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Obstructive Uropathy Associated with Myelomonocytic Infiltration of The 340 J Clin Pathol 1998;51:340–342 Obstructive uropathy associated with myelomonocytic infiltration of the prostate J Clin Pathol: first published as 10.1136/jcp.51.4.340 on 1 April 1998. Downloaded from B Hope-Gill, J R Goepel, R C Collin Abstract The bone marrow showed myeloid and mono- A 72 year old man was diagnosed with cytic hyperplasia and myeloid precursors were chronic myelomonocytic leukaemia hypogranular. There was no excess of blast (CMML) according to the FAB group cells. Micromegakaryocytes were identified in classification. He presented with symp- marrow smears. toms of anaemia, urinary frequency, hesi- In the context of a persistent peripheral tancy, and nocturia. He was later admitted blood monocytosis of > 1.0×109/litre, these with acute urinary retention and acute findings were consistent with a diagnosis of renal failure, which resolved with treat- chronic myelomonocytic leukaemia as defined ment. A transurethral resection of the by the FAB criteria.1 Elective admission was prostate was performed. Histological arranged for a three unit transfusion of packed examination showed fibromuscular hy- red cells a few days later. perplasia with dense infiltration by myelo- While awaiting admission he became in- monocytes which stained positively with creasingly lethargic and nauseous. Examin- chloroacetate esterase; immunohisto- ation revealed a distended bladder and a chemical staining was positive for lyso- smooth, tender, moderately enlarged prostate; zyme, CD43, CD45, and CD68. Following when catheterised, 2300 ml of urine were treatment with oral etoposide he trans- drained. He had not previously experienced formed to acute myeloid leukaemia and any symptoms of urinary obstruction until two eventually died. Myelomonocytic infiltra- weeks before admission. Investigations at this tion of the prostate has not been reported stage revealed Na 131 mmol/litre, K 5.9 mmol/ before. This case extends the spectrum of litre, HCO3 21 mmol/litre, urea 30 mmol/litre, disease previously recognised in CMML. and creatinine 995 µmol/litre. (J Clin Pathol 1998;51:340–342) Treatment with intravenous fluids was started and a blood transfusion was given. He Keywords: chronic myelomonocytic leukaemia; developed postcatheterisation diuresis and his prostate; urinary retention; myelomonocytes serum biochemistry improved such that the creatinine had fallen to 126 µmol/litre two days http://jcp.bmj.com/ later. He was discharged with a urethral Chronic monomyelocytic leukaemia (CMML) catheter in situ to await an elective transure- as defined by the FAB group1 is classified as a thral resection of the prostate. Subsequently a myelodysplastic disorder characterised by a 30 g prostate was resected and histological peripheral monocytosis and particular bone examination revealed dense infiltration with marrow features. Cytopenia, hepatospleno- myelomonocytes. megaly, and lymphadenopathy are common. Postoperatively, he required multiple packed on September 26, 2021 by guest. Protected copyright. Skin infiltration and serous eVusions are also red cell and platelet transfusions owing to recognised, and gingival infiltration occasion- heavy haematuria. ally occurs, particularly if accompanied by Subsequently, he was entered into the Medi- a high peripheral monocytosis (> 2.6×109/ cal Research Council CMML trial and ran- litre).2–5 However, myelomonocytic infiltration domised to receive oral etoposide (VP-16), 50 of other tissues is not reported. mg/day. However, three months later he was Chesterfield Royal readmitted with rigors, a chest infection, and Hospital, Department Case report of Haematology, general deterioration. Full blood count and Calow, Chesterfield, A 72 year old man was referred to our depart- peripheral film revealed a haemoglobin of 10.8 UK ment in September 1995 with two weeks of g/dl and a white blood cell count of 137×109/ B Hope-Gill increasing exertional shortness of breath. He litre (neutrophils 115.5, lymphocytes 0.5, R C Collin also had a four week history of urinary monocytes 16.7, 14% blast cells with large frequency, hesitancy, and nocturia. numbers of Auer rods) signifying transforma- Royal Hallamshire The general practitioner had performed a Hospital, Department tion to acute myeloid leukaemia. His clinical full blood count—haemoglobin 5.7 g/dl (MCV condition deteriorated progressively and in of Histopathology, 9 Beechill Road, 90.8 fl), white blood cell count 5.6×10 /litre conjunction with the patient and his wife the SheYeld, UK (neutrophils 0.6, lymphocytes 3.1, monocytes decision was made to treat palliatively. He died J R Goepel 1.7), platelet count 69×109/litre—and urea and three weeks later at home. No necropsy electrolyte determinations—sodium 138 examination was performed. Correspondence to: Dr R C Collin, Department mmol/litre, potassium 4.2 mmol/litre, HCO3 of Haematology, Chesterfield 25 mmol/litre, urea 8.9 mmol/litre, creatinine Royal Hospital, Calow, 143 µmol/litre. Prostate specific antigen was Histology report Chesterfield S44 5BL, UK. 12.1 ng/ml. The blood film and bone marrow Numerous prostate fragments were received Accepted for publication smears both showed morphological abnormali- fixed in formalin. These showed bladder neck 12 November 1997 ties with abnormal dysplastic granulopoiesis. and prostate, with hyperplasia of prostate Obstructive uropathy from prostatic disease 341 (table 1). The majority presented with the onset of or worsening of symptoms of urinary J Clin Pathol: first published as 10.1136/jcp.51.4.340 on 1 April 1998. Downloaded from outflow obstruction. The best documented and most recent cases occurred with chronic lymphocytic leukaemia, in which 20 cases of 29 presented with acute urinary retention; subse- quent investigation and treatment of this revealed leukaemic infiltration of the prostate. A necropsy study of 503 leukaemic patients showed that the actual incidence of metastases to the prostate is higher than the number of case reports would suggest.10 Necropsy re- vealed up to 40% prostatic infiltration in acute lymphoblastic leukaemia (ALL), 11–20% in chronic lymphocytic leukaemia (CLL), 11– 20% in acute myeloblastic leukaemia (AML), and between 1% and 10% in chronic myelo- cytic leukaemia (CML).10 These frequencies reflect the tendencies of the diVerent leukae- Figure 1 Prostate infiltrated by chronic myelomonocytic leukaemia cells. (Haematoxylin and eosin, ×149.) mias to metastasise to non-reticuloendothelial tissues. The discrepancy between the fre- quency of case reports and incidence of prostatic involvement found at necropsy re- flects the fact that unless urinary symptoms develop prostatic involvement is unlikely to be detected. The extent to which the leukaemic infiltrate contributes to urinary obstruction is unknown. The best documented cases of CLL infiltration of the prostate associated with urinary retention were combined with histological evidence of benign prostatic hypertrophy or with bladder trabeculation, suggesting chronic obstruction. Certainly others suggest that the presence of benign prostatic hypertrophy is necessary to precipitate retention, and not all cases with leu- kaemic infiltration of the prostate develop 6 obstructive symptoms. Cases of acute retention http://jcp.bmj.com/ in acute leukaemia may be explained by other Figure 2 Chronic myelomonocytic leukaemia in prostate. Many cells are positive for mechanisms, such as leukaemic meningitis. CD68. (Immunoperoxidase PGM 1, ×297.) Patients present with typical symptoms of urinary outflow obstruction.6–9 The prostate is Table 1 Summary of reported cases of leukaemic uniformly enlarged and smooth, as in benign infiltration of the prostate gland prostatic hypertrophy. In CLL, lymphocytic Cases with Cases with infiltration is irregular in distribution, so that on September 26, 2021 by guest. Protected copyright. prostatic urinary preoperative needle biopsy is unreliable. There Leukaemia type histology retention are insuYcient published data to show whether CLL 24 15 this is also true for granulocytic leukaemias. It Acute granulocytic 3 3 Chronic granulocytic 2 2 has been suggested that patients who present Chronic myelomonocytic (present with acute granulocytic leukaemia and urinary case) 1 1 retention tolerate surgical transurethral resec- Cases with no prostatic histology 22 tion of the prostate for alleviation of symptoms less well than patients with CLL, in whom the glands and particularly of the fibromuscular five year survival is good.6 Therefore, where the stroma. Prostatic stromal elements were infil- diagnosis is known in advance, preoperative trated by dense masses and cords of cells (fig 1). prostatic needle biopsy is warranted in these These were of medium size with slight pleomor- patients and other treatment options should be phism. The nucleus was ovoid to rounded and considered. This patient responded to surgical vesicular cytoplasm varied in extent; in some it transurethral resection of the prostate and he was granular. Chloroacetate esterase staining subsequently died after transformation to was positive in many of these cells. Immunohis- AML. tochemical staining was positive in most cells Dajani and Burke reported five previous for lysozyme, in many for CD43 and CD45, cases of granulocytic leukaemia (table 1) caus- and in many for CD68 (fig 2). ing urinary retention.6 However, precise de- fined subtyping of the granulocytic infiltrate is Discussion lacking. We were unable to find a conclusive Case reports concerning leukaemic infiltration report in the English language literature of of the prostate are uncommon. Dajani
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