| Session: Extramedullary manifestation of neoplastic myeloid disorder |
| Case number: 204 |
Submitter(s): Paula Kovarik, Chitra Kohli, Sunita Nathan, Rosalind Catchatourian.
Clinical history
The patient was a 64 year old male who presented to the emergency room with a left foot ulcer which developed after a spider bite four months prior. The wound had been previously debrided at another hospital approximately two months prior to presentation. On examination of the left foot, there was a firm lobulated lesion on the lateral left foot with no radiographic evidence of bony destruction. The lesion was again debrided.
Complete blood count at the time of presentation was: WBC 4,800/mm, Hemoglobin 8.5 g, Platelets 121,000/mm, MCV 80.0/fl.
Following examination of the debrided tissue, the patient also underwent bone marrow biopsy and aspiration.
Details of gross/microscopic pathology:
Debrided tissue from the left foot was received in formalin. H&E-stained sections showed large, immature cells infiltrating in soft tissue. Many mitotic figures were seen. Immunohistochemical stains demonstrated positive staining in the large cells for LCA and partial staining for both CD68 and CD15 indicating both granulocytic and monocytic differentiation.
Review of the peripheral blood smear did not identify circulating blasts. The bone marrow aspirate was hypercellular and showed mainly granulocytic precursors. Evidence of trilineage dysplasia was identified in the bone marrow aspirate including small megakaryocyte and forms with separate nuclei, megaloblastic erythroid precursors, and both hyper- and hypogranular myeloid precursors. A bone marrow differential count showed 14% blasts. Immunohistochemical stain for CD68 performed on the bone marrow biopsy also highlighted increased numbers of monocytes. Diffuse increase in reticulin fibers was also seen in the bone marrow biopsy.
Immunophenotype (flow cytometry/immunohistochemistry):
Cytogenetics:
Cytogenetic studies performed on the bone marrow showed the following karyotype: 47,XY,+8. FISH analysis did not detect evidence of BCR/ABL gene rearrangement.
Molecular analysis:
Interesting feature(s) of submitted case:
Unusual presentation of soft tissue granulocytic sarcoma with partial monocytic differentation as a presentation of chronic myelomonocytic leukemia.
Proposed diagnosis:
Soft tissue of left foot: Granulocytic sarcoma with partial monocytic differentiation.
Bone marrow: Myeloproliferative/myelodysplastic disorder compatible with chronic myelomonocytic leukemia with excess blasts.
Panel diagnosis:
Additional immunostains are essential for definitive diagnosis, unstained slides not available
Comments:
Additional information from the submitter: PB data absolute monocyte count 0.2, monocyte 4.1%.
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