Mandibular chloroma demonstrated by magnetic resonance imaging

Oral myeloid sarcoma as an uncommon manifestation of acute myeloid leukemia: A case series and review of the literature

BACKGROUND AND OVERVIEW

Oral myeloid sarcoma (MS) is an extramedullary tumor that can occur in the setting of acute myeloid leukemia, either as the first sign of an underlying disease or later in the course of disease. The authors' aim was to present the clinical features of oral MS and review the literature.

CASE DESCRIPTION

Case 1 was an 82-year-old woman with an asymptomatic erythematous swelling on the maxillary gingiva and no history of hematologic malignancy. Case 2, a 65-year-old man, and case 3, a 58-year-old woman, each had a history of acute myeloid leukemia and a painful ulcer on the palatal mucosa and an asymptomatic ulcer on the lower lip mucosa, respectively. Case 1 was treated with focal radiation then chemotherapy and achieved complete remission initially, but died of relapse 2 years after diagnosis. Case 2 received radiotherapy and immunotherapy and had a complete response. Case 3 received chemotherapy and achieved remission initially, but relapsed and is undergoing investigational targeted therapies.

CONCLUSIONS AND PRACTICAL IMPLICATIONS

Oral MS can manifest as gingival or mucosal swelling or ulceration and can indicate onset or relapse of associated hematologic malignancies, which often have a poor prognosis. Because patients with oral findings are likely to seek treatment from their dentists first, oral clinicians should maintain a broad differential diagnosis list when evaluating oral lesions, especially if treatment prescribed for a more common diagnosis fails to resolve the lesion.

Isolated myeloid sarcoma of the temporal bone: As the first clinical manifestation of acute myeloid leukemia in a patient of down's syndrome

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MS are extremely rare tumors with an aggressive clinical course.

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Morphologically, they can mimic small round cell tumors. This problem is further complicated by the lack of clinical suspicion in patients without any hematological disorder.

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Accurate diagnosis of isolated MS requires a multifactorial approach including histopathology, immunophenotyping, immunohistochemistry and cytogenic abnormalities.

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A high level of suspicion is necessary, because early, accurate diagnosis is important to avoid delaying appropriate chemotherapy. A delay in the diagnosis may result in unwarranted fatality particularly so in pediatric patients.

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Here, we report an unusual case of MS initially presenting as a tumor of the temporal bone and first manifestation of AML, in a pediatric patient suffering from Down’s syndrome. This case illustrates the challenges associated with offering a rapid diagnosis with an early initiation of treatment.

Introduction

Leukemia is the most common malignancy of childhood but myeloid sarcoma is a rare presentation of underlying leukemic disorder. Myeloid sarcoma (MS) is a rare tumor composed of proliferation of myeloid precursors at extramedullary sites.

Presentation of case

We report an unusual case of myeloid sarcoma involving the temporal bone in a young male child who presented with a large mass involving the left temporal region. This lesion was the initial presentation which led to further diagnosis of acute myeloid leukemia in our case. This case report brings awareness to the diverse extramedullary manifestations of isolated myeloid sarcoma, as well as the importance and difficulties that are associated with establishing a rapid diagnosis and initiating treatment.

Discussion

They can arise de novo or in association with hematological malignancies, most commonly acute myeloid leukemia (AML-M2). Clinically, it can masquerade as an abscess, cutaneous ulcer, or as a mass lesion. Morphologically, MS can mimic a variety of small round cell tumors including lymphomas, neuroblatoma and rhabdomyosarcoma. The occurrence of this tumor usually heralds AML or the onset of the blastic phase of chronic myeloid leukemia. Early recognition of this rare entity is important, because early aggressive chemotherapy and focal irradiation can cause regression of the tumor and thus improve patient longevity.

Conclusion

The possibility of MS should be considered when dealing with unusual lymphoma like neoplasms that cannot be categorized as any of the Non-Hodgkin lymphoma subtypes and small blue round cell tumors.

Multiple isolated extramedullary relapse of acute promyelocytic leukemia after allogeneic hematopoietic stem cell transplant: a case report and review of literature

Isolated extramedullary disease (EMD) is uncommon, especially in acute promyelocytic leukemia (APL) after allogeneic hematopoietic stem cell transplantation (HSCT). We review the literature and present a 32 year old woman with APL who developed multiple EMDs after allogeneic HSCT within the calvarium, and later found to have various isolated lesions including femur, humerus and thoraco lumbar vertebrae. She was treated with local radiotherapy (XRT) to EMD lesions, all-trans retinoic acid, arsenic trioxide and donor lymphocyte infusion at different time points in her clinical course, without success. Out of reported cases in clinical setting as ours, average onset of isolated EMD is 25 months and median survival 14 months. Effective treatment of isolated EMD after HSCT is not yet clear, but ATO in combination with local XRT, tamibarotene and second HSCT have shown good results in some reported cases, but accumulation of more cases is needed to elucidate optimal therapy in such setting.

Case of pediatric acute promyelocytic leukemia presenting as extramedullary tumor of the mandible

BACKGROUND

Acute promyelocytic leukemia (APL) is a malignant subtype of acute myeloid leukemia caused by the PML-retinoic acid receptor (RAR)α fusion gene. APL may be discovered in adulthood and diagnosed after spontaneous gingival bleeding or difficulty in hemostasis after oral surgery such as tooth extraction. However, APL is extremely rare in children.

METHODS AND RESULTS

A 1-year-old boy presented with a mass on the mentum of the mandible. The marked periosteal reaction was seen on CT and MRI, leading to strong suspicion of a malignant bone-derived tumor such as a sarcoma. Chromosome banding by fluorescence in situ hybridization (FISH) showed PML-RARα, confirming the diagnosis of APL. Treatment with tretinoin was immediately initiated. No signs of recurrence have been noted 1 year after treatment.

CONCLUSIONS

We report herein a rare case involving an infant with APL who presented with an extramedullary tumor of the mandible, whom we treated with good results.

Acute Shoulder Monoarthritis in a Patient With Acute Myelomonocytic Leukemia With Novel Translocation t(5;13)

We present the case of a patient with acute myelomonocytic leukemia with trisomy 8 and novel translocation t(5;13). In addition to acute leukemia she had debilitating left shoulder arthritis due to granulocytic sarcoma formation in the joint space. Her shoulder pain did not improve during induction chemotherapy but she experienced rapid relief of symptoms with use of local radiation. Her leukemia was found to be primary refractory to chemotherapy and despite an attempt at salvage therapy she died 2 months after diagnosis.

Granulocytic sarcoma (chloroma) presenting as a lateral neck mass: initial manifestation of leukemia: a case report

We present a rare case of granulocytic sarcoma (chloroma) in the lateral neck as an initial manifestation of acute leukemia in a 37-year-old man. The lesion appeared as a solid mass with homogenous contrast enhancement on CT. Recognition of this rare entity is important, because early, aggressive induction chemotherapy can improve prognosis.

Granulocytic sarcoma of gingiva: an unusual case with aleukemic presentation

BACKGROUND

Granulocytic sarcoma (GS) is an uncommon extramedullary tumor composed of dense aggregates of immature myeloid precursor cells, which is usually associated with acute or chronic myeloid leukemia. The tumor may also be a predecessor to acute myeloid leukemia (AML). It may be found in any location throughout the body; however, intraoral occurrence is extremely rare. This report describes a case of gingival granulocytic sarcoma that developed prior to AML in a 12-year-old female.

METHODS AND RESULTS

The patient, who had a 3-month history of gingival enlargement, was diagnosed as having granulocytic sarcoma based on clinical, radiological, and histological findings. Although the tumor regressed significantly after two induction chemotherapy courses, the patient subsequently died due to pneumococcal sepsis and pleurisy.

CONCLUSION

This case report affirms the importance of granulocytic sarcoma in the differential diagnosis of gingival enlargements, since the tumor may occur before bone marrow involvement by leukemic cells.

Granulocytic sarcoma occurring in the maxillary gingiva demonstrated by magnetic resonance imaging

We report the case of a 43-year-old woman presenting with a painless swelling that had developed over 8 months in the maxillary labial vestibule. An oral examination revealed an exophytic, firm, black-pigmented lesion measuring 3.5 x 1.5 cm that bled on palpation. Periapical radiographs showed a slightly enlarged periodontal ligament space of the left central incisor and bone resorption in the region of the missing lateral incisor. Panoramic and other conventional radiographs showed no obvious lytic area, and a magnetic resonance imaging examination demonstrated a low signal intensity lesion on both the T1-weighted and the T2-weighted images. Therefore, granulocytic sarcoma was suspected. Granulocytic sarcoma of the oral cavity is a rare condition, and its diagnosis is usually difficult. Increased awareness of this entity may minimize misinterpretation of radiographic and clinical findings and can assist suitable treatment planning that is essential to this pathosis.

Recurrent granulocytic sarcoma. An unusual variation of acute myelogenous leukemia associated with 8;21 chromosomal translocation and blast expression of the neural cell adhesion molecule

This study reports on a patient with acute myelogenous leukemia (AML) in remission who had a series of 11 granulocytic sarcomas (chloromas or myeloblastomas) appearing periodically over a 29-month interval in a variety of anatomic sites without evidence of bone marrow recurrence. This isolated extramedullary recurrence of AML is distinctly unusual with only 24 cases described previously. This patient had the greatest number and longest reported interval of recurrent granulocytic sarcomas (GS) before bone marrow relapse. Furthermore, he represents the first case of a patient with GS presenting with both an 8;21 chromosomal translocation and neural cell adhesion molecule (CD56) expression. The authors hypothesize that these two abnormalities identified previously as predisposing factors to GS may, in fact, be synergistic for this phenomenon. His case and the review of the literature demonstrate some of the important clinical and management features of a patient who develops GS while in complete marrow remission from previous AML. Although highly sensitive to radiation therapy, the onset of granulocytic sarcomas is almost always followed by bone marrow relapse and should be treated with aggressive reinduction chemotherapy and local irradiation. Such therapy is associated with the longest interval of disease-free survival.