Acute Promyelocytic Leukemia

Hematology Conference Slide 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 Date of Interview Source & Reliability

: 7/08/08, 6am : 7/08/08, 7am : Patient 85% reliability

4 weeks PTA: HPI •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

HPI 3 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

1 week PTA: HPI •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 specialist ADMISSION

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

 Respiratory

(-) cold (-) discharges

(-) hemoptysis (-) wheezing

 Throat/Mouth

 Gastrointestinal

(-) sore throat (-) hoarseness

(-) melena and hematochezia

(-) diarrhea/constipation (-) jaundice

 Neck

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

(-)

 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 immunizations

 Operations: (–)  Illnesses: 2003 gouty arthritis – relieved by

Allopurinol and Colchicine  Allergies: No known allergies to food or drugs  No medications or vitamins  (-) DM, HPN, Hepatitis

Personal and Social History  Smoker: 24 pack year  Alcohol 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, benzene  Good family support/relationship, lives with wife

and 5 children  Good relationship with peers

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

Physical Exam  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  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 5/5 5/5 Gait: normal No sensory deficits DTR's ++ No babinski, No nuchal rigidity 5/5

5/5

Salient Features Subjective data     

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

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 Hgb

7/8

7/9

7/10

7/11

7/12

7/13

7/15

7/17

7/18

7/20

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

3.7

4.9

3.5

5.4

5.2

4.4

4.20

3.6

5.4

9.9

0.09

0.06

0.05

0.31

0.13

0.13

0.05

0.12

0.17

0.10

0.5

0.04

0.01

0.05

0.03

0.07

0.02

0.07

0.04

0.01

0.01

0.02

WBC

Neutrophil Metamyel ocytes Bands

Segmente d Lymphocy tes Blast Myelocyte Promyelocyte

0.01

0.02

0.03

0.02

0.04

0.24

0.1

0.05

0.05

0.09

0.08

0.06

0.66

0.31

0.45

0.46

0.66

0.78

0.92

0.54

0.58

0.46

0.24

0.53

0.43

0.1

0.06

0.03

0.12

0.08

0.05

0.12

0.15

0.04

0.02 0.03

0.16

0.05 0.02 0.16

0.11 0.28

CBC Hgb

81

88

102

99

96

7 /27 () 99

RBC

2.87

2.99

3.54

3.35

3.98

3.32

3.25

3.27

3.02

3.27

Hct

0.23

0.24

0.29

0.28

0.27

0.27

0.27

0.27

0.25

0.27

MCV

81.5

80.8

82.6

82.5

83.4

82.4

84.0 82.82

82.2

82.9

MCH

28.1

29.4

28.9

29.4

29.2

29.7

28.9

28.6

28.7

29.1

MCHC

34.5

36.4

35.0

35.6

35.0

36.1

34.5

34.6

34.9

35.1

RDW

17.8

17.6

17.6

17.6

17.0

17.9

16.3

17.8

17.7

17.5

2 .96 0 .24 8 1.7 2 9.0 3 5.5 17

120

60

40

40

40

20

100

80

60

80

40

152

16.2

37.5

36.5

32.8

33.3

34.8

25.5

13.5

6.4

3.10

2.90

0.24

0.64

0.33

0.87

0.81

0.79

0.42

0.76

0.79

0.78

0.15

0.18

0.18

0.19

0.26

0.18

0.12

0.05

0.03

0.03

1 .60 0 .85

0.12

0.08

0.04

0.02

0.03 0.72

0 .85 0 .15

0.62

Plt WBC Neutrophil Metamyelocytes

7/22

7/23

7/24

7/26

7/29

7/30

7/31

8/1

94

94

87

95

86

95 3.27

0.03 0.18

Segmented

0.06

0.28

0.07

0.64

0.33

0.49

0.22

0.67

0.74

Lymphocytes

0.48

0.06

0.16

0.05

0.02

0.07

0.23

0.10

0.16

Blast

0.13

0.03

0.06

0.02

Myelocyte

0.08

0.12

0.20

0.06

0.05 0.08

0.25

0.4 0.22

7/27 ()

Bands

Promyelocyte

0.08

7/25

0.02 0.06

0.05 0.09

0.10 0.19

0.07 0.02

0.03 0.01

0 .02

8/2

0.27 82.0 29.1 35.5 17.8

0.62

0.38

Coagulation Assay

7/8

PT

12.0

Normal Control Prothrombin Ratio INR

Referenc e Range (sec) 10.3-14.1

Normal Control

Referen ce Range

12.0

10.314.1

12.3

12.2

1.0

1.0

1.0

1.0

Percent Activity Activated PTT

7/13

7/15

Referen ce range

7/17

5.6mg/ dl

4-8.5

3.4

89.2% 33.2 36.4

27.0-45.4

37.4

27.045.4

37.5

Fibrinogen level

2.5 g/L

2.0-4.0

D-dimer

1011.0 g/L

Up to 246.4

Blood Chemistry

7/8

7/13

7/18

7/22

7/24

7/25

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

SGOT-AST

U/L

33.7

18.8

23.4

SGPT-ALT

U/L

59.7

43.3

54.7

0.79

44.2

7/27

7/29

0.81

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

-

RBC

10-15/hpf

8 – 12/hpf

Pus cells

0-2/hpf

0 -1/hpf

Bacteria

Few

Few

Cells:

Mucus threads Amorphous urates

Few 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 7/14/08  Concentric LVH with good wall motion and contractility and good systolic function  EF: 77%

Culture and Sensitivity Throat Culture – 7/22/08  E. coli moderate growth Blood Culture and Sensitivity  7/20/08 – Left and Right arm: no growth after 24 hours incubation  7/24/08 – 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 Leukemia M3-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 AML Can 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 APL 2. 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. 4. 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