Updated: 2/20/2018

Acute Myelogenous Leukemia (AML)

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Snapshot
  • A 63-year-old man presents with fever, increasing fatigue, and actively bleeding gums. Physical exam also reveals several oral mucosal petechiae. His CBC reveal decreased platelet and hemoglobin. His PT and PTT are elevated with low fibrinogen. Peripheral blood smear shows blasts and schistocytes. His D-dimer level is elevated. He is diagnosed with DIC and given fresh frozen plasma. He is referred to a hematologist-oncologist.
Introduction

  • Acute leukemia resulting in bone marrow failure from neoplastic proliferation
  • Epidemiology
    • median onset 65 years of age
  • Subtypes
    • M3 aka acute promyelocytic leukemia (APL)
      • t(15;17)
        • disruption of retinoic acid receptor (RAR) required for myeloblast maturation
      • associated with DIC
      • presence of Auer rods
        • peroxidase-positive cytoplasmic inclusions
    • acute megakaryoblastic leukemia
      • associated with Down syndrome
      • < 5 years (recall leukemia in Down syndrome occurring in > 5 years = ALL)
    • acute monocytic leukemia
      • infiltration of gums
  • Risk factors
    • alkylating chemotherapy
    • radiation
    • myeloproliferative disorders
    • Down syndrome
    • smoking
Presentation
  • Symptoms of pancytopenia (high WBC count but WBCs are dysfunctional)
    • fatigue
    • dyspnea
    • infection due to dysfunctional blasts
    • bleeding
  • Physical exam
    • lymphadenopathy (infiltration of leukemia)
    • hepatosplenomegaly (infiltration of leukemia)
    • fever
    • swollen gums (infiltration of leukemia)
Evaluation
  • Best initial test - peripheral blood smear
    • > 20% blasts in blood smear
  • Most accurate test
    • flow cytometry
  • Bone marrow biopsy with cytogenetics     
    • myeloblasts with Auer rods in APL
    • myeloperoxidase positive in APL, negative in other subtypes
  • Labs - CBC
    • ↓ RBCs
    • ↓ mature WBCs
    • ↓ platelets
Differential Diagnosis
  • ALL
  • Myelodysplastic syndrome
  • CML blast crisis
  • Leukemoid reaction
Treatment
  • Initial treatment with chemotherapy
    • to induce remission
    • cytarabine
  • Bone marrow transplant after remission
    • especially for cytogenetics revealing high chance of relapse
  • All-trans-retinoic acid (ATRA) to those with M3 (APL)
Prognosis, Prevention, and Complications
  • Prognosis
    • prognostic indicator is cytogenetics
    • 90% complete response rate from initial chemotherapy in those with good cytogenetics
    • relapse rate > 50% with median survival 3-12 months
  • Complications
    • febrile neutropenia
    • DIC (especially with APL)
    • gout
    • tumor lysis syndrome

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Questions (3)
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(M2.ON.15.72) A patient presents to the primary care clinic complaining of 3 months of progressive fatigue. A blood smear is performed and the intracellular inclusions shown in Figure A are seen. A genetic screen is performed showing a t(15:17) translocation. What is the most appropriate treatment for this patient?

QID: 106526
FIGURES:
1

Splenectomy

0%

(0/26)

2

Taxol

0%

(0/26)

3

Cisplatin

8%

(2/26)

4

All-trans retinoic acid

77%

(20/26)

5

Imatinib

12%

(3/26)

M 7 E

Select Answer to see Preferred Response

(M2.ON.15.4671) A 52-year-old man presents to his primary care physician. The man has been feeling very tired lately and thinks that he looks more pale. The physician orders a complete blood count, which shows: Hgb 8.5 g/dL; WBC 1,200/microliter; platelets 70,000/microliter. The patient is referred for bone marrow biopsy, which shows the findings in Figure A. Which of the following is the correct diagnosis?

QID: 107168
FIGURES:
1

Acute lymphoblastic leukemia

6%

(5/79)

2

Acute myelogenous leukemia

56%

(44/79)

3

Chronic lymphocytic leukemia

13%

(10/79)

4

Chronic myelogenous leukemia

18%

(14/79)

5

Multiple myeloma

6%

(5/79)

M 6 D

Select Answer to see Preferred Response

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