Clinicopathological characteristics, genetics and prognosis of patients with myeloid sarcoma: a single-center study

AIM

Myeloid sarcoma (MS) is a rare tumour comprising myeloid blasts occurring at an anatomical site other than the bone marrow. We sought to investigate both paediatric and adult patients with MS diagnosed at our institution and determine possible correlations among their clinicopathological, phenotypic, molecular and prognostic features.

METHODS

This study retrospectively evaluated the data of 45 patients diagnosed with MS at Ege University Faculty of Medicine Hospital, Turkey, over a 17-year period.

RESULTS

The male-to-female ratio was 1.5:1, and the median age was 39.12 years. The most commonly involved sites were the skin, lymph nodes, soft tissues and bone. Immunohistochemically, CD68-KP1 was the most commonly expressed marker, followed by CD33, myeloperoxidase, CD117, lysozyme, CD68-PGM1 and CD34. Of the patients, 26 (57.7%) presented with de novo MS, 7 (15.5%) had simultaneous acute myeloid leukaemia and 12 (26.8%) had a previous history of haematological disorders. Kaplan-Meier survival analysis revealed that the 2-year and 5-year overall survival (OS) rates were 46.4% and 39.8%, respectively; the median OS duration was 11 months. Increasing age had a negative prognostic relationship with survival (p = 0.04). Chromosomal abnormalities were detected in approximately 6/10 (60%) of paediatric patients and 6/9 (66.7%) of adult patients. t(8;21)(q22;q22) translocation was identified in 20% of paediatric patients.

CONCLUSIONS

MS diagnosis is usually challenging; an expanded immunohistochemical panel should be used for an accurate diagnosis. Although MS generally has a poor prognosis, increasing age appears to be associated with a worse outcome.

Granulocytic sarcoma causing long spinal cord compression: Case report and literature review

Context: Granulocytic sarcoma (GS) is an extramedullary form of proliferating myeloblasts. It is frequently reported in patients with acute myeloid leukemia (AML) but rarely in patients with chronic myeloid leukemia (CML). Spinal cord compression caused by CML-associated GS is exceedingly rare, with only few cases reported in the literature. To our knowledge, this is the first reported case in which GS caused such extensive compression.Findings: A 37-year-old man with CML suffered from back pain for 2 months. Notably, he had already achieved molecular remission (MR) after receiving imatinib mesylate for CML; bone marrow aspiration results were consistent with CML in chronic phase. Image examination revealed that developed GS occupied nearly the entire thoracic spinal canal, thereby causing extensive spinal cord compression. The tumor completely diminished after his treatment regimen was upgraded. He showed no signs of recurrence after 1-year follow-up.Conclusion: Extramedullary infiltration of CML should be taken into consideration when a mass lesion develops and compresses the spinal cord in a CML patient who has been receiving routine and standard treatment modalities; thus, a sudden and unexpected progression mandates a refinement and upgrade of treatment modality.

Extramedullary myeloid sarcoma mimicking tuberculosis of spine: A case report and literature review

Background:

A definitive diagnosis of spinal tuberculosis (TB) remains challenging. The “gold standard” is to obtain histopathological confirmation of the lesion. This analysis highlights how to avoid missing the diagnosis of an extramedullary myeloid sarcoma (EMS) versus TB.

Case Description:

A 25-year-old male presented with paraparesis. Although this was first attributed to TB spondylodiscitis, a PET-CT and reevaluation of the biopsy specimen both confirmed the diagnosis of an EMS.

Conclusion:

Nontubercular spinal disease should be suspected when a patient deteriorates despite the institution of antitubercular therapy for a reasonable duration. Further, microbiological and/or pathological confirmation is warranted to direct appropriate treatment and differentiate spinal TB from other entities as, in this case, an EMS.

Epidural Spinal Mass as the Presenting Feature of B-Acute Lymphoblastic Leukemia in a Young Child

An isolated epidural mass is a rare presentation of childhood B-acute lymphoblastic leukemia with an estimated incidence of 0.4%. Of the cases reported in the literature, the majority involve adults presenting with spinal cord compression and/or systemic evidence of disease. We describe a young child presenting with pain leading to a refusal to weight-bear secondary to a sacral epidural mass. A biopsy of the sacral lesion confirmed the diagnosis of B-acute lymphoblastic leukemia. Unique to this case is the young age of the child and the lack of spinal cord compression.

Epidural myeloid sarcoma as the presenting symptom of chronic myeloid leukemia blast crisis

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.

Sacral Myeloid Sarcoma Manifesting as Radiculopathy in a Pediatric Patient: An Unusual Form of Myeloid Leukemia Relapse

Myeloid sarcoma (MS), granulocytic sarcoma or chloroma, is defined as a localized extramedullary mass of blasts of granulocytic lineage with or without maturation, occurring outside the bone marrow. MS can be diagnosed concurrently with acute myeloid leukemia (AML) or myelodysplastic syndrome (MDS). The authors report a case of sacral MS occurring as a relapse of myeloid leukemia in a 5-year-old girl who was taken to the emergency department with radiculopathy symptoms.

A persistent epidural mass in a child with B-lineage ALL

Epidural spinal cord compression as the initial presentation of acute lymphoblastic leukemia (ALL) is a rare and serious complication. Extramedullary disease is rarely reported in patients with ALL. The most common sites are bone, followed by soft tissue, skin and lymph nodes. We describe a child with common B-lineage ALL who presented with a mass in the spinal epidural space. She was initially treated with intrathecal chemotherapy and intravenous dexamethasone with total resolution of her clinical symptoms but a persistent epidural mass. An open biopsy of the residual epidural mass was performed 7 months after diagnosis. The histological examination did not reveal any tumor infiltration, only fibrosis. We conclude that a persistent epidural mass in patients with ALL may not indicate resistant disease and may require over a year for resolution, even when response to therapy is adequate.

Imaging of back pain in children

While back pain presents less frequently in children than in adults, it still poses a significant clinical challenge with respect to making a firm diagnosis and developing an effective treatment plan. When children have back pain and medical attention is sought, an underlying pathology is usually suspected. Pediatric patients are evaluated, first, with a complete clinical history and examination and, second, by an imaging work-up that is based on initial findings, including the child's age and size, signs and symptoms, and suspected etiology. This article describes 1) the epidemiology of back pain in children, 2) the imaging work-up used, and 3) the correlation of imaging findings with disease entities that may cause back pain in the pediatric patient. The list of diseases giving rise to back pain is not meant to be exhaustive but rather reflective of the most commonly identified pathologies and disorders among young children and adolescents, from athletic injuries to lethal cancers.

Pathological dislocation of the dorsal spine following granulocytic sarcoma in a non-leukaemic patient

We describe a previously healthy, non-leukaemic young male presenting with neurological deficit and a pathological dislocation of D8 over D9 vertebra. The magnetic resonance imaging showed an enhancing soft tissue tumour. His basic laboratory workup as well as a bone marrow biopsy was normal. Through a single midline posterior approach, he underwent a decompressive laminectomy of D8 and D9 vertebra, anterior column reconstruction with a meshed titanium cage and posterior pedicle screw instrumentation. The histological diagnosis of granulocytic sarcoma was confirmed by appropriate immuno-histochemical studies. He received postoperative radiotherapy following which his wound dehiscesed and the tumour fungated and spread to his left thigh. He declined chemotherapy and unfortunately expired 9 months later. This case is presented to draw attention to the unusual presentation and to stress that granulocytic sarcoma should be kept in mind when making the differential diagnosis in patients with signs of spinal cord compression even in non-leukaemic individuals.

Spinal granulocytic sarcoma manifesting as radiculopathy in a nonleukemic patient

A 26-year-old nonleukemic woman presented with lumbosacral granulocytic sarcoma manifesting as progressive low back pain and numbness of her left lower leg persisting for 3 months. Physical examination revealed hypesthesia within the left S1 area of the sensory dermatome, decreased Achilles tendon reflex in the left lower extremity, and walking impairment due to severe pain in her left hip and leg. Magnetic resonance imaging confirmed an extradural mass in the spinal canal at the L5-S2 levels with invasion to the pelvis from the left sacral foramen. Positron emission tomography with [18F]fluorodeoxyglucose (FDG-PET) showed hyperaccumulation indicating malignant tumor. Baseline laboratory data were normal. Decompressive laminectomy and tumor removal were performed. Histological examination identified granulocytic sarcoma. Bone marrow involvement was absent. She underwent adjuvant chemotherapy and radiotherapy, resulting in reduced residual lesion and neurological improvement. Immediate diagnosis and adequate systematic treatment are recommended for spinal granulocytic sarcoma in nonleukemic patients to prevent or delay progression to leukemia. The importance of immunohistochemical staining in the differential diagnosis from other types of spinal tumor, and the efficacy of FDG-PET for evaluation of the treatment are also emphasized.

Acute Lymphocytic Leukemia Recurring in the Spinal Epidural Space -Case Report-

A 27-year-old man presented with a very rare spinal epidural mass associated with recurrence of acute lymphocytic leukemia (ALL) manifesting as acute progressive neurological deficits. The patient presented with shoulder pain and ambulatory difficulties 3 years after remission of ALL treated by bone marrow transplantation. Magnetic resonance imaging revealed an epidural mass extending from C-7 to T-3, which compressed the cord and extended to the intervertebral foramen along the roots. After decompression surgery, the symptoms dramatically improved. Histological examination showed clusters of immature lymphocytes consistent with recurrence of leukemia, so chemotherapy and radiation therapy were carried out. At 1 year after the operation, no local mass expansion or systemic progression of leukemia had occurred. Leukemic mass must be considered in the differential diagnosis of spinal epidural mass, even in patients with ALL.

Myeloid sarcoma with multiple lesions of the central nervous system in a patient without leukemia

✓ The authors report the unusual case of a 35-year-old woman suffering from left leg numbness and radiculopathy due to multiple lesions in the central nervous system: one right parietal extracranial–intracranial lesion with invasion of the sensory cortex, and two intraspinal, intradural lesions compressing the spinal cord at T3–5 and S1–4. Biopsy sampling of the extracranial part of the parietal lesion led to a diagnosis of myeloid sarcoma. Further examination revealed no evidence of leukemic disease or myeloproliferative disorder. An aggressive multimodal approach to treatment in this patient with a combination of chemotherapy, whole-body radiotherapy, and allogeneic bone marrow transplantation was started immediately. The patient experienced full neurological recovery and complete disappearance of all lesions. At the 7-year follow-up examination, there was no evidence of disease. To the authors’ knowledge, this is the first report of a myeloid sarcoma with both intracranial and intraspinal manifestations in a patient without leukemia.

Acute myeloid leukemia presenting as spinal cord compression

We report the findings of a 10-year-old boy who presented to a pediatric emergency department with symptoms of spinal cord compression. Radiological imaging demonstrated multiple soft tissue masses in the head and spine. The surgical pathology showed that the masses were comprised of myeloid leukemia cells. These findings were consistent with those observed on bone marrow aspiration. The characteristics and management of extramedullary leukemia are discussed.

Granulocytic sarcoma of the spine in a child without bone marrow involvement: a case report and literature review

We report a 2-year-old Japanese boy without bone marrow involvement who developed a primary granulocytic sarcoma in his spinal canal. Tumour cells were positive for myeloperoxidase, MIC2, CD56 and, CD68 on formalin-fixed, paraffin-embedded tissue sections and CD13, CD33, CD45, and CD64 on acetone-fixed fresh frozen sections. Nine months after the initiation of treatment, the tumour had significantly regressed and the patient was able to walk with help.

CONCLUSION

Our patient is the youngest case of granulocytic sarcoma of the spine without bone marrow involvement. Immunohistochemical methods are very helpful in establishing a diagnosis of granulocytic sarcoma.

Sarcoma granulocítico de sistema nervoso central pós transplante de medula óssea: relato de caso

Sarcoma granulocítico é tumor sólido, constituído por células precursoras de granulócitos, localizado em sítio extra medular. Geralmente surge precedendo uma leucemia mielóide aguda ou concomitantemente a ela, sendo considerado fator de mau prognóstico. Tem como principais modalidades terapêuticas a radioterapia e a quimioterapia. Um caso de sarcoma granulocítico intracraniano ocorrido seis meses após transplante de medula óssea por leucemia mielóide aguda é relatado. A paciente apresentava cefaléia e hemiplegia esquerda, causada por extensa lesão fronto-parietal direita. Após a ressecção completa do tumor, houve total recuperação do déficit neurológico. A paciente completou o tratamento radio e quimioterápico, estando livre de doença após três meses de acompanhamento. O manejo cirúrgico do sarcoma granulocítico é modalidade adjuvante, indicada quando o efeito compressivo tumoral determina déficit neurológico. É o meio mais rápido de descompressão do tecido nervoso, possibilitando a chance de recuperação funcional, melhorando a qualidade de vida do paciente.

Comparison in treatments of nonleukemic granulocytic sarcoma: report of two cases and a review of 72 cases in the literature

BACKGROUND

The purpose of this study was to reveal the clinical characteristics of nonleukemic granulocytic sarcoma (GS) and an association between the therapeutic regimens and the nonleukemic period.

METHOD

Clinical records of 2 patients reported here and 72 patients gathered using a literature search on Medline from other institutions were analyzed. The patients consisted of 57 patients who preceded acute nonlymphoblastic leukemia (ANLL) and 17 patients who did not develop ANLL. These patients were divided into 3 groups by therapeutic regimens; Group I included 12 patients who received only biopsy or surgical resection of the tumor, Group II was 20 patients who received local irradiation for the tumor, and Group III consisted of 42 patients who received systemic chemotherapy. The nonleukemic periods between these groups were compared. In Group III, the period in the patients who were treated with chemotherapy given to ANLL was compared with that in the patients who received chemotherapy used for malignant lymphoproliferative disorders (MLPDs).

RESULTS

Thirty-five patients (47%) initially were misdiagnosed, and the disease was most often malignant lymphoma. Preferential sites of GS were the small intestine, mediastinum, epidural site, uterus, and ovary, which often are difficult for the detection and diagnosis in addition to the skin and lymph nodes known commonly. The nonleukemic period after the diagnosis of GS was significantly longer in Group III than in the other groups (median, 12 months in Group III vs. 3 and 6 months in Groups I and II, respectively). The aggressive chemotherapy given to ANLL led to a longer nonleukemic period than the chemotherapy used for MLPDs.

CONCLUSIONS

To reduce the risk of subsequent ANLL in patients with nonleukemic GS, it is important that accurate histologic diagnosis is established initially for GS and that all isolated cases of GS, even those that appear to be cured by resection or irradiation of the tumor, are treated with intensive chemotherapy similar to that used to treat ANLL during the nonleukemic period as soon as possible.