Granulocytic sarcoma of the female genital tract: a clinicopathologic study of 11 cases

Bilateral adnexal masses: A case report of acute myeloid leukemia presenting with myeloid sarcoma of the ovary and review of literature

•We report a case of a patient with acute myeloid leukemia (AML) presenting as myeloid sarcoma.•This patient with bilateral adnexal masses was managed via total robotic hysterectomy with bilateral salpingo-oophorectomy.•There are a limited number of reports of bilateral ovarian occurrences that exist in the literature.•Myeloid sarcoma of the ovaries may present with vaginal bleeding to dysmenorrhea, dysuria, and palpable abdominal mass.

RNA sequencing of myeloid sarcoma, shed light on myeloid sarcoma stratification

BACKGROUND

Myeloid sarcoma (MS) is a rare, extramedullary tumor consisting of myeloid blasts. Little is known about the genetic background of MS and the prognostic value of genetic abnormalities in MS. In particular, the broad variety of gene fusions that occur in MS is marginally covered by traditional testing methods due to lack of fresh tumor specimens.

METHODS

Here, we analyzed the clinical and genetic features of 61 MS cases. We performed RNA sequencing (RNA-seq) on formalin-fixed paraffin-embedded (FFPE) or fresh samples to analyze fusion genes in 26 cases. In addition, we performed genetic abnormalities-based risk stratification using fusion genes and gene mutations.

RESULTS

A total of 305 fusion genes were identified in 22 cases, including the following five recurrent fusion genes: RUNX1-RUNX1T1, CBFβ-MYH11, ETV6-MECOM, FUS-ERG, and PICALM-MLLT10. The prognosis in the adverse-risk group was significantly worse than that in the favorable/intermediate-risk group (median survival: 12 months vs. not reached; p = 0.0004).

CONCLUSION

These results indicated the efficacy of RNA-seq using FFPE-derived RNA as a clinical routine for detecting fusion genes, which can be used as markers for risk stratification in MS.

Myeloid sarcoma arising at the uterine cervix in a patient with intestinal Behçet's disease and concurrent myelodysplastic syndrome: A case report

INTRODUCTION

Myeloid sarcoma (MS) is an extramedullary tumor that consists of myeloblasts and rarely involves the female reproductive organs. Intestinal Behçet's disease (BD) is a chronic, inflammatory illness that is often associated with myelodysplastic syndrome (MDS). When MDS is diagnosed, some patients with intestinal BD experience synchronous gastrointestinal flares.

CASE PRESENTATION

We report the case of a 49-year-old woman who presented with vaginal bleeding and an incidentally identified MS in the uterine cervix. Subsequent bone marrow biopsy showed simultaneous MDS without chromosomal abnormalities. This is the first reported case of concomitant MS, myelodysplastic disease, and intestinal BD.

CONCLUSIONS

The accurate diagnosis of MSs that develop at non-predominant sites is crucial for a positive patient prognosis. MDS should be suspected in patients with a history of intestinal BD diagnosed with MS.

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.

Myeloid sarcoma of uterine cervix: A case report with review of the literature

•

Myeloid sarcoma of uterine cervix is very uncommon and can be the initial presentation of acute myeloid leukaemia.

•

Myeloid sarcoma can mimic other malignant tumours arising in the cervix and can therefore pose a diagnostic challenge.

•

Myeloid sarcoma should be considered in the differential diagnosis of undifferentiated malignant tumours arising in the gynaecological tract.

Myeloid sarcoma is a rare clinical entity, characterised by the extramedullary presence of myeloblasts. It can occur de novo or signify disease recurrence. Involvement of the female reproductive tract is uncommon, with most cases involving the uterine corpus or ovary. Patients with non-leukaemic myeloid sarcoma are treated with acute myeloid leukaemia (AML) regimens, but the optimal therapy is unclear due to the relative rarity of the condition and lack of clinical trial data. We present an unusual case of myeloid sarcoma of the uterine cervix diagnosed incidentally in a patient with cervical-intraepithelial neoplasia grade 2 (CIN2), followed by a literature review.

Rare Pediatric Vaginal Granular Cell Tumor: A Case Report

BACKGROUND

Granular cell tumors (GCTs) are usually benign and occur primarily in the trunk and head. Vaginal tumors are rare, particularly in children.

CASE

A 9-year-old girl was admitted with irregular vaginal bleeding for 1 year. The bleeding had worsened in the previous 1 month. B-ultrasound and computed tomography showed a round mass in the vagina. We performed vaginoscopy using a hysteroscopic exploration and tumor resection via an open technique. The pathology of the resected tumor confirmed a vaginal wall GCT. No recurrence was noted in the following 16 months.

SUMMARY AND CONCLUSION

To our knowledge, our prepubescent girl is the youngest patient with GCT in the literature. Histopathological evaluation and complete tumor resection with clear margins is the primary treatment for benign or malignant GCTs.

Bilateral ovarian granulocytic sarcoma as the primary manifestation of acute myelogenous leukemia treated with allogenic stem cell transplantation: A case report

RATIONALE

Granulocytic sarcoma (GS), also known as chloroma, is a tumor comprising myeloblasts or monoblasts, potentially occurring as an extramedullary mass. Systemic chemotherapy should be used to induce complete remission. However, such patients with chloroma have a poorer treatment outcome than those without extramedullary myeloid sarcomas.

PATIENT CONCERNS

A 30-year-old woman who initially presented with bilateral ovarian masses and splenomegaly was admitted to hospital. Also, her complete blood cell counts showed pancytopenia and blood smear revealed a few immature cells (3%).

DIAGNOSES

A bone marrow biopsy demonstrated acute myelomonocytic leukemia, and the chromosomal analysis revealed a 46, XX, del18 (p11) [20] karyotype and cytogenetics and molecular markers showed all negative results.

INTERVENTIONS

Since this diagnosis, she received remission-inducing chemotherapy comprising anthracycline and cytarabine, which is a standard regimen for acute myeloid leukemia (AML), and followed by allogenic hematopoietic stem cell transplantation from Human leukocyte antigen (HLA)-identical sibling donor.

OUTCOMES

After transplantation, the bone marrow engrafted successfully without complications. She visited our clinic regularly with no evidence of leukemia relapse or graft-versus host disease.

LESSONS

This report represents the first case of ovarian GS, wherein treatment was successful with high-dose chemotherapy, followed by allogenic hematopoietic stem cell transplantation without oophorectomy.

Vulvar myeloid sarcoma as the presenting symptom of acute myeloid leukemia: a case report and literature review of Chinese patients, 1999-2018

BACKGROUND

Myeloid sarcoma (MS), which represents a rare malignancy that comprises of myeloid blasts occurring at extra-medullary sites, closely correlates with the onset and relapse of acute myeloid leukemia (AML) and other hemopoietic neoplasm. Female genital system is an uncommon location of MS, with the vulvar MS being even rarer that only eight cases have been reported in English-written literature.

CASE PRESENTATION

A 47-year-old woman presented with chronic ulceration on her vulva for one and a half month. Microscopic examination of incisional biopsy revealed dermal infiltration of myeloid precursor cells, which were positive for MPO, lysozyme, CD43, CD68, CD38 and CD117. Bone marrow flowcytometric analysis showed myeloblast count of 74%, which expressed CD13, CD33, CD117 and HLA-DR. A diagnosis of AML (M2 type) was made and vulvar MS was the earliest symptom. The patient achieved complete remission after chemotherapy with no evidence of recurrence in a 27-month follow-up. We reviewed the literature and identified 54 cases of Chinese patients with gynecological MS between 1999 and 2018, and discovered that in Chinese population, MS most frequently involved uterine cervix followed by the ovary and vulva, and ovarian MS onset much earlier than other sites. Remarkably, vulvar MS exhibited a high rate of concurrent AML and secondary myeloid leukemia within a short time of its occurrence. Despite its limited distribution, MS should be tackled aggressively with chemotherapy followed by allogeneic hematopoietic stem cell transplantation if the appropriate donor is available.

CONCLUSIONS

Female genital MS, especially vulvar MS, should be included in the differential diagnosis of gynecological neoplasm, which will facilitate its early diagnosis and prompt management.

Imaging features of immune-mediated genitourinary disease

PURPOSE

Imaging features of immune-mediated genitourinary diseases often overlap, and the same disease may manifest in different ways, so understanding imaging findings in the context of the patient's entire clinical picture is important in providing the correct diagnosis.

METHODS

In this article, diseases mediated by the immune system which affect the genitourinary system are reviewed. Examples of immune-mediated genitourinary disease including IgG4-related disease, post-transplant lymphoproliferative disorder, immunodeficiency-associated lymphoproliferative disorder due to immunosuppressive and immunomodulatory medications, lymphoma, leukemia, myeloma, amyloidosis, and histiocytosis.

RESULTS

Clinical and imaging features will be presented which may help narrow the differential diagnosis for each disease.

CONCLUSION

Recognition of immune-related genitourinary disease is important for appropriate medical management as they may mimic other diseases both by imaging and clinical presentation.

Female Genital Tract Involvement in Acute Lymphoblastic Leukemia: A Rare Case Report

Female Genital Tract (FGT) involvement with hematologic neoplasms is uncommon and the hematologic malignancies which involve the female genital organs are usually non-Hodgkin's lymphoma. Involvement of the uterus and cervix with Acute Lymphoblastic Leukaemia (ALL) is extremely rare, and ovarian involvement is even rarer. We report the case of a young lady who presented with tubo-ovarian mass, excessive post-operative bleeding (post-total abdominal hystrerctomy and bilateral salpingo-oophorectomy) and was diagnosed to have ALL with blood and tissue involvement by histopathology and flow cytometry.

Non-leukemic myeloid sarcoma involving the vulva, vagina, and cervix: a case report and literature review

Myeloid sarcoma (MS) is defined as a tumor mass consisting of myeloid blast with or without maturation occurring at an anatomical site other than bone marrow with normal architectural effacement. It can also precede the onset of leukemia which is called non-leukemic MS. Non-leukemic MS is a kind of rare disease and easy to be misdiagnosed as other common malignancies due to the rarity and nonspecific manifestation. We herein report an unusual case of non-leukemic MS involving the vulva, vagina, and cervix in a female patient. The bone marrow aspiration and biopsy of the patient revealed no hematological abnormality. Immunohistochemical staining of the biopsies was strongly positive for myeloperoxidase, CD68, leukocyte common antigen (LCA), CD117, CD34, CD38, CD79a, and negative for cytokeratin (CK), epithelial memberane antigen (EMA), CD2, CD3, CD20, CD5, CD138. Then a diagnosis of non-leukemic MS was made. Unfortunately, our patient received only one cycle of chemotherapy consisting of cytosine arabinoside and daunorubicin, then refused any further treatment and died 4 months after diagnosis. Although systemic chemotherapy is widely accepted to be a promising strategy, its benefit still needs to be further assessed. Certain questions still need to be answered for this disease: 1) Why can approximately 20% of the patients with non-leukemic MS remain disease-free after local therapy alone? 2) How many cycles of chemotherapy are needed for these patients after achievement of complete remission? 3) What are the prognostic or risk factors in these patients who have no abnormality of karyotype, fusion genes, or gene mutation to predict responsiveness to chemotherapy and outcome? 4) What is the risk factor for relapse? The rarity of non-leukemic MS makes it almost impossible to conduct large-scale randomized trials, but judicious study for each patient with MS is helpful for a further understanding of the nature of the disease.

Vulvar sarcomas: Short guideline for histopathological recognition and clinical management. Part 2

Malignant tumors of the female reproductive system are a serious health and social problem, as they are the second most common cause of death among women, after breast cancer. Vulvar tumors represent only 4% of all gynecological neoplasms, and they are fourth in frequency after tumors of the cervix, uterus, and ovary. Ninety-eight percent of all vulvar tumors are benign and only 2% are malignant. Sarcomas of the vulva comprise approximately 1–3% of all vulvar cancers. They are characterized by rapid growth, high metastatic potential, frequent recurrences, aggressive behavior, and high mortality rate. In Part 1 of this paper, we presented the most common forms of sarcoma of the vulva: leiomyosarcoma, epithelioid sarcoma, malignant rhabdoid tumor, and rhabdomyosarcoma. The second part of this review will focus mainly on the rarest variants of vulvar sarcoma: low-grade fibromyxoid sarcoma, synovial sarcoma, monophasic synovial sarcoma, carcinosarcoma, Ewing sarcoma, myeloid sarcoma, dermatofibrosarcoma protuberans, malignant fibrous histiocytoma, angiomatoid fibrous histiocytoma, liposarcoma, malignant peripheral nerve sheath tumor, and malignant mesothelioma.

Primary vaginal myeloid sarcoma: a rare case report and review of the literature

Myeloid sarcoma (chloroma, granulocytic sarcoma, or extramedullary myeloid tumour) is an extramedullary mass forming neoplasm composed of myeloid precursor cells. It is usually associated with myeloproliferative disorders but very rarely may precede the onset of leukemia. Here, we are presenting a rare case of primary vaginal myeloid sarcoma in a geriatric female patient without initial presentation of acute myeloid leukemia (AML). A 68-year-old female patient with ECOG Performance Score of 1 presented with pervaginal bleeding for 20 days. On colposcopic examination, she was found to have mass in the anterior fornix of vagina. A punch biopsy specimen revealed chloromatous infiltration of the vagina. LCA (leukocyte common antigen), MPO (myeloperoxidase), and c-kit were strongly positive on IHC (immunohistochemistry). The patient's routine blood investigations were normal including peripheral smear, lactose dehydrogenase, uric acid, 2D echocardiography, conventional cytogenetics, bone marrow aspiration, and biopsy. The patient was given 4 cycles of decitabine (Decitex, manufactured by Sun Pharmaceutical Industries Limited, India), 20 mg/m(2) for 5 days at an interval of 28 days. There was a partial response to decitabine according to RECIST criteria. As decitabine therapy was well tolerated, we are continuing in the same way until disease progression without any complications. The patient is undergoing regular follow-up at our centre.

Granulocytic Sarcoma of the Stomach Presenting as Dysphagia during Pregnancy

Granulocytic sarcoma also known as extramedullary myeloid sarcoma or chloroma is an uncommon manifestation of leukemia and presents as a deposit of leukemic cells outside the bone marrow. We report a case of a twenty-five-year-old pregnant woman who presented with progressive dysphagia and recurrent postprandial vomiting. Upper GI endoscopy had shown large flat laterally spread nodular lesions in the cardia and proximal body of stomach. Biopsies from the gastric lesion showed granulocytic sarcoma of the stomach. Concurrent peripheral and bone marrow picture was suggestive of acute myeloid leukemia (AML–M4). There is limited reported literature on granulocytic sarcoma of the stomach. Concurrent gastric granulocytic sarcoma involving cardia and AML in pregnancy has not been reported till date.

Isolated vaginal myeloid sarcoma in a 16-year-old girl

Involvement of the female genital tract by myeloid sarcoma as the initial presentation is extremely uncommon, especially in the vagina. The lack of specific histologic features and the unusual location can be a diagnostic challenge to both the surgical pathologist and the clinician. The very few reported cases of myeloid sarcoma occurring in the vagina have been exclusively seen in adults. We report a 16-year-old girl who presented with a vaginal mass of 4 weeks duration. The initial clinical impression was a Bartholin cyst vs an abscess. However, because of persistence of the vaginal mass after a full course of antibiotic treatment, a biopsy was performed. Immunohistochemistry supported the diagnosis of myeloid sarcoma. Peripheral blood and bone marrow studies were normal. The patient received 4 cycles of chemotherapy and remained disease free 5 months from therapy completion. The clinical course, diagnostic workup, and differential diagnosis of our patient are discussed. Reported cases of myeloid sarcoma occurring in the vagina are reviewed and summarized.

Chloroma/Granulocytic sarcoma: abdominal & pelvic presentation of acute myelogenous leukemia

There is limited literature documenting granulocytic sarcoma of the colon. We report a case of a 28 year-old female with a colonic granulocystic sarcoma of the colon as a complication of AML, as it is an important consideration with surgical management of typhilitis.

Myeloid sarcoma of the vagina: a report of 2 cases

OBJECTIVE

To describe 2 cases of myeloid sarcoma of the vagina, in a patient without a history of acute myeloid leukemia (AML) and in another whose condition was previously diagnosed with AML.

MATERIALS AND METHODS

The clinical histories of 2 patients whose conditions were diagnosed with myeloid sarcoma of the vagina were obtained from their medical records.

RESULTS

Case 1: A 77-year-old woman with no systemic illnesses presented with a vaginal lump. Clinically, there was a 6-cm periurethral mass that was examined by biopsy. The histopathologic specimen was evaluated on routine and immunohistochemical stains, and myeloid sarcoma was diagnosed after extensive immunohistochemical analysis. The patient was treated with pelvic radiation. She developed extensive myeloid sarcoma of the skin and AML 4.5 months later; she died 2 weeks later, 5 months after the initial presentation. Case 2: A 36-year-old woman with a known history of AML who has had multiple leukemic and extramedullary recurrences presented with a pelvic mass. Physical findings revealed large masses in the vagina and rectovaginal septum, which were confirmed as myeloid sarcoma after biopsy and histologic examination. The patient was treated with pelvic/vaginal radiation. Five months later, she had another leukemic relapse and died within 1 day of palliative chemotherapy.

CONCLUSIONS

Myeloid sarcoma of the vagina is extremely rare. Most patients have a poor prognosis and either have a history of or will subsequently develop AML.

Successful treatment of a granulocytic sarcoma of the uterine cervix in complete remission at six-year follow-up

Background. Localized granulocytic sarcoma of the uterine cervix in the absence of acute myelogenous leukemia (AML) at presentation is very rare, its diagnosis is often delayed, and its prognosis almost always ominous evolving into refractory AML. Case. We present the case of a 30-year-old woman with vaginal bleeding and a large cervical mass. Further evaluation confirmed the presence of a granulocytic sarcoma but failed to reveal systemic involvement. Results. AML type chemotherapy followed by radiotherapy of the uterus led to a durable complete remission. She remains in complete remission six years after diagnosis. Conclusion. Granulocytic sarcoma of the cervix is a rare entity for which early intensive AML type therapy is effective.

Postmenopausal bleeding as first sign of an acute myelogenous leukaemia: A case report and review of the literature

Postmenopausal bleeding (PMB) can have various causes and malignancy must always be excluded. Extramedullary manifestations of a haematological disease in the female genital tract are rare. We present the case of a woman with PMB as the first sign of an acute myelogenous leukaemia (AML). An 81-year-old patient presented with PMB. Manual and colposcopic examination raised suspicion of a cervical carcinoma, but histopathology and cervical Pap smear altered the diagnosis to granulocytic sarcoma (GS), an extramedullary manifestation of AML. The patient had a normal blood count 2 weeks prior to the examination, but at the time of presentation her leukocytes had risen to 116000/microl. The patient died 3 days later due to a pulmonary embolism, most probably as a result of leukostasis. In this case, GS of the cervix was the first sign of the AML with simultaneous appearance of leukocytosis and peripheral blasts. PMB was the reason for presentation. GS of the female genital tract is very rare and diagnosis is challenging, especially on the basis of the Pap smear. Abnormal inflammatory cells must be a warning sign and an indication for further examinations. GS as the presenting sign of AML has a poor prognosis with only 6% of patients surviving for more than 2 years.

Primary Granulocytic Sarcoma of Ovary—A Rare Presentation

Granulocytic sarcomas (GS) are rare extra medullary tumors composed of myeloid progenitor cells. Bones, lymph nodes and skin are favored sites of involvement. Primary involvement of the ovary is exceedingly rare leading to under diagnosis of GS. We report on a 19-year-old woman who presented with an ovarian mass without any underlying hematologic disorder. A high index of suspicion aided by immunohistochemistry established the correct diagnosis.

Apoptosis-inducing high (.)NO concentrations are not sustained either in nascent or in developed cancers

Nitric oxide ((.)NO) induces apoptosis at high concentrations by S-nitrosating proteins such as glyceraldehyde-3-phosphate dehydrogenase. This literature analysis revealed that failure to sustain high (.)NO concentrations is common to all cancers. In cervical, gastric, colorectal, breast, and lung cancer, the cause of this failure is the inadequate expression of inducible nitric oxide synthase (iNOS), resulting from the inhibition of iNOS expression by TGF-beta1 at the mRNA level. In bladder, renal, and prostate cancer, the reason for the insufficient (.)NO levels is the depletion of arginine, resulting from arginase overexpression. Arginase competes with iNOS for arginine, catalyzing its hydrolysis to ornithine and urea. In gliomas and ovarian sarcomas, low (.)NO levels are caused by inhibition of iNOS by N-chlorotaurine, produced by infiltrating neutrophils. Stimulated neutrophils express myeloperoxidase, catalyzing H2O2 oxidation of Cl- to HOCl, which N-chlorinates taurine at its concentration of 19 mM in neutrophils. In squamous cell carcinomas of the skin, ovarian cancers, lymphomas, Hodgkin's disease, and breast cancers, low (.)NO concentrations arise from the inhibition of iNOS by N-bromotaurine, produced by eosinophil-peroxidase-expressing infiltrating eosinophils. Eosinophil peroxidase catalyzes the H2O2 oxidation of Br- to HOBr, which N-brominates taurine to N-bromotaurine at its concentration of 15 mM in eosinophils. In microvascularized tumors, the (.)NO concentration is further depleted; (.)NO is rapidly consumed by red blood cells (RBCs) through S-nitrosation of RBC glutathione and hemoglobin, and by oxidation to nitrate by RBC oxyhemoglobin. Angiogenesis-inhibiting antibodies are currently used to treat cancers; their mode of action is not, as previously thought, reduction of the tumor O2 or nutrient supply. They actually decrease the loss of (.)NO to RBCs.

[A granulocytic sarcoma of right uterine adnexa region as an extramedullary relapse in a patient with chronic myeloid leukemia.]

Granulocytic sarcoma of the uterine adnexa is a rare event. A 50-year-old woman, who had previously been diagnosed as chronic myeloid leukemia (CML), but had a complete hematologic response, presented with lower abdominal pain and a large pelvic mass involving the right uterine adnexa region and extending to the right posterior wall of the bladder and right distal ureter. A biopsy of the uterine adnexa revealed granulocytic sarcoma, and a subsequent bone marrow biopsy confirmed the diagnosis of CML in the blastic phase.

Myeloid sarcomas: a histologic, immunohistochemical, and cytogenetic study

Context. -

Myeloid sarcoma (MS) is a neoplasm of immature granulocytes, monocytes, or both involving any extramedullary site. The correct diagnosis of MS is important for adequate therapy, which is often delayed because of a high misdiagnosis rate.

Objective. -

To evaluate the lineage differentiation of neoplastic cells in MS by immunohistochemistry, and to correlate the results with clinicopathologic findings and cytogenetic studies.

Design. -

Histologic and immunohistochemical examinations were performed on formalin-fixed paraffin-embedded tissue samples from 13 cases of MS. They were classified according to the World Health Organization criteria. Chromosomal analysis data were available in 11 cases. Clinical, pathological, and cytogenetic findings were analyzed.

Results. -

The study included six male and seven female patients with an age range of 25 to 72 years (mean, 49.3 years) and a male to female ratio of 1:1.2. MS de novo occurred in 4/13 (31%) of cases examined. The most sensitive immunohistochemical markers were CD43 and lysozyme present in all cases with MS (13/13, 100%). All de novo MS showed a normal karyotype, monoblastic differentiation, and lack of CD34. The most common chromosomal abnormalities in MS associated with a hematopoietic disorder were trisomy 8 and inv(16) (2/11, 18%).

Conclusion. -

An immunohistochemical panel including CD43, lysozyme, myeloperoxidase (MPO), CD68 (or CD163), CD117, CD3 and CD20 can successfully identify the vast majority of MS variants in formalin-fixed paraffin-embedded tissue sections. The present report expands the spectrum of our knowledge showing that de novo MS has frequent monoblastic differentiation and frequently carries a normal karyotype.

Granulocytic sarcoma: 32 cases and review of the literature

Thirty-two cases of granulocytic sarcoma (GS) are reported in this paper. Age range was from 16 - 70 years. GS was accompanied by AML in 13 cases, ALL (My+) in one case, CML in 11 cases and MDS in two cases. GS was diagnosed simultaneously with leukemia in five cases and preceded the leukemia in eight. Lymph node and soft tissue were the most commonly detected localizations. Seven cases had first been diagnosed as NHL. Histopathologically blastic, immature and mature variants were found in 11, nine and 11 cases respectively and overall survival was shortest in the blastic type. Myeloperoxidase and lysozyme were found to be positive in 30 and 24 cases respectively. Therapy was radiation in five cases and surgery in three. Systemic chemotherapy was given to the cases. The clinical outcome of the patients after the diagnosis of GS was poor. GS is a unique entity; prognosis is poor but it is important to detect the signaling pathways associated with migration of myeloid cells to the extra-medullary tissues. The critical factors for detecting this interesting tumor are to be aware of this disease, cooperation between clinician and pathologist and the application of special stains to detect the myeloid origin.

Therapy-related, mixed-lineage leukaemia translocation-positive, monoblastic myeloid sarcoma of the uterus

Myeloid sarcomas are tumour masses of myeloid leukaemic cells at extramedullary sites. These tumours can, on occasion, occur without concurrent or antecedent leukaemia. Myeloid sarcomas have been described at unusual locations including the female genital tract. An unusual case of therapy-related acute myeloid leukaemia (t-AML) presenting as isolated monoblastic myeloid sarcoma of the uterus in a patient who had received adjuvant chemotherapy for breast cancer is presented. Fluorescence in situ hybridisation analysis performed on paraffin-wax-embedded tumour tissue revealed a mixed-lineage leukaemia (MLL) gene rearrangement, supporting the association of this malignancy with prior chemotherapy. This case illustrates that t-AML can rarely present as isolated extramedullary tumours, and the detection of specific chromosomal abnormalities in these myeloid sarcomas can be useful for risk assessment and guiding definitive therapy.

[Ovary tumor in chronic myeloid leukaemia. Case report]

Granulocytic sarcoma or chloroma is a neoplasia consisting of myeloid precursors in an extramedullary site. Its appearance in chronic myeloid leukaemia is unusual. We report a case of ovary tumor associated with chronic myeloid leukaemia in chronic phase.

Myeloid sarcoma: clinico-pathologic, phenotypic and cytogenetic analysis of 92 adult patients

Myeloid sarcoma (MS) is a rare neoplasm whose knowledge is largely based on case reports and/or technically dated contributions. Ninety-two MSs in adulthood with clinical data available were evaluated both morphologically and immunohistochemically. Seventy-four cases were also studied by fluorescent in situ hybridization on tissue sections and/or conventional karyotyping on bone marrow or peripheral blood. Histologically, 50% of the tumors were of the blastic type, 43.5% either monoblastic or myelomonocytic and 6.5% corresponded to different histotypes. CD68/KP1 was the most commonly expressed marker (100%), followed by myeloperoxidase (83.6%), CD117 (80.4%), CD99 (54.3%), CD68/PG-M1 (51%), CD34 (43.4%), terminal-deoxy-nucleotidyl-transferase (31.5%), CD56 (13%), CD61/linker for activation of T cells (2.2%), CD30 (2.2%) and CD4 (1.1%). Foci of plasmacytoid monocyte differentiation were observed in intestinal cases carrying inv16. Chromosomal aberrations were detected in about 54% of cases: monosomy 7(10.8%), trisomy 8(10.4%) and mixed lineage leukemia-splitting (8.5%) were the commonest abnormalities, whereas t(8;21) was rare (2.2%). The behavior was dramatic irrespective of presentation, age, sex, phenotype and cytogenetics. Most if not all, long survivors received bone-marrow transplantation. The present report expands the spectrum of our knowledge showing that MS has frequent monoblastic/myelomonocytic differentiation, displays distinctive phenotypic profile, carries chromosomal aberrations other than t(8;21), and requires supra-maximal therapy.

Immunohistochemistry as a diagnostic aid in the evaluation of ovarian tumors

Aspects of immunohistochemistry (IHC), which are useful in the diagnosis of ovarian tumors (mostly neoplasms but also a few tumor-like lesions), are discussed. The topic is first approached by considering the different growth patterns and cell types that may be encountered. Then a few other specific situations in which IHC may assist are reviewed. Selected findings largely, or only, of academic interest are also mentioned. One of the most common situations in which IHC may aid is in the evaluation of tumors with follicles or other patterns which bring a sex cord-stromal tumor into the differential. The distinction between a sex cord tumor and an endometrioid carcinoma with sex-cord-like patterns may be greatly aided by the triad of epithelial membrane antigen (EMA), inhibin, and calretinin, the latter two being typically positive and EMA negative in sex cord tumors, the converse being typical of endometrioid carcinoma. It should be emphasized that granulosa cell tumors may be inhibin negative and, albeit less specific, calretinin is more reliable in evaluating this particular issue. Lack of staining for inhibin and calretinin may also be supportive in leading to consideration of diverse other neoplasms that may form follicles, including metastatic tumors as varied as carcinoid and melanoma. The well-known staining of the latter neoplasm for S-100 protein and HMB-45 may be very helpful in evaluating melanomas with follicular or other unusual patterns, a challenging aspect of ovarian tumor interpretation. The most common monodermal teratoma, struma ovarii, usually has an overt follicular pattern and is easily recognized, but recognition of unusual appearances ranging from oxyphilic to clear cell to various patterns of malignant struma may be greatly aided by a thyroglobulin or TTF 1 stain. IHC for neuroendocrine markers may assist in the diagnosis of primary and metastatic carcinoid tumor. The broad differential diagnosis of glandular neoplasms with an endometrioid-pseudoendometrioid morphology, or mucinous cell type, has been the subject of much exploration in recent years, particularly the distinction between primary and metastatic neoplasms. The well-known CK7 positive, CK20 negative phenotype of primary endometrioid carcinoma, and the converse profile in most metastatic large intestinal adenocarcinomas with a pseudoendometrioid morphology, has been much publicized but albeit an appropriate supportive adjunct in many cases, exceptions from the typical staining pattern may be encountered. It is even less helpful in the case of primary versus metastatic mucinous neoplasia. Evaluation of the expression of mucin gene products has shown mixed, essentially unreliable, results. Experience with other new markers, such as CDX-2, villin, beta catenin, and P504S (racemase), is limited but is in aggregate promising with regard to providing some aid in this area. The rare differential of metastatic cervical adenocarcinoma versus primary ovarian mucinous or endometrioid carcinoma may be aided by strong p16 staining of the former. Staining for alpha-fetoprotein may aid in confirming the diagnosis of endometrioid-like (and hepatoid) variants of yolk sac tumor. Ependymoma of the ovary may also have an endometrioid-like glandular pattern, but positive stains for glial fibrillary acidic protein contrast with the negative results in others neoplasms with a similar pattern. Immunostains may be very helpful in the evaluation of oxyphilic tumors and tumor-like lesions and in some unusual forms of clear cell neoplasia, such as clear cell struma, both subjects being reviewed herein. Immunostains may highlight both the presence and extent of epithelial cells in a variety of circumstances, including microinvasive foci in cases of serous borderline tumors and mucinous carcinomas, and in determining the extent of carcinoma cells and reactive cells within mural nodules of mucinous neoplasms. As in tumor pathology in general, various markers may be crucial in the diagnosis of small round cell tumors of the ovary, and familiar markers of epithelial, lymphoid, leukemic, and melanocytic neoplasms may assist in the analysis of high grade tumors with a poorly differentiated carcinoma, lymphoma-granulocytic sarcoma, malignant melanoma differential. The evaluation of ovarian cystic lesions may be aided by thyroglobulin or TTF 1 (cystic struma), glial fibrillary acid protein (ependymal cysts), and inhibin-calretinin (follicle cysts and unilocular granulosa cell tumors). Stains for trophoblast markers may occasionally aid in the evaluation of germ cell tumors, although routine stains should usually suffice; they may be of academic interest in confirming trophoblastic differentiation in some high grade surface epithelial carcinomas.

Magnetic resonance imaging findings of small round cell tumors of the ovary: a report of 5 cases with literature review

OBJECTIVE

To study the magnetic resonance imaging characteristics of the ovarian involvement of small round cell tumors.

METHODS

Magnetic resonance imaging findings were retrospectively reviewed in 5 patients seen at this institution and in 7 patients reported in the literature with ovarian small round cell tumors. Laterality, signal intensity, existence of hemorrhage, calcification, necrosis, septa, cerebroid appearance, and peripheral cysts were evaluated.

RESULTS

Seven patients had bilateral disease, and the others had unilateral disease. The signal intensity was low on T1-weighted imaging (T1WI) in all cases. Signal on T2-weighted imaging (T2WI) and the degree of contrast enhancement varied. No case showed hemorrhage or calcification. Only 1 case demonstrated necrosis. Septa were observed in 3 cases, and a cerebroid appearance was observed in 5 cases. Six patients of reproductive age had multiple small cysts at the periphery of the masses.

CONCLUSION

Despite the limited number of cases, peripheral small cysts in the large lobulated solid mass seemed to be a characteristic of the ovarian small round cell tumors in patients of reproductive age.

Granulocytic sarcoma presenting as tumors of the cervix

BACKGROUND

Granulocytic sarcoma of the cervix, leading to the diagnosis of acute myelogenous leukemia (AML), is a rare event.

CASE

A 33-year-old woman presented with vaginal bleeding, pain, and a large pelvic mass involving the cervix, extending bilaterally to the pelvic side walls. A biopsy of the cervix revealed granulocytic sarcoma, and a subsequent bone marrow biopsy confirmed the diagnosis of AML.

RESULTS

The majority of patients with cervical granulocytic sarcoma present with vaginal bleeding, sometimes with abdominal pain and other systemic symptoms. The overall 2-year survival rates for all patients with granulocytic sarcoma in the literature is 6%, and none of the patients lived 5 years.

CONCLUSION

Granulocytic sarcoma of the cervix is rare. Awareness of this entity will allow earlier diagnosis and appropriate treatment.

Granulocytic Sarcoma of the Female Genital Tract: Report of a Case with an Unusual Presentation

Granulocytic sarcoma of the female genital tract is a rare occurrence. A case of a perimenopausal female is presented who reported with a history of menorrhagia with a lump in the abdomen. A diagnosis of fibroid uterus was made but laparotomy findings were suggestive of inoperable ovarian malignancy with metastases. Postoperatively the patient suddenly became very anemic. Hematological investigations and histopathological reports from ovaries, myometrium, endometrium and intraperitoneal deposits all revealed acute myeloid leukemia. The patient received two cycles of chemotherapy but later succumbed to her disease. Extrauterine causes of menorrhagia should be considered before instituting definitive treatment. Preoperative induction chemotherapy may be more successful in cases of granulocytic sarcoma who tend to have a poor prognosis.

Extramedullary myeloid tumour (EMMT) of the gallbladder

This report describes a rare case of an extramedullary myeloid tumour (EMMT) of the gallbladder in a patient without leukaemia. A 33 year old man visited a local hospital because of jaundice. Abdominal computed tomography revealed a tumorous mass measuring 6.0 x 4.5 cm and involving the entire gallbladder. A percutaneous needle biopsy was attempted, but because adenocarcinoma could not be completely ruled out, the use of undue force was considered dangerous. Under a preoperative diagnosis of gallbladder carcinoma, a hepatopancreatoduodenectomy was performed. The tumour cells exhibited various amounts of eosinophilic cytoplasm, had medium sized round nuclei with indentation and grooving, and were strongly immunoreactive for myeloperoxidase, CD43, and c-kit protein (CD117). After surgery, the patient underwent combination chemotherapy as prescribed for cases of acute myeloblastic leukaemia. The patient did not develop acute leukaemia during a follow up period of four years. In conclusion, a correct diagnosis of EMMT can be made using appropriate immunohistochemical staining.

Extramedullary hematopoietic proliferations, extraosseous plasmacytomas, and ectopic splenic implants (splenosis)

Hematopoietic proliferations are well known to present ectopically outside the bone marrow, either in benign or malignant form. As such, they present a distinct problem with respect to morphologic interpretation because of their uncommonality in extramedullary sites and their capacity to simulate other lesions histologically. This review considers extramedullary myeloid tumors ("granulocytic sarcoma," "erythroblastic sarcoma," "megakaryocytic sarcoma"), tumefactive extramedullary hematopoiesis, and the peculiar condition known as "splenosis," with consideration of their clinical, microscopic, and cytohistochemical chararacteristics.

Myeloid sarcoma: clinical and morphologic criteria useful for diagnosis

Extramedullary accumulation of myeloblasts or immature myeloid cells form tumors called myeloid sarcoma in the WHO classification. Such tumors develop in lymphoid organs, bone (skull, orbit, etc.), skin, soft tissue, various mucosae and organs, and the CNS. They may precede or occur concurrently with acute myeloid leukemia, or reveal blastic transformation of chronic myeloproliferative disorders or myelodysplastic syndromes. They may also reveal relapses in treated patients. They are constituted by a diffuse infiltrate made up of medium-to-large cells. The cells are difficult to identify. Imprints are very useful. Immunohistochemistry can help diagnose and distinguish four variants: granulocytic myeloperoxidase (MPO+, CD 68+ [KP1+/-, PGM1-] lysozyme+, CD 34+/-), monoblastic (MPO-, CD 68+, [KP1+, PGM1+] lysozyme+, CD 34-), myelomonoblastic (MPO-, CD 68+, [KP1+, PGM1+] lysozyme+, CD 34-), or megakaryoblastic (positivity for factor VIII, CD 61, CD 31). Immunohistochemistry sometimes demonstrates expression of CD 43, CD 7, CD 79a, and CD 56 (particularly the monoblastic variant with t[8;21]). Recently the demonstration of CD 99 and CD 117, which can now be done on paraffin sections, may be useful to identify blasts of granulocytic origin. The diagnosis is missed in about 50% of cases when immunohistochemistry is not used. Patients with myeloid sarcomas should be treated in the same way as patients with acute myeloblastic leukemia. Disease progression and prognosis are similar for the two conditions.

Primary myeloid sarcoma of the gynecologic tract: a report of two cases progressing to acute myeloid leukemia

Primary gynecologic myeloid sarcomas are rare, and their diagnosis is often difficult. Differential diagnosis includes lymphomas and carcinomas of the gynecologic tract. We report the clinical, morphological, immunohistochemical and cytogenetic features of two cases of chloromas of the female genital tract, which progressed to acute myeloid leukemia in spite of aggressive therapy.

Isolated myelosarcoma in children--update and review

Primary myelosarcomas, also called leukemia cutis, granulocytic sarcomas or chloromas, are rare extramedullary manifestations of acute myeloid leukemia (AML) which precede bone marrow involvement. Skin infiltration was the most frequent localization associated with a myelomonocytic differentiation. Although first remission was achieved by most children, risk of relapse seemed to be increased. This might be caused by the specific biology of myelosarcomas, but also may be the result of delayed or reduced treatment. During the AML-BFM-studies 87/93/98 (11/1987-7/2000) 37 children with isolated myelosarcomas were diagnosed. Eighteen of the 37 patients survived with a 5-year overall survival estimation of 0.54+/-0.09 compared to 0.59+/-0.02; p(log rank) = 0.94. However, reduced or delayed treatment in 17 children led to an increased relapse rate of 71% compared to 35% in children treated soon after diagnosis. The 5-year overall survival in these patients was 0.41+/-0.11. According to our experience and review of the literature, an early diagnostic workup is needed in children with unusual skin lesions or tumors, considering myelosarcoma as primary manifestation of AML. Intensive AML-specific chemotherapy is generally recommended soon after diagnosis.

The value of CD34, myeloperoxidase and chloroacetate esterase (Leder) stain in the diagnosis of granulocytic sarcoma

BACKGROUND

The differentiation of extramedullary myelogenous leukemia/granulocytic sarcoma (GS) from malignant lymphoma can sometimes be difficult. In the current study, we explored the value of CD34, myeloperoxidase and nonspecific esterase (Leder) stains in differentiating GS from lymphomas.

MATERIALS AND METHODS

Fifteen cases of phenotypically confirmed GS were stained for CD34, myeloperoxidase and Leder stains. The same stains were performed in 16 malignant lymphomas as controls. The GS cases were also immunostained for CD3 and CD20 to detect the incidence of aberrant T and B lymphocyte expression.

RESULTS

CD34 was expressed in 7 of the 15 cases of GS (46%). Myeloperoxidase was expressed in 10 of the 15 cases (66%), and Leder stain was positive in 9 cases (60%). All 15 cases had expression of at least one marker; 8 cases had expression of two markers and one case had expression of all 3 markers. None of the lymphomas showed expression of any of the three markers. Five cases (35%) of GS showed T cell antigen expression and 2 (14%) showed B cell antigen expression.

CONCLUSION

Our findings suggest that in cases of GS, the use of the combination of CD34, myeloperoxidase and Leder stains can help reach a definitive diagnosis, especially if lymphoma is difficult to exclude. Expression of B and T cell antigens in such lesions should not rule out the diagnosis of GS.