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ACUTE MYELOID ACUTE MYELOID

LEUKEMIALEUKEMIAMarlon M.Marlon M. MaramionMaramion, MD, DPSP, MD, DPSP



OUTLINEOUTLINE

AML, Overview AML, Overview

ClassificationClassification

General Aspects of TreatmentGeneral Aspects of Treatment



LEUKEMIALEUKEMIAGeneralizedGeneralized neoplasticneoplastic proliferation or proliferation or accumulation of leukopoietic cells with or accumulation of leukopoietic cells with or

without involvement of the peripheralwithout involvement of the peripheral

bloodbloodVariable presentationVariable presentation

--leukocytosisleukocytosis

--abnormal circulating cellsabnormal circulating cells--infiltration of other tissues (spleen,infiltration of other tissues (spleen,

liver, lymph nodes)liver, lymph nodes)



LEUKEMIALEUKEMIA

Problem: ABNORMAL PROLIFERATIONProblem: ABNORMAL PROLIFERATIONOF STEM CELLSOF STEM CELLS

Etiology: INCOMPLETELY UNDERSTOODEtiology: INCOMPLETELY UNDERSTOOD

-- RadiationRadiation

-- Chemicals (Benzene)Chemicals (Benzene)

-- Chemotherapy (Alkylating Agents)Chemotherapy (Alkylating Agents)

-- GeneticsGenetics



PathogenesisPathogenesis



ACUTE MYELOID LEUKEMIA ACUTE MYELOID LEUKEMIA

Syndrome of self perpetuating proliferationSyndrome of self perpetuating proliferationof one or more type of bone marrow cellsof one or more type of bone marrow cells

((erythroiderythroid, granulocytic,, granulocytic, monocyticmonocytic andand

megakaryocytic precursors)megakaryocytic precursors)Most common acute leukemia in theMost common acute leukemia in the firstfirstfew months of lifefew months of life

rare: Childhood & adolescencerare: Childhood & adolescence

22ndnd peakpeak: Middle & late ages: Middle & late ages (most(mostcommon form of acute leukemia)common form of acute leukemia)



ACUTE MYELOID LEUKEMIA ACUTE MYELOID LEUKEMIA

Onset: Acute InfectionOnset: Acute Infection

SepsisSepsis

Granulocytic insufficiencyGranulocytic insufficiency

Ulcerations of mucous membranesUlcerations of mucous membranes

Fever Fever

Enlargement of lymph nodes, spleen, liver Enlargement of lymph nodes, spleen, liver

MalaiseMalaise

Rapid progressive courseRapid progressive course



AML Diagnosis AML Diagnosis

MorphologyMorphology

CytogeneticsCytogenetics

ImmunophenotypingImmunophenotypingPolymerase Chain ReactionPolymerase Chain Reaction

Fluorescence In Situ Hybridization (FISH)Fluorescence In Situ Hybridization (FISH)



AML Diagnosis AML Diagnosis

Initial Assessment: 500 cell countInitial Assessment: 500 cell count

DIAGNOSISDIAGNOSIS

20% of the nucleated cells are blasts20% of the nucleated cells are blasts

and/or leukemic cellsand/or leukemic cells ((abNabN promyelocytepromyelocyteor or promonocytepromonocyte))

-- Calculate the percentage of Calculate the percentage of ErythroidErythroid

precursor cellsprecursor cells-- Differential count of NonDifferential count of Non ErythroidErythroid CellsCells

(NEC) for classification into subtypes(NEC) for classification into subtypes



AML Classification AML Classification

FrenchFrench--American American--British (FAB)British (FAB)Cooperative group (1976)Cooperative group (1976)

-- Morphology of cells inMorphology of cells in RomanowskyRomanowsky--

stained blood & marrow filmsstained blood & marrow films

-- Supplemented bySupplemented by CytochemicalCytochemical

reactions or serumreactions or serum lysozymelysozyme levelslevels

World Health Organization (WHO)World Health Organization (WHO)

(2001)(2001)

-- multilayered approachmultilayered approach



WHO ClassificationWHO Classification

Recurrent Acquired CytogeneticRecurrent Acquired Cytogenetic

Abnormalities Abnormalities

History of PredisposingHistory of PredisposingFactors/Factors/MultilineageMultilineage AML AML

-- prior prior cytotoxiccytotoxic therapytherapy

-- prior MDSprior MDSMorphologic Stratification (FAB)Morphologic Stratification (FAB) ± ± AML not AML not

otherwise categorizedotherwise categorized



AML with Recurrent Genetic AML with Recurrent Genetic

Abnormalities Abnormalities Affects children & young adults Affects children & young adults

Involvement of committed precursor Involvement of committed precursor

High rate of complete remissionHigh rate of complete remission withwithchemotherapychemotherapy

-- Formation of fusion geneFormation of fusion gene-- CHIMERIC PROTEINCHIMERIC PROTEIN



AML with Recurrent Genetic AML with Recurrent Genetic

Abnormalities Abnormalities AML with t(8:21) AML with t(8:21)-- seen in 1/3 of M2 casesseen in 1/3 of M2 cases

AML with inv(16) AML with inv(16)-- correspond to M4correspond to M4

Acute Acute PromyelocyticPromyelocytic Leukemia withLeukemia witht(15:17)t(15:17)

AML with 11q23 abnormalities AML with 11q23 abnormalities



CytogeneticsCytogenetics



FISHFISH



AML with AML with MultilineageMultilineage DysplasiaDysplasia

-- Arise from Arise from MyelodysplasticMyelodysplastic SyndromeSyndrome

(MDS) or arise de novo but with features(MDS) or arise de novo but with features

of MDSof MDS

-- Typically occur inTypically occur in older peopleolder people & have& have

poor prognosispoor prognosis

-- 20% blasts in blood &/or marrow 20% blasts in blood &/or marrow

-- Dysplasia in >50% of cells of at least 2Dysplasia in >50% of cells of at least 2

lineageslineages



Dysplasia?Dysplasia?



AML, Therapy Related AML, Therapy Related

1.1. Alkylating Alkylating Agent Agent-- Related AMLRelated AML

-- ChlorambucilChlorambucil,, CyclophosphamideCyclophosphamide or or

radiationradiation-- occur 5occur 5--6 years after exposure6 years after exposure

-- poor response to therapypoor response to therapy

2.2. TopoisomeraseTopoisomerase II Inhibitor II Inhibitor-- Related AMLRelated AML-- after less than 3 years from exposureafter less than 3 years from exposure

-- favorable response to chemotherapyfavorable response to chemotherapy



AML not Otherwise Classified AML not Otherwise Classified

FAB classificationFAB classification

-- based on morphology &based on morphology & cytochemicalcytochemical

reactionreaction-- requires presence of 20% blasts in therequires presence of 20% blasts in the

blood and/or marrowblood and/or marrow



MyeloblastsMyeloblasts

--central nucleicentral nuclei--fine uncondensed chromatinfine uncondensed chromatin

--prominent nucleoli (3prominent nucleoli (3--5)5)



MyeloblastsMyeloblasts

PrimitivePrimitive MyeloblastsMyeloblasts

-- positive for MPO, CD13, CD33, CD117positive for MPO, CD13, CD33, CD117

antigensantigens

MatureMature MyeloblastsMyeloblasts

-- FlowFlow cytometrycytometry-- CytohemicalCytohemical reactions:reactions: MyeloperoxidaseMyeloperoxidase

(MPO), Sudan Black B (SBB) & ASD(MPO), Sudan Black B (SBB) & ASD--

ChloroacetateChloroacetate esterase (CAE)esterase (CAE)



AUER RODS AUER RODS

-Derivatives of Azurophilic granules-Seen in myeloblasts or

promyelocytes

-found in any subtype

(more in M1-M3)

- ENSURES THE DIAGNOSIS



Cytochemistry in AcuteCytochemistry in Acute

LeukemiaLeukemia



Cytochemistry in AMLCytochemistry in AML

Myeloperoxidase

Sudan Black

Chloroacetate

Non-specific Esterase



Antibody Specificity

CD13 myeloid

CD33 myeloid

CD117 myeloid

CD65 myeloid

Anti-

myeloperoxidase

myeloid

CD41, CD42 megakaryocyteCD61 megakaryocyte

Anti-glycophorin erythroid

CD19 B-lymphocyte lineage

CD79a B-lymphocyte lineage

CD10 B-lymphocyte lineage (if strongly expressed)

CD3 T-lymphocyte lineage

CD7 T-lymphocyte and myeloid lineages

Anti-terminal

deoxynucleotidyl

transferase (TdT)

B- and T-lineage lymphoblasts and a lower

proportion of myeloid blasts

CD13

CD42



The Granulocytic LineageThe Granulocytic Lineage

myeloblast promyelocyte myelocyte metamyelocyte band neutrophil



MYELOBLASTMYELOBLAST

-15-20 µm

-Central Nuclei

-High N:C

-Fine uncondensed chromatin

-Prominent nucleoli (3-5)-Cytoplasm-moderately blue

lighter at perinuclear region



PROMYELOCYTEPROMYELOCYTE

-Larger than myeloblast (22-25 µm)

-Less N:C

-AZUROPHILIC GRANULES

-Golgi zone-Less defined nucleoli



NEUTROPHILIC MYELOCYTENEUTROPHILIC MYELOCYTE

-Smaller than promyelocyte

-18-20 µm

-Nucleolus not visible

-Nucleus is round to oval

-SPECIFIC GRANULES

-Pinkish cytoplasm



Eosinophilic MyelocyteEosinophilic Myelocyte

- Orange red granules



Basophilic MyelocyteBasophilic Myelocyte

- Purple basophilic granules



metamyelocytemetamyelocyte

- Nuclear indentation




band



BandBand



TheThe ErythroidErythroid LineageLineage



12-20 µm-deep blue narrow rim of cytoplasm

-nucleus- reddish purple with fine

chromatin pattern



- 10-16 µm-Nucleus- large

- thick strands of chromatin

-No visible nucleolus



- 8-14 µm

-Acidic and basic cytoplasmic rxn

-Nucleus- deeply staining

with clumped chromatin



- 8-10 µm

-Small nucleus

-Very coarse clumped chromatin

-Acidophilic cytoplasm



about 18 to 22 µm 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 showevidence of indentation or folding

cytoplasm is agranular, stains moderately to lightlybasophilic, and often has an intensely stained

periphery and a prominent perinuclear zone.

Monoblasts



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 blasts20% ANC are blasts

<3% of blasts are<3% of blasts are MyeloperoxidaseMyeloperoxidase andandSBB positiveSBB positive

20% of blasts are positive for myeloid20% of blasts are positive for myeloid

associated antigensassociated antigens



M0 AML with minimal evidence of myeloid

differentiation (BMA)

CD13



M1 Acute myeloblastic leukaemia without

maturation

20% of ANC are blasts20% of ANC are blasts

90% of NEC are90% of NEC are myeloblastsmyeloblasts

3% of blasts are3% of blasts are PxPx/SBB/SBB

Can be confused with ALL L2,Can be confused with ALL L2, cytochemicalcytochemicalstaining is importantstaining is important




maturation




maturation

Myeloperoxidase Sudan Black



M2 Acute myeloblastic leukaemia with

maturation

20% of ANC are20% of ANC are MyeloblastsMyeloblasts

3030--89% of NEC are blasts89% of NEC are blasts

10% NEC are10% NEC are promyelocytespromyelocytes or moreor moremature granulocytesmature granulocytes

<20% are of <20% are of monocyticmonocytic lineagelineage

Usually >85% of leukemic cells areUsually >85% of leukemic cells arepositive for SBB/PX/CAEpositive for SBB/PX/CAE



M2 Acute myeloblastic leukaemia with

maturation



M3 Acute Promyelocytic Leukemia

20% blasts & abnormal granular 20% blasts & abnormal granular

PromyelocytesPromyelocytes

Auer rods and multiple Auer rods Auer rods and multiple Auer rods

Usually >85% of leukemic cells areUsually >85% of leukemic cells are

positive for SBB/PX/CAEpositive for SBB/PX/CAE



M3 Acute Promyelocytic Leukemia



Auer Rods



M4 Acute Myelomonocytic LeukemiaM4 Acute Myelomonocytic Leukemia

20% of ANC are20% of ANC are MyeblastsMyeblastsGranulocytic series represent 30Granulocytic series represent 30--80% of the80% of the

NECsNECs

Sum of Sum of monoblastsmonoblasts,, promonocytespromonocytes andandmonocytesmonocytes is more than 20% but less than 80%is more than 20% but less than 80%

of NECsof NECs

>20% of blasts are positive for SBB/PX/CAE>20% of blasts are positive for SBB/PX/CAE

>20% of blasts are positive for >20% of blasts are positive for NAE,NAE,NBENBE



M4 Acute MyelomonocyticM4 Acute Myelomonocytic

LeukemiaLeukemia

Monoblasts



M4 Acute MyelomonocyticM4 Acute Myelomonocytic

LeukemiaLeukemia



M4E Myelomonocytic withM4E Myelomonocytic with

EosinophiliaEosinophilia



M5A Monoblastic (Monocytic,M5A Monoblastic (Monocytic,

Poorly Diff)Poorly Diff)


80% of NECs are80% of NECs are monoblastsmonoblasts,, promonocytespromonocytes

or or monocytesmonocytes

80% of 80% of monocyticmonocytic cells arecells are monoblastsmonoblasts

< 20% of leukemic cells are CAE positive< 20% of leukemic cells are CAE positive

80% of leukemic cells are80% of leukemic cells are NAE,NAE,NBENBEpositivepositive





PS BMA



M5BM5B MonocyticMonocytic ((MonocyticMonocytic,,

Differentiated)Differentiated)


80% of NECs are80% of NECs are monoblastsmonoblasts,, promonocytespromonocytes

or or monocytesmonocytes

<80% of <80% of monocyticmonocytic cells arecells are monoblastsmonoblasts

< 20% of leukemic cells are CAE positive< 20% of leukemic cells are CAE positive

80% of leukemic cells are80% of leukemic cells are NAE,NAE,NBENBEpositivepositive



M5BM5B MonocyticMonocytic ((MonocyticMonocytic,,

Differentiated)Differentiated)PS BMA



M6 ErythroleukemiaM6 Erythroleukemia

50% of ANC are Erythroblasts50% of ANC are Erythroblasts

ManyMany erythroiderythroid precursors are PASprecursors are PAS

positivepositive



AML, M6 (BMA)



M6 ErythroleukemiaM6 Erythroleukemia

Anti- Glycophorin Polyclonal

Antibody



M7 MegakaryoblasticM7 Megakaryoblastic

20% of NEC are 20% of NEC are megakaryoblastsmegakaryoblasts or or

leukemic cellsleukemic cells

Leukemic cells are plateletLeukemic cells are platelet peroxidaseperoxidase

positive on electron microscopy or positivepositive on electron microscopy or positive

for for glycoproteinsglycoproteins IbIb or or IIbIIb//IIIaIIIa asas

demonstrated bydemonstrated by immunocytochemicalimmunocytochemical

methodsmethods



M7 MegakaryoblasticM7 Megakaryoblastic

Confirmed with CD41



TREATMENTTREATMENT

CHEMOTHERAPYCHEMOTHERAPY

PhasesPhases

1. Remission Induction Chemotherapy1. Remission Induction Chemotherapy2. Post2. Post-- Remission (Consolidation)Remission (Consolidation)

ChemotherapyChemotherapy



Remission InductionRemission Induction

Goal: get rid of all visible leukemiaGoal: get rid of all visible leukemia

Drugs:Drugs:

1.1. CytarabineCytarabine ((araara--C)C)2.2. Anthracycline Anthracycline ((DaunomycinDaunomycin or or IdamycinIdamycin))

administered in a weekadministered in a week

-- Requires hospitalizationRequires hospitalization-- Target:Target: <5% blast<5% blast in the marrow after 1 or 2in the marrow after 1 or 2

weeks (40weeks (40--80% success rate)80% success rate)



Consolidation TherapyConsolidation Therapy

Goal: destroy any remaining leukemia cellsGoal: destroy any remaining leukemia cells

& prevent relapse& prevent relapse

-- High doseHigh dose CytarabineCytarabine in 5 daysin 5 days

-- 1515--40% success rate40% success rate



Stem Cell TransplantStem Cell Transplant

After successful induction After successful induction1.1. Allogenic Allogenic

2.2. Autologous Autologous

Factors consideredFactors considered-- more intensive inductionmore intensive induction

-- availability of tissue matchavailability of tissue match

-- presence of 1 or more adversepresence of 1 or more adverseprognostic factors (ex. prior MDS)prognostic factors (ex. prior MDS)

-- young patientsyoung patients

-- patient¶s wishpatient¶s wish



Treatment of AMLTreatment of AML

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