Journal of Cytology
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CASE REPORT Table of Contents   
Year : 2009  |  Volume : 26  |  Issue : 2  |  Page : 88-90
Multicentric extramedullary myeloid tumor


Department of Pathology, Nizam's Institute of Medical Sciences, Hyderabad, India

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Date of Web Publication26-Aug-2009
 

   Abstract 

Granulocytic sarcomas or extramedullary myeloid tumors represent the soft tissue counterpart of acute myeloid leukemia. The term is used for any solid collection of leukemic cells. There have been reports of these tumors occurring before the involvement of blood or bone marrow. Our patient had simultaneous involvement of three sites, which was diagnosed on cytology. Further confirmation was done on peripheral blood and bone marrow evaluation.

Keywords: Acute myeloid leukemia; chloroma; extramedullary myeloid tumor.

How to cite this article:
Dhingra M, Radhika K, Paul RT, Aruna PK. Multicentric extramedullary myeloid tumor. J Cytol 2009;26:88-90

How to cite this URL:
Dhingra M, Radhika K, Paul RT, Aruna PK. Multicentric extramedullary myeloid tumor. J Cytol [serial online] 2009 [cited 2019 Sep 22];26:88-90. Available from: http://www.jcytol.org/text.asp?2009/26/2/88/55231



   Introduction Top


Granulocytic sarcoma or extramedullary myeloid tumor (EMMT) is an uncommon neoplasm of immature hematopoetic cells. The term 'chloroma' was earlier used because the tumor acquires a greenish tint due to myeloperoxidase. These tumors are reported in 3.1-9.1% of patients with myeloblastic leukemia and occur concomitantly with, after, or rarely before the onset of leukemia. We report a case with multiple tumors involving the lymph nodes, breast and orbit. The diagnosis was established on fine needle aspiration cytology (FNAC) of the masses which subsequently led to the diagnosis of the underlying leukemia.


   Case Report Top


A 15 year-old girl presented with bilateral, cervical lymphadenopathy, bilateral breast masses, and gradually developing proptosis of both eyes, in that order. She had complained of general malaise and weakness for six months. Examination revealed that there was bilateral cervical lymphadenopathy, the smallest measured 1.5 cm. Nodes were firm to hard with restricted mobility and the breast masses were 4.5 cm (left) and 5.0 cm (right) along their maximum dimension. Overlying skin was normal but the lumps were fixed on both sides. The proptosis was bilateral and uniform in both eyes. There was no hepatosplenomegaly or any other palpable lymphadenopathy.

Fine needle aspiration cytology (FNAC) was done from the lymph nodes and breast masses. Aspirate from breast masses was scant. Both wet-fixed and air-dried smears were prepared for Papanicolaou and May-Grünwald Giemsa (MGG) staining respectively.

Smears from lymph nodes and the breast showed similar features with a polymorphous population of large atypical cells scattered in a background of mostly mature and a few reactive lymphoid cells [Figure 1] and [Figure 2]. The cells were round, discrete, and twice the size of mature lymphocytes. The nuclei were round to oval with fine chromatin and 2-3 nucleoli. Cytoplasm was pale blue and a fair number of cells showed  Auer rods More Details and a few fine granules; the background showed lymphoglandular bodies. Smears from the breast did not show any ductal epithelial cell clusters. Cell morphology from both sites was suggestive of myeloid blasts, so a diagnosis of granulocytic sarcoma/extramedullary myeloid tumor was made.

The peripheral smear showed normocytic, normochromic anemia with leukocytosis. Total leucocyte count (TLC) was 48000 cells/mm 3 with the differential count showing 70% blasts, 2% promyelocytes, 8% myelocytes, 8% metamyelocytes, 2% band forms, and 10% lymphocytes. Platelet count was adequate and the blasts were as described above with mostly indented nuclei and Auer rods [Figure 3]. Bone marrow showed increased cellularity with myeloid predominance. Megakaryocytes were normal and there were 29% blasts in the marrow. Out of these, a considerable proportion showed monocytoid features; the blasts were diffusely positive for Sudan Black B (SBB) and negative for periodic acid schiff (PAS). Non specific enolase (NSE) was noncontributory, based on which, a diagnosis of acute myeloid leukemia (AML)-M4 was given.

The patient was started on standard chemotherapy to which she responded well.


   Discussion Top


Granulocytic sarcoma or extramedullary myeloid tumor may be seen in association with chronic myeloid leukemia (CML), myelodysplastic syndrome, (MDS), myeloproliferative syndrome (MPS), polycythemia vera, and essential thrombocytosis. A distinct association has been seen with FAB type AML M4 and M5. EMMT may be seen in known patients of AML or may occur (rarely) as the first manifestation of the disease. In other cases, it may be the first sign of systemic relapse of a case of treated AML.

EMMTs may occur at any site in the body, common ones being the skin (leukemia cutis), lymph nodes, and mediastinum. Other sites such as epidural, uterus, ovaries, testis, and orbits have also been reported. A few case reports have described it in the breast [1],[2],[3] where it is often misdiagnosed as lymphoma. Granulocytic sarcomas of the orbit have mostly been described as isolated masses which may precede systemic manifestations. [4] The soft tissue counterparts may present months before the involvement of peripheral blood and bone marrow. [5] They produce symptoms according to their anatomic location but they may be asymptomatic as well.

Problems in diagnosis arise when they are suspected in patients without a background of myeloprolifrative disease. They may often be misdiagnosed as non-Hodgkin's lymphomas, rhabdomyosarcomas, amelanotic melanomas, or undifferentiated carcinomas. [6]

Definitive diagnosis requires biopsy. Light microscopy reveals collections of cells that can be usually recognised as being myeloid. Undifferentiated or minimally differentiated blasts generally pose diagnostic problems and these are cases that are misdiagnosed as lymphoma. Diagnosis must be supported by cytochemistry and immunohistochemistry. Leder stain for naphthol-ASD chloracetate esterase is very useful. The cells in our case were positive for SBB and myeloperoxidase; PAS was negative. Immunostaining with monoclonal antibodies against myeloperoxidase; anti-CD43, and anti-lysozyme are the most sensitive antibodies; CD68 and CD20 are useful in differentiating it from lymphoma.

Prognostic significance of EMMT is not very well known. It is regarded as a poor prognostic indicator by some, [7] whereas others have not considered it as an independent prognostic factor. [7] If they are diagnosed in patients previously treated for AML, they signify relapse whereas in a patient of chronic myeloproliferative disease, they may be indicative of an impending blast crisis.

The mainstay of treatment of EMMT is treating the underlying leukemia. Most tumors, whether detected prior to or during the therapy of leukemia, respond well to standard chemotherapeutic agents. Evidence of residual tumor may be an indication of surgery or radiation therapy. Relapse during the course of treatment indicates poor outcome.[8]

 
   References Top

1.Barloon TJ, Young DC, Bass SH. Multicentric granulocytic sarcoma (chloroma) of the breast: Mammographic findings. AJR Am J Roentgenol 1993;161:963-4.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]
2.Azim HA Jr, Gigli F, Martinelli G, Peccatori FA, Pruneri G, Travaini LL, et al . Extramedullary myeloid sarcoma of the breast. J Clin Oncol 2008;26:4041-3.  Back to cited text no. 2    
3.Thachil J, Richards RM, Copeland G. Granulocytic sarcoma: A rare presentation of a breast lump. Ann R Coll Surg Engl 2007;89:W7-9.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]
4.Stockl AF, Dolmetsch MA, Saornil MA, Font LR, Burnier MN. Orbital granulocytic sarcoma. Br J Ophthalmol 1997;81:1084-8.  Back to cited text no. 4    
5.D'Costa GF, Hastak MS, Patil YV. Granulocytic sarcoma of breast: an aleukemic presentation. Indian J Med Sci 2007;61:152-5.  Back to cited text no. 5    
6.Paul TR, Sundaram C, Gayathri K, Prayaga A, Raghunadha Rao D. Extramedullary myeloid cell tmors- The NIMS experience. Indian J Pathol Microbiol 2005;48:318-21.  Back to cited text no. 6    
7.Tanravahi R, Qumsiyeh M, Patil S. Extramedullary leukemia adversely affects hematologic complete remission and overall survival in patients with t(8;21)(q22;q22): Results from Cancer and Leukemia Group B 8461. J Clin Oncol 1997;15:466.  Back to cited text no. 7    
8.Bisschop MM, Revesz T, Bierings M. Extramedullary infiltrates at diagnosis have no prognostic significance in children with acute myeloid leukemia. Leukemia 2001;15:46.  Back to cited text no. 8    

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Correspondence Address:
Meetu Dhingra
Department of Pathology, Nizam's Institute of Medical Sciences, Hyderabad
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9371.55231

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    Figures

  [Figure 1], [Figure 2], [Figure 3]

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