Myeloid Sarcoma Involving the Gynecologic Tract

Bilateral adnexal masses: A case report of acute myeloid leukemia presenting with myeloid sarcoma of the ovary and review of literature

•We report a case of a patient with acute myeloid leukemia (AML) presenting as myeloid sarcoma.•This patient with bilateral adnexal masses was managed via total robotic hysterectomy with bilateral salpingo-oophorectomy.•There are a limited number of reports of bilateral ovarian occurrences that exist in the literature.•Myeloid sarcoma of the ovaries may present with vaginal bleeding to dysmenorrhea, dysuria, and palpable abdominal mass.

Myeloid sarcoma arising at the uterine cervix in a patient with intestinal Behçet's disease and concurrent myelodysplastic syndrome: A case report

INTRODUCTION

Myeloid sarcoma (MS) is an extramedullary tumor that consists of myeloblasts and rarely involves the female reproductive organs. Intestinal Behçet's disease (BD) is a chronic, inflammatory illness that is often associated with myelodysplastic syndrome (MDS). When MDS is diagnosed, some patients with intestinal BD experience synchronous gastrointestinal flares.

CASE PRESENTATION

We report the case of a 49-year-old woman who presented with vaginal bleeding and an incidentally identified MS in the uterine cervix. Subsequent bone marrow biopsy showed simultaneous MDS without chromosomal abnormalities. This is the first reported case of concomitant MS, myelodysplastic disease, and intestinal BD.

CONCLUSIONS

The accurate diagnosis of MSs that develop at non-predominant sites is crucial for a positive patient prognosis. MDS should be suspected in patients with a history of intestinal BD diagnosed with MS.

Myeloid sarcoma of uterine cervix: A case report with review of the literature

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Myeloid sarcoma of uterine cervix is very uncommon and can be the initial presentation of acute myeloid leukaemia.

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Myeloid sarcoma can mimic other malignant tumours arising in the cervix and can therefore pose a diagnostic challenge.

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Myeloid sarcoma should be considered in the differential diagnosis of undifferentiated malignant tumours arising in the gynaecological tract.

Myeloid sarcoma is a rare clinical entity, characterised by the extramedullary presence of myeloblasts. It can occur de novo or signify disease recurrence. Involvement of the female reproductive tract is uncommon, with most cases involving the uterine corpus or ovary. Patients with non-leukaemic myeloid sarcoma are treated with acute myeloid leukaemia (AML) regimens, but the optimal therapy is unclear due to the relative rarity of the condition and lack of clinical trial data. We present an unusual case of myeloid sarcoma of the uterine cervix diagnosed incidentally in a patient with cervical-intraepithelial neoplasia grade 2 (CIN2), followed by a literature review.

A clinical report of intracranial granulocytic sarcoma and a literature review

BACKGROUND

Granulocytic sarcoma (GS), is also referred to as myeloid sarcoma. It is a solid mass formed by the primitive or immature myeloid cells extramedullary infiltration, which is commonly caused by acute myelogenous leukemia (AML) or chronic myelogenous leukemia (CML). It mainly involves bones, lymph nodes, skin and soft tissues of the head and neck. In general, the incidence is low and central nervous system (CNS) involvement is relatively rare. The clinical manifestations of the disease are varied and the treatment is intractable.

CASE DESCRIPTION

A 53-year-old male with intracranial granulocytic sarcoma who suffered a pressing pain on the left cheek. The patient had a hypophasis with left corneal reflex diminished. He had bilateral anisocoria, lower jaw and tongue tilted to the left upon opening the mouth and the left pharyngeal reflex was declined. The whole blood routine was normal except for eosinophils, head magnetic resonance imaging plain scan revealed a space-occupying lesion. Postoperative pathology suggested GS. Unfortunately, the disease progressed quickly and the patient died.

CONCLUSION

Isolated GS is often difficult to diagnose accurately. The patient's medical history should be carefully reviewed, all relevant tests should be performed, and various differential diagnoses should be familiarized with to improve the accuracy of diagnosis. And on this basis, to develop a personalized treatment plan for different patients.

A Focus of Differentiated Myeloid Sarcoma in a Ligation Specimen of the Fallopian Tube: No Evidence of Hematologic Abnormality in 18 Years of Follow-up Despite Absence of Treatment

A 0.2-cm intramural focus composed predominantly of myelocytes and metamyelocytes, many CD3+, CD43+ T-lymphocytes, scanty CD20+ B-lymphocytes, rare mast cells, but no eosinophils or myeloblasts was incidentally found in a ligation specimen of the left fallopian tube. The myeloid cells were positive for chloroacetate esterase, myeloperoxidase, myeloid marker BM2, and CD43, and they were negative for CD30, CD34, CD117, ERG, and TDT. The findings in the left fallopian tube were consistent with the diagnosis of differentiated myeloid sarcoma. The right fallopian tube was normal. No hematologic abnormalities were found elsewhere in the body. Curiously, the patient remains free of any hematologic abnormality for 18 years despite absence of treatment.

Nonleukemic granulocytic sarcoma of orbit after blunt trauma: A case report and review of literature

RATIONALE

Granulocytic sarcoma without invasion of bone marrow or blood is very rare. The diagnosis of it is usually overlooked and the treatment has not reached a consensus. Meanwhile, the onset of this kind of disease is not clear.

PATIENT CONCERNS

Diagnose patients in early stage and help choose the right treatment strategies.

DIAGNOSES

The ultimate diagnosis was nonleukemic granulocytic sarcoma after blunt trauma.

INTERVENTIONS

Surgery was the initial treatment option. Chemotherapy including idarubicin (70 mg, D1-D3) and cytosine arabinoside (100 mg, D1-D7) and radiotherapy of total 3,060 cGy were then administered but failed to control the disease. Hematopoietic stem cell transplantation was finally administered.

OUTCOMES

No evidence of disease progression or spread according to the latest follow-up.

LESSONS

The etiology of nonleukemic granulocytic still remains unclear, though trauma seems to be a potential predisposing factor and deserves more attention for early diagnosis and timely and proper treatment. Systemic chemotherapy is more effective than radiotherapy or surgery. Hematopoietic stem cell transplantation is an alternative choice after the failure of chemotherapy.

Myeloid sarcoma identified on liquid-based cervical cytology samples: A report of two cases

The purpose of the Papanicolaou (Pap) smear is to detect primary squamous lesions of the uterine cervix. Although most successful at detection of squamous lesions, the Pap may also detect metastatic carcinomas, sarcomas, and melanomas. We report two rare cases of myeloid sarcoma (MS) of the uterine cervix identified on screening Pap smears with concurrent confirmatory cervical biopsies. The purpose of our study is to identify and report cytologic features of MS on Pap smears utilizing a liquid-based ThinPrep method, which has not been previously documented in literature. Two Pap smears were identified from the pathology laboratory information system, both with positive cervical biopsy findings of MS. Both women, age 40 and 39, presented with ureteral obstruction, hydronephrosis, and past medical histories significant for acute myeloid leukemia (AML). On imaging, cervical masses were identified, and subsequent work-up with Pap smears and biopsies were performed. Cytologic examination of the ThinPrep Pap smears were negative for squamous intraepithelial lesion. Atypical hematologic cells were seen in the background with irregular nuclear contours, increased nuclear to cytoplasmic ratios, variably prominent nucleoli, and variable amounts of agranular cytoplasm. The biopsy confirmed these findings to represent MS. MS is defined as a tumor mass of myeloblasts or immature myeloid cells occurring in an extramedullary site. This rarely involves the female genital tract, about 50 reported cases. Although very rare, MSs in the setting of a history of AML are able to be identified on liquid-based ThinPrep smears.

Starry Sky Pattern in Hematopoietic Neoplasms: A Review of Pathophysiology and Differential Diagnosis

The starry sky pattern is a distinctive histologic feature wherein a rapidly proliferating hematolymphoid neoplasm contains scattered histiocytes with abundant pale cytoplasm in a background of monomorphic neoplastic cells. The cytoplasm of these histiocytes typically contains cellular remnants, also known as tingible bodies, incorporated through active phagocytosis. Although common and widely recognized, relatively little is known about the pathophysiological underpinnings of the starry sky pattern. Its resemblance to a similar pattern seen in the germinal centers of secondary follicles suggests a possible starting point for understanding the molecular basis of the starry sky pattern and potential routes for its exploitation for therapeutic purposes. In this review, we discuss the historical, pathophysiological, and clinical implications of the starry sky pattern.

An unusual relapse in acute myeloid leukaemia

A 40-year-old nulliparous woman, with a history of acute myeloid leukaemia (AML), presented at a gynaecological clinic with an incidental finding of a 5 cm pelvic mass on ultrasound during workup for subfertility. Biopsies confirmed a myeloid sarcoma. The patient underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy, followed by chemotherapy and radiotherapy. She recovered well from her surgery, 21 months postsurgery with no evidence of recurrence.

A rare case of acute leukemia relapsing with a granulocytic sarcoma causing ectopic pregnancy

A 33 year old female was admitted to department of obstetric and gynaecology with profuse vaginal bleeding. She was diagnosed with acute myeloid leukemia 3 months ago. Pelvic ultrasound was unremarkable. Since vaginal bleeding persisted despite normal platelet counts low dose methotrexate was administered with the presumptive diagnosis of ectopic pregnancy. A laparoscopic investigation was performed as she did not respond to this treatment which revealed an intraluminal ectopic pregnancy in her right fallopian tube. A pathological specimen was obtained. Granulocytic sarcoma is an infiltrate of immature granulocytic precursor cells in an extramedullary site. To best of our knowledge, this case is the third patient with GS in the fallopian tube and the first case causing ectopic pregnancy.

Use of immunohistochemistry in the diagnosis of miscellaneous and metastatic tumors of the uterine corpus and cervix

Uncommon tumors in the uterus present diagnostic challenges. In some cases, the tumor subtype is usually seen outside the gynecologic tract and the possibility of a uterine primary is not considered. In other cases, histologic overlap with more common uterine tumors leads to potential misdiagnosis. Finally, metastatic carcinoma may involve the uterus and cervix. Rarely, symptoms related to the uterine metastasis may precede diagnosis of an extrauterine primary. Without the proper clinical context, the possibility of a missed diagnosis is increased. One must first be aware of these possibilities, but immunoperoxidase studies are often necessary to confirm the diagnosis. In this review, unusual and metastatic tumors involving the uterine corpus and cervix and immunoperoxidase studies used to diagnosis such tumors are discussed.

Myeloid sarcoma of the vulva post-bone marrow transplant presenting as isolated extramedullary relapse in a patient with acute myeloid leukemia

Myeloid sarcoma is a tumor of myoblasts or immature myeloid cells occurring in an extramedullary site. Myeloid sarcoma of the female genital tract as an isolated initial presentation or isolated relapse is very rare as evidenced from a literature review. We report a case of vulvar myeloid sarcoma presenting as isolated relapse of acute myeloid leukemia (AML) after allogeneic hematopoietic stem cell transplant (HSCT). A 41-year-old female diagnosed with AML M5 achieved remission with chemotherapy and underwent allogeneic HSCT from an HLA-matched sibling donor. The post-transplant period was complicated with chronic graft-versus-host disease. At 10 months post-transplant, she presented with a vulvar mass of six weeks duration. Excisional biopsy of the vulvar mass confirmed the diagnosis of myeloid sarcoma as extramedullary relapse. Bone marrow biopsy was without evidence of leukemia. Involvement of the vulva, vaginal and adjacent cervical area only was confirmed. She received re-induction chemotherapy with clinical regression of both the vulvar, vaginal and the cervical masses; this was followed by radiation therapy to an extramedullary site. The correct diagnosis of myeloid sarcoma, particularly of an isolated mass in the genital area, is important because of its rarity and the need for appropriate institution of therapy.

Aleukemic granulocytic sarcoma presenting at multiple sites: ovary, breast and soft tissue

An 18 year old female presented with the history of pain in abdomen, breast engorgement, swelling over both legs and breathlessness for three month. On clinical examination diagnosis of fibroadenoma breast was made. Ultrasonography of abdomen showed bilateral ovarian mass. Bilateral salpingo-ophrectomy was done and specimen was sent for histological examination. Two lobulated solid masses of tissues the larger one measuring 13×8×5 cm and smaller one measuring 10×7×5 cm in size received. Microscopic examination showed monomorphic population of discohesive, hyperchromatic small round cells had high N:C ratio, coarse chromatin, conspicuous nucleoli and scant to moderate amount of basophilic cytoplasm, lying in sheets and separated by fibrous strands and diffusely infiltrating the ovarian stroma. Fine needle aspiration from breast lump and leg swelling showed predominant population of blast cells. Myeloperoxidase was strongly positive and diagnosis of granulocytic sarcoma was confirmed.

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.

Isolated vaginal myeloid sarcoma in a 16-year-old girl

Involvement of the female genital tract by myeloid sarcoma as the initial presentation is extremely uncommon, especially in the vagina. The lack of specific histologic features and the unusual location can be a diagnostic challenge to both the surgical pathologist and the clinician. The very few reported cases of myeloid sarcoma occurring in the vagina have been exclusively seen in adults. We report a 16-year-old girl who presented with a vaginal mass of 4 weeks duration. The initial clinical impression was a Bartholin cyst vs an abscess. However, because of persistence of the vaginal mass after a full course of antibiotic treatment, a biopsy was performed. Immunohistochemistry supported the diagnosis of myeloid sarcoma. Peripheral blood and bone marrow studies were normal. The patient received 4 cycles of chemotherapy and remained disease free 5 months from therapy completion. The clinical course, diagnostic workup, and differential diagnosis of our patient are discussed. Reported cases of myeloid sarcoma occurring in the vagina are reviewed and summarized.

Uterine extramedullary hematopoiesis: what is the clinical significance?

Extramedullary hematopoiesis (EMH) represents abnormal development and growth of hematopoietic tissue outside the bone marrow. Recent studies have shown its association with myelofibrosis and myeloid metaplasia, chronic myeloproliferative disorders, and other hematologic malignancies in up to two-thirds of the cases. Eleven cases of uterine EMH (UEMH) have been reported earlier; of these half had a concurrent, or subsequently developed a clinically significant hematologic disorder. We studied a larger group of patients with UEMH to understand the relationship with hematologic disorders. Cases diagnosed as UEMH between 1995 and 2007 were retrieved from our files (n=20). UEMH was confirmed in all 20 cases. Eighteen cases were located in the fundus including 5 in endometrial polyps and 5 in leiomyomas. Two foci were located within the cervix. The erythroid lineage was present in all foci; 35% also had myeloid precursors, and 2% had megakaryocytes. Twelve of 20 patients had underlying anemia (mean Hgb of 11 mg/dL, range: 5.5 to 15.7 mg/dL). No preexisting hematologic malignancy was identified in any of the patients. Follow-up information was available on 17 patients (mean: 2.88 yr; range: 0.2 to 9 yr). None of the patients developed a significant hematologic disorder other than anemia during follow-up. On the basis of our study, UEMH is frequently associated with chronic anemia. In comparison with existing literature suggesting a strong link between UEMH and hematopoietic disorders, our findings suggest that UEMH is rarely associated with serious underlying hematologic conditions and therefore does not warrant extensive hematologic workup.

Myeloid sarcoma of the vagina: a report of 2 cases

OBJECTIVE

To describe 2 cases of myeloid sarcoma of the vagina, in a patient without a history of acute myeloid leukemia (AML) and in another whose condition was previously diagnosed with AML.

MATERIALS AND METHODS

The clinical histories of 2 patients whose conditions were diagnosed with myeloid sarcoma of the vagina were obtained from their medical records.

RESULTS

Case 1: A 77-year-old woman with no systemic illnesses presented with a vaginal lump. Clinically, there was a 6-cm periurethral mass that was examined by biopsy. The histopathologic specimen was evaluated on routine and immunohistochemical stains, and myeloid sarcoma was diagnosed after extensive immunohistochemical analysis. The patient was treated with pelvic radiation. She developed extensive myeloid sarcoma of the skin and AML 4.5 months later; she died 2 weeks later, 5 months after the initial presentation. Case 2: A 36-year-old woman with a known history of AML who has had multiple leukemic and extramedullary recurrences presented with a pelvic mass. Physical findings revealed large masses in the vagina and rectovaginal septum, which were confirmed as myeloid sarcoma after biopsy and histologic examination. The patient was treated with pelvic/vaginal radiation. Five months later, she had another leukemic relapse and died within 1 day of palliative chemotherapy.

CONCLUSIONS

Myeloid sarcoma of the vagina is extremely rare. Most patients have a poor prognosis and either have a history of or will subsequently develop AML.

Postmenopausal bleeding as first sign of an acute myelogenous leukaemia: A case report and review of the literature

Postmenopausal bleeding (PMB) can have various causes and malignancy must always be excluded. Extramedullary manifestations of a haematological disease in the female genital tract are rare. We present the case of a woman with PMB as the first sign of an acute myelogenous leukaemia (AML). An 81-year-old patient presented with PMB. Manual and colposcopic examination raised suspicion of a cervical carcinoma, but histopathology and cervical Pap smear altered the diagnosis to granulocytic sarcoma (GS), an extramedullary manifestation of AML. The patient had a normal blood count 2 weeks prior to the examination, but at the time of presentation her leukocytes had risen to 116000/microl. The patient died 3 days later due to a pulmonary embolism, most probably as a result of leukostasis. In this case, GS of the cervix was the first sign of the AML with simultaneous appearance of leukocytosis and peripheral blasts. PMB was the reason for presentation. GS of the female genital tract is very rare and diagnosis is challenging, especially on the basis of the Pap smear. Abnormal inflammatory cells must be a warning sign and an indication for further examinations. GS as the presenting sign of AML has a poor prognosis with only 6% of patients surviving for more than 2 years.