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Prostate Mass as a First Manifestation of Myeloid Sarcoma in a Patient With an Occult Acute Myeloid Leukemia—A Case Report
Accepted Manuscript Title: Prostate Mass as a First Manifestation of Myeloid Sarcoma in a Patient with an Occult Acute Myeloid Leukemia - a Case Report Author: Natally Horvat, Pedro Sergio Brito Panizza, Frederico Perego Costa, Publio Cesar Cavalcanti Viana PII: DOI: Reference:
S0090-4295(17)30598-8 http://dx.doi.org/doi: 10.1016/j.urology.2017.05.043 URL 20488
To appear in:
Urology
Received date: Accepted date:
2-2-2017 25-5-2017
Please cite this article as: Natally Horvat, Pedro Sergio Brito Panizza, Frederico Perego Costa, Publio Cesar Cavalcanti Viana, Prostate Mass as a First Manifestation of Myeloid Sarcoma in a Patient with an Occult Acute Myeloid Leukemia - a Case Report, Urology (2017), http://dx.doi.org/doi: 10.1016/j.urology.2017.05.043. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
TITLE PAGE
Title: Prostate mass as a first manifestation of myeloid sarcoma in a patient with an occult acute myeloid leukemia - a case report. Authors: Natally Horvat1, Pedro Sergio Brito Panizza1, Frederico Perego Costa2, Publio Cesar Cavalcanti Viana1 1
, SP,
-Libane
01308-050, Brazil 2
-Libane
,
SP, 01308-050, Brazil
Corresponding Author: Natally Horvat Adma Jaf
, SP, 01308-050, Brazil
Tel: +55 11 3394-5305 E-mail: [email protected]
Key words: Prostate; Magnetic Resonance Imaging; Myeloid Sarcoma; Positron Emission Tomography Computed Tomography; Neoplasms; Prostatic Neoplasms
The authors Natally Horvat, Pedro Sergio Brito Panizza, Frederico Perego Costa and Publio Cesar Cavalcanti Viana were equally involved in this study. The authors disclose no conflict of interest. 1
Page 1 of 5
Abstract: Myeloid sarcoma (MS) with either primary or secondary prostate involvement is extremely rare.
Its diagnostic is particularly challenging when prostate lesion
precedes the systemic manifestation of a myeloproliferative disorder. We report such a case in a 44-year-old man with a prostate mass as a first manifestation of myeloid sarcoma associated with acute myeloid leukemia (AML). The diagnosis of lymphoproliferative disorder was suspected in the prostate magnetic resonance imaging (MRI) and MS was confirmed after transrectal ultrasound-guided prostate core biopsy.
Case report: 44-year-old man with a recent history of lower urinary tract symptoms (LUTS) presenting an enlarged prostate in the digital rectal examination and a total PSA levels of 0.95 ng/mL. Prostate MRI demonstrates an ill-defined lesion with low signal intensity on T2-weighted image (Fig. 1A,B,C) and homogeneous enhancement (Fig. 1D). The lesion infiltrates the basal and middle peripheral posterior zone, extends into the anterior mesorectal fascia, seminal vesicles and ureters, causing mild bilateral hydronephrosis. The patient underwent transrectal ultrasound-guided prostate biopsy and the histopathological and immunohistochemical staining analysis revealed myeloid sarcoma (MS). Bone marrow biopsy demonstrates acute myeloid leukemia and the whole body PET-CT scan shows increased FDG uptake only in prostatic tissue without bone lesions (Fig.1 E,F).
Discussion: MS is an extramedullary leukemic tumor more common in patients with acute myeloid leukemia (1). MS may occurs concomitantly with, during the course of, or 2
Page 2 of 5
as a relapse of a hematological malignancy, and it is classified as secondary form. The primary presentation is rare and occurs in nonleukemic patients (1); however most of the cases subsequently develop leukemia within 1 year (2). MS is very infrequent in urogenital organs and there are less than 20 prostate MS reported in the English literature (3). The differential diagnosis is lengthy including non‑Hodgkin lymphoma, lymphoblastic leukemia, rhabdomyosarcoma, Ewing sarcoma and should also be considered the possibility of prostate small cell cancer (PSCC). Immunohistochemical presents a great value in identifying antigens associated with myeloid lineage. In MS CD68‑KP1 (100%) is the most commonly expressed marker followed by MPO (83.6%) Others commonly expressed myeloid markers include lysozyme, CD2, CD3, CD20, CD33, CD43, CD68, and CD117. In contradistinction, the immunohistochemical pattern of PSCC shows others markers like synaptophysin (84–89%), chromogranin (61–75%), CD56 (83–92%) and PSMA (50%) (5). The patient was treated with chemotherapy, followed by bone marrow transplantation and presented excellent therapeutic response with reduction of prostate mass and continued to be followed up.
References 1.
Yilmaz AF, Saydam G, Sahin F, Baran Y. Granulocytic sarcoma: a systematic
review. American journal of blood research. 2013;3(4):265-70. 2.
Breccia M, Mandelli F, Petti MC, D'Andrea M, Pescarmona E, Pileri SA, et al.
Clinico-pathological characteristics of myeloid sarcoma at diagnosis and during followup: report of 12 cases from a single institution. Leukemia Res. 2004;28(11):1165-9. 3
Page 3 of 5
3.
Koppisetty S, Edelman BL, Rajpurkar A. Myeloid sarcoma of the periprostatic
tissue and prostate: Case report and review of literature. Urology annals. 2016;8(3):34854. 4.
Pileri SA, Ascani S, Cox MC, Campidelli C, Bacci F, Piccioli M, et al. Myeloid
sarcoma: Clinico‑pathologic, phenotypic and cytogenetic analysis of 92 adult patients. Leukemia 2007;21:340‑50. 5.
R. Nadal, M. Schweizer, O.N. Kryvenko, et al. Small cell carcinoma of the prostate.
Nat Rev Urol, 11 (2014), pp. 213–219. Figures Legends
Figure 1. T2WI in sagittal (A), axial (B) and coronal (C) planes demonstrate an illdefined mass with low signal intensity in the basal and middle peripheral posterior zone of the prostate (asterisks). The lesion infiltrates the anterior mesorectal fascia (arrowheads), the seminal vesicles (arrows) and ureters, causing mild bilateral hydronephrosis (dashed arrows). Note that the seminal vesicles, despite being infiltrated, did not show substantial distortion. The lesion shows homogeneous and persistent enhancement following gadolinium administration (D) and increased FDG uptake in the prostate (E) and no uptake in bones (F). Considering the infiltration and enhancement patterns, the diagnosis of adenocarcinoma was considered less likely and lymphoproliferative disorder was suggested as the most likely diagnosis.
4
Page 4 of 5
Figure 2. Microscopy (A,B) shows immature myeloid cells within the prostate and the immunohistochemistry samples myeloperoxidase (C), lysozyme (D), CD-67 (E) and CD68 (F) were consistent with the diagnosis of granulocytic sarcoma.
5
Page 5 of 5
S0090-4295(17)30598-8 http://dx.doi.org/doi: 10.1016/j.urology.2017.05.043 URL 20488
To appear in:
Urology
Received date: Accepted date:
2-2-2017 25-5-2017
Please cite this article as: Natally Horvat, Pedro Sergio Brito Panizza, Frederico Perego Costa, Publio Cesar Cavalcanti Viana, Prostate Mass as a First Manifestation of Myeloid Sarcoma in a Patient with an Occult Acute Myeloid Leukemia - a Case Report, Urology (2017), http://dx.doi.org/doi: 10.1016/j.urology.2017.05.043. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
TITLE PAGE
Title: Prostate mass as a first manifestation of myeloid sarcoma in a patient with an occult acute myeloid leukemia - a case report. Authors: Natally Horvat1, Pedro Sergio Brito Panizza1, Frederico Perego Costa2, Publio Cesar Cavalcanti Viana1 1
, SP,
-Libane
01308-050, Brazil 2
-Libane
,
SP, 01308-050, Brazil
Corresponding Author: Natally Horvat Adma Jaf
, SP, 01308-050, Brazil
Tel: +55 11 3394-5305 E-mail: [email protected]
Key words: Prostate; Magnetic Resonance Imaging; Myeloid Sarcoma; Positron Emission Tomography Computed Tomography; Neoplasms; Prostatic Neoplasms
The authors Natally Horvat, Pedro Sergio Brito Panizza, Frederico Perego Costa and Publio Cesar Cavalcanti Viana were equally involved in this study. The authors disclose no conflict of interest. 1
Page 1 of 5
Abstract: Myeloid sarcoma (MS) with either primary or secondary prostate involvement is extremely rare.
Its diagnostic is particularly challenging when prostate lesion
precedes the systemic manifestation of a myeloproliferative disorder. We report such a case in a 44-year-old man with a prostate mass as a first manifestation of myeloid sarcoma associated with acute myeloid leukemia (AML). The diagnosis of lymphoproliferative disorder was suspected in the prostate magnetic resonance imaging (MRI) and MS was confirmed after transrectal ultrasound-guided prostate core biopsy.
Case report: 44-year-old man with a recent history of lower urinary tract symptoms (LUTS) presenting an enlarged prostate in the digital rectal examination and a total PSA levels of 0.95 ng/mL. Prostate MRI demonstrates an ill-defined lesion with low signal intensity on T2-weighted image (Fig. 1A,B,C) and homogeneous enhancement (Fig. 1D). The lesion infiltrates the basal and middle peripheral posterior zone, extends into the anterior mesorectal fascia, seminal vesicles and ureters, causing mild bilateral hydronephrosis. The patient underwent transrectal ultrasound-guided prostate biopsy and the histopathological and immunohistochemical staining analysis revealed myeloid sarcoma (MS). Bone marrow biopsy demonstrates acute myeloid leukemia and the whole body PET-CT scan shows increased FDG uptake only in prostatic tissue without bone lesions (Fig.1 E,F).
Discussion: MS is an extramedullary leukemic tumor more common in patients with acute myeloid leukemia (1). MS may occurs concomitantly with, during the course of, or 2
Page 2 of 5
as a relapse of a hematological malignancy, and it is classified as secondary form. The primary presentation is rare and occurs in nonleukemic patients (1); however most of the cases subsequently develop leukemia within 1 year (2). MS is very infrequent in urogenital organs and there are less than 20 prostate MS reported in the English literature (3). The differential diagnosis is lengthy including non‑Hodgkin lymphoma, lymphoblastic leukemia, rhabdomyosarcoma, Ewing sarcoma and should also be considered the possibility of prostate small cell cancer (PSCC). Immunohistochemical presents a great value in identifying antigens associated with myeloid lineage. In MS CD68‑KP1 (100%) is the most commonly expressed marker followed by MPO (83.6%) Others commonly expressed myeloid markers include lysozyme, CD2, CD3, CD20, CD33, CD43, CD68, and CD117. In contradistinction, the immunohistochemical pattern of PSCC shows others markers like synaptophysin (84–89%), chromogranin (61–75%), CD56 (83–92%) and PSMA (50%) (5). The patient was treated with chemotherapy, followed by bone marrow transplantation and presented excellent therapeutic response with reduction of prostate mass and continued to be followed up.
References 1.
Yilmaz AF, Saydam G, Sahin F, Baran Y. Granulocytic sarcoma: a systematic
review. American journal of blood research. 2013;3(4):265-70. 2.
Breccia M, Mandelli F, Petti MC, D'Andrea M, Pescarmona E, Pileri SA, et al.
Clinico-pathological characteristics of myeloid sarcoma at diagnosis and during followup: report of 12 cases from a single institution. Leukemia Res. 2004;28(11):1165-9. 3
Page 3 of 5
3.
Koppisetty S, Edelman BL, Rajpurkar A. Myeloid sarcoma of the periprostatic
tissue and prostate: Case report and review of literature. Urology annals. 2016;8(3):34854. 4.
Pileri SA, Ascani S, Cox MC, Campidelli C, Bacci F, Piccioli M, et al. Myeloid
sarcoma: Clinico‑pathologic, phenotypic and cytogenetic analysis of 92 adult patients. Leukemia 2007;21:340‑50. 5.
R. Nadal, M. Schweizer, O.N. Kryvenko, et al. Small cell carcinoma of the prostate.
Nat Rev Urol, 11 (2014), pp. 213–219. Figures Legends
Figure 1. T2WI in sagittal (A), axial (B) and coronal (C) planes demonstrate an illdefined mass with low signal intensity in the basal and middle peripheral posterior zone of the prostate (asterisks). The lesion infiltrates the anterior mesorectal fascia (arrowheads), the seminal vesicles (arrows) and ureters, causing mild bilateral hydronephrosis (dashed arrows). Note that the seminal vesicles, despite being infiltrated, did not show substantial distortion. The lesion shows homogeneous and persistent enhancement following gadolinium administration (D) and increased FDG uptake in the prostate (E) and no uptake in bones (F). Considering the infiltration and enhancement patterns, the diagnosis of adenocarcinoma was considered less likely and lymphoproliferative disorder was suggested as the most likely diagnosis.
4
Page 4 of 5
Figure 2. Microscopy (A,B) shows immature myeloid cells within the prostate and the immunohistochemistry samples myeloperoxidase (C), lysozyme (D), CD-67 (E) and CD68 (F) were consistent with the diagnosis of granulocytic sarcoma.
5
Page 5 of 5