Practical Radiation Oncology (2011) 1, 135–138
www.practicalradonc.org
Teaching Case
Myeloid sarcoma of the upper extremity causing compartment syndrome: a case report Brandon M. Barney MD a,⁎, Blake P. Gillette MD b , Yolanda I. Garces MD a , Wei Ding MBBS, PhD c , John C. Cheville MD d , Peter S. Rose MD b a
Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota c Department of Hematology and Oncology, Mayo Clinic, Rochester, Minnesota d Department of Pathology, Mayo Clinic, Rochester, Minnesota b
Received 12 October 2010; revised 16 November 2010; accepted 17 November 2010
Introduction
Case presentation
Myeloid sarcoma, also known as chloroma, granulocytic sarcoma, or myeloblastoma, is a rare, solid neoplasm comprised of immature extramedullary granulocytic cells, seen most frequently as a manifestation of myeloid leukemia. It often occurs either as the presenting symptom of leukemia, or as the harbinger of leukemia to come several months later, developing at some point in the disease course of 2% to 8% of patients with acute nonlymphoblastic leukemia overall. When occurring in patients without overt systemic signs of leukemia, the average time to the development of systemic disease is less than 1 year.1,2 Common sites of disease include the soft tissues, skin, bone, and lymph nodes. Less commonly, myeloid sarcoma can be seen in the intestines, mediastinum, epidural space, uterus, or ovary.3-6 Myeloid sarcoma presenting in the extremities is extremely rare. In this report we detail the unusual presentation of a compartment syndrome as the index presentation of a myeloid sarcoma in the soft tissues of the upper extremity.
A 59-year-old Caucasian male presented to the Emergency Department with a 2-week history of constant, progressive pain and swelling in the left upper extremity after several months of intermittent pain. This pain had worsened acutely over the 24-hour period prior to presentation, to the point where it became unbearable. Physical examination was significant for prominent swelling and ecchymosis of the left proximal forearm, with a maximum measured circumference of 35.0 cm compared to 25.0 cm in the unaffected contralateral forearm. The left forearm was nontender to the touch; however, the palmar aspect of the hand was exquisitely sensitive to palpation of any kind. The left hand was in a fixed, “clawed" position and any passive stretch of the digits resulted in severe pain radiating up the arm. There was loss of two-point discrimination on all fingertips and a sensory deficit to light touch in the digits, particularly in the distribution of the median nerve. Radial pulse was normal, at 2+. Laboratory studies revealed the following: white blood count, 287.5 × 109/L (57% neutrophils, 2% lymphocytes, 1% monocytes, 3% eosinophils, 5% basophils, 2% blasts, and 30% other immature forms); hemoglobin, 7.1 g/dL; and platelets, 234 × 109/L. Plain film x-rays were unremarkable, but magnetic resonance imaging revealed a large mass in the deep volar compartment of the left forearm measuring
Conflicts of interest: None. ⁎ Corresponding author. Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN 55905. E-mail address: [email protected] (B.M. Barney).
1879-8500/$ – see front matter © 2011 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved. doi:10.1016/j.prro.2010.11.005
136
B.M. Barney et al
Practical Radiation Oncology: April-June 2011
Figure 1
3.0 × 3.2 × 9.3 cm, with homogeneous signal on T1 and heterogeneous signal on T2. Figure 1 shows the mass in the deep volar compartment of the left forearm on T2-weighted fast spin-echo sequence with fat suppression magnetic resonance images (A, axial view; B, sagittal view). Note the heterogenous appearance of the bone marrow (see arrow) suggestive of a possible hematopoietic process. The clinical diagnosis of an acute worsening of a chronic compartment syndrome was made in the Emergency Department, and the patient was admitted to the hospital on the orthopedic surgery service. The measurement of compartment pressures, often part of the workup for compartment syndrome when the diagnosis is in doubt, was not performed as this was deemed unnecessary by the orthopedic surgery team. As the patient had given no history of trauma, the cause of the compartment syndrome was presumed to be related to either infection or malignancy. While the patient's blood and imaging findings were most consistent with hematogenous malignancy, fasciotomy was temporarily delayed until a tissue diagnosis could be obtained. The concern was that if the patient had a bloodborne cancer he would likely require systemic therapy and having open fasciotomies would delay these treatments. An urgent ultrasound-guided needle biopsy of the forearm mass was obtained, showing a myeloproliferative neoplasm. Figure 2 shows representative hematoxylin and eosin staining of tissue retrieved from the needle biopsy of the left forearm mass. The overview (400×) shows a diffuse infiltrate of small round cells. The inset (600×) shows higher magnification views. The arrow indicates a large, immature myeloid-type cell, consistent with the diagnosis of myeloid sarcoma. Immunoperoxidase studies were strongly positive for CD43, lysozyme, and CD33, and weakly, focally positive for myeloperoxidase. These results, combined with the clinical picture, were consistent with a diagnosis of myeloid sarcoma.
In lieu of these findings, the attending orthopedic surgeon recommended consultations with HematologyOncology and Radiation Oncology departments. The standard treatment for acute compartment syndrome, emergent decompressive surgery with fasciotomy, was considered, but the patient's hematologist indicated that proceeding down this route would postpone the immediate initiation of systemic therapy in order to allow for postfasciotomy wound healing. As a delay in chemotherapy was unacceptable, the patient was treated emergently with external beam radiation therapy, receiving a total of 20 Gy in 5 daily fractions. His first fraction was administered immediately after biopsy, the same day as his hospital admission. He had a MAHURKAR catheter (Covidien, Mansfield, MA) placed and began leukophoresis the next day. He was also started on hydroxyurea. Bone marrow aspirate and peripheral blood smear were obtained, BCR-ABL translocation was
Figure 2
Practical Radiation Oncology: April-June 2011
Myeloid sarcoma compartment syndrome
identified by fluorescent in situ hybridization, and a diagnosis of chronic myeloid leukemia in the chronic phase was made. The patient was started on imatinib (Gleevec; Novartis AG, Basel, Switzerland) in addition to the hydroxyurea, and has continued on Gleevec since that time. The patient's clinical picture improved rapidly after initiating treatment. Within 12 hours of receiving his first fraction of radiotherapy, the left forearm circumference had decreased by 2 cm, to 32.7 cm. His pain had improved significantly. At the time of his discharge from the hospital 6 days after admission, the forearm circumference was 28.0 cm, and he was pain free. The sensations of light touch and two-point discrimination had improved significantly in the radial and ulnar nerve distributions, though the return of median nerve sensation lagged behind. His white blood cell count upon discharge was 57.7 × 109/L. One month later, on outpatient follow-up, the patient's left forearm was noted to be 25.5 cm, and the mass was no longer clinically apparent. There was still some subtle two-point discrimination discrepancy in the median nerve distribution and the patient reported some subjective weakness, though this was not confirmed on formal strength testing. His white blood cell count was 2.3 × 109/L.
Discussion Reports of myeloid sarcoma occurring in the soft tissues of the extremities are rare.5,7-15 The published cases of extremity myeloid sarcoma are summarized in Table 1. A great majority of these patients were treated with chemotherapy alone. Compartment syndrome as a result of myeloid sarcoma is exceedingly rare, with only 1 other reported case in the medical literature, occurring in the left lower extremity of a patient who was ultimately diagnosed with acute myeloid leukemia.12 In Table 1
137
that case, preoperative biopsy was not performed and the diagnosis of myeloid sarcoma was made by excisional biopsy during fasciotomy. That patient experienced an outcome similar (with some residual permanent sensorineural changes) to the patient described in this case report, although systemic therapy was delayed after surgery. In our case report, the patient's remarkable leukocytosis was suggestive of hematogenous malignancy, facilitating the decision to biopsy the mass. In spite of this, if consideration had not been given to treatment options other than emergent fasciotomy, the patient's systemic therapy could have been delayed, possibly resulting in a poorer clinical outcome. The optimal therapeutic approach for myeloid sarcoma is unknown and will be difficult to establish given the rarity of the tumor.2 A majority of published reports on this topic are case studies, akin to this report, without long-term follow-up. In a large review of patients with extramedullary myeloid tumors, Byrd et al concluded radiotherapy was an effective local treatment for symptomatic myeloid sarcoma.3 That review does not suggest a specific radiotherapy dose, although other retrospective series have shown doses of 20 to 30 Gy to be sufficient for tumor control.16,17 Systemic therapy has also been shown to be effective for local therapy in addition to being the primary treatment for the often underlying leukemia. 18 The inherent sensitivity of myeloid sarcoma to both chemotherapy and radiotherapy makes surgery an impractical and unnecessary treatment for many patients. Although myeloid sarcoma is a rare entity and would not typically be found on a short differential diagnosis for acute compartment syndrome, this case emphasizes the need for careful evaluation of the entire clinical picture before making treatment decisions. The decision to treat any malignancy causing a compartment syndrome with radiotherapy followed by chemotherapy over a standard surgical approach of fasciotomy should only be made as part of a team
Literature review
Reference
Age (years)
Location
Index presentation of leukemia?
Treatment
Symptoms
Di Palma, Feudale8 Taverna et al14 Jenkins, Sorour10 Paydas et al5
59 62 62 41 42 43 30 11 9 23 57 59
Arm Upper leg Hip Arm Arm Hip Lower leg Forearm Forearm Brachial plexus Forearm, upper leg Arm
— No Yes Yes No No Yes Yes No No No Yes
— Chemotherapy — — — Chemotherapy Surgery, chemotherapy Chemotherapy Chemotherapy Chemotherapy, RT Chemotherapy RT, chemotherapy
Soft tissue swelling Lower extremity pain Hip pain — — Hip pain Compartment syndrome Soft tissue swelling Median nerve palsy Brachial plexopathy Tibial nerve palsy, pain Compartment syndrome
Agarwal et al7 Scheipl et al12 Haresh et al9 Warme et al15 Karam et al11 Takahashi et al13 This report RT, radiation therapy.
138
B.M. Barney et al
approach, including a radiation oncologist, surgeon, and medical oncologist. The risks of inadequately treated compartment syndrome, ranging from subtle neurologic deficits to limb loss or even fatality, must be balanced against the risk of an open surgical procedure delaying systemic therapy. In the case of a myeloid sarcoma causing acute worsening of chronic compartment syndrome, immediate radiation therapy and rapid initiation of chemotherapy resulted in a good clinical outcome, both in terms of overall neurologic function and systemic disease control, without the need for surgery.
References 1. Meis JM, Butler JJ, Osborne BM, Manning JT. Granulocytic sarcoma in nonleukemic patients. Cancer. 1986;58:2697-2709. 2. Neiman RS, Barcos M, Berard C, et al. Granulocytic sarcoma: a clinicopathologic study of 61 biopsied cases. Cancer. 1981;48: 1426-1437. 3. Byrd JC, Edenfield WJ, Shields DJ, Dawson NA. Extramedullary myeloid cell tumors in acute nonlymphocytic leukemia: a clinical review. J Clin Oncol. 1995;13:1800-1816. 4. Choi EK, Ha HK, Park SH, et al. Granulocytic sarcoma of bowel: CT findings. Radiology. 2007;243:752-759. 5. Paydas S, Zorludemir S, Ergin M. Granulocytic sarcoma: 32 cases and review of the literature. Leuk Lymphoma. 2006;47:2527-2541. 6. Yamauchi K, Yasuda M. Comparison in treatments of nonleukemic granulocytic sarcoma: report of two cases and a review of 72 cases in the literature. Cancer. 2002;94:1739-1746. 7. Agarwal N, Tepe EM, Mishra A, Ward JH. Relapse of acute promyelocytic leukemia presenting as granulocytic sarcoma in the hip. Ann Hematol. 2006;85:741-742.
Practical Radiation Oncology: April-June 2011 8. Di Palma S, Feudale E. Granulocytic sarcoma with myxoid stroma. Report of a case. Tumori. 1993;79:71-73. 9. Haresh KP, Joshi N, Gupta C, et al. Granulocytic sarcoma masquerading as Ewing's sarcoma: a diagnostic dilemma. J Cancer Res Ther. 2008;4:137-139. 10. Jenkins CI, Sorour Y. Case report: a large extramedullary granulocytic sarcoma as the initial presenting feature of chronic myeloid leukemia. MedGenMed. 2005;7:23. 11. Karam C, Khorsandi A, MacGowan DJ. Clinical reasoning: a 23year-old woman with paresthesias and weakness. Neurology. 2009;72:e5-e10. 12. Scheipl S, Leithner A, Radl R, et al. Myeloid sarcoma presenting in muscle-tissue of the lower limb: unusual origin of a compartmentsyndrome. Am J Clin Oncol. 2007;30:658-659. 13. Takahashi T, Tsukuda H, Kimura H, Yoshimoto M, Tsujisaki M. Extramedullary relapse of AML with t(9;11)(p22;q23) associated with clonal evolution from trisomy 8 into tetrasomy 8. Intern Med. 2010;49:447-451. 14. Taverna C, Vogt P, Pestalozzi BC. Uncommon sites of presentation of hematologic malignancies. Case 2: diffuse muscle infiltration by granulocytic sarcoma seven years after acute myelomonocytic leukemia. J Clin Oncol. 1999;17:1642-1643. 15. Warme B, Sullivan J, Tigrani DY, Fred DM. Chloroma of the forearm: a case report of leukemia recurrence presenting with compression neuropathy and tenosynovitis. Iowa Orthop J. 2009;29:114-116. 16. Chak LY, Sapozink MD, Cox RS. Extramedullary lesions in nonlymphocytic leukemia: results of radiation therapy. Int J Radiat Oncol Biol Phys. 1983;9:1173-1176. 17. Dusenbery KE, Arthur DC, Howells W, et al. The role of radiation therapy in the management of granulocytic sarcomas (chloromas) in pediatric patients with newly diagnosed acute myeloid leukemia: a report from the children's cancer group. Int J Radiat Oncol Biol Phys. 1996;36:367. 18. Landis DM, Aboulafia DM. Granulocytic sarcoma: an unusual complication of aleukemic myeloid leukemia causing spinal cord compression. A case report and literature review. Leuk Lymphoma. 2003;44:1753-1760.
www.practicalradonc.org
Teaching Case
Myeloid sarcoma of the upper extremity causing compartment syndrome: a case report Brandon M. Barney MD a,⁎, Blake P. Gillette MD b , Yolanda I. Garces MD a , Wei Ding MBBS, PhD c , John C. Cheville MD d , Peter S. Rose MD b a
Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota c Department of Hematology and Oncology, Mayo Clinic, Rochester, Minnesota d Department of Pathology, Mayo Clinic, Rochester, Minnesota b
Received 12 October 2010; revised 16 November 2010; accepted 17 November 2010
Introduction
Case presentation
Myeloid sarcoma, also known as chloroma, granulocytic sarcoma, or myeloblastoma, is a rare, solid neoplasm comprised of immature extramedullary granulocytic cells, seen most frequently as a manifestation of myeloid leukemia. It often occurs either as the presenting symptom of leukemia, or as the harbinger of leukemia to come several months later, developing at some point in the disease course of 2% to 8% of patients with acute nonlymphoblastic leukemia overall. When occurring in patients without overt systemic signs of leukemia, the average time to the development of systemic disease is less than 1 year.1,2 Common sites of disease include the soft tissues, skin, bone, and lymph nodes. Less commonly, myeloid sarcoma can be seen in the intestines, mediastinum, epidural space, uterus, or ovary.3-6 Myeloid sarcoma presenting in the extremities is extremely rare. In this report we detail the unusual presentation of a compartment syndrome as the index presentation of a myeloid sarcoma in the soft tissues of the upper extremity.
A 59-year-old Caucasian male presented to the Emergency Department with a 2-week history of constant, progressive pain and swelling in the left upper extremity after several months of intermittent pain. This pain had worsened acutely over the 24-hour period prior to presentation, to the point where it became unbearable. Physical examination was significant for prominent swelling and ecchymosis of the left proximal forearm, with a maximum measured circumference of 35.0 cm compared to 25.0 cm in the unaffected contralateral forearm. The left forearm was nontender to the touch; however, the palmar aspect of the hand was exquisitely sensitive to palpation of any kind. The left hand was in a fixed, “clawed" position and any passive stretch of the digits resulted in severe pain radiating up the arm. There was loss of two-point discrimination on all fingertips and a sensory deficit to light touch in the digits, particularly in the distribution of the median nerve. Radial pulse was normal, at 2+. Laboratory studies revealed the following: white blood count, 287.5 × 109/L (57% neutrophils, 2% lymphocytes, 1% monocytes, 3% eosinophils, 5% basophils, 2% blasts, and 30% other immature forms); hemoglobin, 7.1 g/dL; and platelets, 234 × 109/L. Plain film x-rays were unremarkable, but magnetic resonance imaging revealed a large mass in the deep volar compartment of the left forearm measuring
Conflicts of interest: None. ⁎ Corresponding author. Department of Radiation Oncology, Mayo Clinic, 200 First St SW, Rochester, MN 55905. E-mail address: [email protected] (B.M. Barney).
1879-8500/$ – see front matter © 2011 American Society for Radiation Oncology. Published by Elsevier Inc. All rights reserved. doi:10.1016/j.prro.2010.11.005
136
B.M. Barney et al
Practical Radiation Oncology: April-June 2011
Figure 1
3.0 × 3.2 × 9.3 cm, with homogeneous signal on T1 and heterogeneous signal on T2. Figure 1 shows the mass in the deep volar compartment of the left forearm on T2-weighted fast spin-echo sequence with fat suppression magnetic resonance images (A, axial view; B, sagittal view). Note the heterogenous appearance of the bone marrow (see arrow) suggestive of a possible hematopoietic process. The clinical diagnosis of an acute worsening of a chronic compartment syndrome was made in the Emergency Department, and the patient was admitted to the hospital on the orthopedic surgery service. The measurement of compartment pressures, often part of the workup for compartment syndrome when the diagnosis is in doubt, was not performed as this was deemed unnecessary by the orthopedic surgery team. As the patient had given no history of trauma, the cause of the compartment syndrome was presumed to be related to either infection or malignancy. While the patient's blood and imaging findings were most consistent with hematogenous malignancy, fasciotomy was temporarily delayed until a tissue diagnosis could be obtained. The concern was that if the patient had a bloodborne cancer he would likely require systemic therapy and having open fasciotomies would delay these treatments. An urgent ultrasound-guided needle biopsy of the forearm mass was obtained, showing a myeloproliferative neoplasm. Figure 2 shows representative hematoxylin and eosin staining of tissue retrieved from the needle biopsy of the left forearm mass. The overview (400×) shows a diffuse infiltrate of small round cells. The inset (600×) shows higher magnification views. The arrow indicates a large, immature myeloid-type cell, consistent with the diagnosis of myeloid sarcoma. Immunoperoxidase studies were strongly positive for CD43, lysozyme, and CD33, and weakly, focally positive for myeloperoxidase. These results, combined with the clinical picture, were consistent with a diagnosis of myeloid sarcoma.
In lieu of these findings, the attending orthopedic surgeon recommended consultations with HematologyOncology and Radiation Oncology departments. The standard treatment for acute compartment syndrome, emergent decompressive surgery with fasciotomy, was considered, but the patient's hematologist indicated that proceeding down this route would postpone the immediate initiation of systemic therapy in order to allow for postfasciotomy wound healing. As a delay in chemotherapy was unacceptable, the patient was treated emergently with external beam radiation therapy, receiving a total of 20 Gy in 5 daily fractions. His first fraction was administered immediately after biopsy, the same day as his hospital admission. He had a MAHURKAR catheter (Covidien, Mansfield, MA) placed and began leukophoresis the next day. He was also started on hydroxyurea. Bone marrow aspirate and peripheral blood smear were obtained, BCR-ABL translocation was
Figure 2
Practical Radiation Oncology: April-June 2011
Myeloid sarcoma compartment syndrome
identified by fluorescent in situ hybridization, and a diagnosis of chronic myeloid leukemia in the chronic phase was made. The patient was started on imatinib (Gleevec; Novartis AG, Basel, Switzerland) in addition to the hydroxyurea, and has continued on Gleevec since that time. The patient's clinical picture improved rapidly after initiating treatment. Within 12 hours of receiving his first fraction of radiotherapy, the left forearm circumference had decreased by 2 cm, to 32.7 cm. His pain had improved significantly. At the time of his discharge from the hospital 6 days after admission, the forearm circumference was 28.0 cm, and he was pain free. The sensations of light touch and two-point discrimination had improved significantly in the radial and ulnar nerve distributions, though the return of median nerve sensation lagged behind. His white blood cell count upon discharge was 57.7 × 109/L. One month later, on outpatient follow-up, the patient's left forearm was noted to be 25.5 cm, and the mass was no longer clinically apparent. There was still some subtle two-point discrimination discrepancy in the median nerve distribution and the patient reported some subjective weakness, though this was not confirmed on formal strength testing. His white blood cell count was 2.3 × 109/L.
Discussion Reports of myeloid sarcoma occurring in the soft tissues of the extremities are rare.5,7-15 The published cases of extremity myeloid sarcoma are summarized in Table 1. A great majority of these patients were treated with chemotherapy alone. Compartment syndrome as a result of myeloid sarcoma is exceedingly rare, with only 1 other reported case in the medical literature, occurring in the left lower extremity of a patient who was ultimately diagnosed with acute myeloid leukemia.12 In Table 1
137
that case, preoperative biopsy was not performed and the diagnosis of myeloid sarcoma was made by excisional biopsy during fasciotomy. That patient experienced an outcome similar (with some residual permanent sensorineural changes) to the patient described in this case report, although systemic therapy was delayed after surgery. In our case report, the patient's remarkable leukocytosis was suggestive of hematogenous malignancy, facilitating the decision to biopsy the mass. In spite of this, if consideration had not been given to treatment options other than emergent fasciotomy, the patient's systemic therapy could have been delayed, possibly resulting in a poorer clinical outcome. The optimal therapeutic approach for myeloid sarcoma is unknown and will be difficult to establish given the rarity of the tumor.2 A majority of published reports on this topic are case studies, akin to this report, without long-term follow-up. In a large review of patients with extramedullary myeloid tumors, Byrd et al concluded radiotherapy was an effective local treatment for symptomatic myeloid sarcoma.3 That review does not suggest a specific radiotherapy dose, although other retrospective series have shown doses of 20 to 30 Gy to be sufficient for tumor control.16,17 Systemic therapy has also been shown to be effective for local therapy in addition to being the primary treatment for the often underlying leukemia. 18 The inherent sensitivity of myeloid sarcoma to both chemotherapy and radiotherapy makes surgery an impractical and unnecessary treatment for many patients. Although myeloid sarcoma is a rare entity and would not typically be found on a short differential diagnosis for acute compartment syndrome, this case emphasizes the need for careful evaluation of the entire clinical picture before making treatment decisions. The decision to treat any malignancy causing a compartment syndrome with radiotherapy followed by chemotherapy over a standard surgical approach of fasciotomy should only be made as part of a team
Literature review
Reference
Age (years)
Location
Index presentation of leukemia?
Treatment
Symptoms
Di Palma, Feudale8 Taverna et al14 Jenkins, Sorour10 Paydas et al5
59 62 62 41 42 43 30 11 9 23 57 59
Arm Upper leg Hip Arm Arm Hip Lower leg Forearm Forearm Brachial plexus Forearm, upper leg Arm
— No Yes Yes No No Yes Yes No No No Yes
— Chemotherapy — — — Chemotherapy Surgery, chemotherapy Chemotherapy Chemotherapy Chemotherapy, RT Chemotherapy RT, chemotherapy
Soft tissue swelling Lower extremity pain Hip pain — — Hip pain Compartment syndrome Soft tissue swelling Median nerve palsy Brachial plexopathy Tibial nerve palsy, pain Compartment syndrome
Agarwal et al7 Scheipl et al12 Haresh et al9 Warme et al15 Karam et al11 Takahashi et al13 This report RT, radiation therapy.
138
B.M. Barney et al
approach, including a radiation oncologist, surgeon, and medical oncologist. The risks of inadequately treated compartment syndrome, ranging from subtle neurologic deficits to limb loss or even fatality, must be balanced against the risk of an open surgical procedure delaying systemic therapy. In the case of a myeloid sarcoma causing acute worsening of chronic compartment syndrome, immediate radiation therapy and rapid initiation of chemotherapy resulted in a good clinical outcome, both in terms of overall neurologic function and systemic disease control, without the need for surgery.
References 1. Meis JM, Butler JJ, Osborne BM, Manning JT. Granulocytic sarcoma in nonleukemic patients. Cancer. 1986;58:2697-2709. 2. Neiman RS, Barcos M, Berard C, et al. Granulocytic sarcoma: a clinicopathologic study of 61 biopsied cases. Cancer. 1981;48: 1426-1437. 3. Byrd JC, Edenfield WJ, Shields DJ, Dawson NA. Extramedullary myeloid cell tumors in acute nonlymphocytic leukemia: a clinical review. J Clin Oncol. 1995;13:1800-1816. 4. Choi EK, Ha HK, Park SH, et al. Granulocytic sarcoma of bowel: CT findings. Radiology. 2007;243:752-759. 5. Paydas S, Zorludemir S, Ergin M. Granulocytic sarcoma: 32 cases and review of the literature. Leuk Lymphoma. 2006;47:2527-2541. 6. Yamauchi K, Yasuda M. Comparison in treatments of nonleukemic granulocytic sarcoma: report of two cases and a review of 72 cases in the literature. Cancer. 2002;94:1739-1746. 7. Agarwal N, Tepe EM, Mishra A, Ward JH. Relapse of acute promyelocytic leukemia presenting as granulocytic sarcoma in the hip. Ann Hematol. 2006;85:741-742.
Practical Radiation Oncology: April-June 2011 8. Di Palma S, Feudale E. Granulocytic sarcoma with myxoid stroma. Report of a case. Tumori. 1993;79:71-73. 9. Haresh KP, Joshi N, Gupta C, et al. Granulocytic sarcoma masquerading as Ewing's sarcoma: a diagnostic dilemma. J Cancer Res Ther. 2008;4:137-139. 10. Jenkins CI, Sorour Y. Case report: a large extramedullary granulocytic sarcoma as the initial presenting feature of chronic myeloid leukemia. MedGenMed. 2005;7:23. 11. Karam C, Khorsandi A, MacGowan DJ. Clinical reasoning: a 23year-old woman with paresthesias and weakness. Neurology. 2009;72:e5-e10. 12. Scheipl S, Leithner A, Radl R, et al. Myeloid sarcoma presenting in muscle-tissue of the lower limb: unusual origin of a compartmentsyndrome. Am J Clin Oncol. 2007;30:658-659. 13. Takahashi T, Tsukuda H, Kimura H, Yoshimoto M, Tsujisaki M. Extramedullary relapse of AML with t(9;11)(p22;q23) associated with clonal evolution from trisomy 8 into tetrasomy 8. Intern Med. 2010;49:447-451. 14. Taverna C, Vogt P, Pestalozzi BC. Uncommon sites of presentation of hematologic malignancies. Case 2: diffuse muscle infiltration by granulocytic sarcoma seven years after acute myelomonocytic leukemia. J Clin Oncol. 1999;17:1642-1643. 15. Warme B, Sullivan J, Tigrani DY, Fred DM. Chloroma of the forearm: a case report of leukemia recurrence presenting with compression neuropathy and tenosynovitis. Iowa Orthop J. 2009;29:114-116. 16. Chak LY, Sapozink MD, Cox RS. Extramedullary lesions in nonlymphocytic leukemia: results of radiation therapy. Int J Radiat Oncol Biol Phys. 1983;9:1173-1176. 17. Dusenbery KE, Arthur DC, Howells W, et al. The role of radiation therapy in the management of granulocytic sarcomas (chloromas) in pediatric patients with newly diagnosed acute myeloid leukemia: a report from the children's cancer group. Int J Radiat Oncol Biol Phys. 1996;36:367. 18. Landis DM, Aboulafia DM. Granulocytic sarcoma: an unusual complication of aleukemic myeloid leukemia causing spinal cord compression. A case report and literature review. Leuk Lymphoma. 2003;44:1753-1760.
