Breast relapse of myeloid sarcoma and SARS-CoV-2 infection following hematopoietic stem cell transplantation in mixed-phenotype acute leukemia: a case report

Abstract

Background: Mixed-phenotype acute leukemia is a rare high-risk subtype of acute leukemia. Myeloid sarcoma is a localized tumor formed by the proliferation and infiltration of primitive or immature myeloid cells outside the bone marrow. It is often an extramedullary manifestation of acute myeloid leukemia and imaging lacks specificity leading to potential misdiagnosis.

Case Presentation: A female patient diagnosed with mixed-phenotype acute leukemia achieved complete remission after chemotherapy and allogeneic hematopoietic stem cell transplantation. However a relapse occurred in the breast after transplantation. The patient achieved local control through mastectomy and removal of the axillary lymph nodes on the affected side. Unfortunately during the subsequent course of chemotherapy the patient died of a severe pulmonary infection caused by coronavirus disease 2019.

Conclusion: Continuous treatment and monitoring of mixed-phenotype acute leukemia patients are essential especially for those with extramedullary manifestations (such as breast involvement).

Keywords

Breast / Case report / COVID-19 / Myeloid sarcoma / Mixed-phenotype acute leukemia

Conflict of interest statement

The authors declare no conflict of interest.

Author contributions

The article was written and interpreted by Hu C. Clinical pathological and photographic data collection were conducted by Liu H Zhao S and Shang M. The study was supervised by Zhu J Dong X and Ma R who also approved the final article. The final version of the article was approved by all authors.

Funding

None.

Ethical approval of studies and informed consent

The study followed the principles of the Declaration of Helsinki as revised in 2013. This study was approved by the Ethics Committee of Qilu Hospital of Shandong University (KYLL-2020(KS)-237 March 25 2020) and written informed consent was obtained from the patient during treatment.

Acknowledgments

The authors acknowledge all the staff members at Qilu Hospital of Shandong University who actively contributed to this study providing insightful perspectives through constructive discussions and suggestions. The authors convey our sincere gratitude to Prof. Yunyun Gong and Prof. Chengming Chiang for their valuable suggestions and guidance.

References

[1] George BS, Yohannan B, Gonzalez A, Rios A. Mixed-phenotype acute leukemia: clinical diagnosis and therapeutic strategies. Biomedicines. 2022; 10(8):1974. doi:10.3390/biomedicines10081974

[2] Arzoun H, Srinivasan M, Thangaraj SR, Thomas SS, Mohammed L. The progression of chronic myeloid leukemia to myeloid sarcoma: a systematic review. Cureus. 2022; 14(1):e21077. doi:10.7759/cureus.21077

[3] Thachil J, Richards RM, Copeland G. Granulocytic sarcoma—a rare presentation of a breast lump. Ann R Coll Surg Engl. 2007; 89(7):7-9. doi:10.1308/147870807X227827

[4] Hwang JI, Kim TY. Primary granulocytic sarcoma of the face. Ann Dermatol. 2011; 23(Suppl 2):S214-S217. doi:10.5021/ad.2011.23.S2.S214

[5] Toyaja Jadhav PB. Myeloid sarcoma: an uncommon presentation of myeloid neoplasms, a case series of 4 rare cases reported in a tertiary care institute. Autops Case Rep. 2021; 11:e2021339. doi:10.4322/acr.2021.339

[6] Kumarasamy S, Garg K, Sharma MC, Chandra PS. Intracranial myeloid sarcoma as the first presentation of acute myeloid leukemia and literature review. Childs Nerv Syst. 2023; 39(12):3607-3612. doi:10.1007/s00381-023-06016-w

[7] Yilmaz AF, Saydam G, Sahin F, Baran Y. Granulocytic sarcoma: a systematic review. Am J Blood Res. 2013; 3(4):265-270

[8] Cunningham I. Extramedullary sites of leukemia relapse after transplant. Leuk Lymphoma. 2006; 47(9):1754-1767. doi:10.1080/10428190600632857

[9] Yamauchi K, Yasuda M. Comparison in treatments of nonleukemic granulocytic sarcoma: report of two cases and a review of 72 cases in the literature. Cancer. 2002; 94(6):1739-1746. doi:10.1002/cncr.10399

[10] Valbuena JR, Admirand JH, Gualco G, Medeiros LJ. Myeloid sarcoma involving the breast. Arch Pathol Lab Med. 2005; 129(1):32-38. doi:10.5858/2005-129-32-MSITB

[11] Pettinato G, de Chiara A, Insabato L, de Renzo A. Fine needle aspiration biopsy of a granulocytic sarcoma (chloroma) of the breast. Acta Cytol. 1988; 32(1):67-71

[12] Liang J, Yang L, Yang B, Tian Y, Ren J, Yang L. Clinical characteristics treatment options and prognosis of myeloid sarcoma: analysis using the SEER database. Hematology. 2023; 28(1):2247898. doi:10.1080/16078454.2023.2247898

[13] Singh S, Singh J, Paul D, Jain K. Treatment of acute leukemia during COVID-19: focused review of evidence. Clin Lymphoma Myeloma Leuk. 2021; 21(5):289-294. doi:10.1016/j.clml.2021.01.004