Granulocytic Sarcoma in Breast after Bone Marrow Transplantation
A 39-year-old woman was admitted to our breast clinic with a palpable mass in the right breast that had been increasing in size for the past four months. Upon physical examination, a fixed and firm mass was palpated on the right breast. There were no signs of nipple retraction or skin abnormalities. Breast ultrasonography demonstrated multiple masses on the right breast with enlarged axillary lymph node (). Core needle biopsy was performed and atypical mononuclear hematopoietic cells were identified along with diffuse periductal infiltration of hyperchromatic cells which had a large nuclear-cytoplasmic ratio. The results of immunohistochemistry were positive for cluster of differentiation (CD)34, lysozyme, and myeloperoxidase (MPO) and were negative for CD3 and CD20. We could conclude granulocytic sarcoma by these immunohistochemical findings.\nThe patient had an admission history for petechiae and easy bruises along the whole body 4 years previously. The thrombocytopenia and anemia were identified (platelet count 16,000/µL, hemoglobin 8.6 g/dL, hematocrit 23.9%) and 21% of blasts were observed by peripheral blood smear. In suspicion of acute leukemia, she was referred to the Department of Hematology-Oncology and received bone marrow examination. The blast cells in the bone marrow were infiltrated diffusely and cellularity was increased up to 95%. The results of immunophenotyping were positive for human leukocyte antigen (HLA)-DR (39%), CD10 (31%), CD19 (43%), CD22 (36%), CD3 (34%), CD5 (33%), CD7 (34%), CD33 (27%), and CD34 (52%), which was in accordance with biphenotype acute leukemia (acute lymphoid leukemia > acute myeloid leukemia). She received remission induction therapy (cytarabine 200 mg/m2/day for 7 days, daunorubicin 60 mg/m2/day for 3 days) and then consolidation therapy (cytarabine 2 g/m2/day for 4 days, daunorubicin 45 mg/m2/day for 3 days). She eventually received an unrelated bone marrow transplantation. During following observation, she visited our breast clinic for a palpable mass in the right breast and was diagnosed with granulocytic sarcoma. We recommended chemotherapy but the treatment was delayed because of her financial circumstances. She was admitted with a headache 2 months later. Multiple brain metastases were identified by computed tomography (CT). She underwent salvage chemotherapy (imatinib 400 mg and hyperCVAD: cyclophosphamide 300 mg/m2/day every 12 hours for 3 days, vincristine 2 mg/day for 2 days, doxorubicine 50 mg/m2/day for 1 day, dexamethasone 40 mg/day for 8 days) but the disease progressed rapidly and she expired 2 months after salvage chemotherapy.