Turkish Journal of Hematology Volume: 37 Issue: 1 / 2020

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LETTERS TO THE EDITORTurk J Hematol 2020;37:57-76Vacuolated Blasts in the Bone Marrow of a Child withRhabdomyosarcomaRabdomyosarkomlu Çocukta Kemik İliğinde Vakuollü BlastlarEda Ataseven 1 , Dilek Ece 2 , Nazan Özsan 3 , Mehmet Kantar 41Ege University Faculty of Medicine, Department of Pediatric Hematology and Oncology, İzmir, Turkey2Ege University Faculty of Medicine, Department of Pediatrics, Division of Pediatric Hematology and Oncology, İzmir, Turkey3Ege University Faculty of Medicine, Department of Pathology, İzmir, Turkey4Ege University Faculty of Medicine, Department of Pediatrics, Division of Pediatric Oncology, İzmir, TurkeyTo the Editor,Rhabdomyosarcoma (RMS) is the most common soft tissuesarcoma in children. The most common locations are the head/neck region and genitourinary tract. Leukemic presentationof RMS with diffuse bone marrow involvement and unknownprimary mass is very rare [1]. Most of the time it can bemisdiagnosed as acute leukemia.A 3-year-old female patient was admitted to the hospital withright arm pain, a limp while walking, and abdominal pain. Fromher medical history we learned that one month earlier she wasdiagnosed with a humerus fracture in the orthopedics clinic,and despite fixation her pain had gradually increased anddisseminated. Magnetic resonance imaging of the humerus hadrevealed diffuse bone marrow edema and pathological lymphnode enlargement in the axillary region. She was referred to ourclinic with a suspicion of hematologic malignancy.RMS rarely involves the bone marrow. Blastic cells in RMSresemble lymphoid blasts and it can mimic acute leukemia orBurkitt’s lymphoma with marrow involvement, especially ifthere are prominent vacuolizations, as in our case [1,2]. In theliterature, all patients presenting with bone marrow involvementwere diagnosed with alveolar type RMS [3]. We could notdistinguish the type of RMS in our patient. RMS should be keptin mind in the differential diagnosis of patients, especially ifthere are clustering blastic cells, multinucleated giant cells withdeep blue cytoplasm, and prominent vacuolization [4].Upon physical examination, she had local swelling and painin the right arm. There was no organomegaly or pathologicallymph node enlargement on palpation. Laboratory examinationrevealed hemoglobin level of 10.3 g/dL, white blood cell countof 8.8x10 9 /L, and platelet count of 218x10 9 /L. Examinationof the peripheral blood smear was normal. Biochemical testresults were normal, except elevated lactate dehydrogenase anduric acid levels. Abdominal ultrasonography was normal. Weperformed bone marrow aspiration and biopsy with a suspicionof leukemia.The bone marrow aspiration smear showed immature cellswith disseminated intranuclear/intracytoplasmic vacuolization(Figure 1). In the bone marrow biopsy, diffuse blastic infiltrationwas noticed. Blastic cells were positive for myogenin anddesmin staining. The diagnosis was RMS metastasis in thebone marrow. Work-up of the primary site of the disease wasperformed. Abdominal computed tomography showed a hugemass in the left pararectal fossa and multiple bone metastases(Figure 2).Figure 1. Bone marrow aspiration smear showed immature cellswith disseminated intranuclear/intracytoplasmic vacuolization.70
Turk J Hematol 2020;37:57-76LETTERS TO THE EDITORInformed Consent: Informed consent form was received fromthe family/patient to use medical records of the patient.Authorship ContributionsData collection or Processing: E.A., D.E., N.Ö., M.K.; Analyses orInterpretration: E.A., D.E., N.Ö., M.K.; Literature Search: E.A., D.E.,N.Ö., M.K.Conflict of Interest: No author of this paper has a conflict ofinterest, including specific financial interests, relationships, oraffiliations relevant to the subject matter or materials includedin this manuscript.Financial Disclosure: The authors declared that this studyreceived no financial support.Figure 2. Abdominal CT showed a huge mass in pararectal fossa.CT: Computed tomography.Keywords: Rhabdomyosarcoma, Vacuolated blasts, Bone marrowinvolvementAnahtar Sözcükler: Rabdomyosarkom, Vakuollü blast, Kemikiliği tutulumuReferences1. Imataki O, Uemura M, Uchida S, Yokokura S, Takeuchi A, Ishikawa R, Kondo A,Seo K, Kadowaki N. Complete mimicry: a case of alveolar rhabdomyosarcomamasquerading as acute leukemia. Diagn Pathol 2017;12:77:1-7.2. Naithani R, Kumar R, Mahapatra M, Agrawal N, Saxena R, Sharma S. Pelvicalveolar rhabdomyosarcoma with bone marrow involvement misdiagnosedas acute myeloid leukemia. Pediatr Hematol Oncol 2007;24:153-155.3. Stall JN, Bailey NG. Metastatic alveolar rhabdomyosarcoma to the bonemarrow mimicking acute leukemia. Blood 2012;120:3632.4. Patiroglu T, Isik B, Unal E, Canoz O, Deniz K, Kosemehmetoglu K, KarakukcuM, Ozdemir MA. Cranial metastatic alveolar rhabdomyosarcoma mimickinghematological malignancy in an adolescent boy. Childs Nerv Syst2014;30:1737-1741.©Copyright 2020 by Turkish Society of HematologyTurkish Journal of Hematology, Published by Galenos Publishing HouseAddress for Correspondence/Yazışma Adresi: Eda Ataseven, M.D., Ege University Faculty of Medicine,Department of Pediatric Hematology and Oncology, İzmir, TurkeyPhone : +90 505 687 96 25E-mail : edataseven@yahoo.com ORCID: orcid.org/0000-0003-3419-5814Received/Geliş tarihi: August 28, 2019Accepted/Kabul tarihi: November 27, 2019DOI: 10.4274/tjh.galenos.2019.2019.032471
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Turkish Journal of Hematology Volume: 37 Issue: 1 / 2020

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