Granulocytic sarcoma of the jejunum diagnosed by biopsies during double‐balloon endoscopy before treatment (with video)

Abstract

A 56-year-old man was admitted to Saku Central Hospital as a result of repeated vomiting. He was afebrile and tender in the upper abdomen. Computed tomography showed an enhancing mass lesion (well contrasted by a radiopaque substance), 50 mm in diameter, arising from the small intestine and dilatation of its oral side. Double-balloon endoscopy (DBE) with oral approach revealed a circumferential tumorous lesion with obstruction (Fig. 1, left panel). Indigocarmine dye spray enhanced swelling villi of different sizes (Fig. 1, right panel). Biopsy specimens revealed diffuse infiltration of tumor cells, including mononuclear cells with polymorphisms and large nuclei with a few eosinophils (Fig. 2, left panel). Immunohistochemical tests revealed a definitive diagnosis of granulocytic sarcoma (GS) as a result of positive staining of granulocyte markers such as CD45 and CD68 (Fig. 2b, right panel). Bone marrow examinations revealed that the patient did not have leukemia, so he underwent surgical resection of the jejunum. Pathological diagnosis of the resected specimen was GS that invaded into the subserosa, and surgical margins were negative. The patient received adjuvant chemotherapy that comprised cytarabine and daunorubicin hydrochloride. He survives without recurrence 54 months later. GS is defined as a localized tumor composed of myeloid blasts and immature myeloid cells at an extramedullary site. The proportion of GS found in the small intestine was reported to be approximately 10% of all sites. GS typically occurs concomitant with or after the onset of acute myeloid leukemia. There has been only one case that was diagnosed by endoscopic biopsy before surgery. To the best of our knowledge, this is the first case that could be diagnosed by biopsy using DBE before surgery.