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Cytologic Diagnosis of Two Rarities

This issue of Acta Cytologica contains a case report1 and an article2 on entities that are rarely encountered in specimens sent to a cytopathology laboratory: granulocytic sarcoma (chloroma) and Microsporidia. The granulocytic sarcoma was manifested in ascitic fluid by cells exfoliated from a retroperitoneal mass, and the Microsporidia were detected in bile examined by routine techniques of cytopathology and parasitology. Granulocytic sarcoma, a long-recognized entity, is a rare, solid, extramedullary manifestation of granulocytic leukemia, usually of the acute type. The article by Rowlands1 describes the case of a woman suffering from abdominal pain and jaundice who was found to have a retroperitoneal mass and ascites. The peritoneal fluid contained immature and mature myeloid cells, and the biopsy specimen of the abdominal mass was also composed of the same cells. Subsequent examination of bone marrow revealed it to be also largely replaced by immature and mature myeloid cells. Granulocytic sarcoma, also known as extramedullary myeloid tumor, is a localized, solid, neoplastic mass composed of myeloid cells of various degrees of differentiation. It usually presents as a solitary mass in subcutaneum or lymph nodes, but it has also been observed in many other organs. Twenty-five of the 28 cases analyzed by Traweek and colleagues3 occurred in patients who were known to be leukemic; patients who develop the lesion but who are not known to be leukemic almost always develop leukemia in a matter of weeks or years. Granulocytic sarcoma is also known as chloroma, a term prevalent in the earlier literature. The term was adopted because of the greenish appearance of freshly cut lesions due to the presence of peroxidase in the leukemic cells. Since this appearance is not present in all tumors of this type, the less-specific designation granulocytic sarcoma is preferred. (It would be interesting to know if this greenish hue has ever been noticed in a freshly obtained cytologic specimen from a granulocytic sarcoma, particularly a fine needle aspirate.) Granulocytic sarcomas usually are solitary lesions, and any symptoms they may cause depend on the location of the lesion. In cytopathologic practice this means that cellular specimens from granulocytic sarcomas are usually obtained by fine needle aspiration of either a superficial or deeply situated lesion; in Rowland’s article1 granulocytic sarcoma was diagnosed by cytology of a serous fluid, an extremely uncommon event. The cells of a granulocytic sarcoma may range from immature myeloblastic cells, with their round nuclei and prominent nucleoli, through myeloid precursors to granulocytic myeloid cells, with the eosinophilic granulocyte the most obvious evidence of myeloid lineage. When the cells are blastic or poorly differentiated, cytoplasmic granules may be absent or difficult to observe; however, the appearance of such granules is a strong indication of the myeloid origin of the cells. The cytologic appearance of an undifferentiated granulocytic sarcoma may give few clues to its origin; however, if the patient is known to have or to have had treatment for myeloid leukemia, the diagnosis is greatly facilitated. Otherwise, if the patient is not known to be leukemic, the differential diagnosis is essentially lymphoma, poorly differentiat-