Gallium-67 Scan in Granulocytic Sarcoma (Chloroma) Dong-Ling You1, Mei-Ching Liu2, Yu-Chen Tsai3, Mei-Hua Tsou4 Departments of 1Nuclear Medicine, 2Medical Oncology, 3Radiation Oncology and 4 Pathology, Koo-Foundation Sun Yat-Sen Cancer Center, Taipei, Taiwan
Granulocytic sarcoma is an extramedullary tumor of
may include blastic, immature or differentiated cells depend-
myeloproliferative precursors and may involve multiple
ing on the level of myeloid maturation [1,2]. Granulocytic
sites of body. The role of gallium scan in patients with
sarcoma is a widespread disease and may involve orbit, nasal
granulocytic sarcoma is uncertain. This article demon-
sinus, paranasal sinus, facial bones, lymph nodes, breast,
strates the findings of gallium-67 scan on a case with
skin, central nervous system, respiratory, gastrointestinal or
granulocytic sarcoma that was proved by histopatholo-
genitourinary tracts [1-4].
gy and immunohistology. The gallium-67 scan revealed
Gallium-67 scan has been widely used to evaluate
multiple focal areas with intensively abnormal uptake of
malignant tumors, including malignant lymphoma,
gallium-67 in the ethmoid, right nasal, right maxillary,
melanoma, lung malignancy and soft tissue sarcoma [5-10].
bilateral neck, bilateral chest, mediastinal, abdominal,
However, there were only few case reports of using gallium-
pelvic and bilateral renal regions. The gallium-67 scan
67 scan to evaluate patients with granulocytic sarcoma in the
indicated the disease was widespread and suggested
literature [11-13]. The role of gallium scan in patients with
poor prognosis of the patient. This article delineates
granulocytic sarcoma is uncertain. We describe intense galli-
granulocytic sarcoma has high affinity for gallium-67
um-67 uptake at multiple regions in a case with granulocytic
and suggests gallium-67 scan has the role for the whole
sarcoma.
body evaluation of the extension of granulocytic sarcoma. Key words: granulocytic sarcoma, gallium-67 scan
Ann Nucl Med Sci 2001;14:125-128
Granulocytic sarcoma is an extramedullary tumor of myeloid precursors [1]. Because the cut surface of the tumor is greenish, granulocytic sarcoma is also called chloroma [1]. The histopathology of granulocytic sarcoma is variable and
Received 10/21/2000; revised 11/14/2000; accepted 11/21/2000 For correspondence or reprints contact: Dong-Ling You, M.D., Department of Nuclear Medicine, Sun Yat-Sen Cancer Center, 125, Lih-Der Road, Pei-Tou District, Taipei, Taiwan. Tel: (886)2-28970011 ext. 1110, Fax: (886)2-28971100, E-mail:
[email protected]
Case Report A 31-year-old male patient was a case of acute myeloid leukemia (AML) which was diagnosed at age of 18. This patient had received chemotherapy and radiotherapy for the treatment of AML, and the disease was complete remission after treatment. The patient, however, followed up irregularly at our clinic after the complete remission of the disease. Because of eye pain and neck masses, this patient admitted to our hospital again for further management. During this admission, physical examination revealed multiple masses in bilateral upper and lower neck regions. Magnetic resonance imaging (MRI) of head and neck revealed multiple tumors involved right ethmoid, left and right maxillary sinuses and also revealed multiple enlarged lymph nodes in the bilateral upper and lower neck regions (Figure 1).
You DL et al
Figure 1. Gadolinium enhanced T1-weighted MRI of neck showed multiple masses in the bilateral neck regions Figure 3. Gallium-67 scan: (A) anterior and (B) posterior whole body views on the 3rd day after injection show multiple gallium-67 avid lesions. (C)-(H) Anterior and lateral views of head, neck, chest, abdomen and pelvis on the 4th day after injection
formed on the 3rd and 4th day after intravenous injection of 6 mCi (222 MBq) of gallium-67 citrate. Bowel preparation with laxative agent was done before scanning. The whole body gallium-67 scan showed multiple focal areas with intensively increased uptake of gallium-67 in the ethmoid, right nasal, right maxillary, bilateral neck, bilateral chest, mediastinal, abdominal, pelvic and bilateral renal regions (Figure 3). These abnormal gallium avid lesions were correFigure 2. The histopathological examination (H&E, 400) shows extensive leukemic cells infiltration within connective tissue. The cells have ovoid nuclei with fine chromatin and eosinophilic cytoplasm
sponding to the orbit, facial bones, sinuses, lymph nodes, kidneys and soft tissues. The gallium-67 scan suggested a widespread disease involving bones and soft tissues. In spite of treatment, this patient died one month later
To determine the nature of neck masses, surgical biop-
after admission because of rapid progression of the disease.
sy was made on left neck mass. The histopathological examination showed leukemic cell infiltration with myeloblast predominant (Figure 2). The immunochemical stain was also performed and revealed the leukemic cells were strongly reactive with myeloperoxidase(DAKO, polyclonal), and leukocyte common antigen(DAKO, PD7/26) and CD43(Biogenex, MT1). Granulocytic sarcoma was confirmed by histopathological and immunochemical examinations. Whole body gallium-67 scan, using a dual-head gamma camera equipped with medium-energy collimators, was per-
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Discussion Granulocytic sarcoma can occur as a clinical manifestation of AML at relapse or as a manifestation of blastic transformation of myeloproliferative disorders [1,2]. It occurs in 2% to 14% of patients with AML [2]. Our patient was a typical case of AML relapsing with granulocytic sarcoma in neck and eyes. In view of widespread involvement, a simple diagnostic tool for the whole body survey of the extension of granulocytic sarcoma is necessary clinically. Gallium-67 scan has been proved to be useful in stag-
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-67 Ga-67 scan in chloroma
ing and post-therapeutic monitoring of malignant lymphoma
3. Neiman RS, Barcos M, Berard C, et al. Granulocytic sar-
and other malignancies [5-10]. The mechanism of gallium-
coma: a clinicopathologic study of 61 biopsied cases.
67 taken up by tumor is not quite understood. However it is
Cancer 1981;48:1426-1437.
usually believed that gallium-67 taken up by tumor may be related to its acting like as an analog of ferric ion [14]. It is
4. Wiernik PH, Serpick AA. Granulocytic sarcoma (chloroma). Blood 1970;35:361-369.
proposed that, after intravenous injection, gallium-67 is
5. Israel O, Front D, Lam M, et al. Gallium 67 imaging in
bound to the cell membrane of tumor by transferrin receptors
monitoring lymphoma response to treatment. Cancer
and then transported into intracellular cytoplasm. After moving into cytoplasm, gallium-67 mainly localizes in lysosome-
1988;61:2439-2443. 6. Hagemeister FB, Fesus SM, Lamki LM, Haynie TP. Role of the gallium scan in Hodgkin’s disease. Cancer
like granules in the cytoplasm [14,15]. It is reasonable to believe that granulocytic sarcoma
1990;65:1090-1096.
cell can take up gallium-67 because of its origin from
7. McLaughlin AF, Magee MA, Greenough R, et al. Current
hematopoietic system similar as malignant lymphoma. In
role of gallium scanning in the management of lym-
1980, Luddy et al. reported uptake of gallium-67 in the
phoma. Eur J Nucl Med 1990;16:755-771.
femur, pelvis, mediastinum and nasopharynx on a case with
8. Bekerman C, Hoffer PB, Bitran JD. The role of gallium-
granulocytic sarcoma [11]. Our patient was much more
67 in the clinical evaluation of cancer. Semin Nucl Med
prominent in intensity of uptake and lesions on gallium-67
1984;14:296-323.
scan than the patient reported by Luddy et al. Although the
9. Kagan R, Witt T, Bines S, Mesleh G, Economou S.
mechanism for the localization of gallium-67 in granulocytic
Gallium-67 scanning for malignant melanoma. Cancer
sarcoma cell is unknown, we believe that may be similar to
1988;61:272-274.
that of gallium-67 localizing in lymphoma cell.
10. Serafini AN, Jeffers LJ, Reddy KR, Heiba S, Schiff ER.
Delineating the extension of the disease is necessary
Early recognition of recurrent hepatocellular carcinoma
because patients with widespread granulocytic sarcoma has
utilizing gallium-67 citrate scintigraphy. J Nucl Med
poor prognosis [3,4]. The patient reported by Luddy et al.
1988;29:712-716.
died 8 months later after diagnosis. Our patient, with much extensive involvement on whole body gallium-67 scan than
11. Luddy RE, Levy BE, Schwartz AD. 67Ga scintigraphy in granulocytic sarcoma. Cancer 1980;46:1357-1359.
that reported by Luddy et al., died 1 month later after diagno-
12. Caner BE, Mezaki Y, Suto Y, et al. Scintigraphic and
sis. One of the advantages of gallium-67 scan is whole body
MRI studies in a patient with granulocytic sarcoma
survey of the disease extension in a scanning. Our study sug-
accompanied with CML and myelofibrosis. Radiat Med
gests poor prognosis should be considered in patients with widespread disease revealed by gallium-67 scan.
1989;7:165-168. 13. Pui MH, Fletcher BD, Langston JW. Granulocytic sarcoma in childhood leukemia: imaging features. Radiology
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