Myeloid sarcoma of the tongue as a first manifestation of acute promyelocytic leukemia: A case report

Granulocytic sarcoma as an initial manifestation of acute promyelocytic leukemia: A case report with literature review

RATIONALE

Granulocytic sarcoma (GS) is a rare tumor consisting of myeloid blasts with or without maturation and occurs in sites other than the bone marrow. Due to its low prevalence, clinical cases and pathogenesis need to be studied. Therefore, we present a rare case of humerus GS occurring simultaneously with acute promyelocytic leukemia (APL) and studied a retrospective analysis of clinical characteristics and related treatment strategies, hoping that it could help to standardize the early diagnosis and treatment of APL/GS.

PATIENT CONCERNS

We present a case of humerus GS complicated with APL in a 22-year-old woman who experienced pain in right clavicle and shoulder for 6 months without any cause. While the aggravated pain were persistent for 2 months, causing limited movement of her right upper arm.

DIAGNOSES

The presence of tumor in her right proximal humerus and end of clavicle was revealed by positron emission tomography-computed tomography. Subsequently, the mass collected during the operation was confirmed to be GS by the pathological immunohistochemical examination. Further progression to APL was based on marrow smears, flow cytometry, fluorescence in situ hybridization, and PML/RARα gene detection.

INTERVENTIONS AND OUTCOMES

The patient underwent the tumorectomy, and then received 28-day induction therapy with all-trans retinoic acid (ATRA) (25 mg/m2/d) and arsenic trioxide. The posttreatment bone marrow smear and flow cytometry showed that she was in a complete remission. Consolidation treatment was performed with ATRA 25 mg/m2 PO BID for 2 weeks every 4 weeks and arsenic trioxide 0.16 mg/kg IV 5 days a week for 4 weeks every 8 weeks for a total of 6 cycles. Currently, the patient was routinely followed-up at an outpatient clinic, and has been maintained complete remission for 15 months.

LESSONS

We present an uncommon case of a humeral APL/GS, and conducted a comprehensive analysis of 28 cases of APL/GS. Despite the rarity of APL/GS, it should be diagnosed at an early stage. Furthermore, ATRA are recommended in the treatment plan of APL/GS.

A case report of acute promyelocytic leukemia with myeloid sarcoma of the lumbar spine and literature review

Acute promyelocytic leukemia (APL) presenting solely as myeloid sarcoma (MS) is extremely rare. This report describes a 53-year-old male who presented with low back pain and a movement disorder in his lower limbs. MRI and PET/CT scans of the lumbar spine revealed an intraspinal mass. Pathological analysis of the surgically resected mass identified it as myeloid in origin. Routine blood tests were unremarkable, and bone marrow smears and immunophenotyping showed no evidence of abnormal myeloblasts or promyelocytes. However, bone marrow aspirates testing for acute leukemia fusion genes by qPCR revealed the presence of the PML::RARA fusion. Further investigation via FISH confirmed the fusion in both the bone marrow and the extramedullary mass. The patient was ultimately diagnosed with isolated promyelocytic extramedullary sarcoma (MS/APL). Treatment with all-trans retinoic acid and arsenic trioxide alleviated the back pain and restored the patient's mobility. After 1 year of consolidation therapy, bone marrow smears confirmed sustained remission, and the PML::RARA fusion gene was undetectable. In addition to this case, we review 41 other APL patients with extramedullary sarcoma as their first symptom (MS/APL) at the time of diagnosis and provide an analysis of these cases.

Oral Myeloid Sarcoma as a Marker of Relapse in Acute Myeloid Leukemia

ABSTRACT

A 20-year-old woman with acute myeloid leukemia (AML) with monocytic differentiation in remission presented with a recent onset painful indurated swelling on the tongue with fever. Although her peripheral blood picture was normal, the bone marrow biopsy was suggestive of a relapse of AML. A biopsy from the tongue lesion showed diffuse infiltration of lamina propria and submucosa by blast cells, positive for myeloperoxidase and CD11c and suggestive of oral myeloid sarcoma (MS). This presents an uncommon site of occurrence of MS and was a marker of relapse of AML. This case highlights the variable presentation of MS. It should prompt investigation for relapse of hematological malignancy in the bone marrow even in the absence of evidence from peripheral blood.

Dysphagia as an Initial Presentation of Acute Myeloid Leukemia: A Rare Presentation of Myeloid Sarcoma

Myeloid sarcoma (MS) represents a unique clinical presentation of acute myeloid leukemia (AML). This report describes a case of MS in a 66-year-old man who presented with dysphagia, nausea, vomiting, anorexia, and fatigue. Generalized lymphadenopathy was noted on physical exam and confirmed by CT scans which also showed diffuse esophageal wall thickening. Axillary lymph node biopsy was positive for MS. Bone marrow biopsy confirmed AML with 88% blasts. The patient received induction chemotherapy with decitabine and venetoclax and was planned for four cycles of treatment over three months while monitoring the response.

Case Report: Extramedullary Acute Promyelocytic Leukemia: An Unusual Case and Mini-Review of the Literature

Background

Acute promyelocytic leukemia (APL) constitutes a serious hematological emergency necessitating rapid diagnosis and therapy to prevent lethal bleedings resulting from APL-induced thrombocytopenia and coagulopathy. Atypical manifestations of APL, such as extramedullary disease at first presentation, pose diagnostic challenges and delay the onset of appropriate therapy. Nevertheless, extramedullary manifestations of APL are mostly accompanied by blood count alterations pointing to an underlying hematological disease. In this report, we present the first case of APL bearing close resemblance to a metastasized laryngeal carcinoma with normal blood counts and absent coagulopathy.

Case Presentation

A 67-year-old man with a previous history of smoking was admitted to our hospital with progressive hoarseness of voice, odynophagia, dysphagia and exertional dyspnea. Laryngoscopy revealed a fixed right hemi larynx with an immobile right vocal fold. Imaging of the neck via magnetic-resonance imaging (MRI) and positron emission tomography–computed tomography (PET/CT) with F-18-fluordeoxyglucose (FDG) showed a large hypermetabolic tumor in the right piriform sinus and tracer uptake in adjacent lymph nodes, highly suspicious of metastasized laryngeal carcinoma. Surprisingly the histological examination revealed an extramedullary manifestation of acute promyelocytic leukemia. Remarkably, blood counts and coagulation parameters were normal. Moreover, no clinical signs of hemorrhage were found. PML-RARA fusion was detected in both laryngeal mass and bone marrow. After diagnosis of APL, ATRA-based chemotherapy was initiated resulting in complete remission of all APL manifestations.

Conclusions

This is the first case report of APL initially presenting as laryngeal chloroma. Additionally, we performed a comprehensive literature review of previously published extramedullary APL manifestations. In aggregate, a normal blood count at first presentation constitutes an extremely rare finding in patients initially presenting with extramedullary APL manifestations.

Acute Promyelocytic Leukemia Presenting With a Myeloid Sarcoma of the Spine: A Case Report and Literature Review

Myeloid sarcoma is a rare extramedullary tumor of immature myeloid cells. Certain known acute myeloid leukemia cytogenetic abnormalities, in particular t(8,21), has been associated with a higher incidence. Myeloid sarcoma, which rarely happens in acute promyelocytic leukemias, is more common in recurrent patients after the advent of all-trans retinoic acid (ATRA) and are rare in untreated acute promyelocytic leukemia. We described a case of, to our knowledge, de novo myeloid sarcoma of the spine confirmed as acute promyelocytic leukemia. Myeloid sarcoma is diagnosed by spinal tumor biopsy, and microscopic examination of a bone marrow smear and cytogenetic analysis led to a confirmed diagnosis of acute promyelocytic leukemia.

Myeloid sarcoma of the colon as initial presentation in acute promyelocytic leukemia: A case report and review of the literature

BACKGROUND

Myeloid sarcoma (MS) rarely occurs in acute promyelocytic leukemia (APL) at onset, but it can develop in relapse cases, especially after APL treated with all-trans retinoic acid (ATRA). Therefore little is known about the clinical features and suitable treatment for APL related MS due to the rarity of the disease, although this may be different from the treatment and prognosis of MS in the relapse stage. To our best knowledge, this is the second case report of APL initial presentation as colon MS.

CASE SUMMARY

A 77-year-old woman complained of intermittent right lower abdominal pain, black stool, and difficult defecation for 2 mo. Physical examination showed diffuse tenderness during deep palpation and an anemic appearance. Laboratory findings showed positivity for fecal occult blood testing; white blood cell count: 3.84 × 10⁹/L; hemoglobin: 105 g/L; platelet count: 174 × 10⁹/L; and negativity for tumor markers. Abdominal enhanced computed tomography showed a space occupying lesion in the colon (1.9 cm). Fibrocolonoscopy revealed a polypoid and ulcerated mass measuring 2.5 cm. The tumor was removed. To our surprise, MS was confirmed by immunohistochemistry. PML/RARα fusion gene was detected in colon specimens by fluorescent in situ hybridization and real-time reverse transcription polymerase chain reaction, which was consistent with the bone marrow. She was diagnosed as having APL related MS. A smooth and unobstructed intestinal wall was found by fibrocolonoscopy, and continuous molecular remission was confirmed in both the bone marrow and colon after four courses of ATRA + arsenic trioxide (ATO). ATRA + ATO showed a favorable therapeutic response for both APL and MS.

CONCLUSION

Early use of ATRA can benefit APL patients, regardless of whether MS is the first or recurrent manifestation.

Myeloid sarcoma in the tongue

Leukemic cells are rarely present in the oral cavity, and there are very few reports regarding such cases. However, we identified some reports of leukemic cells infiltrating tissues in the oral cavity, including gingival involvement. Recurrent painful oral ulcerations and prominent generalized periodontal destruction are the most common oral features of neutrophil disorders, and they may even be the initial symptoms of the disease. The ulcers may affect any part of the oral mucosa, including the tongue and palate. The objective of this report is to describe and discuss a case of myeloid sarcoma in the oral cavity of a 48-year-old male patient.