British Journal of Radiology (2006) 79, e112-e115
© 2006 British Institute of Radiology
doi: 10.1259/bjr/17948311
MR findings of granulocytic sarcoma of the breasts
H Nishida, MD
1,2
T Kinoshita, MD
2
N Yashiro, MD
2
Y Ikeda, MD
1 and
T O'Uchi, MD
2
1 Division of Hematology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, 2 Department of Radiology, Kameda Medical Center, Chiba, Japan
Correspondence: Hiroko Nishida, Department of Internal Medicine, Keio University School of Medicine, 35 Shnanomachi Sinjuku-ku, Tokyo, 160–8582, Japan.
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Abstract
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We report a case of isolated extramedullary relapse of acute myeloid leukaemia (AML) that presented as granulocytic sarcoma of both breasts, with no other signs of relapse even in the bone marrow. The T2 weighted coronal images on MR showed both multiple ill-defined heterogeneous hyperintense masses relative to breast parenchyma; these masses were seen also with a visual washout enhancement. Pathohistological study showed infiltration by myeloblasts, which were relatively uniform in appearance, featuring round or oval nuclei and a small cytoplasm. After chemotherapy and radiotherapy, both breast masses disappeared on MR images. Although the MR findings of granulocytic sarcoma were indistinguishable from those of multicentric carcinoma and malignant lymphoma, the MR images were useful for evaluating and monitoring responses to the treatments, as well as for detecting non-palpable relapsed tumours.
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Introduction
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Granulocytic sarcoma, a rare malignant haematological tumour, is an extramedullary solid tumour composed of immature myeloid precursor cells. It is one of the uncommon manifestations of the disease progression of acute myeloid leukaemia (AML). The central nervous system, subcutaneous tissues and genitourinary system were found to be the most common sites of granulocytic sarcoma [1]. We report the MR findings of granulocytic sarcoma of the bilateral breasts in an adult without systemic relapse of AML at presentation.
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Case report
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A 53-year-old woman with AML (FAB M2), who had been successfully treated with induction chemotherapy (Ara-C and MIT), was admitted to our hospital in July 1999, 4 months after complete remission of AML. She complained of palpable masses in both breasts. Physical examination revealed hard masses in both breasts with mild tenderness. There were no findings of bone pain, palpable axillary lymph nodes, or hepatosplenomegaly.
Mammography (Figure 1
) showed multiple ill-defined non-calcifying high-density masses in both breasts.
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Figure 1. Mediolateral oblique mammogram shows multiple ill-defined high-density masses without calcification in the left breast. Non-associated calcification is demonstrated in the upper portion. Similar mass lesions were seen in the right breast.
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MRI examination was performed using a 1.5 T scanner (Magnetom Vision; Siemens, Erlangen, Germany) with the patient in the prone position, using a mamma double coil. T2 weighted coronal images (repetition time (TR)/echo time (TE) 4700/90 ms) were obtained. The pre- and post-contrast MR images were obtained with a fat-saturated, three-dimensional fast low-angle shot (3D-FLASH) sequence with TR/TE 30/4 ms, flip angle 30°, field of view 156 mm x 250 mm, matrix size 160 x 256, and 2-mm gapless sections). The coronal fat-suppressed 3D-FLASH sequence with these characteristics was obtained at 2 min 30 s after rapid intravenous administration of gadopentetate dimeglumine (Gd-DTPA with a dose of 0.1 mmol kg–1 body weight (Magnevist; Schering AG, Berlin, Germany), followed by flushing with 20 ml of saline. Maximum intensity projection (MIP) images were reconstructed using the fat-suppressed coronal 3D-FLASH images (TR/TE 32/4 ms, flip angle 30°, field of view 180 mm x 180 mm, matrix size 210 x 180 and 3-mm gapless sections).
The T2 weighted coronal images showed multiple ill-defined heterogeneous hyperintense masses relative to the breast parenchyma. A MIP image in transverse orientation showed multicentric masses with smooth edges in both mammary glands (Figure 2). A fine-needle biopsy under CT pathohistologically showed infiltration by myeloblasts, which were relatively uniform in appearance, featuring round or oval nuclei and a small amount of cytoplasm. These myeloblasts were positive for myeloperoxidase and CD 13, 33, 56 and HLA-DR, with no cytogenetic abnormalities. At that time, no other signs of relapse, even in the bone marrow, were demonstrated.
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Figure 2. A maximum-intensity projection (MIP) image in transverse orientation shows enhancing multicentric masses with smooth edges in the both mammary glands.
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The patient received chemotherapy. As a result, the breast masses almost disappeared on MR images by August 17, 48 days after she was admitted (Figure 3). However, on October 9, although her general condition was good and the breast masses were not palpable, MR images revealed recurrent multiple breast masses bilaterally. An early contrast MIP image in sagittal orientation (at 2 min 30 s) showed the enhanced masses with smooth edges in both breasts (Figure 4). These masses were consistent with relapse. She therefore received chemotherapy and radiotherapy to the bilateral breasts by a tangential irradiation technique with a total dose of 30 Gy. On December 18, the enhanced masses did not appear on MR images.
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Figure 3. After systemic chemotherapy, bilateral multiple breast masses almost disappeared from the 17 August maximum intensity projection(MIP) image in transverse orientation.
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Figure 4. An early contrast enhanced maximum intensity projection(MIP) image in sagittal orientation (at 2 min 30 s) demonstrated multiple enhanced masses in both breasts at relapse on 9 October.
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Discussion
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Granulocytic sarcoma is a rare extramedullary tumour composed of immature malignant myeloid precursor cells. Burns was originally credited as the first author to describe green tumour, in 1811 [2]. In 1853, King first used the term "chloroma" based on the colour of the tumour (from the Greek chloros, meaning greenish-yellow), attributable to the high content of myeloperoxidase [3]. The incidence of granulocytic sarcoma overall was 2.5–8% in one autopsy series of acute leukaemia and it was more than twice as common in children as in adults [4, 5]. Although these lesions can occur anywhere in the body, the most common setting was disease progression in 50% of AML cases [1]. The lesions were multiple, solid and most commonly found in the central nervous system, subcutaneous tissues and genitourinary system, accounting for up to 52% of all cases [1]. Other sites of involvement included muscle, bone, skeleton, conjunctiva, nasopharynx, paranasal sinuses, thorax, external auditory canal, lymph node, pleural and peritoneal cavities, lung, thyroid gland, stomach, and pancreas [1, 6]. Byrd et al reported 10 cases of granulocytic sarcoma of the breast among 154 cases of acute leukaemia [7]. Similarly Kurita et al found 31 cases of granulocytic sarcoma of the breast in 267 cases of acute leukaemia [8]. Many cases pre-dated or coincided with acute leukaemia [1, 6]. In recent years, other reports of granulocytic sarcoma of the breasts were shown [9–11].
Recently, Kinkel et al advocated that the visual washout enhancement pattern on dynamic high-spatial-resolution MR images using a 3D sequence was useful when combined with morphological criteria for distinguishing benign lesions from malignant lesions [12]. They reported that the sensitivity and specificity in the diagnosis of breast cancer were 97% and 96%, respectively. They reported that lesions with irregular margins and with visual washout enhancement were diagnosed as a breast cancer with high accuracy, although their patient data did not include granulocytic sarcoma [12]. On the basis of the diagnostic criteria in their description, our case may be considered as multiple malignant lesions, although MR findings of granulocytic sarcoma were indistinguishable from those of multicentric carcinoma or malignant lymphoma and may be misdiagnosed [13], especially in the absence of bone marrow involvement, but special stains and immunochemical studies were necessary for our diagnosis.
MR imaging, especially a MIP technique, was useful for detecting lesions and monitoring treatment response in our case. A MIP technique has been valuable for visualizing the full three-dimensional extent of a lesion in a single image. We utilized MIP images to estimate the extent of tumours in both breasts as a whole. The extent of each tumour was evaluated by contrast-enhanced 3D-FLASH images. The MR images revealed non-palpable relapsed lesions during the follow-up after treatments. It was also helpful in the decision to start radiation therapy after chemotherapy during the earlier stage.
In conclusion, the MR findings of granulocytic sarcoma showed multiple, enhancing masses with smooth edges and visual washout enhancement. The MR findings of granulocytic sarcoma, like those of the other modalities, were indistinguishable from those of multicentric carcinoma or malignant lymphoma. In such cases, ultrasound, MR or clinical guidance could be used, with the needle to obtain cells by fine needle aspiration for accurate diagnosis. MR images were useful for evaluating and monitoring the patient's response to treatments and for detecting the non-palpable relapsed tumours.
Received for publication March 26, 2005.
Revision received November 8, 2005.
Accepted for publication November 21, 2005.
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References
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Abstract
Introduction
