Final Diagnosis -- Acute Myeloid Leukemia Relapse


FINAL DIAGNOSIS

PART 1: PERIPHERAL BLOOD

  1. ACUTE MYELOID LEUKEMIA RELAPSE (see comment).
  2. ATYPICAL LYMPHOCYTOSIS.
  3. NEUTROPENIA AND THROMBOCYTOPENIA.

PARTS 2 AND 3:

BONE MARROW, BIOPSY AND TOUCH IMPRINTS

  1. ACUTE MYELOID LEUKEMIA RELAPSE (see comment).
  2. PERSISTENT INVOLVEMENT BY SMALL B-CELL LYMPHOID NEOPLASM (see comment).
  3. MODERATE RETICULIN FIBROSIS.
  4. [HISTORY OF ACUTE MYELOID LEUKEMIA AND SMALL B-CELL LYMPHOID NEOPLASM IN 2007]
DIAGNOSTIC COMMENT

The peripheral blood smear and marrow aspirates show numerous blasts which account for 45% and 95% of nucleated cells, respectively. The bone marrow is 95% cellular with complete effacement of normal hematopoiesis which is replaced by leukemic infiltrate. The leukemic blasts are medium-sized with high N/C ratio and cup-shaped nuclei. Several small lymphoid aggregates which account for about 5% of marrow cells are also noted. The flow cytometric studies reveal a large myeloid blast population that is CD45 (dim+), CD34-, CD33+, CD117 (dim+), CD56+, CD15-, CD19- and CD14-. A second, lambda-restricted B-cell population is also present. These results are similar to previously reported acute myeloid leukemia and concurrent B-cell lymphoid neoplasm.

CONTRIBUTOR'S NOTE

A small subset of patients with acute myeloid leukemia (AML) have cup-like nuclei. Several previous studies have demonstrated that AML with cup-like nuclei morphology has distinctive clinicopathologic and molecular features. They are associated with fms-like tyrosine kinase 3 (FLT3) internal tandem duplication (ITD); nucleophosmin 1 (NPM1) mutations; normal karyotype; myeloperoxidase positivity; higher D-dimer levels and loss of CD34 and HLA-DR expression. These findings suggest that AML with cup-like nuclei features may represent a distinct AML subset.

REFERENCE

  1. Chen W, Konoplev S, Medeiros LJ, Koeppen H, Leventaki V, Vadhan-Raj S, Jones D, Kantarjian HM, Falini B, Bueso-Ramos CE. Cuplike nuclei (prominent nuclear invaginations) in acute myeloid leukemia are highly associated with FLT3 internal tandem duplication and NPM1 mutation. Cancer. 2009 Dec 1;115(23):5481-9.
  2. Manabe M, Nakamura K, Nakamura J, Fukuyama T, Fukada E, Senzaki H, Ohta K. Acute myeloid leukemia with cuplike nuclei and intracytoplasmic inclusions following myelodysplastic syndrome. Int J Hematol. 2009 Jul;90(1):11-2. Epub 2009 Jun 17.
  3. Okano A, Inaba T. Acute myeloid leukemia-cuplike: characteristic peroxidase staining pattern. Int J Hematol. 2007 Apr;85(3):185.
  4. Kussick SJ, Stirewalt DL, Yi HS, Sheets KM, Pogosova-Agadjanyan E, Braswell S, Norwood TH, Radich JP, Wood BL. A distinctive nuclear morphology in acute myeloid leukemia is strongly associated with loss of HLA-DR expression and FLT3 internal tandem duplication. Leukemia. 2004 Oct;18(10):1591-8.

Contributed by Lin Liu, MD, PhD and Miroslav Djokic, MD




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