“ White blood / Weisses Blut “
Claudia Meyer
Edendale hospital
October 2007
Index patient:
Main complaint
21 year old gentleman from Edendale
Main complaint: Gingival bleeding and fatigue
for 7 months
Epistaxis and dizziness for 2 weeks
No haematuria, no haematemesis, no melaena, no
haemoptysis
PMH: HIV positive, CD 4 unknown, not on HAART.
No previous opportunistic infections, no previous
malignancy
Drugs: Nil. Not on Co-trimoxazole
History cont.
Allergies: Nil known
Social: Non-smoker. No ethanol use. Salesman.
One sister from same parents, 8 half-siblings.
No occupational exposure to radiation,
pesticides, benzene.
Family History: Nil of note.
Travel History: Nil.
Systemic enquiry: No LOW, no night sweats or
fever. Decreased exercise tolerance. No other
resp or cvs S. No ecchymosis or jaundice. No
polyarthralgia, no photosensitivity.
Clinical examination
General : Pallor, anicteric, acyanotic, small
mobile LN submandibular, no oedema, no oral
candidiasis
No ecchymosis, no skin nodules, no lesions
suggestive of Kaposi’s sarcoma
Vital signs: Apyrexial, BP 99/48 mmHg,
HR 112bpm, weight 57kg
CVS: APPE, JVP →, tachycardia, regular, good
volume, apex undisplaced, hyperdynamic,
heart sounds normal, 2/6 ESM at LSB
Clinical examination
Resp: RR 14, resonant, clear, bilat b/s
Abdomen: soft, non-tender, no organomegaly
Neuro: alert, orientated, no focal signs,
no retinal haemorrhages
ENT: no gingival hypertrophy, enlarged tonsils
bilaterally, but not inflamed.
Urine: No macroscopic or microscopic
haematuria. No proteinuria. No urobilinogen.
Ward Hb: 2 g/dl
Clinical assessment
21 year old salesman presents with symptoms
suggestive of a qualitative or quantitative
platelets defect and severe anaemia, in the
absence of palapable organomegaly.
The patient is HIV positive, without prior
opportunistic infections.
Differentials:
Aplastic anaemia
Malignancies: ALL, AML, lymphoma
Myelodysplasia
Opportunistic infections
Investigations
FBC: HB 3.2 g/dl; MCV 87 fl; MCH 32.2 pg;
WCC 1.25; abs neutr 0.43, abs lymph 0.58;
mono 0.02; PLT 20, MPL 7.8 fl
Corrected Reticulocyte count : 0.77%
U&E, CMP: normal, LDH: 275 iu/l, Uric acid: 0,29
mmol/l
LFT: TP 95 g/l, alb 21 g/l, rest normal
Coagulation: 1.22; APTT 23.7 secs, control 28,9
secs, D-Dimer 1000 ng/ml, Fibrinogen 2,0 g/l
CD4 count: 268 cells/ul
Investigations cont.
Smear: pancytopenia, anisocytosis 2+,
occasional promyelocytes noted
Urgent BMAT and Trephine:
Acute promyelocytic leukemia, trephine
demonstrates neoplastic infiltration.
PCR, cytogenetic tests and flow cytometry
pending.
Ultrasound abdomen: no organomegaly, no
lymphadenopathy, normal
CXR: normal
Blood culture, u-MCS: no growth
Acute myelocytic leukemia
Acute myelocytic leukemia
Heterogeneous group of diseases
Clonal disorder of haematopoietic progenitor
cells which lose the ability to differentiate
normally and to respond to normal regulators
of proliferation.
Incidence of AML 3,6 per 100 000 per year,
increases with age. Median age at
presentation at 70 years.
Acute promyelocytic leukemia is a subtype of
AML, median age of presentation 25 years.
Etiology
Heredity: Somatic cell aneuploidy eg. Trisomy21;
Excessive chromosome fragility eg Bloom S
Ionising radiation: ↑ Incidence AML 5-7 yrs
after atomic bomb explosion.
Chemicals: Benzene, smoking, petroleum
products, paint, ethylene oxide, pesticides.
Drugs: 1. Alkylating agent-associated leukemias
4-6 yrs after exposure (chr 5; 7); 2. Topoisomerase II inhibitor-associated leukemias
occur 1-3 yrs after exposure (chr 11; t 15:17;
t 8:21); 3. Chloramphenicol, chloroquine →
BM failure that may evolve into AML
Haematopoiesis
Neutrophil
development
Multipotent stem cell
↓
Common myeloid progenitor cell
↓
GM Commited precursor cell
↓
Granulocytic progenitor cell ( lineage committed cells )
↓
Myeloblast →
↓
← Promyelocyte
↓
Myelocyte
↓
Metamyelocyte
↓
Band form →
↓
Neutrophil
Classification
French-American-British Classification (1985)
8 major subtypes according to morphology &
cytochemisty. Required > 30% myeloblasts in
BM for diagnosis.
M0
M1
M2
M3
M4
M5
M6
M7
Minimally differentiated leukemia
Myeloblastic leukemia without maturation
Myeloblastic leukemia with maturation
Hypergranular promyelocytic leukemia
Myelomonocytic leukemia
Monocytic leukemia
Erythroleukemia
Megakaryoblastic leukemia
WHO Classification
Requires presence of > 20% myeloblasts in blood
and/or BM. Incorporates molecular & cytogenetic,
morphologic (multi-lineage dysplasia ), clinical
features ( prior haematologic disorder ).
- Recurrent translocations: t(8;21)(q22;q22),
t(15;17)(q22;q22), t(16;16)(p13;q22). t(v:11q23)
- Multi-lineage dysplasia
- Therapy related AML & myelodysplastic S
- Not otherwise categorised
- Acute myelomonocytic L
- Acute leukemia of ambiguous lineage
- Bilineal acute L
Leukemogenesis of AML
Two-hit model:
Class 1 genetic damage: results in constitutive
activation of cell surface receptors ( eg RAS ), or
receptor tyrosine kinases ( eg FLT 3, c-KIT ) →
clonal expansion
Class 2 genetic damage: results in formation of
fusion genes that block myeloid differentiation.
FAB Classification & associated genetic
abnormalities
Leukemogenesis of M3
RARs are nuclear receptors that act as
ligand-dependent transciption factors
↓
t ( 15;17) ( q22;q12)
↓
PML-RARα fusion protein binds
retinoid acid response elements
↓
suppresses gene transcription
and blocks differentiation of the cell
↓
differentiation at promyelocyte
stage arrested
Clinical presentation
Symptoms related to pancytopaenia: easy
fatigue, infections, hemorrhagic findings
Constitutional Sx: LOA, LOW, fever
Pallor, fever, infection, hemorrhage including
retinal hemorrhages
Hepatosplenomegaly, lymphadenopathy
Infiltration of gingivae, skin, soft tissues or
meninges ( monocytic subtype M4 and M5)
Granulocytic sarcoma ( chloroma ): mass
consisting of leukemic cells in soft tissues,
breast, uterus , ovary, GIT, lung or other
organs → associated with t(8;21)
Clinical presentation: M3
APL can be complicated by DIC ( at diagnosis
or initiation of chemotherapy). Mechanism:
1. Tissue factor → forms a complex with F VII
to activate F X and IX
2. Cancer procoagulant, which activates F X
3. ↑ Annexin R expression on surface of
leukemic promyelocyes→ annexin II R binds
plasminogen & tissue plasminogen activator →
this results in increased plasmin formation
Thrombocytopenia as well as platelet
dysfunction
Diagnosis
BM aspirate & trephine biopsy
Cytogenetic: RT-PCR for AML 1ETO and CBFB-MYH 11 in nonAPL and PML-RARA in suspected
APL, FISH in selected cases
Cytochemistry ( MPO or Sudan
Black, combined esterase )
Immunophenotyping for specific
intracellular & surface antigens
Treatment of AML: Overview
Induction Rx : age
younger
> 60 – 65 yrs
↓
↓
“3+7“
Standard Rx or
↓
investigational Rx
Postremission Rx:
or supportive Rx
risk stratify
↓
↓
↓
favourable intermed averse risk
(good)
(standard) (poor)
↓
↓
↓
cytarabine cytarabine allogenic tplt
or new drugs
Treatment of AML
Induction therapy:
Aim is complete remission:
BM < 5% blasts, neutrophils > 1000, PLT > 100 000
3 + 7 combination “→ daunorubicin IVI 3 days,
cytarabin IVI for 7 - 10 days
Postremission
therapy:
Risk stratify !
Cytogenetic
abnormalities
Elderly AML patients
Associated with:
1. more adverse cytogenetics
2. overexpression of MDR 1 gene encoding a drug
efflux pump p-glycoprotein
3. ↑ incidence of prior myelodysplasia
4. generally do not tolerate chemotherapy as well as
younger patients
Options:
A) Standard treatment
B) Palliative chemoR: low-dose cytarabine
C ) investigational treatment (clinical trial )
D ) supportive care ( very poor performance
status, abn organ Function, > 80 yrs old )
General measure & supportive care
Hyperleukocytosis: leucopheresis if Sx ( but
not in PML)
Tumour lysis S: hydration, allopurinol, monitor
I + O, recombinant urate oxidase
(rasburicase)
Platelet transfusion
Packed cell transfusion
Anti-infective Rx
Use of prophylactic AB controversial
Haematopoietic growth factors
G-CSF given after completion of
chemotherapy → reduce duration of
neutropenia and decrease AB use, but no
effect on rates of remission or overall
survival.
“ Priming effect “: G-CSF could stimulate
leukaemic cells to proliferate, which could
increase their susceptibility to
chemotherapy→ reduction in relapse and
improved survival for patients with standardrisk AML.
Treatment M3: ATRA
ATRA as soon as Dx of APL suspected and
given for prolonged time ( 21-60days)
Treatment M3
Retinoic acid syndrome: ATRA → diff. of
APL cells → cytokine release & surface
adhesion molecule modulation → capillary
leak & fluid retention as well as organ
infiltration by leukaemic cells.
Sx/Tx: cough, dyspnoea, fever, pulm
infiltrates, pleural & pericardial effusion,
oedema, Lab: ↑ WBC
Management: stop ATRA temporarily,
dexamehtasone 10mg bd IVI; prophylactic
steroids with induction Rx – benefit
uncertain.
Treatment M3
Induction:
- ATRA
- daunorubicin & cytarabin IVI
Consolidation: 2-3 anthracycline- based
courses, ATRA
Maintenance therapy: ATRA
Coagulopathy:
1. Keep PLT > 50 until remission.
2. Keep coagulation times normal with FFPs
3. Anti-fibrinolytic agents if life threatening
hemorrhage
Patient progress
Initial resuscitation with packed cells,
developed massive epistaxis 4 days later,
hence received a total of 8 units packed
cells and 1 pool of platelets over the next
10 days
Cyclokapron, H2 receptor antagonist,
Piperacillin-Tazobactam and Gentamycin
No isolation facilities were available at
EDH
Patient progress
Whilst awaiting transfer to IALCH:
ATRA 40mg bd, Prednisone 30mg dly,
Omeprazole 20mg dly, Cyclokapron
The patient is currently undergoing induction
therapy at IALCH with ATRA, daunorubicin &
cytarabin.
References
Estey E. AML. Lancet 2006; 368:1894 - 90
Lowenberg G. AML. NEJM 1999; 341: 1051 - 1059
British Committee for Standards in Haematology.
British Journal of Haematology 2006; 135: 450 - 474
UpToDate
Schiffer C. Hematopoietic Growth factors and AML.
NEJM 2003; 349: 727 - 729
Lowenberg B. Effecy of Priming with G-CSF on the
outcome of chemotherapy for AML. NEJM 2003; 349:
743 - 52
Menell J. Annexin II and Bleeding in acute
promyelocytic leukemia,. NEJM 1999; 340: 994 – 1004
References cont.
Pedersen-Bjergaard. Insights into leukemogenesis
from therapy-related leukemia. NEJM 2005. 352:
1591-1594
McPhee S. Pathophysiology of disease. Lange. Fifth
edition p 116
Kaushansky K. Lineage-Specific Hematopoietic
Growth Factors. NEJM 2006;354:2034-45
Thank you !
Molecular monitoring : RT-PCR assay to
detect
minimal residual disease and relapse.
Relapse: ATRA + chemoRx followed by rescue
using allogenic stem cells
Mechanism of chemotherapy
ATRA: All-trans retinoic acid ( tretinoin):
discussed previously
Cytarabine: inhibition of DNA polymerase
Daunorubicin: Anthracycline AB
1. inhibits topoisomerase II
2. High affinity binding to DNA through
intercallation → results in blockade of DNA &
RNA synthesis
3. Alteration in cell membrane transport
4 Generation of oxygen free radicals that
cause DNA strands to break
Topoisomerase II