Orbital granulocytic sarcoma and AML with poor prognosis in Turkish children

Orbital Swelling and Ptosis as an Initial Presentation of Childhood Acute Lymphoblastic Leukaemia: A Case Report and Review of the Literature

We are reporting the case of a 3-year-old-girl who initially presented with unilateral eyelid swelling and ptosis. A diagnosis of acute lymphoblastic leukaemia (ALL) was eventually made based on an orbital incisional biopsy and a bone marrow examination. Historically, orbital involvement had been linked to myeloid leukaemia; however, in lymphoid leukaemia, they are increasingly being implicated and had been reported as the sole presentation of the disease. These findings stress the importance of conducting ophthalmologic assessments in cases diagnosed with ALL in order to prevent delays in proper assessment and treatment. Management options in orbital disease are fortunately not significantly different than well-established treatment protocols.

Prognostic Role of Postinduction Minimal Residual Disease and Myeloid Sarcoma Type Extramedullary Involvement in Pediatric RUNX1-RUNX1T1 (+) Acute Myeloid Leukemia

BACKGROUND

Acute myeloid leukemia with the t(8;21)(q22;q22) rearrangement (RUNX1-RUNX1T1 (+) AML) is known to have a favorable prognosis. Our study aimed to determine the most important prognostic variables among an aggregate of clinical, genetic, and treatment response-based factors in pediatric RUNX1-RUNX1T1 (+) AML.

MATERIALS AND METHODS

We analyzed the characteristics and outcome of 40 patients who were diagnosed with and treated for RUNX1-RUNX1T1 (+) AML from April 2008 to December 2016 at our institution.

RESULTS

A<-2.2 log fusion transcript decrement after remission induction, myeloid sarcoma type extramedullary involvement (EMI) at diagnosis, higher initial white blood cell count, and presence of KIT mutation predicted lower event-free survival. Both lower fusion transcript decrement after remission induction and the presence of EMI at diagnosis proved to be significant adverse factors in the multivariate study. The 5-year event-free survival was 70.0±7.2% (28/40); 8 of the 12 relapsed patients survive disease-free, resulting in 5-year overall survival of 89.5±5.0% (36/40).

CONCLUSIONS

Kinetics of response to remission induction chemotherapy, measured in terms of the PCR value for the fusion transcript, and the presence of myeloid sarcoma type EMI at diagnosis may predict the risk of relapse in pediatric RUNX1-RUNX1T1 (+) AML.

Myeloid sarcoma is associated with poor clinical outcome in pediatric patients with acute myeloid leukemia

PURPOSE

The impact of myeloid sarcoma (MS) on clinical outcome of pediatric acute myeloid leukemia (AML) patients remains controversial. Moreover, little is known about the role of stem cell transplantation (SCT) in such patients.

METHODS

Clinical data of patients with AML under 18 years of age were retrieved from the TARGET dataset. We analyzed the prevalence, clinical profile, molecular characteristics, and prognosis of MS in these patients.

RESULTS

Among 884 pediatric patients with AML, the frequency of MS was 12.3%. Pediatric AML with MS was associated with age under 1-year, abnormal cytogenetics, and KMT2A rearrangement. Moreover, MS was associated with a low complete remission rate, high induction death, poor 5-year EFS, and OS. KMT2A rearrangement had a negative impact on clinical outcome in AML patients with MS. In addition, SCT had no significant effect on the survival of AML patients with MS. Multivariate analysis revealed that MS was an unfavorable prognostic factor in pediatric AML in terms of EFS (Hazard ratio 1.670, P < 0.001) and OS (Hazard ratio 1.623, P = 0.004).

CONCLUSIONS

The presence of MS at diagnosis of pediatric AML is associated with poor clinical outcomes, particularly when associated with KMT2A rearrangements. Moreover, pediatric patients with AML and MS may not benefit from SCT.

Whole Body MR Imaging: A Useful Imaging Modality in the Management of Children With Acute Myeloid Leukemia

INTRODUCTION

To evaluate the distribution of chloromas using whole body magnetic resonance (MR) imaging in pediatric patients with acute myeloid leukemia (AML) and to assess the clinical role of whole body MR imaging in management of pediatric patients with AML.

MATERIALS AND METHODS

We retrospectively searched pediatric patients (< 18 years old) who were diagnosed with AML and underwent whole body MR imaging during their illness between January 2006 and December 2014. The presence of chloromas was defined as when it was proven pathologically or showed typical imaging features. Nonchloroma lesions that were incidentally detected and were not previously seen on other imaging studies were defined as clinically occult nonchloroma lesions.

RESULTS

Sixty-nine whole body MR scans of 40 patients with AML were included. The musculoskeletal system (42.9%) was the most commonly affected by chloromas. A total of 77 chloromas were identified in 11 (27.5%) of 40 patients. Nine (81.8%) of these 11 patients had 2 or more chloromas. There were 39 (50.6%) unexpected chloromas, which were incidentally detected, in 7 patients. Whole body MR scanning provided additional information regarding 21 clinically occult nonchloroma lesions in this patient population.

CONCLUSION

Chloromas tended to show multiplicity and be present without symptoms. The most common site of involvement was the musculoskeletal system. Whole body MR imaging provided additional information that affected the clinical management of children with AML.

Extramedullary Manifestations of Myeloid Neoplasms

OBJECTIVES

This session of the 2013 Society of Hematopathology/European Association for Haematopathology workshop focused on extramedullary manifestations of myeloid neoplasms.

METHODS

We divided the submitted cases into four subgroups: (1) isolated myeloid sarcoma (MS); (2) MS with concurrent acute myeloid leukemia (AML), with a focus on karyotypic and molecular findings; (3) extramedullary relapse of AML, including relapse in the posttransplant setting; and (4) blast phase/transformation of a myeloproliferative neoplasm or chronic myelomonocytic leukemia.

RESULTS

Establishing a diagnosis of isolated MS requires a high index of suspicion and use of immunophenotypic methods. Recurrent cytogenetic abnormalities or gene mutations that occur in MS mirror those known to occur in AML.

CONCLUSIONS

In the era of targeted therapy and sophisticated risk stratification, every attempt must be made to perform a complete workup on MS cases (or concurrent AML) since the diagnosis of MS, in itself, is no longer adequate for patient management. Cases of blastic plasmacytoid dendritic cell neoplasm were also included and discussed in this session.

Orbital myeloid sarcoma presenting as massive proptosis

A 10-year-old boy presented with right proptosis for 8 months. The eyeball was grossly pushed down, with diffuse corneal haze and non-reactive pupil. Systemic examination was normal. Previous investigations in another centre included a computerized tomography scan, which showed a well-defined enhancing retro-bulbar mass, a non-contributory fine needle aspiration cytology and a biopsy showing fibrocollagenous tissue with moderate lympho-monocytic infiltrate suggestive of non-specific inflammation. PET-CT scan revealed the presence of enlarged fluoro-deoxyglucose-avid cervical and mesenteric lymph nodes. Biopsy of the retro-bulbar mass was repeated in our centre. It showed fibrocollagenous and skeletal muscle tissue infiltrated by lymphoid follicles, dispersely lying lymphocytes and plasma cells, and admixed large atypical cells with vesicular nuclei, prominent nucleoli and scanty cytoplasm, strongly positive for myeloperoxidase, CD43 and CD99 immunohistochemistry. Hemogram was normal. Bone marrow aspiration/biopsy and CSF showed no evidence of acute myeloid leukemia. The child received chemotherapy in another centre and is in complete remission 6 months after completion.

Superior outcome of pediatric acute myeloid leukemia patients with orbital and CNS myeloid sarcoma: a report from the Children's Oncology Group

BACKGROUND

Extramedullary leukemia (EML) is common in pediatric acute myeloid leukemia (AML) and occurs as leukemia cells within the cerebrospinal fluid (CSF) or as a solid tumor (myeloid sarcoma-MS). The effect of MS on survival is unknown.

METHODS

Patients on CCG protocols 2861, 2891, 2941, and 2961 being treated for AML with intensive-timing chemotherapy were classified for the presence of EML (CSF leukemia, CNS-MS, orbital-MS, or non-CNS MS). CSF leukemia was classified as CNS3 (>5 WBC in the CSF with blasts) and non-CSF leukemia as CNS1/2 (<5 WBC in the CSF with or without blasts). Characteristics and outcomes of these patients were compared.

RESULTS

Of the 1,459 total patients, 1,206 (82%) had no EML, 154 (11%) had CSF leukemia, 19 (1%) had CNS-MS, 23 (2%) had orbital-MS, and 57 (4%) had non-CNS MS. The CR rate was significantly higher in patients with orbital-MS and CNS-MS than in those with non-MS and non-CNS MS (96% and 95% vs. 78% and 78%, P = 0.034). Patients with orbital-MS and CNS-MS had significantly higher overall survival than patients with non-CNS MS (92% and 73% vs. 38%, P < 0.001), CNS3 patients (92% and 73% vs. 51, P < 0.001), and CNS1/2 patients (92% and 73% vs. 50%, P < 0.001). Patients with orbital-MS had a significantly lower relapse rate.

CONCLUSION

Patients with MS involving orbital and CNS sites had a significantly better survival than patients with non-CNS MS, with CSF leukemia, or with no EML.

Extramedullary orbital granulocytic sarcoma without bone marrow involvement: a report of two cases

The authors present herein 2 extramedullary orbital granulocytic sarcoma (GS) cases without bone marrow involvement in view of their rarity and also to reevaluate the treatment approach in this disease. Seven days of high-dose methyl prednisolone (HDMP) treatment (3 days 30 mg/kg/day and 4 days 20 mg/kg/day) was administered initially, and subsequently Acute Myeloid Leukaemia-Berlin Frankfurt Münster (AML-BFM) 2004 treatment protocol was continued for 2 cases. Eye findings of the cases resolved considerably with HDMP treatment. They have still been under systemic chemotherapy without any complication for 1 year. Thus, early diagnosis and AML-targeted intensive chemotherapy improve the prognosis of GS even if there is no bone marrow involvement.