Granulocytic Sarcoma (Chloroma)

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1970 35: 361-369

Granulocytic Sarcoma (Chloroma) PETER H. WIERNIK and ARTHUR A. SERPICK

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Granulocytic By

PETER

Sarcoma H.

WIERNIK

(Chioroma)

AND

A. Sriipici

ARTHUR

E

XTRAMEDULLARY SOLID TUMORS of early myeloid of monocytoid precursors are a rare but well-documented variant of acute myelocytic leukemia. Originally the term chioroma was applied to these tumors because of their green color. However, because such tumors often have no distinct coloration

the

appears This

granulocytic

term

to be report

otherwise

sarcoma

more appropriate.1 describes four

typical

myelocytic

many months before sarcoma or eosinophilic between

granulocytic

leukemia

are

the

has

cases

of

In two

disseminated granuloma

was reticulum

Case

prior

slowly

to

admission

enlarged

over

l)y the

refused in

( USPHS

1 : MAD.

lesion

diameter.

patient.

A

needle

the blood

Peripheral

woman.

was

The

hematocrit

white

cell

count

morphonuclear

The

associated

the

tumor

solid

and with appeared

a diagnosis of reticulum cell The possible relationships

sarcoma

and

acute

myelocytic

next

month

lesion

enlarged,

22

per

82

per

cent

neutrophilic

cent,

lesion, white

cell

of

Auer

was to

acute

in

cell

count

rods

were

noted

color,

and

a

became

on

obese the

right

a differential

6 per of

and

white,

with some

blood

leukemia

and

in

but

A complete

5700/mm.3 lymphocytes

The 2 cm.

was noted unremarkable.

cent

until

approximately

revealed

per

well cheek.

recommended,

myelocytic

diameter

was

right

sarcoma.

examination

4 cm.

12

her

a greenish-brown

examination blood

apparently

on

increased

reticulum

Physical

myeloblasts,

was

surgery

lesion

acquired

physical

granulocytes.

time

a diagnosis

hospital.

of the

was of

the as

greenish-brown

remainder

which

month

revealed this

woman, a “blackhead”

at

interpreted

studies to

35-year-old

developed

next

was

REPORTS

),a

101 she

the

transferred

1 ) . The

( Fig.

the

cheek

A maculopapular,

cheek

239 when

biopsy

papular.

patient

No.

During

count was normal. Ten months later the

cell

Rappaport

sarcoma

patients

disease, and entertained.

by

discussed. CASE

10 months

suggested

granulocytic

leukemia.

sarcoma,

been

the

cent

poly-

myeloblasts.

bone

marrow was markedly hypercellular with no megakaryocytes and 99 per cent of cells were myeloblasts. Biopsy of the cheek lesion was interpreted as granulocytic sarcoma. The patient was treated with a drug regimen consisting of 6-mercaptopurine, methotrex-

the marrow

ate,

prednisone

and

pletely regressed the granuloc’ytic be made. Four began

to reappear,

with

a complete

lesion.

\Ionthlv

From Research

First PETER

Baltimore, Research

BLOOD,

the

vincristine.

but

peripheral

Medical

submitted

months

blood

hematologic bone

Center,

Four

and the patient was sarcoma was biopsied months after complete

and

Service,

Baltimore,

bone

The

peripheral

National

admission

Cancer

marrow

patient blood

institute,

the

cheek

lesion

had

corn-

hematologic remission. The area of and no pathologic diagnosis could obtained, the granulocytic sarcoma examination

refused studies

were

still

radiotherapy were

Baltimore,

done

Md.,

compatible

to and

and

the five

the

cheek months

Cancer

Md.

3, 1969; accepted for publication October 10, 1969. M.D.: Senior Staff Associate, NCI, Baltimore Cancer Research A. SERPICK, M.D.: Chief, Medical Service, NCI, Baltimore Baltimore, Md. July

H. \VIERNIK, Md. ARTHUR Center,

VOL.

and

remission.

marrow

after

in clinical and during remission remission was

35,

No.

3

(MARCH)

1970

Center,

Cancer

361


362

WIERNIK

AND

SERPICK

1.-Cheek

Fig.

gran-

ulocytic sarcoma of patient M.A.D. Biopsy of lesion ously

performed at referring

pital.

Lesion

previhos-

was

dull,

greenish-brown

color;

measured

4-cm.

diarne-

ter.

after

the

reappearance

relapse.

At

this

lesion, 3 cm. maculopapular was

of

time,

the

the

in diameter, lesions 1-2

294,0O0/mm.

granulocytic

with

98

lymph

liver,

spleen,

nodes

were sarcoma.

granulocytic

upon

sectioning

of

acute

from

In

three

no

months

chemotherapy was

and

No.

vealed

her

20

to

nation

were

be

hospital

for

50

per

was 80

cent cent

of

sarcoma

The 31st

patient hospital

the

evaluation

per

nodule

and

revealed below

the

16,500/mm.3 cent

18

per

The

platelet

a

and

devoid

cells.

A diagnosis

the

breast treated

(lay

she

was with became

upon

resulted detectable

of

sepsis

myelocytic

who An

during leukemia

three

weeks

excisional

and

re-

examination,

bone

patient

prior

biopsy

histological

smear

surgical

incision

margin.

marrow

exami-

referred

was

white

cell

of

was

to

right

this

cent A

and

31

per

cent,

of

26

per

cent

progranulocytes, bone

and

marrow

Myeloblasts myelocytic

breast

was

count

4 per

92,000/mm.3 acute

the

hematocrit

differential

megakaryocytes. of

in

The

lymphocytes,

count

hypercellular

was

which,

costal

cent

the of

cm.

healing right

with

bands,

nucleated

breast.

The

diagnosis

sarcoma.

right blood

visceral color

therapy. a recent

2 cm.

died

woman,

in her

leukemia.

the

clinically

acute

a granulocytic

A peripheral

myelocytic

periaortic of

remission

patient of

40-year-old

0.5

x

The

with

infiltration

before

it became

diagnosis

of

),a

245

1.0

but

per

died

to air.

months

hematologic

left,

the

patient

no evidence a greenish-brown

had

count 100

enlarged

was

10

similar cell

leukemic

of exposure

occurred.

appearance 269

tumor

acute

was

after

sarcoma.

myeloblasts.

markedly per

cytic

the

two

sarcoma

peasized

of

hours

three

blood

the was

of similar

contained

and

there

complete

relapse

No.

a granulocytic

diagnostic further

the

were

white

nonpigmented

appeared

When

months

after

firm

Physical examination the liver edge palpable white blood cell count neutrophils,

14

a small

several

made.

hematologic

relapse,

grayish-green,

proved

after

autopsy

diagnostic

a smaller

marrow

process. There of the cheek

sarcoma

of

( USPHS

noticed

a

evidence

months

2: J.T.M.

admission

change

The

the

Some

and there

sternum.

At

leukemic sarcoma

was

before

for

made

Case

not

addition,

again

were

diameter

bone unsuccessful

kidneys.

granulocytic

leukemia

chemotherapy,

again

to

did

In

and

admission.

granulocytic

in

the

was

and

the

iii

case

myelocytic

after

studies

8 cm. it.

over

myeloblasts

lungs

involved The

this

below

chemotherapy days

these

was

diameter

cent

jejunurn,

which

Comment:

just

in

per

myeloblasts. Reinduction Pscudomonas septicemia 20 the

sarcoma

appeared cm.

cent of

sarcoma

granulocytic

aspirate

accounted

leukemia

with

for granulo-

made. hydroxyurea febrile

and and

daunomycin

hypotensive

but and

died

showed the

no next

response. day.

On


SARCOMA

GRANULOCYTIC

Autopsy No

revealed

tumorous

Comment: discovered died

leukemic

masses

or

In this

patient

one

month

363

infiltration

green

of

the

pigmentation

typical

simultaneously.

No

liver,

were

acute

spleen,

myelocytic

response

to

bone

marrow

and

right

breast.

apparent.

leukemia

and

chemotherapy

was

a breast

chloroma

obtained

and

were

the

patient

postdiagnosis. L.J.J. ( USPHS a diagnosis of

Case No. 3: 29, 1967, with and

(CHLOROMA)

hepatomegaly

were

No.

263

acute

noted

on

123), monocytic

a 28-year-old leukemia.

woman, was Mild generalized

physical

examination,

as

well

admitted November lymphadenopathy as

moderate

gingival

hypertrophy.

The

patient

remission.

She

attempt

treated discharged

to maintain

Seven

and

admitted

in

diagnosed was

Three

chest Six to

the

21st

months

in the

left

of

the

therapy

she

lesion

days

after

anterior

and and

achieved

weekly

a

complete

methotrexate

in

an

complete

retreated day.

No

was

remission

with

daunomycin

achieved, and

maintenance

the

patient

complete

chemotherapy

was was

remission

was

given

and

chest

wall.

the

patient L.J.J. subcutaneous.

complete the

time were

in

remission

completely

that its

patient

the

mass

the

left

anterior

subcutaneous

mass

3 cm.

in

Physical diameter

noted was

the

20th

hospital

day,

recurrence 1 X

of

the

parasternal

1 cm. in diameter. (400 R. in one

which

mass

Peripheral week)

time

the

and blood

to

the

returned and

bone

granulocytic

regression. for

a month

after

which

bone

marrow

examination

wall

sarcoma

by

clinically.

Radiotherapy

complete stable

on

resolved

normal.

remained

2.-Chest

granulocytic

in

examination

in

had

examination resulted

a mass nonmovable

intercostal space just lateral to the sternum ( Fig. 2 ) . The was unremarkable. The white blood cell count was a white cell differential count including 27 per cent immature monocytes. contained 90 per cent monoblasts. chest wall mass was interpreted as granulocytic sarcoma. Again, dauno-

At

patient

of

nontender,

second

physical

discharge,

hospital.

Fig.

daunomycin

6-mercaptopurine

complained

a firm,

resulted

wall

sarcoma

after

was

hospital

later

revealed

marrow

The

months

She

24,400/mm.3 with The bone marrow A biopsy of the mycin

and

daily

remission.

one-half the

hydroxyurea on

discharged.

examination remainder

with

her

relapse.

on

patient

located

was was

of

Lesion

t

showed


364

WLERNIK

62

per

cent

monoblasts.

therapeutic days

after

the

the

last

acute monocytic hepatosplenomegaly. dermatitis, but

marrow

of

whereas

months

of

was

sarcoma

acute

were

normal

at that

rapidly

progressive

became

diagnosed,

latter

and

life.

anterior

13-3i

made

time. after

autopsy

no

former

the

complete

regression

evidence

of

the

of

months

after

the

only

sarcoma

a one-week

lesion

granulocytic

21

hemorrhage and mild radiation

Although

gave

of

died

diagnosis

11-3

patient.

multiple she

the

developed

this

SERPIcK

Despite and

months

wall in

radiotherapy,

in

At

chest

was

and

resulted

patient’s

the

leukemia

chemotherapy

the

the

of

monocytic

to both

ponse,

studies

leukemia

relapse

Granulocytic

diagnosis

responded

blood

patient’s

leukemia. Autopsy revealed massive bilateral pulmonary Examination of the anterior chest wall revealed no gross or microscopic evidence of granulocytic sarcoma.

Conment: the

Peripheral

measures,

AND

for

the

sarcoma

retwo

last

was

found.

Case No. 4 : J.R.J. ( USPHS No. 267 909), a 44-year-old woman, was first seen at the Baltimore Cancer Research Center in June 1968 with a history of left hip pain radiating to the lateral aspect of the thigh for 1 1 months. In early January 1968, the patient had a gran(l mal seizure and was admitted to another hospital. An osteolytic lesion in the left ilium

just

was

above

the

performed

Histologic was A second

examinations

CSF received she

biopsy

no to

patient

was

normal.

cells

and

rads

to

5000

began

referred

of

hemogram

right

was

normal.

frontal and right A bone marrow iliac

left occipital

hip.

1250

20,

pain free

which

this

pain

area

found.

etiology in

for

the

the

left

examination

of

There

physical

the

of

of

the

was

at

which

time

of

her

vision.

The

mild

revealed

pain

on

was

metastatic

survey and

medical

normal. of

tumor

bilaterally,

mm. patient

1968,

involvement

skeletal

femur

290

examination

widespread

suggestive

of the

examination

A radiographic

head

May blurring

Physical

revealed

areas,

pressure

hospitalization

until

blood pain

barely

perceived

nodes

were

and

in both

to

The the

the

revealed

the

left

brain.

massive

medial

aspect

of

hematoent polymorphonuclear

cent

monocytes.

yielded

markedly cells

rads

marrow

studies

during

final

admission

Multiple

examination

firm was

1 x

tenderness

per

cent,

white

neutrophils,

myeloblasts.

10

count

was

marrow A

lumbar

the

was

weakness

49,000/mm.3 with

left

no puncture

A

bilaterally.

Repeated

optic and

60 sternal

bilateral

in

no

of which

she

greater hand

and per

and

20 per

marrow

colorless

had

and

axillary

left

myeloblasts bone

she

femoral the

Ninety clear,

time atrophy

left

grasp

megakaryocytes. yielded

grand and

5200/mm.3,

lymphocytes,

severe

phenobarbital

and

ilium of

by Several

at which

bilateral

cell count cent

knee.

supraclavicular

over

blood per

left

to the August

normal.

1968,

revealed

1 cm.

and

were

patient

on

necessitated

hip and

time

the

discharged

admissions

in November

three

time

administered

was

diminished

this

was

this

were

She

diphenylhydantoin progressively

physical

knee.

the

acuity

Her

platelet

left

to

of

Visual

32

the

radiotherapy

administration

hypercellular were

hundred

right

There

The

to

hip was painful. There of the left forearm.

was

were

Fifteen

rads

intravenously

During

received

hips.

palpated.

knee.

900

administered

status.

and

light.

left

and

was resulted.

with no change in her visual course was one of multiple

bone

The right extension

marrow

and

mg/rn.2,

improvement

but

the

fourth

no

left,

she

to

20

but

the

occurred.

patient’s

severe

The

pain

led

trochanter. flexion and

well

the

scan

normal.

the

hips

to

subsequent

seizures

peripheral

No

opening this

bilaterally. of

brain

an

evaluation.

hemorrhages

weeks

in both of

seizures

The

seven

rads

The patient’s bone pain for further

was

severe

microscopic

intermittent

further

(BCNU),

for

developed right hip,

mal

of

4 cm.

crest.

a week

1968,

biopsy X

of

During

relatively

remainder

and

cent. with

for

was

ilium

and

revealed

per did

parietal

Bis-chlorethyl-Nitrosourea times

She

isotope and

3

complained

performed

headaches

The

examination the

mg.

hospital

An

open

granuloma.

again

puncture 40

fundic

frontal

of

the right

the

thigh.

was

lumbar of

this

eosinophilic

she

An

measuring

of cells were myeloblasts and progranulocytes. A radioisouptake in the left frontal region and an electroencephaloin the same area. Bone marrow and peripheral blood

left

numerous

the

involvement

A

to

and

rotation

area

x-ray.

tumor

of

1968,

this

protein

develop

papilledema

of

on

colorless

February

that the majority showed increased a focal disturbance

were

with

demonstrated

a diagnosis

In

open

was

gelatinous,

yielded

determined.

tumor disclosed tope brain scan gram recorded

head

a soft,

examination

seizure hip.

femoral

and

cent

10

per

aspiration cent fluid

of

the

with

39


GRANULOCYTIC

young

SARCOMA

mononuclear

glucose

and

ingeal

leukemia

The in

cells

patient

her

domonas days

later

per

cu.mm.

A diagnosis

of

of

acute

cerebrospinal

fluid.

myelocytic

Protein,

leukemia

with

men-

4600

rads

was

she

becase

aeruginosa

and,

to

the

given

in

severely

despite

posterior an

pelvis

attempt

leukopenic

and

appropriate

with

to

considerable

induce

hematologic

febrile.

Blood

antibiotic

improvement remission,

and

grew

Pseu-

cultures

therapy,

the

patient

of

Rolando

died

several

later.

At autopsy, was approximately similar

in

Several

two

cut

size

and

out

tumor

and

mediastinal The

cells

was

life

but

granulocytic

and

acute

the

of the

sheets

floor

of

femurs

a and

the

early

myeloid

and

orbital

cells

color

bones

the

on

secondfemur

with-

dural

including which

masses

eosinophilic were

sarcoma.

compatible

fossa.

green of the left and spleen

of

granulocytic

hypercellular

Each lesion

pelvic

cavity liver

granules

with

noted.

A third

left

dull

examination

neutrophilic

compatible

3 ).

the

had

The medullary infiltration of

of

were

( Fig.

and

Microscopic

woman At

this

the

the

bone and

the

patient

myelocytic

leukemia,

of

Autopsy

myelocytic

leukemia. to

extensive

The

year

and acute

acute

bone.

then

which

bilateral

marrow of

also

course

next

pain

peroxidase A

with

of

peripheral

a

section

of

diagnosis

of

gram

and

17

months

revealed cavities

of of

were

moderately

of

was

after most

of

first one

the

was

month

clinical orbital

involved

last

entirely

There one

to

the

were

made.

the and

of

responsive Until

sepsis

dural

visual

appearance

examinations was

sar-

interpreted

decreased

the

developed.

negative

two

granulocytic

hip

complained

blood

of

left

consisted

leukemia

died

to

the

blindness

myelocytic

meclullary

secondary

a biopsy

patient

Her

sarcoma

secondary

later

progressive

a diagnosis

chemotherapy, of

time

over

of

months

noted.

time

multiple

complained

Six this

lesions

terminally

diagnosis

of

of

noted. leukemic

contained

death. was

bony

of her to

color

enlarged

cavities

markedly

her

During

response

were

was

44-year-old

painful

fibrotic

picture

papilledema

radiotherapy.

the

disclosed

the

granuloma.

and

normal,

periosteum

pigmentation.

nodes

before

eosinophilic

month

the

were

of

fissure

pea-green

nodes

diffuse

Many

right

dull,

medullary

lymph

This months

multiple

a

leukemia.

Comment:

acuity,

green

marrow

myelocytic

the

chemotherapy There was

histologic

bone

17

from

of

or

metamyelocytes.

coma

arose

the

had

lymph

and color.

formation

vertebral

and

Necrosis

to radiotherapy a light green

overlying

4 cm.

color

surfaces.

positive.

masses

X

mediastinal

ary had

acute

dural 3

superior

their

as

lymphocyte

normal.

made.

Daunomycin

days

one

were

received

pain.

several

and

muramidase was

365

(CHLOROMA)

no after

evidence chloromas bones

were

radiotherapy.

DIscUssIoN The

details

Table

3.-One

Fig.

ral

sar-

discovered

mortem

J.R.J.

post-

in

patient

Tumor

pea-green grossly

of du-

granulocytic

comas

tion.

of the

1.

was in

and

on

dull, color

cut

sec-

patients

reported

in the

present

series

are

summarized

in


366

WIERNIK

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SERPICK


GRANULOCYTIC

The

( CHLOROMA

SARCOMA

first

reported

case

)

367

of chloroma

was

probably

that

of Burns,2

who

in 1823

described a patient with proptosis and green retroorbital tumors. King3 was the first to use the term chioroma in describing a similar patient thirty years later. Dock4 established the relationship of chloroma to acute leukemia; however,

he

Turk5

thought

the

disagreed

with

predominant

and

chloroma

cell

reported

and

the

suggested

of

first

the

case

that

the

tumor

was

of

of myelocytic tumor

lymphoid

origin.

leukemia

cells

were

associated

the

same

as

the

leukemia

cells. Virtually all cases of chloroma reported since then have been shown to be associated with myelocytic or monocytic leukemia. The most common presentation of chloroma is that of a green orbital tumor with resultant proptosis in association with acute myelocytic or occasionally acute

monocytic

adults

and

leukemia.6

has

been

The

reported

tumor

in the

is more

common

newborn.7

The

in children

vast

and

majority

young

of chloromas

occur in the subperiosteal region of the bone, with skull, sternum, ribs and proximal portions of long bones being common sites of involvement.”’8’9 It is thought that the tumor arises from the bone marrow and traverses the Haversian canal

to reach

but

have

and

rarely

harbor

found

do

thyroid,

thymus,

lesions.8

Patches

and

spleen.1

Greenish

case

of acute

of chloroma

than

is absent

from

granulocytic

term Usually,

lung,

may

characteristic

sarcoma’ leukemia and

and

be

a more

appropriate are diagnosed

bladder

been

in an

common

found

otherwise

presentation

distinctive

chloromas,8’9’

is more chioroma

have

marrow

Often

common

dura,8’9’141#{176}

urinary

tissue

bone

formation.915

are less

nodes,6’#{176}and

intestine

of the

leukemia

tumor

to bone

lymph

of chloromatous

coloration

histologically

acute

unrelated

stomach,

or nodules

myelocytic

discrete

the

Chioromas

in ovary,9’1#{176}breast,9’1113

such

in liver typical

the subperiosteum.9

been

pigmentation

and

for

that

reason

than chloroma. simultaneously,

as in our

Case 2.6,89,11 Rarely, chloroma precedes acute leukemia by less than one month to over a year,8’9’16’2#{176}as in Cases 1 and 4 of the present series. Granulocytic sarcoma

The tients

late

occurring

apparently

very

survival with

in

the

of patients

acute

with

myelocytic

probably uniformly appeared.17’18 Tumor documented16’17’19 1 and 3 responded induced regression Granulocytic

course

of

acute

granulocytic

leukemia

tissue

The

by

fatal; only response

with

hydrogen

storing

the

cause

of the

study.

found

it to be

for the

color

as

our

Case

green

green

of the

3,

is

appear

green

and

in

white

may

be

preserved

is

contrary has been

light,

green color usually is intensified by restored in formalin

of pa-

disease

have well

of

Cases Drugreported. and

often

fades upon exsuch exposure.2’ fixed tissue by

temporarily

in fresh

in glycerin.8

color

and

isolated in color tumor.

The

in our Cases 3 and 4. The tumors but only temporarily to chemotherapy. sarcoma has not been previously

peroxide

Agner22

to that

formation.6

questionable reports to the to localized external irradiation

usually

tissue

is similar

tumor

two

and occurred completely, of granulocytic sarcomas

much

such

sarcoma

without

fluoresce red with ultraviolet light.2’ The posure to air,8 but occasionally the color The faded green color can be temporarily treatment

leukemia,

rare.

crude and

Amano23

red

fluorescence

has

myeloperoxidase

suggested suggested

that that

been from

this

enzyme

porphyrins

the

subject

leukocytes was

responsible

were

responsible

of and


368

for

the

tumor’s

red

color

was

due

work

of

Schultz

has the

fluorescence.

Zeldenrust,

to protoporphyrins. and

Rosenthal25

a green color and fluorescent material

et al.24

The

problem

who

found

a red fluorescence as porphyrins

apparently Chloromas

that

are not readily recognizable as belonging to the granulocytic negative. identification encountered is apparent.

Under cell

depending

such

on

the

with that

acute

typical cell It

the

myeloperoxidase

light. They the enzyme

identified myeloper-

complex. This enzyme has the oxidation of amino acids and neoplastic granulocytes uniform,

are

variants

cell sarcoma, more malignant commonly

cell

occurs form

occurs

as

pathologist

primitive

cells

tumor

cells.

myeloid leukemia.32 of the orbit is reticulum

are

sarcoma, of the same

primarily of the

fact

that

a widespread

formation. sarcoma,

Intermediate a phase of the

diffuse

infiltration

generally

1 and with

4,

these

cell sarcoma terminating sarcoma developing in It has cell

infiltrative

monocytic leukemia cell sarcomas assogranulocytic

sarcomas myelocytic reticulum

solid tumors. or monocytic

malignancy

these where

in the

been said that the most sarcoma, and two cases

sarcoma, and acute One form of the disease, or multiple myelocytic

between spectrum

a diagnosis Cases

is interesting

nonpigmented

granulocytic disease.

as a single disease, acute

tumor ulocytic

It

associated with acute that many reticulum

in

suggest

as in our

of reticulum reticulum cell

sarcoma is possible

may

granuloma,’7

the

reports or

leukemia

reticulum

leukemia

of

to review leukemia27-3’

reticulum reported.3’

the

or eosinophilic

maturity

of otherwise lymphosarcoma

of orbital have been and

green by

hematoxylin and eosin stained sections The cells may be perioxidase positive or

circumstances

sarcoma

thoughts in mind acute myelocytic

ciated

the

Rappaport’ maintains that a definite diagnosis must be based on the of such cells in the blood and marrow. The diagnostic difficulty when nonpigmented granulocytic sarcoma precedes acute leukemia

of reticulum

course common

SERPICK

resolved

crystalline

studied.26 of relatively

in routine series.

that

to be

under ultraviolet postulated that

and

similar in all aspects are usually composed

proposed

appears

oxidase may be derived from a porphyrin protein a molecular weight of about 160,000 and catalyses by hydrogen peroxide.26 The enzymes from normal are

AND

WIERNIK

Another leukemia,

without

two extremes solid tumors

discrete

may be granand widespread

coexist. SUMMARY

Four patients with granulocytic sarcoma are described. Granulocytic of the cheek occurred in one patient 10 months before the diagnosis myelocytic leukemia could be made. Another patient had multiple dural granulocytic sarcomas 17 months before she developed acute

leukemia. leukemia

One

patient

diagnosis

granulocytic kemia. The to antileukemic a permanent

had

a breast

simultaneously,

sarcoma 11-% months cheek and chest wall

granulocytic

sarcoma

and

patient

a fourth

after the granulocytic

chemotherapy but subsequently complete remission of the chest

sion of the bone The possibility

granulocytic that acute

sarcomas myelocytic

diagnosis sarcomas

and developed

acute

sarcoma of acute bone and myelocytic myelocytic a chest

recurred. Radiotherapy wall sarcoma, and partial

in another leukemic,

wall

of acute monocytic leuresponded completely

case. granulocytic

sarcoma

effected regresand


CRANULOCYTIC

cell

reticulum

369

(cHL0R0MA)

SARCOMA

sarcoma

are

variations

of

the

same

disease

is suggested

and

discussed. REFERENCES 1.

Rappaport,

H. :

thology.

Sec.

Institute

of

III,

Atlas

of

Fasicle

Pathology,

p.

3.

J. Med. to

l’extremite

Forces

traite

D.C.

de

on the Surgical Neck. Baltimore,

Sci.

of

chloroma.

(London)

Dock,

7:97,

C. : Chloroma

leukemia.

Amer.

J.

20.

its

Med.

ing

relation

Sci.

106:152,

mit

Turk,

W. :

Acute

Grunfarbung

Gesellach. 6. Ross, kemia.

7.

der

F. Med. R.

J. Dis.

Brannan,

D. :

Hosp.

9.

Bull.

Kojima,

21.

Reardon,

C.,

M.,

chloroleu-

Enzym. 23.

with

58:332,

1939.

Johns K.,

78:812,

1959.

11.

Blackwell,

B.:

senting

as

a

lump

50:769,

875,

in

the

breast.

Obstet.

A.

Studien

chloroma.

uber

Arch.

Heilk.

13.

Simon,

W.

malignant

tumor

Wehnschr.

49:839,

14. study

two

38:22,

1942.

15.

Myelogenous

) with of

the

the

picture

breast.

a

KIm.

and

chloromas.

Brmndley, and leukemia

Texas

P. :

A in-

Filip,

0.,

and

Bednar,

B.:

Chloroma

Neoplasma

roma.

J.

B.,

and

Neuropath.

Tmnsley,

Exp.

M.:

17.

Washburn,

Chloroma

Child. 18.

vs.

Neurol.

A. H.,

and

granuloma.

104:126, Lecene,

cell Marin-Padilla,

Dittes, Amer.

W.

J.

1962. M.

P.:

L.: Dis.

nating

in

Path.

41:402,

29.

Cancer

cas

de

“chloroma”

cell

coma.

Iron

J. T.,

J.:

Sznajd,

4:540,

leuco-

1968.

development

of acute

in

with

a patient

Ann.

re-

Intern.

Dariush,

40:

F.,

and

reticulum

cell

cell

sarcoma

leukemia).

termi-

J.

Amer.

Clin.

and

E.:

in acute

1960. Crode,

H.

reticulum

E. : Granucell

sarcoma.

1967. A. :

Orbital

monocytic Arch.

J.

myeloid

J. Clin.

J.

Ultmann,

terminating

and

20:545,

cases.

and

15:277,

J.,

leukemia

Howell,

L.,

sarcoma

Blood Laszlo,

with

Chronic Un

and

Leukemic

J.

Zeifren,

Mortada,

two

S. :

1964.

31.

32.

C. :

acute

sarcoma of

the

87:

leukaemic

M.,

( Reticulum

9:186,

of

geneesk.

J.,

lymphoma.

sarcoma

30.

1950.

Nota,

cause

Stelmaszynska,

human

leukemia

leukemia.

Chlo-

C., and

Rosenthal,

E. : The

W.

locytic A.

4:25,

myeloperoxidase.

J. Biochem.

Europ.

28.

13:525,

1966. Ragins,

Sci.

1959.

of

Reticulum

chloroleukemia. 16.

W.,

Maloney,

J. Med.

State

and

J. M., Naskaiski,

Zgliczynski,

ticulum 127.

chloroof

Berlin

anatomy

tydschr.

234:2486,

myelogenous

1912.

Griffin, L. L., of lymphosarcoma

eluding

and

V. :

( chloroma

the

of

27. Beutler,

19:129,

W.

and

J.,

Schultz,

Myeloperoxidase

so-

1878.

leukemia

1961. Advances

J., Vees,

inactivation

Ostrowski,

J.

das

108:864,

J. Med.

Nederl.

Chem.

cyte.

C. :

C.: neo-

1943.

Biol.

preBrit.

Dis.

W.

pathological

Jap.

: Chloroma

color.

( II )

B.:

1963.

Huber,

genannte

diseases.

green

Med.

leukemia

J.

Maloney, Med.

S. : The

Zeldenrust,

26. Acute

as a presentAmer.

1943.

Amano,

25.

Gynec.

12.

24.

1963. P.

leukemia.

myeloblastic

Intern.

3:137,

and blood

1939.

Dazai,

J. Exp.

leukemia.

W.,

K. : Verdoperoxidase.

blood

Hop-

and

A. acute

and

related

Arch. Agner,

J. H. W.

10. Hinkamp, J. F., and Szanto, Chloroma of the ovary. Amer. J.

Surg.

of

1926.

Kikuta,

and

plasmas.

nat.

preceding

leukemia.

1964.

22.

Fayen, of

acute

108:62,

1903.

leukemia

Chioroma.

of

Child.

1955.

Child.

38:189,

A. : Tumor-forming 81:256,

and

18:671,

M. : Congenital Amer.

Mitt.

2:39,

R. : Chloroma

Morrison,

8.

Knochenmarks.

Soc.

1965. J. M. : Chloroma

Lusher,

Chloroma

Leukamie

Kinderhk.

J. Med.

Amer.

chloroma. kins

myeloide

E.,

evidence

feature

1893. 5.

D.

P. : Myeloblastoma 18:253,

l’humerus

entendue. 1927.

Comings, marrow

1853. and

de

resection

53:1328,

Cancer

Monthly

le

chir.,

and A. : Case

susperieure

par

19. Carter,

386.

King,

4.

de

Pa-

Washington,

2. Bums, A. : Observation Anatomy of the Head and 1823,

Tumor

8, Armed

Ophthal. S.,

and

leukemia

Path.

reticulum leukemia.

16:432,

67:572,

Whitfield, with

1963.

cell Report 1962.

G. W.: lymphosar-