PRIMARY GRANULOCYTIC SARCOMA OF THE URINARY BLADDER: CASE REPORT AND REVIEW OF THE LITERATURE HILAL AKI, ZAFER BASLAR, NESRIN UYGUN, MUSTAFA OZGUROGLU, AND NUKHET TUZUNER ABSTRACT We report a case of granulocytic sarcoma of the urinary bladder, with no evidence of hematologic involve- ment. The patient was initially misdiagnosed and was treated with chemotherapy for transitional carcinoma grade 3. Despite this treatment, the clinical features of the patient progressed, and a repeated biopsy yielded the correct diagnosis. Three cases of granulocytic sarcoma of the urinary bladder have been reported in published studies, with only one of these primary. To our knowledge, ours is the second case of granulocytic sarcoma of the urinary bladder presenting with urologic symptoms but without hematologic findings. UROLOGY 60: 345xxiv–345xxvi, 2002. © 2002, Elsevier Science Inc. G ranulocytic sarcoma is a rare tumor composed of immature cells of the granulocytic series. 1 The lesion is also referred to as chloroma because of the greenish hue caused by the presence of my- eloperoxidase within the leukemic cells. It has been reported to occur in association with known acute myelogenous leukemia (AML) and other my- eloproliferative and myelodysplastic syndromes. The most common sites of involvement are soft tissue, orbit, skin, and lymph nodes. In addition to these sites, granulocytic sarcomas localized in var- ious organs have also been reported. 1–3 In this report, we present an unusual case of granulocytic sarcoma of the urinary bladder with- out hematologic manifestations of acute leukemia. CASE REPORT A 36-year-old man was hospitalized in March 1997 with fatigue, pollakiuria, pain in the supra- pubic region, and hematuria. Physical examination revealed normal findings. His past medical history was unremarkable. Laboratory studies revealed normal electrolytes, urea (34 mg/dL; normal 10 to 50), and creatinine (1.1 mg/dL; normal 0.5 to 1.5) and a hemoglobin of 15 g/dL, white blood cell count of 7100 cells/mm 3 (differential 49% seg- mented neutrophils, 42% lymphocytes, 7% mono- cytes, and 2% eosinophils), and platelet count of 261,000 platelets/mm 3 . Computed tomography of the abdomen revealed a 76  67  36-mm solid polypoid mass extending along the left anterolat- eral wall of the urinary bladder. Diagnostic cystos- copy and biopsy were done. Histologic examination of the biopsy material re- vealed many crush artefacts and an area of a dense cellular infiltrate composed of immature cells obliterating the lamina propria and mucosa of the bladder. The neoplastic cells were predominantly medium to large in size with vesicular, round or lobulated nuclei and small to medium-size nucleoli and gray-blue cytoplasm (Fig. 1). The tumor cells stained negative for cytokeratin, CD20, CD45RO, CD45, vimentin, desmin, muscle-specific actin, S-100, HMB-45, kappa, and lambda. These mor- phologic and immunophenotypical findings were interpreted as representing an undifferentiated round cell tumor. However, it was suggested that the neoplastic cells could have an hematopoietic origin. After pathology consultation with a center in the United States, the histopathologic diagnosis was transitional cell carcinoma, grade 3. On the basis of this diagnosis the patient was treated with four cycles of MVAC combination chemotherapy (methotrexate 30 mg/m 2 on days 1, 15, and 22; vinblastine 3 mg/m 2 on days 1, 15, and 22; adria- From the Departments of Pathology, Internal Medicine (Division of Hematology), and Internal Medicine (Division of Oncology), Cerrahpasa Medical School, University of Istanbul, Istanbul, Turkey Address for correspondence: Hilal Akı, M.D., I ˙ stanbul U ¨ niver- sitesi, Cerrahpas ¸a Tıp Faku ¨ ltesi, Patoloji Anabilim Dalı, I ˙ stanbul 34303, Turkey Submitted: December 14, 2001, accepted (with revisions): April 3, 2002 CASE REPORT © 2002, ELSEVIER SCIENCE INC. 0090-4295/02/$22.00 345xxiv ALL RIGHTS RESERVED PII S0090-4295(02)01750-8