PMC8597781_01
A - Peripheral blood smear showing blasts (arrow). (Leishman's stain, 1000x); B - Bone marrow aspirate smear showing blasts of myeloid lineage (Leishman's stain,1000x)
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Bone marrow evaluation displayed 61% blasts of myeloid lineage (Figure 1), which accorded the relapse of AML.
A - A gross view of the excised breast lump. Note the external surface appears smooth with the cut surface showing a greenish tinge (scale bar = 4 cm); B, C and D show sections from the breast mass, which reveal tumor cells composed of monomorphic population of cells, predominantly composed of blasts along with few scattered mature and immature granulocytes. Normal breast parenchyma is seen at the periphery in B, indicating that the tumor was circumscribed (H&E, B-100x; C - 200x; D - 400X).
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No lobulations or raw areas were noted on the surface, neither were necrotic or hemorrhagic foci (Figure 2A). The periphery of the tumor showed sparse normal breast parenchyma with terminal ductal lobular units (TDLUs) (Figure 22C, and 2D).
- Immunohistochemical profile of the breast lump - The tumor cells are strongly reactive for A - LCA; B - TdT highlights the myeloblasts; C - The tumor cells also react diffusely to CD43; D - CD68 (diffuse reactivity); E - CD117 (intermediate to weak reactivity); and F - CD99 (diffuse reactivity) (A to F, 400X).
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On further immunohistochemical profiling, the tumor cells showed strong immunoreactivity to antibodies against CD43, CD56, CD68, Leucocyte common antigen (LCA), and CD99 with an intermediate to weak reaction to CD117 and TdT (Figure 3), while they were non-reactive for lymphoid B and T cell markers.
PMC8597781_02
A - Photomicrograph of the lymph node showing the replacement of lymph node parenchyma with sheets of blasts (H&E, 400x); B - Bone marrow aspirate showing numerous blasts (arrows) along with other cells of myeloid lineage, indicating blast crises of CML (Leishman's stain,1000x); C-F - Immunohistochemical profile of the lymph node reveals the blasts being diffusely positive for: C - CD34; D - MPO; E - focal reactivity to CD117; and F - non-reactivity to ALK1 - (C to F, 400x).
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Based upon these attributes, besides the relevant immunohistochemistry showing focal positivity for CD3 and CD5, an initial diagnosis of Non-Hodgkin's Lymphoma (NHL) favoring T cell lymphoblastic leukemia was entertained (Figure 4A). However, bone marrow studies revealed 70% myeloid blasts (Figure 4B), along with t(9;22) on cytogenetic evaluation, which was consonant with a diagnosis of CML - Blast crisis. On additional immunohistochemical evaluation, the atypical cells within the lymph node, now established as blasts, showed reactivity for CD34 along with MPO, CD43, CD56, and CD117 with a Mib-1 labeling index of 70-80% (Figure 4C-F).
PMC8597781_03
A - Peripheral blood smear showing an abnormal promyelocyte composed of an eccentric folded nucleus with nucleolus and abundant cytoplasm showing numerous granules along with the presence of Auer rods (arrow) (Leishman's stain, 1000x); B - Bone marrow aspirate shows promyelocytes (arrows) along with a few blasts and myeloid precursors (Leishman's stain, 1000x)
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Bone marrow assessment revealed 28% promyelocytes of hypergranular type (Figure 5A and 5B), which was compatible with a diagnosis of APML.
May Grunwald - Giemsa (MGG) stained smears from the FNAC of temporal swelling reveal a monomorphous population of cells composed of intermediate-sized cells with pinkish granular cytoplasm and prominent nucleoli (arrows), suggesting overall features to be of a hematolymphoid malignancy in a known case of APML (400x).
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Many cells also showed reniform nuclei suggesting overall features to be of a hematolymphoid neoplasm in a known case of APML (Figure 6).
PMC8597781_04
A - Peripheral blood smear showing the presence of myeloid blasts (Leishman stain,1000x); B - Bone marrow aspirate reveals presence blasts (arrows) with cells of myeloid lineage (Leishman stain, 1000x).
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Concurrent PBS showed 15% blasts (Figure 7A). Bone marrow assessment revealed 24% blasts along with promyelocytes (Figure 7B), which established the diagnosis of secondary AML following the transformation of MDS - EB2.
Photomicrographs of the cervical mass: A - shows scant endocervical glands along with stroma being infiltrated by atypical monomorphic cells in sheets (H&E, 400x); B-D - Immunohistochemical reactions reveal the atypical cells showing strong reactivity to: B - LCA, C - MPO, and D - CD117, indicating their myeloid lineage (400x).
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Microscopic evaluation of the cervical mass revealed focal endocervical lining and few endocervical glands with stroma showing infiltration by atypical monomorphic cells arranged in sheets, cords, and singly scattered, at places encroaching upon the endocervical glands (Figure 8A). On immunohistochemical evaluation, the atypical cells showed reactivity for MPO, LCA, and CD117 (Figure 8B-D).