Isolated granulocytic sarcoma of the breast

Breast leukemia: an update

BACKGROUND

Breast leukemia is extremely rare. The published data on this manifestation include predominantly case reports and do not provide any statistical information.

PURPOSE

To identify clinical signs and radiological features of breast leukemia.

MATERIAL AND METHODS

PubMed and Medline databases between 1980 and 2010 were screened using 'breast leukemia' and 'leukemia of the breast' as keywords. Secondary references were also reviewed. By this search, a total of 139 patients were identified from the literature.

RESULTS

In most patients (n = 85, 61.2%) acute myeloid leukemia was diagnosed. Acute lymphatic leukemia occurred in 35 patients (25.2%). Isolated BL before bone marrow infiltration was seen in 24 patients (17.3%). Involvement of the breast during the course of leukemia was diagnosed in 25 cases (18%). Intramammary leukemic relapse after therapy/stem cell transplantation occurred in 59 patients (42.4%). In 71 cases (51.1%) the lesions were solitary and in 57 (41%) multiple. The number of lesions was not reported in 11 patients (7.9%). There was no significant difference between the number of lesions in ML and LL. Clinically, 73% of the patients presented with palpable breast masses. Most of them were painless. Mammography was performed in 39 patients, allowing the identification of the following three mammographic patterns: breast masses (28 patients, 72%), architectural distortion (5 patients, 13%), no abnormalities (6 patients, 15%). On ultrasound, most identified masses were homogeneously hypoechoic with microlobulated or indistinct margins. On MRI, on T2-weighted images breast lesions were hyperintense. After venous administration of contrast medium, BL showed marked inhomogeneous contrast enhancement. Treatment of BL is the same as for other localizations and is based on chemotherapy and/or radiotherapy.

CONCLUSION

In the present study the clinical and radiological features of BL are described. They are non-specific. However, BL should be considered in the differential diagnosis of breast disorders, especially in patients with leukemia.

A clinical review of breast involvement in acute leukemia

The breast continues to be reported as a site of resistant leukemia despite current curative protocols. To characterize disease behavior and potential for lengthy survival after breast relapse, a study was undertaken of 153 cases reported between 1969 and 2005. Authors were contacted for follow-up. There were 105 AML and 48 ALL cases identified. Ninety percent of female patients were younger than 50 and leukemia was temporally related to pregnancy in 13. Eight cases were males. Remissions were typically of short duration, principally due to further extramedullary relapses, in 3 main sites in both AML and ALL: contralateral breast, gynecologic organs, and CNS. However, there are cases of disease-free survival up to 26+ years after intensive treatment. Leukemia growing in the breast may follow a distinctive pattern, and prompt initiation of intensive multi-cycle treatment, assuming occult site involvement, with consideration of CSF prophylaxis, should increase the potential for disease eradication.

Granulocytic sarcoma of the breast without development of bone marrow involvement: a case report

A 29-year-old woman presented with a breast tumor with a primary diagnosis of MALT lymphoma. A repeat biopsy revealed a hematological neoplasm with diffuse, Indian file, and targetoid patterns. The cells were intermediate size with eosinophilic granules; the immunophenotyping showed monocytic differentiation, and no lymphoepithelial lesion was observed. The diagnosis was granulocytic sarcoma. Three different bone marrow biopsies were negative for neoplastic infiltration. After treatment, she developed secondary pancytopenia which contributed to her death 16 months after primary diagnosis. Granulocytic sarcoma of the breast is uncommon. A complete panel of immunohistochemistry is necessary to perform this diagnosis.

Granulocytic sarcoma: 32 cases and review of the literature

Thirty-two cases of granulocytic sarcoma (GS) are reported in this paper. Age range was from 16 - 70 years. GS was accompanied by AML in 13 cases, ALL (My+) in one case, CML in 11 cases and MDS in two cases. GS was diagnosed simultaneously with leukemia in five cases and preceded the leukemia in eight. Lymph node and soft tissue were the most commonly detected localizations. Seven cases had first been diagnosed as NHL. Histopathologically blastic, immature and mature variants were found in 11, nine and 11 cases respectively and overall survival was shortest in the blastic type. Myeloperoxidase and lysozyme were found to be positive in 30 and 24 cases respectively. Therapy was radiation in five cases and surgery in three. Systemic chemotherapy was given to the cases. The clinical outcome of the patients after the diagnosis of GS was poor. GS is a unique entity; prognosis is poor but it is important to detect the signaling pathways associated with migration of myeloid cells to the extra-medullary tissues. The critical factors for detecting this interesting tumor are to be aware of this disease, cooperation between clinician and pathologist and the application of special stains to detect the myeloid origin.

Myeloid Sarcoma Involving the Breast

Context.—Myeloid sarcoma is a neoplasm of myeloid cells that can arise before, concurrent with, or following acute myeloid leukemia. Rarely, it can also occur as an isolated mass.

Objective.—To describe the clinicopathologic features of 6 patients with myeloid sarcoma involving the breast.

Design.—Clinical information for all 6 patients was obtained from the medical record. Routine hematoxylin-eosin–stained slides; naphthol AS-D chloroacetate stain; and immunohistochemical stains for myeloid, B-cell, and T-cell antigens were prepared.

Results.—There were 6 women with a median age of 52 years (range, 31–73 years). Two patients presented with isolated tumors of the breast, with no history or subsequent development of acute myeloid leukemia. In 3 patients, the breast tumors represented relapse of acute myeloid leukemia. One patient who presented initially with myeloid sarcoma involving the breast, skin, and spleen was lost to follow-up. Histologically, these tumors were classified as well differentiated (n = 3), poorly differentiated (n = 2), and blastic (n = 1). Naphthol AS-D chloroacetate esterase was positive in all 3 cases assessed. Immunohistochemistry showed that myeloperoxidase (n = 5) and CD43 (n = 3) were positive, and CD3 (n = 5) and CD20 (n = 5) were negative in all cases assessed. Lysozyme was positive in 4 (80%) of 5; CD117 was positive in 2 (67%) of 3; and single cases were positive for CD45 (1/3), TdT (1/2), CD79a, and the PAX5 gene product.

Conclusions.—Myeloid sarcoma involving the breast is uncommon. In the literature, as in this study, these tumors most often represent relapse or the initial presentation of acute myeloid leukemia. However, 2 of the cases we report presented with isolated masses, without a history or subsequent development of acute myeloid leukemia at last follow-up. Immunohistochemical studies are extremely helpful for recognizing isolated myeloid sarcoma.

Granulocytic Sarcoma (Chloroma) of the Breast: A Diagnostic Dilemma and Review of the Literature

Primary granulocytic sarcoma (GS) is a rare entity, and even more unusual is the presence of primary GS of the breast. We describe such a case and report on the 19 cases of primary breast GS in the literature. Primary GS presents most commonly in skin and lymph nodes, therefore when it presents in the breast, misdiagnosis is a common problem. Primary breast GS is misdiagnosed most frequently as lymphoma or sarcoma. Histologic testing and immunostains are essential to provide the proper diagnosis. It appears that early initiation of systemic acute myelogenous leukemia (AML)-type chemotherapy is beneficial and may delay or avert the development of AML in bone marrow and blood.

Acute myeloid leukemia relapsing as gynecomastia

Granulocytic sarcoma (GS) is an increasingly common relapse feature of acute myeloid leukemia (AML), late in the disease course or post bone marrow transplantation (BMT). Any solid organ can be affected, and there have been a number of reports of GS in breast tissue in female patients. We present a unique case of GS in a male AML patient, presenting as painless gynecomastia immediately before BMT at advanced disease. Aberrant expression of CD56 was found in the relapsed GS tissue but not in the original AML clone. Twelve months after allogeneic BMT, leukemia relapsed again in the same breast, with normal marrow morphology and full donor chimerism. The lesion failed to respond to donor lymphocyte infusion, chemotherapy and radiotherapy, and disseminated to other subcutaneous tissues.