Ultrasonic characterization of whole cells and isolated nuclei

High frequency ultrasound imaging (20 to 60 MHz) is increasingly being used in small animal imaging, molecular imaging and for the detection of structural changes during cell and tissue death. Ultrasonic tissue characterization techniques were used to measure the speed of sound, attenuation coefficient and integrated backscatter coefficient for (a) acute myeloid leukemia cells and corresponding isolated nuclei, (b) human epithelial kidney cells and corresponding isolated nuclei, (c) multinucleated human epithelial kidney cells and d) human breast cancer cells. The speed of sound for cells varied from 1522 to 1535 m/s, while values for nuclei were lower, ranging from 1493 to 1514 m/s. The attenuation coefficient slopes ranged from 0.0798 to 0.1073 dB mm(-1) MHz(-1) for cells and 0.0408 to 0.0530 dB mm(-1) MHz(-1) for nuclei. Integrated backscatter coefficient values for cells and isolated nuclei showed much greater variation and increased from 1.71 x 10(-4) Sr(-1) mm(-1) for the smallest nuclei to 26.47 x 10(-4) Sr(-1) mm(-1) for the cells with the largest nuclei. The findings suggest that integrated backscatter coefficient values, but not attenuation or speed of sound, are correlated with the size of the nuclei.

Nuclear localizing sequences promote nuclear translocation and enhance the radiotoxicity of the anti-CD33 monoclonal antibody HuM195 labeled with 111In in human myeloid leukemia cells

Our objective was to evaluate the toxicity of the anti-CD33 monoclonal antibody HuM195 modified with peptides (CGYGPKKKRKVGG) harboring the nuclear localizing sequence (NLS; underlined) of simian virus 40 large T antigen and labeled with (111)In against acute myeloid leukemia (AML) cells.

METHODS

HuM195 was derivatized with sulfosuccinimidyl-4-(N-maleimidomethyl)-cyclohexane-1-carboxylate (sulfo-SMCC) to introduce maleimide groups for reaction with NLS-peptides and then conjugated with diethylenetriaminepentaacetic acid for labeling with (111)In. The immunoreactivity of NLS-HuM195 was evaluated by its ability to displace the binding of (111)In-HuM195 to HL-60 leukemia cells. Nuclear localization was measured in HL-60 cells by subcellular fractionation. The antiproliferative effects of (111)In-NLS-HuM195 and (111)In-HuM195 on HL-60, U937, or K562 cells with high, intermediate, or minimal CD33 expression, respectively, were studied. The survival of HL-60 cells or patient AML specimens treated with (111)In-NLS-HuM195 or (111)In-HuM195 was studied. Normal tissue toxicity was evaluated in BALB/c mice injected intravenously with of 3.7 MBq (22 microg) of (111)In-NLS-HuM195 or (111)In-HuM195.

RESULTS

NLS-HuM195 exhibited relatively preserved CD33 binding affinity (dissociation constant [K(d)] = 4.3 +/- 1.7 x 10(-9) mol/L to 6.9 +/- 1.3 x 10(-9) mol/L). Nuclear uptake increased from 10.5% +/- 0.5% for (111)In-HuM195 to 28.5% +/- 4.1% or 65.9% +/- 1.5% for (111)In-HuM195 substituted with 4 or 8 NLS-peptides, respectively. The inhibitory concentrations of 50% (IC(50)) and 90% (IC(90)) for HL-60 cells treated with (111)In-NLS-HuM195 were 37 kBq per 10(3) cells and 77-81 kBq per 10(3) cells, respectively. The IC(50) and IC(90) values for (111)In-HuM195 were 92 kBq per 10(3) cells and 203 kBq per 10(3) cells. Growth inhibition was correlated with the level of CD33 expression. The survival of HL-60 cells was reduced from 232 +/- 22 colonies (control) to 7 +/- 1 colonies with 1.48 mBq per cell of (111)In-NLS-HuM195; no colonies were found at 3.33 mBq per cell. The surviving fraction decreased >2-fold in 7 of 9 AML specimens treated with an excess of (111)In-NLS-HuM195 and >10-fold in 2 of these specimens. There were no decreases in body weight or hematologic parameters or increases in alanine aminotransferase or creatinine in mice administered 3.7 MBq (22 microg) of (111)In-NLS-HuM195 or (111)In-HuM195. There was no morphologic damage to the liver or kidneys.

CONCLUSION

We conclude that NLS-peptides routed (111)In-HuM195 to the nucleus of AML cells, where the emitted Auger electrons were lethal. (111)In-NLS-HuM195 is a promising targeted radiotherapeutic agent for AML.

Extramedullary myeloid leukemia: the value of cytogenetic analysis in pediatric orbital tumors

Orbital extramedullary myeloid tumor, or granulocytic sarcoma, can be difficult to diagnose even with the use immunohistochemical stains, especially if it precedes the development of systemic leukemia. We describe a 6-year-old boy with a rapidly progressive orbital tumor. This patient underwent an orbital biopsy, which was consistent with extramedullary myeloid tumor but not conclusive. Cytogenetic studies on a bone marrow biopsy revealed a translocation consistent with acute myelogenous leukemia.

Long-term transfusion of polymerized bovine hemoglobin in a Jehovah's Witness following chemotherapy for myeloid leukemia: a case report

A 52-year-old female Jehovah's Witness presented with relapsed secondary acute myeloid leukemia. Because of chemotherapy-induced anemia, she was infused with the bovine hemoglobin (Hb)-based oxygen carrier HBOC-201 (Biopure) as the sole means of transfusion support. HBOC-201 has only been used for management of acute hemorrhage, and its utility in providing longer term transfusion support is unknown. Over a period of 18 days, a total dose of 1230 g of HBOC-201 was delivered. Although the patient succumbed to the disease after 18 days of treatment, this case documents our experience with the highest dose and duration of HBOC-201 ever used. Although possible renal toxicity could not be definitively excluded, the homogeneous extraction of oxygen by the brain in the presence of and perhaps from HBOC-201 was demonstrated.

Myeloid Leukemias and Lung Involvement

Myeloid leukemias are clonal malignancies characterized by the presence of increased numbers of immature myeloid cells in the marrow and peripheral blood. Pulmonary involvement by myeloid leukemia is relatively uncommon and seen mainly in patients with severe disease. The most common form of pulmonary involvement consists of leukemic infiltration along the lymphatics in the peribronchovascular, septal, and pleural interstitial tissue. Less common manifestations include myeloid sarcoma, leukostasis, leukemic cell lysis pneumopathy, and hyperleukocytic reaction. The radiological manifestations of pulmonary leukemic cell infiltration and leukostasis consist mainly of bilateral thickening of the peribronchovascular interstitium and interlobular septa, a pattern that resembles that of interstitial pulmonary edema. The radiological manifestations of leukemic cell lysis pneumopathy and hyperleukocytic reaction consist of symmetric bilateral areas of consolidation. This manuscript reviews the histological and radiological intrathoracic manifestations of myelogenous leukemias.

Imaging of diffuse metastatic and dystrophic pulmonary calcification in children after haematopoietic stem cell transplantation

The authors describe three cases of diffuse pulmonary calcification; two metastatic in children with acute transitory renal failure and the other dystrophic in a child with leukaemia. All three patients underwent haematopoietic stem cell transplantation (HSCT). Chest radiographs disclosed diffuse calcification within the lungs. The distribution of this calcification was bilateral but asymmetric. Diagnosis was made in two cases by high resolution computed tomography (HRCT) and in one case by HRCT and bone scan. Radiological characteristics, scintigraphic features, pathological mechanism and clinical outcome of such pulmonary calcification are discussed.

Haematological malignancies in childhood in Croatia: investigating the theories of depleted uranium, chemical plant damage and 'population mixing'

Some of potential causes proposed to explain the reported increase of haematological malignancies in childhood during or after the war period in several countries include depleted uranium, chemical pollution and population mixing theory. The aim of this study was to define the population of Croatian children aged 0-14 years who were potentially exposed to each of those risks during the war and to investigate any possible association between the exposure and the incidence of haematological malignancies. The authors analyzed the data reported by the Cancer Registry of Croatia during the pre-war period (1986-1990), war period (1991-1995) and post-war period (1996-1999). In the group of 10 counties potentially exposed to depleted uranium and two counties where chemical war damage occurred, no significant difference in incidence of the studied haematological malignancies was noted in comparison to pre-war period. The incidence of lymphatic leukaemia significantly increased in four counties where population mixing had occurred during the war period, supporting the 'mixing theory'. In those counties, the incidence of Hodgkin's lymphoma decreased during and after the war. In Croatia as a whole, decreases in incidence of myeloid leukaemias during war and non-Hodgkin lymphoma after the war were noted.

Acute myeloid leukemia presenting as bilateral proptosis from diffuse extraocular muscle infiltration

PURPOSE

To report a case of acute myeloid leukemia with bilateral proptosis as the sole presenting sign.

DESIGN

Observational case report.

METHODS

A patient with bilateral proptosis was seen in consultation by pediatric ophthalmology.

RESULTS

Complete blood count, computerized tomography, and bone marrow biopsy confirmed the diagnosis of acute myeloid leukemia, with the proptosis due to diffuse infiltration of all extraocular muscles.

CONCLUSION

In a child with the sudden onset of proptosis without any other systemic findings, the diagnosis of acute leukemia must be considered.

Leukaemic pulmonary infiltrates in adult acute myeloid leukaemia: a high-resolution computerized tomography study

Leukaemic infiltration of the lungs may occur in acute myeloid leukaemia (AML). Pulmonary infiltrates are usually microscopic and invariably associated with hyperleucocytosis. Four AML patients with respiratory symptoms and low leucocyte counts underwent standard chest radiography, bronchoscopy with bronchoalveolar lavage and high-resolution computerized tomography (HRCT) of the lungs. HRCT scans showed pulmonary infiltrates with alveolar, interstitial, mixed and peribronchial/perivascular patterns in all patients, including one with negative standard radiographic findings. Infectious agents were excluded. Histology of the lung biopsy/autopsy specimens showed leukaemic infiltrates. Pulmonary leukaemia may be the cause of pulmonary infiltrates, even in non-hyperleucocytosic AML patients with low blast counts.

Myeloablative radioimmunotherapy with Re-188-anti-CD66-antibody for conditioning of high-risk leukemia patients prior to stem cell transplantation: biodistribution, biokinetics and immediate toxicities

BACKGROUND

Stem cell transplantation (SCT) is potentially curative for high-risk leukemia patients. Conditioning regimens affect relapse rate and treatment-related mortality. We evaluated biodistribution, radiation absorbed organ doses and immediate toxicities of myeloablative radioimmunotherapy with marrow selective 188rhenium (188Re)-labeled anti-CD66 monoclonal antibody (mAb).

METHODS

Fifty high-risk leukemia patients were treated 14 +/- 2 days prior to SCT. Dosimetric measurements were performed at 1.5, 3, 20, 26, and 44 hours after about 1 GBq of 188Re followed by radioimmunotherapy with about 10 GBq 188Re. Standard conditioning consisted of high-dose chemotherapy and 12 Gy total-body irradiation. Forty-six patients received allogenic, and four received autologous, stem cell grafts.

RESULTS

The mean radiation absorbed doses (in Gy) were: marrow, 13.9 +/- 4.6; liver, 5.7 +/- 2.7; spleen, 22.6 +/- 25.5; kidneys, 6.8 +/- 2.6; lungs, 0.8 +/- 0.7; total body, 1.4 +/- 0.3. The tumor-to-organ-ratios were 2.4 for liver, 0.6 for the spleen, 2.0 for the kidneys and 17.8 for the lungs. Type of leukemia did not affect radiation absorbed doses of marrow, lungs, kidneys and liver. Mean marrow dose of transplanted patients in complete remission was 1.37 +/- 0.43 Gy/GBq, compared with 1.34 +/- 0.29 Gy/GBq for patients with leukemic blast marrow infiltration of 5-25%. Immediate side effects were moderate. All patients showed primary engraftment. After a median follow-up of 11.0 +/- 7.4 months 28/50 patients (56%) are in ongoing complete remission. Nine patients (5%) have relapsed, seven (4%) of them have died. Another 13 patients (7%) died of treatment-related causes.

CONCLUSIONS

Due to its biodistribution, radiation absorbed organ doses, low toxicity and clinical data, myeloablative radioimmunotherapy with 188Re-labeled anti-CD66 mAb seems to be a promising method for improving standard conditioning of high-risk leukemia patients prior to SCT.

[Vaginal granulocytic sarcoma: CT and MR imaging]

A 30-year-old female patient with vaginal bleeding was referred to the gynecological unit of our hospital. Speculum examination showed a lobulated tumor, 5 cm in size, at the vaginal fornix. MRI demonstrated a tumor encompassing the ventral part of the vagina and the entire cervix. Computed tomography diagnosed pathologically enlarged mediastinal lymph nodes. Subsequent examinations revealed an acute myeloic leukemia, synchronous histopathological examination of the vaginal tumor led to the rare diagnosis of a granulocytic sarcoma.

A new approach to evaluating intestinal acute graft-versus-host disease by transabdominal sonography and colour Doppler imaging

An objective and non-invasive method to assess the extent, severity, course and prognosis of acute graft-versus-host disease (aGvHD) of the gastrointestinal tract would be of great importance. As high-resolution ultrasonography (HRU) and colour Doppler imaging (CDI) are used in inflammatory and ischaemic bowel diseases, we introduced these techniques to evaluate acute intestinal GvHD. In this study, 12 patients with suspected intestinal and/or severe cutaneous aGvHD were investigated by HRU and CDI. The structure and thickness of the bowel wall and the blood flow pattern in the superior mesenteric artery (SMA) as well as in the bowel wall were evaluated. All patients showed thickened bowel wall segments, especially in the ileocaecal region. Even in patients without any clinical signs of intestinal involvement (3/12), sonographic changes were observed. In six patients with severe diarrhoea, sonographic signs of secretory diarrhoea were observed. In 4/12 patients, an increased arterial blood flow in the bowel wall was demonstrated as a typical characteristic of an inflammatory bowel process. In contrast, in 4/12 patients, ischaemic bowel wall lesions with high-resistance flow pattern in the SMA were found. These patients did not respond to immunosuppressive therapy and died. In conclusion, HRU is a useful tool for detecting acute bowel GvHD even before clinical symptoms. Moreover, HRU and CDI can be applied to define the severity of aGvHD and to identify patients with a poor prognosis.

Radiologic manifestations of granulocytic sarcoma in adult leukemia

OBJECTIVE

This study was conducted to summarize the clinical and radiologic presentations including pertinent imaging features of granulocytic sarcoma, a rare extramedullary tumor of acute myeloid leukemia, in 11 adult patients.

CONCLUSION

In patients in our study, the clinical and radiologic manifestations of granulocytic sarcoma were variable and occurred most commonly as disease progression in acute myeloid leukemia (73% of the patients). Granulocytic sarcoma lesions were multiple soft-tissue masses with variable enhancement, recurring in nearly 50% of patients at different sites and points of time during the course of the disease. Lesions in the central nervous system, subcutaneous tissues, and genitourinary system accounted for nearly 52% of all lesions. In general, granulocytic sarcoma masses were isodense to muscle on CT scans, and isointense and hyperintense (mild to moderate) on T1- and T2-weighted MR images, respectively. The presence of peripheral rim enhancement with hypodense or hypointense centers on T1-weighted images may, however, mimic an abscess.

Detection of minimal residual disease in acute leukemia by Tc-99m MIBI femoral marrow imaging

To determine the potential of Tc-99m MIBI femoral marrow imaging for detecting minimal residual disease in acute leukemia, MIBI images of 68 patients with acute leukemia and 110 control patients were examined. MIBI accumulation was classified into three patterns: not detectable, mild accumulation, and clearly visualized accumulation. Clearly visualized accumulation was interpreted as abnormal. The mean uptake ratio of the femoral marrow to muscle was calculated. Forty-five patients who were in complete remission (CR) at the time of MIBI imaging had a follow-up study (mean interval, 23 months). Clearly visualized accumulation was demonstrated in 35 patients with acute leukemia: in 7 patients before starting induction chemotherapy, in 12 patients after relapse, and in 16 of the 49 patients in the CR group. Mild accumulation was demonstrated in 14 patients in the CR group and in 13 control group patients. No detectable accumulation was observed in 19 patients in the CR group and in 97 control patients. The marrow and muscle uptake ratio of patients before starting chemotherapy (2.29 +/- 0.26) was greater compared with that in patients after relapse (1.78 +/- 0.44, P < 0.02) and in patients with abnormal accumulation despite complete remission (1.84 +/- 0.36, P < 0.01). The uptake ratio in patients with abnormal accumulation despite CR was higher compared with patients with mild accumulation in CR (1.26 +/- 0.13, P < 0.001) and controls (1.23 +/- 0.10, P < 0.001) who had mild accumulation. Fifteen patients with abnormal accumulation despite CR had a markedly greater relapse rate (66.7% > 10.0%, P < 0.005), a higher mortality rate (46.7% > 6.7%, P < 0.01), and shorter remission time (8.7 +/- 10.2 months < 35.9 +/- 20.1 months, P < 0.001) compared with 30 patients without abnormal accumulation in CR. MIBI femoral marrow imaging may be a useful and simple method for monitoring levels of residual leukemic cells. Clearly visualized MIBI accumulation may be a marker for relapse.

Nonmammary malignancies of the breast: ultrasound, CT, and MRI

The three major categories of nonmammary malignancies of the breast include primary and secondary lymphoreticular malignancy, primary and secondary sarcoma, and hematogenous metastasis. This article describes the imaging features of 35 nonmammary malignancies of the breast and axilla with histopathologic confirmation. These include primary and secondary breast lymphoma, primary axillary nodal lymphoma, metastatic acute lymphatic leukemia, metastatic plasmacytoma, granulocytic sarcoma, primary angiosarcoma, metastatic rhabdomyosarcoma, hematogenous metastasis from primary lung, ovarian, cervical, thyroid, and colonic carcinoma, malignant melanoma, carcinoma of the nasal cavity, and adenocarcinoma of unknown primary. Wherever possible, correlation between mammography and ultrasound, computed tomography (CT), and/or magnetic resonance (MR) imaging is made.

Orbital and facial granulocytic sarcoma (chloroma): a case report

Granulocytic sarcoma is an uncommon manifestation of myelogenous leukemias in which focal masses of immature myeloid cells from the granulocytic lineage infiltrate bone and soft tissue. It is most common in the pediatric population and may present at any time in the course of the disease, either concurrently with the onset of leukemia or during a remission or relapse. Occasionally, it may precede the clinical onset of acute myelogenous leukemia (AML), presenting a diagnostic challenge.

[Chloroma (granulocytic sarcoma, myeloblastoma). Clinical aspects and radiological diagnosis]

Six cases of granulocytic sarcoma are presented. A mediastinal chloroma and a tumor of the submandibular gland were observed with two patients as single sign of acute myeloic leukaemia. In one patient a chloroma appeared as first manifestation of acute myeloic leukaemia. Two patients exhibited the tumor as first symptom of a blastic crisis of chronic myelogenous leukaemia (femoral bone, lumbar spine). The sixth patient with a myelodyplastic syndrome showed a chloroma of the breast. Various radiological procedures were applied including plain radiography, MRT, CT and mammography. The results are compared with literature. Principles of therapy were supplemented.

Pharmacokinetics and dosimetry of an alpha-particle emitter labeled antibody: 213Bi-HuM195 (anti-CD33) in patients with leukemia

Data from nine patients with leukemia participating in a phase I activity-escalation study of HuM195, labeled with the alpha-particle emitter 213Bi (half-life = 45.6 min), were used to estimate pharmacokinetics and dosimetry. This is the first trial using an alpha-particle emitter in humans. The linear energy transfer of alpha particles is several hundredfold greater than that of beta emissions. The range in tissue is approximately 60-90 microm.

METHODS

The activity administered to patients ranged from 0.6 to 1.6 GBq. Patient imaging was initiated at the start of each injection. Thirty 1-min images followed by ten 3-min images were collected in dynamic mode; a 20% photopeak window centered at 440 keV was used. Blood samples were collected until 3 h postinjection and counted in a gamma counter. Contours around the liver and spleen were drawn on the anterior and posterior views and around a portion of the spine on the posterior views. No other organs were visualized.

RESULTS

The percentage injected dose in the liver and spleen volumes increased rapidly over the first 10-15 min to a constant value for the remaining hour of imaging, yielding a very rapid uptake followed by a plateau in the antibody uptake curves. The kinetic curves were integrated to yield cumulated activity. The mean energy emitted per nuclear transition for 213Bi and its daughters, adjusted by a relative biologic effectiveness of 5 for alpha emissions, was multiplied by the cumulated activity to yield the absorbed dose equivalent. Photon dose to the total body was determined by calculating a photon-absorbed fraction. The absorbed dose equivalent to liver and spleen volumes ranged from 2.4 to 11.2 and 2.9 to 21.9 Sv, respectively. Marrow (or leukemia) mean dose ranged from 6.6 to 12.2 Sv. The total-body dose (photons only) ranged from 2.2 x 10(-4) to 5.8 x 10(-4) Gy.

CONCLUSION

This study shows that patient imaging of 213Bi, an alpha-particle emitter, labeled to HuM195 is possible and may be used to derive pharmacokinetics and dosimetry. The absorbed dose ratio between marrow, liver and spleen volumes and the whole body for 213Bi-HuM195 is 1000-fold greater than that commonly observed with beta-emitting radionuclides used for radioimmunotherapy.

Granulocytic sarcoma of the pancreas: a report of two cases and literature review

Granulocytic sarcomas (GS) are extramedullary tumour masses of immature myeloid cells, also known as chloroma and extramedullary myeloid cell tumour. These neoplasms usually occur simultaneously with, or follow the onset of acute myeloid leukaemia (AML). Rarely, they are the first manifestation of AML. GS may also be the first sign of transformation to AML in patients with chronic myeloproliferative disorders and myelodysplastic syndromes. GS have been reported to occur in a variety of tissues, but presentation as an abdominal mass and, in particular, infiltration of the pancreas is rare. We report two cases of pancreatic GS, review the literature, and discuss recent insights into the basic biological properties of these rare tumours.

Granulocytic sarcoma of orbit preceding acute myeloid leukaemia: a case report

A rare case of granulocytic sarcoma of orbit preceding the onset of acute meyloblastic leukaemia is presented. A 7-year-old boy presented with proptosis and no other systemic complaints. The appearance of an enlarged muscle in initial tomographic imaging with a normal peripheral blood picture caused a diagnostic problem. Biopsy suggested a diagnosis of granulocytic sarcoma. Subsequent bone marrow study revealed the diagnosis of acute myeloid leukaemia.

Mucosa-associated lymphoid tissue type lymphoma of the gallbladder associated with acute myeloid leukemia

We describe a patient with mucosa-associated lymphoid tissue (MALT) type lymphoma of the gallbladder who developed concurrent acute myeloid leukemia (M2). She was admitted because of progressive jaundice and underwent cholecystectomy. Histologic examination of the gallbladder showed diffuse proliferation of atypical lymphoid cells and a formed lymphoepithelial lesion. Because of progressive thrombocytopenia, a bone marrow tap was performed 25 days after the operation. Bone marrow contained 65.5% blasts, and was positive for peroxidase, CD33 and HLA-DR, and negative for lymphoid markers. We discuss the rare association of these disorders.

Leukostasis followed by hemorrhage complicating the initiation of chemotherapy in patients with acute myeloid leukemia and hyperleukocytosis: a clinicopathologic report of four cases

BACKGROUND

Pulmonary and cerebral leukostasis, or parenchymal hemorrhage in these organs, are well-known early complications developing in patients with acute myeloid leukemia (AML), particularly when myelomonocytic features, hyperleukocytosis, and/or a coagulation disorder are initially present. Commonly, these complications arise during increasing leukocyte counts (WBCs).

METHODS

The authors describe four patients with AML and hyperleukocytosis who developed leukostasis followed by parenchymal hemorrhage.

RESULTS

Bleeding in all patients occurred while their WBCs were decreasing following cytosine-arabinoside chemotherapy, and in the absence of disseminated intravascular coagulation or severe thrombocytopenia. Radiologic and histopathologic findings underscoring possible mechanisms are presented in the article.

CONCLUSIONS

Alterations of cell adhesion associated with chemotherapy-induced blast lysis or cellular differentiation are possible factors contributing to this particular sequence (cytosine arabinoside-based chemotherapy, leukostasis, and subsequent hemorrhage). Prophylactic measures for managing this early complication of AML treatment include leukapheresis to reduce the WBC prior to the initiation of chemotherapy.

Hypoechoic periportal cuffing in acute myeloid leukemia

We report a case of hypoechoic periportal cuffing in a patient with acute myeloid leukemia. The hypoechoic area encasing the main portal vein and its branches may have been caused by transient lymphedema resulting from the blockage of small lymph vessels or from direct periportal infiltration by malignant cells. The sonographic abnormality disappeared within 2 weeks of the commencement of chemotherapy.

An autopsy case of granulocytic sarcoma of the porta hepatis causing obstructive jaundice

We describe an extremely rare case of granulocytic sarcoma of the porta hepatis causing obstructive jaundice. The patient was an 84-year-old man admitted because of obstructive jaundice. Ultrasonography (US) and computed tomography (CT) scanning of the abdomen disclosed a mass about 2.5 cm in diameter near the neck of the gallbladder, and thickening of the gallbladder wall. Based on these findings, gallbladder carcinoma was suspected. After endoscopic retrograde biliary drainage (ERBD) was performed, the jaundice resolved. However, blast cells were detected in the peripheral blood 51 days after admission, and laboratory studies disclosed acute myelocytic leukemia (AML: French-American-British [FAB] type M0). We treated him conservatively, with antibiotics and ERBD but he died of disseminated intravascular coagulation. Autopsy showed that the suspected gallbladder carcinoma was actually a granulocytic sarcoma arising in association with AML and causing obstructive jaundice. The largest tumor involved the porta hepatis. It should be kept in mind that granuloctyic sarcoma is a possible cause of obstructive jaundice, even in patients with no evidence of AML.

Orbital granulocytic sarcoma in an elderly patient

PURPOSE

To report a 71-year-old woman with acute myelogenous leukemia in remission who developed orbital granulocytic sarcoma.

METHODS

The patient was referred for acute proptosis and decreased vision of the right eye. Computed tomography of the orbits demonstrated a right extraconal mass compressing the optic nerve. A right lateral orbitotomy was performed, and a portion of the mass was excised for diagnostic purposes and orbital decompression.

RESULTS

Histopathologic and immunohistochemical evaluation disclosed orbital granulocytic sarcoma. With chemotherapy and radiation, vision remained stable and right proptosis resolved.

CONCLUSIONS

Orbital granulocytic sarcoma is usually diagnosed in children with a history of acute myelogenous leukemia. This case demonstrated that this entity may also occur rarely in older patients with a history of acute myelogenous leukemia.

Bone scan of advanced polycythemia vera with malignant transformation

A 69-year-old man with polycythemia vera and myelofibrosis was seen with a 2-week history of increasing arm pain. A bone scan showed diffuse prominence of the long bones, especially in the metaphyseal and epiphyseal regions of the lower extremities. There was relative prominence of the proximal right humerus that suggested the presence of a malignant process in addition to marrow space expansion secondary to myelofibrosis. An MRI of the right upper extremity showed a permeated lesion in the proximal right humerus extending into the adjacent soft tissue with a large soft tissue component. At surgery, a biopsy was followed by placement of a humeral rod. The morphologic features of the tumor together with CD34 positivity were consistent with a granulocytic sarcoma. This is the first reported case of bone scintigraphic findings in advanced p. vera with myelofibrosis and malignant transformation. The case illustrates the scintigraphic appearance of extensive expansion of the marrow and suggests the importance of vigilance for relatively subtle changes of complicating malignancies.

Pelvic granulocytic sarcoma

Granulocytic sarcoma is an uncommon extraskeletal tumor most frequently associated with leukemia. We present a case of bone location with unusual pattern in a patient with no evidence of myeloproliferative disorder at presentation or follow-up.

Bilateral orbital granulocytic sarcoma (chloroma) preceding the blast phase of acute myelogenous leukemia: CT findings

Granulocytic sarcoma (chloroma) is an uncommon malignant neoplasm associated with myelogenous leukemias. Its appearance may precede the clinical manifestations of the acute leukemic phase by months to years. We report the CT findings of a case of bilateral intraorbital granulocytic sarcoma which preceded the blast phase of acute myelogenous leukemia (AML) and led to its diagnosis. An awareness of granulocytic sarcoma and its CT appearance may expedite the diagnosis of AML or prompt close monitoring of those cases of granulocytic sarcoma antedating the appearance of AML.

Plasma kinetics and biodistribution of a lipid emulsion resembling low-density lipoprotein in patients with acute leukemia

Low-density lipoprotein (LDL) could be used as a carrier of chemotherapeutic agents to neoplastic cells that overexpress LDL receptors (rLDL), but LDL is difficult to obtain and handle. Recently, it was observed that a protein-free emulsion resembling the lipid portion of LDL (LDE) behave like native LDL when injected into the bloodstream. In this study, the evidence that LDE is taken up by rLDL was expanded by comparing LDL and LDE plasma decay curves in rabbits and by competition experiments with lymphocytes. To verify whether LDE could be removed from the plasma by neoplastic cells with increased rLDL, LDE labeled with 14Ccholesteryl ester was injected into 14 patients with acute myeloid leukemia (AML) and into 7 with acute lymphocytic leukemia (ALL). In AML rLDL expression is increased but in ALL it is normal. LDE plasma fractional clearance rate (FCR, in h-1) was calculated from the remaining radioactivity measured in plasma samples collected during 24 h following injection. LDE FCR was 3-fold greater in AML than in ALL patients 0.192 +/- 0.210 (SD) and 0.066 +/- 0.033 h-1, respectively, P < 0.035. When LDE injection was repeated in 9 AML patients in hematological remission, LDE FCR diminished 66% compared to the pretreatment values (from 0.192 +/- 0.210 to 0.065 +/- 0.038 h-1, P < 0.02), so that it could be estimated that nearly 66% of the emulsion was taken up by AML cells and only 34% by the normal tissues. As expected, LDE FCR was unchanged in 4 patients with ALL in hematological remission (0.069 +/- 0.044 h-1). Gamma camera images obtained 6 h after the injection of 99mTc-label LDE into one patient with ALL showed biodistribution similar to that of LDL. In one AML patient LDE was comparatively more concentrated over the areas corresponding to the bone marrow infiltrated by AML cells. Our results indicate that LDE FCR is increased in a disease known to contain malignant cells that overexpress rLDL, suggesting that LDE is taken up by malignant cells with increased rLDL.

Meningioma-like intracranial granulocytic sarcoma (chloroma). Radiologic and surgical findings

We present the case of a 23 years old female with chronic granulocytic leukemia and two intracranial tumors with all the radiological characteristics of intracranial meningiomas. Successful removal of the largest tumor was accomplished using the technique described for meningiomas. The recovery was very good and the histopathologic diagnosis was of granulocytic sarcoma. Radiotherapy of the second tumor reduced the tumor mass within one month leaving the patient neurologically intact. We recommended surgery in the future treatment of large chloromas.

[Intraparenchymal granulocytic sarcoma in acute monocytic leukemia; case report]

Granulocytic sarcoma of the parenchyma of the brain present in a patient with acute monocytic leukemia, and its unusual course during treatment, is described. Four years after diagnosis of acute monocytic leukemia, a 24-year-old man developed severe headache during its remission period. The CT scan showed large intraparencymal mass in the right frontal lobe, which was partially removed and diagnosed as granulocytic sarcoma. Following the operation, radiation in total dose of 35.5 Gy was given to the whole brain, and there was also left intraventricular administration of methotrexate (MTX) and cytosine arabinoside (ara-C). The treatment resulted in the complete disappearance of the intraparenchymal mass apart from small calcifications. Five months later, the patient redeveloped severe headache with consciousness disturbance. CT scan revealed marked swelling in the left cerebral hemisphere with irregular contrast-enhanced areas. The patient died of brain herniation in spite of conservative therapy. Photomicroscopic findings of the left cerebral hemisphere proved the presence of "disseminated leukoencephalopathy" and the absence of tumor cells. On the other hand, the right frontal lesion consisted of no tumor cells but scar tissues. This unusual feature of the CT scan in the terminal stage might be caused by combination with the effect of highly concentrated MTX in the left cerebral hemisphere because of the increased permeability of the ependym and the relatively high radiosensitivity in the non-affected left cerebral hemisphere.

Intracranial granulocytic sarcoma: CT, MR, and angiography

Granulocytic sarcoma is a rare, solid tumor composed of immature granulocytes usually found in association with systemic leukemia in younger patients. We present a case of granulocytic sarcoma occurring in an elderly female with no evidence of systemic leukemia. Computed tomography, MR (with and without Gd-DTPA), and angiography showed features commonly found in meningiomas.