Orbital extra-medullary granulocytic sarcoma: clinicopathologic correlation with immunohistochemical features

Orbital Myeloid Sarcoma: An Initial Presentation of Acute Myeloid Leukemia With Maturation

Acute myeloid leukemia (AML) is predominantly an adult disease, with significantly lower incidence in children. Myeloid sarcoma (MS), an extramedullary manifestation of AML, can occur in various tissues, though it is exceptionally rare in the orbit. The variable nature of MS complicates its diagnosis and treatment. In this report, we present the case of an eight-year-old boy who exhibited bilateral proptosis and an orbital mass. Initial investigations revealed thrombocytopenia and leukopenia. Imaging tests confirmed an expansive retroorbital lesion. Immunohistochemistry demonstrated positivity for CD34, CD117, and myeloperoxidase (MPO). The mass was ultimately diagnosed as MS. Subsequent bone marrow analysis confirmed AML. This case highlights that MS, although rare, can serve as an initial presentation of AML in pediatric patients. Epidemiology, diagnosis, treatment, and prognosis for MS were discussed.

Orbital myeloid sarcoma treated with low-dose venetoclax and a potent cytochrome P450 inhibitor

CASE REPORT

We report the first case of orbital myeloid sarcoma that was successfully treated with a standard venetoclax dose of 25%. A 38-year-old man with acute myeloid leukemia (AML) post-haplo-hematopoietic stem cell transplantation (HSCT) presented with a nine-month history of progressive right proptosis and a visual acuity deficit. The patient was treated with venetoclax (100 mg orally on days 1-28), cytarabine (40 mg subcutaneously, days 1-10), and itraconazole (100 mg twice daily orally on days 1-28).

MANAGEMENT AND OUTCOME

The present case report shows that using cytochrome P450 (CYP) inhibitors is a helpful strategy to reduce the cost of expensive treatments.

DISCUSSION

There are limited data on the use of CYP inhibitors as a strategy to reduce the costs of expensive drugs (i.e. venetoclax). This approach has some advantages over standard dose venetoclax (400 mg/day) such as significantly reduced costs (which is relevant for patients in low-income countries). In this case, we used itraconazole-a potent CYP3A4 inhibitor-which can theoretically reduce the dose to 100 mg/day without losing serum therapeutic concentrations.

Bilateral Orbital Myeloid Sarcomas: A Unique Presentation of Acute Myeloid Leukemia

Myeloid sarcomas (MS) are solid manifestations of acute myeloid leukemia (AML) and are commonly present in children. These tumors can arise in many tissues including bone, soft tissue, or skin, and are commonly seen in the orbit. As practically all MS will, if left untreated, eventually present as AML, early diagnosis and initiation of treatment are imperative. We highlighted a case of bilateral orbital MS in a pediatric patient that presented concurrently with AML and the steps taken to diagnose and initiate treatment. Our case highlights the potentially occult presentation of AML as well as myeloid sarcoma and, therefore, the importance of swift workup and diagnosis. Epidemiology, radiographic features, diagnosis, and treatment for myeloid sarcoma and AML were discussed.

Acute Myeloid Leukemia Transformation from Myelofibrosis Upon Remission of an Orbital Myeloid Sarcoma - A Case Report

PURPOSE

To report a case of an orbital myeloid sarcoma concurrent with JAK2 mutation myelofibrosis, which rapidly transformed into acute myeloid leukemia upon aggressive treatment.

RESULTS

A 51-year-old woman had progressive swelling of periorbita for one month. Magnetic resonance imaging demonstrated a well-defined, mild enhanced mass indenting the adjacent right lateral rectus muscle and the globe. Biopsy from anterior orbitotomy revealed an orbital myeloid sarcoma. Bone marrow study showed concurrent myelofibrosis. Although the orbital lesion subsided remarkably under aggressive chemotherapy and radiotherapy, the leukemic transformation was noticed in the third month following the initial presentation.

CONCLUSION

This case demonstrated that myeloid sarcoma should be included in the differential diagnosis of orbital diseases, with or without involvement of hematological disorders. Early diagnosis and aggressive treatment as for AML are crucial as the prognosis is usually poor for adult orbital MS.

Acute unilateral proptosis in childhood: suspect myeloid sarcoma

As the first and only presenting feature of acute myeloid leukemia (AML), unilateral proptosis in children is uncommon. We report the cases of two girls who had no systemic clinical manifestations of AML. Orbital imaging showed space-occupying infiltrating lesions without surrounding bone erosion. Incisional biopsy and immunohistochemistry were diagnostic for myeloid sarcoma. Systemic workup and bone marrow examination showed features of AML. Systemic chemotherapy was administered to both children, who responded well to the treatment. Myeloid sarcoma should be kept in the differentials of the children presenting with isolated proptosis. Immunohistochemistry may provide an accurate diagnosis and early treatment may lead to a prompt recovery with a good prognosis.

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.

Myeloid Sarcoma with Megakaryoblastic Differentiation Arising in the Conjunctiva

An 87-year-old woman not known to have either a lymphoma or leukemia developed a left multinodular, fish-flesh superior epibulbar and forniceal mass. A biopsy disclosed a blastic tumor with scattered multinucleated immature megakaryoblasts. Immunophenotyping of bone marrow cells revealed strong positivity for CD7, CD31, CD43, CD45, CD61, and CD117; CD71, myeloperoxidase, and lysozyme were also positive in scattered cells. Forty percent of the neoplastic cells were Ki-67 positive. Cytogenetic studies indicated a trisomy 8 (associated with worse prognosis) and a t(12; 17) translocation. Desmin, smooth muscle actin, pancytokeratin, CAM 5.2, adipophilin, tryptase, S100, SOX10, MART1, and E-cadherin were negative, ruling out a nonhematopoietic tumor. The conjunctival lesion was diagnosed as a myeloid sarcoma with megakaryoblastic differentiation, a rare variant. It probably arose from a myelodysplastic syndrome. This is the first case of its type to develop in the conjunctiva.

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.

Orbital myeloid sarcoma in adult mimicking nasolacrimal duct obstruction: A case report

Purpose

To describe an orbital myeloid sarcoma in adult presenting with a swollen mass at inferomedial canthal area and epiphora which was misdiagnosed as nasolacrimal duct obstruction.

Observations

A 45-year-old male presented with a swollen right lower eyelid around medial canthal area for 2 months with tearing for 6 month-period earlier. Eye examination demonstrated a high tear meniscus, slightly erythematous eyelid with palpable mass closed to the lacrimal sac along the inferior orbital rim. Computed tomography scan depicted infiltrative mass at the inferomedial aspect of right orbit with bony erosion, extended to adjacent paranasal sinuses. An incisional biopsy was performed. Histopathological study revealed soft tissue which was diffusely infiltrated by monotonous medium-sized round cells resembling blasts with lymphoglandular bodies, focally positive myeloperoxidase and negative lymphoid markers. The findings were consistent with myeloid sarcoma. No systemic involvement was found. The patient underwent chemotherapy and radiation without systemic leukemic disease progression.

Conclusions and importance

Although orbital myeloid sarcoma is rare and difficult to diagnose, it can mimic nasolacrimal duct obstruction. We should consider this condition in our differential diagnosis.

Myeloid sarcoma of the orbit without systemic recurrence of disease in an adult: A clinicopathological case report

Myeloid sarcoma (MS), also known as granulocytic sarcoma (GS) or chloroma (named for the greenish hue attributed to the pigment of myeloperoxidase [MPO]), is a rare solid tumor with a predilection for the orbit. MS usually occurs in conjunction with acute myeloid leukemia (AML), myelodysplastic syndrome (MDS), or myeloproliferative disorder (MPS) and may be the harbinger of disease. Therefore, prompt diagnosis is essential for patient survival. We present a rare case of a 61 year old with an isolated orbital MS without active leukemia.

Granulocytic Sarcoma of the Orbit Presenting as a Fulminant Orbitopathy in an Adult With Acute Myeloid Leukemia

A 64-year-old woman with relapsed acute myelogenous leukemia (AML) undergoing salvage chemotherapy developed rapid onset of right-sided ophthalmoplegia, proptosis, optic neuropathy, and vision loss from 20/30 to hand motions over a 3-hour period on day 4 of her treatment. CT scan of her orbits revealed a superolateral orbital mass and periocular edema. She underwent immediate canthotomy and cantholysis, and lateral orbitotomy with debulking of the mass later the same day. The histopathology was consistent with aggregates of myeloid blasts. Her vision recovered to 20/20 on postoperative day 1. Orbital granulocytic sarcoma is a rare condition often concurrent with AML, typically in the pediatric population and rarely in adults. Presentation as a fulminant orbitopathy with rapidly progressive optic neuropathy and vision loss over several hours has not been previously reported.