Abstract
BackgroundExtramedullary leukemia, also known as myeloid sarcoma, is a rare form of acute myeloid leukemia and often accompanies bone marrow involvement. Myeloid infiltration of the thyroid gland is extremely rare. Here, a unique case in which thyroid cancer tissue was infiltrated with myeloid cells is presented.Case presentationWe present a case of thyroid papillary cancer infiltrated by blastic cells and bilateral breast and axillary myeloid sarcoma in a 30-year-old Caucasian female patient with a history of osteosarcoma and MDS-RAEB2. The patient firstly received 6 cycles of chemotherapy for osteosarcoma, and allogeneic hematopoietic stem cell transplantation was performed after anthracycline-based chemotherapy due to MDS-RAEB2. The patient remained in remission on follow-up in terms of both osteosarcoma and MDS-RAEB2. Malignant features (Bethesda VI) were observed in the fine needle aspiration biopsy performed from a newly developed firm, fixed thyroid nodule approximately 4–5 cm in length in the left thyroid lobe. Because of the Bethesda VI thyroid nodule, the patient underwent total thyroidectomy. In the pathological evaluation, CD34-, CD117-, MPO-, and HLA-DR-positive blastic cells which infiltrated into follicular variant papillary thyroid carcinoma were detected. In the evaluation performed due to blastic cell infiltration, multiple lesions showing increased 18-fluorodeoxyglucose activity in bilateral breast and axillae were detected. Myeloid sarcoma was found as a result of tru-cut biopsy from these lesions. A fungal cystic lesion was detected in the frontal region of the patient who developed altered consciousness after the second cycle of treatment of myeloid sarcoma. During her follow-up in the intensive care unit, she died of cranial septic embolism and acute infarction.ConclusionsHere, we present a very interesting case that is the first. A staged approach to diagnosis with methods including immunohistochemical staining, radiological imaging methods, and cytogenetic and molecular analyses can help make the definitive diagnosis.
Highlights
Extramedullary leukemia, known as myeloid sarcoma, is a rare form of acute myeloid leukemia and often accompanies bone marrow involvement
Diffuse staining with CD34, as well as less frequent staining with myeloperoxidase (MPO) and HLA-DR, was observed in these blastic cells. Considering all these findings, the nodule in the left lobe was defined as a stage II (T3aN0M0) follicular variant of papillary thyroid carcinoma (PTC) (FVPTC) with focal anaplastic differentiation areas and blastic cell infiltration (Fig. 2)
The tru-cut biopsy performed from bilateral breast and axillary lesions showed diffuse blastic cell infiltration
Summary
The papillary thyroid carcinoma (PTC) is characterized pathologically by papillary architecture and typical nuclear features of chromatin pallor, nuclear enlargement, grooves, and pseudoinclusions. In FDG-PET imaging, a 2 × 1.5 cm lesion showing increased FDG uptake (SUV max 3.9) in the lower outer quadrant of the right breast (Fig. 1a) and a lesion showing increased FDG uptake (SUV max 5.7) in the left thyroid lobe were observed (Fig. 1b). Diffuse staining with CD34, as well as less frequent staining with myeloperoxidase (MPO) and HLA-DR, was observed in these blastic cells Considering all these findings, the nodule in the left lobe was defined as a stage II (T3aN0M0) follicular variant of PTC (FVPTC) with focal anaplastic differentiation areas and blastic cell infiltration (Fig. 2). The tru-cut biopsy performed from bilateral breast and axillary lesions showed diffuse blastic cell infiltration. Diffuse staining with CD34, CD117, MPO, and HLA-DR was observed in these blastic cells These results were evaluated in favor of myeloid sarcoma (Fig. 3). In the follow-up of the patient in ICU, who responded to the current treatment and suddenly developed bilateral vision loss and brain MRI showed multiple septic embolism foci and acute infarct foci in the right cerebral hemisphere and occlusion in the right internal carotid artery, the patient died in ICU due to multiple organ failure
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