Acute Promyelocytic Leukemia

Hematology ConferenceSlide Review

August 11, 2008

General Data

E.I. 42 year old, male Married Filipino Mechanic/welder Roman Catholic Resides in Nueva Ecija

CC: Dizziness

Date of Admission : 7/08/08, 6amDate of Interview : 7/08/08, 7amSource & Reliability : Patient 85% reliability

HPI4 weeks PTA:•Hematoma on left shoulder after trauma (grew in size, longer time than usual to resolve)

•Bleeding gums after using a toothpick (bled for two days)

•No fever, abdominal pain, epistaxis nor jaundice

•No medications taken, nor consult done

HPI3 weeks PTA: •Dizziness (lightheadedness) during minimal activities

•Accompanied by weakness, easy fatigability and fever (40.8C)

•Paracetamol 500mg/tab slight relief from fever

•Large hematoma of posterior left thigh with no accompanying trauma

HPI1 week PTA: •Persistance of symptoms•Worsening of dizziness and weakness

•Consult at local hospital•CBC and urinalysis•Dx: Aplastic anemia•Transfused 4 ‘u’ of platelet concentrate and 5 ‘u’ of FWB

•Referred to USTH for specialistA D M I S S I O N

Review of Systems

General(-) weight change(-) chills(-) sweats

Skin(-) rashes (-) sores (-) itching (-) dryness (-) color changes (-) changes in hair or nails

Ears(-) hearing difficulties(-) infection

(-) tinnitus (-) discharge Eyes

(-) redness (-) itchiness (-) glaucoma (-) cataracts

Review of Systems

Nose (-) cold

(-) discharges

Throat/Mouth (-) sore throat (-) hoarseness

Neck(+) submandibular mass, left (-) swollen glands(-) stiff neck

Respiratory (-) hemoptysis (-) wheezing

Gastrointestinal (-) melena and hematochezia

(-) diarrhea/constipation (-) jaundice

Cardiac (-) Chest pain (-) Orthopnea (-) Palpitatons

Review of Systems

Vascular (-) claudication (-) varicosities

Genitourinary (-) urinary frequency (-) hematuria (-) dysuria

Musculoskeletal (-) stiffness (-) muscle pain

(-) joint pain

Psychiatric (-) tension (-) anxiety

Neurologic (+) headache

(-) fainting (-) seizures (-) motor or sensory loss

(-) numbness

Past Medical History

Immunizations: Unrecalled immunizationsOperations: (–) Illnesses: 2003 gouty arthritis – relieved by

Allopurinol and ColchicineAllergies: No known allergies to food or

drugsNo medications or vitamins (-) DM, HPN, Hepatitis

Smoker: 24 pack yearAlcohol beverage drinker – 3x/week (at most

2 bottles of beer each)Used methamphetamine (2002)Diet

Mixed, mostly seafood Water Source MWSS, not boiled Food Source cooks food at home

Personal and Social History

(+) Travel to Aurora province Chemical exposure (at work) – acetylene,

benzeneGood family support/relationship, lives with

wife and 5 childrenGood relationship with peers

Personal and Social History

Family History

(+) Leukemia – cousin (+) Breast Cancer – cousin (–) HPN (–) DM (–) TB (–) Stroke

PE on Admission

BP: 110/80 PR: 88 regular RR: 19 regular Temp: 36.7 C BMI: 25.7

Wt: 70 kg Ht: 165 cm

Physical Exam

General Conscious, coherent, ambulatory, not in CP distress

Skin Warm, moist skin, (-) jaundice, no active dermatoses

HEENT Pink palpebral conjunctiva, anicteric sclerae, pupils 2–3mm

ERTL, no tragal tenderness, no nasoaural discharge (+) Gum bleeding on lower incisors, Moist buccal mucosa,

non hyperemic PPW, tonsils not enlarged Supple neck, (+)1.5 x 1.5 cm, left palpable, tender,

submandibular lymph node, thyroid not enlarged

Breasts Symmetrical, no masses, no discharge

Thorax/Lungs Symmetrical chest expansion, no retractions, equal

tactile and vocal fremiti, no crackles/wheezes Cardiovascular

Adynamic precordium, AB 5th LICS MCL, S1 > S2 at apex, S2 >S1 at base, (-) murmur

Physical Exam

Physical Exam

Abdomen Flabby abdomen, soft, NABS, no bruits No tenderness Non-palpable liver edge Traube’s space not obliterated No CVA tenderness

Physical Exam

Musculoskeletal No muscle atrophy , no swelling in all extremities No tenderness, swelling nor limitation in motion

Extremities no cyanosis, clubbing Pulses full and equal (-) Edema

Physical Exam

Neurologic Mental Status: Conscious, coherent, oriented to time,

person and place, follows commands. Cranial nerves: all intact Motor: No muscle atrophy/hypertrophy, no fasciculations,

tremors, rigidity, spasticity MMT: 5/5 on all extremities Cerebellar: can do FTNT, APST Gait: normal No sensory deficits DTR's ++ No babinski, No nuchal rigidity

5/55/5

5/55/5

Subjective data (+) gum bleeding (+) dizziness (+) weakness (+) easy fatigability (+) fever of 40.8 deg C

Salient Features

Salient Features

Objective data (+) gum bleeding on lower incisors (+) 1.5x1.5 cm palpable, tender submandibular lymph

node, left

Clinical Assessment

t/c Acute Leukemia

LABORATORIES

CBC 7/8 7/9 7/10 7/11 7/12 7/13 7/15 7/17 7/18 7/20

Hgb 81 103 98 98 99 98 96 88 78 74

Hct 0.23 0.29 0.27 0.28 0.26 0.27 0.27 0.25 0.23 0.21

MCV 85.4 85.6 85.8 85.4 82.6 80.1 80.60 80.0 80.7 79.6

MCH 30.7 30.4 30.8 30.2 32 28.6 28.80 28.5 27.3 28.2

MCHC 36 35.5 35.9 35.3 38.8 35.7 35.70 35.6 33.8 35.4

Plt 20 40 20 40 80 80 150 40 140 40

WBC 3.7 4.9 3.5 5.4 5.2 4.4 4.20 3.6 5.4 9.9

Neutrophil 0.09 0.06 0.05 0.31 0.13 0.13 0.05 0.12 0.17 0.10

Metamyelocytes

0.5 0.04 0.01 0.05 0.03 0.07 0.02 0.07 0.04

Bands 0.01 0.02 0.01 0.01 0.02

Segmented 0.03 0.02 0.04 0.24 0.1 0.05 0.05 0.09 0.08 0.06

Lymphocytes 0.66 0.31 0.45 0.46 0.66 0.78 0.92 0.54 0.58 0.46

Blast 0.24 0.53 0.43 0.1 0.06 0.03 0.12 0.05

Myelocyte 0.08 0.05 0.12 0.15 0.04 0.02 0.02 0.11

Promyelocyte 0.03 0.16 0.16 0.28

CBC 7/22 7/23 7/24 7/25 7/26 7/27 ()

7/27 () 7/29 7/30 7/31 8/1 8/2

Hgb 81 88 102 99 96 99 94 94 87 95 86 95

RBC 2.87 2.99 3.54 3.35 3.98 3.32 3.25 3.27 3.02 3.27 2.96 3.27

Hct 0.23 0.24 0.29 0.28 0.27 0.27 0.27 0.27 0.25 0.27 0.24 0.27

MCV 81.5 80.8 82.6 82.5 83.4 82.4 84.0 82.82 82.2 82.9 81.7 82.0

MCH 28.1 29.4 28.9 29.4 29.2 29.7 28.9 28.6 28.7 29.1 29.0 29.1

MCHC 34.5 36.4 35.0 35.6 35.0 36.1 34.5 34.6 34.9 35.1 35.5 35.5

RDW 17.8 17.6 17.6 17.6 17.0 17.9 16.3 17.8 17.7 17.5 17 17.8

Plt 120 60 40 40 40 20 100 80 60 80 40 152

WBC 16.2 37.5 36.5 32.8 33.3 34.8 25.5 13.5 6.4 3.10 1.60 2.90

Neutrophil 0.24 0.64 0.33 0.87 0.81 0.79 0.42 0.76 0.79 0.78 0.85 0.62

Metamyelocytes 0.15 0.18 0.18 0.19 0.26 0.18 0.12 0.05 0.03 0.03

Bands 0.03 0.18 0.08 0.4 0.22 0.12 0.08 0.04 0.02 0.03

Segmented 0.06 0.28 0.07 0.64 0.33 0.49 0.22 0.67 0.74 0.72 0.85 0.62

Lymphocytes 0.48 0.06 0.16 0.05 0.02 0.07 0.23 0.10 0.16 0.15 0.38

Blast 0.13 0.03 0.06 0.02 0.02

Myelocyte 0.08 0.12 0.20 0.06 0.06 0.05 0.10 0.07 0.03 0.02

Promyelocyte 0.05 0.08 0.25 0.09 0.19 0.02 0.01

Coagulation Assay 7/8 Reference Range (sec)

7/13 ReferenceRange

7/15 Reference range

7/17 Reference range

PT 12.0 10.3-14.1 12.0 10.3-14.1

Normal Control 12.3 12.2

Prothrombin Ratio 1.0 1.0

INR 1.0 1.0

Percent Activity 89.2%

Activated PTT 33.2 27.0-45.4 37.4 27.0-45.4

Normal Control 36.4 37.5

Fibrinogen level 2.5 g/L 2.0-4.0 5.6mg/dl 4-8.5 3.4

D-dimer 1011.0g/L Up to 246.4

Blood Chemistry 7/8 7/13 7/18 7/22 7/24 7/25 7/27 7/29

K mmol/L 3.7 3.5

Na mmol/L 139 138

ioCa mmol/L 1.22

Creatinine mg/dl 1.1 0.94 0.85 0.79 0.81

SGOT-AST U/L 33.7 18.8 23.4

SGPT-ALT U/L 59.7 43.3 54.7 44.2 43.5 54.9 74.2

Total Bilirubin mg/dl 0.37 0.35

Direct Bilirubin mg/dl 0.07 0.07

Indirect Bilirubin mg/dl 0.30 0.28

Chest X-Ray

7/10/08 Lungfields are clear The heart is top normal in size Left costophrenic sulcus is blunted Diaphragm and right costophrenic sulcus are intact IMPRESSION: consider mild pleural reaction on the left,

otherwise, no significant findings.

Ultrasound of liver and spleen

7/11/08 Essentially normal liver and spleen

Urinalysis 7/18

Color Yellow Yellow

Transparency Slightly turbid Slightly turbid

pH 6.50 7.0

Specific gravity 1.015 1.010

Albumin Negative -

Sugar Negative -

Cells:

RBC 10-15/hpf 8 – 12/hpf

Pus cells 0-2/hpf 0 -1/hpf

Bacteria Few Few

Mucus threads Few

Amorphous urates Few

No dysmorhic RBC seen No dysmorphic RBC seen

Flow Cytometry

Comprehensive leukemia Panel Bone Marrow: A predominant population of aberrant myeloblasts with highly

variable light scatter properties expressing CD45, CD13, CD33 and CD117 is identified at 79.9% of the white cells. The blast cells show absence of CD34 surface antigen expression of HLA-DR. The phenotypic finding is consistent with Acute Promyelocytic Leukemia.

Interpretation Comment: Correlation with cytogenetic findings for 15,17 translocation is required

Cell Surface markers: Abnormal Cell Population: Aberrant promyelocytes are

detected at 79.9% of the isolated cells. The flow cell sample was analyzed utilizing 14 antibodies

CD45 (+) CD14 (-) HLA-DR (-)

CD4 (-) CD19 (-) Kappa (-)

CD5 (-) CD20 (-) Lambda (-)

CD7 (-) CD33 (+)

CD10 (-) CD34 (-)

CD13 (+) CD117 (+)

2D ECHO

7/14/08Concentric LVH with good wall motion and

contractility and good systolic functionEF: 77%

Culture and Sensitivity

Throat Culture – 7/22/08E. coli moderate growth  Blood Culture and Sensitivity7/20/08 – Left and Right arm: no growth after

24 hours incubation7/24/08 – Left and Right arm: no growth after

5 days incubation

THANK YOU.

Bone Marrow Core Biopsy &Peripheral Blood smears

Bone Marrow Core Biopsy

Bone Marrow Core Biopsy

Bone Marrow Core Biopsy

Bone Marrow Core Biopsy

Marrow biopsy :

- hypercellular

- the abnormal promyelocytes have abundant cytoplasm with numerous granules

- occasional Auer rods may be identified

- nuclei are convoluted

Aspirate smear

Aspirate smears

Aspirate smears

Aspirate smears

Aspirate smears

Aspirate smears

Aspirate smears

Morphology:

Nuclear size and shape in the abnormal promyelocytes of hypergranular APL are irregular (kidney-shaped or bilobed)

Cytoplasm : densely packed cytoplasm, coalescent large granules that almost totally obscure the nuclear, cytoplasmic margin

Characteristic cells containing bundles of Auer rods “faggot cells” are present in most cases.

Myeloblasts with single Auer rods may also be seen.

Acute Promyelocytic LeukemiaM3-AML

Myeloperoxidase : strongly Positive reaction product covering the entire

cytoplasm

Non-specific esterase reaction : weakly Positive 25% cases

Microgranular (Hypogranular) APL – apparent paucity or absence of granules, predominantly bilobed nuclear shape. Hypogranular cytoplasm relates to submicroscopic size of the azurophilic granules.

Flow cytometry

Flow cytometry

Flow cytometry

Flow cytometry

Flow cytometry

Flow cytometry

Flow cytometry

Acute Promyelocytic Leukemia

Immunophenotype:- APL with t(15;17) has a myeloid phenotype- Flowcytometry : CD33

CD13- heterogenous CD2 and CD9 – co-expression

Genetics: - Retinoic acid receptor alpha (RARα) gene on 17q12 fuses with 15q22 (PML gene) = PML-RARα gene fusion product

{171, 272, 857}

Acute Myeloid Leukemia

(FAB-AML-M3)

Acute Promyelocytic Leukemia

An acute myeloid leukemia in which abnormal promyelocytes predominate with both hypergranular or typical APL and microgranular (hypogranular) types exists.

Epidemiology:Comprises 5-8% of AMLCan occur at any age but patients are predominantly

adults in midlife

Acute Promyelocytic Leukemia

Clinical Features of APL- frequently associated with DIC

- Microgranular APL : leukocyte count is very high with rapid doubling time

Acute Promyelocytic Leukemia

Postulated Cell of Origin:- Myeloid stem cell with potential to differentiate to granulocytic lineage

Prognosis:- APL has sensitivity to treatment with all trans-retinoic acid and Anthracine is favorable

Acute Promyelocytic Leukemia

3 Variants of APL1.t (11;17) (q23;21)

- morphological differences with predominance of cells with regular nuclei, many granules, absence of Auer rods, increased number of pseudo Pelger-Huet cells & strong MPO activity.

2.t (15;17) (q32;q12)-predominant population of hypergranular promyelocytes- minor population of hypogranular promyelocytes-Auer rods not identified with LM

3. t (11;17) (q13;q21)

Aspirate smears