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Granulocytic Sarcoma of Bowel: CT Findings¹

¹ From the Department of Radiology and Research Institute of Radiology, University of Ulsan College of Medicine, Asan Medical Center, 388-1 Pungnap-2 Dong, Songpa-gu, Seoul 138-736, Korea (E.K.C., H.K.H., S.H.P., K.W.K., S.S.L.); the Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul (S.J.L.); and the Department of Radiology, St Mary's Hospital, College of Medicine, Catholic University of Korea, Seoul (S.E.J.). Received April 28, 2006; revision requested June 23; revision received June 28; accepted July 21; final version accepted September 18. Address correspondence to H.K.H. (e-mail: hkha{at}amc.seoul.kr).

View larger version (127K): [in this window] [in a new window] [Download PPT slide]   Figure 1: Patient 4. Contrast-enhanced transverse CT scan in 38-year-old man with no known history of leukemia and abdominal pain and diarrhea at presentation shows an exophytic mass (arrowheads) with bowel wall thickening causing small-bowel obstruction in the jejunum with a dilated duodenum (D) and proximal jejunum. This patient never had blood or bone marrow evidence of acute leukemia during 3 years of follow-up and was therefore considered to have isolated granulocytic sarcoma of the small bowel. Microscopic examination (results not shown) revealed leukemic tumor cell infiltration of mucosal surface. Immunohistochemical staining was positive for myeloperoxidase but negative for T-cell and B-cell markers (ie, CD3, CD20), indicating that the tumor cells were of myeloid origin and thus compatible with the diagnosis of granulocytic sarcoma.

View larger version (108K): [in this window] [in a new window] [Download PPT slide]   Figure 2a: Patient 2. Contrast-enhanced transverse CT scans in 48-year-old man with no known history of acute leukemia who presented with diffuse abdominal pain. (a) Initial CT scan shows a mass (arrow) and tumor infiltration of the mesentery. A mesenteric vessel (arrowhead) is situated within the mass. An intraluminal polypoid mass of high attenuation (not shown) was noted in the ileum. Exploratory laparotomy was performed for obstructive symptoms, and open lesion biopsy enabled diagnosis of granulocytic sarcoma. (b, c) Follow-up scans obtained 1 month later show large amount of ascites with enhancement of the peritoneum (black arrowheads in b), diffuse bowel wall thickening (white arrowhead in b), infiltration of the mesentery, and rapid interval development of diffuse mesenteric infiltration by soft tissue (arrowheads in c). (d, e) Second set of follow-up scans obtained 1 month after b and c, after chemotherapy, shows marked reduction of tumor dissemination with substantial resolution of ascites, infiltration of bowel wall and mesentery, and the tumor mass, which had once largely occupied the pelvic cavity. There remains some thickening of the bowel (arrowheads) and residual infiltration of the mesentery.

View larger version (118K): [in this window] [in a new window] [Download PPT slide]   Figure 2b: Patient 2. Contrast-enhanced transverse CT scans in 48-year-old man with no known history of acute leukemia who presented with diffuse abdominal pain. (a) Initial CT scan shows a mass (arrow) and tumor infiltration of the mesentery. A mesenteric vessel (arrowhead) is situated within the mass. An intraluminal polypoid mass of high attenuation (not shown) was noted in the ileum. Exploratory laparotomy was performed for obstructive symptoms, and open lesion biopsy enabled diagnosis of granulocytic sarcoma. (b, c) Follow-up scans obtained 1 month later show large amount of ascites with enhancement of the peritoneum (black arrowheads in b), diffuse bowel wall thickening (white arrowhead in b), infiltration of the mesentery, and rapid interval development of diffuse mesenteric infiltration by soft tissue (arrowheads in c). (d, e) Second set of follow-up scans obtained 1 month after b and c, after chemotherapy, shows marked reduction of tumor dissemination with substantial resolution of ascites, infiltration of bowel wall and mesentery, and the tumor mass, which had once largely occupied the pelvic cavity. There remains some thickening of the bowel (arrowheads) and residual infiltration of the mesentery.

View larger version (96K): [in this window] [in a new window] [Download PPT slide]   Figure 2c: Patient 2. Contrast-enhanced transverse CT scans in 48-year-old man with no known history of acute leukemia who presented with diffuse abdominal pain. (a) Initial CT scan shows a mass (arrow) and tumor infiltration of the mesentery. A mesenteric vessel (arrowhead) is situated within the mass. An intraluminal polypoid mass of high attenuation (not shown) was noted in the ileum. Exploratory laparotomy was performed for obstructive symptoms, and open lesion biopsy enabled diagnosis of granulocytic sarcoma. (b, c) Follow-up scans obtained 1 month later show large amount of ascites with enhancement of the peritoneum (black arrowheads in b), diffuse bowel wall thickening (white arrowhead in b), infiltration of the mesentery, and rapid interval development of diffuse mesenteric infiltration by soft tissue (arrowheads in c). (d, e) Second set of follow-up scans obtained 1 month after b and c, after chemotherapy, shows marked reduction of tumor dissemination with substantial resolution of ascites, infiltration of bowel wall and mesentery, and the tumor mass, which had once largely occupied the pelvic cavity. There remains some thickening of the bowel (arrowheads) and residual infiltration of the mesentery.

View larger version (110K): [in this window] [in a new window] [Download PPT slide]   Figure 2d: Patient 2. Contrast-enhanced transverse CT scans in 48-year-old man with no known history of acute leukemia who presented with diffuse abdominal pain. (a) Initial CT scan shows a mass (arrow) and tumor infiltration of the mesentery. A mesenteric vessel (arrowhead) is situated within the mass. An intraluminal polypoid mass of high attenuation (not shown) was noted in the ileum. Exploratory laparotomy was performed for obstructive symptoms, and open lesion biopsy enabled diagnosis of granulocytic sarcoma. (b, c) Follow-up scans obtained 1 month later show large amount of ascites with enhancement of the peritoneum (black arrowheads in b), diffuse bowel wall thickening (white arrowhead in b), infiltration of the mesentery, and rapid interval development of diffuse mesenteric infiltration by soft tissue (arrowheads in c). (d, e) Second set of follow-up scans obtained 1 month after b and c, after chemotherapy, shows marked reduction of tumor dissemination with substantial resolution of ascites, infiltration of bowel wall and mesentery, and the tumor mass, which had once largely occupied the pelvic cavity. There remains some thickening of the bowel (arrowheads) and residual infiltration of the mesentery.

View larger version (99K): [in this window] [in a new window] [Download PPT slide]   Figure 2e: Patient 2. Contrast-enhanced transverse CT scans in 48-year-old man with no known history of acute leukemia who presented with diffuse abdominal pain. (a) Initial CT scan shows a mass (arrow) and tumor infiltration of the mesentery. A mesenteric vessel (arrowhead) is situated within the mass. An intraluminal polypoid mass of high attenuation (not shown) was noted in the ileum. Exploratory laparotomy was performed for obstructive symptoms, and open lesion biopsy enabled diagnosis of granulocytic sarcoma. (b, c) Follow-up scans obtained 1 month later show large amount of ascites with enhancement of the peritoneum (black arrowheads in b), diffuse bowel wall thickening (white arrowhead in b), infiltration of the mesentery, and rapid interval development of diffuse mesenteric infiltration by soft tissue (arrowheads in c). (d, e) Second set of follow-up scans obtained 1 month after b and c, after chemotherapy, shows marked reduction of tumor dissemination with substantial resolution of ascites, infiltration of bowel wall and mesentery, and the tumor mass, which had once largely occupied the pelvic cavity. There remains some thickening of the bowel (arrowheads) and residual infiltration of the mesentery.

View larger version (107K): [in this window] [in a new window] [Download PPT slide]   Figure 3: Patient 3. Contrast-enhanced transverse CT scan in 71-year-old man. Chronic myelogenous leukemia had been diagnosed 18 months after a work-up of splenomegaly with abdominal pain and diarrhea. Scan shows 7.8-cm exophytic isoattenuating mass (white arrowheads) in duodenum, resulting in a compressed lumen (black arrow) with infiltration of the overlying omentum (curved white arrow). There is also evidence of ascites (black arrowhead) and peritoneal thickening (straight white arrow). Note enlarged spleen (*). Endoscopic view (not shown) of duodenal lesion demonstrated an irregular, exophytic fungating mass without any evidence of mucosal ulcerations.

View larger version (123K): [in this window] [in a new window] [Download PPT slide]   Figure 4a: Patient 5. Contrast-enhanced transverse CT scans in 42-year-old man without any known history of leukemia who presented with a palpable abdominal mass. (a) Initial CT scan shows jejunal lesion characterized by bowel wall thickening (black arrowheads) and an exophytic component (white arrowhead). There is also a soft-tissue mass (*) on mesenteric side of lumen that is continuous with primary lesion. This patient underwent surgical resection for suspected GI stromal tumor, and pathologic examination revealed granulocytic sarcoma. (b) CT scan at level of rectum shows soft-tissue mass (arrowheads) anterior to rectum in rectovescical pouch. Microscopic examination (results not shown) demonstrated leukemic cell infiltration of small bowel. (c, d) Follow-up CT scans obtained 2 months after a demonstrate worsening of leukemic dissemination with substantial omental (arrowheads in c) and mesenteric infiltration and rapid enlargement of the rectal soft-tissue mass (arrowheads in d). The patient did not receive any antileukemic treatment between the two CT examinations.

View larger version (100K): [in this window] [in a new window] [Download PPT slide]   Figure 4b: Patient 5. Contrast-enhanced transverse CT scans in 42-year-old man without any known history of leukemia who presented with a palpable abdominal mass. (a) Initial CT scan shows jejunal lesion characterized by bowel wall thickening (black arrowheads) and an exophytic component (white arrowhead). There is also a soft-tissue mass (*) on mesenteric side of lumen that is continuous with primary lesion. This patient underwent surgical resection for suspected GI stromal tumor, and pathologic examination revealed granulocytic sarcoma. (b) CT scan at level of rectum shows soft-tissue mass (arrowheads) anterior to rectum in rectovescical pouch. Microscopic examination (results not shown) demonstrated leukemic cell infiltration of small bowel. (c, d) Follow-up CT scans obtained 2 months after a demonstrate worsening of leukemic dissemination with substantial omental (arrowheads in c) and mesenteric infiltration and rapid enlargement of the rectal soft-tissue mass (arrowheads in d). The patient did not receive any antileukemic treatment between the two CT examinations.

View larger version (127K): [in this window] [in a new window] [Download PPT slide]   Figure 4c: Patient 5. Contrast-enhanced transverse CT scans in 42-year-old man without any known history of leukemia who presented with a palpable abdominal mass. (a) Initial CT scan shows jejunal lesion characterized by bowel wall thickening (black arrowheads) and an exophytic component (white arrowhead). There is also a soft-tissue mass (*) on mesenteric side of lumen that is continuous with primary lesion. This patient underwent surgical resection for suspected GI stromal tumor, and pathologic examination revealed granulocytic sarcoma. (b) CT scan at level of rectum shows soft-tissue mass (arrowheads) anterior to rectum in rectovescical pouch. Microscopic examination (results not shown) demonstrated leukemic cell infiltration of small bowel. (c, d) Follow-up CT scans obtained 2 months after a demonstrate worsening of leukemic dissemination with substantial omental (arrowheads in c) and mesenteric infiltration and rapid enlargement of the rectal soft-tissue mass (arrowheads in d). The patient did not receive any antileukemic treatment between the two CT examinations.

View larger version (94K): [in this window] [in a new window] [Download PPT slide]   Figure 4d: Patient 5. Contrast-enhanced transverse CT scans in 42-year-old man without any known history of leukemia who presented with a palpable abdominal mass. (a) Initial CT scan shows jejunal lesion characterized by bowel wall thickening (black arrowheads) and an exophytic component (white arrowhead). There is also a soft-tissue mass (*) on mesenteric side of lumen that is continuous with primary lesion. This patient underwent surgical resection for suspected GI stromal tumor, and pathologic examination revealed granulocytic sarcoma. (b) CT scan at level of rectum shows soft-tissue mass (arrowheads) anterior to rectum in rectovescical pouch. Microscopic examination (results not shown) demonstrated leukemic cell infiltration of small bowel. (c, d) Follow-up CT scans obtained 2 months after a demonstrate worsening of leukemic dissemination with substantial omental (arrowheads in c) and mesenteric infiltration and rapid enlargement of the rectal soft-tissue mass (arrowheads in d). The patient did not receive any antileukemic treatment between the two CT examinations.