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

Single organ microenvironment and the common features of tumors of leukemia, lymphoma, and myeloma cells growing there: A literature review

OBJECTIVE

To explore whether the growth and treatment resistance of lymphoma and myeloma tumors is similar to that previously observed in leukemic and solid tumors growing in the same organ microenvironment.

METHODS

All published cases of 3 primary hematologic malignancies in breast, without systemic involvement, were identified, with follow-ups solicited from authors. Treatment approaches were analyzed to highlight the most effective.

RESULTS

Similar histologic features and biology among primary tumors of leukemia, lymphoma, plasmacytoma, and solid breast cancer was revealed. Review of treatments: tumor-directed, chemotherapy, or combination showed the benefit of tumor removal, and use of systemic agents in adjunct, not primary, treatment. Optimal assessment is limited by few cases of PET/CT verifying limited tumor extent. The common biology observed and cases of long survival after tumor/stroma eradication point to the complicity of organ microenvironment in the chemoresistance and treatment failure commonly observed in patients.

CONCLUSIONS

The interaction of an organ microenvironment, particularly its adipocytes, with malignant cells, results in similar histologic changes, metastatic potential, and chemoresistance in 3 hematologic malignancies and solid cancers. Improved survival in hematologic malignancies could result from adopting PET/CT to find tumor and its extent, eradicating tumor, and elucidating common therapeutic targets.

Sonographic Features of a Myeloid Sarcoma of the Breast as a Relapse of Acute Myeloid Leukemia After Stem-Cell Transplantation: A Case Report

Patient: Female, 24

Final Diagnosis: Myeloid sarcoma of the breast

Symptoms: Breast lump

Medication: —

Clinical Procedure: Core needle biopsy

Specialty: Radiology

Hematolymphoid lesions of the breast

Hematolymphoid malignancies of the breast are most commonly neoplasms of mature B-lymphocytes, and may arise as a primary disease or by secondary involvement of a systemic disease. Primary breast lymphomas (PBL) account for 0.04-0.5% of breast malignancies, less than 1% of all non-Hodgkin's lymphomas (NHL), and less than 5% of extranodal lymphomas (Lakhani et al., 2012; Swerdlow et al., 2008; Joks et al., 2011; Barişta et al., 2000; Giardini et al., 1992; Brogi and Harris, 1999; Topalovski et al., 1999).^1-7 Secondary breast lymphomas (SBL) are also rare, with an estimated annual incidence of 0.07% (Domchek et al., 2002; Talwalkar et al., 2008).^8,9 Recognition of breast lesions as hematolymphoid is critical to distinguish them from other entities that can occur in the breast.

Ultrasound Findings in a Case of Myeloid Sarcoma of the Breast

Myeloid sarcoma is a rare, solid extramedullary tumor originating from immature granulocytic cells or monocytes. Breast involvement without an aleukemic or myeloproliferative disorder is very infrequent. A 21-year-old female patient was admitted with bilateral palpable breast masses for four months. The patient had given birth approximately one year ago. The ultrasonographic examination revealed multiple, oval shaped—some of them with microlubulated margins—hypoechoic, solid masses of which, the largest mass measured 4.5 × 2.5 cm, evaluated as BI-RADS 4. The histopthological examination suggested hematolymphoid neoplasm. In the differential diagnosis of solid breast lesions, myeloid sarcoma should be kept in mind even without hematological findings. Early diagnosis of this tumor is important for the effectiveness of the medical treatment.

Granulocytic sarcoma of the breast: A case report

Granulocytic sarcoma (GS) is an unusual type of tumor composed of immature cells outside the bone marrow. The disease exhibits a correlation with acute myeloid leukemia and other myeloproliferative disorders. Although it can invade a number of areas of the body, the involvement of the breast is uncommon. The present study reports the case of a 58-year-old female with a mildly tender lump in the left breast that had been apparent for one year. Available diagnostic techniques, including ultrasound, magnetic resonance imaging and mammography, were systematically used to determine a diagnosis of GS, and lumpectomy and systemic chemotherapy were performed. The patient was satisfied with the result of no local recurrence at the one year follow-up examination. The present study discusses the clinical and pathological characteristics of the present case of GC.

Granulocytic sarcoma of the breast in acute myeloid leukemia: Two case reports

Granulocytic sarcoma (GS) of the breast is extremely rare in patients with acute myeloid leukemia (AML) and therefore, is often misdiagnosed as lymphoma or other benign tumors. The current report presents two cases of GS of the breast, of which, one was considered to be a fibroma, as observed by fine-needle aspiration, and the other was misdiagnosed as lymphoma by frozen section. Previous literature that described the clinical and pathological characteristics, treatments and prognosis of GS of the breast in AML were reviewed. In addition to the treatment of mastectomy with/without radiotherapy, lumpectomy may also be received as a good treatment plan.

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 basis for updating our approach to resistant acute leukemia

No studies exist documenting that chemotherapy alone eradicates tumors composed of leukemic cells in a large group of patients with tumors at any one site. Yet, its use has continued over 40 years in the absence of data. Consensus protocols exist only for testis and meningeal tumors, relying on local therapy. To constitute a body of knowledge about tumors at one site, the breast was chosen and all published cases were analyzed, with follow-up obtained, to document the behavior of acute leukemia tumors and survival after presentation. Among 235 cases (52% published since 2000), overall survival was poor, particularly for the 43% with concurrent morphologic marrow relapse, with 66-73% one-year mortality. Only 4 of 106 patients treated with chemotherapy alone survived 4 years. The majority of AML and ALL tumors were only transiently responsive to anti-leukemia treatments, including transplant, and next relapses were as, or more, common in further tumors than in marrow. A pattern of tumors similar to the metastases of invasive lobular breast cancer was revealed. When relapse occurred in marrow, durable remission was only rarely obtained. These data suggest a potential benefit of incorporating extent of disease workup at diagnosis and relapse into prospective trials. This could yield an accurate incidence of extramedullary tumors and a means to identify occult residual disease which could lead to marrow relapse. This approach could potentially result in greater success in curing acute leukemias.

Primary granulocytic sarcoma of the face

Myeloid sarcoma is a tumor which consists of myeloblasts or immature myeloid cells. This tumor presents in the lymphoid organs, bone, skin, soft tissue, various mucosae and organs, and the central nervous system. Granulocytic sarcoma, an extramedullary acute myeloid leukemia, is also referred to as chloroma (GS) because of its greenish surface color. Granulocytic sarcoma is rare and difficult to diagnose. We can easily misdiagnose this tumor as lymphoma or sarcoma, especially when there is no evidence of hematologic disorders. Immunohistochemical studies are helpful in determining the correct diagnosis. Antibodies to myeloperoxidase, lysozyme, and chloroacetate esterase are used for the diagnosis of granulocytic sarcoma. In addition, detection of cell surface markers such as CD 33, CD 34, CD 68, CD 99, and HLA-DR may be useful. We describe a case of GS that presented with bluish nodules on the right cheek of a 54-year-old woman with immunohistochemical findings for correct diagnosis.

FDG PET/CT manifestations of hematopoietic malignancies of the breast

Hematopoietic malignancies that can be encountered in the breast include lymphoma, leukemia, and multiple myeloma/plasmacytoma. These are readily imaged via [18]F-fluorodeoxyglucose position emission tomography (PET)/computed tomography (CT) and can manifest as unilateral, bilateral, single, multiple, round/oval masses, or diffuse. These malignancies can occasionally mimic primary breast cancers. Conversely, benign conditions, such as the lactating breast can resemble hematopoietic malignancies of the breast. Although uncommon, familiarity with hematopoietic malignancies of the breast is important for proper interpretation of PET/CT. In this pictorial review, the PET/CT imaging features of patients with hematopoietic malignancies of the breast will be described, including pathology-proven cases of acute myelogenous leukemia, diffuse B-cell lymphoma, follicular lymphoma, acute myeloid leukemia with neutropenic granulocytic) sarcoma, and plasmacytoma. In addition, potential pitfalls will be discussed.

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.

Advances in the pathologic diagnosis and biology of acute myeloid leukemia

In a general surgical pathology practice, cases of acute myeloid leukemia (AML), including myeloid sarcoma, are relatively rare; the diagnosis is very often difficult, however, and consequences of a missed or improper diagnosis compromise patient care. Currently, accurate diagnosis of every case of AML requires integration of the morphological features and results of cytochemical and immunohistochemical stains, flow cytometric immunophenotyping, cytogenetics, and molecular studies. This review focuses on a practical approach to diagnosis of AML according to current standard of practice and discusses some of recent changes in the field of AML.

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.