Acute Myeloid Leukemia

(AML)

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 Introduction

• The myeloid leukemias are a heterogeneous group of diseases

characterized by infiltration of the blood, bone marrow, and
other tissues by neoplastic cells of the hematopoietic system.

• Based on their untreated course, the myeloid leukemias have

traditionally been designated acute or chronic.

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 ALL
naïve

B-lymphocytes

Plasma
Lymphoid cells
progenitor T-lymphocytes

AML
Hematopoietic Myeloid Neutrophils
stem cell progenitor

Eosinophils

Basophils

Monocytes

Platelets

Red cells
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 Morphological Features of Blasts in Acute Myeloid and Acute
Lymphoblastic Leukemias

ALL AML Feature

Variable, small to medium size Larger, usually uniform Blast size
Coarse to fine Usually finely dispersed Nuclear chromatin
Absent or 1 or 2, often
indistinct often prominent ,1-4 Nucleoli
Usually scant, coarse granules Moderately abundant, fine
granules often present Cytoplasm
sometimes present (~7%)
Not present Present in 60%-- 70% of cases Auer rods

Usually not dysplastic Often dyspastic changes in Other cell types

maturing myeloid cells
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 • Incidence

• The incidence of acute myeloid leukemia (AML) is 3.5 per

100,000 people per year, and the age-adjusted incidence is
higher in men than in women.
• AML incidence increases with age.

• Etiology
• Heredity, radiation, chemical and other occupational
exposures, and drugs have been implicated in the
development of AML.
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Overview of AML
 Also known as
 Acute myelocytic leukemia
 Acute myelogenous leukemia
 Acute nonlymphocytic leukemia

 Stem cell disorder characterized by malignant neoplastic proliferation

and accumulation of immature and nonfunctional hematopoietic cells
in the BM
 Chemo/radiation
 Exposure to benzene
 History of MDS
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Overview of AML
 All acute leukemias begin BEFORE clinical signs and symptoms occur
 As the tumor volume expands, normal functional marrow cells decrease
 Characterized by two major features
 Ability to proliferate continuously
 Due to mutations affecting growth factors
 Transcription errors
 Arrested development of normal cells
 Lacks apoptosis

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Etiology
• Classified by the cellular appearance
of the primary stem cell
• Common myeloid progenitor
(CMP)
• AML or ANLL
• Common lymphoid progenitor
(CLP)
• ALL

• Peak incidence in adults over 60

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Clinical findings
• CLASSIC TRIAD
• Anemia
• Infection
• Bleeding/easy bruising/petechiae
• Fever
• Shortness of breath
• Fatigue
• Weight loss
• Pallor

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Lab Features: Peripheral blood
 WBC count:
 variable at diagnosis
 ( 1-200 x 109/L)
 >20% blasts present
 Auer rods: fused primary granules in myeloblasts
 RBCs
 Decreased
 Hgb < 10g/dL
 Inclusions reflect rbc maturation defects
 Howell-Jolly, Pappenheimer, basophilic stippling
 nRBCs present
 Platelets
 Decreased
 Hypogranular, giant forms
 Megakaryocyte fragments
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Lab Features: MISC.
• BONE MARROW
• Hypercellular
• Decreased fat content
• >20 nonerythroid blasts
• Fibrosis

• MISC
• Hyperuricemic
• Increased LDH

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WHO Classification of AML
• AML is classified according to the World Health
Organization (2008) scheme.
• There is an increasing focus on the genetic
abnormalities within the malignant cells and it is likely
that ultimately almost all AML cases has been
classified by specific genetic subtype to six main
groups of AML are recognized .

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1 AML with recurrent genetic abnormalities
• encompasses subtypes with specific chromosomal translocations or
gene mutations.
• The detection of these abnormalities defines the tumour as AML and
so the diagnostic criteria for this subgroup are relaxed in that the bone
marrow blast cell count does not need to exceed 20% in order to make
a diagnosis.
• In general these disorders have a good prognosis.

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2 AML with myelodysplasia‐related
changes.
• In this group the AML is associated with microscopic features of dysplasia in at
least 50% of cells in at least two lineages.
• The clinical outcome of these patients is impaired in relation to the first subgroup.

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3 Therapy‐related myeloid neoplasms (t‐
AML)
• arise in patients who have been previously treated with drugs such
as etoposide or alkylating agents.
• They commonly exhibit mutations in the MLL gene and the clinical
response is usually poor.

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4 AML, not otherwise specified.
• This group is defined by the absence of cytogenetic abnormalities and
comprises around 30% of all cases.
• Mutations in the NPM1 and FLT3 genes are more frequent in those
with normal
cytogenetics

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5 Myeloid sarcoma
is rare but refers to a disease that resembles a solid tumour but is
composed of myeloid blast cells.

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6 Myeloid proliferations related to Down’s
syndrome.
Children with Down’s syndrome have a greatly increased risk
of acute leukaemia.
Two myeloid variants are recognized:
(i) transient abnormal myelopoiesis in which there is a self‐
limiting leucocytosis; and
(ii) AML.

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Mixed phenotype acute leukaemia
•
These rare cases express two markers for both myeloid and
lymphoid differentiation either on the same blast cells or
on two different cell populations.
• They usually have a poor
prognosis

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 FAB Classification of AML

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 Leukemias

Acute leukemias Chronic leukemias

Lymphoid Myeloid
L1 M0
L2 M1
L3 M2
M3
M4
M5
M6
M7

,The original FAB-Classification system of Acute Leukemias

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heavily based on morphologic findings
 Maturation and Morphology of Immature Granulocytes
myeloblast promyelocyte myelocyte metamyelocyte band neutrophil

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MATURATION
 Cytochemical Reactions in Acute Leukemia

Blasts Identified Cellular Element Stained Cytochemical Reaction

Myeloblasts strong positive; monoblasts Neutrophil primary Myeloperoxidase (MPO)
faint positive granules
Myeloblasts strong positive; monoblasts Phospholipids Sudan Black B (SBB)
faint positive
Myeloblasts strong positive Cellular enzyme Specific esterase
Monoblasts strong positive Cellular enzyme Nonspecific esterase (NSE)

Variable, coarse or block-like positivity often

seen in
lymphoblasts and pronormoblasts, Glycogen and related
myeloblasts usually substances Periodic acid-Schiff
negative although faint diffuse reaction may
occasionally be seen
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 Leukocyte Alkaline phosphatase
(LAP)
 Alkaline phosphatase is located in the specific granules
of neutrophils.

Negative LAP reaction Positive LAP reaction

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 Myeloperoxidase (MPO)
• Peroxidase is an enzyme from oxydoreductase group.
• It is found in myeloid cells and is then called
myeloperoxidase.
• Myeloid cells can destroy microorganisms with the
help of this enzyme.
• Peroxidase is present in primary granules of
neutrophils, and in the granules of eosinophils and
monocytes.

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 Myeloperoxidase (MPO)

Bluish-black granules Red brown precipitate

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 Myeloperoxidase stain,
bone marrow aspirate

The red granular staining

peroxidase activity.

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 Sudan Black B
• Sudan staining is the use of Sudan dyes to stain sudanophilic substances, usually
lipids. Sudan lysochromes (Sudan II, Sudan III, Sudan IV, Oil Red O, and Sudan
Black B are used.
• Sudan dyes have high affinity to fats, therefore they are used to demonstrate
triglycerides, lipids, and lipoproteins.
• Sudan black B stain is the most sensitive stain for granulocyte precursors.
Brownish‑black cytoplasmic granules occur in myeloid precursors.
• Monocytes have a few small brownish‑black granules.
• Eosinophilic granules are brown and usually show a central pallor. Lymphoid
cells rarely stain

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 Sudan Black B

• Positive sudan black B (SBB) stain in a patient with AML ,

• Not the black staining cytoplasmic granules in the myeloblasts

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 Acid phosphtase
( with tartarate resistance)
• The acid phosphatase within the cell hydrolyzes the substrate
naphthol AS‑BI phosphoric acid.
• The hydrolyzed substrate then couples with the dye (hexagotized
pararosaniline) and because the colored complex is insoluble, it
precipitates out at the site of enzyme activity.
• Tartaric acid when added to the incubation mixture, will not inhibit
the enzyme fraction found in hairy cell leukemia.
•

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Non Specific Esterase:
{with fluoride inhibition}

NSEs α-naphthyl acetate positivity in M5b.

Not the granular positiviy in the monoblasts and immature monocytes

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Periodic Acid – PAS
(Schiff Reaction)
• PAS stains glycogen. Periodic acid oxidizes glycols to
aldehydes. The aldehydes react with Schiff's reagent.

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Periodic Acid – PAS
(Schiff Reaction)

Giant multinucleate late normoblasts (left). Granular PAS

positivity in proerythroblasts and homogeneous positivity in the
later normoblasts
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 PAS positvity in M6. Not the intense
staining of the large abnormal
erythroblast.

Positive PAS stain acute

.megakaryocytic leukemia AML, M7

Positive PAS stain in ALL

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 Specific esterase or chloroacetate

• Naphthol (AS-D)
Chloroacetate Esterase
stain in a patint with
AML,M2. Not the bright
red satining indicating
that these two blasts are
of myeloid origin.

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 Acute Non-Lymphoblastic Leukaemia
Class Alternative Bone Marrow Appearance
M0 AML with minimal Identified by ultrastructural myeloperoxidase activity or
differentiation immunophenotyping.
M1 AML without maturation Monomorphic with one or more distinct nucleoli, occasional
auer rod and at least 3% myeloperoxidase positivity.

M2 AML with maturation 50% OR > myeloblasts & promyelocytes and common single
auer rod. Dysplastic myeloid differentiation may also be
present.
M3 APL Dominant cell type is promyelocyte with heavy azurophilic
granulation. Bundles of Auer rods confirm diagnosis.
Microgranular variant exist (M3v)

M4 AMMoL As M2 but > 20% promonocytes & monocytes.

M5 AMoL > 80% monoblasts is poorly differentiated (M5a)
> 80% monoblasts, promonocytes or monocytes is well
differentiated (m5b)

M6 AEL >50% bizzar, dysplastic nucleated red cells with

multinucleate forms and cytoplasmic bridging. Myeloblasts
usually > 30%.
M7 AMegL Fibrosis, heterogeneous blasts population with cytoplasmic
blebs. Platelet peroxidase positive.
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 French-American-British (FAB) Classification

• MO: Minimally differentiated leukemia

• Ml: Myeloblastic leukemia without maturation
• M2: Myeloblastic leukemia with maturation
• M3: Hypergranular promyelocytic leukemia
• M4: Myelomonocytic leukemia
• M4Eo: Variant: Increase in abnormal marrow eosinophils
• M5: Monocytic leukemia
• M6: Erythroleukemia (DiGuglielmo's disease)
• M7: Megakaryoblastic leukemia
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 • A major difference between the WHO and FAB systems is the blast
cutoff for a diagnosis of AML as opposed to myelodysplastic
syndrome (MDS); it is 20% in the WHO classification and 30% in the
FAB.

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 Clinical Presentation
• Symptoms
• Patients with AML most often present with nonspecific symptoms
that begin gradually or abruptly and are the consequence of
anemia, leukocytosis, leukopenia or leukocyte dysfunction, or
thrombocytopenia.
• Nearly half have had symptoms for 3 months before the leukemia
was diagnosed.

• Half mention fatigue as the first symptom, but most complain of

fatigue or weakness at the time of diagnosis.

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 • Anorexia and weight loss are common. Fever with or without an
identifiable infection is the initial symptom in 10% of patients.

• Signs of abnormal hemostasis (bleeding, easy bruising) are noted

first in 5% of patients.

• On occasion, bone pain, lymphadenopathy, nonspecific cough,

headache, or diaphoresis is the presenting symptom.

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 Physical Findings

• Fever, splenomegaly, hepatomegaly, lymphadenopathy, sternal

tenderness, and evidence of infection and hemorrhage are
often found at diagnosis.
• Significant gastrointestinal bleeding, intrapulmonary
hemorrhage, or intracranial hemorrhage occur most often in
APL.
• Bleeding associated with coagulopathy may also occur in
monocytic AML and with extreme degrees of leukocytosis or
thrombocytopenia in other morphologic subtypes.
• Retinal hemorrhages are detected in 15% of patients.
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 Hematologic Findings
• The anemia is usually normocytic normochromic. Decreased
erythropoiesis often results in a reduced reticulocyte count, and
red blood cell (RBC) survival is decreased by accelerated
destruction.

• Active blood loss also contributes to the anemia.

• The median presenting leukocyte count is about 15,000/L.

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 • In AML, the cytoplasm often contains primary (nonspecific)
granules, and the nucleus shows fine, lacy chromatin with one or
more nucleoli characteristic of immature cells.

• Abnormal rod-shaped granules called Auer rods are not uniformly

present, but when they are, myeloid lineage is virtually certain.

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 Laboratory and Radiologic Studies

• CBC with manual differential cell count

• Chemistry tests (electrolytes, creatinine, BUN, calcium,
phosphorus, uric acid, hepatic enzymes, bilirubin, LDH, amylase,
lipase)
• Clotting studies (prothrombin time, partial thromboplastin time,
fibrinogen, D-dimer)
• Viral serologies (CMV, HSV-1, varicella-zoster)
• RBC type and screen
• HLA typing for potential allogeneic HSCT
• Bone marrow aspirate and biopsy (morphology, cytogenetics, flow
cytometry.
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 Management of Adult Patients
with AML
• History
• Increasing fatigue or decreased exercise tolerance (anemia)
• Excess bleeding or bleeding from unusual sites (DIC,
thrombocytopenia)
• Fevers or recurrent infections (granulocytopenia)
• Headache, vision changes, nonfocal neurologic abnormalities
(CNS leukemia or bleed)
• Early satiety (splenomegaly)
• Family history of AML (Fanconi, Bloom, or Kostmann
syndromes or ataxia-telangiectasia)
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 Finis
h
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