Myeloid Sarcoma: An Unusual Case of Mediastinal Mass and Malignant Pleural Effusion with Review of Literature

Abstract

Myeloid sarcoma is an extramedullary tumor seen most commonly in patients with acute myeloid leukemia and less frequently in chronic myeloid leukemia, myelodysplastic syndrome and rarely, in an isolated form without any other underlying malignancy. Malignant pleural effusion in hematological malignancies is rare when compared with solid tumors. We present an unusual case of myeloid sarcoma in which a mediastinal mass with pleural effusion was the initial presentation. A 27 year old gentleman presented with complaints of fever, chest pain and swelling in the anterior chest wall for 6 months. Examination revealed a lump measuring 5 9 5 cm on the left side of the chest wall. Hematological evaluation showed hemoglobin-14.2 g/dL, platelet count-233 9 10 9 /L, TLC-117 9 10 6 /L with normal differential counts. Contrast enhanced computerised tomography (CECT) confirmed the presence of a soft tissue mass in the superior mediastinum abutting against the chest wall. Core biopsy was suggestive of myeloid sarcoma and immunohistochemistry was positive for myeloperoxidase and negative for CD3, CD 20 and CD 23. Pleural fluid analysis showed the presence of malignant cells. Bone marrow examination did not show an excess of blasts. A final diagnosis of extramedullary myeloid sarcoma with malignant pleural effusion was made. The patient was given induction chemotherapy (3 ? 7 regimen) with daunorubicin and cytosine arabinoside. Repeat CECT done on day 28 showed complete resolution of pleural effusion and significant reduction in the size of mediastinal mass. The patient has successfully completed three cycles of consolidation therapy following which there has been complete resolution of the mass. He remains asymptomatic on close follow up. Keywords Myeloid sarcoma Á Malignant cytology Á Acute myeloid leukemia Case ReportA 27-year old gentleman presented with complaints of fever, chest pain and swelling in the anterior chest wall for 6 months. Examination showed presence of a non-tender lump (5 9 5 cm) on the left chest wall which was fixed to overlying skin. Laboratory investigations showed hemoglobin-14.2 g/dL, platelet count-233 9 10 9 /L and TLC-11.7 9 10 9 /L with differential count of 65 % neutrophils, 13 % lymphocytes, 6 % monocytes, 16 % eosinophils with normal RBC indices and peripheral blood smear. Chest X ray showed mediastinal widening with left sided moderate pleural effusion (Fig. 1). CECT chest showed soft tissue mass in superior mediastinum abutting against the chest wall (Fig. 2). Positron emission tomography (PET) scan showed increased FDG avid uptake in the superior mediastinum (Fig. 3). A core biopsy from the mass was suggestive of myeloid sarcoma. Immunohistochemistry confirmed the presence of tumor cells that were positive for myeloperoxidase stain and negative for CD3, CD 20 and CD 23 (Fig. 4). Pleural fluid staining showed scattered population of hematopoietic cells intermixed with reactive cells while high power view showed increased cellularity with abundant blasts, myelocytes, metamyelocytes, eo...

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