Loading

JSM Clinical Oncology and Research

Published: 6-Dec-18Spinal Myeloid Sarcoma Presenting as Paraplegia: A Case Report

Case Report | Open Access Volume 7 | Issue 1 |

  • 1. Department of Clinical Oncology, Jinnah Postgraduate Medical Center, Pakistan
+ Show More - Show Less
Corresponding Authors
Maryum Nouman, Department of Clinical Oncology, Jinnah Postgraduate Medical Center, Karachi, Pakistan, Tel: +92-332-3393166
Abstract

Objective: Myeloid sarcoma comprising of immature granulocytic cells is a rare, extra medullary tumor. Spinal cord compression caused by a myeloid sarcoma is even more so. This study reports a case of spinal myeloid sarcoma presenting with paraplegia.

Patient and method: 18-year-old male presented with progressively worsening back pain leading to paraplegia. Magnetic resonance imaging (MRI) dorsal spine revealed a soft tissue mass extending from D4 through D8 causing compression of cord in mid dorsal region. The patient underwent surgical decompression. Histology confirmed the diagnosis of myeloid sarcoma. Post operatively bone marrow biopsy showed no evidence of myeloproliferative neoplasm. The patient then received systemic chemotherapy in line of Acute Myeloid Leukemia (AML).

Result: After 9 months patient reports complete relief of symptoms. Post treatment MRI shows no evidence of compressive or residual disease.

Conclusion: Spinal myeloid sarcoma presenting as paraplegia is very rare. We suggest that clinical suspicion can lead to early diagnosis and appropriate management.

Keywords
  • Myeloid sarcoma
  • Myeloid leukemia
  • Spinal tumor
  • Paraplegia

 

Citation

Nouman M, Shaikh M, Haider G, Meher K (2019) Published: 6-Dec-18Spinal Myeloid Sarcoma Presenting as Paraplegia: A Case Report. JSM Clin Oncol Res 7(1): 1061.

INTRODUCTION

Myeloid sarcoma or chloroma comprising of immature granulocytic cells is a rare, extramedullary tumor. It may be seen in the setting of acute or chronic leukemia or myeloproliferative disorders but seldom reported in otherwise healthy patients without any evidence of systemic disease [1]. Spinal epidural myeloid sarcoma is uncommon, and spinal cord compression caused by a myeloid sarcoma is even more so[2]. This study reports a rare case of spinal myeloid sarcoma presenting as paraplegia. It was treated successfully with surgical decompression of spinal cord followed by chemotherapy.

CASE PRESENTATION

An 18-year-old male presented to us with progressively worsening back pain for the past 18 months. It was dull and continuous, not radiating. There were no predisposing factors like trauma. Initially he consulted a local medical practitioner and received systemic and local analgesics along with muscle relaxants. In spite of these measures, his pain continued to increase over the time and eventually led to paraplegia.

Following this, the patient consulted a neurosurgeon who referred him for imaging of the spine.

MRI dorsal spine with contrast revealed large enhancing extradural soft tissue mass extending from D4 through D8 with intra the cal extension causing compression of cord in mid dorsal region. It was predominantly on the right side with extension in the right paraspinal muscles with cranio-caudal extension of about 10.2cm (Figure 1).

Figure 1 Showing an enhancing extradural soft tissue mass extending  from D4 through D8.

Figure 1 Showing an enhancing extradural soft tissue mass extending from D4 through D8.

Keeping in view the worsening of symptoms and paraplegia, he underwent excisional biopsy of dorsal spinal mass, laminectomy and decompression.

Following surgical decompression, he underwent radiation therapy of the spinal cord for cord compression; total dose of 30Gy.

Histopathology revealed a neoplastic lesion comprising of intermediate to large sized cells arranged in sheets with background showing abundant eosinophil infiltrate. These cells stained positive for LCA, MPO, CD 68, CD 117 with increased Ki-67 proliferative index. It was negative for Pan B (CD 20/ 79a), Pan T (CD 3), Tdt, CD 30, CD 138 and PAX 5. These immunohistochemical findings were consistent with the diagnosis of myeloid sarcoma.

The patient was referred to us in Medical Oncology for further management. We carried out thorough history and physical examination. Karyotyping showed normal cytogenetics. We did bone marrow biopsy to rule out myeloid sarcoma associated with Acute Myeloid Leukemia (AML). It showed no evidence of bone marrow involvement with myeloproliferative disorder.

The patient underwent “3+7” induction chemotherapy with daunorubicinand cytarabine followed by four cycles of consolidation with high dose cytarabine.

Post consolidation MRI of the dorsal spine with contrast revealed complete response to treatment with no residual disease. It shows post-surgical changes with evidence of laminectomy from D2 to D8 (Figure 2).

Figure 2 Showing laminectomy with complete resolution of mass.

Figure 2 Showing laminectomy with complete resolution of mass.

The patient reports complete resolution of symptoms with ability to walk and perform daily activities. He is disease and symptom free on follow up of one year.

DISCUSSION

A myeloid sarcoma also known as chloroma or granulocytic sarcoma is a rare, extra medullary myeloid tumor. It is a solid tumor composed of immature granulocytes [3]. It is a rare hematologic phenomenon in patients with AML with an incidence as low as 2.5 to 9.1% [1, 4].It may occur during the course or just preceding or following leukemia [1,4].

Myeloid sarcoma has a predilection for males (male-to-female ratio, 1.2:1) [5,6].

Sites commonly involved include the skin, lymph nodes, gastrointestinal tract, bone, soft tissue, and testis.[7,8] However, spinal cord involvement is even less than 1 percent [9].

Spinal myeloid sarcoma may present with varied symptoms depending upon the site. Those with involvement of para-spinal muscles may lead to spinal cord compression due to mass effect [2]. In the case presented here, patient initially reported progressively increasing back pain that eventually led to paraplegia.

Spinal myeloid sarcoma is often challenging to diagnose because the clinical data and imaging is usually nonspecific. It often appears as a soft tissue mass on computed tomography or MRI that does not point to a specific diagnosis [2,9]. Hence, it is crucial to obtain a tissue biopsy to formulate a diagnosis of myeloid sarcoma. Following this, immunohistochemistry and a series of markers is a practical guide that aids in the diagnosis and further characterization of the tumor [10].

In this case, the patient underwent excisional biopsy of the dorsal spinal mass, laminectomy, and cord decompression. Immunohistochemical stains showed positive staining with LCA, MPO, CD 68, CD 117 with increased Ki-67 proliferative index which helped to confirm the diagnosis as these are the most commonly expressed markers of myeloid differentiation[11].

Given the rare incidence of spinal myeloid sarcoma, the clinical suspicion of the disease should be kept high so that the treatment can start at optimal timing. Possible treatment strategies include chemotherapy, hematopoietic stem cell transplantation (HSCT), radiotherapy and surgery. Literature reveals large randomized studies, which assessed the prognosis of isolated myeloid sarcoma. Systemic chemotherapy used in the treatment of AML remains the best strategy for treating this set of patients, but the optimal timing remains controversial [13,15-17]. Surgery is however limited to the cases with symptomatic compression due to the tumor [12]. We reviewed cases of spinal myeloid sarcoma presenting with cord compression from the literature (Table 1), [18-26]. Surgical excision of the tumor appeared to be the first treatment option in these cases.

In our case, patient underwent surgery for decompression followed by systemic chemotherapy that led to complete response.

Inoue et al identified 26 patients of myeloid sarcoma from the literature who had no evidence of myeloid leukemia, and it was found that the treatment strategy varied from individual to individual [14]. Surgical decompression was performed in 22 patients, and 21 of the patients received additional AML-type systemic treatment. However, the outcome of the patients varied and was poor in those who showed progression to leukemia. Overall, prompt diagnosis and adequate treatment are critical to achieve a better outcome.

CONCLUSION

Spinal myeloid sarcoma presenting as paraplegia is very rare. Clinical suspicion of the disease can lead to early diagnosis and appropriate management. Keeping in view our patient and previous cases from literature, we suggest that prompt diagnosis followed by emergency decompression and intensive chemotherapy in the line of management of AML can lead to complete recovery objectively and clinically and can prevent neurological damage.

Table 1:

No. Reference Age/ Gender Diagnosis and IHC           Site / Extent Signs and symptoms Treatment Outcome
1 Amalraj et. Al [18] 4/M Granulocytic sarcoma promyelocytic leukemia AML M3 T3-T10 *Acute paraplegia
*Weakness of both lower limbs
*Numbness of both lower limbs
*Back pain
radiotherapy and chemotherapy Paraplegia improved
2 Olcay et al. 2009 [19] 12/M Acute myeloid leukemia CD45:95.15%,  
CD15: 35.56%, 
CD33:77.57%, 
CD117:79.3%, 
CD34:43.38%, 
CD13:29.32 %.
*Lumbar (L3) 
-Conus medullaris
*Left maxillary mass
Conus medullaris syndrome *Chemotherapy + triple intratecal therapy *Radiotherapy Symptom partially resolved died because of pneumonia and disseminated intravascular coagulation
3 Yin et al. 2010 [20] 28/M myeloid sarcoma with acute myeloid leukemia CD68, CD45, CD43, CD117 and lysozyme but not of MPO, CD20 T12-L1 *low back pain
*numbness of his legs
*bladder incontinence
*hypoesthesia below T12 paraparesis
High-dose methyl-prednisolone Decompression with T12-L1 laminectomy and tumor resection. Paraparesis Improvement
4 Bittencourt et al. 2011[21] 53/M *Acute promyelocytic leukemia presenting as extradural mass *PCR for the PML-RARα gene was positive T6-T8 *Progressive fatigue, pain legs weakness 
Paraparesis
*Gingival hemorrhage, hepatomegaly
*delais 4 months/ chemotherapy 
(daunorubicin) 
*Radiotherapy
/Evolution: no neurologic improvement + died of sepsis
5 Kyaw et al. 2012[22] 26/M Myeloid sarcoma: acute promyelocytic leukemia CD33, CD117, CD64, CD34 and cytoplasmic MPO were presented Reverse transcriptase-polymerase chain reaction showed BCR1-type PML-RARα fusion copies T2-T4 and T12 – L2 Progressive back pain and bilateral leg weakness: -paraparesis Loss of pain and sensory perception *Radiotherapy
*Chemotherapy: 
retinoic acid + ida rubicin
*Neurological improvement -Good remission
6 Ben et al. 2013 [23] 21/M *chloroma
*positive for myeloperoxidase
*acute myeloblasti cleukaemia (AML
T4/ T7, T1-T2 Progressive paraplegia. urinary retention *laminectomy  +  tumour was totally removed.
*rubidomycine 
(45 mg/m2 daily for 3 days) and cytosine arabinoside (200 mg/ mm2continuous infusion for 7 days)
improvement paraplegia
7 Krishna murthy et al. 2014 [24] 16 /M Granulocytic sarcoma associated with acute myeloblasticleukaemia (AML)   Low backaches follow proptosis, spinal cord causing significant compression of the spinal cord. -radiotherapy and chemotherapy  
8 Joseph JR 2015 [25] 20/M Myeloid sarcoma associated with AML   acute onset weakness and numbness in his lower extremities *Radiation
*surgical decompression
Worsening of symptoms
9 Hyun Ho Oh 2016 [26 66/M Myeloid Sarcoma T12-L2 *Progressive back pain
*Numbness in lower extremities
*Dexamethasone
*Radiation
chemotherapy with daunorubucin and cytarabine
Partial improvement in symptoms

 

REFERENCES

1. Bakst R, Wolden S, Yahalom J. Radiation therapy for chloroma (granulocytic sarcoma). Int J Radiat Oncol Biol Phys. 2012; 82: 1816- 1822.

2. Hu X, Shahab I, Lieberman IH. Spinal Myeloid Sarcoma “Chloroma” Presenting as Cervical Radiculopathy: Case Report. Global Spine J. 2015; 5: 241-246.

3. Karlin L, Itti E, Pautas C, Rachid M, Bories D, Cordonnier C, et al. “PET-imaging as a useful tool for early detection of the relapse site in the management of primary myeloid sarcoma”. Haematologica. 2006; 91: (12 Suppl): EcR54.

4. Bakst R L, Tallman M S, Douer D, Yahalom J. How I treat extramedullary acute myeloid leukemia. Blood. 2011; 118: 3785-3793.

5. Falini B, Lenze D, Hasserjian R, Coupland S, Jaehne D, Soupir C, et al. Cytoplasmic mutated nucleophosmin (NPM) defines the molecular status of a significant fraction of myeloid sarcomas. Leukemia. 2007; 21: 1566-1570.

6. Pileri SA, Ascani S, Cox MC, Campidelli C, Bacci F, Piccioli M, et al. Myeloid sarcoma: clinico-pathologic, phenotypic and cytogenetic analysis of 92 adult patients. Leukemia. 2007; 21: 340-350.

7. Tran CN, Collie AM, Flagg A, Rhee A. Testicular myeloid sarcoma: a rare manifestation of acute myeloid leukemia in an infant. Urology. 2014; 84: 925-927.

8. Seifert RP, Bulkeley W, Zhang L, Menes M, Bui MM. A practical approach to diagnose soft tissue myeloid sarcoma preceding or coinciding with acute myeloid leukemia. Ann Diagn Pathol. 2014; 18: 253-260.

9. Seok J H, Park J, Kim S K, Choi J E, Kim C C. Granulocytic sarcoma of the spine: MRI and clinical review. AJR Am J Roentgenol. 2010; 194: 485-489.

10. Bakst R L, Tallman M S, Douer D, Yahalom J. How I treat extramedullary acute myeloid leukemia. Blood. 2011; 118: 3785-3793.

11. Campidelli C, Agostinelli C, Stitson R, Pileri SA. Myeloid sarcomextramedullary manifestation of myeloid disorders. Am J Clin Pathol. 2009; 132: 426-437.

12. Cheah KL, Lim LC, Teong HH, Chua SH. A case of generalized cutaneous granulocytic sarcoma in an elderly patient with myelodysplastic syndrome. Singapore Med J. 2002; 43: 527-529.

13. Zago LBR, Ladeia AAL, Etchebehere RM, de Oliveira LR. Testicular myeloid sarcoma: case report. Rev Bras Hematol Hemoter. 2013; 35: 68-70.

14. Inoue T, Takahashi T, Shimizu H, Kanamori M, Kumabe T, Watanabe M, et al. Spinal granulocytic sarcoma manifesting as Radiculopathy in a nonleukemic patient. Neurol Med Chir (Tokyo). 2008; 48: 131-136.

15. Yilmaz AF, Saydam G, Sahin F, Baran Y. Granulocytic sarcoma: a systematic review. Am J Blood Res. 2013; 3: 265-270.

16. Bakst RL, Tallman MS, Douer D, Yahalom J. How I treat extramedullary acute myeloid leukemia. Blood 2011; 118: 3785-3793.

17. Avni B, Koren-Michowitz M. Myeloid sarcoma: current approach and therapeutic options. Ther Adv Hematol .2011; 2: 309-316.

18. Amalraj P, Syamlal S. Unusual case of paraplegia. Ann Indian Acad Neurol. 2009; 12: 188-190.

19. Olcay L, Ariba? BK, Gökçe M. A patient with acute myeloblastic leukemia who presented with conus medullaris syndrome and review of the literature. J PediatrHematolOncol. 2009; 31: 440-447.

20. Yin Q, Zhou YY, Chen D, Li WL. Different outcome of myeloid sarcoma with spinal cord compression preceding acute myeloid leukemia: report of two cases and review of literature. Chin J Cancer Res. 2010; 22:156-162.

21. Bittencourt H, Teixeira Junior AL, Glória AB, Ribeiro AF, Fagundes EM. Acute promyelocytic leukemia presenting as an extradural mass. Rev Bras HematolHemoter. 2011; 33: 478-480.

22. Kyaw TZ, Maniam JAS, Bee PC, Cin EFM, Nadarajan VS, Shanmugam H, et al. Myeloid sarcoma: an unusual presentation of acute promyelocytic leukemia causing spinal cord compression. Turk J Hematol. 2012; 29: 278-282.

23. Ben FW, Zahra K, Ben HI, Hadhri R, Khelif A. Paraplegia due to chloroma as the initial presenting feature of acute myeloid leukemia. Pan Arab J Neurosurg. 2013; 17: 4.

24. Krishnamurthy VG, Narendra SS, Bhagwat KA, Shashikala P, Prashanth S, Khanpur R. Granulocyte sarcoma presenting as acute paraplegia and Proptosis. J Pub Health Med Res. 2014; 2: 52-54.

25. Joseph JR, Wilkinson DA, Bailey NG, Lieberman AP, Tsien CI, Orringer DA. Aggressive Myeloid Sarcoma Causing Recurrent Spinal Cord Compression. World Neurosurg. 2015; 84: 866e7-10.

26. Hyun Ho Oh, Hyun-Jung Kim, Tae-Hee Han, Min Kwan Kwon, Soo Ya Bae, Young JinYuh. Isolated Myeloid Sarcoma Presenting as Cord Compression by Paraspinal Mass. Ewha Med J. 2016; 39: 17-22

Nouman M, Shaikh M, Haider G, Meher K (2019) Published: 6-Dec-18Spinal Myeloid Sarcoma Presenting as Paraplegia: A Case Report. JSM Clin Oncol Res 7(1): 1061.

Received : 19 Jan 2018
Accepted : 06 Feb 2019
Published : 08 Feb 2019
Journals
Annals of Otolaryngology and Rhinology
ISSN : 2379-948X
Launched : 2014
JSM Schizophrenia
Launched : 2016
Journal of Nausea
Launched : 2020
JSM Internal Medicine
Launched : 2016
JSM Hepatitis
Launched : 2016
JSM Oro Facial Surgeries
ISSN : 2578-3211
Launched : 2016
Journal of Human Nutrition and Food Science
ISSN : 2333-6706
Launched : 2013
JSM Regenerative Medicine and Bioengineering
ISSN : 2379-0490
Launched : 2013
JSM Spine
ISSN : 2578-3181
Launched : 2016
Archives of Palliative Care
ISSN : 2573-1165
Launched : 2016
JSM Nutritional Disorders
ISSN : 2578-3203
Launched : 2017
Annals of Neurodegenerative Disorders
ISSN : 2476-2032
Launched : 2016
Journal of Fever
ISSN : 2641-7782
Launched : 2017
JSM Bone Marrow Research
ISSN : 2578-3351
Launched : 2016
JSM Mathematics and Statistics
ISSN : 2578-3173
Launched : 2014
Journal of Autoimmunity and Research
ISSN : 2573-1173
Launched : 2014
JSM Arthritis
ISSN : 2475-9155
Launched : 2016
JSM Head and Neck Cancer-Cases and Reviews
ISSN : 2573-1610
Launched : 2016
JSM General Surgery Cases and Images
ISSN : 2573-1564
Launched : 2016
JSM Anatomy and Physiology
ISSN : 2573-1262
Launched : 2016
JSM Dental Surgery
ISSN : 2573-1548
Launched : 2016
Annals of Emergency Surgery
ISSN : 2573-1017
Launched : 2016
Annals of Mens Health and Wellness
ISSN : 2641-7707
Launched : 2017
Journal of Preventive Medicine and Health Care
ISSN : 2576-0084
Launched : 2018
Journal of Chronic Diseases and Management
ISSN : 2573-1300
Launched : 2016
Annals of Vaccines and Immunization
ISSN : 2378-9379
Launched : 2014
JSM Heart Surgery Cases and Images
ISSN : 2578-3157
Launched : 2016
Annals of Reproductive Medicine and Treatment
ISSN : 2573-1092
Launched : 2016
JSM Brain Science
ISSN : 2573-1289
Launched : 2016
JSM Biomarkers
ISSN : 2578-3815
Launched : 2014
JSM Biology
ISSN : 2475-9392
Launched : 2016
Archives of Stem Cell and Research
ISSN : 2578-3580
Launched : 2014
Annals of Clinical and Medical Microbiology
ISSN : 2578-3629
Launched : 2014
JSM Pediatric Surgery
ISSN : 2578-3149
Launched : 2017
Journal of Memory Disorder and Rehabilitation
ISSN : 2578-319X
Launched : 2016
JSM Tropical Medicine and Research
ISSN : 2578-3165
Launched : 2016
JSM Head and Face Medicine
ISSN : 2578-3793
Launched : 2016
JSM Cardiothoracic Surgery
ISSN : 2573-1297
Launched : 2016
JSM Bone and Joint Diseases
ISSN : 2578-3351
Launched : 2017
JSM Bioavailability and Bioequivalence
ISSN : 2641-7812
Launched : 2017
JSM Atherosclerosis
ISSN : 2573-1270
Launched : 2016
Journal of Genitourinary Disorders
ISSN : 2641-7790
Launched : 2017
Journal of Fractures and Sprains
ISSN : 2578-3831
Launched : 2016
Journal of Autism and Epilepsy
ISSN : 2641-7774
Launched : 2016
Annals of Marine Biology and Research
ISSN : 2573-105X
Launched : 2014
JSM Health Education & Primary Health Care
ISSN : 2578-3777
Launched : 2016
JSM Communication Disorders
ISSN : 2578-3807
Launched : 2016
Annals of Musculoskeletal Disorders
ISSN : 2578-3599
Launched : 2016
Annals of Virology and Research
ISSN : 2573-1122
Launched : 2014
JSM Renal Medicine
ISSN : 2573-1637
Launched : 2016
Journal of Muscle Health
ISSN : 2578-3823
Launched : 2016
JSM Genetics and Genomics
ISSN : 2334-1823
Launched : 2013
JSM Anxiety and Depression
ISSN : 2475-9139
Launched : 2016
Clinical Journal of Heart Diseases
ISSN : 2641-7766
Launched : 2016
Annals of Medicinal Chemistry and Research
ISSN : 2378-9336
Launched : 2014
JSM Pain and Management
ISSN : 2578-3378
Launched : 2016
JSM Women's Health
ISSN : 2578-3696
Launched : 2016
Clinical Research in HIV or AIDS
ISSN : 2374-0094
Launched : 2013
Journal of Endocrinology, Diabetes and Obesity
ISSN : 2333-6692
Launched : 2013
Journal of Substance Abuse and Alcoholism
ISSN : 2373-9363
Launched : 2013
JSM Neurosurgery and Spine
ISSN : 2373-9479
Launched : 2013
Journal of Liver and Clinical Research
ISSN : 2379-0830
Launched : 2014
Journal of Drug Design and Research
ISSN : 2379-089X
Launched : 2014
JSM Bioinformatics, Genomics and Proteomics
ISSN : 2576-1102
Launched : 2014
JSM Chemistry
ISSN : 2334-1831
Launched : 2013
Journal of Trauma and Care
ISSN : 2573-1246
Launched : 2014
JSM Surgical Oncology and Research
ISSN : 2578-3688
Launched : 2016
Annals of Food Processing and Preservation
ISSN : 2573-1033
Launched : 2016
Journal of Radiology and Radiation Therapy
ISSN : 2333-7095
Launched : 2013
JSM Physical Medicine and Rehabilitation
ISSN : 2578-3572
Launched : 2016
Annals of Clinical Pathology
ISSN : 2373-9282
Launched : 2013
Annals of Cardiovascular Diseases
ISSN : 2641-7731
Launched : 2016
Journal of Behavior
ISSN : 2576-0076
Launched : 2016
Annals of Clinical and Experimental Metabolism
ISSN : 2572-2492
Launched : 2016
Clinical Research in Infectious Diseases
ISSN : 2379-0636
Launched : 2013
JSM Microbiology
ISSN : 2333-6455
Launched : 2013
Journal of Urology and Research
ISSN : 2379-951X
Launched : 2014
Journal of Family Medicine and Community Health
ISSN : 2379-0547
Launched : 2013
Annals of Pregnancy and Care
ISSN : 2578-336X
Launched : 2017
JSM Cell and Developmental Biology
ISSN : 2379-061X
Launched : 2013
Annals of Aquaculture and Research
ISSN : 2379-0881
Launched : 2014
Clinical Research in Pulmonology
ISSN : 2333-6625
Launched : 2013
Journal of Immunology and Clinical Research
ISSN : 2333-6714
Launched : 2013
Annals of Forensic Research and Analysis
ISSN : 2378-9476
Launched : 2014
JSM Biochemistry and Molecular Biology
ISSN : 2333-7109
Launched : 2013
Annals of Breast Cancer Research
ISSN : 2641-7685
Launched : 2016
Annals of Gerontology and Geriatric Research
ISSN : 2378-9409
Launched : 2014
Journal of Sleep Medicine and Disorders
ISSN : 2379-0822
Launched : 2014
JSM Burns and Trauma
ISSN : 2475-9406
Launched : 2016
Chemical Engineering and Process Techniques
ISSN : 2333-6633
Launched : 2013
Annals of Clinical Cytology and Pathology
ISSN : 2475-9430
Launched : 2014
JSM Allergy and Asthma
ISSN : 2573-1254
Launched : 2016
Journal of Neurological Disorders and Stroke
ISSN : 2334-2307
Launched : 2013
Annals of Sports Medicine and Research
ISSN : 2379-0571
Launched : 2014
JSM Sexual Medicine
ISSN : 2578-3718
Launched : 2016
Annals of Vascular Medicine and Research
ISSN : 2378-9344
Launched : 2014
JSM Biotechnology and Biomedical Engineering
ISSN : 2333-7117
Launched : 2013
Journal of Hematology and Transfusion
ISSN : 2333-6684
Launched : 2013
JSM Environmental Science and Ecology
ISSN : 2333-7141
Launched : 2013
Journal of Cardiology and Clinical Research
ISSN : 2333-6676
Launched : 2013
JSM Nanotechnology and Nanomedicine
ISSN : 2334-1815
Launched : 2013
Journal of Ear, Nose and Throat Disorders
ISSN : 2475-9473
Launched : 2016
JSM Ophthalmology
ISSN : 2333-6447
Launched : 2013
Journal of Pharmacology and Clinical Toxicology
ISSN : 2333-7079
Launched : 2013
Annals of Psychiatry and Mental Health
ISSN : 2374-0124
Launched : 2013
Medical Journal of Obstetrics and Gynecology
ISSN : 2333-6439
Launched : 2013
Annals of Pediatrics and Child Health
ISSN : 2373-9312
Launched : 2013
JSM Clinical Pharmaceutics
ISSN : 2379-9498
Launched : 2014
JSM Foot and Ankle
ISSN : 2475-9112
Launched : 2016
JSM Alzheimer's Disease and Related Dementia
ISSN : 2378-9565
Launched : 2014
Journal of Addiction Medicine and Therapy
ISSN : 2333-665X
Launched : 2013
Journal of Veterinary Medicine and Research
ISSN : 2378-931X
Launched : 2013
Annals of Public Health and Research
ISSN : 2378-9328
Launched : 2014
Annals of Orthopedics and Rheumatology
ISSN : 2373-9290
Launched : 2013
Journal of Clinical Nephrology and Research
ISSN : 2379-0652
Launched : 2014
Annals of Community Medicine and Practice
ISSN : 2475-9465
Launched : 2014
Annals of Biometrics and Biostatistics
ISSN : 2374-0116
Launched : 2013
JSM Clinical Case Reports
ISSN : 2373-9819
Launched : 2013
Journal of Cancer Biology and Research
ISSN : 2373-9436
Launched : 2013
Journal of Surgery and Transplantation Science
ISSN : 2379-0911
Launched : 2013
Journal of Dermatology and Clinical Research
ISSN : 2373-9371
Launched : 2013
JSM Gastroenterology and Hepatology
ISSN : 2373-9487
Launched : 2013
Annals of Nursing and Practice
ISSN : 2379-9501
Launched : 2014
JSM Dentistry
ISSN : 2333-7133
Launched : 2013
Author Information X