myeloid sarcoma ( ms ) are solid tumours composed of immature myeloid cells involving an extramedullary site .
these tumours are also named chloroma in view of their green coloration due to high myeloperoxydase content .
ms occurs mainly in patients with known acute myeloid leukaemia ( aml ) , myeloproliferative disorder or myelodysplastic syndrome [ 1 , 2 ] . in few cases
, ms may be the presenting feature of aml , and the most common sites of involvement are bones , soft tissue , lymph nodes , skin , gastrointestinal tract and body cavities .
presentations in the female genital tract ( fgt ) are uncommon . radioiodine ( i )
is used in the treatment of thyroid cancer in order to eliminate residual thyroid tissue following total thyroidectomy and to treat metastatic disease [ 3 , 4 ] .
it is known that ionizing radiations , including i , are highly effective in producing chromosomal aberrations that sometimes are linked to the occurrence of secondary leukaemia .
aml is an uncommon complication of exposure to i , occurring mostly after a cumulative dose higher than 800 mci [ 3 , 5 ] . although cases of patients developing leukaemia after low - dose radioactive iodine are reported , the link with the treatment is still a matter of debate .
we report a case of acute myeloid leukaemia revealed by a ms of the uterine cervix in a 48-year - old woman , 17 months after receiving a total dose of 100 mci i for papillary thyroid cancer .
a 48-year - old woman , gravida 3 , para 3 , was referred to our unit in april 2007 for a large uterine cervical mass detected during an intrauterine device change .
her medical history was marked by a total thyroidectomy for papillary carcinoma performed 17 months before .
she received a single dose of 100 mci radioiodine ( i ) and a suppressive dose of thyroid hormone .
six months later she had a negative whole - body i scan . on admission , besides pallor and moderate asthenia , the physical examination revealed a large gray - green - tinged cervical mass extended to both parametriae .
her last gynecological examination and pap smear ( one year before ) were normal , as were the last laboratory examinations .
cervical smear performed by the gynecologist revealed the presence of atypical squamous cells of undetermined significance ( ascus - bethesda system 2001 ) .
imaging confirmed the presence of a homogeneous cervical tumour measuring 6 cm , extending to both parametriae .
cervical biopsy showed cervical stroma being infiltrated by sheets of medium sized immature cells , many of which had clear cytoplasm ( fig . 1 ; hematoxylin and eosin stain ; original magnification  200 ) .
2 ; original magnification  200 ) , cd 117 and cd 34 antigens , leading to the diagnosis of ms .
laboratory examinations revealed the following values : hemoglobin 5.4 g / dl , hematocrit 16% , white blood cell count 5.1  10/mm with 75% of blast cells and a platelet count of 19  10/mm .
a bone marrow biopsy confirmed the diagnosis of acute aml type m2 according to the french - american - british classification scheme .
cytogenetic studies on bone marrow cells failed to show any translocation or inversion , but demonstrated a trisomy 3 confirmed by fish .
induction treatment was carried out using high - dose cytarabine and daunorubicin according to lam 2006 protocol . as the medullogram showed 66% pathological blasts 15 days after the beginning of the treatment , the patient underwent reinduction therapy using the same drugs .
the patient 's course was complicated by febrile neutropenia and staphylococcal sepsis which was successfully treated .
a post - chemotherapy medullogram done prior to discharge in may 2007 showed a hypocellular marrow with 3% blasts ( 1% pathological blasts ) .
one month later , a bone marrow biopsy showed the persistence of 11% pathological blasts .
a compensation treatment according to the lam 2006 protocol ( high doses of amsacrine and aracytine ) was performed .
they occur mainly in patients with known aml , myeloproliferative disorder or myelodysplastic syndrome . in very few cases
ms of the uterine cervix as an initial clinical presentation of acute myeloid leukaemia is uncommon [ 1 , 2 ] .
radioiodine is used in the treatment of thyroid cancer in order to eliminate residual thyroid tissue following total thyroidectomy and to treat metastatic disease [ 3 , 4 ] .
aml is an uncommon complication of exposure to i , which when it occurs , does so mostly after cumulative doses higher than 800 mci [ 3 , 5 ] .
although cases of patients developing leukaemia after low - dose radioactive iodine are reported , the link with the treatment is still a matter of debate . in this report
the patient had received a single dose of 100 mci i for the treatment of a thyroid cancer 17 months before the diagnosis .
ms occurs most commonly in bone , periosteum , soft tissue , lymph nodes and skin , whereas the fgt is rarely involved [ 1 , 2 ] . the ovaries and breasts deserve special mention as sites of involvement , but garcia et al
only 23 cases of ms of the uterine cervix have been reported before . the majority of patients with ms of the cervix present vaginal or postcoital bleeding .
diagnosis is especially difficult when the tumour mass is isolated with no evidence of systemic aml . in these cases ,
ms are frequently misdiagnosed in biopsies and the most common incorrect diagnosis cited is large cell lymphoma .
cytochemical and immunohistochemical studies are extremely helpful for establishing the correct diagnosis in such cases .
prognosis of ms of the uterine cervix is poor , ranging from an average survival of 9 months in patients without manifest leukaemia to 3.2 months for patients with manifest aml at presentation . in our case
she was asymptomatic and an examination of peripheral blood and bone marrow after the diagnosis of fgt involvement revealed aml m2 .
the development of aml is a rare but known complication of radioiodine therapy usually occurring after a cumulative dose of more than 800 mci .
however , a few cases of aml after a lower dose of i have already been reported .
table 1 summarizes a review of published reports of acute myeloid leukaemia in patients treated with i for thyroid disorders .
two groups can clearly be distinguished : patients who developed leukaemia 12 to 24 months after the radioiodine therapy , and those whose disease occurred after a period longer than 2 years .
cytogenetic analysis of bone marrow showed described chromosomal rearrangement in cases 6 and 7 ( trisomy 8 and t(15,17 ) , respectively ) . in our patient
we do not know whether these cases of aml can be considered as a second neoplasia or as a secondary effect of radioactive treatment .
nevertheless , ionizing radiation , including i , is known to be highly involved in producing chromosome aberrations that could be linked to the occurrence of secondary leukaemia [ 8 , 9 ] .
it has actually been shown that the frequency of complex abnormalities in karyotypes is higher in radioiodine treatment - related aml than in de novo aml .
it is unclear whether treatment with low - dose radioactive iodine contributed to the development of leukaemia in the patients described .
the development of aml after low - dose radioiodine could represent a therapy - induced complication .
alternatively , we could also hypothesize that the bone marrow of these patients shows individual susceptibilities that put them at greater risk for the potential damaging effect of i therapy .
finally , these patients could represent a part of the population that would have developed aml without any i therapy .
as the incidence of leukaemia after low - dose radioiodine therapy is unclear , a strict hematological follow - up of patients treated with any dose of i therapy is recommended to accurately detect any hematological complication which might have been underestimated .
unusual presentations , such as chloroma of the uterine cervix , may reveal myeloid malignancy and should therefore be kept in mind .
 the development of acute myeloid leukaemia after low - dose radioiodine therapy and its presentation as a myeloid sarcoma of the uterine cervix are both rare events . 
 we report a case of acute myeloid leukaemia revealed by a myeloid sarcoma of the uterine cervix in a 48-year - old woman , 17 months after receiving a total dose of 100 mci 131i for papillary thyroid cancer . 
 a strict hematological follow - up of patients treated with any dose of 131i is recommended to accurately detect any hematological complications which might have been underestimated . 
 unusual presentations , such as chloroma of the uterine cervix , may reveal myeloid malignancy and should be kept in mind . 