Granulocytic sarcoma in childhood leukemia: imaging features

Granulocytic neoplasm suggestive of primary myeloid sarcoma in 3 dogs

Myeloid sarcoma (MS) is a solid tumor of granulocytic origin with extramedullary localization. This tumor is rare in humans and animals. The diagnostic approach is heterogeneous, and the definitive diagnosis may be difficult to achieve. Primary MS has never been described as a spontaneous neoplasm in companion dogs. Two purebred and 1 mixed-breed dogs, 6- to 11-year-old, developed round cell tumors in the mediastinum, lymph nodes (LNs) and tonsils, and LNs, respectively. Granulocytic origin and exclusion of lymphoid lineage were confirmed by flow cytometry, supported by immunohistochemistry or immunocytochemistry. Pivotal to the diagnosis were positive labeling for myeloid (CD11b, CD14) and hematopoietic precursors (CD34) markers, along with negative labeling for lymphoid markers. Blood and bone marrow infiltration were not detected at initial diagnosis, excluding acute myeloid leukemia. The behavior of these tumors was aggressive, resulting in poor clinical outcomes, even when chemotherapy was attempted.

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.

Myeloid Sarcoma: A Primer for Radiologists

ABSTRACT

Myeloid sarcoma (MS) is a rare extramedullary neoplasm that can present in association with acute myeloid leukemia, most commonly in children younger than 15 years. This unique extramedullary malignancy may involve a variety of different organ systems and can present following, preceding, simultaneous with, or in insolation to acute myeloid leukemia. Common areas of extramedullary involvement include soft tissues, bones, lymph nodes, and the peritoneum. Imaging plays a critical role in the diagnosis and management of MS, with commonly used modalities including positron emission tomography-computed tomography, magnetic resonance imaging, computerized tomography, and ultrasound. The purpose of this review article is to provide radiologists with a comprehensive guide summarizing the relevant imaging and clinical features of MS, with emphasis on the role of imaging in the diagnosis, treatment, and follow-up of patients with MS. The relevant pathophysiology, epidemiology, clinical presentations, and differential diagnosis of MS will be reviewed. The relevance of different imaging modalities in diagnosis, monitoring of treatment response, and assessment of treatment-related complications will also be outlined. Through summarizing these topics, this review article aims to provide radiologists with a guide for understanding the existing knowledge of MS in the literature and the current role of imaging in the management of this unique malignancy.

TG, H. CS. Imaging of the Infratemporal Fossa: a Comprehensive Pictorial Essay

While radiologists are familiar with the masticator space, the surgeons are more familiar with the infratemporal fossa (ITF). Though often used interchangeably, there exists a subtle difference between them, which needs to be understood. The close anatomical relationship of the infratemporal fossa to critical structures makes timely diagnosis vital. In this pictorial review, we present a spectrum of various pathologies affecting ITF.

Extramedullary Myeloid Leukemia in the Setting of a Myeloproliferative Neoplasm

Extramedullary acute myeloid leukemia (EML), also known as myeloid sarcoma (MS), is an extramedullary solid mass derived from the proliferation of myeloblasts outside of the bone marrow. EML can present independently or concurrently with intramedullary acute myeloid leukemia (iAML). It can happen de novo or secondary to iAML, myeloproliferative neoplasm (MPN), chronic myelomonocytic leukemia (CMML), or myelodysplastic syndrome (MDS). We present a 57-year-old female with a history of Janus kinase 2 (JAK-2)-positive essential thrombocythemia (ET) evolving into EML in the setting of a persistent TP53 mutation. We discuss the essential diagnostic studies including tissue biopsy and fluorodeoxyglucose positron emission tomography/computed tomography (F-FDG PET/CT) imaging. We also investigate the significance of cytogenetics and next-generation sequencing (NGS) along with the unique pathogenesis, treatment and prognostic implications.

Presentation of Chloromas in B-Mode Ultrasound and Contrast-Enhanced Ultrasound

Chloromas, also referred to as myeloid sarcomas, describe rare extramedullary tumor aggregates of malignant myeloid progenitor cells. The aim of this study was investigate the diagnostic features and characteristics of chloromas using contrast-enhanced ultrasound (CEUS). Between July 2007 and April 2021, 15 patients with 20 myeloid neoplasms and suspected chloroma manifestations were examined using B-mode US (B-US) and CEUS. Clinical data and B-US (echogenicity, border, size) and CEUS (hyper-, iso-, hypo- or complex enhancement) characteristics were retrospectively analyzed. Absolute and relative frequencies were determined. In B-US, the chloromas were most frequently hypo-echoic (n = 15, 75%). In addition, a hyperechoic (n = 2, 10%) or echocomplex (n = 3, 15%) presentation was observed. On CEUS, 7 chloromas (35%) had an arterial hyperenhancement, 8 (40%) an iso-enhancement and 3 (15%) a complex enhancement. Two chloromas (10%) did not exhibit any enhancement. We describe for the first time CEUS and B-US patterns of chloromas. They are typically hypo-echoic on B-US and have a strong iso- or hyperenhancement on CEUS, which may help in the differential diagnosis of some unclear masses (e.g., hematoma, abscess) in patients with myeloid neoplasias. Nevertheless, histology is necessary for a reliable diagnosis.

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.

Clinical and molecular characterization of myeloid sarcoma without medullary leukemia

Myeloid sarcoma (MS) in the setting of concomitant medullary AML is relatively well described, while much less is known about patients presenting with MS with <20% bone marrow blasts. We conducted a retrospective analysis of 56 patients with MS with <20% marrow blasts seen at MD Anderson between 2005 and 2020. The prevalence of MS without medullary AML was 1.4% among all newly diagnosed AML patients. The majority (75%) of patients had a single known anatomic site involved, with the skin (34%) being the most frequent. The most common histologic subtype was monocytic, and 11% of patients had a known history of an antecedent hematologic disorder. The majority of patients (70%) received frontline intensive chemotherapy induction, with 75% of those evaluable attaining complete or partial responses. The median overall survival (OS) and event-free survival (EFS) were 3.41 and 3.07 years, respectively. Patients with bone marrow blasts of ≥5% or medullary relapse had inferior outcomes, while age (>60 years) was not associated with outcomes. There was a suggestion that patients with isolated leukemia cutis may have had better outcomes compared to patients with other organ involvement, but this did not reach statistical significance. Most patients who had cytogenetic analysis had a diploid karyotype within their MS and bone marrow. RAS pathway mutations were enriched in MS at diagnosis, and at time of medullary relapse. Our study provides a large dataset summarizing the clinical and molecular analysis of patients with MS with <20% BM blasts and suggests that monitoring for medullary leukemia is important for early detection of relapse.

Intestinal Chloroma

Chloromas are an atypical cellular infiltrate of immature granulocytic cells that can occur specially in patients with acute myelogenous leukemia (AML), but can be present in nonleukemic patients. Its clinical course will be dependent on its size and location, from asymptomatic to simulating a malignant gastrointestinal neoplasia. Definitive diagnosis is made upon an immunoprofile that is similar to that present in the blasts and precursor cells of acute myeloid leukemia. Endoscopic and CT images are variable being only part of the protocol panel. Treatment is the same as to AML, but surgery and radiation must be used in order to maintain low relapse and better overall survival.

Diagnostic and Therapeutic Considerations for Extramedullary Leukemia

PURPOSE OF REVIEW

The purpose of this review is to summarize the current literature on the presentation, diagnosis, and treatment options available for extramedullary (EM) manifestations of leukemia including myeloid sarcoma (MS) and leukemia cutis (LC).

RECENT FINDINGS

Advanced imaging using 18FDG-PET/CT is an effective screening tool for EM manifestations of leukemia. The role of radiation therapy has been more clearly delineated in the treatment of both MS and LC. FDA-approved targeted agents have improved outcomes in patients with AML but have not demonstrated improvements specifically for EM; however, a checkpoint inhibitor, Ipilimumab, holds promise in impacting local control for the treatment of AML-related EM. EM manifestations of leukemia pose significant therapeutic challenges. Treatment of EM is predicated on multiple factors including the presence of concomitant bone marrow involvement, AML-risk classification, and timing of presentation at initial diagnosis or relapse following systemic therapy.

Epidural myeloid sarcoma as the presenting symptom of chronic myeloid leukemia blast crisis

Epidural myeloid sarcoma revealing chronic myeloid leukemia is scarce. Herein, we describe a patient that presented with back pain and bilateral sciatica secondary to root compression due to epidural deposition of leukemic cells. The magnetic resonance imaging showed epidural masses, causing a slight restriction of the spinal canal with bilateral L5 root compression. Laboratory examinations showed hyperleukocytosis (white blood cell count: 83 × 109/L, absolute neutrophil count: 60 × 109/L). The bone marrow cytology and immunophenotypic findings confirmed the diagnosis of myeloid leukemia. The diagnosis of spinal myeloid sarcoma revealing chronic myeloid leukemia during the blast phase was established. The patient underwent induction chemotherapy. Then, bone marrow cytology revealed less than 3% of blasts, which correspond to cytological remission. Three months later, MRI showed complete disappearance of the epidural masses. A literature review was conducted by searching PubMed using these terms: "Leukemia, Myeloid" AND "Spine" AND "Sarcoma, Myeloid". We emphasize clinical and radiological findings of spinal myeloid sarcoma. This diagnosis should be considered when the MRI reveals epidural mass lesion. The early management of this disease is necessary, and the treatment of myeloid sarcoma is not codified. Our case highlighted that chemotherapy treatment could be sufficient to lead to the disappearance of myeloid sarcoma and the remission of leukemia.

Myeloid Sarcoma

Hematological malignancies can manifest as extramedullary soft tissue masses in relatively rare cases. The rarity of it causes a diagnostic and therapeutic challenge. One of the rarest manifestations is myeloid sarcoma (MS). MS develops as part of acute myeloid leukemia, myeloproliferative neoplasm, or myelodysplastic syndrome or at relapse, especially following allogeneic hematopoietic stem cell transplant. The tumor displays high myeloperoxidase expression, hence the color green, and is called chloroma. It most commonly appears in lymph nodes, skin and soft tissues, bone, testes, gastrointestinal tract, and peritoneum. Immunohistochemistry shows CD68-KP1 as the most commonly expressed marker, then myeloperoxidase, CD117, CD99, CD68/PG-M1, lysozyme, CD34, terminal deoxynucleotidyl transferase, CD56, CD61, CD30, glycophorin A, and CD4. Different chromosomal abnormalities including MLL rearrangement, t(8; 21), monosomy 7, trisomy 8, trisomy 11, trisomy 4, inversion (16), monosomy 16,16q deletion, 5q deletion, and 20q deletion were reported. Most of the literature about MS are case reports and small retrospective studies, thus there is limited clinical knowledge of the cases and their presentation and management plans. Here, we provide a review of what has been reported in the literature about MS in the light of our experiences.

Peritoneal Myeloid Sarcoma in a Patient Treated for a Testicular Seminoma

BACKGROUND Myeloid sarcoma is a rare extramedullary soft tissue neoplasm composed of myeloblastic cells, usually associated to hematologic tumor disorders and a poor prognosis. Its diagnosis is very difficult as radiological images are not specific. Histology and immunohistochemistry are necessary for an accurate diagnosis. CASE REPORT We report the case of 46-year-old, Caucasian, non-smoker male, treated in 2014 by orchiectomy and systemic chemotherapy for a stage IIB testicular seminoma. Considering the rapid increase of lactate dehydrogenase (LDH) levels without any evident medical reason, a computed tomography/positron emission tomography (CT/PET) scan was performed and revealing a diffuse, nodular, peritoneal tumor infiltration associated with multiple mesenteric and mediastinal adenopathies. Laparoscopy confirmed a diffuse tumor infiltration of the peritoneum. Histology and immunohistochemistry were consisted with the diagnosis of a myeloid monoblastic sarcoma. Cytology of bone marrow documented an monocytic acute myeloid leukemia. The patient started a systemic induction chemotherapy with high dose cytarabine and idarubicin that was complicated by an infectious pneumonia and colitis, and a grade IV thrombocytopenia leading to a brain subdural hemorrhage and quickly to patient's death. CONCLUSIONS We describe a rare, peritoneal, myeloid sarcoma in a young patient who had been treated by systemic chemotherapy for testicular seminoma 4 years earlier. The patient was clinically asymptomatic and presented only elevated LDH levels without any evident clinical reason. Considering the persistence of this biochemical abnormality, more investigations were performed leading to a diagnosis of peritoneal myeloid sarcoma associated with monocytic acute myeloid leukemia, probably secondary to the past chemotherapy.

Use of Radiation in Extramedullary Leukemia/Chloroma: Guidelines From the International Lymphoma Radiation Oncology Group

Survival times for patients with leukemia generally have improved in recent decades, and this improvement has been attributed to an enhanced understanding of the genetics driving the cause of the disease and improved combinations of chemotherapy and targeted therapy. Durable control of systemic disease in blood and bone marrow has significantly improved survival, but extramedullary relapse can pose therapeutic challenges for which radiation therapy can have an important role. This report discusses the current role of radiation therapy for patients with leukemia, specifically the extramedullary manifestations of leukemia.

Sacral Myeloid Sarcoma Manifesting as Radiculopathy in a Pediatric Patient: An Unusual Form of Myeloid Leukemia Relapse

Myeloid sarcoma (MS), granulocytic sarcoma or chloroma, is defined as a localized extramedullary mass of blasts of granulocytic lineage with or without maturation, occurring outside the bone marrow. MS can be diagnosed concurrently with acute myeloid leukemia (AML) or myelodysplastic syndrome (MDS). The authors report a case of sacral MS occurring as a relapse of myeloid leukemia in a 5-year-old girl who was taken to the emergency department with radiculopathy symptoms.

Imaging appearances of soft-tissue tumors of the pediatric foot: review of a 15-year experience at a tertiary pediatric hospital

Tumors of the foot are rare in children. In this review the authors illustrate radiographic, sonographic and MR imaging findings of foot soft-tissue tumors in children based on all cases presenting at a tertiary pediatric hospital during the 15-year period of 1999-2014. Among these cases there were 155 tumors of the foot - 72 of the bones and 83 of the soft tissues. Vascular malformations, fibromatosis and sarcomas were respectively the most frequent benign, intermediate and malignant soft-tissue tumors. Some tumors showed specific imaging findings. In imaging investigations, ultrasound can be used as the first imaging modality for diagnostic workup of most lesions because it is noninvasive, low-cost and readily available, and can confirm the presence of the mass and evaluate cystic components, especially in young children who would otherwise require sedation for MR imaging. MR imaging is the reference standard technique because of its high tissue contrast, which allows for detection and characterization of soft-tissue and bone abnormalities. MR imaging is useful as the first imaging modality in select cases, including those with high suspicion of malignancy, very large lesions or pre-treatment lesions. Recognition of some typical imaging findings in pediatric soft-tissue foot tumors is helpful to establish diagnosis and facilitate patient management.

A myeloid sarcoma involving the small intestine, kidneys, mesentery, and mesenteric lymph nodes: A case report and literature review

RATIONALE

Myeloid sarcomas (MSs) are rare malignant hematological tumors. They most commonly occur in patients with acute or chronic myeloid leukemia. A de novo MS with no evidence of blood system disease is rare, but may represent the first sign of a systemic illness that precedes a full-blown disease. Herein, we report the computed tomography (CT) findings of an extremely rare case of a nonleukemic MS that progressed to acute myelogenous leukemia (AML) and simultaneously involved the small intestine, kidneys, mesentery, and mesenteric lymph nodes. Moreover, we provide CT findings before and after AML chemotherapy, which have not been reported previously.

PATIENT CONCERNS

A 25-year-old man with intermittent upper abdominal pain for 6 months was admitted to the hospital on November 28, 2015. Initial CT showed concentric wall thickening of the jejunum with an adjacent mesenteric soft tissue mass and mesenteric lymph nodes enlargement. Both kidneys were involved as indicated by the presence of well-defined mildly dilated lesions. During the laparoscopic surgery, the small intestinal tumor, mesenteric soft tissue mass, and mesenteric lymph nodes were removed.

DIAGNOSES

The pathological diagnosis was an MS.

INTERVENTIONS

The patient refused systemic chemotherapy and was rehospitalized with persistently aggravated abdominal distension on February 17, 2016. Follow-up CT showed diffuse small bowel wall thickening, widespread infiltration of the peritoneum, omentum, and mesentery, mesenteric lymph node enlargement, and large amounts of ascites fluid. The lesions in both kidneys were substantially larger and more numerous than on initial CT. Then the patient was treated with conventional AML chemotherapy.

OUTCOMES

The patient achieved complete hematological remission on bone marrow examination. Follow-up CT in September 4, 2016, showed none of the abnormalities seen on initial CT. Currently, the patient is in complete remission.

LESSONS

If the radiological examination shows lesions at multiple sites, and these lesions are soft tissue masses with homogenous enhancement, MS should be considered in the differential diagnosis, and an aspiration biopsy should be performed to provide a definitive pathological diagnosis. If MS is diagnosed, systemic chemotherapy is crucial to recovery; otherwise, the disease may progress rapidly. Medical imaging is helpful for diagnosing MS and for monitoring treatment response.

Chloroma of the testis in a patient with a history of acute myeloid leukemia

Chloroma, or granulocytic sarcoma, is a rare extramedullary solid hematologic cancer, found concomitant with acute myeloid leukemia. It is infrequently associated with other myeloproliferative disorders or chronic myelogenous leukemia. Chloroma of the testis after allogeneic bone marrow transplantation is particularly sparsely represented in the literature. It is suggested that an appropriate panel of marker studies be performed along with clinical correlation and circumspection to avoid misleading conclusions. We report an interesting case of a 32-year-old male with a clinical history of acute myelogenous leukemia, postallogeneic peripheral blood stem cell transplantation that was found to have chloroma of the right testis.

Clinicoradiological characteristics, management and prognosis of primary myeloid sarcoma of the central nervous system: A report of four cases

Myeloid sarcoma (MS) is a localized tumor composed of premature precursors of granulocytic cells, which may occur in any organ and most commonly involves the soft tissue and musculoskeletal system. This malignancy may occur in the presence or absence of hematological disorders. Primary MS involving the central nervous system (CNS-MS) is rare, and has only been described in a small number of isolated case reports. The diagnosis of CNS-MS is challenging and strategies for its management are undefined. The present study describes 4 cases of CNS-MS. The hematological indices at admission were normal and all patients presented with location-associated nonspecific symptoms. In magnetic resonance imaging scans, the tumors appeared isointense on T1-weighted and T2-weighted images, with marked enhancement following contrast agent administration. Only 1 patient progressed to acute myeloblastic leukemia (AML), with this occurring 3 weeks following histological diagnosis. During the follow-up period, the patient with AML succumbed to the disease, local recurrence was noted in another patient for which a second surgery was requested and no progression was observed in the remaining 2 patients. CNS-MS has unique radiological characteristics and, due to its diffuse tissue infiltration, gross total resection is challenging. It is important for clinicians to be aware of potential hematological disorders in patients with CNS-MS. A combined surgical and chemotherapeutic strategy may be able to provide long-term control of this malignancy.

Myeloid Sarcoma: Presentation, Diagnosis, and Treatment

Myeloid sarcoma is an extramedullary tumor of immature granulocytic cells. It is a rare condition, most often associated with acute myeloid leukemia (AML), although in some rare cases it may present in nonleukemic patients. It should therefore be considered as a differential diagnosis of any atypical cellular infiltrate. It may occur at any site, leading to very varied clinical presentations. Diagnosis is challenging and relies on a high index of suspicion as well as radiology, histology, immunophenotyping, and molecular analyses, which also are essential for risk stratification and treatment planning. Systemic chemotherapy using AML-like regimens should be commenced early, even in nonleukemic disease. Surgery and/or radiotherapy may be indicated for symptomatic lesions or tumors causing local organ dysfunction or obstruction. Allogeneic hematopoietic stem cell transplantation has demonstrated promising results, particularly in patients who achieved complete remission with AML-induction protocols, and recent advances in genetic profiling may enable the development of novel targeted therapies. Prospective multicenter controlled trials are required to further refine management decisions and investigate the role of novel targeted therapies.

Whole Body MR Imaging: A Useful Imaging Modality in the Management of Children With Acute Myeloid Leukemia

INTRODUCTION

To evaluate the distribution of chloromas using whole body magnetic resonance (MR) imaging in pediatric patients with acute myeloid leukemia (AML) and to assess the clinical role of whole body MR imaging in management of pediatric patients with AML.

MATERIALS AND METHODS

We retrospectively searched pediatric patients (< 18 years old) who were diagnosed with AML and underwent whole body MR imaging during their illness between January 2006 and December 2014. The presence of chloromas was defined as when it was proven pathologically or showed typical imaging features. Nonchloroma lesions that were incidentally detected and were not previously seen on other imaging studies were defined as clinically occult nonchloroma lesions.

RESULTS

Sixty-nine whole body MR scans of 40 patients with AML were included. The musculoskeletal system (42.9%) was the most commonly affected by chloromas. A total of 77 chloromas were identified in 11 (27.5%) of 40 patients. Nine (81.8%) of these 11 patients had 2 or more chloromas. There were 39 (50.6%) unexpected chloromas, which were incidentally detected, in 7 patients. Whole body MR scanning provided additional information regarding 21 clinically occult nonchloroma lesions in this patient population.

CONCLUSION

Chloromas tended to show multiplicity and be present without symptoms. The most common site of involvement was the musculoskeletal system. Whole body MR imaging provided additional information that affected the clinical management of children with AML.

Diagnosis in subdural myeloid sarcoma

Introduction A 74-year-old man presented to hospital with a headache, thrombocytopaenia and an acute deterioration in cognition on a background of acute monocytic leukaemia in remission. Method This is a case report with computed tomography (CT), magnetic resonance (MR) and histopathology imaging. Results Preoperative CT and limited MR demonstrated a subdural lesion with marked midline shift. Craniotomy performed for evacuation of the presumed subdural haematoma revealed a solid tumour-like lesion. Histopathology identified the presence of a myeloid sarcoma (chloroma). Postoperative MRI with contrast revealed the solid nature of the mass. Conclusion The use of contrast is critical in the assessment of intracranial lesions to distinguish myeloid sarcoma from subdural haematoma in the context of leukaemia and a neurologically deteriorating patient.

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 Mass in a Child With Acute Lymphoblastic Leukemia: A Case Report and Review of the Literature

Acute lymphoblastic leukemia arising from lymphoid precursor cells of the bone marrow, the lymphoreticular system, and the soft tissue can present with medullary and extramedullary involvement. Extramedullary involvement has the propensity to affect a multitude of organs. Presentation with proptosis secondary to orbital mass in childhood acute lymphoblastic leukemia (ALL) is very rare. We report a child with pre-B cell ALL with an extramedullary soft tissue mass involving both orbits presenting with proptosis, and give a brief overview of the literature about this unusual entity. Rapid investigation and timely initiation of treatment are needed to salvage the eye and the vision. Orbital involvement is considered to confer a poorer prognosis to children with ALL.

Myeloid sarcoma of the periprostatic tissue and prostate: Case report and review of literature

Myeloid sarcoma (MS) is a rare extramedullary tumor composed of immature cells of myeloid lineage that destroy the original tissue architecture in which it is found. It is most commonly identified in patients with acute myelogenous leukemia, and less often in myelodysplastic syndromes (MDSs) and other myeloproliferative disorders. It is most commonly reported in the periosteum, bone, skin, and lymph nodes but has been reported in many other sites of the body. Herein, we describe a case of MS involving the periprostatic tissue and review of literature of MS of the prostate. Our patient was initially diagnosed with MDS and was in remission following successful treatment. Six months later, the patient was diagnosed with prostate adenocarcinoma, and MS of the periprostatic tissue was incidentally discovered in the postprostatectomy pathology specimen. An extensive review of literature from 1997 to 2014 revealed a total of eight cases of MS involving the prostate. Of the eight cases of MS of the prostate, four were primary MS (absence of a history of leukemia) and four were secondary MS. Three received local radiation to the prostate with relief of obstructive symptoms, and one of them had a repeat prostate biopsy negative for leukemic cells. Despite being a rare entity, MS should be considered as a differential diagnosis of soft tissue masses, especially in patients with a history of hematological malignancies.

Ptosis Shmosis

A 10-year-old girl presented with painless unilateral left upper lid ptosis. A nontender hard mass was palpated in the left upper lid. Blood smear was compatible with the diagnosis of leukemia. The cause of ptosis was now thought to be a mass composed of myeloid blast cells (myeloid sarcoma).

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.

[Radiotherapy of chloroma or granulocytic sarcoma: A literature review]

Granulocytic sarcoma, or chloroma, is a rare clinical entity, usually associated with a blood disease, including acute myeloid leukemia. Management strategies are based on the combination of systemic therapy and local therapy (surgery or radiation). Data for radiotherapy dose are derived from retrospective studies and case reports. We conducted a literature review using the Pubmed search engine to clarify the terms and indications for radiotherapy of chloromas.

Primary intraoral granulocytic sarcoma: A rare case presenting as generalized gingival enlargement

Granulocytic sarcoma (GS) is an extremely rare condition involving infiltration of myeloblasts or immature myeloid cells in an extramedullary site. It is also known as chloroma, myeloid sarcoma or extramedullary myeloid tumor. It usually occurs concomitantly with acute myelogenous leukemia or with the onset of blastic phase of chronic myelogenous leukemia. On rare occasions, it evolves even before the onset of leukemias, and when it precedes leukemias without any overt signs, it is referred to as the primary type. Although GSs can involve any body part, localization in the oral cavity is extremely rare. The recognition of this rare primary entity is important because early aggressive chemotherapy can cause regression of the tumor and improve survival. Here, we report a rare case of GS in a nonleukemic 62-year-old female who presented with generalized gingival enlargement involving both maxilla and mandible.

CNS and spinal tumors

Primary CNS tumors consist of a diverse group of neoplasms originating from various cell types in the CNS. Brain tumors are the most common solid malignancy in children under the age of 15 years and the second leading cause of cancer death after leukemia. The most common brain neoplasms in children differ consistently from those in older age groups. Pediatric brain tumors demonstrate distinct patterns of occurrence and biologic behavior according to sex, age, and race. This chapter highlights the imaging features of the most common tumors that affect the child's CNS (brain and spinal cord).

Sacral myeloid sarcoma involving multiple metastases to the brain: A case report

The presentation of myeloid sarcoma (MS) in the bone is common; however, rarely does the tumor occur in the sacral spine, and in a normal patient with no history of acute myeloid leukemia. The present study describes the rare case of a previously healthy 24-year-old male patient, who presented with a history of six months of repeated pain in the right leg and hip and limping for less than a month, who was diagnosed with sacral MS. Despite receiving surgical management and chemotherapy promptly subsequent to the diagnosis and undergoing close observation following the treatment, the patient still developed metastases to multiple sites of the brain. Taking into account the similar presentation of this rare disease to other entities, the early and accurate diagnosis of MS is vital, and the condition should be considered as a threatening manifestation with the possibility of metastasis to other sites of the body.

Acute appendicitis secondary to acute promyelocytic leukemia

Patient: Female, 43

Final Diagnosis: Myeloid sarcoma appendicitis

Symptoms: Abdominal pain • chills • fever

Medication: —

Clinical Procedure: Laparoscopic appendectomy, bone marrow biopsy

Specialty: Gastroenterology and Hepatology

Orbital mass secondary to acute lymphoblastic leukaemia in a child: a rare presentation

We report the case of a 3-year-old child, who presented with lid swelling which progressed to proptosis of the left eye. He also had systemic symptoms of fatigue and weight loss. An examination revealed hepatosplenomegaly and lymph node enlargement. Investigations showed a peripheral smear with blast cells, which were also revealed through a bone marrow biopsy. A CT scan showed a mass lesion in the left orbit that had infiltrated into the surrounding tissues. He was diagnosed with acute lymphoblastic leukaemia (ALL) with left-sided orbital mass secondary to it. Haematogenous masses in the orbit are commonly due to granulocytic sarcomas, which are usually associated with acute myelogenous leukaemia (AML), not ALL, and are rare especially when they precede systemic disease.

Metachronous bilateral granulocytic sarcoma of the testis in a young adult: a report of an unusual entity

Granulocytic sarcomas are rare tumors composed of neoplastic blood cells, typically occurring during the course of acute nonlymphoblastic leukemia or before its onset. We present a case of a 23-year-old young adult man with metachronous granulocytic sarcoma of the testis without hematologic manifestations who was diagnosed with granulocytic sarcoma (GS). The patient was treated with right orchiectomy but relapsed with a left testicular mass 16 months later when a left orchiectomy was performed. The patient has been free of disease for 13 months following the left orchiectomy. This case highlights a rare hematologic cancer that urologists and pathologists should be aware of since it can present as a testicular mass. Only 3 cases of testicular GS without an associated hematologic disorder have been described. To the best of our knowledge, our patient is the first reported case in the English literature of metachronous GS of the testis with no evidence of hematologic disorder.

Granulocytic Sarcoma of the Uterus: A Rare Presentation of Extramedullary Relapse of AML and Importance of MRI

Granulocytic sarcoma (GS) is a solid tumor that is the extramedullary presentation of acute myelogenous leukemia, other myeloproliferative disorders, or myelodysplastic syndromes. Less commonly, it also may arise as an isolated mass. In this report, we describe a 23-year-old female patient, with a GS in the uterus and we stress the value of diffusion weighted imaging for the evaluation of uterine neoplasms. To our knowledge, our case is the first in the literature to report diffusion weighted imaging (DWI) findings of GS.

Generalized lymphadenopathy as the first presentation of granulocytic sarcoma: a diagnostic challenge

Introduction. Granulocytic sarcoma (GS), also known as chloroma or extramedullary myeloblastoma, is a solid tumor composed of primitive precursors of the granulocytic series that include myeloblasts, promyelocytes, and myelocytes. Granulocytic sarcoma is a rare tumor that may develop during acute myeloid leukemia (AML) but less frequently may precede its presentation. Although generalized lymph node enlargement is a presentation for malignant lymphoma, it can also rarely be the early presenting sign of GS. Methods. We present a case of GS mimicking lymphoma in a 45-year-old male. The patient presented with bilateral neck masses and had widespread, prominent lymphadenopathy secondary to AML as the first presenting manifestation of GS for the last 4 months with concurrent marrow AML. Result. A clinical diagnosis of lymphoma was suspected; fine needle aspiration cytology findings were also suggestive of lymphoma. However, peripheral blood and bone marrow examination reported as acute myeloid leukemia with monocytic differentiation and histopathology of excised lymph node confirmed it to be a GS not lymphoma. Conclusion. GS is often misdiagnosed as malignant lymphoma because of cytomorphologic and histologic similarities of the blasts to large cell lymphoma. A careful search for immature myeloid is a useful clue to the diagnosis accompanied with appropriate immunophenotyping.

Extramedullary disease in patients with acute myeloid leukemia assessed by 18F-FDG PET

BACKGROUND

Prevalence of extramedullary disease (EMD) in acute myeloid leukemia (AML) at the time of diagnosis is unknown. Previous estimates range from 2.5% to 30.5% and are usually based on clinical examination. This may cause an under diagnosis of EMD as not all extramedullary manifestations are easily detectable. Few recent studies have used positron emission tomography (PET) scans for diagnosing EMD in patients AML.

METHOD

During a 9-month period, newly diagnosed patients with AML who were candidates for intensive chemotherapy were 18F-Fluoro-deoxy-glucose (FDG) PET-scanned prior to induction treatment. We compared the prevalence of EMD diagnosed by PET scans and by clinical examination. Subsequent PET scans following induction chemotherapy were performed for response evaluation of EMD.

RESULTS

Twenty-six patients were included in the study. 18-F-FDG PET scans revealed more than twice as many patients with EMD than found by clinical examination (65% vs. 31%). PET demonstrated 55 EMD lesions compared with 15 diagnosed by clinical examination. In general, the responses of EMD detected by PET scans were concordant with the bone marrow responses assessed by pathology examination.

CONCLUSION

18-F-FDG PET is a useful tool for diagnosing EMD in AML and for assessing treatment responses of EMD in AML.

Brachial Plexopathy due to Myeloid Sarcoma in a Patient With Acute Myeloid Leukemia After Allogenic Peripheral Blood Stem Cell Transplantation

Myeloid sarcoma is a solid, extramedullary tumor comprising of immature myeloid cells. It may occur in any organ; however, the invasion of peripheral nervous system is rare. Herein, we report the case of myeloid sarcoma on the brachial plexus. A 37-year-old woman with acute myelogenous leukemia achieved complete remission after chemotherapy. One year later, she presented right shoulder pain, progressive weakness in the right upper extremity and hypesthesia. Based on magnetic resonance images (MRI) and electrophysiologic study, a provisional diagnosis of brachial plexus neuritis was done and hence steroid pulse therapy was carried out. Three months later the patient presented epigastric pain. After upper gastrointestinal endoscopy, myeloid sarcoma of gastrointestinal tract was confirmed pathologically. Moreover, 18-fluoride fluorodeoxyglucose positron emission tomography showed a fusiform shaped mass lesion at the brachial plexus overlapping with previous high signal lesion on the MRI. Therefore, we concluded the final diagnosis as brachial plexopathy due to myeloid sarcoma.

Contrast-enhanced ultrasound findings in a case of renal extramedullary hematopoiesis

We present the case of an 80-year-old man with two renal solid masses found at sonography, which were imaged by contrast-enhanced ultrasound, CT, and MRI and confirmed histologically. Contrast-enhanced ultrasound findings suggested a benign mass and a CT-guided biopsy yielded a diagnosis of extramedullary hematopoiesis.

Imaging findings in recurrent extramedullary leukaemias

Acute leukaemias are relatively common malignancies. Treatment has advanced significantly in the recent past and there has been improved patient survival. This improved initial response is leading to an increasing number of cases of relapse. Extramedullary relapse occurs in a wide variety of locations with varying presentations, imaging findings and differentials. The pathophysiology and clinical course of recurrent extramedullary myeloid and lymphocytic leukaemias are reviewed in this article. The wide variety of imaging findings associated with many important sites of recurrence and the associated differential diagnosis are discussed and illustrated.

Chloroma of perianal region masquerading as perianal abscess

Chloroma, also called granulocytic sarcoma (GS) or Myeloid Sarcoma, is a rare malignant extra-medullary neoplasm of myeloid precursor cells. It is usually associated with myeloproliferative disorders but its appearance may precede the onset of leukaemia. The presence of a chloroma is certainly a sign of poor prognosis. We report a case of chloroma in a middle aged female without a prior history of leukemia in the perianal skin region with clinical diagnosis of perianal abscess. When there is no concomitant leukaemia, diagnosis of chloroma may be difficult. Differential diagnoses include acute lymphoblastic leukemia, large cell NHL, lymphoblastic lymphoma, Ewing's sarcoma and cutaneous T cell lymphoma.

Granulocytic sarcoma of the urinary bladder in a pediatric patient

Granulocytic sarcoma (GS) is a rare tumor consisting of immature cells of granulocytic lineage. It is also called chloroma, referring to the green color of the tumor caused by high levels of myeloperoxidase in the cells. GS is often associated with acute myeloblastic leukemia. We report the case of a 4-year-old boy with a diagnosis of acute myeloblastic leukemia. Abdominal ultrasonography demonstrated a solid, vascularized, heterogeneous, polypoid formation involving the posterior wall of the bladder. Further studies confirmed the etiology of the tumor. On control ultrasonography, a marked decrease in tumor size 15 days after treatment was revealed. We describe the imaging findings in this patient and review the literature about this infrequent entity. Although imaging findings are not specific and considering that extramedullary involvement in leukemia is very sensitive to treatment, inclusion of GS in the differential diagnosis and awareness of the possible sites of occurrence and imaging features is essential to avoid unnecessary therapeutic measures.