Orbital granulocytic sarcomas (myeloid sarcomas) in acute nonlymphocytic leukemia

[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.

Nontraumatic orbital hemorrhage

Nontraumatic orbital hemorrhage (NTOH) is uncommon. I summarize the published reports of NTOH and offer a classification based on anatomic and etiologic factors. Anatomic patterns of NTOH include diffuse intraorbital hemorrhage, "encysted" hemorrhage (hematic cyst), subperiosteal hemorrhage, hemorrhage in relation to extraocular muscles, and hemorrhage in relation to orbital floor implants. Etiologic factors include vascular malformations and lesions, increased venous pressure, bleeding disorders, infection and inflammation, and neoplastic and nonneoplastic orbital lesions. The majority of NTOH patients can be managed conservatively, but some will have visual compromise and may require operative intervention. Some will suffer permanent visual loss, but a large majority have a good visual outcome.

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.

[Tumors and tumor-like lesions of the orbit]

This article gives an overview of the most common and clinically relevant tumors of the orbit and their treatment. The most common orbital tumors in childhood are cystic tumors, such as dermoid and epidermoid cysts. Capillary hemangiomas are the most common primary benign tumors of the orbit and appear mostly in the first year of life. In contrast teratomas are rare and histologically mostly benign. Neural tumors are, for example, gliomas of the optic nerve and in 25-50% of cases are associated with neurofibromatosis. Rhabdomyosarcoma is a rapidly growing malignant orbital tumor whereby the stage and localization are the most important prognostic factors for survival chance in children. Leukemia can be associated with a chloroma especially in the first decade of life. Lymphoproliferative diseases, vascular and cystic tumors in particular are known as tumors of adulthood. In addition to fibroosseous and mesenchymal tumors, neural forms, such as schwannomas are also important. Secondary tumors of the orbit are often manifested in the nose and paranasal sinuses.

Extramedullary myeloid leukemia mimicking lepromatous leprosy

Granulocytic sarcoma is an extramedullary localized tumoral lesion of myeloid precursors. It is composed of immature cells of the granulocytic series known to occur in patients with myelodysplastic syndrome, chronic myelogenous leukemia or acute myelogenous leukemia. We present a 29-year-old female who was admitted to hospital for lesions that appeared on the face, lips and nose, mimicking lepromatous leprosy. It should be kept in mind that granulocytic sarcoma may mimick lepromatous leprosy.

Precursor B lymphoblastic leukemia 32 months after local therapy for a primary extramedullary myeloid cell tumor

A primary extramedullary myeloid cell tumor (pEMT) of an inguinal lymph node was completely excised without subsequent anti-tumor therapy in a 6-year-old child. Clinical observation and monitoring of blood and bone marrow (BM) did not reveal any pathologic results before 32 months, when a precursor B lymphoblastic leukemia was diagnosed. Identical T-cell receptor gamma rearrangement in nodal pEMT and in precursor B lymphoblastic leukemia in BM indicates a clonal relationship of these two tumors.

Children with acute myeloblastic leukemia presenting with extramedullary infiltration: the effects of high-dose steroid treatment

To evaluate whether children with acute myeloblastic leukemia (AML) presenting with extramedullary infiltration (EMI) have different clinical, morphologic features and prognosis from children without EMI, a 127 consecutive previously untreated children with AML were entered in this study. Fifty-one children (40%) had EMI at diagnosis and 27% of these showed multiple site involvement. Twenty-seven of 127 children (21%) presented myeloid tumors. No age related differences in the incidence of EMI was noted. However, analysis of clinical and biological features at diagnosis showed that WBC count > or =50 x 10(9) l(-1), hepatosplenomegaly >5 cm, FAB AML-M4 and AML-M5 subtypes and CD13, CD14 expression of bone marrow (BM) leukemic cells (>20%) were more frequent in children with EMI. Two consecutive treatment protocols were used. In both protocols remission was achieved with combined high-dose methylprednisolone (HDMP) as a differentiating and apoptosis inducing agent with mild cytotoxic chemotherapy (low-dose cytosine arabinoside (LD Ara-C), weekly mitoxantrone and Ara-C or 6-thioguanine). Administration of short-course (4-7 days) HDMP (20-30 mg/kg per day) alone resulted in a remarkable decrease in peripheral blood, BM blasts and in the size of EMI in responding patients. In both protocols, remission rate in patients with EMI was 71 and 80%, which was lower than that of the patients without EMI (87 and 89%). This may be attributed to the higher frequency of unfavorable features in children with EMI. However, in patients who presented with myeloblastoma and treated with a more intensive post-remission therapy (AML-94), the 4-year disease-free survival (DFS) and event-free survival (EFS) rates were not found to be significantly different from children who had no EMI (P>0.05). Whereas, the outcome of children who presented with gingival infiltration did not improve. In further studies, the prognostic significance of different localisation of EMI and the effect of addition of HDMP to cytotoxic chemotherapy should be explored in larger series.

Extramedullary leukemia in children with newly diagnosed acute myeloid leukemia: a report from the Children's Cancer Group

OBJECTIVES

To describe features of patients with acute myeloid leukemia presenting with extramedullary leukemic tumors (EML).

METHODS

Among 1,832 patients entered on Children's Cancer Group's chemotherapy trials with acute myeloid leukemia, 199 patients had EML, defined as any leukemic collection outside the bone marrow cavity. Three patient groups were denoted: group 1 (n=109) with EML involving skin (with or without other sites of EML), group 2 (n=90) with EML in sites other than skin, and group 3 (n=1,633) without EML.

RESULTS

The incidence of EML was 10.9%. Group 1 patients tended to be younger, had higher white blood cell counts, were more often CNS positive, had FAB M4 or M5 subtypes, and possessed more abnormalities of chromosome 11 than group 3 patients. Group 2 patients were younger, more often had the FAB M2 subtype, and had a higher incidence of t(8;21)(q22;q22) abnormality than group 3, but had similar white blood cell counts and incidence of CNS positivity at diagnosis. For group 1 the 5-year event-free survival was 26%, significantly worse than for group 3 at 29%. Event-free survival was better for group 2 patients (5-year estimate 46%), which remained a favorable prognostic factor by multivariate analysis. The authors retrospectively determined whether 118 (59%) of the EML patients received localized radiotherapy to the site of EML: 42 did and 76 did not. There were no differences in estimated event-free survival between patients who did and did not receive radiotherapy.

CONCLUSIONS

Non-skin (group 2) EML appeared to be an independent favorable prognostic factor. Localized radiotherapy to the site of EML at the end of induction chemotherapy did not improve outcome.

Parvovirus-B19 infection preceding acute myeloid leukemia with orbital granulocytic sarcoma

We report here an unusual presentation of acute nonlymphoblastic leukemia with ocular granulocytic sarcoma who was firstly diagnosed iron deficiency anemia and acute parvovirus infection induced erythroid hypoplasia. To our knowledge this is the first paper of acute myeloblastic leukemia (AML) with granulocytic sarcoma, preceded by acute Parvovirus B19 infection.

Extramedullary infiltrates at diagnosis have no prognostic significance in children with acute myeloid leukaemia

This retrospective study was designed to review the relative frequency and prognostic significance of extramedullary infiltrates in children with acute myeloid leukaemia (AML). The registration data and initial discharge summaries were reviewed for all children diagnosed with AML, and registered by the Dutch Childhood Leukaemia Study Group (DCLSG). Between 1972 and 1998, 477 children were diagnosed with AML. Of these patients, 120 (25.1%) had extramedullary leukaemia (EML) at diagnosis. Four categories of EML were found: skin, soft tissue or bone, gingival infiltration and central nervous system (CNS) involvement. Patients who presented with gingival infiltrates, were older than those without EML or those in the other EML subgroups, had a high initial WBC count and a high proportion of M4/M5 morphological variants. This type of presentation could indicate a special biological entity. Univariate analysis of prognostic factors in patients treated after 1985 with intensive protocols showed that initial WBC count and the presence of favourable cytogenetic findings were significant. The presence of EML at diagnosis had no significant effect on event-free survival. In a stepwise multiple regression analysis only favourable cytogenetic findings remained significant.

Extramedullary myeloid tumors in children: the limited value of local treatment

PURPOSE

To determine the incidence of extramedullary tumors (EMT) in Saudi Arabian children with acute myeloid leukemia, the factors associated with these tumors and the impact of local treatment on local tumor control, complete remission and survival rates.

PATIENTS AND METHODS

One hundred children, median age 6 years, who received their primary treatment for acute myeloid leukemia at King Faisal Specialist Hospital and Research Center, from 1983 to 1997 were studied. EMT at diagnosis occurred in 18 (18%) patients at 25 sites. Meningeal leukemia, hepatosplenomegaly, lymph node enlargement, gingival hypertrophy, and cutaneous infiltration were not included in the definition of EMT. With these exclusions, children with EMT were younger than those without EMT (median age, 3.5 v. 7.5 years) and were more likely to have meningeal leukemia at diagnosis (33% v. 10%). The t(8;21) translocation was associated with a 47% EMT incidence compared with 23% without the translocation. Local radiation treatment was given to 16 of 25 (64%) EMT sites.

RESULTS

The overall 5-year survival rate for all patients was 28%, and this was not significantly influenced by the drug regimen used, meningeal leukemia at diagnosis, the presence of the (8;21) translocation, M4 and M5 morphology combined, or EMT at diagnosis. Significant differences were observed in the 5-year survival rates for patients who underwent allogeneic bone marrow transplantation (52%; N = 37) and those who attained complete remission (CR) but did not undergo transplantation (21%; N = 44) and those who did not achieve complete remission with initial therapy (5%; N = 19). Systemic and local EMT CR was achieved in 17 of 18 patients with EMT, including 12 patients who underwent radiation treatment and 5 of 6 of those who did not. Isolated relapse was not seen at an EMT site and was not noted at any later stage of the disease.

CONCLUSIONS

Permanent local control at sites of EMT was achieved in all patients who attained a bone marrow CR, whether or not the site was irradiated. Local radiation treatment of an EMT site did not appear to contribute to overall CR and survival rates. The use of radiation treatment should be conservative and limited to patients in whom there is a real and immediate threat to vision or renal function or when the spinal cord is compromised.

The problem of pediatric malignancies in the developing world

In industralized countries, 70 to 80% of children with cancer can be cured by expensive interdisciplinary teamwork and by cooperation on the national or international level. As a result of poor socio-economic conditions, worldwide, less than 20% of the approximately 185,000 children developing cancer each year get adequate treatment. This is also true for 14 to 15 million children dying each year of diarrhea and infections, but while this number is decreasing, the number of children with cancer is increasing. In "middle income" developing countries, cancer is now a leading cause of death for children between 5 and 15 years of age. The "geography" of pediatric cancer reveals complex interactions between environment, lifestyle, and carcinogenesis. The "mapping" of pediatric cancer is far from complete, and the investigation of carcinogenetic interactions has barely started. A great challenge is the planning of pediatric oncology in developing countries. The goals are to improve the access to treatment and treatment results. Even if pediatric oncology has a low priority, the institution, in each country or large province, of at least one pediatric cancer unit may improve not only cancer treatment but medical care in general. By promoting education, organizing meetings, and setting minimum standards for training and care, international organizations can contribute to the development of pediatric oncology worldwide.

Granulocytic sarcoma of uterine cervix as presentation of acute myeloid leukemia: a case report and review of literature

Localized extramedullary collection of leukemic cells is termed as granulocytic sarcoma. Incidences of 2-8% in acute myeloid leukemia have been reported in various autopsy studies. In female it usually involves ovary. Since most of such tumors are asymptomatic, they are detected only at autopsy. We report here a case who manifested as abnormal vaginal bleeding, large cervical mass, renal failure, and aspergillous fungaemia. The patient died before she could be treated. From the present report it would appear that granulocytic sarcoma at times may precede other manifestations of leukemia.

Granulocytic sarcomas: clinical, diagnostic and therapeutical aspects

Granulocytic sarcomas (GS) are extramedullary tumor masses of immature myeloid cells most frequently associated with acute myeloblastic leukemia. We report our diagnostic, clinic and therapeutic approaches in the treatment of 6 patients affected by GS who presented with different localizations and symptoms: mediastinal mass with chest pain, rectal tumor with bowel occlusion, bladder mass with acute kidney failure, quadriceps tumor with pain, vertebral localization with pain and bowel mass with pain, respectively. The correct diagnosis of GS by bone biopsy, the immunohistological evaluation of the tumor masses, the prompt use of active drugs in the first line therapy schedule as for acute myeloblastic leukemia are the parameters for the achievement of the long-term remission.

Cerebrospinal fluid examination in a case of childhood orbital granulocytic sarcoma

The diagnosis of a case of childhood orbital granulocytic sarcoma, initially classified as a poorly-differentiated malignant tumor, was finally considered at the time of relapse following primary treatment with chemotherapy and local irradiation. At this time, systematic cerebrospinal fluid examination showed numerous blast cells with Auer rods, consistent with the diagnosis of meningeal acute myeloid leukemia of M2 type, and concomitant biopsy of the tumor indicated the diagnosis of chloroma. Reevaluation of the primary biopsy confirmed this diagnosis.

Extramedullary blastic transformation in a child with adult chronic myelocytic leukemia

We report a case of Philadelphia chromosome positive (Ph+) chronic myelocytic leukemia (CML) in a 4-year-old child presenting with a one-sided cervical chloroma (granulocytic sarcoma) of 5 months duration preceded by an inflammatory reaction in the same area. Blood and bone marrow were consistent with CML in chronic phase. Cytogenetic analysis of blood, bone marrow and chloroma showed, in addition to the classical Ph+ cell line, another clone with additional aberrations: 50,XY,+Y,+8,t(9;22)(q34;q11), +19,+21, present predominantly in the chloroma. In conclusion, this is the first report of a Ph+ CML in a young child with a chloroma as an isolated extramedullary localization of blastic transformation. It is hypothesized that local events such as inflammation might be inductive of extramedullary blastic transformation.