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Li SH, Yang CX, Xing XM, Gao XR, Lu ZY, Ji QX. Myeloid sarcoma with maxillary gingival swelling as the initial symptom: A case report and review of literature. World J Clin Cases 2024; 12:3985-3994. [PMID: 38994293 PMCID: PMC11235421 DOI: 10.12998/wjcc.v12.i19.3985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Revised: 04/25/2024] [Accepted: 05/07/2024] [Indexed: 06/29/2024] Open
Abstract
BACKGROUND Myeloid sarcoma (MS), also referred to as granulocytic sarcoma or chloroma, is a rare type of extramedullary malignant tumor. MS comprises primitive granulocytic precursor cells that play a key role in the early stages of white blood cell development. Notably, the occurrence of this tumor in the gingiva is rare. CASE SUMMARY The present study reported the case of MS with gingival swelling in the maxillary region, with aleukemic presentation in a 32-year-old male patient. Following two courses of chemotherapy, computed tomography of the region demonstrated complete clearance of the tumor. At the 12-month follow-up appointment, the patient was in a stable condition with the absence of progression. The etiology, clinical features, diagnosis, and relevant treatment of MS are discussed in the present study. CONCLUSION Diagnosis of MS may be confirmed following histological and immunohistochemical examinations.
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Affiliation(s)
- Shu-Han Li
- Department of Periodontology, The Affiliated Hospital of Qingdao University, Qingdao 266003, Shandong Province, China
- Department of Periodontology, School of Stomatology of Qingdao University, Qingdao 266000, Shandong Province, China
| | - Cai-Xiu Yang
- Department of Periodontology, The Affiliated Hospital of Qingdao University, Qingdao 266003, Shandong Province, China
- Department of Periodontology, School of Stomatology of Qingdao University, Qingdao 266000, Shandong Province, China
| | - Xiao-Ming Xing
- Department of Pathology, The Affiliated Hospital of Qingdao University, Qingdao 266003, Shandong Province, China
| | - Xiang-Ru Gao
- Department of Periodontology, The Affiliated Hospital of Qingdao University, Qingdao 266003, Shandong Province, China
- Department of Periodontology, School of Stomatology of Qingdao University, Qingdao 266000, Shandong Province, China
| | - Zhao-Yu Lu
- Department of Periodontology, The Affiliated Hospital of Qingdao University, Qingdao 266003, Shandong Province, China
- Department of Periodontology, School of Stomatology of Qingdao University, Qingdao 266000, Shandong Province, China
| | - Qiu-Xia Ji
- Department of Periodontology, The Affiliated Hospital of Qingdao University, Qingdao 266003, Shandong Province, China
- Department of Periodontology, School of Stomatology of Qingdao University, Qingdao 266000, Shandong Province, China
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Patnaik MM, Tefferi A. Chronic myelomonocytic leukemia: 2024 update on diagnosis, risk stratification and management. Am J Hematol 2024; 99:1142-1165. [PMID: 38450850 PMCID: PMC11096042 DOI: 10.1002/ajh.27271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 02/09/2024] [Indexed: 03/08/2024]
Abstract
DISEASE OVERVIEW Chronic myelomonocytic leukemia (CMML) is a clonal hematopoietic stem cell disorder with overlapping features of myelodysplastic syndromes and myeloproliferative neoplasms, characterized by prominent monocytosis and an inherent risk for leukemic transformation (~15%-20% over 3-5 years). DIAGNOSIS Newly revised diagnostic criteria include sustained (>3 months) peripheral blood (PB) monocytosis (≥0.5 × 109/L; monocytes ≥10% of leukocyte count), consistent bone marrow (BM) morphology, <20% BM or PB blasts (including promonocytes), and cytogenetic or molecular evidence of clonality. Cytogenetic abnormalities occur in ~30% of patients, while >95% harbor somatic mutations: TET2 (~60%), SRSF2 (~50%), ASXL1 (~40%), RAS pathway (~30%), and others. The presence of ASXL1 and DNMT3A mutations and absence of TET2 mutations negatively impact overall survival (ASXL1WT/TET2MT genotype being favorable). RISK STRATIFICATION Several risk models serve similar purposes in identifying high-risk patients that are considered for allogeneic stem cell transplant (ASCT) earlier than later. Risk factors in the Mayo Molecular Model (MMM) include presence of truncating ASXL1 mutations, absolute monocyte count >10 × 109/L, hemoglobin <10 g/dL, platelet count <100 × 109/L, and the presence of circulating immature myeloid cells; the resulting 4-tiered risk categorization includes high (≥3 risk factors), intermediate-2 (2 risk factors), intermediate-1 (1 risk factor), and low (no risk factors); the corresponding median survivals were 16, 31, 59, and 97 months. CMML is also classified as being "myeloproliferative (MP-CMML)" or "myelodysplastic (MD-CMML)," based on the presence or absence of leukocyte count of ≥13 × 109/L. TREATMENT ASCT is the only treatment modality that secures cure or long-term survival and is appropriate for MMM high/intermediate-2 risk disease. Drug therapy is currently not disease-modifying and includes hydroxyurea and hypomethylating agents; a recent phase-3 study (DACOTA) comparing hydroxyurea and decitabine, in high-risk MP-CMML, showed similar overall survival at 23.1 versus 18.4 months, respectively, despite response rates being higher for decitabine (56% vs. 31%). UNIQUE DISEASE ASSOCIATIONS These include systemic inflammatory autoimmune diseases, leukemia cutis and lysozyme-induced nephropathy; the latter requires close monitoring of renal function during leukocytosis and is a potential indication for cytoreductive therapy.
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Affiliation(s)
- Mrinal M Patnaik
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Ayalew Tefferi
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Diral E, Catalano G, Cicinelli MV, Distefano A, Mastaglio S, Vago L, Lupo Stanghellini MT, Bernardi M, Ponzoni M, Ciceri F, Carrabba MG. Spontaneous remission of choroidal involvement by chronic myelomonocytic leukemia: a case report. Front Oncol 2024; 14:1399894. [PMID: 38756666 PMCID: PMC11096476 DOI: 10.3389/fonc.2024.1399894] [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: 03/12/2024] [Accepted: 04/19/2024] [Indexed: 05/18/2024] Open
Abstract
Chronic myelomonocytic leukemia (CMML) is a rare hematological disorder characterized by variable risk of evolution to acute myeloid leukemia; to date, allogeneic stem cell transplantation is the only curative treatment. We report a case of choroidal involvement in a woman affected by CMML and presenting only with visual impairment. The patient was initially evaluated for an intensive therapeutic approach, but after biopsy the ocular lesion spontaneously regressed. Thus a "watch and wait" strategy was preferred. One year and a half after initial diagnosis, the patient is alive, with stable hematological disease and without any ocular involvement. Therefore, a close, not invasive follow up could be useful to tailor treatment for patients affected by single ocular lesions in CMML.
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Affiliation(s)
- Elisa Diral
- Department of Hematology and Bone Marrow Transplantation, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - Maria Vittoria Cicinelli
- Vita-Salute San Raffaele University, Milan, Italy
- Department of Ophthalmology, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - Sara Mastaglio
- Department of Hematology and Bone Marrow Transplantation, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Luca Vago
- Department of Hematology and Bone Marrow Transplantation, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | | | - Massimo Bernardi
- Department of Hematology and Bone Marrow Transplantation, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Maurilio Ponzoni
- Vita-Salute San Raffaele University, Milan, Italy
- Pathology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Fabio Ciceri
- Department of Hematology and Bone Marrow Transplantation, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
| | - Matteo G. Carrabba
- Department of Hematology and Bone Marrow Transplantation, IRCCS San Raffaele Scientific Institute, Milan, Italy
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4
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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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Rybski KJ, El Hussein S. Coexisting Extra-Medullary Manifestation of Chronic Myelomonocytic Leukemia and Follicular Lymphoma What's Between Neoplastic Follicles Matters. Int J Surg Pathol 2022; 31:415-418. [PMID: 35656760 DOI: 10.1177/10668969221102535] [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
We illustrate a rare case of coexisting extramedullary manifestation of CMML and new onset follicular lymphoma within the same core-needle biopsy of a lymph node. We discuss the differences between extramedullary hematopoiesis and extramedullary manifestation of myeloid neoplasms. We also highlight the importance of generous tissue sampling and thorough examination of nodal tissue in the setting of an established myeloid neoplasm to avoid missing rare but possible nodal involvement.
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Affiliation(s)
- Kristin J Rybski
- Department of Pathology, 6923University of Rochester Medical Center, Rochester, New York, USA
| | - Siba El Hussein
- Department of Pathology, 6923University of Rochester Medical Center, Rochester, New York, USA
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6
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Hunter AM, Al Ali N, Mai A, Shah S, Swoboda DM, Kuykendall A, Talati C, Sweet KL, Sallman DA, Lancet JE, Komrokji RS, Padron E. Leukocytosis is associated with end organ damage and mortality in chronic myelomonocytic leukemia and can be mitigated by cytoreductive therapy. Leuk Res 2021; 109:106640. [PMID: 34144312 DOI: 10.1016/j.leukres.2021.106640] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 06/02/2021] [Accepted: 06/08/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Anthony M Hunter
- Department of Hematology and Medical Oncology, Winship Cancer Institute, Emory University School of Medicine, Atlanta, GA, USA
| | - Najla Al Ali
- Malignant Hematology Department, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Anne Mai
- Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Savan Shah
- Malignant Hematology Department, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA; Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - David M Swoboda
- Malignant Hematology Department, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA; Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Andrew Kuykendall
- Malignant Hematology Department, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Chetasi Talati
- Malignant Hematology Department, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Kendra L Sweet
- Malignant Hematology Department, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - David A Sallman
- Malignant Hematology Department, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Jeffrey E Lancet
- Malignant Hematology Department, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Rami S Komrokji
- Malignant Hematology Department, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA
| | - Eric Padron
- Malignant Hematology Department, H. Lee Moffitt Cancer Center and Research Institute, Tampa, FL, USA.
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Coston T, Pophali P, Vallapureddy R, Lasho TL, Finke CM, Ketterling RP, Carr R, Binder M, Mangaonkar AA, Gangat N, Al‐Kali A, Litzow M, Zblewski D, Pardanani A, Tefferi A, Patnaik MM. Suboptimal response rates to hypomethylating agent therapy in chronic myelomonocytic leukemia; a single institutional study of 121 patients. Am J Hematol 2019; 94:767-779. [PMID: 30964202 DOI: 10.1002/ajh.25488] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 04/03/2019] [Accepted: 04/04/2019] [Indexed: 12/21/2022]
Abstract
Hypomethylating agents (HMA) are currently the only FDA approved therapy for patients with chronic myelomonocytic leukemia (CMML). In the current retrospective study, we assessed response rates as adjudicated by the IWG (International Working Group) MDS (myelodysplastic syndrome) and MDS/MPN myeloproliferative neoplasm overlap syndrome response criteria, in 121 CMML patients treated with Azacitidine (AZA, n = 56) and Decitabine (DAC, n = 65). The overall response rates were 41% by the IWG MDS (AZA- 45%, DAC-39%), and 56% by the IWG MDS/MPN (AZA-56%, DAC-58%) response criteria, with CR (complete remission) rates of <20% for both agents, by both criteria. There were no significant differences in response rates between proliferative and dysplastic CMML. Moreover, 29% of CMML patients in a CR with HMA progressed to AML (blast transformation), underscoring the limited impact of these agents on disease biology. Progression after HMA response was associated with a median overall-survival (OS) of 8 months, while median OS in patients with primary HMA failure was 4 months. Lower serum LDH levels (<250 Units/L) were associated with HMA responses by both criteria; while ASXL1 and TET2 mutational status had no impact. HMA treated patients had a longer median OS (31 vs 18 months; P = .01), in comparison to those treated with conventional care regimens (excluding observation only patients), without any differences between AZA vs DAC (P = .37). In conclusion, this study highlights the inadequacies of HMA therapy in CMML, retrospectively validates the IWG MDS/MPN response criteria and underscores the need for newer, rationally derived therapies.
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Affiliation(s)
- Tucker Coston
- Division of Hematology, Department of Internal MedicineMayo Clinic Rochester Minnesota
| | - Prateek Pophali
- Division of Hematology, Department of Internal MedicineMayo Clinic Rochester Minnesota
| | - Rangit Vallapureddy
- Division of Hematology, Department of Internal MedicineMayo Clinic Rochester Minnesota
| | - Terra L. Lasho
- Division of Hematology, Department of Internal MedicineMayo Clinic Rochester Minnesota
| | - Christy M. Finke
- Division of Hematology, Department of Internal MedicineMayo Clinic Rochester Minnesota
| | - Rhett P. Ketterling
- Division of Hematopathology, Department of Laboratory MedicineMayo Clinic Rochester Minnesota
| | - Ryan Carr
- Division of Hematology, Department of Internal MedicineMayo Clinic Rochester Minnesota
| | - Moritz Binder
- Division of Hematology, Department of Internal MedicineMayo Clinic Rochester Minnesota
| | | | - Naseema Gangat
- Division of Hematology, Department of Internal MedicineMayo Clinic Rochester Minnesota
| | - Aref Al‐Kali
- Division of Hematology, Department of Internal MedicineMayo Clinic Rochester Minnesota
| | - Mark Litzow
- Division of Hematology, Department of Internal MedicineMayo Clinic Rochester Minnesota
| | - Darci Zblewski
- Division of Hematology, Department of Internal MedicineMayo Clinic Rochester Minnesota
| | - Animesh Pardanani
- Division of Hematology, Department of Internal MedicineMayo Clinic Rochester Minnesota
| | - Ayalew Tefferi
- Division of Hematology, Department of Internal MedicineMayo Clinic Rochester Minnesota
| | - Mrinal M. Patnaik
- Division of Hematology, Department of Internal MedicineMayo Clinic Rochester Minnesota
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Matanes F, AbdelAzeem BMA, Shah G, Reddy V, Saad A, Papadantonakis N. Chronic myelomonocytic leukemia associated with myeloid sarcomas and NPM1 mutation: a case report and literature review. Ther Adv Hematol 2019; 10:2040620719854596. [PMID: 31217941 PMCID: PMC6557017 DOI: 10.1177/2040620719854596] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 05/12/2019] [Indexed: 12/18/2022] Open
Abstract
We present a case of chronic myelomonocytic leukemia (CMML) associated with myeloid sarcomas. The CMML also harbored a NPM1 mutation, which is uncommonly described outside the context of acute myeloid leukemia (AML). We describe our treatment strategy, which involved remission-induction chemotherapy that led to rapid resolution of myeloid sarcomas, and we present a literature review highlighting the treatment challenges that similar cases pose.
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Affiliation(s)
- Faris Matanes
- Jordan University of Science and Technology, Irbid, Jordan; and Vascular Biology and Hypertension Program, University of Alabama at Birmingham, USA
| | | | - Gaurav Shah
- Internal Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Vishnu Reddy
- Department of Genetics, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Ayman Saad
- Division of Hematology, Ohio State University, Columbus, OH, USA
| | - Nikolaos Papadantonakis
- Division of Hematology/Oncology, Department of Medicine, University of Alabama at Birmingham, 1720 2nd Avenue South, NP 2540, Birmingham, AL 35294-3300, USA
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Pophali P, Horna P, Lasho TL, Finke CM, Ketterling RP, Gangat N, Nagorney D, Tefferi A, Patnaik MM. Splenectomy in patients with chronic myelomonocytic leukemia: Indications, histopathological findings and clinical outcomes in a single institutional series of thirty-nine patients. Am J Hematol 2018; 93:1347-1357. [PMID: 30105755 PMCID: PMC6196105 DOI: 10.1002/ajh.25246] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 08/03/2018] [Accepted: 08/06/2018] [Indexed: 12/13/2022]
Abstract
In a 28-year period, 39 (7%) patients with chronic myelomonocytic leukemia (CMML) (median age 66 years, 64% male) underwent a splenectomy at our institution. Primary indications for splenectomy were refractory thrombocytopenia (36%), progressive spleen related symptoms (33%), emergent splenectomy for splenic rupture (21%), refractory anemia (8%), and prior to allogeneic stem cell transplant (3%). Eleven (28%) patients had anemia at the time of splenectomy, of which 3 (27%) were autoimmune. The median time to splenectomy from CMML diagnosis was 6 months (0-40); perioperative morbidity and mortality rates were 43% and 13%, while the median postsplenectomy survival was 25 months (11-38). Durable remission in spleen related symptoms, thrombocytopenia, complications from splenic rupture, and anemia were achieved in 85%, 50%, 62%, and 21% of patients, respectively. Perioperative morbidity (n = 30) included infections/sepsis in 6 (20%), intraabdominal bleeding in 4 (13%), venous thromboembolism (VTE) in 3 (10%), and acute lung injury in 2 (7%) patients. The median duration of hospital stay was 6 days (1-25), with 5 deaths occurring secondary to respiratory failure (n = 2), multiorgan dysfunction (n = 2) and hemorrhagic shock (n = 1). There was no difference in overall survival between CMML patients that underwent splenectomy, in comparison to those that did not. Unlike in myelofibrosis, portal hypertension was not an indication for splenectomy and no patients developed post-splenectomy thrombocytosis. In conclusion, apart from being a lifesaving emergent modality in the event of splenic rupture, splenectomy has an important palliative role in patients with CMML, with significant and durable improvements in spleen related symptoms and refractory cytopenias.
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Affiliation(s)
- Prateek Pophali
- Division of Hematology, Department of Internal Medicine,
Mayo Clinic, Rochester, MN
| | - Pedro Horna
- Division of Hematopathology, Department of Laboratory
Medicine, Mayo Clinic, Rochester, MN
| | - Terra L. Lasho
- Division of Hematology, Department of Internal Medicine,
Mayo Clinic, Rochester, MN
| | - Christy M. Finke
- Division of Hematology, Department of Internal Medicine,
Mayo Clinic, Rochester, MN
| | - Rhett P. Ketterling
- Division of Hematopathology, Department of Laboratory
Medicine, Mayo Clinic, Rochester, MN
| | - Naseema Gangat
- Division of Hematology, Department of Internal Medicine,
Mayo Clinic, Rochester, MN
| | - David Nagorney
- Department of General Surgery, Mayo Clinic, Rochester,
MN
| | - Ayalew Tefferi
- Division of Hematology, Department of Internal Medicine,
Mayo Clinic, Rochester, MN
| | - Mrinal M. Patnaik
- Division of Hematology, Department of Internal Medicine,
Mayo Clinic, Rochester, MN
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