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an 86-year-old man&#44; had been diagnosed with myelodysplastic syndrome 2 years earlier&#46; He had consulted for 2 basal cell carcinomas&#44; one on the left temple and the other on the right ala nasi&#46; Both tumors were excised&#46; The surgical defect was repaired by direct closure in the first case and with a nasolabial fold flap in the second&#46; A few hours after surgery&#44; the patient presented at the emergency department with diffuse hemorrhage from both surgical wounds and a large hematoma in the area of the skin flap&#46; Laboratory tests showed a leukocyte count of 12&#160;200&#47;&#956;L &#40;upper limit of normal&#44; 10&#160;000&#47;&#956;L&#59; neutrophils&#44; 31&#46;2&#37;&#59; lymphocytes&#44; 21&#46;3&#37;&#59; monocytes&#44; 43&#46;6&#37;&#41;&#59; a hemoglobin level of 11&#46;7<span class="elsevierStyleHsp" style=""></span>g&#47;dL &#40;lower limit of normal&#44; 13<span class="elsevierStyleHsp" style=""></span>g&#47;dL&#41;&#44; a platelet count of 65&#160;000&#47;&#956;L &#40;lower limit of normal&#44;&#160;150&#160;000&#47;&#956;L&#41;&#44; and a creatinine level of 1&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;dL &#40;upper limit of normal&#44;&#160;1&#46;3<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#41;&#46; The other tests &#40;coagulation studies&#44; liver function tests&#44; and lactate dehydrogenase&#41; were normal&#46; One month after surgery&#44; a fast-growing asymptomatic nodule appeared in the area of the skin flap&#44; accompanied by progressive infiltration of the lower part of the flap &#40;which had healed perfectly&#41; and ulceration &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Biopsy of the nodule and the infiltrated scar revealed a diffuse neoplastic proliferation of medium-sized&#44; round&#47;oval mononuclear cells with eosinophilic cytoplasm and basophilic nuclei in the dermis and adipose tissue &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Immunohistochemical staining showed diffuse positivity for myeloperoxidase &#40;MPO&#41;&#44; CD68&#44; and CD43&#44; and focal positivity for CD34&#44; leading to a diagnosis of myeloid sarcoma &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; During this time&#44; the patient&#39;s myelodysplastic syndrome progressed to AML-M4&#46; Palliative treatment was initiated with thioguanine&#44; but the patient died 3 weeks later&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Myeloid sarcoma presents as one or more tumor masses composed of immature myeloid cells&#46; While the tumors can affect any part of the body except the bone marrow&#44; the most common sites of involvement are bone&#44; periosteum&#44; skin&#44; gums&#44; and lymph nodes&#46; Multifocal disease is seen in less than 10&#37; of cases&#46; Myeloid sarcoma can precede&#44; coincide with&#44; or indicate recurrence of AML&#46; It can also indicate blastic transformation of a myelodysplastic syndrome&#44; chronic myeloid leukemia&#44; or other myeloproliferative disorders&#46; It is slightly more common in men than in women &#40;male to female ratio&#44; 1&#46;42&#58;1&#41; and in advanced ages &#40;mean age at diagnosis&#44; 56 years&#41;&#46; Myeloid sarcoma of the skin presents as a solitary tumor that grows in a matter of days or weeks and typically affects the face&#44; the scalp&#44; or the trunk&#46; There have also been reports of multiple and even disseminated lesions&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;4</span></a> The literature contains approximately 20 reports of myeloid sarcoma in leukemia cutis&#44; arising at sites of previous skin lesions or trauma&#44; mainly at central venous catheterization sites &#40;11 cases&#41;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> and puncture sites for venous and arterial sampling and bone marrow aspiration &#40;4 cases&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> There have also been isolated reports of myeloid sarcoma at sites of extravasation of chemotherapy agents&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> traumatic scars and excoriations&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Mantoux test injection sites&#44;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> decubitus ulcer&#44; Sister Mary Joseph&#39;s nodule&#44; pyoderma gangrenosum&#44;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> tetanus booster injection sites&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> and within a basal cell carcinoma&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> We reexamined the surgical specimens from the basal cell carcinomas removed from the patient&#39;s temple and nose but found no evidence of leukemic infiltration&#46; Myeloid sarcoma in a patient with AML is normally a marker of recurrence and rapid disease progression&#46; Of 4 such cases described in the literature&#44; it was aleukemic in just 1 case<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>&#59; in the other 3&#44; its appearance coincided with transformation of a myelodysplastic syndrome into AML&#46; Prognosis is generally very poor&#46; It is noteworthy that while text books state that leukemia cutis can occur at the site of surgical scars&#44; we found no such cases reported in the literature&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Histologic diagnosis of myeloid sarcoma requires a high level of clinical suspicion and diagnosis might be missed if there is no previous history of AML&#46; Histologic findings include dense neoplastic infiltration of the dermis and adipose tissue&#44; typically most intense around vessels and adnexa&#44; without epidermotropism&#46; The papillary dermis is usually spared &#40;Grenz zone&#41;&#46; Cytology varies greatly according to the origin of the tumor and the degree of cell maturation&#46; Immunohistochemical studies are essential for diagnosis&#44; with CD68&#44; MPO&#44; CD43&#44; CD3&#44; CD20&#44; and chloroacetate esterase staining recommended&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The pathogenesis of leukemia cutis and myeloid sarcoma is not clear&#44; but it appears to be influenced by both the type of leukemia and local factors&#46; Infiltration would appear to be more common in monocytic variants because neoplastic monocytes have a greater capacity to adhere to vessel walls and invade extravascular spaces&#44; forming skin tumors&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;8</span></a> Nevertheless&#44; local skin trauma of any type can activate keratinocytes or fibroblasts in old lesions&#44; releasing chemotactic factors for leukocytes and inflammatory cells that would lead to the recruitment of leukemic cells&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;9</span></a> Of particular interest in the case presented is the fact that the leukemic infiltration was confined to the area of the skin flap&#44; ie&#44; it did not affect the surgical defect repaired by direct closure&#46; This might be because skin flap surgery causes greater tissue damage than direct closure&#44; and this damage&#44; combined with the profuse hemorrhage and subsequent hematoma &#40;related to the patient&#39;s underlying disease&#41;&#44; would have caused greater local inflammation&#44; which&#44; in turn&#44; would have promoted the recruitment of leukemic cells in a process that coincided with the transformation of myelodysplastic syndrome to AML&#46;</p></span>"
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Case and Research Letters
Myeloid Sarcoma in the Area of a Skin Flap
Sarcoma mieloide en un área de plastia
M. García-Arpaa,
Autor para correspondencia
mgarciaa73@yahoo.es

Corresponding author.
, M. Rodríguez-Vázquezb, C. Murillo Lázaroc, C. Calle Primod
a Servicio de Dermatología, Hospital General de Ciudad Real, Spain
b Servicio de Dermatología, Hospital General de Albacete, Spain
c Servicio de Anatomía Patológica, Hospital General de Ciudad Real, Spain
d Servicio de Hematología, Hospital General de Ciudad Real, Spain
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an 86-year-old man&#44; had been diagnosed with myelodysplastic syndrome 2 years earlier&#46; He had consulted for 2 basal cell carcinomas&#44; one on the left temple and the other on the right ala nasi&#46; Both tumors were excised&#46; The surgical defect was repaired by direct closure in the first case and with a nasolabial fold flap in the second&#46; A few hours after surgery&#44; the patient presented at the emergency department with diffuse hemorrhage from both surgical wounds and a large hematoma in the area of the skin flap&#46; Laboratory tests showed a leukocyte count of 12&#160;200&#47;&#956;L &#40;upper limit of normal&#44; 10&#160;000&#47;&#956;L&#59; neutrophils&#44; 31&#46;2&#37;&#59; lymphocytes&#44; 21&#46;3&#37;&#59; monocytes&#44; 43&#46;6&#37;&#41;&#59; a hemoglobin level of 11&#46;7<span class="elsevierStyleHsp" style=""></span>g&#47;dL &#40;lower limit of normal&#44; 13<span class="elsevierStyleHsp" style=""></span>g&#47;dL&#41;&#44; a platelet count of 65&#160;000&#47;&#956;L &#40;lower limit of normal&#44;&#160;150&#160;000&#47;&#956;L&#41;&#44; and a creatinine level of 1&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;dL &#40;upper limit of normal&#44;&#160;1&#46;3<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#41;&#46; The other tests &#40;coagulation studies&#44; liver function tests&#44; and lactate dehydrogenase&#41; were normal&#46; One month after surgery&#44; a fast-growing asymptomatic nodule appeared in the area of the skin flap&#44; accompanied by progressive infiltration of the lower part of the flap &#40;which had healed perfectly&#41; and ulceration &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; Biopsy of the nodule and the infiltrated scar revealed a diffuse neoplastic proliferation of medium-sized&#44; round&#47;oval mononuclear cells with eosinophilic cytoplasm and basophilic nuclei in the dermis and adipose tissue &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Immunohistochemical staining showed diffuse positivity for myeloperoxidase &#40;MPO&#41;&#44; CD68&#44; and CD43&#44; and focal positivity for CD34&#44; leading to a diagnosis of myeloid sarcoma &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; During this time&#44; the patient&#39;s myelodysplastic syndrome progressed to AML-M4&#46; Palliative treatment was initiated with thioguanine&#44; but the patient died 3 weeks later&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Myeloid sarcoma presents as one or more tumor masses composed of immature myeloid cells&#46; While the tumors can affect any part of the body except the bone marrow&#44; the most common sites of involvement are bone&#44; periosteum&#44; skin&#44; gums&#44; and lymph nodes&#46; Multifocal disease is seen in less than 10&#37; of cases&#46; Myeloid sarcoma can precede&#44; coincide with&#44; or indicate recurrence of AML&#46; It can also indicate blastic transformation of a myelodysplastic syndrome&#44; chronic myeloid leukemia&#44; or other myeloproliferative disorders&#46; It is slightly more common in men than in women &#40;male to female ratio&#44; 1&#46;42&#58;1&#41; and in advanced ages &#40;mean age at diagnosis&#44; 56 years&#41;&#46; Myeloid sarcoma of the skin presents as a solitary tumor that grows in a matter of days or weeks and typically affects the face&#44; the scalp&#44; or the trunk&#46; There have also been reports of multiple and even disseminated lesions&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;4</span></a> The literature contains approximately 20 reports of myeloid sarcoma in leukemia cutis&#44; arising at sites of previous skin lesions or trauma&#44; mainly at central venous catheterization sites &#40;11 cases&#41;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> and puncture sites for venous and arterial sampling and bone marrow aspiration &#40;4 cases&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> There have also been isolated reports of myeloid sarcoma at sites of extravasation of chemotherapy agents&#44;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> traumatic scars and excoriations&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Mantoux test injection sites&#44;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> decubitus ulcer&#44; Sister Mary Joseph&#39;s nodule&#44; pyoderma gangrenosum&#44;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> tetanus booster injection sites&#44;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> and within a basal cell carcinoma&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> We reexamined the surgical specimens from the basal cell carcinomas removed from the patient&#39;s temple and nose but found no evidence of leukemic infiltration&#46; Myeloid sarcoma in a patient with AML is normally a marker of recurrence and rapid disease progression&#46; Of 4 such cases described in the literature&#44; it was aleukemic in just 1 case<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a>&#59; in the other 3&#44; its appearance coincided with transformation of a myelodysplastic syndrome into AML&#46; Prognosis is generally very poor&#46; It is noteworthy that while text books state that leukemia cutis can occur at the site of surgical scars&#44; we found no such cases reported in the literature&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">Histologic diagnosis of myeloid sarcoma requires a high level of clinical suspicion and diagnosis might be missed if there is no previous history of AML&#46; Histologic findings include dense neoplastic infiltration of the dermis and adipose tissue&#44; typically most intense around vessels and adnexa&#44; without epidermotropism&#46; The papillary dermis is usually spared &#40;Grenz zone&#41;&#46; Cytology varies greatly according to the origin of the tumor and the degree of cell maturation&#46; Immunohistochemical studies are essential for diagnosis&#44; with CD68&#44; MPO&#44; CD43&#44; CD3&#44; CD20&#44; and chloroacetate esterase staining recommended&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The pathogenesis of leukemia cutis and myeloid sarcoma is not clear&#44; but it appears to be influenced by both the type of leukemia and local factors&#46; Infiltration would appear to be more common in monocytic variants because neoplastic monocytes have a greater capacity to adhere to vessel walls and invade extravascular spaces&#44; forming skin tumors&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;8</span></a> Nevertheless&#44; local skin trauma of any type can activate keratinocytes or fibroblasts in old lesions&#44; releasing chemotactic factors for leukocytes and inflammatory cells that would lead to the recruitment of leukemic cells&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8&#44;9</span></a> Of particular interest in the case presented is the fact that the leukemic infiltration was confined to the area of the skin flap&#44; ie&#44; it did not affect the surgical defect repaired by direct closure&#46; This might be because skin flap surgery causes greater tissue damage than direct closure&#44; and this damage&#44; combined with the profuse hemorrhage and subsequent hematoma &#40;related to the patient&#39;s underlying disease&#41;&#44; would have caused greater local inflammation&#44; which&#44; in turn&#44; would have promoted the recruitment of leukemic cells in a process that coincided with the transformation of myelodysplastic syndrome to AML&#46;</p></span>"
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2021 Marzo 102 30 132
2021 Febrero 77 24 101
2021 Enero 69 14 83
2020 Diciembre 69 19 88
2020 Noviembre 38 15 53
2020 Octubre 34 11 45
2020 Septiembre 41 17 58
2020 Agosto 25 20 45
2020 Julio 16 14 30
2020 Junio 47 36 83
2020 Mayo 25 23 48
2020 Abril 28 21 49
2020 Marzo 38 35 73
2020 Febrero 6 5 11
2020 Enero 0 1 1
2019 Diciembre 4 3 7
2019 Noviembre 0 5 5
2019 Octubre 0 1 1
2019 Septiembre 4 6 10
2019 Agosto 0 8 8
2019 Julio 0 11 11
2019 Junio 2 10 12
2019 Mayo 0 19 19
2019 Abril 0 17 17
2019 Marzo 2 10 12
2019 Febrero 0 1 1
2019 Enero 1 4 5
2018 Diciembre 1 0 1
2018 Noviembre 1 0 1
2018 Octubre 3 0 3
2018 Septiembre 3 1 4
2018 Abril 0 7 7
2018 Marzo 2 1 3
2018 Febrero 59 3 62
2018 Enero 69 11 80
2017 Diciembre 58 8 66
2017 Noviembre 48 6 54
2017 Octubre 48 8 56
2017 Septiembre 45 10 55
2017 Agosto 57 10 67
2017 Julio 46 4 50
2017 Junio 63 11 74
2017 Mayo 64 10 74
2017 Abril 48 8 56
2017 Marzo 57 36 93
2017 Febrero 101 12 113
2017 Enero 52 16 68
2016 Diciembre 70 5 75
2016 Noviembre 85 11 96
2016 Octubre 130 21 151
2016 Septiembre 178 10 188
2016 Agosto 108 11 119
2016 Julio 56 13 69
2016 Junio 12 0 12
2016 Mayo 6 16 22
2016 Abril 6 2 8
2016 Marzo 10 0 10
2016 Febrero 11 2 13
2016 Enero 8 2 10
2015 Diciembre 14 0 14
2015 Noviembre 22 4 26
2015 Octubre 38 1 39
2015 Septiembre 27 3 30
2015 Agosto 10 3 13
2015 Julio 96 10 106
2015 Junio 69 7 76
2015 Mayo 99 22 121
2015 Abril 84 15 99
2015 Marzo 56 7 63
2015 Febrero 52 12 64
2015 Enero 71 13 84
2014 Diciembre 58 9 67
2014 Noviembre 47 11 58
2014 Octubre 53 23 76
2014 Septiembre 55 13 68
2014 Agosto 52 17 69
2014 Julio 61 22 83
2014 Junio 97 13 110
2014 Mayo 116 20 136
2014 Abril 89 9 98
2014 Marzo 95 20 115
2014 Febrero 76 10 86
2014 Enero 54 12 66
2013 Diciembre 61 14 75
2013 Noviembre 50 12 62
2013 Octubre 16 6 22
2013 Septiembre 21 2 23
2013 Agosto 16 5 21
2013 Julio 18 13 31
2013 Junio 13 12 25
2013 Mayo 26 3 29
2013 Abril 15 16 31
2013 Marzo 16 7 23
2013 Febrero 22 4 26
2013 Enero 24 9 33
2012 Diciembre 15 5 20
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