Granulocytic sarcoma of gingiva: an unusual case with aleukemic presentation

Paraplegia as a Rare Clinical Presentation of Relapsed Acute Myeloid Leukemia

Myeloid sarcoma, also known as granulocytic sarcoma or chloroma, is an extra-medullary accumulation of malignant myeloid blast cells, leading to a solid tumor formation. Herein, we report a rare presentation of a case with acute myeloid leukemia (AML), whose disease relapse was clinically evident as acute flaccid paraplegia with a certain sensory level. On thoracic spine magnetic resonance imaging (MRI), an epidural mass compressing the spinal cord at the level of the thoracic spine segment 4 (T4) was found. The mass histology confirmed the diagnosis of myeloid sarcoma.

Oral myeloid sarcoma as an uncommon manifestation of acute myeloid leukemia: A case series and review of the literature

BACKGROUND AND OVERVIEW

Oral myeloid sarcoma (MS) is an extramedullary tumor that can occur in the setting of acute myeloid leukemia, either as the first sign of an underlying disease or later in the course of disease. The authors' aim was to present the clinical features of oral MS and review the literature.

CASE DESCRIPTION

Case 1 was an 82-year-old woman with an asymptomatic erythematous swelling on the maxillary gingiva and no history of hematologic malignancy. Case 2, a 65-year-old man, and case 3, a 58-year-old woman, each had a history of acute myeloid leukemia and a painful ulcer on the palatal mucosa and an asymptomatic ulcer on the lower lip mucosa, respectively. Case 1 was treated with focal radiation then chemotherapy and achieved complete remission initially, but died of relapse 2 years after diagnosis. Case 2 received radiotherapy and immunotherapy and had a complete response. Case 3 received chemotherapy and achieved remission initially, but relapsed and is undergoing investigational targeted therapies.

CONCLUSIONS AND PRACTICAL IMPLICATIONS

Oral MS can manifest as gingival or mucosal swelling or ulceration and can indicate onset or relapse of associated hematologic malignancies, which often have a poor prognosis. Because patients with oral findings are likely to seek treatment from their dentists first, oral clinicians should maintain a broad differential diagnosis list when evaluating oral lesions, especially if treatment prescribed for a more common diagnosis fails to resolve the lesion.

Clinical characteristics and management of primary granulocytic sarcoma of the oral cavity: A case report and literature review

INTRODUCTION

Granulocytic sarcoma (GS) is a commonly occurring tumor comprising immature myeloid cells, which are usually related to acute or chronic myelocytic leukemia. The tumor rarely precedes leukemia without bone marrow involvement and is called primary GS. Although primary GS can occur in any body part, the involvement of the oral cavity is uncommon.

PATIENT CONCERNS

A 49-year-old woman hospitalized at the Department of Plastic and Maxillofacial Surgery presented with a growing mass in her left maxillary hard palate dating two months back. No obvious physical findings were noted during general examination. She was diagnosed with an oral ulcer at a local clinic, and received antibiotics. However, the symptoms did not improve; the mass became bigger and painful.

DIAGNOSIS

An incisional biopsy of the oral mass was performed, the immunohistochemistry showed that the tumor cells tested positive for myeloperoxidase, CD4, BCL-2, KI-67. Bone marrow aspiration was negative for malignant cells, and the laboratory test results revealed only monocytosis. Standard bone marrow cytogenetic analysis showed a normal karyotype and leukemia-related fusion gene detection was normal. Therefore, the final diagnosis was intraoral primary GS.

INTERVENTIONS

The patient was treated with a chemotherapy regimen based on idarubicin and cytarabine arabinoside.

OUTCOMES

After 2 cycles of idarubicin and cytarabine arabinoside regimen chemotherapy, the patient achieved complete remission. The tumor was barely visible in the left maxillary hard palate. There has been no evidence of disease spread and progression after 1 year of follow-up.

CONCLUSIONS

Careful morphological and immunohistochemical analyses, correlating with clinical data are necessary to establish the diagnosis of oral primary GS. Early aggressive systemic chemotherapy can effectively relieve symptoms, significantly reducing primary GS conversion into acute myelocytic leukemia and prolonging overall survival.

Investigation of foreign materials in gingival lesions: a clinicopathologic, energy-dispersive microanalysis of the lesions and in vitro confirmation of pro-inflammatory effects of the foreign materials

OBJECTIVES

This study aimed to evaluate the clinical and histopathologic features of gingival lesions containing foreign material (GLFMs). In parallel, the composition of the foreign material and its effects in primary human gingival fibroblasts (HGFs) were investigated.

STUDY DESIGN

Eighty-six GLFMs were retrieved from an oral pathology biopsy service. Clinical and microscopic data were analyzed, and the composition of the particles was identified by using energy-dispersive X-ray spectroscopy (EDX). Furthermore, HGFs were stimulated with silica (SiO₂) microparticles to investigate the production of collagen type 1 (COL-1), matrix metalloproteinase 2 (MMP2), and inflammatory cytokines.

RESULTS

GLFMs were most commonly found in women (60.5%) and most frequently described as white plaques. Histopathologic examination identified verrucous hyperplasia in 59% and epithelial dysplasia in 28% of the cases. EDX microanalysis revealed that Si (94%) was the most frequently detected foreign element. SiO₂ microparticles induced higher COL-1 expression; higher levels of proinflammatory cytokines, such as interleukin-6 (IL-6), IL-8, and transforming growth factor-β, and increased MMP-2 activity in HGFs.

CONCLUSIONS

There was a strong association between the presence of foreign material in the gingiva and white verrucous clinical lesions. In addition, the most common element in the foreign material was Si, and our in vitro findings demonstrate the importance of silica-mediated effects on gingival fibroblasts.

Myeloid sarcoma of the Gingiva with myelodysplastic syndrome: A Case Report

The purpose of this report is to present a case of myeloid sarcoma of the gingiva with myelodysplastic syndrome.A 52-year-old male diagnosed with myelodysplastic syndrome with skin lesions presented with gingival swelling and gingival redness involving the maxillary left second premolar and the maxillary left first molar. The patient was referred from the Department of Hematology for a biopsy of the lesion. Full-thickness flaps were elevated and inflamed, and neoplastic soft tissue was removed from a lesion and the samples sent for histopathologic analysis.Histopathologic results showed leukemic cell infiltration beneath the oral epithelium, and the specimen was positive for the leukocyte marker. The diagnosis was myeloid sarcoma. Uneventful healing was observed at 2-week follow-up, but relapse of the lesions with the hyperplastic and neoplastic tissue was noted at 4-week follow-up. Further follow-up or treatment could not be performed because the patient did not visit at the next follow-up.In conclusion, myeloid sarcoma should be a diagnosis option for gingival growth because it can involve intraoral lesion. In this report, a biopsy was performed due to referral considering the patient's medical history. Although myeloid sarcoma in the oral cavity is extremely rare, a small biopsy and consultation with a hematologist may be beneficial for patients and may provide a differential diagnosis.

Aleukaemic leukaemia presenting with pathological fracture

A 19-month-old Chinese girl presented with pathological fracture of her right distal tibia. Peripheral blood revealed no abnormal cells, electrolytes were normal and bone biopsy at the fracture site only showed small aggregates of unremarkable lymphocytes. A bone marrow study could not provide a definitive diagnosis of acute leukaemia on morphology and immunohistochemistry. A diagnosis of precursor B-cell acute lymphoblastic leukaemia was unequivocally confirmed by a cytogenetic study which showed a hyperdiploid clone with gain of chromosome 4 among other trisomies.

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.

Acute myeloid leukaemia diagnosed by intra-oral myeloid sarcoma. A case report

Myeloid sarcoma (MS) is a rare extramedullary malignant tumor composed of immature myeloid cells. It is strongly associated with a well known or covert acute myeloid leukaemia, chronic myeloproliferative diseases or myelodysplastic syndromes. Intraoral MS scarcely occurs. An unusual case of acute myeloid leukaemia, which was diagnosed by mandibular MS that was developed in the alveolar socket after a dental extraction, is reported. The histological examination (including immunohistochemical analysis) of a subsequent biopsy showed infiltration of the oral mucosa by neoplastic cells. This lesion was therefore classified as acute myeloid leukaemia. The patient was referred to oncologists that confirmed the initial diagnosis. The patient underwent chemotherapy and the mandibular tumor disappeared. Forty days later, a relapse of the disease, which appeared as a great-ulcerated lesion, was developed in the hard palate. Thirty days after the second chemotherapy had finished, a new intraoral tumor was developed in the vestibular maxillary gingiva. Review of the literature shows no report of intraoral relapse and particularly multiple relapse of a MS that involves the oral cavity. Even though MS is encountered infrequently in the oral cavity, it should be considered in the differential diagnosis of conditions (especially tumors) with a similar clinical appearance.

Myeloid sarcomas: a histologic, immunohistochemical, and cytogenetic study

Context. -

Myeloid sarcoma (MS) is a neoplasm of immature granulocytes, monocytes, or both involving any extramedullary site. The correct diagnosis of MS is important for adequate therapy, which is often delayed because of a high misdiagnosis rate.

Objective. -

To evaluate the lineage differentiation of neoplastic cells in MS by immunohistochemistry, and to correlate the results with clinicopathologic findings and cytogenetic studies.

Design. -

Histologic and immunohistochemical examinations were performed on formalin-fixed paraffin-embedded tissue samples from 13 cases of MS. They were classified according to the World Health Organization criteria. Chromosomal analysis data were available in 11 cases. Clinical, pathological, and cytogenetic findings were analyzed.

Results. -

The study included six male and seven female patients with an age range of 25 to 72 years (mean, 49.3 years) and a male to female ratio of 1:1.2. MS de novo occurred in 4/13 (31%) of cases examined. The most sensitive immunohistochemical markers were CD43 and lysozyme present in all cases with MS (13/13, 100%). All de novo MS showed a normal karyotype, monoblastic differentiation, and lack of CD34. The most common chromosomal abnormalities in MS associated with a hematopoietic disorder were trisomy 8 and inv(16) (2/11, 18%).

Conclusion. -

An immunohistochemical panel including CD43, lysozyme, myeloperoxidase (MPO), CD68 (or CD163), CD117, CD3 and CD20 can successfully identify the vast majority of MS variants in formalin-fixed paraffin-embedded tissue sections. The present report expands the spectrum of our knowledge showing that de novo MS has frequent monoblastic differentiation and frequently carries a normal karyotype.

Intraoral granulocytic sarcoma presenting as multiple maxillary and mandibular masses: a case report and literature review

Granulocytic sarcoma (GS) is an unusual localized tumor composed of immature granulocytic precursor cells that occurs in extramedullary sites. However, GS involving the oral cavity is rare. We report a case of intraoral GS with an unusual clinical presentation, including a history of chronic myelogenous leukemia in remission, multiple maxillary and mandibular gingival masses mimicking acute inflammation that developed over a short period, complete remission after 1 week of treatment with imatinib mesylate (Gleevec), and no bone marrow or peripheral blood involvement over a 6-month follow-up period. To our knowledge, this is the first report of treatment of intraoral GS with Gleevec resulting in a complete remission.

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.

[Mandibular chloroma]

CASE REPORT

A 23 year-old girl was admitted for a facial tumefaction, fixed to the mandible. The X-rays showed a fuzzy osteolytic lesion of the mandibular angle. The CT-scan confirmed the rupture of the cortical bone and the extension to the soft tissue. Biopsy provided the diagnosis of granulocytic monoblastic sarcoma (chloroma). Chemotherapy was efficient.

DISCUSSION

Mandibular localizations of chloroma are rare. Granulocytic monoblastic sarcoma is a localized tumor made of extramedullar immature granulocytes, in general associated (or more rarely preceded by) with leukemia. Early diagnosis is important because high dose chemotherapy induction may completely cure leukemia.

Isolated biliary granulocytic sarcoma followed by acute myelogeneous leukemia with multilineage dysplasia: a case report and literature review

Granulocytic sarcoma is a rare extramedullary tumor composed of myeloid progenitor cells. Primary involvement of the biliary tract without evidence of leukemia is exceedingly rare. Here, we report an isolated biliary granulocytic sarcoma in a 30-yr-old man who presented with jaundice, fever, and chill without any evidence of leukemia. However, five months after the diagnosis, he developed acute myelogenous leukemia with multilineage dysplasia and chromosomal abnormality. A rare possibility of biliary granulocytic sarcoma should be considered as a differential diagnosis in patients with obstructive jaundice. A histologic evaluation by aggressive diagnostic intervention is important and may improve prognosis.

Myeloid sarcoma occurring concurrently with drug-induced gingival enlargement

BACKGROUND

Myeloid sarcoma is an extramedullary malignancy of myeloblasts. An unusual case of myeloid sarcoma presenting in the gingiva and affected by drug-induced gingival enlargement is presented.

METHODS

A 63-year-old male taking amlodipine for his hypertension presented with a 3-week gingival enlargement. Although the obvious clinical impression was that of drug-induced gingival enlargement, an incisional biopsy was performed to corroborate chemical enlargement while ruling out diseases such as lymphoma and leukemia.

RESULTS

Microscopic examination of the thickened gingiva revealed surface stratified squamous epithelium having needle-like rete pegs characteristic of drug-induced gingival enlargement. Beneath the surface epithelium, the fibrous tissue was virtually replaced by a dense infiltrate of malignant cells. Immunohistochemical studies were performed with CD117 and myeloperoxidase identifying the malignant cell population as myeloblasts, leading to a diagnosis of myeloid sarcoma.

CONCLUSION

Myeloid sarcoma and hematopoietic malignancies must be included in a differential diagnosis of gingival enlargement until the definitive diagnosis is reached by histologic/laboratory examination.

Granulocytic Sarcoma Manifesting as Multiple Skeletal Lesions

Granulocytic sarcoma is an extramedullary collection of myeloblasts that is usually associated with acute or chronic myeloid leukemia. It can be found in any location throughout the body; however, multifocal skeletal involvement is extremely rare. This report describes a case of granulocytic sarcoma in a 33-year-old man, manifesting as multiple skeletal lesions along with signs of cord compression without any preceding history of myeloid leukemia. Cytogenetic studies revealed t(8,9) translocation, which has never been reported in association with granulocytic sarcoma. The prognostic significance of this finding is unknown. This case report underscores the importance of considering granulocytic sarcoma in the differential diagnosis of spinal tumors, since the tumor may occur before other manifestations of myeloid leukemia are evident.

Chloroma of the Testis After Allogeneic Peripheral Blood Stem Cell Transplantation: A Case Report

Chloroma, or granulocytic sarcoma, is a rare extramedullary solid hematologic cancer that affects many sites, usually in concert with acute myeloid leukemia. It is infrequently associated with other myeloproliferative disorders or chronic myelogenous leukemia. Chloroma of the testis after allogeneic bone marrow transplantation is particularly sparsely represented in the literature. It is often incorrectly diagnosed as malignant lymphoma, especially large-cell lymphoma, owing to the similarity of the histologic morphology, scanty eosinophilic myelocytes, and no or overlooked history of leukemia. Although erroneous diagnosis is decreasing with the advent of ancillary studies, the diagnosis of chloroma continues to be a nightmare for pathologists. It is thus suggested that an appropriate panel of marker studies be performed in conjunction with clinical correlation and circumspection to avoid reaching a misleading conclusion and improper treatment of patients. We report an interesting case of a 35-year-old male with a clinical history of chronic myelogenous leukemia post allogeneic peripheral blood stem cell transplantation and complete molecular remission, who was found to have chloroma of the left testis.