Myeloid sarcoma has to be treated as AML. In patients who are fit enough, the cytosine - anthracycline 7+ 3 regimen is the remission induction chemotherapy of chioce.

I treat myeloid sarcoma with /+3, however I add local radiotherapy. It's very important also the cytogenetic chracterization of  myeloid sarcoma. Treatment should be also guided by cytogenetics.

The most common cytogenetics associated with myeloid sarcoma is t(8,21) right?

Prof. Leone,

I wonder if you give radiation to every body and when you give it.

Dr. Devasia,

I think you are right and t(8;21) is the most common cytogenetic abnormality reported in patients with myeloid sarcoma.

Recently we have had a patient with histologically verified myelosarcoma infiltrating pleura and lungs, and there was found  infiltration 10% with AML blasts NPM-1 positive in the bone marrow. The patient was treated with 7+3 induction followed by HIDAC+Mitox and proceeded to allogeneic stem cells transplantation in the 1.st CR because of high-risc pattern of the disease. No radiotherapy was given  to the  patient.

Radiation therapy is to be considered in patients with 100% solitary myelosarcoma, in patients with residual tumor mass after chemotherapy or transplantation, or in patients with solitary myelosarcoma relapse after chemotherapy or transplantation. The decision depends also on the age, comorbidities, localisation, distribution of the myelosarcoma.

The situation must be considered individualy.

Dr. Vokurka,

Thank you for your reply which is helpful. Your patient was positive for NPM-1; however, you took the patient to transplant. May I ask what the patient's high risk pattern was? Thanks.

In NPM-1 positive patient we do not perform aloBMT in 1st.CR if no risc factors (i.e. FLT3, no-CR after inducton) are present. We consider myelosarcoma as a high-risk factor and moreover the patient was not in CR after the 7+3 induction.

Dr. Vokurka,

Thank you for your reply. I agree with your management. That patient did need an allogeneic hematopoietic stem cell transplant.

Dear Dr. Mojtaba,

I strongly agree with Dr. Vokurka who explained brilliantly the issue. I can only add that precisely depending on some facts (as the posible effects of radiation therapy on tissues where myeloid sarcoma is located attending to the risk of second neoplasms)  we decide wether to use chemo alone or chemo + radiation, but it would always be a high risk patient. We had good results with cases using chemo+radiotherapy + aloBMT even when masses were located in delicate places as the CNS.  Good luck with your case. 

Dr. Roman,

I have recently had a patient who had myeloid sarcoma of the right orbit; I treated her with 7+3 and when her counts recovered, we started her on radiation. She is still getting XRT and tolerating it quite well.

Dr. Mojtaba,

The 7+3 protocol is the gold standard treatment we first consider to use for patients with AML wether if they have a myeloid sarcoma or not. Of course we do so after assessing patient´s status performance to know if he/she can face such a tratement with an acceptable risk/benefits balance.

Dr. Roman,

Thank you for your reply. I wonder if you incorporate local radiation in your therapeutic intervention for such patients.

The decision for treatment does not depend on the chronologic patient age but on the biological age. At this monet I have a lady aged 71 years who is getting ready for allogeneic tranplant after 2nd. remission of AML. 

Radiation is another thing, there is no contraindication, but these are the ages with higher incidence of COPD and other pulmonary problems that are important risk factors for invasive fungal diseases...

Dr. Mojtaba,

We do use to combine RT with 7+3 regimen, always making a previous evaluation of the different elements that every particular patient has regarding mass size and location, kind of affected tissue, performance status, previous history of RT (previous cumullative dosage exposure) and such...it is sort of a tailored decision with every new patient. Anyway we use RT only on the affected area not TBR that is why complications are generally manageable.

Dr Graymer:

All those studies are indead treatment alternatives but for de novo AML  "7+3" stills gold standard. Even when 2+5 has been used since many years as an alternative for those patients with a poorer performance status (not older, because a joung patient may have a performance status that makes 7+3 a not suitable option) some other study groups like HOVON/SAAK (if I remember well the name) have demostrated very good results treating elderly patients with good performance status and AML secundary to MDS (very poor prognosis group usually refractory to treatment and short OS) with intensified versions of 7+3 using high dose daunorubicin. Side effects where not greatter than expected but results where significantly better. This strategy has been extrapolated to younger patients in an aproach directed to avoid earlier relapses.

Yes, is it a relapse of AML, although extramedullary. In a patient with good PS it is the first choice. I am little skeptical about involved field RT, as AML is a systemic disease and if untreated, it will appear elsewhere.

Dear Dr Mojtaba Akhtari, 

I do suggest to give 3+7 and some doses of HDCA.  Later, if bone marrow is not involved autologous stem cell transplantation can work in myeloid sarcoma.