ACUTE MYELOID LEUKEMIA

Marlon M. Maramion, MD, DPSP Maramion,

OUTLINE
AML, Overview Classification General Aspects of Treatment

LEUKEMIA
Generalized neoplastic proliferation or accumulation of leukopoietic cells with or without involvement of the peripheral blood Variable presentation -leukocytosis -abnormal circulating cells -infiltration of other tissues (spleen, liver, lymph nodes)

LEUKEMIA
Problem: ABNORMAL PROLIFERATION OF STEM CELLS Etiology: INCOMPLETELY UNDERSTOOD - Radiation - Chemicals (Benzene) - Chemotherapy (Alkylating Agents) - Genetics

Pathogenesis

ACUTE MYELOID LEUKEMIA

Syndrome of self perpetuating proliferation of one or more type of bone marrow cells (erythroid, granulocytic, monocytic and erythroid, megakaryocytic precursors) Most common acute leukemia in the first few months of life rare: Childhood & adolescence 2nd peak: Middle & late ages (most peak: common form of acute leukemia)

ACUTE MYELOID LEUKEMIA

Onset: Acute Infection Sepsis Granulocytic insufficiency Ulcerations of mucous membranes Fever Enlargement of lymph nodes, spleen, liver Malaise Rapid progressive course

AML Diagnosis
Morphology Cytogenetics Immunophenotyping Polymerase Chain Reaction Fluorescence In Situ Hybridization (FISH)

AML Diagnosis
Initial Assessment: 500 cell count DIAGNOSIS 20% of the nucleated cells are blasts and/or leukemic cells (abN promyelocyte or promonocyte) promonocyte) - Calculate the percentage of Erythroid precursor cells - Differential count of Non Erythroid Cells (NEC) for classification into subtypes

AML Classification
French-AmericanFrench-American-British (FAB) Cooperative group (1976) - Morphology of cells in RomanowskyRomanowskystained blood & marrow films - Supplemented by Cytochemical reactions or serum lysozyme levels World Health Organization (WHO) (2001) - multilayered approach

WHO Classification
Recurrent Acquired Cytogenetic Abnormalities History of Predisposing Factors/Multilineage Factors/Multilineage AML - prior cytotoxic therapy - prior MDS Morphologic Stratification (FAB) AML not otherwise categorized

AML with Recurrent Genetic Abnormalities

Affects children & young adults Involvement of committed precursor High rate of complete remission with chemotherapy - Formation of fusion gene- CHIMERIC PROTEIN gene-

AML with Recurrent Genetic Abnormalities

AML with t(8:21)- seen in 1/3 of M2 cases t(8:21)AML with inv(16)- correspond to M4 inv(16)Acute Promyelocytic Leukemia with t(15:17) AML with 11q23 abnormalities

Cytogenetics

FISH

AML with Multilineage Dysplasia

- Arise from Myelodysplastic Syndrome (MDS) or arise de novo but with features of MDS - Typically occur in older people & have poor prognosis - 20% blasts in blood &/or marrow - Dysplasia in >50% of cells of at least 2 lineages

Dysplasia?

AML, Therapy Related

1. Alkylating Agent- Related AML Agent- Chlorambucil, Cyclophosphamide or Chlorambucil, radiation - occur 5-6 years after exposure 5- poor response to therapy 2. Topoisomerase II Inhibitor- Related AML Inhibitor- after less than 3 years from exposure - favorable response to chemotherapy

AML not Otherwise Classified

FAB classification - based on morphology & cytochemical reaction - requires presence of 20% blasts in the blood and/or marrow

Myeloblasts
-central nuclei -fine uncondensed chromatin -prominent nucleoli (3-5) (3-

Myeloblasts
Primitive Myeloblasts - positive for MPO, CD13, CD33, CD117 antigens Mature Myeloblasts - Flow cytometry - Cytohemical reactions: Myeloperoxidase (MPO), Sudan Black B (SBB) & ASDASDChloroacetate esterase (CAE)

AUER RODS
-Derivatives of Azurophilic granules -Seen in myeloblasts or promyelocytes -found in any subtype (more in M1-M3) - ENSURES THE DIAGNOSIS

Cytochemistry in Acute Leukemia

Cytochemistry in AML
Myeloperoxidase Chloroacetate

Sudan Black

Non-specific Esterase

Antibody CD13 CD33 CD117 CD65 Antimyeloperoxidase CD41, CD42 CD61 Anti-glycophorin CD19 CD79a CD10 CD3 CD7

Specificity myeloid myeloid myeloid myeloid myeloid megakaryocyte megakaryocyte erythroid B-lymphocyte lineage B-lymphocyte lineage

CD13

CD42

B-lymphocyte lineage (if strongly expressed) T-lymphocyte lineage T-lymphocyte and myeloid lineages

B- and T-lineage lymphoblasts and a lower Anti-terminal deoxynucleotidyl proportion of myeloid blasts transferase (TdT)

The Granulocytic Lineage

myeloblast promyelocyte myelocyte metamyelocyte band neutrophil

MYELOBLAST
-15-20 m -Central Nuclei -High N:C -Fine uncondensed chromatin -Prominent nucleoli (3-5) -Cytoplasm-moderately blue lighter at perinuclear region

PROMYELOCYTE
-Larger than myeloblast (22-25 m) -Less N:C -AZUROPHILIC GRANULES -Golgi zone -Less defined nucleoli

myeloblast promyelocyte

myelocyte

metamyelocyte

band

neutrophil

NEUTROPHILIC MYELOCYTE
-Smaller than promyelocyte -18-20 m -Nucleolus not visible -Nucleus is round to oval -SPECIFIC GRANULES -Pinkish cytoplasm

myeloblast promyelocyte myelocyte

metamyelocyte

band

neutrophil

Eosinophilic Myelocyte
- Orange red granules

Basophilic Myelocyte
- Purple basophilic granules

metamyelocyte
- Nuclear indentation

myeloblast promyelocyte myelocyte

metamyelocyte

band

neutrophil

band

Band

The Erythroid Lineage

12-20 m -deep blue narrow rim of cytoplasm -nucleus- reddish purple with fine chromatin pattern

- 10-16 m -Nucleus- large - thick strands of chromatin -No visible nucleolus

- 8-14 m -Acidic and basic cytoplasmic rxn -Nucleus- deeply staining with clumped chromatin

- 8-10 m -Small nucleus -Very coarse clumped chromatin -Acidophilic cytoplasm

Monoblasts

about 18 to 22 m in diameter cytoplasm to nucleus ratio of 4:1 to 3:1 round to oval nucleus with fine chromatin structure One to four nucleoli are usually visible nucleus can be central or eccentric and it can show evidence of indentation or folding cytoplasm is agranular, stains moderately to lightly basophilic, and often has an intensely stained periphery and a prominent perinuclear zone.

Large monoblasts with central nuclei and abundant cytoplasm. The inset shows the monoblasts positive with alpha-napthyl acetate esterase (brown), and one blue chloroacetate esterase positive myelocyte.

This cell is the largest of the leukocytes and is agranular. The nucleus is most often "U" or kidney bean shaped; the cytoplasm is abundant and light blue (more blue than this micrograph illustrates). These cells leave the blood stream (diapedesis) to become macrophages. As a monocyte or macrophage, these cells are phagocytic and defend the body against viruses and bacteria. These cells account for 3-9% of all leukocytes. In people with malaria, endocarditis, typhoid fever, and Rocky Mountain spotted fever, monocytes increase in number.

FAB Classification

M0 AML with minimal evidence of myeloid differentiation 20% ANC are blasts <3% of blasts are Myeloperoxidase and SBB positive 20% of blasts are positive for myeloid associated antigens

M0 AML with minimal evidence of myeloid differentiation (BMA)

CD13

M1

Acute myeloblastic leukaemia without maturation

20% of ANC are blasts 90% of NEC are myeloblasts 3% of blasts are Px/SBB Px/SBB

Can be confused with ALL L2, cytochemical staining is important

M1

Acute myeloblastic leukaemia without maturation

M1

Acute myeloblastic leukaemia without maturation

Myeloperoxidase

Sudan Black

M2 Acute myeloblastic leukaemia with maturation 20% of ANC are Myeloblasts 3030-89% of NEC are blasts 10% NEC are promyelocytes or more mature granulocytes <20% are of monocytic lineage Usually >85% of leukemic cells are positive for SBB/PX/CAE

M2

Acute myeloblastic leukaemia with maturation

M3 Acute Promyelocytic Leukemia

20% blasts & abnormal granular Promyelocytes Auer rods and multiple Auer rods Usually >85% of leukemic cells are positive for SBB/PX/CAE

M3 Acute Promyelocytic Leukemia

Auer Rods

M4 Acute Myelomonocytic Leukemia

20% of ANC are Myeblasts Granulocytic series represent 30-80% of the 30NECs Sum of monoblasts, promonocytes and monoblasts, monocytes is more than 20% but less than 80% of NECs >20% of blasts are positive for SBB/PX/CAE >20% of blasts are positive for NAE, NBE

M4 Acute Myelomonocytic Leukemia

Monoblasts

M4 Acute Myelomonocytic Leukemia

M4E Myelomonocytic with Eosinophilia

M5A Monoblastic (Monocytic, Poorly Diff)

20% of ANC are Myeloblasts 80% of NECs are monoblasts, promonocytes monoblasts, or monocytes 80% of monocytic cells are monoblasts < 20% of leukemic cells are CAE positive 80% of leukemic cells are NAE, NBE positive

M5A Monoblastic (Monocytic, Poorly Diff)

PS BMA

M5A Monoblastic (Monocytic, Poorly Diff)

M5B Monocytic (Monocytic, Monocytic, Differentiated)

20% of ANC are Myeloblasts 80% of NECs are monoblasts, promonocytes monoblasts, or monocytes <80% of monocytic cells are monoblasts < 20% of leukemic cells are CAE positive 80% of leukemic cells are NAE, NBE positive

M5B Monocytic (Monocytic, Monocytic, Differentiated)

PS BMA

M6 Erythroleukemia
50% of ANC are Erythroblasts Many erythroid precursors are PAS positive

AML, M6 (BMA)

M6 Erythroleukemia

Anti- Glycophorin Polyclonal Antibody

M7 Megakaryoblastic
20% of NEC are megakaryoblasts or leukemic cells Leukemic cells are platelet peroxidase positive on electron microscopy or positive for glycoproteins Ib or IIb/IIIa as IIb/ demonstrated by immunocytochemical methods

M7 Megakaryoblastic
Confirmed with CD41

TREATMENT
CHEMOTHERAPY Phases 1. Remission Induction Chemotherapy 2. Post- Remission (Consolidation) PostChemotherapy

Remission Induction
Goal: get rid of all visible leukemia Drugs: 1. Cytarabine (ara-C) ara2. Anthracycline (Daunomycin or Idamycin) Idamycin) administered in a week - Requires hospitalization - Target: <5% blast in the marrow after 1 or 2 weeks (40-80% success rate) (40-

Consolidation Therapy
Goal: destroy any remaining leukemia cells & prevent relapse - High dose Cytarabine in 5 days - 15-40% success rate 15-

Stem Cell Transplant

After successful induction 1. Allogenic 2. Autologous Factors considered - more intensive induction - availability of tissue match - presence of 1 or more adverse prognostic factors (ex. prior MDS) - young patients - patients wish

Treatment of AML