Orbital granulocytic sarcoma

Solitary eosinophilic granulocytic sarcoma in a dog

A 6-year-old male golden retriever presented with swelling of the left upper eyelid of 2 months duration, which did not improve following a course of antibiotics. Routine serum biochemistry, complete blood count and diagnostic imaging identified no clinically significant abnormalities. The mass was surgically excised, and histopathologic examination was performed. Eosinophilic granulocytic sarcoma (GS) was diagnosed based on the results of histopathology and immunohistochemistry. This is the first report of GS affecting the eyelid of a dog.

Consolidative Proton Radiotherapy for Pediatric Extramedullary Ocular Acute Myeloid Leukemia

Purpose

Pediatric acute myeloid leukemia (AML) often involves extramedullary sites, which can be resistant to standard induction chemotherapy. Consolidative radiation therapy can be used in select cases to improve local control rates and help bridge patients to curative stem cell transplants. However, there is no previously published data to support the use of proton radiotherapy (PT) in this setting. We present radiographic findings and pathologic outcomes of the first reported patient with extramedullary ocular AML to be treated with PT.

Patients and Methods

Details regarding diagnostic evaluation and treatment were obtained from the electronic medical records at the University of Florida Proton Therapy Institute, Nemours Children's Health, and St. Joseph's Children's Hospital.

Results

This 7-month-old patient presented with biopsy-proven relapsed AML in the bilateral anterior chambers of the eyes, which did not resolve with induction chemotherapy. The patient then received PT to a dose of 24 cobalt gray equivalent to both eyes and was found to have no evidence of disease following treatment.

Conclusion

This case provides further evidence that consolidative radiotherapy may be considered for select patients with extramedullary AML who have limited response to induction chemotherapy. Given the increased prevalence of extramedullary AML in pediatric patients, it is worth considering the utilization of PT to mitigate damage to nearby organs and the risk of secondary malignancies.

Bilateral Orbital Myeloid Sarcomas: A Unique Presentation of Acute Myeloid Leukemia

Myeloid sarcomas (MS) are solid manifestations of acute myeloid leukemia (AML) and are commonly present in children. These tumors can arise in many tissues including bone, soft tissue, or skin, and are commonly seen in the orbit. As practically all MS will, if left untreated, eventually present as AML, early diagnosis and initiation of treatment are imperative. We highlighted a case of bilateral orbital MS in a pediatric patient that presented concurrently with AML and the steps taken to diagnose and initiate treatment. Our case highlights the potentially occult presentation of AML as well as myeloid sarcoma and, therefore, the importance of swift workup and diagnosis. Epidemiology, radiographic features, diagnosis, and treatment for myeloid sarcoma and AML were discussed.

Early Ophthalmological Manifestations of Acute Myeloid Leukemia: Current Perspectives

Acute myeloid leukemia (AML) is a hematological malignancy affecting different organ systems including the eye. The purpose of this review is to present and evaluate the medical literature regarding the early ophthalmological manifestations of acute myeloid leukemia. AML affects the ocular system through direct infiltration of tissues, secondary to hematological abnormalities, or in the form of chloroma or myeloid sarcoma in the brain or orbit consequently leading to a variety of manifestations depending on the ocular tissue involved. It is imperative for ophthalmologists to be aware of the early ophthalmological manifestations of AML which will allow for earlier diagnosis and treatment of this life-threatening disease.

Unilateral Proptosis: A Rare Presenting Sign of Acute Myeloid Leukemia

Unilateral proptosis is a rare initial presenting sign of acute myeloid leukemia (AML). We report a case of unilateral proptosis in a six-year-old girl as the initial manifestation of AML. The cancer link was initially missed and the case was investigated as one of hyperthyroidism. Peripheral blood smear and bone marrow aspirate evaluation showed signs diagnostic of AML. Computed tomography scan of orbits showed infiltrative process in the right orbit, right maxillary, and right ethmoidal sinuses. Unilateral proptosis as an extramedullary first presenting feature of AML is very rare; however, it should always be considered in the differential diagnosis of proptosis in pediatric age group.

Acute Myeloid Leukemia Transformation from Myelofibrosis Upon Remission of an Orbital Myeloid Sarcoma - A Case Report

PURPOSE

To report a case of an orbital myeloid sarcoma concurrent with JAK2 mutation myelofibrosis, which rapidly transformed into acute myeloid leukemia upon aggressive treatment.

RESULTS

A 51-year-old woman had progressive swelling of periorbita for one month. Magnetic resonance imaging demonstrated a well-defined, mild enhanced mass indenting the adjacent right lateral rectus muscle and the globe. Biopsy from anterior orbitotomy revealed an orbital myeloid sarcoma. Bone marrow study showed concurrent myelofibrosis. Although the orbital lesion subsided remarkably under aggressive chemotherapy and radiotherapy, the leukemic transformation was noticed in the third month following the initial presentation.

CONCLUSION

This case demonstrated that myeloid sarcoma should be included in the differential diagnosis of orbital diseases, with or without involvement of hematological disorders. Early diagnosis and aggressive treatment as for AML are crucial as the prognosis is usually poor for adult orbital MS.

Acute unilateral proptosis in childhood: suspect myeloid sarcoma

As the first and only presenting feature of acute myeloid leukemia (AML), unilateral proptosis in children is uncommon. We report the cases of two girls who had no systemic clinical manifestations of AML. Orbital imaging showed space-occupying infiltrating lesions without surrounding bone erosion. Incisional biopsy and immunohistochemistry were diagnostic for myeloid sarcoma. Systemic workup and bone marrow examination showed features of AML. Systemic chemotherapy was administered to both children, who responded well to the treatment. Myeloid sarcoma should be kept in the differentials of the children presenting with isolated proptosis. Immunohistochemistry may provide an accurate diagnosis and early treatment may lead to a prompt recovery with a good prognosis.

Bilateral Ocular Exophthalmia - A Case of Atypical Acute Myeloblastic Leukemia in a Child

Introduction

In acute myeloblastic leukaemia (AML) explosive proliferation and accumulation of immature myeloid cell clones take place, replacing the bone marrow, with the possibility of the formation of extramedullary tumour masses composed of myeloid cells. The onset of the disease less frequently consists of symptoms of extramedullary manifestation.

Case presentation

A Caucasian male child aged three years and 11 months was hospitalized for bilateral exophthalmos and otorrhea, due to an alteration in his general condition. Ocular ultrasound revealed an inhomogeneous thickening of the upper right muscles superior to the eyeball. A complete blood count showed severe anaemia, leucocytosis with neutropenia and thrombocytopenia. A peripheral blood smear evidenced myeloblasts. The result of the cytology of bone marrow confirmed the diagnosis of AML. Following blood product replacements and cytostatic treatment (AML-BFM 2004 HR protocol), the remission of exophthalmos and the correction of haematological parameters were favourable.

Conclusion

In a child with a sudden onset of exophthalmia and altered general condition, the diagnosis of acute leukaemia should be considered. The importance of performing a peripheral blood smear and bone marrow examination is emphasized so that diagnosis and initiation of treatment are not delayed.

[Primary granulocytic sarcoma of lacrimal gland]

The article presents clinical description and instrumental findings (ultrasound examination and multi-slice computed tomography of the orbits) of a rare lacrimal gland tumor, which precedes or concurs with acute myeloblastic leukemia. Due to the low incidence of myeloid (granulocytic) sarcoma, it is not possible to develop a proper algorithm for its diagnosis and treatment. Few descriptions that are available in the literature neither give an idea of the variety of manifestations and the order of organ involvement, nor allow any vital prognosis. Verification of the diagnosis can only be based on immunohistochemical findings of the primary tumor and bone marrow biopsy material. The authors emphasize the importance of combination treatment (radiation therapy of the orbits and chemotherapy) in the prevention of leukemia.

Ocular Manifestations in Leukemias and Their Correlation with Hematologic Parameters at a Tertiary Care Setting in South India

PURPOSE

To determine the prevalence of ocular manifestations and the association of these manifestations with hematologic parameters among patients with leukemia attending a hemato-oncology unit at a tertiary care government hospital in South India.

DESIGN

This was a cross-sectional observational study.

PARTICIPANTS

All patients attending a hemato-oncology unit at a tertiary care government hospital in South India who were diagnosed with acute or chronic leukemia that was confirmed by a bone marrow biopsy.

METHODS

Consecutive patients with leukemia presenting at the hematology clinic underwent standardized leukemia blood workup and comprehensive ophthalmic evaluation. Patient demographics, the type of leukemia, ophthalmic features, and hematological parameters such as hemoglobin level, white blood cell count, and platelet counts were recorded. The association between ophthalmic manifestations and blood counts was analyzed using multivariable regression analysis.

MAIN OUTCOME MEASURES

The study measured the prevalence of various ocular manifestations in different types of leukemias and their association with hematologic parameters.

RESULTS

In total, 133 eyes of 133 patients were examined during the study period. The prevalence of leukemic ophthalmopathy was found to be 68% in cases of acute myeloid leukemia, 42% in cases of acute lymphoid leukemia, 33% in cases of chronic lymphoid leukemia, and 13% in cases of chronic myeloid leukemia. Vision-threatening complications such as subhyaloid hemorrhage involving the posterior pole (20%) and vitreous hemorrhage (10%) were seen exclusively in patients with acute leukemias. Multivariable logistic regression after adjusting for the type of leukemia, patient age, and white blood cell and platelet counts showed that the hemoglobin level was the only factor predictive of developing subhyaloid hemorrhage (every 1-g/L increment increase in hemoglobin level led to a 30% reduction in the likelihood of developing subhyaloid hemorrhage; 95% confidence interval 0.5-0.9; P = 0.02). The probability of developing subhyaloid hemorrhage was reduced by >50% when hemoglobin level improved from 5 to 7 g/L and when platelet count improved from 10 000 to 50 000 cells/mm³ for both types of acute leukemia. There was no association between white blood cell counts and ophthalmic manifestations.

CONCLUSION

Leukemic ophthalmopathy is more common in acute and myeloid cases and less common in chronic and lymphoid subtypes. It is predominantly due to secondary rheological changes. Blood transfusion should be considered when hemoglobin level and platelet count decrease below 7 g/L and 50 000 cells/mm³, respectively, to prevent vision-threatening complications. Patients with acute leukemias should undergo ophthalmic screening at baseline and then periodically to prevent visual morbidity.

Orbital myeloid sarcoma in adult mimicking nasolacrimal duct obstruction: A case report

Purpose

To describe an orbital myeloid sarcoma in adult presenting with a swollen mass at inferomedial canthal area and epiphora which was misdiagnosed as nasolacrimal duct obstruction.

Observations

A 45-year-old male presented with a swollen right lower eyelid around medial canthal area for 2 months with tearing for 6 month-period earlier. Eye examination demonstrated a high tear meniscus, slightly erythematous eyelid with palpable mass closed to the lacrimal sac along the inferior orbital rim. Computed tomography scan depicted infiltrative mass at the inferomedial aspect of right orbit with bony erosion, extended to adjacent paranasal sinuses. An incisional biopsy was performed. Histopathological study revealed soft tissue which was diffusely infiltrated by monotonous medium-sized round cells resembling blasts with lymphoglandular bodies, focally positive myeloperoxidase and negative lymphoid markers. The findings were consistent with myeloid sarcoma. No systemic involvement was found. The patient underwent chemotherapy and radiation without systemic leukemic disease progression.

Conclusions and importance

Although orbital myeloid sarcoma is rare and difficult to diagnose, it can mimic nasolacrimal duct obstruction. We should consider this condition in our differential diagnosis.

Myeloid sarcoma of the orbit without systemic recurrence of disease in an adult: A clinicopathological case report

Myeloid sarcoma (MS), also known as granulocytic sarcoma (GS) or chloroma (named for the greenish hue attributed to the pigment of myeloperoxidase [MPO]), is a rare solid tumor with a predilection for the orbit. MS usually occurs in conjunction with acute myeloid leukemia (AML), myelodysplastic syndrome (MDS), or myeloproliferative disorder (MPS) and may be the harbinger of disease. Therefore, prompt diagnosis is essential for patient survival. We present a rare case of a 61 year old with an isolated orbital MS without active leukemia.

Granulocytic Sarcoma in an Adult with Relapsed Acute Myeloid Leukaemia

Granulocytic sarcoma is an extramedullary tumour consisting of malignant granulocytic precursor cells that is common among children with acute myeloid leukaemia (AML). We report a case of orbital granulocytic sarcoma in an adult with relapsed undifferentiated AML-M0. It presented as bilateral medial canthal swellings. An incisional biopsy confirmed the diagnosis of granulocytic sarcoma. The swelling resolved with re-induction chemotherapy.

Bilateral orbital myeloid sarcoma preceding acute myeloid leukemia in an adult: a case report and review of the literature

Background

Acute myeloid leukemia is typically a disease of the older population and presents mostly in the fifth decade of life. Myeloid sarcoma is a rare initial presentation of acute myeloid leukemia. Previously it has only been documented in children and younger patients.

Case Presentation

We present an unusual case of retro-orbital myeloid sarcoma as an initial presentation of acute myeloid leukemia in a 43-year-old Caucasian man, with rearrangement of chromosome 11q23 involving the MLL gene.

Conclusions

We present an unusual case of retro-orbital myeloid sarcoma as an initial presentation of acute myeloid leukemia in a 43-year-old man, with rearrangement of chromosome 11q23 involving the MLL gene.

Combined orbital proptosis and exudative retinal detachment as initial manifestations of acute myeloid leukemia

We report bilateral orbital and choroidal involvement as the presenting sign of acute myeloid leukemia in a 2-year-old white girl. The patient presented with painless proptosis and subconjunctival hemorrhage. Ophthalmic examination and magnetic resonance imaging revealed bilateral leukemic infiltrates of the orbits and choroid, with an exudative retinal detachment in the right eye. Bone marrow biopsy confirmed acute myeloid leukemia. Following radiation treatment, chemotherapy, and hematopoietic stem cell transplantation, the patient was doing well 12 months after presentation. Outcomes can be poor, even with treatment; prompt recognition of ophthalmic manifestations of leukemia, including proptosis, choroidal infiltration, and retinal detachment, is necessary.

Granulocytic Sarcoma of the Orbit Presenting as a Fulminant Orbitopathy in an Adult With Acute Myeloid Leukemia

A 64-year-old woman with relapsed acute myelogenous leukemia (AML) undergoing salvage chemotherapy developed rapid onset of right-sided ophthalmoplegia, proptosis, optic neuropathy, and vision loss from 20/30 to hand motions over a 3-hour period on day 4 of her treatment. CT scan of her orbits revealed a superolateral orbital mass and periocular edema. She underwent immediate canthotomy and cantholysis, and lateral orbitotomy with debulking of the mass later the same day. The histopathology was consistent with aggregates of myeloid blasts. Her vision recovered to 20/20 on postoperative day 1. Orbital granulocytic sarcoma is a rare condition often concurrent with AML, typically in the pediatric population and rarely in adults. Presentation as a fulminant orbitopathy with rapidly progressive optic neuropathy and vision loss over several hours has not been previously reported.

The paradox of recurrent with rare: A rare case of bilateral proptosis and facial palsy in acute myeloid leukemia with recurrent cytogenetic translocation t(8:21)

A 13-year-old female child presented with bilateral proptosis and subconjuctival hemorrhage of 2 months duration. Subsequently, the biopsy and peripheral smears confirmed the diagnosis of acute myeloid leukemia (AML). Recurrent cytogenetic translocation t(8:21) in AML associated with extramedullary manifestation; was discovered which is a rare event. Furthermore, myeloperoxidase negative blasts and periodic acid Schiff negative blasts in AML with t(8:21) is a very rare combination to the best of our knowledge.

Primary oral myeloid sarcoma: Report of a case

Myeloid sarcoma is defined as a tumor mass of immature myeloid cells that may be observed in a variety of locations including bone, skin, lymph nodes and soft tissues. However, oral involvement of myeloid sarcoma is extremely rare. These tumors are considered as specific lesions of acute myeloid leukemia. We present a case of a myeloid sarcoma of the upper vestibular gingiva in a 29-year-old woman who has no hematologic disease history. Multiple metastases were found in floor of the nasal cavity, left breast, and left lacrimal gland 12 months after primary diagnosis.

Orbital myeloid sarcoma in an adult with acute myeloid leukemia, FAB M1, and 12p-deletion

A 49-year-old woman with acute myeloid leukemia, FAB M1 subtype, and 12p deletion, presented with progressive right proptosis and diplopia for 1 week. Orbital CT revealed a homogenously enhancing, orbital mass engulfing the inferior rectus muscle. Histopathology revealed myeloid sarcoma for which she underwent external beam radiotherapy. Subsequently, there was no sign of local recurrence, but she succumbed to leukemia involving the central nervous system. This is the first case, to the authors' knowledge, of an orbital sarcoma of FAB M1 myeloblasts bearing a 12p deletion.

Orbital extra-medullary granulocytic sarcoma: clinicopathologic correlation with immunohistochemical features

Orbital granulocytic sarcoma (chloroma), a rare tumor of immature myeloid cells, has nonspecific clinical and radiological features that make it a diagnostic challenge. Light microscopy and confirmation by immunostaining aid in the diagnosis. Knowledge of this entity is important because early diagnosis and prompt treatment are associated with better prognosis. We report a series of 31 biopsy-proven orbital granulocytic sarcomas with their immunohistochemical features and review the literature.

Proptosis and facial palsy as an unusual clinical presentation of acute myeloid leukemia

Simultaneous proptosis and facial palsy as the clinical presentation of childhoodAcute Myeloid Leukaemia (AML) is very rare. To date, no case have beenreported anywhere to the best of our knowledge. Extra medullary leukemic deposits or Granulocytic Sarcoma (GS) is a rare manifestation in about 3% of childhood AML, 9.3% of GS manifested as orbit deposits causing proptosis in one or both eyes. CNS infiltration or acute otomastoiditis subsequent to leukemic infiltration of the temporal bone may be implicated with facial paralysis. We are here with reporting the case in a 3-year-old boy who presented with proptosis and facial palsy in a case of AML. The purpose of reporting this case is to emphasize the need of examining the peripheral blood and bone marrow in children presenting as proptosis and facial palsy for early diagnosis of childhood AML.

The 2011 PEMpix photo competition award winner: Vanessa Perez, MD: An unusual case of pallor, the eyes have it!

This is a case report of 7-year-old boy who presented with diplopia. Physical examination was remarkable for pallor and right-eye proptosis. Differential diagnosis of this chief complaint and the management of the suspected condition are discussed. This case was presented at the Section of Emergency Medicine Meeting at the National Conference and Exhibition of the American Academy of Pediatrics in 2011 and was awarded first place in the PEMpix photo competition.

Clinicopathological characteristics of extramedullary acute megakaryoblastic leukemia (AMKL): report of a case with initial mastoid presentation and review of literature to compare extramedullary AMKL and non-AMKL cases

Extramedullary acute megakaryoblastic leukemia (AMKL) is a rare neoplasm with a varied clinical presentation. AMKL with initial mastoid presentation has never been reported. The extreme rarity of mastoid AMKL, together with the tendency of extramedullary AMKL to mimic other small blue cell tumors, can create a diagnostic challenge. We report a case of AMKL that initially presented as a mastoid lesion and provide a comprehensive review and analysis that compares the characteristics of extramedullary AMKL and nonmegakaryoblastic acute myeloid leukemia (AML) in reported pediatric cases over the past 30 years. We found that patients with extramedullary AMKL were not only younger than patients without megakaryocytic differentiation but were also limited to those ≤ 2 years of age. In addition, girls predominated in both AMKL and AML MLL(+) groups compared with other types of AML (P  =  0.0366 and P  =  0.0082). Furthermore, we found that extramedullary AMKL was more likely to involve bone than AML MLL(+) (P < 0.0001) or other types of AML (P  =  0.0002). These findings suggest that extramedullary AMKL should be considered in the differential diagnosis of SBCT in children, especially in patients with mastoid or other bony lesions, those ≤ 2 years of age, and female patients.

Unilateral eyelid swelling, proptosis and diplopia as initial manifestation of acute myeloid leukemia

Myeloid sarcoma is a tumor of immature myeloid cells occurring in many extramedullary sites, orbit being one of them where the tumor may occur prior to or after the diagnosis of underlying disease. We report a case of a 17-year-old male who presented with upper eyelid swelling, proptosis and diplopia after presumed blunt trauma without any other clinical signs and symptoms. Initial imaging suggested possibility of subperiosteal hematoma. Magnetic resonance imaging studies demonstrated a solid tumor. Complete excision of the tumor and histopathologic diagnosis revealed evidence of acute myeloid leukemia (AML). There were no other sites indicating any tumoral process; however, bone marrow aspirate revealed an evidence of systemic disease. After chemotherapy and allogenic bone marrow transplant, the patient had complete remission of his disease. An episode of graft vs host reaction resulting in severe dry eyes along with skin eruptions was treated successfully by immunosuppression and topical lubrication without any visual or systemic sequela. This case emphasizes on the need for an aggressive work-up for any unusual orbital lesion in the absence of any explainable etiology. Further, AML may be suspected in the cases of orbital tumors even in the absence of systemic manifestations of leukemia at any age.

Multicentric extramedullary myeloid tumor

Granulocytic sarcomas or extramedullary myeloid tumors represent the soft tissue counterpart of acute myeloid leukemia. The term is used for any solid collection of leukemic cells. There have been reports of these tumors occurring before the involvement of blood or bone marrow. Our patient had simultaneous involvement of three sites, which was diagnosed on cytology. Further confirmation was done on peripheral blood and bone marrow evaluation.

Bilateral proptosis and bitemporal swelling: A rare manifestation of acute myeloid leukemia

Background:

In Acute Myeloid Leukemia (AML), malignant clones of immature myeloid cells (primarily blasts) proliferate, replace bone marrow, circulate in blood and invade other tissues. The unique presentation of bilateral proptosis and bilateral temporal swelling in AML is being reported.

Case Report:

A 6-year-old girl presented with low-grade fever, progressively increasing bitemporal swelling and bilateral proptosis. Contrast Enhanced Computed Tomographic (CECT) images revealed enhancing infiltrates occupying the lateral orbital wall, causing proptosis. The infiltrate extended toward the bilateral temporal fossae beneath the temporalis muscle and extradurally beneath the frontal and temporal bones. A high total leucocytic count with immature and deformed cells and, Fine Needle Aspiration Cytology (FNAC) from the temporal swelling, the bone marrow aspirate and biopsy showing leukemic blast cells confirmed the diagnosis of AML. Chemotherapy brought about remission of the disease.

Conclusions:

To the best of the authors’ knowledge, simultaneous presence of both bilateral proptosis and bitemporal swellings have not been previously reported in AML. A peripheral blood smear with bone marrow aspirate and biopsy help in the early detection of AML. Institution of early intervention in this potentially fatal disease is often associated with gratifying survival rates.

Granulocytic Sarcoma of the Nasal Cavity: A Case Report

Granulocytic sarcoma of the nasal cavity is exceedingly rare. We describe the case of a 55-year-old man who presented with an intranasal mass that was later diagnosed as a granulocytic sarcoma. The mass was treated with rapid initiation of chemotherapy, which produced a substantial decrease in tumor bulk. Granulocytic sarcoma is often mistaken for lymphoma or other poorly differentiated malignancies, and the correct diagnosis requires a high index of clinical suspicion.

Extraconal orbital tumors in children--a spectrum

Orbital masses in children are uncommon but extremely challenging problems for clinicians and pathologists due to their critical location and availability of limited diagnostic material. We analyzed 47 specimens comprising biopsies, excision specimens, and FNAC of extraconal pediatric orbital masses (excluding retinoblastoma) accessioned in the pathology department over 5 years in a tertiary referral cancer center. Immunohistochemistry (IHC-74%) and molecular methods (one case) were done where necessary. The chief presenting symptom was proptosis in 55.3% patients and radiologically 53.8% malignant tumors showed extraorbital extension. A diagnostic algorithm was formulated to assess which cases needed pathology evaluation. Malignant round cell tumors (76.6%), chiefly embryonal rhabdomyosarcoma (51%), benign spindle cell neoplasms, and infectious lesions (tuberculosis, fungal infections), were seen. Of the malignant tumors, those confined to the orbit achieved good treatment response and had an event-free follow-up while those with extraorbital spread had poor outcome. Pediatric orbital masses range from completely treatable infectious lesions, surgically resectable benign neoplasms to aggressive malignancies requiring chemotherapy and radiotherapy. Pathologists play a key role in distinguishing these on small biopsy material and expediating accurate treatment thus saving the vision or life of a patient.

Extramedullary leukemia in children presenting with proptosis

Background

We highlight the orbital manifestations of acute myeloid leukemia and the role of peripheral blood smear in the diagnosis of these cases. A total of 12 patients who presented with proptosis and were subsequently diagnosed to have acute myeloid leukemia based on incision biopsy or peripheral blood smear were included in the study.

Results

A retrospective review of all cases of acute myeloid leukemia presenting to the Orbital clinic was performed. The age at presentation, gender, presenting features, duration of symptoms and fundus features were noted. In addition the temporal relationship of the orbital disease to the diagnosis of leukemia, laterality, location of the orbital mass, imaging features and the diagnostic tools used to diagnose leukemia were noted. The median age at presentation was 6 years. The male: female ratio was 0.7:1. None of these patients had been diagnosed earlier as having acute myeloid leukemia. The presenting features included proptosis in all patients, orbital mass in 5 (41.7%), visual symptoms in 2 (16.7%) and subconjunctival hemorrhage in one patient (8.3%). A diagnosis of acute myeloid leukemia was established by incision biopsy in 4 patients, subsequently confirmed by peripheral blood smear testing and bone marrow biopsy in 2 patients which revealed the presence of systemic involvement. Imprint smears of the biopsy identified blasts in 2 of 4 cases. In 8 patients presenting with ocular manifestations, diagnosis was established by peripheral blood smear examination alone which revealed a diagnosis of acute myeloid leukemia.

Conclusion

A peripheral blood smear should be performed in all cases of sudden onset proptosis or an orbital mass in children and young adults along with an orbital biopsy. It can always be complemented with a bone marrow biopsy especially in cases of aleukemic leukemia or when the blood smear is inconclusive.

Orbital tumour as initial manifestation of acute myeloid leukemia: granulocytic sarcoma: case report

We report orbital involvement as an initial manifestation of acute myeloid leukemia in a 57-year-old woman. The patient presented with painful proptosis and limited ocular motility. Orbital computed tomography revealed bilateral homogeneous masses. Orbital biopsy was performed on the right side; and histopathology disclosed a myelocytic tumour. Despite treatment using irradiation and chemotherapy, the patient died eleven months after presentation. There appear to be only a few previous reports of acute myeloid leukemia cases presenting with orbital involvement, and most cases occurred in children. This very rare condition has a poor survival prognosis, even with radiation treatment and chemotherapy.

Clinical and imaging characteristics of orbital leukemic tumors

PURPOSE

To characterize the clinical and imaging features of orbital leukemic tumors in 27 patients seen and treated at St. Jude Children's Research Hospital.

METHODS

A retrospective review was performed on the clinical and imaging records of 27 consecutive patients with a diagnosis of orbital leukemic tumors. The following data were extracted from the patients' records: age at diagnosis of orbital leukemic tumors, sex, race, national origin, type of leukemia, temporal relationship of orbital disease to diagnosis of leukemia, survival from diagnosis of orbital leukemic tumor, laterality of the orbital disease, location of the mass within the orbit, imaging features of the mass, chemotherapeutic protocol, treatment with bone marrow transplant, and orbital radiation.

RESULTS

The median age at diagnosis of orbital leukemic tumor was 8 years (range, 1-18 years). Nineteen of the 27 patients were male, and 21 patients were born and lived in the United States. Twenty-one patients had acute myeloid leukemia, five had acute lymphoblastic leukemia, and one had chronic myelogenous leukemia. In 85% of patients (n = 23), the diagnosis of leukemia was based on the bone marrow examination findings. Orbital imaging revealed homogenous masses that molded to one or more orbital walls without bony destruction. Nine patients had bilateral orbital involvement. All patients received multiagent systemic chemotherapy, and 14 underwent bone marrow transplantation. Five patients received external beam radiation for the treatment of orbital disease. Fifteen (55.6%) of the 27 patients were alive at the time of the study. The median survival for all patients was 4.75 years (range, 0.1-24 years) after the diagnosis of orbital disease.

CONCLUSIONS

Orbital leukemic tumors occur most commonly in the first decade of life, in association with acute myeloid leukemia. They appear as homogenous masses along the orbital walls. Although the overall survival rate for patients with leukemia has improved over the past 3 decades, the mortality of patients who develop orbital leukemic tumors remains high.

Myeloid sarcoma presenting with bilateral proptosis and kidney infiltration

The authors describe a male infant with a history of transient pancytopenia who developed progressive bilateral proptosis associated with diffuse infiltration of the kidney and normal bone marrow. The histopathological examination of the kidney revealed diffuse infiltration of cells of myeloid origin with monocytic differentiation. Although orbital involvement by myeloid sarcoma, with or without concurrent acute myeloid leukemia, is well known, there are distinctive features in this patient that are not reported in the literature, namely bilateral proptosis and simultaneous presence of bilateral kidney infiltration, which enabled diagnosis.

Extramedullary myeloid leukemia: the value of cytogenetic analysis in pediatric orbital tumors

Orbital extramedullary myeloid tumor, or granulocytic sarcoma, can be difficult to diagnose even with the use immunohistochemical stains, especially if it precedes the development of systemic leukemia. We describe a 6-year-old boy with a rapidly progressive orbital tumor. This patient underwent an orbital biopsy, which was consistent with extramedullary myeloid tumor but not conclusive. Cytogenetic studies on a bone marrow biopsy revealed a translocation consistent with acute myelogenous leukemia.

Sino-orbital chloroma presenting as unilateral proptosis in a boy

Granulocytic sarcoma or chloroma is an unusual localized tumor composed of cells of myeloid origin. Involvement of the orbit and the ethmoid sinuses and presenting as proptosis is rare. Diagnosis could be difficult and delayed when there are no other systemic manifestations, especially with normal peripheral blood and bone marrow picture. We present one such case with unilateral proptosis as the sole presenting sign that posed a diagnostic challenge to us. Orbital decompression by an otolaryngologist may have a role in managing such a case.

Myeloid sarcoma: clinical and morphologic criteria useful for diagnosis

Extramedullary accumulation of myeloblasts or immature myeloid cells form tumors called myeloid sarcoma in the WHO classification. Such tumors develop in lymphoid organs, bone (skull, orbit, etc.), skin, soft tissue, various mucosae and organs, and the CNS. They may precede or occur concurrently with acute myeloid leukemia, or reveal blastic transformation of chronic myeloproliferative disorders or myelodysplastic syndromes. They may also reveal relapses in treated patients. They are constituted by a diffuse infiltrate made up of medium-to-large cells. The cells are difficult to identify. Imprints are very useful. Immunohistochemistry can help diagnose and distinguish four variants: granulocytic myeloperoxidase (MPO+, CD 68+ [KP1+/-, PGM1-] lysozyme+, CD 34+/-), monoblastic (MPO-, CD 68+, [KP1+, PGM1+] lysozyme+, CD 34-), myelomonoblastic (MPO-, CD 68+, [KP1+, PGM1+] lysozyme+, CD 34-), or megakaryoblastic (positivity for factor VIII, CD 61, CD 31). Immunohistochemistry sometimes demonstrates expression of CD 43, CD 7, CD 79a, and CD 56 (particularly the monoblastic variant with t[8;21]). Recently the demonstration of CD 99 and CD 117, which can now be done on paraffin sections, may be useful to identify blasts of granulocytic origin. The diagnosis is missed in about 50% of cases when immunohistochemistry is not used. Patients with myeloid sarcomas should be treated in the same way as patients with acute myeloblastic leukemia. Disease progression and prognosis are similar for the two conditions.

Sarcome granulocytique orbitaire révélant l’acutisation d’un syndrome myélodysplasique

Granulocytic sarcoma is a rare orbital complication of acute leukemia. It concerns primarily children under 10 years of age suffering from primitive acute myeloid leukemia. As this type of symptom can sometimes affect the elderly during the acute phase of myelodysplastic syndrome, it raises a problem with diagnosis and consequently with therapeutic treatments. We report the case of a 77-year-old female patient who had acute inflammatory proptosis during regressive right ethmoiditis. The diagnosis was reached by computed tomography showing an extraconical intraorbital tumor sprouting from the sinus, and by clinical examination and confirmed by the hematological investigation. Acute proptosis developing in an acute myeloblastic leukemia context heavily swayed diagnosis towards orbital granulocytic sarcoma. Chemotherapy by cytarabine and hydroxycarbamide associated with intravenous corticoid therapy resulted in complete disappearance of the proptosis within 10 days. This case report is a reminder of this peculiar sign of tumoral syndrome in acute myeloid leukemia. We also discuss different diagnostic methods and various therapeutic approaches, and analyze the disease course and patient follow-up.

Primary granulocytic sarcoma in the sphenoidal bone and orbit

CASE REPORT

We report a case of a primary cranial chloroma in boy aged 2 years and 8 months. The symptoms were progressive bilateral exophthalmos, right abducens palsy, and bilateral papilledema. The tumor was partially calcified and was a round mass located in the bilateral sphenoidal bone extending into the orbit. Laboratory study did not show hematological abnormality. The tumor was partially removed by bilateral frontotemporal craniotomy and a diagnosis of primary granulocytic sarcoma was made from the surgical specimen. Progressive deterioration of visual acuity was seen and chemotherapy started on the 11th postoperative day followed by local cranium irradiation (24 Gy). The patient has been in complete remission for 37 months. The visual acuity recovered partially and follow-up magnetic resonance imaging showed a significant decrease in the size of the tumor.

DISCUSSION

Radiological diagnosis of primary intracranial granulocytic sarcoma is difficult. Surgical removal may be an option for progressive neurological deterioration but chemotherapy is more important for both neurological stabilization and induction of remission.

Meningeal chloroma (granulocytic sarcoma) in acute lymphoblastic leukemia mimicking a falx meningioma

Isolated chloromas (granulocytic sarcomas) are rare tumors. Chloromas are masses composed of immature granulocytic cells. Granulocytic sarcoma occurs primarily in patients with acute myelogenous leukemia and may also arise in patients with other myeloproliferative disorders, but rarely in patients with acute lymphoblastic leukemia (ALL). When dural-based, granulocytic sarcoma may be indistinguishable from meningioma radiologically. We now describe one patient affected by ALL with isolated granulocytic sarcoma mimicking a falx meningioma as initial CNS relapses. These unusual clinical manifestation and radiological finding in ALL should be considered as recurrence of leukemia. Early detection and antileukemic treatment of granulocytic sarcoma are necessarily important for favorable prognosis.

Isolated myelosarcoma in children--update and review

Primary myelosarcomas, also called leukemia cutis, granulocytic sarcomas or chloromas, are rare extramedullary manifestations of acute myeloid leukemia (AML) which precede bone marrow involvement. Skin infiltration was the most frequent localization associated with a myelomonocytic differentiation. Although first remission was achieved by most children, risk of relapse seemed to be increased. This might be caused by the specific biology of myelosarcomas, but also may be the result of delayed or reduced treatment. During the AML-BFM-studies 87/93/98 (11/1987-7/2000) 37 children with isolated myelosarcomas were diagnosed. Eighteen of the 37 patients survived with a 5-year overall survival estimation of 0.54+/-0.09 compared to 0.59+/-0.02; p(log rank) = 0.94. However, reduced or delayed treatment in 17 children led to an increased relapse rate of 71% compared to 35% in children treated soon after diagnosis. The 5-year overall survival in these patients was 0.41+/-0.11. According to our experience and review of the literature, an early diagnostic workup is needed in children with unusual skin lesions or tumors, considering myelosarcoma as primary manifestation of AML. Intensive AML-specific chemotherapy is generally recommended soon after diagnosis.

The value of CD34, myeloperoxidase and chloroacetate esterase (Leder) stain in the diagnosis of granulocytic sarcoma

BACKGROUND

The differentiation of extramedullary myelogenous leukemia/granulocytic sarcoma (GS) from malignant lymphoma can sometimes be difficult. In the current study, we explored the value of CD34, myeloperoxidase and nonspecific esterase (Leder) stains in differentiating GS from lymphomas.

MATERIALS AND METHODS

Fifteen cases of phenotypically confirmed GS were stained for CD34, myeloperoxidase and Leder stains. The same stains were performed in 16 malignant lymphomas as controls. The GS cases were also immunostained for CD3 and CD20 to detect the incidence of aberrant T and B lymphocyte expression.

RESULTS

CD34 was expressed in 7 of the 15 cases of GS (46%). Myeloperoxidase was expressed in 10 of the 15 cases (66%), and Leder stain was positive in 9 cases (60%). All 15 cases had expression of at least one marker; 8 cases had expression of two markers and one case had expression of all 3 markers. None of the lymphomas showed expression of any of the three markers. Five cases (35%) of GS showed T cell antigen expression and 2 (14%) showed B cell antigen expression.

CONCLUSION

Our findings suggest that in cases of GS, the use of the combination of CD34, myeloperoxidase and Leder stains can help reach a definitive diagnosis, especially if lymphoma is difficult to exclude. Expression of B and T cell antigens in such lesions should not rule out the diagnosis of GS.