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

Top Ten Lymphoproliferative Lesions Not to Miss When Evaluating Oral Ulcer Biopsies

BACKGROUND

Oral ulcers represent a full thickness loss of the mucosal epithelium leading to exposure of the submucosal connective tissue. These are common and usually self-limited lesions, although they may sometimes result from neoplasms, most commonly squamous cell carcinoma. Lymphoproliferative disorders may be difficult to diagnose in apthous ulcers since they mimic reactive inflammation.

METHODS

This review presents ten rare oral lymphoid proliferations which should not be missed when assessing oral ulcer biopsies.

RESULTS

The ten lesions include several with diagnostic cells which look similar to the histiocytes of a reactive inflammatory ulcer, including Rosai-Dorfman disease, reticulohistiocytoma, Langerhans cell histiocytosis, and traumatic ulcerative granuloma. Other lesions, such as EBV-positive mucocutaneous ulcer, extranodal marginal zone lymphoma of mucosal-associated lymphoid tissue, and plasmablastic lymphoma have lymphoid and/or plasma cell differentiation that mimic the reactive lymphocytes and plasma cells found in reactive ulcers. Two dendritic cell lesions, follicular dendritic cell sarcoma and blastic plasmacytoid dendritic cell neoplasm, both have distinct phenotypes which are required to make an accurate diagnosis.

CONCLUSION

Each of these lesions are diagnosed by evaluating their histology, along with their phenotypic profile, which is sometimes enhanced by pertinent molecular findings.

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.

Myeloid sarcoma of the oral cavity: A case report and review of 89 cases from the literature

Myeloid sarcoma is a tumor mass of immature myeloid or granulocytic cells that affects extramedullary anatomic sites, including uncommonly the oral cavity. A 24-year-old female was referred for evaluation of a fast growing painful gingival swelling lasting 2 weeks, associated with fever, fatigue, and cervical lymphadenopathy. Intraoral examination showed a bluish swelling on the right posterior lower gingiva exhibiting necrotic surface. Incisional biopsy of the gingival lesion displayed diffuse infiltration of undifferentiated tumor cells with granulocytic appearance, strongly immunopositive for CD99, myeloperoxidase and Ki-67 (60%), and negative for CD20, CD3, CD34 and TdT. Blood tests presented a severe pancytopenia, and genetic analysis confirmed the diagnosis of acute promyelocytic leukemia. The final diagnosis was of oral myeloid sarcoma associated with acute promyelocytic leukemia with t(15;17). The patient was submitted to chemotherapy but died of the disease one month later. The clinicopathologic and immunohistochemical features of the present case are compared with the 89 cases of oral myeloid sarcoma previously reported in the English-language literature.

Key words:Myeloid sarcoma, chloroma, granulocytic sarcoma, gingiva, oral, acute promyelocytic leukemia, acute myeloid leukemia.

Leukemic Oral Manifestations and their Management

Leukemia is the most common neoplastic disease of the white blood cells which is important as a pediatric malignancy. Oral manifestations occur frequently in leukemic patients and may present as initial evidence of the disease or its relapse. The symptoms include gingival enlargement and bleeding, oral ulceration, petechia, mucosal pallor, noma, trismus and oral infections. Oral lesions arise in both acute and chronic forms of all types of leukemia. These oral manifestations either may be the result of direct infiltration of leukemic cells (primary) or secondary to underlying thrombocytopenia, neutropenia, or impaired granulocyte function. Despite the fact that leukemia has long been known to be associated with oral lesions, the available literature on this topic consists mostly of case reports, without data summarizing the main oral changes for each type of leukemia. Therefore, the present review aimed at describing oral manifestations of all leukemia types and their dental management. This might be useful in early diagnosis, improving patient outcomes.

Intraoral Myeloid sarcoma with bilateral involvement: Case report

Background: Myeloid sarcoma (MS) is a solid malignant tumour associated with infiltration of immature myeloid precursor cells in an extramedullary site. The term MS has replaced the term granulocytic sarcoma and chloroma, which were used in the past. MS in the oral cavity is very uncommon, with less of 40 cases reported until recently. Case Report: We report the first case, the features, and the diagnostic sequence, of intraoral MS with bilateral palatal involvement, which presented as an initial manifestation, and preceded the appearance of acute myeloid leukemia (AML). Diagnostic confirmation of such oral mucosal lesions usually requires biopsy, histopathological examination with additional immunohistochemical investigation. MS can occur during the course of acute or chronic myelogenous leukemia, and myelodysplastic syndromes. In the vast majority of the reported cases, only one site was involved with a single intraoral MS lesion, and the cases predominantly associated with AML. Conclusion: The majority of intraoral MS occurs in patients with known AML, but in some of them, presented as an initial manifestation, and preceded the appearance of the disease. Therefore, clinicians should carefully evaluate all unusual oral lesions of unknown origin.

Granulocytic sarcoma in non-leukaemic child involving maxillary sinus with long term follow up: A rare case report

Granulocytic sarcoma (GS) is a rare extramedullary malignant tumor composed of immature myeloid cells. It is strongly associated with acute myeloid leukaemia, chronic myeloproliferative diseases. Occurrence of GS in the oral cavity is extremely uncommon. Present case reported an unusual occurrence of GS without leukemia involving maxillary sinus of a child. The patient underwent chemotherapy followed by radiotherapy with complete remission. A long-term follow-up of the patient was carried without any evidence of recurrence with special focus on diagnostic difficulties. The present case highlights the perplexity in diagnosing such lesions with emphasis on the need of careful interpretation of all clinical, radiographic, histopathological and immunohistochemical details as it is one of the most frequently misdiagnosed disorder.

A fatal case of rapid gingival enlargement: Case report with brief review

Myeloid sarcoma (MS) is a rare extramedullary tumor composed of primitive granulocytic cells. These lesions are commonly associated with other hematologic disorders such as myeloid leukemia and other myeloproliferative neoplasms. Although extremely rare in the oral cavity, this lesion was reported in gingiva, palate, buccal mucosa and extraction sockets. MS is an aggressive lesion associated with poor prognosis. Early identification and prompt treatment holds the key for increasing the disease-free period in these patients. In this context, we report a rare and aggressive case of MS, which ran a fatal course in a 45-year-old female patient.

Primary oral myeloid sarcoma: Report of a case

Myeloid sarcoma is defined as a tumor mass of immature myeloid cells that may be observed in a variety of locations including bone, skin, lymph nodes and soft tissues. However, oral involvement of myeloid sarcoma is extremely rare. These tumors are considered as specific lesions of acute myeloid leukemia. We present a case of a myeloid sarcoma of the upper vestibular gingiva in a 29-year-old woman who has no hematologic disease history. Multiple metastases were found in floor of the nasal cavity, left breast, and left lacrimal gland 12 months after primary diagnosis.

Myeloid sarcoma of the head and neck region

CONTEXT

Myeloid sarcoma of the head and neck region can pose diagnostic challenges because of the low frequency of myeloid sarcoma and the potential for tumors of almost any lineage to occur in the head and neck.

OBJECTIVE

To study the clinicopathologic and immunohistochemical characteristics of myeloid sarcoma in the head and neck region and to review the differential diagnosis.

DESIGN

We searched for cases of myeloid sarcoma involving the head and neck region for a 24-year period at our institution. The medical records and pathology slides were reviewed. Additional immunohistochemical stains were performed.

RESULTS

We identified 17 patients, age 17 to 85 years. Most tumors involved the oral cavity. Myeloid sarcoma was the initial diagnosis in 9 patients (53%); the remaining 8 patients (47%) had a history of bone marrow disease. Immunohistochemical analysis using antibodies specific for lysozyme, CD43, and CD68 were highly sensitive for diagnosis but were not specific. By contrast, assessment for myeloperoxidase in this study was less sensitive but more specific. We also used antibodies specific for CD11c and CD33 in a subset of cases, and these reagents seem helpful as well.

CONCLUSIONS

The clinical presentation of myeloid sarcoma involving the head and neck, particularly the mouth, is often nonspecific, and a high degree of suspicion for the possibility of myeloid sarcoma is needed. Immunohistochemistry is very helpful for establishing the diagnosis.

Case of pediatric acute promyelocytic leukemia presenting as extramedullary tumor of the mandible

BACKGROUND

Acute promyelocytic leukemia (APL) is a malignant subtype of acute myeloid leukemia caused by the PML-retinoic acid receptor (RAR)α fusion gene. APL may be discovered in adulthood and diagnosed after spontaneous gingival bleeding or difficulty in hemostasis after oral surgery such as tooth extraction. However, APL is extremely rare in children.

METHODS AND RESULTS

A 1-year-old boy presented with a mass on the mentum of the mandible. The marked periosteal reaction was seen on CT and MRI, leading to strong suspicion of a malignant bone-derived tumor such as a sarcoma. Chromosome banding by fluorescence in situ hybridization (FISH) showed PML-RARα, confirming the diagnosis of APL. Treatment with tretinoin was immediately initiated. No signs of recurrence have been noted 1 year after treatment.

CONCLUSIONS

We report herein a rare case involving an infant with APL who presented with an extramedullary tumor of the mandible, whom we treated with good results.

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.

[Granulocytic sarcoma in the mandibular gingiva of an HIV+ patient]

INTRODUCTION

The association between malignant tumors and HIV infection is well known. We report a rare case of gingival granulocytic sarcoma (GS) associated to HIV infection.

OBSERVATION

A 31 year-old HIV patient consulted for left maxillary tumefaction. His viral load was high (40,112 copies/ml) and CD4 count low (287cells/mm(3)). After biopsy-exeresis, histology and an immunohistochemical study confirmed the diagnosis of GS. Chemotherapy similar to that of acute myeloid leukemia (AML) completed the treatment. The remission was complete at 5 years.

DISCUSSION

Only one case of intra-oral GS associated to HIV infection has been reported so far. The clinical and radiological presentation is unspecific. Histology proves the diagnosis. The treatment is comparable to that of AML. The prognosis is usually bad.