Value of Positron Emission Tomography Scan in Staging Cancers, and an Unusual Presentation of Acute Myeloid Leukemia

De Novo Pure Erythroid Leukemia With Rapid Progression and Multiple Lytic Bone Lesions: A Case Report

 A 62-year-old male patient presented with malaise and severe macrocytic anemia. Computed tomography revealed an osteolytic lesion in the left iliac bone. Bone marrow examination revealed that 90% of erythroblasts were large with periodic acid-Schiff (PAS)-positive staining while flow cytometry and immunostaining revealed CD71 (+), GP-A (+), p53 (+), CD117 (+), and CD34 (-) results, indicating pure erythroid leukemia (PEL) diagnosis. A needle biopsy of the osteolytic lesion revealed the same characteristics as PEL. Azacitidine therapy was administered as the first-line treatment, and his general condition temporarily improved. However, PEL quickly deteriorated, and he died 42 days of hospitalization after initial admission. PEL is an extremely rare form of acute myeloid leukemia (AML) and has presented cytogenetic characteristics in addition to the TP53 mutation. Other AML treatment is used because a standard treatment method is unavailable. However, the prognosis is extremely poor. Furthermore, few cases of concurrent bone lesions are reported globally, and more cases must be accumulated and analyzed.

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.

Singular case of osteolytic lesions revealing transformation of myeloproliferative syndrome to acute leukemia

Hematological malignancies can cause bone lesions, of which the most common are the punched-out foci of osteolysis seen in multiple myeloma. However, osteosclerotic lesions are more common in myeloproliferative disorders. We report the unusual case of a patient with myeloproliferative syndrome in whom the development of osteolytic lesions revealed transformation to acute leukemia. In 2007, this 82-year-old man with essential thrombocythemia since 1994 developed primary polycythemia with the JAK2 mutation V617F. In July 2017, he was evaluated for an osteolytic lesion in the right humerus with incipient fracturing. Bone marrow smear results provided only limited information, due to the myelofibrosis, showing 7% of blast cells with no plasmacytosis. No solid malignancies were identified by imaging studies. Examination of a right humeral biopsy specimen taken during internal fixation showed myeloproliferative syndrome with osteosclerosis and grade-3 myelofibrosis, as well as a malignant proliferation of large cells carrying the leukocyte cluster of differentiation antigens CD45, CD 43, CD4, and CD34. The diagnosis was transformation of the myeloproliferative syndrome to acute myeloid leukemia. The development of an osteolytic lesion during the course of myeloproliferative syndrome is an exceedingly rare event that should suggest acute leukemic transformation.

Extensive Bone Marrow Necrosis and Osteolytic Lesions in a Case of Acute Myeloid Leukemia Transformed from Polycythemia Vera

Acute myeloid leukemia (AML) is the most common leukemia in adults. In rare cases, bone marrow necrosis (BMN) and osteolytic lesions are presenting features of AML. The following case describes a patient with known polycythemia vera (PV) that presented with signs of multiple myeloma, including hypercalcemia, anemia, and lytic lesions of the thoracic spine and skull. Laboratory workup was not indicative of myeloma. A bone marrow biopsy was performed, which revealed extensive BMN and initial pathology was consistent with metastatic carcinoma. However, no immunohistochemical stains could be performed due to the extent of BMN; a repeat biopsy was therefore performed. Flow cytometry and CD45 staining were consistent with PV that had transformed to AML. Due to the patient's comorbidities, she was a poor candidate for stem cell transplant and did not wish to pursue chemotherapy. Ultimately, she pursued hospice care. Based on our literature review, both BMN and osteolytic lesions are rare manifestations of AML and have not been reported to occur simultaneously. These findings can lead to a diagnostic dilemma and suspicion of other malignancies. This case demonstrates that AML should remain in the differential diagnosis in those patients who present with BMN and osteolytic lesions.

Osteolytic Bone Lesions - A Rare Presentation of AML M6

Acute myeloid leukemia (AML) M6 is a rare form of AML accounting for < 5 % of all AML. Extramedullary involvement is very rarely seen in this entity. Skeletal lesion has not been described in AML M6 before. We discuss the case of a 17 year old boy with AML M6, who presented with osteolytic lesion of right humerus. He was treated with induction and consolidation chemotherapy. The present case is the first report in literature of AML M6 presenting with skeletal lesions.

FDG-PET is effective in the detection of granulocytic sarcoma in patients with myeloid malignancy

Granulocytic sarcomas (GSs) are extramedullary tumors that consist of myeloid cells in patients with myeloid malignancies. The role for (18)F-fluorodeoxyglucose-positron-emission tomography (FDG-PET) to detect GSs has been unclear. We retrospectively evaluated seven patients with pathologically proven GSs. Compared with other diagnostic tools, FDG-PET was more effective or at least equivalent in the detection of GSs in six patients, but was less effective in one patient. Maximum standardized uptake value (SUVmax) for the lesions widely varied from 2.6 to 9.7. When our findings and previous reports taken together, FDG-PET is an effective tool to search for GSs, however, other diagnostic tools including computed tomography (CT) are still necessary to detect morphological abnormalities.

Differences in Nephrotoxicity of Intravenous Bisphosphonates for the Treatment of Malignancy- Related Bone Disease

Renal dysfunction is a particularly problematic adverse event that requires additional management and can prohibit the use of certain medications. Due to their renal uptake and elimination, some bisphosphonates can cause nephrotoxicity when used for the treatment of skeletal-related events in patients with bone metastases. However, clinical studies and post-marketing experience indicate that renal effects do not appear to be the same for all bisphosphonates. Zoledronic acid and pamidronate appear to be associated with a greater risk of renal toxicity, especially when given in high doses or over short infusion times. In contrast, high loading doses of intravenous ibandronate (3 x 6 mg given on days 1-3) have shown no additional renal safety concerns, and intravenous ibandronate 6 mg appears to have a renal safety profile comparable to placebo. This paper reviews the renal safety of intravenously administered bisphosphonates and makes some suggestions, based on preclinical and clinical data, as to why renal safety profiles may differ.