granulocytic sarcoma or extramedullary myeloid tumor ( emmt ) is an uncommon neoplasm of immature hematopoetic cells . these tumors are reported in 3.1 - 9.1% of patients with myeloblastic leukemia and occur concomitantly with , after , or rarely before the onset of leukemia . we report a case with multiple tumors involving the lymph nodes , breast and orbit . the diagnosis was established on fine needle aspiration cytology ( fnac ) of the masses which subsequently led to the diagnosis of the underlying leukemia . a 15 year - old girl presented with bilateral , cervical lymphadenopathy , bilateral breast masses , and gradually developing proptosis of both eyes , in that order . nodes were firm to hard with restricted mobility and the breast masses were 4.5 cm ( left ) and 5.0 cm ( right ) along their maximum dimension . fine needle aspiration cytology ( fnac ) was done from the lymph nodes and breast masses . both wet - fixed and air - dried smears were prepared for papanicolaou and may - grnwald giemsa ( mgg ) staining respectively . smears from lymph nodes and the breast showed similar features with a polymorphous population of large atypical cells scattered in a background of mostly mature and a few reactive lymphoid cells [ figures 1 and 2 ] . cytoplasm was pale blue and a fair number of cells showed auer rods and a few fine granules ; the background showed lymphoglandular bodies . cell morphology from both sites was suggestive of myeloid blasts , so a diagnosis of granulocytic sarcoma / extramedullary myeloid tumor was made . smears from lymph node show infiltration by numerous myelomonoblasts ( mgg , 400 ) aspirate from breast with leukemic cells ( mgg , 400 ) the peripheral smear showed normocytic , normochromic anemia with leukocytosis . total leucocyte count ( tlc ) was 48000 cells / mm with the differential count showing 70% blasts , 2% promyelocytes , 8% myelocytes , 8% metamyelocytes , 2% band forms , and 10% lymphocytes . platelet count was adequate and the blasts were as described above with mostly indented nuclei and auer rods [ figure 3 ] . out of these , a considerable proportion showed monocytoid features ; the blasts were diffusely positive for sudan black b ( sbb ) and negative for periodic acid schiff ( pas ) . non specific enolase ( nse ) was noncontributory , based on which , a diagnosis of acute myeloid leukemia ( aml)-m4 was given . peripheral smear shows myeloblasts with auer rods and cells in mitosis ( giemsa , 1000 ) the patient was started on standard chemotherapy to which she responded well . granulocytic sarcoma or extramedullary myeloid tumor may be seen in association with chronic myeloid leukemia ( cml ) , myelodysplastic syndrome , ( mds ) , myeloproliferative syndrome ( mps ) , polycythemia vera , and essential thrombocytosis . emmt may be seen in known patients of aml or may occur ( rarely ) as the first manifestation of the disease . in other cases , it may be the first sign of systemic relapse of a case of treated aml . emmts may occur at any site in the body , common ones being the skin ( leukemia cutis ) , lymph nodes , and mediastinum . other sites such as epidural , uterus , ovaries , testis , and orbits have also been reported . a few case reports have described it in the breast[13 ] where it is often misdiagnosed as lymphoma . granulocytic sarcomas of the orbit have mostly been described as isolated masses which may precede systemic manifestations . the soft tissue counterparts may present months before the involvement of peripheral blood and bone marrow . they produce symptoms according to their anatomic location but they may be asymptomatic as well . problems in diagnosis arise when they are suspected in patients without a background of myeloprolifrative disease . they may often be misdiagnosed as non - hodgkin 's lymphomas , rhabdomyosarcomas , amelanotic melanomas , or undifferentiated carcinomas . light microscopy reveals collections of cells that can be usually recognised as being myeloid . undifferentiated or minimally differentiated blasts generally pose diagnostic problems and these are cases that are misdiagnosed as lymphoma . the cells in our case were positive for sbb and myeloperoxidase ; pas was negative . immunostaining with monoclonal antibodies against myeloperoxidase ; anti - cd43 , and anti - lysozyme are the most sensitive antibodies ; cd68 and cd20 are useful in differentiating it from lymphoma . it is regarded as a poor prognostic indicator by some , whereas others have not considered it as an independent prognostic factor . if they are diagnosed in patients previously treated for aml , they signify relapse whereas in a patient of chronic myeloproliferative disease , they may be indicative of an impending blast crisis . most tumors , whether detected prior to or during the therapy of leukemia , respond well to standard chemotherapeutic agents .