrospective study was to assess the utility of magnetic resonance imaging (MRI) for evaluating post-treatment responses in patients with myeloid sarcoma (MS) of the brain. We evaluated images from both conventional and advanced MR, including diffusion weighted imaging (DWI), arterial spin labeling (ASL) and susceptibility weighted imaging (SWI). Parameters of our qualitative review included lesion location, number, size, morphologic characteristics, surrounding edema, mass effect, pattern and degree of enhancement, ± restricted diffusion, ±susceptibility artifact and ± higher perfusion. Our quantitative assessments were calculated from DW and ASL MR images. The 10 patients had a total of 40 lesions in their brains (mean lesion size of 2.0 ± 0.8 cm). The majority of cases exhibited restricted diffusion (90%) and mild-to-moderate low perfusion (80%). Follow-up MRI after chemotherapy revealed that most lesions (80%) were significantly alleviated after two chemotherapy courses and further improved after four courses. Only a few lesions (5%) were residual after six courses. These findings demonstrate that brain MS can be characterized by changes in various MRI parameters and that MRI can be a useful and predictive assessment tool for brain MS diagnosis and treatment management.
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Affiliation(s)
- Xuewen Hou
- Department of Radiology, Baoan Central Hospital of Shenzhen, Baoan District, Shenzhen 518102, China
| | - Longting Du
- Department of Radiology, Baoan Central Hospital of Shenzhen, Baoan District, Shenzhen 518102, China
| | - Haitao Yu
- Department of Radiology, Aerospace Center Hospital, Haidian District, Beijing 100049, China
| | - Xiaojin Zhang
- Department of Radiology, Aerospace Center Hospital, Haidian District, Beijing 100049, China
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44
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Lee JY, Chung H, Cho H, Jang JE, Kim Y, Kim SJ, Kim JS, Hyun SY, Min YH, Cheong JW. Clinical characteristics and treatment outcomes of isolated myeloid sarcoma without bone marrow involvement: a single-institution experience. Blood Res 2017; 52:184-192. [PMID: 29043233 PMCID: PMC5641510 DOI: 10.5045/br.2017.52.3.184] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 05/20/2017] [Accepted: 06/17/2017] [Indexed: 02/07/2023] Open
Abstract
Background Isolated myeloid sarcoma (MS) is a rare extramedullary tumor mass composed of malignant myeloid precursor cells without any evidence of leukemia in the peripheral blood and bone marrow. We describe the clinical characteristics and outcomes of patients diagnosed with isolated MS at our institution. Methods We retrospectively reviewed 9 of 497 acute myeloid leukemia (AML) patients (1.8%) with isolated MS. Isolated MS patients were divided into 2 groups according to the first-line treatment strategy: systemic treatment only (S) or local treatment with or without systemic treatment (LS). Results The most common site of MS occurrence was the head and neck area (N=4, 44.4%), followed by the anterior mediastinum (N=2, 22.2%) and the gastrointestinal tract (N=2, 22.2%). The tumors of 4 patients (44.4%) eventually evolved to AML, in a median time of 13.4 months (range, 2.4–20.1 mo). The number of patients achieving complete remission after first-line treatment was higher in the LS group (N=5, 83.3%) than in the S group (N=1, 33.3%) (P =0.226). All patients in the LS group survived, but those in the S group died (P=0.012). Conclusion Accurate and rapid diagnosis using various modalities and the early initiation of intensive combined treatment may be the optimal strategies to reduce the risk of isolated MS subsequently evolving to AML. To fully understand the characteristics of isolated MS, a larger number of patients from a multinational study is necessary.
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Affiliation(s)
- Jung Yeon Lee
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Haerim Chung
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Hyunsoo Cho
- Graduate School of Medical Science and Engineering, Korea Advanced Institute of Science and Technology, Daejeon, Korea
| | - Ji Eun Jang
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Yundeok Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Soo-Jeong Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jin Seok Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Shin Young Hyun
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Yoo Hong Min
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - June-Won Cheong
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
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45
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Goyal G, Bartley AC, Patnaik MM, Litzow MR, Al-Kali A, Go RS. Clinical features and outcomes of extramedullary myeloid sarcoma in the United States: analysis using a national data set. Blood Cancer J 2017; 7:e592. [PMID: 28841208 PMCID: PMC5596389 DOI: 10.1038/bcj.2017.79] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Affiliation(s)
- G Goyal
- Division of Hematology, Mayo Clinic, Rochester, MN 55905, USA
| | - A C Bartley
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, MN 55905, USA
| | - M M Patnaik
- Division of Hematology, Mayo Clinic, Rochester, MN 55905, USA
| | - M R Litzow
- Division of Hematology, Mayo Clinic, Rochester, MN 55905, USA
| | - A Al-Kali
- Division of Hematology, Mayo Clinic, Rochester, MN 55905, USA
| | - R S Go
- Division of Hematology, Mayo Clinic, Rochester, MN 55905, USA
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46
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Almond LM, Charalampakis M, Ford SJ, Gourevitch D, Desai A. Myeloid Sarcoma: Presentation, Diagnosis, and Treatment. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2017; 17:263-267. [PMID: 28342811 DOI: 10.1016/j.clml.2017.02.027] [Citation(s) in RCA: 135] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Revised: 02/13/2017] [Accepted: 02/28/2017] [Indexed: 12/22/2022]
Abstract
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.
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Affiliation(s)
- L Max Almond
- Midlands Abdominal and Retroperitoneal Sarcoma Unit (MARSU), University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom.
| | - Maria Charalampakis
- Department of Haematology and Stem Cell Transplantation, Heart of England NHS Foundation Trust, Birmingham, United Kingdom
| | - Samuel J Ford
- Midlands Abdominal and Retroperitoneal Sarcoma Unit (MARSU), University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - David Gourevitch
- Midlands Abdominal and Retroperitoneal Sarcoma Unit (MARSU), University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Anant Desai
- Midlands Abdominal and Retroperitoneal Sarcoma Unit (MARSU), University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
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47
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Chandra P, Dhake S, Purandare N, Agrawal A, Shah S, Rangarajan V. Role of FDG PET/CT in Diagnostic Evaluation of Granulocytic Sarcomas: A Series of 12 Patients. Indian J Nucl Med 2017; 32:198-202. [PMID: 28680203 PMCID: PMC5482015 DOI: 10.4103/ijnm.ijnm_10_17] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE Granulocytic sarcoma (GS) is a rare extramedullary manifestation in patients with acute myeloid leukemia (AML), which can precede the diagnosis or occur in the posttreatment setting. Unlike its established role in other hematological malignancies like Hodgkin's on non-Hodgkin's disease, the exact role of positron emission tomography/computed tomography (PET/CT) in AML with or without GS remains to be defined. MATERIALS AND METHODS We retrospectively reviewed PET/CT scans of 12 patients with histologically proven GS. Marrow examination of these patients identified nine patients with isolated GS (without existent leukemia) and three patients with coexistent leukemia. RESULTS PET/CT accurately identified all clinically evident GS in all 12 patients at initial staging and at follow-up with tumors, showing moderate to high 2-deoxy-2-fluoro-D-glucose uptake. Coexistent marrow disease was seen on PET/CT in three patients, which was confirmed on histopathology. In the same patients, PET/CT also detected additional sites of extramedullary disease in 66.6% (n = 8), which was either clinically occult or not evident on routine CT. CONCLUSION PET/CT appears to be a highly sensitive imaging modality in diagnostic evaluation of GS. The most important indication of using PET/CT in these cases is to identify additional sites of clinically occult extramedullary disease, which can potentially impact treatment decisions and outcomes.
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Affiliation(s)
- Piyush Chandra
- Department of Nuclear Medicine and Molecular Imaging, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Sanket Dhake
- Department of Nuclear Medicine and Molecular Imaging, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Nilendu Purandare
- Department of Nuclear Medicine and Molecular Imaging, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Archi Agrawal
- Department of Nuclear Medicine and Molecular Imaging, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Sneha Shah
- Department of Nuclear Medicine and Molecular Imaging, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Venkatesh Rangarajan
- Department of Nuclear Medicine and Molecular Imaging, Tata Memorial Hospital, Mumbai, Maharashtra, India
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48
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Park SS, Yoon JH, Kim HJ, Jeon YW, Lee SE, Cho BS, Eom KS, Kim YJ, Lee S, Min CK, Cho SG, Kim DW, Lee JW, Min WS. Characteristics and Survival Outcome Analysis of Extramedullary Involvement in Adult Patients With t(8;21) Acute Myeloid Leukemia. CLINICAL LYMPHOMA MYELOMA & LEUKEMIA 2016; 17:38-45.e2. [PMID: 27742476 DOI: 10.1016/j.clml.2016.09.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Revised: 09/04/2016] [Accepted: 09/08/2016] [Indexed: 01/24/2023]
Abstract
BACKGROUND Acute myeloid leukemia (AML) with t(8;21)(q22;q22) is classified into a favorable-risk group. Extramedullary (EM) involvement has frequently been reported in this subgroup as resulting in a poor prognosis. However, characteristics or standard treatments of t(8;21) AML with EM involvement (EM-positive t(8;21)) have not yet been elucidated. PATIENTS AND METHODS We retrospectively analyzed 154 adult AML patients with t(8;21). Among them, 17 were EM positive and 137 were EM negative at the time of diagnosis. EM involvement was evaluated only when a patient showed suspicious signs or symptoms. All EM-positive patients were treated according to a strategy based on allogeneic hematopoietic cell transplantation (allo-HCT). RESULTS Central nervous system was the most frequently involved site (70.6%). EM-positive t(8;21) was associated with age ≤ 45 years, leukocytosis (≥ 30 × 109/L), and c-kit mutation compared to EM-negative t(8;21) in multivariate analysis. After intensive chemotherapy with or without local therapy, high-risk t(8;21) AML including EM-positive t(8;21) underwent allo-HCT for postremission therapy. Three-year OS (52.3% vs. 60.0%, P = .658) and event-free survival (51.5% vs. 58.0%, P = .496) were not different between the 2 groups. The subgroup of patients who underwent allo-HCT also showed similar outcomes. CONCLUSION EM-positive t(8;21) was associated with young age, leukocytosis, and c-kit mutation, and central nervous system was frequently involved. Allo-HCT resulted in good outcomes in EM-positive t(8;21).
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Affiliation(s)
- Sung-Soo Park
- Department of Hematology, Catholic Blood and Marrow Transplantation Center, Leukemia Research Institute, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jae-Ho Yoon
- Department of Hematology, Catholic Blood and Marrow Transplantation Center, Leukemia Research Institute, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hee-Je Kim
- Department of Hematology, Catholic Blood and Marrow Transplantation Center, Leukemia Research Institute, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea.
| | - Young-Woo Jeon
- Department of Hematology, Catholic Blood and Marrow Transplantation Center, Leukemia Research Institute, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sung-Eun Lee
- Department of Hematology, Catholic Blood and Marrow Transplantation Center, Leukemia Research Institute, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Byung-Sik Cho
- Department of Hematology, Catholic Blood and Marrow Transplantation Center, Leukemia Research Institute, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Ki-Seong Eom
- Department of Hematology, Catholic Blood and Marrow Transplantation Center, Leukemia Research Institute, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Yoo-Jin Kim
- Department of Hematology, Catholic Blood and Marrow Transplantation Center, Leukemia Research Institute, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seok Lee
- Department of Hematology, Catholic Blood and Marrow Transplantation Center, Leukemia Research Institute, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Chang-Ki Min
- Department of Hematology, Catholic Blood and Marrow Transplantation Center, Leukemia Research Institute, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seok-Goo Cho
- Department of Hematology, Catholic Blood and Marrow Transplantation Center, Leukemia Research Institute, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Dong-Wook Kim
- Department of Hematology, Catholic Blood and Marrow Transplantation Center, Leukemia Research Institute, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jong-Wook Lee
- Department of Hematology, Catholic Blood and Marrow Transplantation Center, Leukemia Research Institute, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Woo-Sung Min
- Department of Hematology, Catholic Blood and Marrow Transplantation Center, Leukemia Research Institute, Seoul St Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Sengupta M, Das I, Chatterjee U, Majumdar B. De novo myeloid sarcoma involving mandible in a child: Report of a rare occurrence. J Oral Maxillofac Pathol 2016; 20:304-7. [PMID: 27601827 PMCID: PMC4989565 DOI: 10.4103/0973-029x.185911] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Myeloid sarcoma (MS) is a rare malignant disease defined as extramedullary infiltration of immature myeloid cells. We reporte a 2-year-old male of isolated MS who presented with swelling over the left side of the body of the mandible. Proper histological examination and adequate panels of immunohistochemical stain led to the accurate diagnosis. Early intervention with systemic chemotherapy regimens based on cytarabine is the treatment of choice. The role of chromosomal aberrations and genetic abnormality related to prognosis remain uncertain.
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Affiliation(s)
- Moumita Sengupta
- Department of Pathology, Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal, India
| | - Indranil Das
- Department of Pathology, Chittaranjan National Cancer Institute, Kolkata, West Bengal, India
| | - Uttara Chatterjee
- Department of Pathology, Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal, India
| | - Boby Majumdar
- Department of Pathology, Institute of Postgraduate Medical Education and Research, Kolkata, West Bengal, India
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Wang HQ, Li J. Clinicopathological features of myeloid sarcoma: Report of 39 cases and literature review. Pathol Res Pract 2016; 212:817-24. [DOI: 10.1016/j.prp.2016.06.014] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Revised: 06/25/2016] [Accepted: 06/28/2016] [Indexed: 02/07/2023]
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