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| | CASE REPORT | | | | | Year : 2007 | Volume : 61 | Issue : 3 | Page : 152-155 | | | Granulocytic sarcoma of breast: An aleukemic presentation
Grace F D'costa, Meenal S Hastak, Yoganand V Patil
Dept. of Pathology, Grant Medical College and Sir J.J. Gr. of Hospitals, Byculla, Mumbai, Maharashtra, India
Correspondence Address:
Yoganand V Patil
Dept. of Pathology, Grant Medical College and Sir J.J. Gr. of Hospitals, Byculla, Mumbai - 400 008
India
DOI: 10.4103/0019-5359.30750 PMID: 17337816 Granulocytic sarcoma is a rare extramedullary tumor composed of immature myeloid cells. It is usually associated with leukemia or other myeloproliferative disorders but can also occur without overt hematologic diseases. The breast is an uncommon site of presentation and requires a high index of suspicion for diagnosis. We report such a case in a 45-year-old female, who presented with nontender left breast lump of 6 months' duration. A peripheral smear and bone marrow examination at that time was normal. A lumpectomy was done. An H and E diagnosis of lobular carcinoma vs. non-Hodgkin's lymphoma was entertained. Immunostains, however, revealed myeloperoxidase, naphthol AS-D chloroacetate esterase and CD43 positivity, indicating a diagnosis of granulocytic sarcoma. It appears that early initiation of systemic AML-type chemotherapy is beneficial and may delay or avert the development of AML in bone marrow and blood. Eight months later, the patient presented with an orbital mass; bone marrow and peripheral smear involvement by AML.
Keywords: Breast, granulocytic sarcoma
How to cite this article:
D'costa GF, Hastak MS, Patil YV. Granulocytic sarcoma of breast: An aleukemic presentation. Indian J Med Sci 2007;61:152-5 |
| ¤ Introduction | |  |
The term granulocytic sarcoma designates an infrequent solid tumor composed of aggregates of immature granulocytic precursor in extramedullary sites. These neoplasms are known by a variety of other names in literature, including monocytic sarcoma, extramedullary myeloid cell tumor, myeloblastoma and chloroma. The lesion generally occurs either during the natural course of AML or after a remission has been achieved; however, it may rarely represent the initial manifestations of the disease,[1] as was the case in our patient, who presented with a granulocytic sarcoma of the breast 8 months prior to the appearance of acute myeloid leukemia. Myeloid sarcoma presenting as a breast mass is uncommon, with only 61 cases reported in literature. Most cases reported occurred in patients with a history of AML or other myeloid disorders. We have identified six cases in literature with adequate follow-up that occurred as an isolated breast mass, without a history or subsequent development of AML.
| ¤ Case Report | | |
A 45-year-old female presented with a left-sided nontender breast lump of 6 months' duration. A peripheral smear at that stage was normal. Mammography showed a single noncalcified, irregular mass with poorly defined feathery margin. A lumpectomy was done, following an inconclusive fine needle aspiration cytology report, which was scanty and nonrepresentative in nature.
Gross examination
Gross examination revealed a well-demarcated but unencapsulated tumor measuring 6 × 5 × 2.5 cm, covered by fibroadipose tissues. Cut section was firm, grayish white and solid [Figure - 1].
Histopathology
Histopathology revealed a diffuse discohesive proliferation of small round-to-oval cells (myeloblasts), with high N/C ratio, hyperchromatic vesicular nuclei, with raised mitotic activity. The rest of the neoplastic cells in all stages of maturation included promyelocytes, myelocytes, metamyelocytes and stab forms. Tubule formation was not seen. An Indian file and targetoid pattern were seen at places [Figure - 2],[Figure - 3]. The stroma was densely desmoplastic. A diagnosis of lobular carcinoma v/s. non-Hodgkin lymphoma (NHL) was made based on the HandE slides.
Immunohistochemistry
Immunohistochemistry study revealed myeloperoxidase, naphthol AS-D chloroacetate esterase and CD43 positivity. LCA, CK and EMA were negative, establishing a diagnosis of granulocytic sarcoma and ruling out diagnoses of lymphoma and carcinoma.
Peripheral smear and bone marrow examination were performed after diagnosis of GS on lumpectomy and IHC, but they revealed normal findings. Eight months later, the patient presented with an orbital mass, bone marrow and peripheral smear involvement by acute myeloid leukemia. Peripheral smear showed 50% myeloblasts, and bone marrow aspirate showed 80% myeloblasts. The blasts were myeloperoxidase-positive, showing auer rodes; and naphthol AS-D chloroacetate esterase positive, showing myeloid differentiation. There was no hepatosplenomegaly, lymphadenopathy, and the other breast was normal.
| ¤ Discussion | | |
This primary extramedullary lesion may indeed represent a diagnostic and therapeutic dilemma for both the hematopathologist and oncologist[2] and requires a high index of suspicion for diagnosis. It may follow, accompany or signal AML or CML.[2],[3] Granulocytic sarcoma may also occur in patients with myelodysplastic syndrome, where it is a sign of imminent disease progression.[4] In our case, it antedated the presentation of AML by 8 months, as described in literature.[5],[6]
The primary sites of occurrence are usually the lymph nodes, skin, CNS and small intestine,[7],[8] but the breast is an uncommon site of presentation.[7],[8] The age at presentation ranges from 31-73 years, with an average of 52 years.[3] Our patient was 45 years of age. The patients are usually female, as was our case, though it has been reported in males too, who present with gynecomastia.[9] Histologically well-differentiated, poorly differentiated and blastic forms have been described in literature.[3] Our case was a well-differentiated form [Figure - 2],[Figure - 3].
The differential diagnosis should include all tumors with a diffuse proliferation of small tumor cells, i.e., lymphoma, NHL, carcinomas and melanomas.[8] Among the carcinomas, lobular carcinoma and undifferentiated carcinoma enter the differential diagnosis.[10] Non-neoplastic conditions like inflammation and extramedullary hemopoiesis should also be considered.[10] In our case also, the initial diagnosis was lobular carcinoma v/s. NHL. It was only after immunohistochemistry was done, which revealed CD 43 positivity, LCA, CK and EMA negativity, that a diagnosis of granulocytic sarcoma was made, for which the patient was treated as acute myelogenous leukemia with systemic chemotherapy. Eight months later, the patient presented with an orbital mass, bone marrow and peripheral smear involvement by acute myeloid leukemia. Our case presented with isolated mass in the breast, without history of acute myeloid leukemia at last follow-up. Immunohistochemical studies were extremely helpful for recognizing isolated myeloid sarcoma. Such isolated presentation is extremely rare, and to diagnose such cases early is beneficial and may delay or avert the development of AML in bone marrow and blood.
| ¤ References | | |
| 1. | Fitoz S, Atasoy C, Yavuz K, Gozdasoglu S, Erden I, Akyar S. Granulocytic sarcoma. Cranial and breast involvement. Clin Imaging 2002;26:166-9.  | | 2. | Breccia M, Petti MC, Fraternali-Orcioni G, Monarca B, Latagliata R, D'Elia GM, et al . Granulocytic sarcoma with breast and skin presentation: A report of a case successfully treated by local radiation and systemic chemotherapy. Acta Haematol 2000;104:34-7. | | 3. | Valbuena JR, Admirand JH, Gualco G, Medeiros LJ. Myeloid sarcoma involving the breast. Arch Pathol Lab Med 2005;129:32-8. [PUBMED] [FULLTEXT] | | 4. | Mwanda WO, Rajab JA. Granulocytic sarcoma: Report of three cases. East Afr Med J 1999;76:594-6. [PUBMED] | | 5. | Eshghabadi M, Shojania AM, Carr I. Isolated granulocytic sarcoma: Report of a case and review of the literature. J Clin Oncol 1986;4:912-7. [PUBMED] [FULLTEXT] | | 6. | Gartenhaus WS, Mir R, Pliskin A, Grunwald H, Wise L, Papantoniou PA, et al . Granulocytic sarcoma of breast: Aleukemic bilateral metachronous presentation and literature review. Med Pediatr Oncol 1985;13:22-9. | | 7. | Shea B, Reddy V, Abbitt P, Benda R, Douglas V, Wingard J. Granulocytic sarcoma (chloroma) of the breast: A diagnostic dilemma and review of the literature. Breast J 2004;10:48-53. [PUBMED] [FULLTEXT] | | 8. | Quintas-Cardama A, Fraga M, Antunez J, Forteza J. Primary extramedullary myeloid tumor of the breast: A case report and review of the literature. Ann Hematol 2003;82:431-4. [PUBMED] [FULLTEXT] | | 9. | Au WY, Ma SK, Kwong YL, Lie AK, Shek WH, Chow WC, et al . Acute myeloid leukemia relapsing as gynecomastia. Leuk Lymphoma 1999;36:191-4. | | 10. | Ngu IW, Sinclair EC, Greenaway S, Greenberg ML. Unusual presentation of granulocytic sarcoma in the breast: A case report and review of the literature. Diagn Cytopathol 2001;24:53-7. [PUBMED] [FULLTEXT] |
Figures [Figure - 1], [Figure - 2], [Figure - 3]
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