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Granulocytic sarcoma of the breast in a patient with acute myeloblastic leukemia in remission
European Journal of Radiology Extra 47 (2003) 17 /21 http://intl.elsevierhealth.com/journals/ejrx
Granulocytic sarcoma of the breast in a patient with acute myeloblastic leukemia in remission M. Imbriaco a,*, L. di Nuzzo b, A. Riccardi b, E. Vicenzo, b, F. Fulciniti b, A. Sodano b a
Department of Radiology and Institute of Biostructures and Bioimaging (I.B.B.), Via Manzoni 214/0, Parco Flory, Isolato 4, Apt. 1, Naples 80123, Italy b Department of Biomorphological and Functional Sciences, University ‘Federico II’, Napoli, Italy Received 9 September 2002; received in revised form 23 October 2002; accepted 25 October 2002
Abstract A case of granulocytic sarcoma (GS) of the breast in a patient with acute myeloblastic leukemia whose disease was in remission is reported. Rarely hematological tumors such as lymphoma or leukemia affect the breast as primary malignancies, and more frequently involve the breast as part of a widespread multicentric process. GS also called chloroma is a rare manifestation of acute myeloblastic leukemia, mainly composed of premature precursors of the granulocytic series. Our patient presented with swelling in both breasts and with a previous history of acute myeloblastic leukemia diagnosed 6 months before on the basis of a bone marrow biopsy that revealed 85% immature myeloblasts. After induction chemotherapy, a second bone marrow biopsy showed evidence of disease remission with less than 5% blast cells. On ultrasound two inhomogeneous hypoechoic nodules, with irregular margins and without posterior acoustic shadowing, located, respectively, in the inferior inner quadrant of the right breast and in the upper outer quadrant of the left breast were observed. A subsequent mammogram showed heterogeneously dense breasts without evidence of microcalcifications. A fine needle aspiration biopsy was performed and the cytologic results highlighted the presence of immature myeloid cells, mingled with groups of benign ductal cells. On the basis of the negativity of a subsequent bone marrow biopsy, a final diagnosis of mammary infiltration from acute myeloblastic leukemia was formulated. Due to the lack of specificity of mammographic and sonographic features of breast chloroma definite diagnosis of this rare entity must be accomplished by fineneedle aspiration and cytologic markers, especially for accurate differential diagnosis from other breast malignancies, such as lymphoma or carcinoma. The case presented is unusual because of the multicentric location of the GS and because of the onset in a patient considered to be in remission by bone marrow biopsy. # 2002 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Breast; Leukemia; Granulocytic sarcoma
1. Introduction The breast is an unusual site of metastases from extramammary tumors. When this involvement occurs, the usual primary sources are melanoma, lung carcinoma, soft tissue sarcoma and ovarian carcinoma [1,2]. Rarely, hematological malignant tumors may involve
* Corresponding author. Tel.: /39-081-575-7370; fax: /39-081545-7081 E-mail address: [email protected] (M. Imbriaco).
the breast including lymphoma and less frequently leukemia and multiple myeloma [2]. In particular, lymphoma and leukemia rarely affect the breast as primary malignancies, and more frequently involve the breast as part of a widespread multicentric process [3,4]. Granulocytic sarcoma (GS), also called extramedullary myeloblastoma or chloroma, is a rare, solid tumor composed of premature precursors of the granulocytic series [5,6] that has been reported to occur in three clinical settings, (1) in association with acute myeloblastic leukemia, (2) in association with myelodysplastic syndromes with leukemic transformation, or (3) in
1571-4675/03/$ - see front matter # 2002 Elsevier Science Ireland Ltd. All rights reserved. doi:10.1016/S-1571-4675(03)00072-5
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M. Imbriaco et al. / European Journal of Radiology Extra 47 (2003) 17 /21
association with chronic myeloid leukemia, with impending blast crisis. GS can involve any site in the body and can be multiple. Only few cases of GS of the breast have been reported in literature [2,6,7]. We hereby report a case of GS of the breast, in a patient with acute myeloblastic leukemia whose disease was in remission.
2. Case report A 22-year-old woman, was admitted to our hospital with swelling in both breasts. History revealed acute myeloblastic leukemia diagnosed 6 months before on the basis of a bone marrow biopsy that revealed 85% immature myeloblasts (cytodensity confirmed). The patient underwent two courses of induction chemotherapy and a second bone marrow biopsy that showed evidence of disease remission with less than 5% blast cells. At physical examination both breasts showed glandular swelling. Enlarged lymph nodes, skin changes and nipple retraction were not found. The patient underwent ultrasound (GE Logic 500 Pro scanner with a 11 MHz linear array transducer) that showed two inhomogeneous hypoechoic nodules, with irregular margins and without posterior acoustic shadowing, located, respectively, in the inferior inner quadrant of the right breast with a maximum diameter of 3 /2 cm (Fig. 1a) and in the upper outer quadrant of the left breast measuring 2 /1.5 cm (Fig. 1b). Subsequently, bilateral two-view mammography (Alpha RT, Instrumentarium, Finland) performed in cranio /caudal and
oblique view projections showed heterogeneously dense breasts especially in the upper outer quadrant without evidence of microcalcifications (Fig. 2a, right breast; Fig. 2b, left breast). A fine needle aspiration biopsy, under ultrasound guidance, was obtained at the level of the two hypoechogenic nodules, previously described. The cytologic result highlighted the presence of immature myeloid cells, mingled with groups of benign ductal cells, with round or oval nuclei, a moderate amount of cytoplasm and prominent eosinophilic granules (Fig. 3). These cells showed cytoplasmic positivity for the myeloperoxidase. Cytochemistry was consistent with the diagnosis of GS of the breast. In addition, examination of the peripheral blood smear and bone marrow continued to show normal findings. Therefore, on the basis of the negativity of the peripheral blood and bone marrow biopsy, a diagnosis of mammary infiltration from acute myeloblastic leukemia was formulated. The patient consented to a program of radiation therapy by using a source axis distance (SAD) technology with two opposed tangential fields (6 MV photons) at the level of both breasts. The total delivered radiation dose was 24 Gy in 15 daily fractions (160 cGy, 5 days a week, for 3 weeks). Furthermore, it was associated a chemotherapeutic treatment with MITOX, VP 16 (ethoposide), ARA-C (arabinoside cytosine). As a result of therapy, an ultrasound test, performed 2 months after the initial US examination, showed a significant reduction of the size of the two hypoechogenic areas, previously described, respectively, in the right breast (Fig. 4a) and in the left breast (Fig. 4b). Subsequently,
Fig. 1. Ultrasound showing two inhomogeneous hypoechoic nodules, with irregular margins and without posterior acoustic shadowing in the inferior inner quadrant of the right breast 3 /2 cm (a) and in the upper outer quadrant of the left breast measuring 2 /1.5 cm (b).
M. Imbriaco et al. / European Journal of Radiology Extra 47 (2003) 17 /21
19
Fig. 2. Mammography, bilateral oblique view (a, right breast; b, left breast) showing heterogeneously dense breasts especially in the upper outer quadrant (arrows) without evidence of microcalcifications.
Fig. 3. Cytology image showing the presence of immature myeloid cells (arrows), mingled with groups of benign ductal cells, with round or oval nuclei, a moderate amount of cytoplasm and prominent eosinophilic granules.
20
M. Imbriaco et al. / European Journal of Radiology Extra 47 (2003) 17 /21
Fig. 4. Ultrasound performed 2 months after the initial examination showing a reduction of the size of the two hypoechogenic nodules previously described, respectively, in the right breast (a) and in the left breast (b).
the patient underwent a medullary autograft and a new ultrasound test performed 4 months after the medullary grafting showed no evidence of morphological abnormalities in both breasts.
3. Discussion Hematological malignant tumors can occur in the breast most often with lymphoma, less frequently with leukemia and rarely with multiple myeloma [1]. Lymphoma or leukemia may rarely be a primary breast tumor but usually involve the breast as part of a diffuse multicentric, or disseminated process [1,2]. GS is a rare manifestation of acute myeloblastic leukemia and affects 3 /9% of these patients [8]. The name ‘chloroma’ is used because of the green color on cut sections of the tumor which is caused by the activity of the cytoplasmic myeloperoxidase (verdoperoxidase) enzyme and porphyrins [9], even if is preferable to use the term ‘granulocytical sarcoma’ because not all such tumors are green. The tumor mass can infact be also gray, white, or brown, depending on the concentration of the different enzymes in the cells. GS can affect every age, can occur in different part of the body and, frequently, is multiple [10]. Common sites of involvement are lymph nodes, bones, periosteum, the skin, orbit, retroperitoneum, mediastinum and ovary [11 /14]. GS can also be symptomatic, in this case affects more frequently the skeleton, particularly the skull, the spinal column, the sternum and the ribs. The central nervous system can also be involved months or years
after the basic disease’s complete remission most commonly with a blast infiltration through the arachnoid’s veins [15]. Only a few cases have been reported in the English literature of mammary GS, either antedating or coincident with acute leukemia [2,6,16,17]. Even more rarely, this entity has been described in patients treated for acute myeloblastic leukemia and considered in remission [2,7,18]. In agreement with previous reports, in the case presented, mammography showed bilateral heterogeneously dense breasts, without evidence of calcifications [2]. As previously described, in ultrasound the masses presented as a inhomogeneous hypoechoic lesions without posterior acoustic shadowing [7]. Due to the lack of specificity of mammographic and sonographic features of breast chloroma definite diagnosis of this rare entity must be accomplished by fine-needle aspiration and cytologic markers especially for accurate differential diagnosis from other breast malignancies, mainly lymphoma or carcinoma, especially in the absence of bone marrow involvement. Furthermore, a definite diagnosis of GS is based on the demonstration of myeloid cells within the lesion. The morphological features are variable depending on the degree of maturation. In particular, the myeloid cell with prominent eosinophilic granules is the best morphological clue to myeloid differentiation [19]. The case presented is unusual because of the multicentric location of the breast GS and because of the onset in a patient considered to be in remission by bone marrow biopsy.
M. Imbriaco et al. / European Journal of Radiology Extra 47 (2003) 17 /21
As previously reported, GS is extremely radiosensitive and as shown in this case low radiation therapy allowed complete mammographic and sonographic resolution of the mass.
[11]
References
[12]
[1] Paulus DD, Libshitz HI. Metastasis to the breast. Radiol Clin North Am 1982;20:561 /8. [2] Barloon TJ, Young DC, Bass SH. Multicentric granulocytic sarcoma (chloroma) of the breast: mammographic findings. Am J Roentgenol 1993;161:963 /4. [3] Domchek SM, Hecht JL, Fleming MD, Pinkus GS, Canellos GP. Lymphomas of the breast: primary and secondary involvement. Cancer 2002;94:6 /13. [4] Khoury NJ, Hanna Al-Kass FM, Jaafar HN, Taher AT, Shamseddine AI. Bilateral breast involvement in acute myelogenous leukemia. Eur Radiol 2000;10:1031. [5] Mwanda WO, Rajab JA. Granulocytic sarcoma: report of three cases. East Afr Med J 1999;76:594 /6. [6] Fitoz S, Atasoy C, Yavuz K, Gozdasoglu S, Erden I, Akyar S. Granulocytic sarcoma: cranial and breast involvement. Clin Imaging 2002;26:166 /9. [7] Hiorns MP, Murfitt J. Granulocytic sarcoma (chloroma) of the breast: sonographic findings. Am J Roentgenol 1997;169:1639 / 40. [8] Geelhoed GW, Graff KS, Duttera MJ, Jr, Henderson ES. Acute leukemia presenting as a breast mass. J Am Med Assoc 1973;233:1488 /9. [9] Muss HB, Moloney WE. Chloroma and other myeloblastic tumors. Blood 1973;42:721 /8. [10] Bekassy AN, Hermans J, Gorin NC, Gratwohl A. Granulocytic sarcoma after allogenic bone marrow transplantation: a retro-
[13]
[14]
[15]
[16]
[17]
[18]
[19]
21
spective European multicenter survey. Acute and chronic leukemia working parties of the European Group for Blood and Marrow Transplantation. Bone Marrow Transplant 1996;17:801 /8. Neiman RS, Barcos M, Bernard C, Bonner H, Mann R, Rydell RE, Bennett JM. Granulocytic sarcoma: a clinicopathologic study of 61 biopsied case. Cancer 1981;48:1426 /37. Gartenhaus WS, Mir R, Pliskin A, Grunwald H, Wise L, Papantoniou PA, Kahn LB. Granulocytic sarcoma of breast: a leukemic bilateral metachronous presentation and literature review. Med Pediatr Oncol 1985;13:22 /9. Magliocco AM, Demetrick DJ, Jones AR, Kossakowska AE. Granulocytic sarcoma of the ovary. An unusual case presentation. Arch Pathol Lab Med 1991;115:830 /4. Mockli G. Granulocytic sarcoma presenting as a retroperitoneal lymph node mass. A case report with diagnosis by fine needle aspiration biopsy and flow cytometry. Acta Cytol 1997;41:1525 / 7. Sham RL, Phatak PD, Kouides PA, Janas JA, Marder VJ. Hematologic neoplasia and the central nervous system. Am J Hematol 1999;62:234 /8. Son HJ, Oh KK. Multicentric granulocytic sarcoma of the breast: mammographic and sonographic findings. Am J Roentgenol 1998;171:274 /5. Ahrar K, McLeary MS, Young LW, Masotto M, Rouse GA. Granulocytic sarcoma (chloroma) of the breast in an adolescent patient. Ultrasonographic findings. J Ultrasound Med 1998;17:383 /4. Guermazi A, Quoc SN, Socie G, Briere J, de Kerviler E, SolalCeligny P, Frija J, Rousselot P. Myeloblastoma (chloroma) in leukemia: case 1. Granulocytic sarcoma (chloroma) of the breast. J Clin Oncol 2000;18:3993 /6. Silverman JF, Geisinger KR, Park HK, Strausbauch PR, Frable WJ. Fine-needle aspiration cytology of granulocytic sarcoma and myeloid metaplasia. Diagn Cytopathol 1990;6:106 /11.
Granulocytic sarcoma of the breast in a patient with acute myeloblastic leukemia in remission M. Imbriaco a,*, L. di Nuzzo b, A. Riccardi b, E. Vicenzo, b, F. Fulciniti b, A. Sodano b a
Department of Radiology and Institute of Biostructures and Bioimaging (I.B.B.), Via Manzoni 214/0, Parco Flory, Isolato 4, Apt. 1, Naples 80123, Italy b Department of Biomorphological and Functional Sciences, University ‘Federico II’, Napoli, Italy Received 9 September 2002; received in revised form 23 October 2002; accepted 25 October 2002
Abstract A case of granulocytic sarcoma (GS) of the breast in a patient with acute myeloblastic leukemia whose disease was in remission is reported. Rarely hematological tumors such as lymphoma or leukemia affect the breast as primary malignancies, and more frequently involve the breast as part of a widespread multicentric process. GS also called chloroma is a rare manifestation of acute myeloblastic leukemia, mainly composed of premature precursors of the granulocytic series. Our patient presented with swelling in both breasts and with a previous history of acute myeloblastic leukemia diagnosed 6 months before on the basis of a bone marrow biopsy that revealed 85% immature myeloblasts. After induction chemotherapy, a second bone marrow biopsy showed evidence of disease remission with less than 5% blast cells. On ultrasound two inhomogeneous hypoechoic nodules, with irregular margins and without posterior acoustic shadowing, located, respectively, in the inferior inner quadrant of the right breast and in the upper outer quadrant of the left breast were observed. A subsequent mammogram showed heterogeneously dense breasts without evidence of microcalcifications. A fine needle aspiration biopsy was performed and the cytologic results highlighted the presence of immature myeloid cells, mingled with groups of benign ductal cells. On the basis of the negativity of a subsequent bone marrow biopsy, a final diagnosis of mammary infiltration from acute myeloblastic leukemia was formulated. Due to the lack of specificity of mammographic and sonographic features of breast chloroma definite diagnosis of this rare entity must be accomplished by fineneedle aspiration and cytologic markers, especially for accurate differential diagnosis from other breast malignancies, such as lymphoma or carcinoma. The case presented is unusual because of the multicentric location of the GS and because of the onset in a patient considered to be in remission by bone marrow biopsy. # 2002 Elsevier Science Ireland Ltd. All rights reserved. Keywords: Breast; Leukemia; Granulocytic sarcoma
1. Introduction The breast is an unusual site of metastases from extramammary tumors. When this involvement occurs, the usual primary sources are melanoma, lung carcinoma, soft tissue sarcoma and ovarian carcinoma [1,2]. Rarely, hematological malignant tumors may involve
* Corresponding author. Tel.: /39-081-575-7370; fax: /39-081545-7081 E-mail address: [email protected] (M. Imbriaco).
the breast including lymphoma and less frequently leukemia and multiple myeloma [2]. In particular, lymphoma and leukemia rarely affect the breast as primary malignancies, and more frequently involve the breast as part of a widespread multicentric process [3,4]. Granulocytic sarcoma (GS), also called extramedullary myeloblastoma or chloroma, is a rare, solid tumor composed of premature precursors of the granulocytic series [5,6] that has been reported to occur in three clinical settings, (1) in association with acute myeloblastic leukemia, (2) in association with myelodysplastic syndromes with leukemic transformation, or (3) in
1571-4675/03/$ - see front matter # 2002 Elsevier Science Ireland Ltd. All rights reserved. doi:10.1016/S-1571-4675(03)00072-5
18
M. Imbriaco et al. / European Journal of Radiology Extra 47 (2003) 17 /21
association with chronic myeloid leukemia, with impending blast crisis. GS can involve any site in the body and can be multiple. Only few cases of GS of the breast have been reported in literature [2,6,7]. We hereby report a case of GS of the breast, in a patient with acute myeloblastic leukemia whose disease was in remission.
2. Case report A 22-year-old woman, was admitted to our hospital with swelling in both breasts. History revealed acute myeloblastic leukemia diagnosed 6 months before on the basis of a bone marrow biopsy that revealed 85% immature myeloblasts (cytodensity confirmed). The patient underwent two courses of induction chemotherapy and a second bone marrow biopsy that showed evidence of disease remission with less than 5% blast cells. At physical examination both breasts showed glandular swelling. Enlarged lymph nodes, skin changes and nipple retraction were not found. The patient underwent ultrasound (GE Logic 500 Pro scanner with a 11 MHz linear array transducer) that showed two inhomogeneous hypoechoic nodules, with irregular margins and without posterior acoustic shadowing, located, respectively, in the inferior inner quadrant of the right breast with a maximum diameter of 3 /2 cm (Fig. 1a) and in the upper outer quadrant of the left breast measuring 2 /1.5 cm (Fig. 1b). Subsequently, bilateral two-view mammography (Alpha RT, Instrumentarium, Finland) performed in cranio /caudal and
oblique view projections showed heterogeneously dense breasts especially in the upper outer quadrant without evidence of microcalcifications (Fig. 2a, right breast; Fig. 2b, left breast). A fine needle aspiration biopsy, under ultrasound guidance, was obtained at the level of the two hypoechogenic nodules, previously described. The cytologic result highlighted the presence of immature myeloid cells, mingled with groups of benign ductal cells, with round or oval nuclei, a moderate amount of cytoplasm and prominent eosinophilic granules (Fig. 3). These cells showed cytoplasmic positivity for the myeloperoxidase. Cytochemistry was consistent with the diagnosis of GS of the breast. In addition, examination of the peripheral blood smear and bone marrow continued to show normal findings. Therefore, on the basis of the negativity of the peripheral blood and bone marrow biopsy, a diagnosis of mammary infiltration from acute myeloblastic leukemia was formulated. The patient consented to a program of radiation therapy by using a source axis distance (SAD) technology with two opposed tangential fields (6 MV photons) at the level of both breasts. The total delivered radiation dose was 24 Gy in 15 daily fractions (160 cGy, 5 days a week, for 3 weeks). Furthermore, it was associated a chemotherapeutic treatment with MITOX, VP 16 (ethoposide), ARA-C (arabinoside cytosine). As a result of therapy, an ultrasound test, performed 2 months after the initial US examination, showed a significant reduction of the size of the two hypoechogenic areas, previously described, respectively, in the right breast (Fig. 4a) and in the left breast (Fig. 4b). Subsequently,
Fig. 1. Ultrasound showing two inhomogeneous hypoechoic nodules, with irregular margins and without posterior acoustic shadowing in the inferior inner quadrant of the right breast 3 /2 cm (a) and in the upper outer quadrant of the left breast measuring 2 /1.5 cm (b).
M. Imbriaco et al. / European Journal of Radiology Extra 47 (2003) 17 /21
19
Fig. 2. Mammography, bilateral oblique view (a, right breast; b, left breast) showing heterogeneously dense breasts especially in the upper outer quadrant (arrows) without evidence of microcalcifications.
Fig. 3. Cytology image showing the presence of immature myeloid cells (arrows), mingled with groups of benign ductal cells, with round or oval nuclei, a moderate amount of cytoplasm and prominent eosinophilic granules.
20
M. Imbriaco et al. / European Journal of Radiology Extra 47 (2003) 17 /21
Fig. 4. Ultrasound performed 2 months after the initial examination showing a reduction of the size of the two hypoechogenic nodules previously described, respectively, in the right breast (a) and in the left breast (b).
the patient underwent a medullary autograft and a new ultrasound test performed 4 months after the medullary grafting showed no evidence of morphological abnormalities in both breasts.
3. Discussion Hematological malignant tumors can occur in the breast most often with lymphoma, less frequently with leukemia and rarely with multiple myeloma [1]. Lymphoma or leukemia may rarely be a primary breast tumor but usually involve the breast as part of a diffuse multicentric, or disseminated process [1,2]. GS is a rare manifestation of acute myeloblastic leukemia and affects 3 /9% of these patients [8]. The name ‘chloroma’ is used because of the green color on cut sections of the tumor which is caused by the activity of the cytoplasmic myeloperoxidase (verdoperoxidase) enzyme and porphyrins [9], even if is preferable to use the term ‘granulocytical sarcoma’ because not all such tumors are green. The tumor mass can infact be also gray, white, or brown, depending on the concentration of the different enzymes in the cells. GS can affect every age, can occur in different part of the body and, frequently, is multiple [10]. Common sites of involvement are lymph nodes, bones, periosteum, the skin, orbit, retroperitoneum, mediastinum and ovary [11 /14]. GS can also be symptomatic, in this case affects more frequently the skeleton, particularly the skull, the spinal column, the sternum and the ribs. The central nervous system can also be involved months or years
after the basic disease’s complete remission most commonly with a blast infiltration through the arachnoid’s veins [15]. Only a few cases have been reported in the English literature of mammary GS, either antedating or coincident with acute leukemia [2,6,16,17]. Even more rarely, this entity has been described in patients treated for acute myeloblastic leukemia and considered in remission [2,7,18]. In agreement with previous reports, in the case presented, mammography showed bilateral heterogeneously dense breasts, without evidence of calcifications [2]. As previously described, in ultrasound the masses presented as a inhomogeneous hypoechoic lesions without posterior acoustic shadowing [7]. Due to the lack of specificity of mammographic and sonographic features of breast chloroma definite diagnosis of this rare entity must be accomplished by fine-needle aspiration and cytologic markers especially for accurate differential diagnosis from other breast malignancies, mainly lymphoma or carcinoma, especially in the absence of bone marrow involvement. Furthermore, a definite diagnosis of GS is based on the demonstration of myeloid cells within the lesion. The morphological features are variable depending on the degree of maturation. In particular, the myeloid cell with prominent eosinophilic granules is the best morphological clue to myeloid differentiation [19]. The case presented is unusual because of the multicentric location of the breast GS and because of the onset in a patient considered to be in remission by bone marrow biopsy.
M. Imbriaco et al. / European Journal of Radiology Extra 47 (2003) 17 /21
As previously reported, GS is extremely radiosensitive and as shown in this case low radiation therapy allowed complete mammographic and sonographic resolution of the mass.
[11]
References
[12]
[1] Paulus DD, Libshitz HI. Metastasis to the breast. Radiol Clin North Am 1982;20:561 /8. [2] Barloon TJ, Young DC, Bass SH. Multicentric granulocytic sarcoma (chloroma) of the breast: mammographic findings. Am J Roentgenol 1993;161:963 /4. [3] Domchek SM, Hecht JL, Fleming MD, Pinkus GS, Canellos GP. Lymphomas of the breast: primary and secondary involvement. Cancer 2002;94:6 /13. [4] Khoury NJ, Hanna Al-Kass FM, Jaafar HN, Taher AT, Shamseddine AI. Bilateral breast involvement in acute myelogenous leukemia. Eur Radiol 2000;10:1031. [5] Mwanda WO, Rajab JA. Granulocytic sarcoma: report of three cases. East Afr Med J 1999;76:594 /6. [6] Fitoz S, Atasoy C, Yavuz K, Gozdasoglu S, Erden I, Akyar S. Granulocytic sarcoma: cranial and breast involvement. Clin Imaging 2002;26:166 /9. [7] Hiorns MP, Murfitt J. Granulocytic sarcoma (chloroma) of the breast: sonographic findings. Am J Roentgenol 1997;169:1639 / 40. [8] Geelhoed GW, Graff KS, Duttera MJ, Jr, Henderson ES. Acute leukemia presenting as a breast mass. J Am Med Assoc 1973;233:1488 /9. [9] Muss HB, Moloney WE. Chloroma and other myeloblastic tumors. Blood 1973;42:721 /8. [10] Bekassy AN, Hermans J, Gorin NC, Gratwohl A. Granulocytic sarcoma after allogenic bone marrow transplantation: a retro-
[13]
[14]
[15]
[16]
[17]
[18]
[19]
21
spective European multicenter survey. Acute and chronic leukemia working parties of the European Group for Blood and Marrow Transplantation. Bone Marrow Transplant 1996;17:801 /8. Neiman RS, Barcos M, Bernard C, Bonner H, Mann R, Rydell RE, Bennett JM. Granulocytic sarcoma: a clinicopathologic study of 61 biopsied case. Cancer 1981;48:1426 /37. Gartenhaus WS, Mir R, Pliskin A, Grunwald H, Wise L, Papantoniou PA, Kahn LB. Granulocytic sarcoma of breast: a leukemic bilateral metachronous presentation and literature review. Med Pediatr Oncol 1985;13:22 /9. Magliocco AM, Demetrick DJ, Jones AR, Kossakowska AE. Granulocytic sarcoma of the ovary. An unusual case presentation. Arch Pathol Lab Med 1991;115:830 /4. Mockli G. Granulocytic sarcoma presenting as a retroperitoneal lymph node mass. A case report with diagnosis by fine needle aspiration biopsy and flow cytometry. Acta Cytol 1997;41:1525 / 7. Sham RL, Phatak PD, Kouides PA, Janas JA, Marder VJ. Hematologic neoplasia and the central nervous system. Am J Hematol 1999;62:234 /8. Son HJ, Oh KK. Multicentric granulocytic sarcoma of the breast: mammographic and sonographic findings. Am J Roentgenol 1998;171:274 /5. Ahrar K, McLeary MS, Young LW, Masotto M, Rouse GA. Granulocytic sarcoma (chloroma) of the breast in an adolescent patient. Ultrasonographic findings. J Ultrasound Med 1998;17:383 /4. Guermazi A, Quoc SN, Socie G, Briere J, de Kerviler E, SolalCeligny P, Frija J, Rousselot P. Myeloblastoma (chloroma) in leukemia: case 1. Granulocytic sarcoma (chloroma) of the breast. J Clin Oncol 2000;18:3993 /6. Silverman JF, Geisinger KR, Park HK, Strausbauch PR, Frable WJ. Fine-needle aspiration cytology of granulocytic sarcoma and myeloid metaplasia. Diagn Cytopathol 1990;6:106 /11.