21 Feb

Primary Granulocytic Sarcoma Presenting with Pleural and Pulmonary Involvement: Discussion

A simultaneous serum LDH was 203 IU/L, and the total protein was 6.1 g/dl. The pleural effusion cytology study showed atypical leukocytes, but it was not diagnostic for leukemic involvement. Bronchoscopy showed a 50 percent narrowing of the left mainstem bronchus and severe narrowing of the lobar bronchi. The mucosa was red-purple, friable, and hemorrhagic. The segmental bronchi could not be seen due to the bleeding and narrowing. The bronchial biopsy showed a dense mononuclear cell infiltrate with rare atypical cells. The bronchial cytology specimen was negative. A pleural biopsy showed fibrosis and a bland mononuclear cell infiltrate. Bilateral iliac crest bone marrow aspirates and biopsies showed increased storage iron and decreased sideroblast iron without evidence of a neoplastic infiltrate. An endomyocardial biopsy showed no abnormalities. Doxycycline

The patient underwent a limited thoracotomy with biopsies of the left paratraeheal lymph nodes and left lower lobe. Histologic sections of the lung and lymph nodes showed a monotonous infiltrate of immature cells with scattered eosinophilic metamyelocytes and myelocytes. The chloroacetate esterase (Leder) stain, ahistochemical marker for neutrophilic precursors, mature neutrophils, and mast cells, showed scattered positive cells. Touch preparations stained with hematoxylin and eosin and Giemsa (Romanovsky) stain showed granulocytic and eosinophilic precursors with Auer rod-containing blasts (Fig 2). Based on these findings, a diagnosis of granulocytic sarcoma was made.
Discussion
Granulocytic sarcoma is a rare extramedullary manifestation of acute nonlymphocytic leukemia, chronic myelogenous leukemia, and the myeloproliferative syndrome. The incidence of granulocytic sarcoma in leukemic patients is 2.9 percent. In autopsy series the incidence has varied from 3.1 to 7.0 percent. It usually occurs in conjunction with bone marrow involvement or as a late complication in known leukemics. In patients with chronic myelogenous leukemia and the myeloproliferative syndrome, granulocytic sarcoma heralds a more aggressive stage of the disease. Granulocytic sarcoma rarely represents the initial presentation of acute nonlymphocytic leukemia. Our review of the literature suggests that this is the first reported case of granulocytic sarcoma presenting with prominent pleural and pulmonary involvement.

Figure 2. Touch preparation showing blasts, with an Auer rod-containing blast in the center. Giemsa (x 1,000)

Figure 2. Touch preparation showing blasts, with an Auer rod-containing blast in the center. Giemsa (x 1,000)

Categories: Pulmonary Involvement
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