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LETTER TO EDITOR
Year : 2011  |  Volume : 48  |  Issue : 3  |  Page : 378-380
 

Granulocytic sarcoma of the oral cavity


Department of Oral and Maxillofacial Pathology, I.T.S. -C.D.S.R., Muradnagar, Ghaziabad, Uttar Pradesh, India

Date of Web Publication14-Sep-2011

Correspondence Address:
S Seema
Department of Oral and Maxillofacial Pathology, I.T.S. -C.D.S.R., Muradnagar, Ghaziabad, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-509X.84929

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How to cite this article:
Seema S, Jay G R, Devi C S, Aadithya B U, Niharika S. Granulocytic sarcoma of the oral cavity. Indian J Cancer 2011;48:378-80

How to cite this URL:
Seema S, Jay G R, Devi C S, Aadithya B U, Niharika S. Granulocytic sarcoma of the oral cavity. Indian J Cancer [serial online] 2011 [cited 2019 Dec 16];48:378-80. Available from: http://www.indianjcancer.com/text.asp?2011/48/3/378/84929


Sir,

A 5½-year-old male child was referred to the outpatient department with a huge painless soft tissue swelling in the right mandibular region which had been present for a period of 30-40 days [Figure 1]. It had increased rapidly in size due to which the patient was unable to close his mouth. There were occasional episodes of bleeding due to trauma and a history of spontaneous exfoliation of the regional teeth. Patient had suffered bouts of fever. There was no history of any medication. Medical history of the patient was insignificant. The patient revealed that a distant relative had died of blood cancer. On examination there was a swelling involving the entire right mandibular ridge area with a largest dimension of 5 cm. [Figure 2] The mucosal surface was covered with necrotic debris. The swelling was non tender and soft to firm on palpation. Teeth in the 83-46 region were mobile. Ipsilateral lymph nodes were palpable and non tender. Physical examination revealed mild hepatomegaly and splenomegaly. Radiological examination showed extensive bone loss involving right side of both the body of mandible and ramus. It revealed loss of three teeth and displacement of the teeth in 83-46 region [Figure 3].
Figure 1: Extraoral view showing swelling in the right mandibular region

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Figure 2: Intraoral view-expansile swelling with a necrotic surface in the entire right mandibular ridge region causing exfoliation and displacement of the regional teeth

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Figure 3: X-ray OPG showed extensive bone loss involving right side of both the body of mandible and ramus

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Clinically, the differential diagnosis included lymphoma, acute leukemia, malignant histiocytosis, and sarcoma. During the blood examination hemoglobin count was found to be 6.8 g%, white blood cell count was 7300/mm 3 , and platelet count was 77 000/mm 3 . The most striking finding was the presence of blast cells in the peripheral blood smear which exceeded 20%. The blast cells had a fine chromatin pattern, high nucleocytoplasmic ratio and prominent nucleoli [Figure 4].
Figure 4: H/E × 100× of bone marrow showed blast cells of myeloid origin

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Bone marrow examination showed the presence of more than 20% blast cells with fine chromatin pattern and high nucleocytoplasmic ratio.  Auer rods More Details were present in greater than 3% of the blast cells. A biopsy from the tumor was taken to correlate the tumor mass with the systemic findings. The histopathological examination showed a relatively uniform population of immature cells admixed with eosinophilic myelocytes and neutrophils. The immature cells showed brisk mitotic activity [Figure 5].
Figure 5: H/E × 40× of lesional tissue showed a relatively uniform population of immature cells admixed with eosinophilic myelocytes and neutrophils

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For final diagnosis, a panel of antibodies was used during the immunohistochemical staining procedures in the paraffin block. The tumor cells expressed myeloperoxidase (MPO) and terminal deoxynucleotidyl transferase (Tdt) enzymes. They were immunonegative for CD 10, CD3, and CD99. Our diagnosis was Granulocytic Sarcoma in a case of AML M2 subtype on the basis of history, physical examination, complete blood Count, bone marrow aspiration, tissue biopsy, and immunophenotyping procedures. No cytogenetic analysis of the case could be performed. The patient was immediately admitted to the hematology department of the medical college but unfortunately the patient died of acute lung infection even before chemotherapy was instituted.

Granulocytic sarcoma (GS), also known as extramedullary myeloid tumor or chloroma, is a rare solid tumor composed of immature cells of the granulocyte series, which occur in an extramedullary site. [1] It is thought to arise in the bone marrow and travel via the Haversian canals to reach the subperiosteal region of bone. Once in the periosteum, the tumor cells can spread to other parts of the body. [2] Oral involvement by granulocytic sarcoma is rare, with only 38 cases described to date. [3] The use of a large immunohistochemistry panel has been suggested by most authors when making a differential diagnosis between GS and lymphoid as well as other myeloid tumors. [4] Since granulocytic sarcoma often precedes leukemia, so, its diagnosis is very important for proper and timely treatment.

 
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1.Osterne RL, Matos-Brito RG, Alves AP, Nogueira TN, Rocha-Filho FD, Meneses FA, et al. Oral granulocytic sarcoma: A case report. Med Oral Patol Oral Cir Bucal 2009;14:e232-5.  Back to cited text no. 1
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2.Bassichis B, McClay J, Wiatrak B. Chloroma of the masseteric muscle. Int J Pediatr Otorhinolaryngol 2000;53:57-61.  Back to cited text no. 2
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3.Da Silva-Santos PS, Silva BS, Coracin FL, Yamamoto FP, Pinto-Junior DD, Magalhães MG. Granulocytic sarcoma of the oral cavity in a chronic myeloid leukemia patient: An unusual presentation. Med Oral Patol Oral Cir Bucal 2010;15:e350-2.  Back to cited text no. 3
    
4.Menasce LP, Banerjee SS, Beckett E, Harris M. Extra-medullary myeloid tumour (granulocytic sarcoma) is often misdiagnosed: A study of 26 cases. Histopathology 1999;34:391-8.  Back to cited text no. 4
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]

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