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Diffuse Pleural Myeloid Sarcoma Mimicking Malignant Mesothelioma

  • Aisheng Dong
    Affiliations
    Department of Nuclear Medicine, Changhai Hospital, Second Military Medical University, Shanghai, People's Republic of China
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  • Chong Bai
    Affiliations
    Department of Respiratory Medicine, Changhai Hospital, Second Military Medical University, Shanghai, People's Republic of China
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  • Changjing Zuo
    Correspondence
    Corresponding author. Address for correspondence: Changjing Zuo, MD, Department of Nuclear Medicine, Changhai Hospital, 168 Changhai Road, Yangpu District, Shanghai 200433, People's Republic of China.
    Affiliations
    Department of Nuclear Medicine, Changhai Hospital, Second Military Medical University, Shanghai, People's Republic of China
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Open ArchivePublished:December 24, 2015DOI:https://doi.org/10.1016/j.jtho.2015.12.101
      A 23-year-old male was referred to our hospital because of a 2-month history of cough and chest discomfort. Chest enhanced computed tomography (CT) (Fig. 1) showed an ill-circumscribed tumor of the mediastinum encasing the vessels and diffuse thickness of the right pleura with effusion. Fluorine 18–labeled fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT showed increased FDG uptake by the mediastinal tumor and a thickened right pleura (Fig. 2). There were large pericardial and right pleural effusions. Right pleural malignant mesothelioma with mediastinal involvement was suspected. The patient underwent CT-guided biopsy of the mediastinal tumor. Photomicrographs revealed tumor cells positive for vimentin, leukosialin, myeloperoxidase, and leukocyte common antigen, which were consistent with myeloid sarcoma.
      Figure thumbnail gr1
      Figure 1Chest enhanced computed tomography at different levels of the thorax (AD) showed an ill-circumscribed tumor (arrows) of the mediastinum encasing the vessels and diffuse thickness of the right pleura (arrowheads) with effusion.
      Figure thumbnail gr2
      Figure 2Maximum intensity projection positron emission tomography (A), transverse CT (B and C), corresponding positron emission tomography (D and E) and fused (F and G) images showed the fluorodeoxyglucose-avid mediastinal tumor (arrow) and diffuse fluorodeoxyglucose uptake by the right thickened pleura (arrowheads). There were large pericardial and right pleural effusions.
      Myeloid sarcoma is an uncommon localized tumor formed by primitive myeloid cells at an extramedullary site, and it may precede, follow, or occur in the absence of systemic acute myeloid leukemia.
      • Byrd J.C.
      • Edenfield W.J.
      • Shields D.J.
      • et al.
      Extramedullary myeloid cell tumors in acute nonlymphocytic leukemia: a clinical review.
      It appears to be more common in the infant and pediatric age groups and less common in adults. Myeloid sarcoma presents as either a single tumor or multiple tumors. It can occur at nearly every anatomic site. In adults, the most common sites of involvement are the skin, the central nervous system, bone, and the lymph nodes.
      • Byrd J.C.
      • Edenfield W.J.
      • Shields D.J.
      • et al.
      Extramedullary myeloid cell tumors in acute nonlymphocytic leukemia: a clinical review.
      • Klco J.M.
      • Welch J.S.
      • Nguyen T.T.
      • et al.
      State of the art in myeloid sarcoma.
      FDG PET/CT is useful for early disease detection, staging, and assessment of treatment response.
      • Ueda K.
      • Ichikawa M.
      • Takahashi M.
      • et al.
      FDG-PET is effective in the detection of granulocytic sarcoma in patients with myeloid malignancy.
      • Aschoff P.
      • Häntschel M.
      • Oksüz M.
      • et al.
      Integrated FDG-PET/CT for detection, therapy monitoring and follow-up of granulocytic sarcoma. Initial results.
      • Lee E.Y.
      • Anthony M.P.
      • Leung A.Y.
      • et al.
      Utility of FDG PET/CT in the assessment of myeloid sarcoma.
      • Karlin L.
      • Itti E.
      • Pautas C.
      • et al.
      PET-imaging as a useful tool for early detection of the relapse site in the management of primary myeloid sarcoma.
      • Stölzel F.
      • Röllig C.
      • Radke J.
      • et al.
      18F-FDG-PET/CT for detection of extramedullary acute myeloid leukemia.
      • Rao S.
      • Langston A.
      • Galt J.R.
      • et al.
      Extramedullary acute myeloid leukemia and the use of FDG-PET/CT.
      Cribe et al. reported that FDG PET scans revealed more than twice as many patients with extramedullary disease than are found by clinical examination.
      • Cribe A.S.
      • Steenhof M.
      • Marcher C.W.
      • et al.
      Extramedullary disease in patients with acute myeloid leukemia assessed by 18F-FDG PET.
      In this case, the diffuse pleural and mediastinal involvement was unusual for myeloid sarcoma. Although rare, myeloid sarcoma should be considered in the differential diagnosis of diffuse pleural thickness and abnormal FDG accumulation along with malignant and nonmalignant processes, including malignant mesothelioma and tuberculosis.

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