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Indian Journal of Cancer, Vol. 48, No. 3, July-September, 2011, pp. 378-380 Letter to Editor Granulocytic sarcoma of the oral cavity S Seema, GR Jay, CS Devi, BU Aadithya, S Niharika Department of Oral and Maxillofacial Pathology, I.T.S. -C.D.S.R., Muradnagar, Ghaziabad, Uttar Pradesh, India Code Number: cn11105 PMID: 21921350 DOI: 10.4103/0019-509X.84929 Sir, A 5½-year-old male child was referred to the outpatient department with a huge painless soft tissue swelling in the right mandibular region which had been present for a period of 30-40 days [Figure - 1]. It had increased rapidly in size due to which the patient was unable to close his mouth. There were occasional episodes of bleeding due to trauma and a history of spontaneous exfoliation of the regional teeth. Patient had suffered bouts of fever. There was no history of any medication. Medical history of the patient was insignificant. The patient revealed that a distant relative had died of blood cancer. On examination there was a swelling involving the entire right mandibular ridge area with a largest dimension of 5 cm. [Figure - 2] The mucosal surface was covered with necrotic debris. The swelling was non tender and soft to firm on palpation. Teeth in the 83-46 region were mobile. Ipsilateral lymph nodes were palpable and non tender. Physical examination revealed mild hepatomegaly and splenomegaly. Radiological examination showed extensive bone loss involving right side of both the body of mandible and ramus. It revealed loss of three teeth and displacement of the teeth in 83-46 region [Figure - 3]. Clinically, the differential diagnosis included lymphoma, acute leukemia, malignant histiocytosis, and sarcoma. During the blood examination hemoglobin count was found to be 6.8 g%, white blood cell count was 7300/mm 3 , and platelet count was 77 000/mm 3 . The most striking finding was the presence of blast cells in the peripheral blood smear which exceeded 20%. The blast cells had a fine chromatin pattern, high nucleocytoplasmic ratio and prominent nucleoli [Figure - 4]. Bone marrow examination showed the presence of more than 20% blast cells with fine chromatin pattern and high nucleocytoplasmic ratio. Auer rods were present in greater than 3% of the blast cells. A biopsy from the tumor was taken to correlate the tumor mass with the systemic findings. The histopathological examination showed a relatively uniform population of immature cells admixed with eosinophilic myelocytes and neutrophils. The immature cells showed brisk mitotic activity [Figure - 5]. For final diagnosis, a panel of antibodies was used during the immunohistochemical staining procedures in the paraffin block. The tumor cells expressed myeloperoxidase (MPO) and terminal deoxynucleotidyl transferase (Tdt) enzymes. They were immunonegative for CD 10, CD3, and CD99. Our diagnosis was Granulocytic Sarcoma in a case of AML M2 subtype on the basis of history, physical examination, complete blood Count, bone marrow aspiration, tissue biopsy, and immunophenotyping procedures. No cytogenetic analysis of the case could be performed. The patient was immediately admitted to the hematology department of the medical college but unfortunately the patient died of acute lung infection even before chemotherapy was instituted. Granulocytic sarcoma (GS), also known as extramedullary myeloid tumor or chloroma, is a rare solid tumor composed of immature cells of the granulocyte series, which occur in an extramedullary site. [1] It is thought to arise in the bone marrow and travel via the Haversian canals to reach the subperiosteal region of bone. Once in the periosteum, the tumor cells can spread to other parts of the body. [2] Oral involvement by granulocytic sarcoma is rare, with only 38 cases described to date. [3] The use of a large immunohistochemistry panel has been suggested by most authors when making a differential diagnosis between GS and lymphoid as well as other myeloid tumors. [4] Since granulocytic sarcoma often precedes leukemia, so, its diagnosis is very important for proper and timely treatment. References
Copyright 2011 - Indian Journal of Cancer The following images related to this document are available:Photo images[cn11105f3.jpg] [cn11105f1.jpg] [cn11105f5.jpg] [cn11105f4.jpg] [cn11105f2.jpg] |
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