Granulocytic sarcoma: A clinicopathologic study of 61 biopsied cases

Granulocytic Sarcoma:

A Clinicopathologic Study of 67 Biopsied Cases

RICHARD S. NEIMAN, MD,* MAURICE BARCOS, MD,t COSTAN BERARD, MD,S HUGH BONNER, MD,§ RlSA MANN, MD,” ROBERT E. RYDELL, MD,T AND JOHN M. BENNETT. MD#

Granulocytic sarcoma is an uncommon tumor composed of granulocytic precursor cells. Be- cause it occurs in a variety of clinical settings and because the tumor cells are primitive it is frequently unrecognized during life. This presentation details the authors’ experience with 61 biopsy-proven granulocytic sarcomas. The patient age range was from 2 to 81 years (mean 48 years). In eight patients the tumors were multiple. Most common sites of involvement were bone, periosteum, soft tissue, lymph node and skin. Twenty-two tumors occurred in 15 patients with no known disease, 26 occurred in 24 patients with a known myeloproliferative disorder, and 13 occurred in 11 patients with proven acute myeloid leukemia. Thirteen of the 15 patients with no known disease developed acute leukemia in from one to 49 months after the biopsy of their tumors (mean 10 months). Most tumors occurring in patients with a known myeloproliferative disorder were associated with blast crisis. The authors’ cases displayed a morphologic range from well-differentiated to those tumors that displayed virtually no evidence of differentiation by conventional microscopy. It was therefore not surprising that most tumors were originally diagnosed as lymphoma. Chloro-acetate esterase (CAE) stains were performed on 56 tumors and 47 were studied with the antilysozyme immunoperoxidase technique. Fifty- six of the 57 specimens studied by either technique were positive. Antilysozyme immunoperoxidase stains were particularly useful in confirming the diagnosis.

Cancer 48:1426-1437, 1981.

RAN ULOCYTIC SARCOMA (chloroma) is a localized G tumor mass composed of immature cells of the granulocytic series. The lesion was first described by

Conducted by the Eastern Cooperative Oncology Group (Paul P. Carbone, MD, Chairman, CA-21115) and supported by Public Health Service grants from the NCI, National Institutes of Health, and the Department of Health, Education and Welfare.

* Mallory Institute of Pathology, Boston University Medical Center, Boston, Massachusetts.

i Roswell Park Memorial Institute, Buffalo, New York (CA- 12296).

$ National Cancer Institute, Bethesda, Maryland. !4 Hospital of the University of Pennsylvania, Philadelphia,

‘ I John Hopkins Oncology Center, Baltimore, Maryland (CA-

ll University of Minnesota, Minneapolis, Minnesota (CA-20365). # University of Rochester Cancer Center, Rochester, New York

(CA-11083). Address for reprints: Richard S. Neiman, MD, Hematology Sec-

tion, Mallory Institute of Pathology, 784 Massachusetts Avenue, Boston, MA 02118.

The authors acknowledge the contributions of many of our col- leagues, both clinicians and pathologists, who generously provided material for this study. They also thank Mrs. S. Smith, Mrs. M. Webb, Miss M. Harsch, and Mr. M. Snyder for their valuable tech- nical, secretarial, and photographic assistance.

Accepted for publication March 23, 1981.

Pennsylvania (C A- 15488).

16116).

Burns in 1811.’ The term “chloroma” was given the lesion by King2 because such tumors often display a greenish color that fades on exposure to air. This color is due to the presence of myeloperoxidase (ver- doperoxidase) in the tumor cells. “Granulocytic sarcoma,” the preferred term, was first used by Rap- paport . 3

Since Dock4 first noted the association of granulocytic sarcoma with acute leukemia, most such tumors have been reported in patients with acute myeloid leukemia (AML),3,5-14 most notably in ~ h i l d h o o d , ~ ~ ’ ~ ~ ’ ~ and frequently are noted only at a u t o p ~ y . ’ ~ Scattered case reports describing granulocytic sarcomas occurring in patients who display none of the blood or bone marrow manifestations of acute leukemia have been published, h o w e ~ e r , ~ , ’ ~ - ~ ~ ; and others have described the tumor in patients with a number of myeloproliferative disorder^.^^-^^ Muss and Maloneyz6 have stated that the incidence of granulocytic sarcoma is twice as high in patients with chronic granulocytic leukemia than in those with acute granulocytic leukemia.

The diagnosis of granulocytic sarcoma during life has frequently been a problem for the pathologist because of the relatively immature nature of the tumor

0008-543X/81/0915/1426 $1.10 0 American Cancer Society

1426

No. 6 GRANULOCYTIC SARCOMA, CHLOROMA, ACUTE LEUKEMIA - Neiman et a/ . 1427

cells. Such techniques as tissue imprints, electron mi- c r o ~ c o p y , ~ ~ and the performance of ASD-chloro- acetate esterase (CAE) stains32 have been used to confirm the diagnosis. The recent development of immunohistologic stains for the demonstration of intracellular antigens has provided a potential tool by which granulocytic sarcoma may be recognized.

Lysozyme (muramidase) is an enzyme known to occur in the primary granules of monocytes and myeloid cell^.^^-"^ Although it has not been demonstrated in normal myeloblasts, it has been noted in eosinophil precursors and leukemic m y e l ~ b l a s t s . ~ ~ The antilysozyme immunoperoxidase technique has been shown to be a sensitive and specific method for the identification of myeloid cells in various myeloproliferative d i s o r d e r ~ . ~ ~ , ~ ~ For this reason, it might be of value in proving the myeloid nature of granulocytic sarcomas, particularly in cases in which the tumor cells appear too primitive to recognize by conventional light microscopy.

The present study of 61 biopsied cases of granulocytic sarcoma was undertaken by the Hematopathol- ogy Subcommittee of the Eastern Cooperative Oncol- ogy Group in an attempt to define the varying clinical settings in which granulocytic sarcoma may occur; to describe its morphologic features in detail; and to eval- uate the use of an immunoperoxidase stain for intracellular lysozyme as an aid in diagnosis.

Materials and Methods

Members of the Eastern Cooperative Oncology Group Pathology Committee were asked to submit pathologic material of presumed or proven granulocytic sarcoma to the Hematopathology Subcommittee. The slides were reviewed by members of the subcommittee and paraffin blocks were obtained where feasi- ble. Cases were included in the study only if the granulocytic origin of the tumor could be substantiated either by the presence of eosinophilic myelocytes in routine morphologic sections or by positive esterase (CAE) stains. Relevant clinical data were obtained from attending physicians or from review of hospital charts or discharge summaries. Relevant bone marrow specimens and peripheral blood smears were reviewed by at least one of us in all cases.

Romanowsky-stained touch imprints of the tumor were available for study in only four cases and appro- priately prepared material for ultrastructural study was available in only one case.

In addition to H & E and PAS stains, the naphthol- ASD chloro-acetate esterase (CAE) stain32,39 and immunoperoxidase stain for lysozyme (muramida~e)"~ , "~ were performed in 56 and 47 tumors, respectively, in

TABLE 1 . Tumor Sites

No. of sites

Soft tissue, periosteurn and bone Bone (lytic) Vertebral and paravertebral Soft tissue

Chest wall Soft palate Nasopharynx Orbit

Lymph node Skin G.I. tract Testis Brain Salivary gland Anterior mediastinum Vagina Pleura

21 8 7 6

3 I I 1

15 13 4 3 1 1 1 1 1

the laboratory of one of us (RSN). The esterase stain was performed using a method from this laboratory previously published.40 The immunoperoxidase technique was performed using a modification of a method previously described. 37338 Rabbit antihuman lysozyme, swine antirabbit IgG, peroxidase-rabbit antiperoxidase complex (PAP) and normal swine and rabbit sera were obtained from Dakopatts through their U.S. agent, Accurate Chemical & Scientific Corporation, West- bury, NY. Purity and specificity of the rabbit antihuman lysozyme was checked by immunodiffusion. Endogenous peroxidase activity was blocked by incu- bating sections for 30 minutes in 0.5% methanolic solution of aqueous hydrogen peroxide. Polymorpho- nuclear leukocytes present in the sections provided internal controls for lysozyme staining. In addition, however, we performed controls by substituting normal rabbit serum for rabbit antihuman lysozyme, which gave no staining reaction.

Esterase and antilysozyme sections were considered positive if staining could be demonstrated in cells having the morphologic features of tumor cells, upon careful comparison with H & E and PAS stains. At- tempts to quantitate intensity of staining were aban- doned because of lack of reproducibility.

Results

The relevant clinical data are summarized in Tables 1 and 2. The 61 tumors occurred in 50 patients. Twenty-nine of these were males and 21 were females. The ages ranged from 2 to 81 years with a mean of 48 years. Three patients developed three granulocytic sarcomas each. In one patient the tumors occurred simultaneously. In two others, the tumors occurred 9, 8 and 3 and 2, 1 and 1 months respectively, before the

1428 CANCER September 15 1981 Vol. 48

TABLE 2. Details of Clinical Setting and Follow-Up

No. of No. of patients tumors

No known disease I5 AML in 1-49 months (mean 10.5 months) 13 20 Dead in 3 months-no leukemia 1 1 Dead in 10 months-no leukemia 1 I

Known myeloproliferative disorder 24 CGL 12

Accelerated phase 5 5 AML in I - 15 months 4 4 Lost to follow-up 3 3

Hypereosinophilic syndrome 4 AML in 15 months, 71 months 1 2 Lost to follow-up 3 3

CGL with hypereosinophilia (AML in 5 months) I 1 MMM (Associated with metamorphosis) 3 4

AML in 1 month 2 2 "MPD" in 1 year 1 1

Chronic monocytic leukemia I Died in 16 months-no AML 1 1

Presenting feature 6 7 During course 5 6

AML = acute myeloid leukemia; CGL = chronic granulocytic leukemia; MMM = myelofibrosis with myeloid metaplasia; "MPD" = undefined myeloproliferative disorder.

P. Vera 3

AML I I

development of leukemia. Five patients each had two separate tumors that were studied. In three of these patients the tumors occurred simultaneously. In the remaining two patients, the tumors occurred eight and one months apart respectively; but the interval before the development of leukemia was not known, since both patients were lost to follow-up. The tumor sites in the 61 cases studied are listed in Table 1. The most common sites were periosteum, soft tissue and bone, lymph nodes and skin. Eight tumors presented as symptomatic osteolytic lesions. Seven tumors presented as paraspinous masses and six additional cases presented in soft tissue directly contiguous to bone. There seemed to be no predilection for any specific lymph node chains. A variety of peripheral and abdominal lymph nodes were involved. The skin lesions all occurred on areas of the trunk, face or scalp. The remaining tumors arose in a wide variety of anatomic sites.

By analyzing clinical data we were able to divide the cases into three clinical settings. Relevant examples of each are briefly presented. Twenty-two tumors occurred in 15 patients with no known hematologic disease, 26 tumors occurred in 24 patients with known myeloproliferative disorders and 13 tumors occurred in I 1 patients with acute myeloid leukemia. Those patients who presented with no symptoms other than those referable to the tumor mass were arbitrarily considered to be patients in whom granulocytic sarcoma was associated with myeloid leukemia if on the same hospital admission myeloid leukemia was demonstrated subsequent to the diagnosis of granulocytic

sarcoma. If the diagnosis of myeloid leukemia or another myeloproliferative disorder was made on a subsequent hospital admission to that in which the biopsy was performed, the tumor was arbitrarily considered to be one occurring in an asymptomatic patient.

Table 2 details the clinical background and follow-up in each of the 61 tumors. Among the 22 tumors presenting in 15 patients with no known disease at the time of biopsy, 20 occurred in 13 patients who developed acute myeloid leukemia from one to 49 months after- wards (mean 10.5 months). The two remaining tumors occurred in two patients who died three months and ten months after the diagnosis of granulocytic sarcoma. Neither patient was known to have leukemia at the time of death.

Case I: A 47-year-old white male developed a tumor in the skin of the nasolabial fold in March 1975. A biopsy of the lesion was interpreted as malignant lymphoma. Physical examination revealed a small lump in the skin of the anterior abdominal wall at the lower end of the sternum. A bone scan showed increased uptake in the skull and proximal fibula. Examina- tion of the peripheral blood and bone marrow smears revealed no evidence of leukemia. Two weeks later the mass at the lower end of the sternum was biopsied. The histologic diagnosis was malignant tumor, ? malignant lymphoma. The patient was started on CVP. Six months later the patient developed enlargement of the testis. Orchiectomy was performed and a histologic diagnosis of malignant lymphoma was made. One month after the orchiectomy the patient was noted to have thrombocytopenia. Hematologic work-up at that time revealed no evidence of leukemia in blood or marrow. In January 1976 the patient was noted to have 3% blasts in the peripheral blood. A bone marrow aspirate was hypercellular with a preponderance of myeloblasts. The patient died several weeks thereafter.

Case 2: A 50-year-old man presented with supraclavicular lymphadenopathy. A biopsy was interpreted as malignant lymphoma. A bone marrow biopsy performed for staging was unremarkable, and examination of the peripheral blood revealed no abnormalities. The patient was treated with vincristine and prednisone.

Forty-nine months later he noted fever and leg pain. His WBC was 36,000 with 21% myeloblasts. A bone marrow biopsy revealed replacement of the marrow by myeloblasts and promyelocytes. He was treated with COAP, but rapidly became obtunded and died. Autopsy revealed extensive leukemia in marrow, spleen and lymph nodes.

Twenty-six sarcomas were noted in 24 patients with known myeloproliferative disorders (Table 2). Chronic granulocytic leukemia was the most common myeloproliferative disorder in which granulocytic sarcoma occurred. The fact that granulocytic sarcoma is associated with an ominous prognosis in chronic granulocytic leukemia can be inferred from the follow-up data in the 12 patients in which the two coexisted. Five

No. 6 GRANULOCYTIC SARCOMA, CHLOROMA, ACUTE LEUKEMIA * Neiman et af. 1429

FIG. 1. Well-differentiated granulocytic sarcoma. Many of the tumor cells contain cytoplasmic (eosinophilic) granules (H & E, x 1000).

tumors occurred in association with the accelerated phase of CGL; and four others occurred in patients who developed acute myeloid leukemia in from one to 15 months following the diagnosis. Three patients were lost to follow-up.

Case 3: A 49-year-old woman was admitted in September 1978 with cervical lymphadenopathy. Seven years previously Phl-positive chronic granulocytic leukemia had been diagnosed. She had been treated with leukophoresis, BCG and combination chemotherapy. Upon admission in 1978 her disease was under control. The lymph node was biopsied and diagnosed as a lymphoblast proliferation. In October 1978 a CT scan revealed increase in size of retroperitoneal lymph nodes and in November 1978 a lymphangiogram revealed increased size of paraaortic lymph nodes. The patient re- ceived 3000 rads to the paraaortic lymph node chain and 2000 rads to the neck. In December 1978 the patient presented with a 20-pound weight loss, fatigue and increase in axillary and inguinal adenopathy. On admission she was found to be febrile and her white count was 86,000/mm3 with 50% blasts which displayed TdT positivity. She was treated with cytosine arabinoside with good response. In January 1979 a bone marrow aspirate revealed 95% myeloblasts. The patient died in March 1979 with leukemia.

Five granulocytic sarcomas occurred in four patients with hypereosinophilic syndrome. The cytogenetic findings in one patient have been previously In another patient, two tumors antedated the development of AML by 15 and 71 months respectively. In three additional cases the patient was lost to follow-up. In one additional case hypereosinophilic syndrome coexisted with Phl-positive chronic granulocytic leukemia. In that case acute myeloid leukemia developed five months after the diagnosis of granulocytic sarcoma.

Case 4: A 21-year-old male was admitted in the fall of 1971 with eosinophilia. A white blood cell (WBC) count was 16,000 with 79% eosinophils, 4% neutrophils, 15% lymphocytes, 1% monocytes and 1% basophils. The hemoglobin was 12.5 gldl; platelets were 400,000. Eight months prior to hospitalization the patient had had a work-up for eosinophilia in Japan. No parasitic or other etiologic agent was found. The patient was readmitted in May 1972 because of chest pain. The hemoglobin ranged from 10.5 to 12.5 g/dl and the WBC count ranged between 19,000 and 28,000 with 20% neutrophils and 66% eosinophils. A bone marrow biopsy was hypercellular with 48% eosinophils and normal myeloid maturation. Be- cause of abdominal pain and clinically palpable splenomegaly the patient underwent splenectomy. The spleen weighed 1800 g and showed multiple recent infarcts, extramedullary hematopoiesis and eosinophilia. In June 1973 the patient presented with weakness and hyperreflexia of both lower extremities. A myelogram revealed a complete block at T-7 and the patient underwent decompressive laminectomy and removal of an extradural tumor extending from T-4 to T-8. Histologic examination of the tumor revealed a granulocytic sarcoma. The hemoglobin was 12 g/dl, the WBC count was 15,000 with 60% eosinophils and no evidence of granulocytic immaturity. The patient remained reasonably well for the next nine months with a WBC count rang- ing between 30,000 and 40,000 with 60-70% eosinophils. In September 1974 the patient was readmitted with low back pain and progressive leg weakness. His hemoglobin was 13.2 g/dl, his WBC count 145,000 with 13% myeloblasts, 64% eosinophils and 10% monocytes. The platelet count was 145,000. Myelogram demonstratea a block at T-9-10 and decornpressive laminectomy showed extensive tumor which was also diagnosed as granulocytic sarcoma. The patient did extremely poorly following surgery. A bone marrow study at this time showed an increased number of myeloblasts and increased granulopoiesis. The patient died several weeks after surgery and at autopsy was found to have multiple


chloromas involving the dura of the vertebral column and the convexity of the brain.

Granulocytic sarcomas occurring in patients with myelofibrosis with myeloid metaplasia (MMM) were prognostically ominous. In four patients with MMM, the development of granulocytic sarcoma was associated with metamorphosis to acute leukemia. In two of these cases, the tumors presented as destructive bone lesions.

Case 5: A 58-year-old white female with known myelo- sclerosis with myeloid metaplasia originally diagnosed six years earlier was admitted in March 1969 with left axillary and right cervical adenopathy. At that time her hematocrit was 32, platelet count 390,000, WBC count was 50,000 with 6% myeloblasts; 8% promyelocytes, 26% myelocytes, 17%

metamyelocytes, 28% polymorphonuclear leukocytes, 5% eosinophils and 10% lymphocytes and 30 nucleated red cells per 100 white cells. A left axillary lymph node biopsy was performed and was interpreted as granulocytic sarcoma. In April of 1969 the patient developed pain in the right femur and right humerus. X-rays revealed lytic lesions in both sites. The lesion of the right humerus was curetted and a diagnosis of granulocytic sarcoma was made. The hematocrit was 20%, platelet count 500,000, WBC count 18,000 witn 10% myeloblasts, 2% promyelocytes, 1% myelocytes, 5% metamyelocytes, 15% bands and 5% polymorphonuclear leukocytes. The patient subsequently developed weight loss, increasing bone pain, and increasing hepatosplenomegaly ; and the white blood cell count rose to 55,000 with 28% myeloblasts. At the end of April 1969 the patient died. Au- topsy revealed acute granulocytic leukemia with multiple chloromas involving the retroperitoneal lymph nodes, the periadrenal fat and the periportal and cervical lymph nodes.

Case 6: A 64-year-old white female with a history of polycythemia Vera since 1958 treated with P32 and busulfan,

FIG. 2. Poorly differentiated granulocytic sarcoma. Most of the cells are blast-like, but occasional eosinophillic myelocytes are present ( f o p C Y I I ~ O Y ( I I Z ~ lower l y f t ) (H & E, X 1000).

developed leukoerythroblastosis, increasing splenomegaly, anemia and thrombocytopenia in 1972. Over the next three years her spleen increased gradually in size and in 1976 a splenectomy was performed. Pathologic examination of the spleen revealed myeloid metaplasia. A bone marrow biopsy revealed findings typical of myelofibrosis with myeloid meta- piasia. In October 1976 the patient developed left hip pain and low-grade fever. Her hematocrit was 35%, platelet count 335,000, WBC count 38,000 with 10% polys, 59% bands, 13% eosinophils, 5% basophils, 2% monocytes, 6% metamyelocytes, 1% myelocytes, 1% promyelocytes and 3% myeloblasts. She was treated with hydroxyurea. However, the pain in her hip became worse and she began having difficulty walk- ing. In November 1976 she underwent surgical replacement of the hip joint. Pathologic examination of the femoral head revealed a large granulocytic sarcoma involving most of the specimen. In December of 1976 the patient developed fever and increasing number of blasts in the peripheral blood. Just before her death the WBC was 52,000 with 16% polymorphonuclear leukocytes, 4% metamyelocytes, 5% myelocytes, 3% promyelocytes, 37% myeloblasts and 28% large blast- like cells containing azurophilic granules. Postmortem examination revealed infiltration of the bone marrow, liver and other organs with leukemic cells having the morphologic features of megakaryoblasts.

Of the three patients with polycythemia Vera and granulocytic sarcoma, two developed AML in one month and the third developed a poorly defined myeloproliferative disorder one year later.

A single additional patient developed an esterase- and lysozyme-positive granulocytic sarcoma during the course of a disorder characterized by an elevated WBC count with an absolute monocytosis which was diagnosed as chronic monocytic leukemia. The patient died 16 months after the diagnosis of chronic pul- monary disease. Although no autopsy was performed

No. 6 GRANULOCYTIC SARCOMA, CHLOROMA, ACUTE LEUKEMIA . Neiman et af.

FIG. 3. Granulocytic sarcoma composed almost exclusively of blastic cells, with no evidence of granulocytic differentiation (H & E, x 1000).

there was no clinical evidence of acute leukemia at the time of his demise.

Thirteen examples of granulocytic sarcoma occurred in 11 patients with known acute myeloid leukemia. In six cases the granulocytic sarcoma was the presenting feature of the disease, and in one of these, two tumors occurred. In five others the granulocytic sarcoma developed during the course of the patient’s myeloid leukemia. One patient developed two tumors, one at presentation and another upon relapse. Among those patients whose tumors occurred during the course of AML, three tumors were unassociated with hematologic evidence of relapse, and occurred 13,20 and 28 months before death from acute leukemia.

Case 7: A 29-year-old male was admitted to the hospital in January 1976 because of abdominal pain and jaundice.

143 1

Laparotomy was performed and an enlarged mesenteric lymph node was removed. A diagnosis of malignant lymphoma was made. The patient was treated with nitrogen mustard and vincristine. A bone marrow biopsy specimen was filled with myeloblasts. The patient was treated with combination chemotherapy and attained partial remission, but in July 1976 he developed a relapse which included symptoms of upper G.I. obstruction. He died in September 1976 of sep- ticemia. No autopsy was performed.

Case 8: A 20-year-old female developed fatigue and petechiae in June 1962. Examination of the peripheral blood revealed 36% blasts containing Auer rods. She was treated with vincristine, cytosine arabinoside, cyclophospharnide, thioguanine and prednisone. Complete response was attained. In March 1978 while still in complete hematologic remission the patient de- livered a normal child. In August 1978 she developed lumbar pain. An extradural mass at L-4 and L-5 was demonstrated, laminectomy was performed and a diagnosis of granulocytic

FIG. 4. Granulocytic sarcoma displaying starry-sky pattern similar to that of Burkitt’s tumor (PAS, X25).


sarcoma was made. Numerous bone marrow biopsies and peripheral blood examinations at this time revealed no hematologic evidence of leukemia. She was treated with x-ray therapy to L-4 and L-5. In September 1979 following an upper respiratory infection she was noted to have 20% blasts in her bone marrow. She was treated with daunorubi- cin and cytosine arabinoside but despite therapy developed septic shock. E . cofi was isolated from her blood and she died in October 1979.

Pathology

The 61 tumors in the present series were arbitrarily divided into well-differentiated, poorly differentiated and blastic categories, on the basis of histologic examination of H & E and PAS-stained sections. Tumors were considered well-differentiated if numerous eosinophilic myelocytes could be seen in any section of a given case (Fig. 1). Thirteen examples were in this category. Nineteen additional tumors were de-

FIG. 5 . Granulocytic sarcoma composed of blastic cells with round to oval nuclei and prominent nucleoli. Mitotic activity is high (PAS, ~ 2 5 0 ) .

scribed as poorly differentiated because they revealed only occasional eosinophilic myelocytes (Fig. 2). In the remaining 29, the lesions were characterized as blastic because no evidence of granulocytic differentiation could be discerned (Fig. 3). Among the blastic cases a significant variation in morphology was noted. In five tumors a starry sky pattern, similar to that described in Burkitt’s tumor, was present (Fig. 4). That this phenomenon may occur in granulocytic sarcoma has been previously commented Al- though most tumors were composed of cells with round to oval nuclei with open chromatin patterns and prominent nucleoli (Fig. 5 ) , seven tumors were composed predominantly of cells with irregularly shaped nuclei with significant cleavage or nuclear infolding, thus mimicking cleaved cell lymphoma (Fig. 6). In eight additional tumors, many of the cells displayed bean-shaped, monocyte-like nuclei (Fig. 7). In five cases, the fine chromatin and inconspicuous nucleoli

FIG. 6 . Granulocytic sarcoma composed of cells with cleaved and irregularly shaped nuclei, similar to those seen in follicular center cell lymphoma (PAS, X250).

No. 6 GRANULOCYTIC SARCOMA. CHLOROMA, ACUTE LEUKEMIA . Neiman et al. 1433

of the tumor cells resembled those of lymphoblasts (Fig. 8).

In many of the 61 tumors, the cytoplasm of the tumor cells was fairly abundant and stained either faintly or somewhat more intensely pink with either H & E or PAS stains. A resemblance, in some cases, to large cell lymphomas with plasmacytoid features or to p l a ~ m a c y t o m a ~ ~ was noted (Fig. 9). Mitotic activity in the 61 tumors was extremely variable. The highest numbers of mitoses were noted in the blastic cases (Fig. 5 ) but even in this group several individual tumors contained surprisingly few mitotic figures.

We reviewed the initial diagnosis in each of the 61 cases and found that in only 27 cases (44%) was the correct diagnosis either made or suspected. Of the remaining 34 cases the diagnosis was malignant lymphoma in 3 1. In one each additional case the diagnosis of malignant histiocytosis, synovial sarcoma and Ewing’s tumor was made. Table 3 compares the cytologic differentiation in each of the 61 tumors with the original diagnosis rendered. In the category of well-differentiated granulocytic sarcoma, the myeloid nature of the tumor was recognized or suspected in seven of 13 cases (54%). Other diagnoses were “lymphosarcoma’ ’ (3 cases), “malignant lymphoma’ ’ (2 cases) , and “malignant lymphoma, undifferentiated” and “immunoblastic sarcoma” (1 each).

Among the 19 tumors categorized as poorly differentiated granulocytic sarcoma, the myeloid nature of the tumor was recognized or suspected in nine of 19 cases (47%). Other diagnoses included “histiocytic lymphoma” ( 5 cases), “malignant lymphoma” (3 cases) and one case each “reticulun cell sarcoma” and “? Ewing’s tumor.” This last tumor occurred in the ischium of a 15-year-old boy.

Of the remaining 29 tumors categorized as blastic, the nature of the tumor was recognized or suspected in only 11 cases (38%). Other diagnoses were malignant lymphoma (6 cases), histiocytic lymphoma (4), ? reticulum cell sarcoma (2), lymphoblastic leukemia or lymphoma (2) and poorly differentiated lymphocytic lymphoma, lymphosarcoma, malignant histiocytosis and synovial sarcoma (1 each). The last case presented as a tumor of the knee joint in a 45-year-old woman.

Special Studies

Table 4 summarizes the results of the napthol- ASD-chloro-acetate esterase (CAE) and antilysozyme immunoperoxidase stains. In 57 of the 61 cases we obtained adequate material to perform CAE stains. Of the 57 cases 42 (75%) were positive for CAE and 15 were negative. Among the I5 cases which did not stain for esterase ten were Zenker-fixed and two were acid decalcified. Of the 15 cases that were negative for es-

FIG. 7. Granulocytic sarcoma with numerous monocytoid cells with bean-shaped nuclei (PAS, x 1000).

terase 1 1 were subsequently shown to be positive for lysozyme using the antilysozyme immunoperoxidase technique.

In 47 of the 61 cases we were able to perform immunoperoxidase stains against lysozyme. Forty-two of the 47 (89%) were positive. Of the five cases that were negative for lysozyme, four were previously shown to be positive with the esterase. In 56 of the 57 cases in which CAE or lysozyme were performed, at least one of the special stains was positive, and in 31 tumors, both were positive. There appeared to be no correlation between degree of histologic differentiation and degree of positivity with either the CAE or the lysozyme stains.

We attempted to correlate the morphology and degree of differentiation of granulocytic sarcoma and positive CAE and lysozyme staining with the clinical

Frc. 8. Granulocytic sarcoma with cytologic features similar to malignant lymphoma, lymphoblastic type (H & E. X 1000).


background in each case. We were unable to establish any distinct correlation between the morphologic ex- pression of the granulocytic sarcoma and the clinical picture in this series with the exception of the fact that in all five tumors associated with hypereosinophilic syndrome numerous eosinophilic myelocytes were present in the tissue sections.

We tried to determine if all the tumors that occurred in a given patient were alike, and if successive tumors might display progressive dedifferentiation. Accord- ingly, we compared the morphologic features of each of the 19 multiple tumors that occurred in eight patients. We noted that there was a striking similarity

TABLE 3. Degree of Histologic Differentiation vs. Original Diagnosis

No. of tumors

Well-differentiated Granulocytic sarcoma recognized or suspected Granulocytic sarcoma not recognized

" Lymphosarcoma" "Malignant lymphoma" "Undifferentiated lymphoma" "lmmunoblastic sarcoma"

Poorly differentiated Granulocytic sarcoma recognized or suspected Granulocytic sarcoma not recognized

"Histiocytic lymphoma" "Malignant lymphoma" "Reticulum cell sarcoma" "? Ewing's tumor"

Blastic Granulocytic Farcoma recognized or suspected Granulocytic sarcoma not recognized

"Malignant lymphoma" "Histiocytic lymphoma" "? reticulum cell sarcoma" "Lymphoblastic leukemia or lymphoma" "Poorly differentiated lymphocytic lymphoma'' " Lymphosarcoma" "Malignant histiocytosis" "Synovial sarcoma"

2 2

13 7 (54%) 6

1 1

19 9 (47%)

10 5 3 I I

29 I I (38%) 18

6 4 2 2 1 1

F I G . 9 . G r a n u l o c y t i c a t c o m a taining cells with abundant c y t o l a n d e c c e n t r i c nucle i . s imulat ing m a c y t o m a (PAS. x 1000).

con- dasm plas-

both in cytologic characteristics and degree of differentiation in each of the successive tumors that occurred in a given patient.

We were particularly interested whether we could discern a correlation between myeloid vs. myelomonocytic differentiation and lysozyme activity in the tumor cells. A weak correlation had been demonstrated by Catovsky and gal tor^,^^ but was not found by Karle et We also found no such correlation, but this may be due to the difficulty in distinguishing myeloid from myelomonocytic differentiation by histologic techniques. There seemed to be no relationship between the intensity of lysozyme activity in the tumor cells and the cytologic subtype of the circulating leukemia cells when studied in the same patient.

Table 4 details the relationship between the degree of histologic differentiation and the results of the CAE and antilysozyme stains in our series. We could discern no correlation, particularly if one excludes the case that were Zenker-fixed or acid decalcified. Spe- cifically, we noted that the great majority of the tumors considered blastic by routine histologic criteria displayed both esterase and lysozyme positivity.

Discussion In the present study we have attempted to define the

clinical and morphologic spectrum of granulocytic sarcoma. Although the tumor is indeed associated with acute myeloid leukemia, our study indicates that the temporal association between the two is extremely variable, and that the prognostic significance of a granulocytic sarcoma depends upon the clinical con- text in which it occurs. Only 13 of the 61 tumors in our study occurred in patients known to have AML at the

No. 6 GRANULOCYTIC SARCOMA, CHLOROMA. ACUTE LEUKEMIA * Neiman et al. 1435

time of biopsy. They occurred both as a presenting manifestation of the leukemia in six patients and during the course of the disease in five patients, occasion- ally while the patient was in apparent complete hematologic remission. It is highly unusual for AML to present with symptoms referable to a tumor mass. Whether patients with this presentation have a differ- ent prognosis from the bulk of patients with AML unassociated with granulocytic tumors is unknown. Our data do not suggest that the occurrence of a granulocytic sarcoma in a patient with AML alters the prognosis, or that the occurrence of such a tumor in a patient with AML in remission necessarily indicates a relapse.

The occurrence of granulocytic sarcomas in patients with known myeloproliferative disorders, however, appears to have great prognostic significance. Our data indicate that in the majority of cases (13 of 20), whether the underlying disease was CGL or another myeloproliferative disorder, the tumor was either the initial manifestation of blast transformation, or a har- binger of AML within four months. It is important to note that granulocytic sarcoma may occur at a time in the evolution of a patient’s myeloproliferative disorder in which the disease appears in all other clinical and hematologic respects to be stable. It is therefore apparent that the clinical significance of a diagnosis of granulocytic sarcoma in such patients is great, since it strongly suggests that blast crisis is imminent.

In two cases of MMM, the tumors presented as destructive bone lesions. Although such lesions have been described by others in patients with CGL,28~29~42 they have not been previously described in patients with MMM. A report by Fayemi et described a “myeloid sarcoma” with such a presentation containing a variety of hematopoietic cells, including megakaryocytes, but the authors carefully noted that it was not a granulocytic sarcoma because of the hetero- geneity of marrow cell types in the tumor.

Twenty-two of the 61 tumors in this study occurred in 15 patients who displayed no discernible hematologic abnormality at the time of the biopsy. Thirteen of the 15 patients in this group developed AML. The granulocytic sarcomas in these 13 patients occurred from one to 49 months before the development of leukemia, and in several cases were multiple or sequen- tial. This phenomenon is not commonly recognized. Many authors have previously commented upon the occurrence of granulocytic sarcoma before the development of acute myeloid l e ~ k e m i a . ~ , ’ ~ - ~ ~ Our data indicate that the interval between the two is relatively short and that in the majority of cases leukemia will make itself manifest within a period of months after the tumor occurs. The 49-month interval in one of

TABLE 4. Relationship Between Histologic Differentiation and Results of Esterase and Lysozyme Stains

Well-differentiated- 13 tumors CAE: 7 pos; 3 neg (all Z) 3 ND LYS: 7pos; 1 neg 5 ND

CAE: 16 pos; 2 neg ( 1 Z) 1 ND LYS: 14 pos; 1 neg 4 ND

CAE: 19 pos; 10 neg (6 Z, 2 AD) LYS: 21 pos; 3 neg

CAE: 42 pos; 15 neg (1 1 pos for LYS) LYS: 42 pos; 5 neg (4 pos for CAE)

Poorly-differentiated- 19 tumors

Blastic-29 tumors

5 ND

4 ND 14 ND

TOTAL

CAE = chloral acetate esterase; LYS = anti-lysozyme immunoperoxidase; (2) = Zenker-Fixed; (AD) = acid decalcified; ND = not done.

our cases appears to be the longest such interval reported, exceeding that reported by Brugo et al. l 7 by ten months. The prognostic significance of the development of a granulocytic sarcoma in this group is therefore great, for it strongly suggests that the patient will develop acute granulocytic leukemia. Whether patients with a granulocytic sarcoma who do not have acute leukemia should be treated as though they did have acute leukemia at the time of biopsy is a matter of conjecture. Our retrospective study cannot answer that question, but a prospective study incorporating cytogenetic study of the marrow in this group of patients would be of interest in this regard.

The morphologic features of granulocytic sarcoma appear to be as variable as the clinical presentations. Although the majority of our cases were composed of granulocytic cells which displayed no appreciable degree of differentiation, in 20% of our cases the degree of differentiation of the tumor was significant. Our data indicate, therefore, that granulocytic sarcoma need not be composed entirely or almost exclusively of very primitive granulocytic elements but may contain a significant number of cells with a relatively high degree of differentiation. Although cytologic features such as copious pink cytoplasm and faint cytoplasmic granularity are common, it is clear that the morphologic features are variable. The histologic diagnosis of granulocytic sarcoma remains a difficult one, particularly in those cases in which the diagnosis is not suspected clinically. Careful examination of tissue sections that are well prepared and thinly cut may pro- vide evidence of granulocytic differentiation in the form of eosinophilic myelocytes. In our experience this single feature is the most helpful in evaluating routine paraffin-embedded and H & E-stained sections.

Several authors have stated that electron microscopic study must be performed to confirm the diagno-


sis of a granulocytic sarcoma."' Since the overwhelm- ing majority of these tumors are not suspected as being hematologic in origin, electron microscopic studies appear to be infrequently performed, as is indicated in our study. Moreover, electron microscopic studies are time-consuming and costly. Although we do not deny the importance of tissue imprints or of ultrastructural studies, it is clear from our study that neither of these modalities are commonly employed, nor, in fact, are they needed to establish the diagnosis in the great majority of cases.

Our study has Confirmed that the CAE stain is a reliable technique that may confirm the granulocytic nature of the tumor cells in cases in which the diagnosis is not apparent by careful examination of routine tissue sections. However, there seemed to be several potential advantages of the anti lysozyme immunoperoxidase technique over the CAE stain. Im- munoperoxidase staining is not inhibited by Zenker- fixation and acid decalcification, as is esterase staining.a7 The immunoperoxidase stains eosinophilic myeloid cells while the esterase does n ~ t ~ ~ - : $ ~ ; leukemic myeloblasts have been shown to contain detectable amounts of lysozyme in many cases,:'6 while displaying no esterase activity.:'!' As a result, we decided to study the tumors using the antilysozyme immunoperoxidase technique as well as the esterase stain.

Our results confirmed that the immunoperoxidase technique has advantages over the esterase stain, for it gave a higher yield of positive results (42/47-89%) than did the CAE (42/57-75%). Moreover, we were able to confirm the diagnosis of granulocytic sarcoma by the immunoperoxidase technique in 1 1 of 15 cases that displayed no esterase staining. Most important, of 12 esterase negative, Zenker fixed or acid decalcified cases, ten were lysozyme-positive, thus suggesting that the lysozyme may be most useful in cases in which the CAE is of limited usefulness. It is our belief that the antilysozyme immunoperoxidase technique is a valuable adjunct to the esterase stain in the diagnosis of granulocytic sarcoma.

The fact that both special stains, but particularly the antilysozyme, were usually positive even in cases in which the tumor was classified as blastic by histologic criteria should occasion no surprise. Histopathologic techniques are much less sensitive in discerning differentiation among hematopoietic cells than histochemi- cal or immunochemical ones. This has previously been demonstrated in the case of erythroid precursor cells46 as well as in the case of granulocytic precursors in this study. Granulocytic sarcomas must display maturation to the myelocytic stage to be recognizable by routine histologic techniques; whereas the esterase and antilysozyme techniques are capable of detecting myeloid

precursor cells at the promyelocyte or even the myeloblast stage.

Many of the cases in this series were initially diagnosed as malignant lymphoma. These patients are rem- iniscent of several others previously reported in the literature as having malignant lymphomas of large cell type terminating in acute l e~ke rn ia .~~-~O It would appear likely that these cases represent granulocytic sarcomas that were not correctly identified,51 and that a relationship between large cell lymphomas and acute myeloid leukemias does not exist

The clinical and morphologic recognition of granulocytic sarcoma remains a problem. The present study indicates that the clinical presentation is extremely variable and the histopathologic recognition of these tumors is difficult. Only by maintaining a high index of suspicion will clinicians and pathologists recognize this tumor in the majority of cases in which it occurs.

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Granulocytic sarcoma: A clinicopathologic study of 61 biopsied cases

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