Clinicopathologic, immunophenotyping and cytogenetic analysis of Sweet syndrome in Egyptian patients with acute myeloid leukemia

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Original article

Clinicopathologic, immunophenotyping and cytogenetic analysis of Sweet syndrome in Egyptian patients with acute myeloid leukemia Mohamed El-Khalawany a,∗ , Soha Aboeldahab b , Al-Sadat Mosbeh a , Aida Thabet c a b c

Department of Dermatology, Al-Azhar University, Cairo, Egypt Department of Dermatology, Sohag University, Sohag, Egypt Department of Clinical Pathology, Banha University, Banha, Egypt

a r t i c l e

i n f o

Article history: Received 11 March 2016 Keywords: Sweet syndrome Leukemia Subcutaneous Genetic Chemotherapy

a b s t r a c t

Background: Sweet syndrome (SS) is an uncommon dermatologic disorder that could be associated with hematologic malignancies. Objective: To describe the clinicopathologic, immunophenotyping and cytogenetic characteristics of SS in Egyptian patients with acute myeloid leukemia (AML). Methods: The study was conducted during the period from April 2011 to March 2015. For each patient, a clinical evaluation and histological assessment of cutaneous lesions were recorded. Diagnostic investigations, immunophenotyping and cytogenetic features of leukemia were analyzed. Therapeutic monitoring and follow up of both diseases were registered. Results: The study included 13 patients (7 males and 6 females) with a mean age of 44.4 ± 17.49 years. Fever was recorded in 10 cases and most of the lesions (61.5%) appeared during the post remission period. Clinically, the lesions were more frequently located on the extremities (61.5%), presented as solitary lesion (53.8%) and mostly tender (69.2%). Atypical presentations were observed in 5 cases and included ulcerative lesion, indurated mass and a gangrenous mass. Histological assessment revealed two patterns of inflammatory reactions described as classic (dermal) form (38.5%) and deep (subcutaneous) form (61.5%). Laboratory investigations showed leukocytosis in 61.5%, neutropenia in 38.5%, anaemia in 92.3%, and thrombocytopenia in 84.6%. Bone marrow aspiration and biopsy showed suppressed trilineage hematopoesis in 84.6% and blast cell count >50% in 69.2%. The common subtypes of AML included M2 and M4 (23.1% for each). Cytogenetic studies revealed genetic abnormalities in 69.2% of cases. Most of the cases (76.9%) showed a poor response to oral prednisolone but responded well to alternative therapies, including dapsone, colchicine and cyclosporine. Conclusion: Sweet syndrome associated with AML may show atypical clinical forms that have an aggressive course and is mostly associated with subcutaneous involvement. Although chemotherapy of AML may play a significant role in the development of SS, the exact mechanism remains unclear. The disease is considered a steroid refractory and genetic abnormalities may have a role in altering the classic nature of the disease. © 2016 Elsevier GmbH. All rights reserved.

1. Introduction Sweet syndrome (SS) is a characteristic dermatologic disorder described as acute febrile neutrophilic dermatosis. The disease is characterized clinically by a sudden onset of fever and painful

∗ Corresponding author at: Department of Dermatology, Al-Azhar University, Box: 32515, Al-Darasah, Cairo, Egypt. E-mail addresses: [email protected] (M. El-Khalawany), Wael ezat [email protected] (S. Aboeldahab), [email protected] (A.-S. Mosbeh), [email protected] (A. Thabet).

succulent red-brown plaques favoring face, shoulders and arms [1]. Histologically, SS is characterized by diffuse dermal infiltrate, mostly neutrophils, and is associated with prominent papillary dermal edema. Classically, the infiltrate is confined to the reticular dermis, and there are no signs of vasculitis [2]. Sweet syndrome may occur as an idiopathic reaction but it is commonly associated with other conditions, such as infections, autoimmune disorders, malignancy and drugs. It was reported that 21% of SS cases are associated with cancer; out of this percentage, approximately 85% are associated with hematologic malignancies.

http://dx.doi.org/10.1016/j.prp.2016.10.008 0344-0338/© 2016 Elsevier GmbH. All rights reserved.

Please cite this article in press as: M. El-Khalawany, et al., Clinicopathologic, immunophenotyping and cytogenetic analysis of Sweet syndrome in Egyptian patients with acute myeloid leukemia, Pathol. – Res. Pract (2016), http://dx.doi.org/10.1016/j.prp.2016.10.008

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Table 1 Demographic and clinical characteristics of 13 patients with SS-associated AML. No

Sex

Age

Fever

Symptoms/sings

Clinical characteristics of lesions (number – morphology – distribution)

1 2 3 4 5 6 7 8 9 10 11 12 13

M M M F F M F F M F M M F

25 41 55 27 69 56 28 81 51 42 33 43 26

+ + – + + ++ + + + – + – ++

Hepataosplenomegly Regional lymphadenopathy Chest pain Gum hypertrophy Ecchymosis Pallor Gum hypertrophy Regional lymphadenopathy Ecchymosis Gum hypertrophy Pallor Chest pain Arthralgia

Solitary Ulcerative lesion Leg Solitary Erythematous plaque Trunk Multiple Erythematous plaques Upper limbs – Face Solitary Indurated mass Arm Multiple Erythematous nodules Upper extremities Multiple Ulcerative lesions Lower extremities Solitary Gangrenous mass Thigh Multiple Erythematous plaques Lower extremities Solitary Indurated mass Trunk Solitary Erythematous plaque Face Solitary Erythematous plaque Thigh Multiple Erythematous plaques Trunk – upper limbs Multiple Erythematous plaques Trunk

Genitourinary tract malignancy constituted the most common solid tumor in association with SS [3]. Acute myelogenous leukemia (AML), chronic lymphocytic leukemia and multiple myeloma are considered the most common hematologic malignancies associated with SS [4]. In 10–15% of cases, an associated leukemia, usually of acute myelomonocytic type, is present or develops later. Hairy cell leukemia developed in one case. In some of these cases, features of atypical pyoderma gangrenosum may be present, and it has been suggested that Sweet’s syndrome and pyoderma gangrenosum may be at opposite ends of the spectrum of one process [5]. To the best of our knowledge, there is no previous report describing the characteristics of SS in Egyptian patients. In this study, we describe the clinicopathological features of SS associated with AML and also describe the pattern of AML along with the cytogenetic and molecular abnormalities in these patients. 2. Patients and methods During the period from April 2010 to March 2015, all patients with SS associated with AML were enrolled in this study. The study was conducted in three dermatology centers at different locations in Egypt. The study was approved by the local ethical committee and institutional review boards. Informed consent was obtained from each patient, and medical photography was performed for some patients after written consent. Data recorded for each patient included age, sex; onset, course, location, description, and duration of the lesions. Skin biopsy was obtained from each lesion, and histological examination was evaluated. The workup of underlying hematologic malignancy, including bone-marrow aspiration and biopsy, immunophenotyping and cytogenetic studies, was registered. Therapeutic response and follow up information were also recorded for each patient. For histological examination, skin specimen was fixed in 4% formalin, embedded in paraffin wax, cut and stained with hematoxylin-eosin. The histologic hallmark of the disease was the presence of moderately dense neutrophilic infiltrate in the reticular dermis associated with papillary dermal edema. Assessment of other histologic features, such as subcutaneous involvement, signs of vasculitis and presence of bacterial colonies, was reported. Special staining with Gram’s, Ziehl–Neelsen (ZN) and Periodic acid Schiff (PAS) was performed routinely for all cases to exclude bacterial or fungal infections. Laboratory investigations were recorded with more concern of total and differential leukocyte count and erythrocyte sedimentation rate (ESR). Radiological examination of the chest was performed for some cases. Blood culture was done for all cases with fever. Blood film was performed for all cases for identification of myeloid cells. Bone marrow aspiration and biopsy were collected

from the pelvic bone (iliac crest) under local anaesthesia. The samples were drawn into EDTA tube and heparin tube for cytogentic studies and immunophenotyping. Flow cytometric analysis was performed using a general panel of fluorescent antibodies against the antigens more specified of acute leukemia panel which included CD2, CD3, CD7, CD10, CD13, CD14, CD15, CD19, CD20, CD22, CD33, CD34, CD45, CD56, CD64, CD79a and CD117 (APC Mouse Anti-Human, BD PharmingenTM , BD Biosciences, UK). Other antibodies that were also used included Kappa and Lambda light chains, IgD, sIgM, Myeloperoxidase (MPO), termi® nal deoxynucleotidyl transferase (TdT) and HLA-DR (SSP UniTray Kit, Thermo Fisher Scientific, USA). Samples were analyzed, and data acquisition and analysis were conducted by BD Cellques Pro software [6]. For cytogenetic analysis, 0.5 ml of each bone marrow sample was collected in lithium heparin for fluorescence-in-situ hybridization (FISH) test. Samples were examined on direct short-term (24 h) cultures with at least 20 metaphases being analyzed. The technique was performed using LSI (local specific identifier) dual color translocation probe (Abbott Molecular/Vysis, Des Plaines, IL, USA) designed to detect any cytogenetic abnormalities [7]. The regimen of treatment was proposed for each patient according to the severity of the lesions and general condition of the patient. The standard treatment was administration of oral prednisolone (0.5 to 1 mg/kg/day). Monitoring of therapeutic response was assessed, and relapse rate was recorded. 3. Results Out of 171 cases diagnosed as SS during the study period, 13 cases (8%) were associated with AML. The study included 7 males (54%) and 6 females (46%) with a mean age of 44.4 ± 17.49 years (ranged from 25 to 81 years). Fever was recorded in 10 cases (77%), and all cases showed a sudden onset of lesions (Table 1). In 3 cases (23%), SS was the presenting sign of AML, while in 2 cases (15%) the lesions developed during induction therapy. In 8 cases (62%), the lesions appeared during the post remission period; after the end of induction treatment and before consolidation therapy. Clinically (Fig. 1), 7 cases (54%) presented with solitary lesion, while 6 cases (46%) presented with multiple lesions. The majority of lesions (61%) were located on the extremities (8 cases). Lesions were tender in 9 cases (69%), slightly pruritic in 3 cases (23%) and asymptomatic in one case (8%). The morphology of the lesions was variable, with a common presentation of classic erythematous and edematous nodules and/or plaques in 8 cases (61%). Atypical presentations were observed in 5 cases (38%) in the form of ulcerative lesion (Fig. 2a), indurated mass (Fig. 2b) and gangrenous mass (Fig. 2c). Chest pain and artheralgia were a significant complaint in 3 cases (23%). Other clinical findings included gum

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Fig. 1. Classic clinical presentations of SS associated with AML presented as erythematous plaques. Solitary lesions showed different locations on the extremities (a and g), face (b) and trunk (c). Multiple lesions were common on the extremities (d–f).

Fig. 2. Atypical clinical presentation of SS associated with AML presented as ulcerative lesion (a), indurated mass (b) and gangrenous mass (c).

hypertrophy in 3 cases (23%), regional lymphadenopathy in 3 cases (23%), marked pallor in 2 cases (15%), ecchymosis in 2 cases (15%) and hepatosplenomegaly in one case (8%). Histological assessment of skin biopsies revealed two patterns of inflammatory reactions described as a classic (dermal) form and a deep (subcutaneous) form. Epidermal changes were observed in 6 cases (46%), moderate to marked papillary dermal edema in 10 cases (77%), heavy interstitial dermal infiltrate in 10 cases (77%),

eosinophils in 5 cases (38%), moderate to marked leukocytoclasis in 11 cases (85%), and vascular changes in 5 cases (38%) (Table 2). Myeloid cells, atypical nuclear segmentation and marked reticular edema were not identified in any case. The classic form was observed in 5 cases (38%), and it was characterized by dense neutrophilic inflammatory infiltrate in the reticular dermis. The infiltrate showed marked interstitial distribution with different grades of leukocytoclasis. Eosinophils were only

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Table 2 Histologic findings of 13 patients with SS-associated AML. No

Epidermis

Papillary dermal edema

Dermal infiltrate

Eosinophils

Leukocytoclasis

Vascular changes

Subcutaneous involvement

Fat necrosis

1

Marked

Heavy interstitial and perivascular

Mild

Marked

Swelling of endothelial cells – extravasation of RBCs

Marked lobular and septal

+

2

Neutrophilic exocytosis – spongiosis – subcorneal vesicles and pustules Mild acanthosis

Moderate

No

Mild

No

No

–

3

No

Marked

Moderate interstitial Heavy interstitial

No

Moderate

No

–

4

No

Mild

No

Marked

5

No

Marked

No

Moderate

Swelling of endothelial cells No

No

–

6

Neutrophilic exocytosis – spongiosis – subcorneal vesicles and pustules Neutrophilic exocytosis – subcorneal pustules

Marked

Heavy interstitial and perivascular Heavy interstitial and perivascular Heavy interstitial, periadnexal and perivascular

Marked septal and mild lobular Mild lobular and septal

Mild

Marked

Swelling of endothelial cells – extravasation of RBCs

Marked lobular and septal

+

No

Marked

–

No

Moderate

No

Moderate

Swelling of endothelial cells – extravasation of RBCs No

Marked lobular and septal

8

No

–

9

No

Mild

Heavy interstitial, periadnexal and perivascular Moderate interstitial and perivascular Heavy interstitial and perivascular

Mild

Marked

Marked lobular and mild septal

–

10

Mild spongiosis

Moderate

Moderate

Mild

No

–

11

No

Marked

No

Moderate

No

No

Marked

No

Marked

No

Marked septal and mild lobular No

+

12

13

Mild acanthosis and spongiosis

Mild

Moderate interstitial Heavy interstitial and perivascular Heavy interstitial and perivascular Heavy interstitial and perivascular

Swelling of endothelial cells – extravasation of RBCs No

Mild

Marked

No

7

Marked

observed in one case (8%). The papillary dermis showed moderate to marked papillary dermal edema, while the epidermis showed mild spongiosis or acanthosis. Dermal blood vessels showed swelling of endothelial cells but without signs of vasculitis (Fig. 3). In correlation with clinical presentation, these histologic features were observed in association with erythematous lesions either solitary or multiple. The subcutaneous form was observed in 8 cases (62%), and it was characterized by markedly dense infiltrate in the reticular dermis that extended into the subcutis. The dermal infiltrate showed more interstitial distribution in addition to perivascular and periadnexal distribution. The subcutaneous infiltrate was mostly lobular in 4 cases (31%), mostly septal in 2 cases (15%) and mild in 2 cases (15%). Eosinophils were observed in 4 cases (31%), while leukocytoclasis was observed in all cases. The dermal vasculatures showed swelling of endothelial cells in 4 cases (31%) with variable degrees of extravasation of RBCs. Epidermal changes were more prominent in ulcerative and gangrenous lesions (Fig. 4). Laboratory investigations showed leukocytosis in 8 cases (62%), neutropenia in 5 cases (38%), anaemia in 12 cases (92%), and thrombocytopenia in 11 cases (85%). Blood film confirmed the presence of

Mild lobular and septal

–

–

–

myloblast cells in all cases with different density and morphology. Bone marrow aspiration and biopsy showed suppressed trilineage hematopoesis in 11 cases (85%) and blast cell count >50% in 9 cases (69%). Eosinophils were more prominent in AML-M4 (Fig. 5). Immunophenotyping studies subclassified AML into M1 in 2 cases (15%), M2 in 3 cases (23%), M3 in one case (8%), M4 in 3 cases (23%), M4 eosinophils in 2 cases (15%), M5a in one case (8%) and M5b in one case (8%). Leukemic cells showed a common localization of cells in blast region in 3 cases (23%), Blast/Monocytic region in 6 cases (46%), Blast/myeloid region in 3 cases (23%) and Blast/Promyeloblast region in one case (8%). The most common immunostaining pattern included positive staining for CD13, CD15, CD33, CD34, CD45, CD117, HLA-DR & MPO. Cytogenetic studies revealed genetic abnormalities in 9 cases (69%); out of these cases, gene translocation was detected in 4 cases (31%) including t (8, 16) (p11/p13), t (6;9) (p23; q34), t (9:22) (q34; q11) and t (15,17) (q23; q12). Although all cases with gene translocation were presented clinically with classic erythematous rash, subcutaneous infiltrate was prominent in 75% of these cases (3 cases).

Please cite this article in press as: M. El-Khalawany, et al., Clinicopathologic, immunophenotyping and cytogenetic analysis of Sweet syndrome in Egyptian patients with acute myeloid leukemia, Pathol. – Res. Pract (2016), http://dx.doi.org/10.1016/j.prp.2016.10.008

CBC

Immunophenotyping

Karyotyping/FISH

AML subtype

1

WBC: 15.6 Neutr: 0.76 Mono: 10.2

RBC: 1.4 Hb: 43 Plt: 55

- Blast cell count: >60% - Suppressed trilineage hematopoesis

• 59.0% in Blast/Monocyte region • +ve CD13, CD33, CD45, CD64, HLA-DR, CD15, CD117 & CD14,

• 47, XY, +8

M4

2

WBC: 44.3 Neutr: 2.7 Mono: 2.9

RBC: 3.7 Hb: 121 Plt: 198

- Blast cell count: >90% - Suppressed trilineage hematopoesis

• 91.0% in Blast region • +ve CD2, CD33, CD7, CD13, CD45, CD117, CD34, HLA-DR & MPO.

• 47, XY, +8

M1

3

WBC: 11.9 Neutr: 5.9 Mono: 4.6

RBC: 2.6 Hb: 76 Plt: 89

- 77% monoblasts/promonocytes - ↑↑ myeloblasts - Few pseudopods

• 82.0% in Blast/Monocytic region • +ve CD13, CD33, CD14, CD15, CD64, CD45, HLA-DR.

• 46, XY, t (8, 16) (p11/p13)

M5a

4

WBC: 6.1 Neutr: 0.9 Mono: 2.9

RBC: 3.1 Hb: 97 Plt: 32

• Blast cell count: 70% • Suppressed trilineage hematopoesis • Eosinophils 6.3%

• 82.0% in Blast region • +ve CD13, CD33, CD34, CD45, CD14, HLA-DR, CD117, CD15 &.MPO.

1. 46, XX, −7,inv (16) (p13;q22)

M4 Eos.

5

WBC: 13.8 Neutr: 0.5 Mono: 0.5

RBC: 3.0 Hb: 93 Plt: 168

- Blast cell count: 55% - Suppressed trilineage hematopoesis

• 52.0% in Blast/Myeloid region • +ve CD13, CD33, CD45, CD34, CD117 &MPO.

• 46,XX

M2

6

WBC: 3.3 Neutr: 0.6 Mono: 1.9

RBC: 3.0 Hb: 96 Plt: 14

- Blast cell count: 27% - Suppressed trilineage hematopoesis

• 31.0% in Blast/Monocytic region • +ve CD13, CD33, CD34, CD14, CD15, CD45, HLA-DR & MPO.

• 46, XY

M4

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Table 3 Laboratory results of 13 patients with SS-associated AML.

5

CBC

Karyotyping/FISH

AML subtype

7

WBC: 225.1 Neutr: 175 Mono: 29.6

RBC: 1.4 Hb: 57 Plt: 12

- Blast cell count: 85% - Suppressed trilineage hematopoesis - Eosinophils 8%

• 83.0% in Blast/Monocytic region • +ve CD13, CD33, CD34, CD14, CD15, CD117, CD45, CD64, HLA-DR & MPO.

• 46, XX, inv (16) (p13q22)

M4 Eos.

8

WBC: 22.9 Neutr: 7.9 Mono: 11.4

RBC: 3.4 Hb: 97 Plt: 69

- Blast cell count: 70% - Suppressed trilineage hematopoesis

• 60.0% in Blast/Monocytic region • +ve CD13, CD33, CD34, CD14, CD45, CD64, CD36 & HLA-DR.

• 46, XX + MLL (11q23 abnormality)

M5b

9

WBC: 4.6 Neutr: 2.2 Mono: 1.0

RBC: 2.1 Hb: 83 Plt: 16

- Blast cell count: 30% - Suppressed trilineage hematopoesis

• 15.0% in Blast/Monocytic region • +ve CD13, CD33, CD34, CD14, CD15, CD45 & HLA-DR.

• 46, XY

M4

10

WBC: 1.0 Neutr: 0.1 Mono: 0.0

RBC: 2.8 Hb: 86 Plt: 106

- Blast cell count: 76% - Suppressed trilineage hematopoesis

• 80.0% in Blast region • +ve CD13, CD33, CD34, CD15, CD45, HLA-DR & MPO.

• 46, XX

M2

11

WBC: 177.6 Neutr: 81.7 Mono: 77.2

RBC: 2.6 Hb: 85 Plt: 36

- Blast cell count: 60% - Depressed erythropoiesis dysplastic & megakaryopoiesis. - Basophiles 3%

• 49.0% in Blast/Myeloid region • +ve CD13, CD33, CD34, CD45, CD117, CD15, HLA-DR&MPO.

• 46, XY, t (6;9) (p23;q34)

M2

12

WBC: 5.1 Neutr: 0.1 Mono: 0.4

RBC: 4.8 Hb: 128 Plt: 25

- Blast cell count: >95% - Suppressed trilineage hematopoesis

• 92.0% in Blast/Myeloid region • +ve CD13, CD33, CD34, CD15, CD117, HLA-DR & MPO.

• 46, XY, t (9:22) (q34;q11) + BCR-ABLI, +MLL

M1

13

WBC: 203 Neutr: 32.2 Mono: 13.5

RBC: 3.1 Hb: 106 Plt: 64

- Blast cell count: 83% - Suppressed trilineage hematopoesis

• 83.0% in Blast/Promyeloblast region • +ve CD13, CD33, CD45, CD15, HLA-DR & MPO.

• 46, XX, t (15,17) (q23; q12)

M3

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Table 3 (Continued)

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Fig. 3. Histologic findings of classic form of SS including dense reticular dermal infiltrate (a H&E, ×20), marked papillary dermal edema (b H&E, ×200), marked interstitial neutrophilic infiltrate (c H&E, ×100) and normal blood vessels (d H&E, ×400).

Fig. 4. Histologic findings of subcutaneous form of SS including dense dermal infiltrate that extend into the sub cutis (a&c H&E, ×20), with septal (b H&E, ×200) or lobular distribution (d, H&E, ×400), epidermal vesiculation and exocytosis of neutrophils (e H&E, ×200), extravasation of RBCs (f H&E, ×200) and leukocytoclasis (g H&E, ×1000).

Inverted gene was found in 2 cases (15%) with a single abnormality of inv (16) (p13; q22). Both cases were manifested clinically with atypical presentation with subcutaneous involvement. Trisomy 8 was observed in 2 cases (15%), while MLL gene was detected in one case (8%). Out of 4 cases with normal gene studies (31%), 3 cases

(23%) showed the classic clinical presentation, while 2 cases (15%) showed subcutaneous involvement (Table 3 ). Systemic steroid (prednisolone 0.5 mg/kg/d) as a first line monotherapy in all cases showed a complete resolution of skin lesions within 2–4 weeks in 3 cases (23%), while in 10 cases (77%) the response was poor. Alternative therapy was used according

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Fig. 5. AML-M4 showed characteristic monoblasts and myeloblasts with folded nuclei (a–c). AML-M4 eosinophils showed myeloblasts with eosinophils (d–f). AML-M3 showed promyelocytes with folded nuclei and the cytoplasm contains clusters of Auer rods (Faggot cell) (g–i).

to the laboratory findings, general condition of the patient, severity of the lesions and drug tolerability. In 5 cases (38%), dapsone (100–150 mg/d) achieved a good response, while in 3 cases (23%) colchicine (0.5 mg twice daily) showed marked improvement of the lesions. Cases with ulcerative lesions mildly responded to dapsone but showed a good response after cyclosporine (3–5 mg/kg/day) therapy. During the follow-up period, 2 cases (15%) died, and only one case (8%) showed relapse (Table 4). 4. Discussion Sweet’s syndrome is characterized by the abrupt onset of tender or painful erythematous plaques and nodules on the face and extremities and, less commonly, on the trunk, in association with fever, malaise, and a neutrophil leukocytosis [5]. The disease is universally distributed among the races. It commonly occurs in adults (between the ages of 30 and 50 years) with more affection of women, while in children, SS is rare (less than 10% of total cases) and distributed equally between the genders. Idiopathic and druginduced forms are more common among adults, while infectious diseases are more precipitating factors in children [8]. Although the association between AML and SS is described in many previous reports, full studies have rarely been published. The incidence of SS in AML patients was reported as 1% [9], while the incidence of AML in SS patients was reported as 4% [10]. In this study, we reported a higher incidence (8%) of AML in SS patients, which may suggest the variation of incidence according to the race groups, geographic location, investigating centers and study period. Reviewing the literature, the majority of reports showed a predominance of SS in females with significant differences between both genders in most studies [11]. In few reports, the difference was insignificant [12], while it was rarely observed that males are more affected than females as reported by Rochet et al., who explained

this gender difference by the referral nature of their practice along with the predominance of adult population in their regional area [10]. We also observed an insignificant higher incidence of male patients, and this could be explained by the higher incidence of AML among Egyptian males as reported by El-Zawahry et al. [13]. In this study, SS was the presenting sign of AML in 3 cases. Sweet syndrome as initial presentation of AML has previously been described in two reports with atypical findings. Travassos et al. reported the presence of atypical myeloid cells in histological examination [14], while Morgan and Callen described atypical presentation of SS with erythematous vesicular eruption of the left eye [15]. The pathogenesis of SS is mainly contributed to altered immune complex and neutrophil function. Montelukast sodium acts as inhibitor of leukotrienes which stimulate leukocyte function, including lysosomal enzyme release, polymorphonuclear leukocyte adhesion and aggregation. It has been hypothesized that altered levels of various cytokines and signaling molecules, such as G-CSF, Interleukin (IL)-1, IL-2, IL-6, IL-8, IL-17, tumor necrosisalpha (TNF␣) and Interferon ␥ (IFN ␥), may contribute to alterations in neutrophil function [16]. Approximately 20% of cases are associated with malignancy, particularly hematologic malignancy. Moreover, an underlying condition, such as streptococcal infection, inflammatory bowel disease, solid tumors, or pregnancy, is found in up to 50% of cases. It was suggested that AML is associated with defective neutrophil functions, including adhesion, migration, chemotaxis and phagocytosis. Thus, such alterations in pro- and anti-inflammatory cytokines and neutrophil function may prevent the occurrence of normal chemotaxis, thereby contributing to the dermal clumping of the mature neutrophils [17]. The occurrence of SS during treatment of AML was described in association with different drugs such as granulocyte – colony stimulating factor (G-CSF) [18], all-trans retinoic acid (ATRA) [19], and

Please cite this article in press as: M. El-Khalawany, et al., Clinicopathologic, immunophenotyping and cytogenetic analysis of Sweet syndrome in Egyptian patients with acute myeloid leukemia, Pathol. – Res. Pract (2016), http://dx.doi.org/10.1016/j.prp.2016.10.008

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SS as a presenting sign

Induction therapy of AML

SS during induction therapy

BM activating therapy

SS during activating/postremission therapy

Response to systemic steroid (grade/duration)

2nd line therapy

Response to 2nd line therapy

3rd line therapy

Response to 3rd line therapy

Follow up

1

–

–

Sargramostim

+

Poor/2w

–

−

+

Excellent/3w

–

Cyclosporine (3 mg/kg/day) –

Excellent/5w

–

Dapsone (150 mg/d) –

Mild/3w

2

–

Died (after 8 months) No relapse

3

+

–

–

–

Poor/4w

Excellent/3w

–

–

No relapse

4

–

–

Sargramostim

+

Poor/3w

Excellent/4w

–

–

No relapse

5

–

Cytarabine + Daunorubicin Cytarabine + Daunorubicin Cytarabine + Daunorubicin Cytarabine + Daunorubicin Azacitidine

–

–

+

Mild/3w

Excellent/4w

–

–

No relapse

6

–

–

–

+

Poor/3w

Mild/3w

Excellent/4w

No relapse

7

−

+

Sargramostim

–

Poor/2w

Excellent/4w

Cyclosporine (3 mg/kg/day) –

–

No relapse

8

+

–

–

–

Mild/4w

Excellent/2w

–

–

9

–

Cytarabine + Daunorubicin

–

–

+

Poor/3w

Excellent/3w

–

–

Died (after 15 months) No relapse

10

–

Cytarabine + Daunorubicin

–

Sargramostim

+

Excellent/2w

–

–

–

11

–

–

–

+

Poor/3w

Excellent/2w

–

–

12

+

–

Sargramostim

–

Excellent/4w

–

–

–

No relapse

13

–

Cytarabine + Daunorubicin Cytarabine + Daunorubicin ATRA + Daunorubicin

Relapsed (after consolidation therapy) No relapse

+

–

–

Poor/4w

Excellent/4w

–

–

No relapse

Cytarabine + Fludarabine Cytarabine + Daunorubicin Azacitidine

Dapsone (100 mg/d) Dapsone (100 mg/d) Colchicine (0.5 mg twice daily) Dapsone (150 mg/d) Dapsone (150 mg/d) Dapsone (100 mg/d) Colchicine (0.5 mg twice daily) –

Dapsone (100 mg/d) – Colchicine (0.5 mg twice daily)

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Please cite this article in press as: M. El-Khalawany, et al., Clinicopathologic, immunophenotyping and cytogenetic analysis of Sweet syndrome in Egyptian patients with acute myeloid leukemia, Pathol. – Res. Pract (2016), http://dx.doi.org/10.1016/j.prp.2016.10.008

Table 4 Course, therapeutic regimens and follow up of 13 patients with SS-associated AML.

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sargramostim (granulocyte-macrophage colony stimulating factor) [20]. We observed 5 cases having developed during chemotherapy (cytarabine + daunorubicin) or bone marrow activation therapy (sargramostim). It was presumed that these medications play a role in stimulating neutrophil proliferation and differentiation through distinct cellular receptor systems that allow exerting their effects [21]. Depending on the most relevant criteria of drug induced SS, which is the recurrence of lesions after re-intake of the incriminated drug, we only confirmed the drug association in only one case that developed skin lesions after sargramostim therapy and relapsed after 2nd administration in consolidation therapy. However, the findings by Paydas et al., who reported two cases of SS that developed during G-CSF therapy and two other cases following long periods of chemotherapy-associated neutropenia, proposed for a more consideration of drug role in AML associated SS [22]. The most striking histologic feature in our cases was the subcutaneous involvement observed in about 60% of cases. Reviewing the literature, subcutaneous SS was described in the last decade within the spectrum of other neutrophilic panniculitides that includes alpha-one-antitrypsin deficiency, infectious panniculitis, factitious panniculitis, neutrophilic/pustular panniculitis associated with rheumatoid arthritis, erythema nodosum-like lesions of Behc¸et disease, bowel bypass panniculitis, and iatrogenic panniculitis [23]. Although our subcutaneous cases showed histologic features not significantly different from those reported by Chan et al. [24], we observed that the dermal infiltrate was more prominent in our cases, while hypersegmentation and Miescher granuloma were not observed in any case. Although the results of both studies may define specific histologic features for subcutaneous SS associated with myeloid disorders, we believe that the histologic spectrum is not fully identified, and it may vary according to the clinical presentation, stage of the disease, associated myeloid disorder and concomitant medications. The low number of cases may be the main limitation in both studies. It has been reported that some medications, such as mitoxantrone, cytarabine, and lenalidomide, which are recognized as a potential cause of classic SS in patients with myeloid disorders, may also induce subcutaneous SS. However, it may be impossible to determine whether SS in these patients is secondary to medication, myeloid disorder, or a combination of both. Treatmentrelated terminal myeloid differentiation of AML blasts into mature neutrophils, as described with quizartinib, may explain the development of SS in some patients after G-CSF, liposomal ATRA and azacitadine treatments [25]. Systemic corticosteroids are known to produce rapid improvement of SS lesions and are considered the “gold standard” for treatment of most forms of SS. The skin lesions usually clear within 3–9 days. Topical and/or intralesional corticosteroids may be effective as either monotherapy or adjuvant therapy [26]. Although both classic and subcutaneous forms are well-known to respond to systemic steroids, we only achieve satisfied results in only 23% of patients, while in the majority of cases, an alternative drug was required for achieving a satisfied result. It was observed that systemic steroid is more effective in classic SS, while in subcutaneous SS other drugs are more favourable. Our results suggested that SS associated with AML is considered a steroid refractory disease. Such cases are often treated with nonsteroidal anti-inflammatory drugs, colchicine, dapsone, potassium iodide, doxycycline and clofazimine, and more recently etanercept, a tumor necrosis factor alpha (TNF-␣) antagonist, based on the hypothesis that TNF-␣ activates neutrophils in this disease [27]. Intravenous immunoglobulin (IVIG) was also reported as a successful treatment in steroid refractory SS [28]. Topical and/or intralesional corticosteroids may be effective as either monother-

apy or adjuvant therapy. Oral potassium iodide or colchicine may induce rapid resolution [29]. Haliasos et al. also reported a successful treatment with IVIG and dapsone in a chronic recurrent SS associated with primary immunodeficiency and thrombocytopenia [30]. In ulcerative colitis-associated SS, tacrolimus was also used as a successful treatment after failure of high-dose steroids and antibiotics [31].

5. Conclusion Sweet syndrome associated with AML may show atypical clinical forms that have an aggressive course, and are mostly associated with subcutaneous involvement. Although chemotherapy of AML may play a significant role in the development of SS, the exact mechanism remains unclear. The disease is considered a steroid refractory, and other immunosuppressive drugs are mostly required to achieve a good improvement. Genetic abnormalities may have a role in altering the classic nature of the disease, but more studies are required to confirm this relation.

References [1] W. Kempf, M. Hantschke, H. Kutzner, W.H.C. Burgdorf, Acute febrile neutrophilic dermatosis (Synonym: Sweet syndrome), chapter 2: inflammatory and infectious dermatoses, in: Dermatopathology, Steinkopff Verlag, Germany, 2008, pp. 106–107 (Part 8.2). [2] P.R. Cohen, Sweet’s syndrome–a comprehensive review of an acute febrile neutrophilic dermatosis, Orphanet J. Rare Dis. 2 (2007) 34. [3] D. Reina, D. Cerdà, D. Roig, R. Fíguls, M.L. Villegas, H. Corominas, Sweet syndrome associated with myelodysplastic syndrome: report of a case. Review of the literature, Reumatol. Clin. 9 (2013) 246–247. [4] I.B. Bayer-Garner, M. Cottler-Fox, B.R. Smoller, Sweet syndrome in multiple myeloma: a series of six cases, J. Cutan. Pathol. 30 (2003) 261–264. [5] D. Weedon, Sweet’s syndrome, chapter 8: the vasculopathic reaction pattern, in: Weedon’s Skin Pathology, third edition, Elsevier, China, 2010, pp. 220–222. [6] G.T. Stelzer, G. Marti, A. Hurley, P. McCoy Jr., E.J. Lovett, A. Schwartz, U.S.-Canadian Consensus recommendations on the immunophenotypic analysis of hematologic neoplasia by flow cytometry: standardization and validation of laboratory procedures, Cytometry 30 (1997) 241–330. [7] T. Liehr, A. Heller, H. Starke, N. Rubtsov, V. Trifonov, K. Mrasek, A. Weise, A. Kuechler, U. Claussen, Microdissection based high resolution multicolor banding for all 24 human chromosomes, Int. J. Mol. Med. 9 (2002) 335–339. [8] T.B. Santos, B.C. Sales, M. Sigres, F. Rosman, A.M. Cerqueira, Sweet syndrome in childhood, An. Bras. Dermatol. 90 (2015) 567–569. [9] S.M. Kazmi, N. Pemmaraju, K.P. Patel, P.R. Cohen, N. Daver, K.M. Tran, F. Ravandi, M. Duvic, G. Garcia-Manero, S. Pierce, A. Nazha, G. Borthakur, H. Kantarjian, J. Cortes, Characteristics of sweet syndrome in patients with acute myeloid leukemia, Clin. Lymphoma Myeloma Leuk. 15 (2015) 358–363. [10] N.M. Rochet, R.N. Chavan, M.A. Cappel, D.A. Wada, L.E. Gibson, Sweet syndrome: clinical presentation, associations, and response to treatment in 77 patients, J. Am. Acad. Dermatol. 69 (2013) 557–564. [11] N.S. Anavekar, R. Williams, A.H. Chong, Sweet’s syndrome in an Australian hospital: a retrospective analysis, Australas. J. Dermatol. 48 (2007) 161–164. [12] T. Diaz-Corpas, A. Mateu-Puchades, M.M. Morales-Suarez-Varela, A. Castells-Rodellas, Retrospective study of patients diagnosed with Sweet syndrome in the health area of a tertiary hospital in the autonomous community of Valencia, Actas Dermosifiliogr. 103 (2012) 233–237. [13] H.M. El-Zawahry, A.A. Zeeneldin, M.A. Samra, M.M. Mattar, M.M. El-Gammal, A. Abd El-Samee, T. Darwish, Cost and outcome of treatment of adults with acute myeloid leukemia at the National Cancer Institute-Egypt, J. Egypt Natl. Cancer Inst. 19 (2007) 106–113. [14] A.R. Travassos, L. Soares-de-Almeida, H. Kutzner, L. Guerra, J. Alves do Carmo, P. Filipe, M.S. Marques, Sweet syndrome-like neutrophilic infiltrate as initial presentation of acute myelogenous leukemia, Am. J. Dermatopathol. 36 (2014) 167–170. [15] K.W. Morgan, J.P. Callen, Sweet’s syndrome in acute myelogenous leukemia presenting as periorbital cellulitis with an infiltrate of leukemic cells, J. Am. Acad. Dermatol. 45 (2001) 590–595. [16] P.R. Cohen, R. Kurzrock, The pathogenesis of Sweet’s syndrome, J. Am. Acad. Dermatol. 25 (1991) 734. [17] P. Ruutu, T. Ruutu, H. Repo, P. Vuopio, T. Timonen, T.U. Kosunen, A. de la Chapelle, Defective neutrophil migration in monosomy-7, Blood 58 (1981) 739–745. [18] W.N. van Mook, M.M. Fickers, J.A. van der Kley, P.H. Theunissen, A case of herpes-like Sweet’s syndrome in acute myelogenous leukemia during treatment with G-CSF, Neth. J. Med. 55 (1999) 235–241. [19] Z.S. Yan, D.P. Li, E.L. Jiang, C.L. Zhou, E.B. Liu, H.S. Chen, S.Z. Feng, M.Z. Han, Development of Sweet syndrome in an acute promyelocyte leukemia patient

Please cite this article in press as: M. El-Khalawany, et al., Clinicopathologic, immunophenotyping and cytogenetic analysis of Sweet syndrome in Egyptian patients with acute myeloid leukemia, Pathol. – Res. Pract (2016), http://dx.doi.org/10.1016/j.prp.2016.10.008

G Model PRP-51660; No. of Pages 11

ARTICLE IN PRESS M. El-Khalawany et al. / Pathology – Research and Practice xxx (2016) xxx–xxx

[20]

[21] [22]

[23] [24]

[25]

[26]

during treatment with all-trans retinoic acid–case report and literature review, Zhonghua Xue Ye Xue Za Zhi 28 (2007) 462–465. G. Kumar, J.M. Bernstein, J.S. Waibel, M.A. Baumann, Sweet’s syndrome associated with sargramostim (granulocyte-macrophage colony stimulating factor) treatment, Am. J. Hematol. 76 (2004) 283–285. B.R. Avalos, Molecular analysis of the granulocyte colony-stimulating factor receptor, Blood 88 (1996) 761–777. S. Paydas, B. Sahin, S. Zorludemir, Sweet’s syndrome accompanying leukaemia: seven cases and review of the literature, Leuk. Res. 24 (2000) 83–86. G. Guhl, A. García-Díez, Subcutaneous sweet syndrome, Dermatol. Clin. 26 (2008) 541–551. M.P. Chan, L.M. Duncan, R.M. Nazarian, Subcutaneous Sweet syndrome in the setting of myeloid disorders: a case series and review of the literature, J. Am. Acad. Dermatol. 68 (2013) 1006–1015. S. Bidyasar, M. Montoya, K. Suleman, A.B. Markowitz, Sweet syndrome associated with granulocyte colony-stimulating factor, J. Clin. Oncol. 26 (2008) 4355–4356. P.R. Cohen, R. Kurzrock, Sweet’s syndrome: a review of current treatment options, Am. J. Clin. Dermatol. 3 (2002) 117–131.

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[27] P.S. Yamauchi, L. Turner, N.J. Lowe, V. Gindi, J.M. Jackson, Treatment of recurrent Sweet’s syndrome with coexisting rheumatoid arthritis with the tumor necrosis factor antagonist etanercept, J. Am. Acad. Dermatol. 54 (2006) 122–126. [28] H.H. Gill, A.Y. Leung, N.J. Trendell-Smith, C.K. Yeung, R. Liang, Sweet syndrome due to myelodysplastic syndrome: possible therapeutic role of intravenous immunoglobulin in addition to standard treatment, Adv. Hematol. 2010 (2010) 328316. [29] S. Suehisa, H. Tagami, F. Inoue, K. Matsumoto, K. Yoshikuni, Colchicine in the treatment of acute febrile neutrophilic dermatosis (Sweet’s syndrome), Br. J. Dermatol. 108 (1983) 99–101. [30] E. Haliasos, B. Soder, D.S. Rubenstein, W. Henderson, D.S. Morrell, Pediatric Sweet syndrome and immunodeficiency successfully treated with intravenous immunoglobulin, Pediatr. Dermatol. 22 (2005) 530–535. [31] K. Fellermann, B. Rudolph, T. Witthöft, K.R. Herrlinger, M. Tronnier, D. Ludwig, E.F. Stange, Sweet syndrome and erythema nodosum in ulcerative colitis, refractory to steroids: successful treatment with tacrolimus, Med. Klin. (Munich) 96 (2001) 105–108.

Please cite this article in press as: M. El-Khalawany, et al., Clinicopathologic, immunophenotyping and cytogenetic analysis of Sweet syndrome in Egyptian patients with acute myeloid leukemia, Pathol. – Res. Pract (2016), http://dx.doi.org/10.1016/j.prp.2016.10.008