Granulocytic sarcoma (leukemia)
CLINICAL HISTORY:
This 27-year old female patient has a 2 year history of acute myelogenous leukemia. She was treated with chemotherapy leading to complete remission. For consolidation a combined bone marrow and stem cell transplantation was performed with complete remission to date. Now she is admitted in status epilepticus. After treatment with chemotherapy the patient awakened.
CLINICAL NEUROLOGICAL EXAMINATION reveals total paralysis of the right arm and leg with normal sensation. There is a central right facial nerve paresis.
CT: (IMAGE 1) shows a left prerolandic hypodense (arrow) lesion with evidence of some hemorrhage in the edge of the lesion.
MRI:
a) TRANSAXIAL T2-WEIGHTED (3380/90/1) SPIN-ECHO SEQUENCE (IMAGES 2 AND 3): A mass lesion (arrow) is seen in the left frontal lobe. The lesion is almost isointense with cortex, and is surrounded by a rim of edema.
b) TRANSAXIAL T1-WEIGHTED (600/15/1) SPIN-ECHO SEQUENCE (not illustrated): The lesion (arrow) is hypointense.
c) TRANSAXIAL (IMAGES 4 AND 5) AND CORONAL (IMAGE 6) AND SAGITTAL (IMAGE 7) GADOLINIUM-ENHANCED SPIN-ECHO SEQUENCES: There is slight enhancement of the lesion (arrowheads), with evidence of increased perilesional vascularity.
RADIOLOGICAL DIFFERENTIAL DIAGNOSIS includes granulocytic sarcoma, infarction, and opportunistic infections.
FOLLOW-UP: Initially the patient responded to chemotherapy and radiotherapy with improvement in speech and motor strength in the right leg over a period of three weeks. Then there was recurrence of epileptic episodes and of the right hemiplegia. Finally acute left hemiparesis developed.
CT: (IMAGE 8) Besides the known left frontal lesion, a right parietal lesion (arrow) has appeared, with some hemorrhagic characteristics and severe mass effect.
b) CONTRAST ENHANCED CT (IMAGE 9): There is some streaky enhancement within the lesions (arrowhead).
MRI:
a) TRANSAXIAL T2-WEIGHTED (3380/90/1) SPIN-ECHO SEQUENCE (IMAGES 10 - 11 - 12): The left prerolandic lesion displays some increase in the surrounding edema. In the right tempoparietal region, there is a slightly hemorrhagic mass (arrowheads) with inhomogeneous character and hypointense strands, surrounded by substantial edema and mass effect on the trigone of the right lateral ventricle.
b) TRANSAXIAL T1-WEIGHTED (560/15/1) SPIN-ECHO SEQUENCE (IMAGES 13 - 14 - 15): The lesions have a definite T1 hyperintense character consistent with hemorrhage.
c) TRANSAXIAL GADOLINIUM-ENHANCED SPIN-ECHO SEQUENCES (IMAGES 16 - 17 - 18): There is suspicion of some faint contrast enhancement.
RADIOLOGICAL DIAGNOSIS: considering the evolution and the hemorrhagic character granulocytic sarcoma is the preferential diagnosis.
FOLLOW-UP: The patient eventually passed away two months after the initial episode of status epilepticus. Autopsy was performed (IMAGES 19 - 20).
Search also:
Leukemia
The ESNR CD-Rom Series