Granulocytic sarcoma (chloroma): imaging findings in adults and children

Subglottic Mass With Hoarseness and Difficulty Breathing

A man in his 70s was referred for a 5-cm submandibular mass, hoarseness, and difficulty breathing with no cough, blood in sputum, or dysphagia. What is your diagnosis?

Mutations in the histone methyltransferase Ezh2 drive context-dependent leukemia in Xenopus tropicalis

CRISPR-mediated simultaneous targeting of candidate tumor suppressor genes in Xenopus tropicalis allows fast functional assessment of co-driver genes for various solid tumors. Genotyping of tumors that emerge in the mosaic mutant animals rapidly exposes the gene mutations under positive selection for tumor establishment. However, applying this simple approach to the blood lineage has not been attempted. Multiple hematologic malignancies have mutations in EZH2, encoding the catalytic subunit of the Polycomb Repressive Complex 2. Interestingly, EZH2 can act as an oncogene or a tumor suppressor, depending on cellular context and disease stage. We show here that mosaic CRISPR/Cas9 mediated ezh2 disruption in the blood lineage resulted in early and penetrant acute myeloid leukemia (AML) induction. While animals were co-targeted with an sgRNA that induces notch1 gain-of-function mutations, sequencing of leukemias revealed positive selection towards biallelic ezh2 mutations regardless of notch1 mutational status. Co-targeting dnm2, recurrently mutated in T/ETP-ALL, induced a switch from myeloid towards acute T-cell leukemia. Both myeloid and T-cell leukemias engrafted in immunocompromised hosts. These data underline the potential of Xenopus tropicalis for modeling human leukemia, where mosaic gene disruption, combined with deep amplicon sequencing of the targeted genomic regions, can rapidly and efficiently expose co-operating driver gene mutations.

Pediatric focal calvarial lesions: an illustrated review

Focal skull lesions in children can be diagnostically challenging with a wide variety of potential etiologies. Understanding the diverse pathologies and recognizing their associated clinical and imaging characteristics is crucial for accurate diagnosis and appropriate treatment planning. We review pertinent anatomy of the scalp and calvarium and review different pathologies that can present with focal skull lesions in pediatric patients. These include neoplastic, non-neoplastic tumor-like, congenital, post traumatic, and vascular-associated etiologies. We review the key clinical and imaging features associated with these pathologies and present teaching points to help make the correct diagnosis. It is important for radiologists to be aware of the common and rare etiologies of skull lesions as well as the clinical and imaging characteristics which can be used to develop an accurate differential to ensure a timely diagnosis and initiate appropriate management.

Myeloid Sarcoma: A Primer for Radiologists

ABSTRACT

Myeloid sarcoma (MS) is a rare extramedullary neoplasm that can present in association with acute myeloid leukemia, most commonly in children younger than 15 years. This unique extramedullary malignancy may involve a variety of different organ systems and can present following, preceding, simultaneous with, or in insolation to acute myeloid leukemia. Common areas of extramedullary involvement include soft tissues, bones, lymph nodes, and the peritoneum. Imaging plays a critical role in the diagnosis and management of MS, with commonly used modalities including positron emission tomography-computed tomography, magnetic resonance imaging, computerized tomography, and ultrasound. The purpose of this review article is to provide radiologists with a comprehensive guide summarizing the relevant imaging and clinical features of MS, with emphasis on the role of imaging in the diagnosis, treatment, and follow-up of patients with MS. The relevant pathophysiology, epidemiology, clinical presentations, and differential diagnosis of MS will be reviewed. The relevance of different imaging modalities in diagnosis, monitoring of treatment response, and assessment of treatment-related complications will also be outlined. Through summarizing these topics, this review article aims to provide radiologists with a guide for understanding the existing knowledge of MS in the literature and the current role of imaging in the management of this unique malignancy.

Presentation of Chloromas in B-Mode Ultrasound and Contrast-Enhanced Ultrasound

Chloromas, also referred to as myeloid sarcomas, describe rare extramedullary tumor aggregates of malignant myeloid progenitor cells. The aim of this study was investigate the diagnostic features and characteristics of chloromas using contrast-enhanced ultrasound (CEUS). Between July 2007 and April 2021, 15 patients with 20 myeloid neoplasms and suspected chloroma manifestations were examined using B-mode US (B-US) and CEUS. Clinical data and B-US (echogenicity, border, size) and CEUS (hyper-, iso-, hypo- or complex enhancement) characteristics were retrospectively analyzed. Absolute and relative frequencies were determined. In B-US, the chloromas were most frequently hypo-echoic (n = 15, 75%). In addition, a hyperechoic (n = 2, 10%) or echocomplex (n = 3, 15%) presentation was observed. On CEUS, 7 chloromas (35%) had an arterial hyperenhancement, 8 (40%) an iso-enhancement and 3 (15%) a complex enhancement. Two chloromas (10%) did not exhibit any enhancement. We describe for the first time CEUS and B-US patterns of chloromas. They are typically hypo-echoic on B-US and have a strong iso- or hyperenhancement on CEUS, which may help in the differential diagnosis of some unclear masses (e.g., hematoma, abscess) in patients with myeloid neoplasias. Nevertheless, histology is necessary for a reliable diagnosis.

Vulvovaginal myeloid sarcoma with massive pelvic floor infiltration: A case report and review of literature

BACKGROUND

Myeloid sarcoma (MS), including isolated and leukaemic MS, is an extramedullary myeloid tumour. MS can involve any anatomical site, but MS of the female genital tract is rare, with the ovaries and uterine body and cervix being the most commonly seen sites. Involvement of the vagina and vulva is extremely rare.

CASE SUMMARY

We report a rare case of MS with involvement of the vulva and vagina and massive infiltration of the pelvic floor. A 26-year-old woman presented with a vulvar mass, irregular vaginal bleeding and night sweats. Magnetic resonance imaging demonstrated an ill-defined, irregular vulvovaginal mass with massive involvement of the paravaginal tissue, urethra, posterior wall of the bladder, and pelvic floor. The signal and enhancement of the huge mass was homogeneous without haemorrhage or necrosis. Positron emission tomography/computed tomography showed high fluorodeoxyglucose uptake by the mass. Peripheral blood count detected blast cells. Vulvovaginal mass and bone marrow biopsies were performed, and immunohistochemistry confirmed the diagnosis of acute myeloid leukaemia (M-2 type, FAB classification) and vulvovaginal MS. The patient was treated with induction chemotherapy followed by allogeneic haematopoietic stem cell transplantation, and achieved complete remission. A systemic review of the literature on vulvovaginal MS was conducted to explore this rare entity’s clinical and radiological features.

CONCLUSION

Vulvovaginal MS is extremely rare. Diagnosis of vulvovaginal MS can only be confirmed histopathologically. Even though its clinical and imaging presentations are nonspecific, MS should be considered in the differential diagnosis of a newly developed T2-hyperintense, homogeneously enhanced vulvovaginal mass, especially in a patient with suspected haematological malignancy.

Spinal Chloroma – Herald of blast crisis in a patient with chronic myeloid leukaemia: A case report

Myeloid sarcoma or chloroma is a localised tumour characterised by extramedullary proliferation of precursor myeloid cells. Commonly occurring in association with acute myeloid leukaemia, chloroma can occasionally be seen in myeloproliferative disorders with subsequent blastic transformation. Imaging plays an important role in the diagnosis and evaluation of this entity. A case of chloroma involving the dorso-lumbar vertebral region is presented in a patient with chronic myeloid leukaemia with subsequent blastic transformation.

Myeloid sarcoma: an uncommon presentation of myeloid neoplasms; a case series of 4 rare cases reported in a tertiary care institute

Myeloid sarcoma (MS) is a rare extramedullary neoplasm of myeloid cells, which can arise before, concurrently with, or following hematolymphoid malignancies. We report 04 such cases of MS, diagnosed in this institute over a period of 6 years, during various phases of their respective myeloid neoplasms/leukemias. These cases include MS occurring as a relapse of AML (Case 1), MS occurring as an initial presentation of CML (Case 2), MS occurring during ongoing chemotherapy in APML (Case 3), and MS presenting as a progression of MDS to AML (Case 4). In the absence of relevant clinical history and unemployment of appropriate immunohistochemical (IHC) studies, these cases have a high risk of being frequently misdiagnosed either as Non-Hodgkin’s Lymphoma (NHL) or small round cell tumors or undifferentiated carcinomas, which may further delay their management, making an already bad prognosis worse. This case series has been designed to throw light on the varied presentation of MS and the lineage differentiation of its neoplastic cells through the application of relevant IHC markers along with their clinical correlation.

Orbital myeloid sarcoma misdiagnosed for subperiostal hematoma: a case report

BACKGROUND

Myeloid sarcoma is a solid tumor that consists of immature myeloid cells occurring at an extramedullary site. It can present before, concurrent with, or after the diagnosis of acute myeloid leukemia or other myeloproliferative diseases, and a proportion of patients never develop bone marrow infiltration. Only a few isolated cases of pediatric orbital myeloid sarcoma have been reported, and they are often associated with a high misdiagnosis rate.

CASE REPORT

We report a rare case of pediatric orbital myeloid sarcoma associated with blunt trauma in a 3-year-old Caucasian male patient, which was clinically and radiologically misdiagnosed for orbital subperiostal hematoma. The patient underwent a surgical intervention to drain the hematoma when an orbital mass was found. The microscopic, immunologic, and genetic features of the tumor and the myelogram were in favor of LAM2, and the patient was started with chemotherapy with a favorable evolution within 18 months follow-up.

CONCLUSION

Orbital myeloid sarcoma usually exhibits clinical and radiological features that can be easily misleading, especially if it happens de novo or as the first manifestation of acute myeloid leukemia. Only a few isolated cases have reported and proposed trauma as a trigger event of the onset of this type of tumor proliferation, but further investigations and evidence are needed to support this hypothesis.

Isolated myeloid sarcoma of lumbar spine without bone marrow involvement: a rare case report and treatment dilemma

Granulocytic sarcoma, chloroma, myeloblastoma, or here referred as myeloid sarcoma (MS), is a rare extramedullary tumor composed of immature myeloid cells called myeloblasts. MS is seen most commonly in patients with acute myeloid leukemia and less frequently in chronic myeloid leukemia, myelodysplastic syndrome. In rarer instances, MS has been shown to precede the development of myeloid tumors by acute myeloblastic leukemia (AML). In particular, isolated MS involving spine is extremely rare. We herein present a rare case of isolated spinal MS in non-leukemic patient. This is a previously relatively healthy 47-year-old man who presented with signs of lumbar spinal cord compression, initially reported as schwannoma on imaging, later diagnosed with spinal MS on pathology. Further workup did not reveal any evidence of bone marrow or other hematological involvement. The patient successfully treated by L4/L5 laminectomy and debulking with subsequent radiation resulting in substantial decrease in size of tumor with significant improvement in symptoms during follow up. This case not only describes a rare case of isolated MS of lumbar spine, but also highlights the potential treatment challenges of such a rare diagnosis. We review the available literature, discuss available treatment options, and highlight the need for further investigations along with increased clinician awareness.

Treatment Outcomes of Intracranial Myeloid Sarcomas: A Meta-Analysis

OBJECTIVE

Intracranial myeloid sarcomas (IMS) are rare central nervous system manifestations of malignant hematopoietic neoplasms of myeloid origin such as acute myeloid leukemia and chronic myeloid leukemia. Reported cases in the literature are limited to primarily case reports. We present a systematic review of this rare central nervous system tumor, characterizing the clinical presentation, tumor location, histopathology, and available treatment modalities. We correlate these variables with mortality, recurrence, and complications to suggest optimal management strategies for IMS.

METHODS

A systematic literature search was performed across Ovid MEDLINE, Scopus, and Embase using 14 search terms in accordance to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. This systematic review examines variables such as patient age, tumor location, size, presenting symptoms, treatment modality, extent of resection, and mortality. We performed descriptive analyses to identify bivariate associations between patient characteristics, treatment, and outcomes.

RESULTS

The mean age at diagnosis was 34.8 years, and the most common etiology was acute myeloid leukemia (68.8%). The most common presenting symptoms were headache (45.5%), vision complaints (27.3%), and weakness/motor symptoms (21.2%). IMS were most commonly located in the temporal lobe (10.1%), cerebellum (10.1%), or falcine/parasagittal (10.1%) region. Patients who received radiotherapy (P < 0.001) or chemotherapy (P < 0.001) had lower rates of mortality versus those who did not. Surgical treatment and extent of resection were not significantly associated with mortality (P > 0.05).

CONCLUSION

The use of adjuvant radiotherapy or chemotherapy for IMS significantly reduces mortality, confirming IMS as a cranial manifestation of a systemic disease. Although surgical treatment is indicated for histopathologic diagnosis and to relieve mass effect, the extent of resection does not predict overall survival.

Neuroimaging of central diabetes insipidus

Central diabetes insipidus (CDI) occurs secondary to deficient synthesis or secretion of arginine vasopressin peptide from the hypothalamo-neurohypophyseal system (HNS). It is characterized by polydipsia and polyuria (urine output >30mL/kg/day in adults and >2l/m²/24h in children) of dilute urine (<250mOsm/L). It can result from any pathology affecting one or more components of the HNS including the hypothalamic osmoreceptors, supraoptic or paraventricular nuclei, and median eminence of the hypothalamus, infundibulum, stalk or the posterior pituitary gland. MRI is the imaging modality of choice for evaluation of the hypothalamic-pituitary axis (HPA), and a dedicated pituitary or sella protocol is essential. CT can provide complimentary diagnostic information and is also of value when MRI is contraindicated. The most common causes are benign or malignant neoplasia of the HPA (25%), surgery (20%), and head trauma (16%). No cause is identified in up to 30% of cases, classified as idiopathic CDI. Knowledge of the anatomy and physiology of the HNS is crucial when evaluating a patient with CDI. Establishing the etiology of CDI with MRI in combination with clinical and biochemical assessment facilitates appropriate targeted treatment. This chapter illustrates the wide variety of causes and imaging correlates of CDI on neuroimaging, discusses the optimal imaging protocols, and revises the detailed neuroanatomy required to interpret these studies.

Imaging of Lacrimal Gland Pathologies: A Radiological Pattern-Based Approach

Despite their unassuming size, lacrimal glands can have a variety of pathologies affecting them which often poses a diagnostic challenge clinically in view of their nonspecific presentation as palpable lump in the superolateral aspect of the orbit. There are a myriad of pathological entities ranging from inflammatory to neoplastic lesions that can affect the lacrimal glands. Cross-sectional imaging is must for the detection, characterization, and mapping of these lesions. In this pictorial review, we propose a radiological pattern-based approach for various lacrimal gland lesions that provides a working algorithm for radiologists in the evaluation of lacrimal gland pathologies.

Orbital myeloid sarcoma (chloroma): Report of 2 cases and literature review

Purpose

Myeloid sarcoma (MS) of the orbit is an uncommon condition in occurring in children, generally coupled to myeloproliferative neoplasms.

Observations

We describe two rare cases of orbital MS in young boys with aggressive local symptoms but without evidence of acute myeloid leukemia (AML), both patients underwent orbitotomy for gross-tumor resection and biopsy. At follow up, there was no evidence of recurrence nor evolution of the myeloproliferative neoplasms clinically and by radiological and laboratory work-up. We also provide a detailed description of the magnetic resonance imaging presentation, with an extensive pathological analysis correlation.

Conclusions and importance

A comprehensive revision of the literature on isolated orbital MS was carried out with particular emphasis on clues for differential diagnosis and treatment options, stressing the need to consider MS even in the absence of sign and symptoms of an underlying myeloproliferative disorders.

Orbital myeloid sarcoma (chloroma): Report of 2 cases and literature review

Purpose

Myeloid sarcoma (MS) of the orbit is an uncommon condition in occurring in children, generally coupled to myeloproliferative neoplasms.

Observations

We describe two rare cases of orbital MS in young boys with aggressive local symptoms but without evidence of acute myeloid leukemia (AML), both patients underwent orbitotomy for gross-tumor resection and biopsy. At follow up, there was no evidence of recurrence nor evolution of the myeloproliferative neoplasms clinically and by radiological and laboratory work-up. We also provide a detailed description of the magnetic resonance imaging presentation, with an extensive pathological analysis correlation.

Conclusions and importance

A comprehensive revision of the literature on isolated orbital MS was carried out with particular emphasis on clues for differential diagnosis and treatment options, stressing the need to consider MS even in the absence of sign and symptoms of an underlying myeloproliferative disorders.

Extramedullary disease in acute promyelocytic leukaemia: A rare presentation

Acute promyelocytic leukaemia consists of 7%–8% of cases of acute myeloid leukaemia. Extramedullary manifestations are rare and show distinct biological features. We describe a 22-year-old female of Malay ethnicity who presented with fever and a left axillary swelling for a week. The peripheral blood smear showed abnormal promyelocytes with faggot cells. PML-RAR-alpha t(15;17) (q22; q12) was detected by polymerase chain reaction. The left axillary swelling histology and immunohistochemical staining confirmed granulocytic sarcoma. She was induced with triple agents consisting of all-trans-retinoic-acid, arsenic trioxide and idarubicin. On day 14 of induction, she developed severe neutropenic sepsis in which she responded to ventilation and antimicrobials. She completed her induction, consolidation and maintenance therapy. Currently she is in molecular and morphological remission. Extramedullary disease in acute promyelocytic leukaemia usually has a severe clinical presentation. Granulocytic sarcoma may present as an early feature of acute promyelocytic leukaemia.

De novo myeloid sarcoma as a rare cause of small bowel obstruction: CT findings and histopathologic correlation

Small bowel obstruction caused by myeloid sarcoma in a patient with any hematological abnormality is very rare. Myeloid sarcoma occurs most commonly in patients with acute myelogenous leukemia (AML) and less with other hematological disorders. A 57-year-old female presented with abdominal pain, nausea, vomiting, and constipation. Radiological studies showed concentric bowel thickening in distal ileum that caused nearly total luminal compromise and signs of obstruction in proximal ileal bowel loops. She underwent laparotomic surgery and ileal resection was done. Diagnosis of myeloid sarcoma was made by histopathological examination of surgical specimens. Bone marrow biopsy was done to rule out systemic acute myelogenous leukemia (AML). Results of bone marrow biopsy were within normal limits. Finally, the patient was diagnosed as de novo myeloid sarcoma. Although the histopathological examination makes a definitive diagnosis, imaging allows to locate the lesion, evaluate its complications, and guide for correct biopsy. Accurate diagnosis of myeloid sarcoma has important prognostic value as transformation to AML can happen without chemotherapy or stem cell transplantation.

Subdural haematoma mimics

A subdural haematoma (SDH) is a frequently encountered pathology seen on an emergency room computed tomography (CT) head scan. An extra-axial crescentic density along the convexity of the brain or within the interhemispheric fissure is generally thought to represent a SDH; however, SDH mimics are known to occur in nature, and can be broadly classified under the subcategories of normal anatomy, artefacts, tumour, inflammation, infection, ischaemia, trauma, and iatrogenic. Understanding the typical characteristics of a SDH, knowledge of normal anatomy, close inspection of the morphology of the subdural process, changes to the adjacent structures, and rigorous attention to clinical details may reveal subtle clues that distinguish a true SDH from a mimic. This is crucial in appropriately directing clinical management. This review amalgamates most of the rare subdural processes that have been reported to mimic SDH, and discusses the imaging and clinical features that help to differentiate between them. This topic is highly valuable for radiology trainees, general radiologists, and emergency room physicians, and may serve as a refresher for the practising neuroradiologist.

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

Myeloid Sarcoma

Hematological malignancies can manifest as extramedullary soft tissue masses in relatively rare cases. The rarity of it causes a diagnostic and therapeutic challenge. One of the rarest manifestations is myeloid sarcoma (MS). MS develops as part of acute myeloid leukemia, myeloproliferative neoplasm, or myelodysplastic syndrome or at relapse, especially following allogeneic hematopoietic stem cell transplant. The tumor displays high myeloperoxidase expression, hence the color green, and is called chloroma. It most commonly appears in lymph nodes, skin and soft tissues, bone, testes, gastrointestinal tract, and peritoneum. Immunohistochemistry shows CD68-KP1 as the most commonly expressed marker, then myeloperoxidase, CD117, CD99, CD68/PG-M1, lysozyme, CD34, terminal deoxynucleotidyl transferase, CD56, CD61, CD30, glycophorin A, and CD4. Different chromosomal abnormalities including MLL rearrangement, t(8; 21), monosomy 7, trisomy 8, trisomy 11, trisomy 4, inversion (16), monosomy 16,16q deletion, 5q deletion, and 20q deletion were reported. Most of the literature about MS are case reports and small retrospective studies, thus there is limited clinical knowledge of the cases and their presentation and management plans. Here, we provide a review of what has been reported in the literature about MS in the light of our experiences.

Diffuse periostitis as the primary presenting radiological finding in an AML patient with disease relapse

Acute myelogenous leukemia is a hematologic malignancy defined by the presence of myeloid blasts causing bone marrow infiltration. Evaluation and workup of acute myelogenous leukemia is based on comprehensive medical history, physical examination, laboratory evaluation, and bone marrow sampling. Magnetic resonance (MR) imaging is the study of choice in the evaluation of this disease including the initial evaluation, treatment follow-up, and complications. Herein, we report a case of relapse of the acute myelogenic leukemia in an adult patient who presented with diffuse periostitis in his lower extremities diagnosed on MR imaging and confirmed on Technetium bone scan, which also showed periostitis along the bilateral humeri. To our knowledge, this was not previously reported in the English literature.

Use of magnetic resonance imaging for diagnosis and after treatment of patients with myeloid sarcoma of the brain

The purpose of this retrospective study was to assess the utility of magnetic resonance imaging (MRI) for evaluating post-treatment responses in patients with myeloid sarcoma (MS) of the brain. We evaluated images from both conventional and advanced MR, including diffusion weighted imaging (DWI), arterial spin labeling (ASL) and susceptibility weighted imaging (SWI). Parameters of our qualitative review included lesion location, number, size, morphologic characteristics, surrounding edema, mass effect, pattern and degree of enhancement, ± restricted diffusion, ±susceptibility artifact and ± higher perfusion. Our quantitative assessments were calculated from DW and ASL MR images. The 10 patients had a total of 40 lesions in their brains (mean lesion size of 2.0 ± 0.8 cm). The majority of cases exhibited restricted diffusion (90%) and mild-to-moderate low perfusion (80%). Follow-up MRI after chemotherapy revealed that most lesions (80%) were significantly alleviated after two chemotherapy courses and further improved after four courses. Only a few lesions (5%) were residual after six courses. These findings demonstrate that brain MS can be characterized by changes in various MRI parameters and that MRI can be a useful and predictive assessment tool for brain MS diagnosis and treatment management.

De Novo Myeloid Sarcoma as a Cause of Small Bowel Obstruction: A Case Report

Myeloid sarcoma (MS) is an extremely rare disease, closely correlated to Acute Myeloid Leukamia (AML) and presenting as a tumoral lesion in potentially any anatomic location. It is seen either concomitant with AML, during remission, or more seldom, prior to any detectable haematological abnormality. While MS remains a difficult diagnosis, this rare tumor must be included in the differential diagnosis of atypical, local obstructive abdominal processes, especially when coinciding with a myeloproliferative disorder. We present a case report of an otherwise healthy young patient with small bowel obstruction due to an invasive ileal mass, histologically diagnosed as a myeloid sarcoma.

Clinical characteristics, molecular profile and outcomes of myeloid sarcoma: a single institution experience over 13 years

BACKGROUND

Myeloid sarcoma (MS) is characterized by extramedullary infiltration by immature myeloid cells. Owing to rarity of this disease, the clinical features and overall outcomes are yet to be clarified.

OBJECTIVE

To define clinical characteristics, epidemiology, pathologic findings, treatment options and outcomes in MS.

METHODS

We conducted a retrospective review of 23 patients diagnosed with MS at our institute over a period of 13 years (2002-2015).

RESULTS

MS presented mostly as a manifestation of relapsed acute myeloid leukemia, seen in 39% of patients. Skin and subcutaneous soft tissues were the most common sites of anatomic involvement (69.5%). Ninety five percent (n = 19) were positive for classical myeloid markers with either cytochemical staining (chloracetate-esterase, MPO), flow-cytometry (CD33, CD34, CD13 and CD117), or immunohistochemistry (CD34, CD43, CD68 and lysozyme). Of these, 52% were positive for CD33 (n = 12), 35% for CD68 (n = 8), 30% for CD34 (n = 7), and 26% for lysozyme (n = 6). Cytogenetic abnormalities were seen in 63% (n = 12/19) patients on bone-marrow aspirate, with five patients displaying a complex (n = 3) or monosomal (n = 2) karyotype. Twenty seven percent patients with a normal karyotype had presence of deleterious mutations (FLT3, ASXL, STAG and JAK2) on further testing with myeloid mutation panel. The Median overall survival (OS) of the entire cohort was 15.9 months (95% CI, 7.4-24.4 months). The OS was significantly better for patients <65 years (24.6 vs. 3.4 months, p = 0.009) of age, and for those attaining a complete remission (CR) to induction therapy (25.7 vs. 0.8 months, p < 0.001). All patients who underwent allogeneic hematopoietic stem cell transplant attained long-term remissions, with a median follow-up of 54 (range 32-120) months.

CONCLUSION

Failure to achieve CR with induction therapy, and age >65 years are associated with poor outcomes in MS. Allogeneic stem-cell transplant in first remission appears to be the most effective modality for achieving long-term remissions.

Unravelling chloroma: review of imaging findings

Chloroma refers to the extramedullary proliferation of immature myeloid precursors occurring in a gamut of myeloproliferative and myelodysplastic conditions; acute myeloid leukaemia being the commonest. With non-specific clinical and imaging manifestations, it runs a high risk of misdiagnosis which may significantly affect the outcome of an otherwise treatable lesion. Also with these lesions heralding impending blast crises, awareness of the imaging findings becomes imperative. Imaging not only helps raise the suspicion but also guides further confirmation by demonstration of specific immunohistochemistry markers, ensuring timely institution of chemotherapy. In general, solid enhancing lesions in any haematological disorder could be chloromas, especially if multifocal with mass effect.

Whole Body MR Imaging: A Useful Imaging Modality in the Management of Children With Acute Myeloid Leukemia

INTRODUCTION

To evaluate the distribution of chloromas using whole body magnetic resonance (MR) imaging in pediatric patients with acute myeloid leukemia (AML) and to assess the clinical role of whole body MR imaging in management of pediatric patients with AML.

MATERIALS AND METHODS

We retrospectively searched pediatric patients (< 18 years old) who were diagnosed with AML and underwent whole body MR imaging during their illness between January 2006 and December 2014. The presence of chloromas was defined as when it was proven pathologically or showed typical imaging features. Nonchloroma lesions that were incidentally detected and were not previously seen on other imaging studies were defined as clinically occult nonchloroma lesions.

RESULTS

Sixty-nine whole body MR scans of 40 patients with AML were included. The musculoskeletal system (42.9%) was the most commonly affected by chloromas. A total of 77 chloromas were identified in 11 (27.5%) of 40 patients. Nine (81.8%) of these 11 patients had 2 or more chloromas. There were 39 (50.6%) unexpected chloromas, which were incidentally detected, in 7 patients. Whole body MR scanning provided additional information regarding 21 clinically occult nonchloroma lesions in this patient population.

CONCLUSION

Chloromas tended to show multiplicity and be present without symptoms. The most common site of involvement was the musculoskeletal system. Whole body MR imaging provided additional information that affected the clinical management of children with AML.

Granulocytic Sarcoma Presenting as a Palpable Breast Lump

We report the case of a 45-year-old woman who palpated a voluminous painless lump in the superior outer quadrant of her left breast. Her past medical history revealed an acute myeloid leukemia (AML) treated and considered in remission 1 month prior to this discovery. Imaging work-up by mammogram, US, and MRI showed multiples masses suspect of malignancy in both breasts. US-guided needle biopsy was performed in the palpable mass and in one of the multiple lesions located in the right breast. Histologic findings were compatible with a granulocytic sarcoma in both breasts, which was considered as a relapse of the AML treated a few months earlier.

Radiation Therapy in Paediatric Orbital Granulocytic Sarcomas: Experience from a Tertiary Cancer Center

INTRODUCTION

Orbital Granulocytic Sarcoma (OGS) is an uncommon manifestation associated with haematological malignancies. Chemotherapy remains the cornerstone of the treatment. The role of radiation is not well-defined.

AIM

To evaluate the effect of radiation in OGS and to define an optimal dose for achieving adequate local control.

MATERIALS AND METHODS

This was a retrospective analysis of 11 patients who received radiation therapy to orbit for Granulocytic Sarcoma (GS) between 2007 and 2014 at a tertiary cancer center in India. Radiotherapy was planned by three dimensional conformal (3DCRT) techniques. Demographic and disease characteristics, including clinical, imaging, histopathology and treatment details in this patient cohort were recorded and their response to therapy was assessed.

RESULTS

The median age was 7 years (Range: 2-16 years). There were 3 female and 8 male patients. Eight patients were diagnosed as Acute Myelogenous Leukemia (AML), two patients had Primary Orbital Granulocytic Sarcoma (POGS) and one had bi-phenotypic leukemia. Median dose was 24.5Gy (Range-15-45 Gy). Two anterior oblique field design were used most commonly. Out of 11 patients, 5 (45.4%) had complete response, 3 (27.27%) had partial response, 1 patient had stable disease (9%) and 2 developed progressive disease (18%). Median follow-up was 24 months (Range 24-84 months). At last follow-up, 7 (63.6%) patients were alive and 4 patients (37.4%) were dead due to progressive disease.

CONCLUSION

In patients with residual orbital disease after chemotherapy, low dose radiation can be used to improve local disease control and improve quality of life. Local conformal radiotherapy of 24-30 Gy in conventional fractionation appears optimal with excellent local control and minimal morbidity.

Immunohistochemical patterns in the differential diagnosis of rhinopharyngeal granulocytic sarcoma

Granulocytic sarcoma (GS) is a rare extramedullary manifestation of acute myeloid leukemia (AML). GS may develop simultaneously to AML or as a relapse of leukemia, particularly following allogeneic hematopoietic stem cell transplant. Subperiosteal bone, lymph nodes and skin are commonly involved, whereas rhinopharyngeal involvement is less common, with only 14 cases reported in the literature. Due to its rarity, rhinopharyngeal GS may lead to diagnostic pitfalls, particularly when it is poorly differentiated or is without concomitant marrow involvement. Thus, immunohistochemical findings play a key role in diagnosis. The current report describes a case of a 53-year-old female suffering from rhinopharyngeal GS and with a history of AML treated with chemotherapy and radiotherapy, focusing on the importance of the immunohistochemical pattern to assess the right diagnosis. Recent studies have demonstrated that the immunophenotype is of utmost importance for the diagnosis of GS. The high expression of myeloperoxidase (MPO) is common in GS; however, ~30% of GSs do not contain MPO. Therefore, the presence of other markers is required to confirm the diagnosis of GS.

Imaging of Spinal Manifestations of Hematological Disorders

Imaging manifestations of hematological diseases and their potential complications are broad, and there may be significant overlap in features of various disease processes. Knowledge of appropriate choice of imaging test, pertinent imaging patterns, and pathophysiology of disease can help the reader increase specificity in the diagnosis and treatment of the patient. Most importantly, we encourage readers of this review to engage their radiologists during the diagnostic, treatment, and management phases of care delivery.

Extramedullary Relapse of Acute Myeloid and Lymphoid Leukemia in Children: A Retrospective Analysis

Background

Extramedullary relapse (EMR) is a recurrence of leukemia in sites other than the bone marrow, and it exhibits a relatively rare presentation of relapse of acute leukemia. However, EMR is an important cause of treatment failure among patients with acute leukemia. Therefore, early detection of these relapses may improve the prognosis.

Objectives

To describe the disease-related demographic and clinical features and radiologic findings for children diagnosed with EMR in acute leukemia.

Patients and Methods

The study was based on 22 children (M: F = 14: 8; mean age 7.30 (2.1 - 15.7) years) with 8 acute myeloid leukemia (AML) and 14 acute lymphoid leukemia (ALL) who had experienced an EMR. Age, gender, clinical symptoms, initial extramedullary disease (EMD), French-American-British (FAB) morphology, cytogenetics, time to and site of EMR, concurrent bone marrow relapse (BMR), radiologic findings, and outcomes were evaluated.

Results

No definite relationship was found between initial EMD and EMR. A predilection for AML to relapse in the central nervous system (CNS), except for the CSF and bone, and for ALL to relapse in the CSF and kidney seemed to occur. Patients with EMR had a significantly higher incidence of t(8: 21) cytogenetics and FAB M2 and L1 morphologies. EMR accompanied with concurrent BMR occurred in 31.8% of the patients, who exhibited a relatively grave clinical course. Radiologic findings were nonspecific and had a great variety of structure involved, including bulging enhancing mass in the CT scan, hypoechoic mass in the US, and enhanced mass-like lesion in the MRI.

Conclusions

Knowledge of the potential sites of EMR, their risk factors, and their clinical and radiologic features may be helpful in the early diagnosis of relapse and planning for therapy.

CNS and spinal tumors

Primary CNS tumors consist of a diverse group of neoplasms originating from various cell types in the CNS. Brain tumors are the most common solid malignancy in children under the age of 15 years and the second leading cause of cancer death after leukemia. The most common brain neoplasms in children differ consistently from those in older age groups. Pediatric brain tumors demonstrate distinct patterns of occurrence and biologic behavior according to sex, age, and race. This chapter highlights the imaging features of the most common tumors that affect the child's CNS (brain and spinal cord).

Hematologic neoplasms: Interpreting lung findings in chest computed tomography

Lung disease is very common in patients with hematologic neoplasms and varies in function of the underlying disease and its treatment. Lung involvement is associated with high morbidity and mortality, so it requires early appropriate treatment. Chest computed tomography (CT) and the analysis of biologic specimens are the first line diagnostic tools in these patients, and sometimes invasive methods are necessary. Interpreting the images requires an analysis of the clinical context, which is often complex. Starting from the knowledge about the differential diagnosis of lung findings that radiologists acquire during training, this article aims to explain the key clinical and radiological aspects that make it possible to orient the diagnosis correctly and to understand the current role of CT in the treatment strategy for this group of patients.

Hematologic neoplasms: interpreting lung findings in chest computed tomography

La patología pulmonar en la historia de un paciente con neoplasia hematológica es muy frecuente y variable en función de la enfermedad de base y la terapia recibida. La morbimortalidad asociada es alta, por lo que requiere un tratamiento correcto y precoz. La tomografía computarizada (TC) torácica, junto con el análisis de muestras biológicas, son las herramientas de diagnóstico de primera línea empleadas en estos pacientes, y en determinados casos se requieren métodos invasivos. La interpretación de las imágenes exige el análisis de un contexto clínico en muchas ocasiones complejo. Partiendo del conocimiento que adquiere el radiólogo en su formación sobre el diagnóstico diferencial de los hallazgos pulmonares, el objetivo de este trabajo es explicar los aspectos clínicos y radiológicos claves que permiten orientar correctamente el diagnóstico y asimilar el papel actual de la TC en la estrategia terapéutica de este grupo de enfermos.

Intracranial CNS Manifestations of Myeloid Sarcoma in Patients with Acute Myeloid Leukemia: Review of the Literature and Three Case Reports from the Author's Institution

Myeloid sarcoma (MS) of the central nervous system (CNS) is a rare presentation of leukemic mass infiltration outside of the bone marrow. It may involve the subperiosteum and dura mater and, on rare occasions, can also invade the brain parenchyma. The disease is most commonly seen in children or young adults; however, it has been described in multiple age groups. MS can be seen in patients with acute myeloid leukemia (AML), chronic myeloid leukemia and other myeloproliferative disorders. This entity has the potential to be underdiagnosed if the MS appearance precedes the first diagnosis of leukemia. The main reason is that their appearance on CT and MRI has a broad differential diagnosis, and proper diagnosis of MS can only be made if the imaging findings are correlated with the clinical history and laboratory findings. Herein, we describe the intracranial CNS manifestations of MS in patients with AML on CT and MRI involving the brain and/or meninges. This study is based on a systematic review of the literature. In addition, three case reports from the author's institution with AML and intracranial involvement of MS are included. Our aim is to enhance the awareness of this entity among both clinicians and radiologists.

Sacral myeloid sarcoma involving multiple metastases to the brain: A case report

The presentation of myeloid sarcoma (MS) in the bone is common; however, rarely does the tumor occur in the sacral spine, and in a normal patient with no history of acute myeloid leukemia. The present study describes the rare case of a previously healthy 24-year-old male patient, who presented with a history of six months of repeated pain in the right leg and hip and limping for less than a month, who was diagnosed with sacral MS. Despite receiving surgical management and chemotherapy promptly subsequent to the diagnosis and undergoing close observation following the treatment, the patient still developed metastases to multiple sites of the brain. Taking into account the similar presentation of this rare disease to other entities, the early and accurate diagnosis of MS is vital, and the condition should be considered as a threatening manifestation with the possibility of metastasis to other sites of the body.

Acute appendicitis secondary to acute promyelocytic leukemia

Patient: Female, 43

Final Diagnosis: Myeloid sarcoma appendicitis

Symptoms: Abdominal pain • chills • fever

Medication: —

Clinical Procedure: Laparoscopic appendectomy, bone marrow biopsy

Specialty: Gastroenterology and Hepatology

CT and MRI evaluation of cardiac complications in patients with hematologic diseases: a pictorial review

Cardiac complications with hematologic diseases are not uncommon but it is difficult to diagnose, due to non-specific clinical symptoms. Prompt recognition of these potentially fatal complications by cardiac computed tomography (CT) or cardiac magnetic resonance imaging (MRI) may help to direct clinicians to specific treatments according to causes. Thrombosis is often related to central venous catheter use and is usually located at the catheter tip near the atrial wall. Differentiation of thrombosis from normal structure is possible with CT and, distinction of a thrombus from a tumor is possible on a delayed enhancement MRI with a long inversion time (500-600 ms). Granulocytic sarcoma of the heart is indicated by an infiltrative nature with involvement of whole layers of myocardium on CT and MRI. MRI with T2* mapping is useful in evaluating myocardial iron content in patients with hemochromatosis. Diffuse subendocardial enhancement is typically observed on delayed MRIs in patients with cardiac amyloidosis. T1 mapping is an emerging tool to diagnose amyloidosis. Myocardial abscess can occur due to an immunocompromised status. CT and MRI show loculated lesions with fluid density and concomitant rim-like contrast enhancement. Awareness of CT and MRI findings of cardiac complications of hematologic diseases can be helpful to physicians for clinical decision making and treatment.

Primary granulocytic sarcoma of larynx

BACKGROUND

Granulocytic sarcoma is an extramedullary tumor of myeloblasts. The purpose of this report was to present a case of a primary laryngeal granulocytic sarcoma and review of the literature.

METHODS

A literature review was performed using Medline and PubMed databases to search for cases of all primary and secondary myelogenous tumors of the larynx.

RESULTS

A 36-year-old man presented with a mass involving the preepiglottic space that was histologically confirmed as an extramedullary acute myeloid leukemia, or granulocytic sarcoma. Our review found 18 cases of secondary involvement of the larynx by myelogenous tumors, and only 1 previously reported case of primary laryngeal granulocytic sarcoma.

CONCLUSION

The detection of granulocytic sarcoma is difficult given its rarity and nonspecific presentation. To our knowledge, this is the second reported case of primary granulocytic sarcoma of the larynx reported in the literature.

Orbital mass secondary to acute lymphoblastic leukaemia in a child: a rare presentation

We report the case of a 3-year-old child, who presented with lid swelling which progressed to proptosis of the left eye. He also had systemic symptoms of fatigue and weight loss. An examination revealed hepatosplenomegaly and lymph node enlargement. Investigations showed a peripheral smear with blast cells, which were also revealed through a bone marrow biopsy. A CT scan showed a mass lesion in the left orbit that had infiltrated into the surrounding tissues. He was diagnosed with acute lymphoblastic leukaemia (ALL) with left-sided orbital mass secondary to it. Haematogenous masses in the orbit are commonly due to granulocytic sarcomas, which are usually associated with acute myelogenous leukaemia (AML), not ALL, and are rare especially when they precede systemic disease.

Outside the inside: a review of soft-tissue abnormalities seen on thoracoabdominal computed tomography

In this review, we illustrate the computed tomographic features of thoracoabdominal soft-tissue abnormalities, which may be easily overlooked and often can provide important information regarding systemic processes. Examples include necrotizing fasciitis, heterotopic ossification, fat necrosis, benign and malignant neoplasms, endometriosis, and collagen vascular disease as well as systemic and congenital pathology.