Transcript 398 - SH/EAHP

Case 398
Submitting Author: Hutchison, Robert E, MD
Institution: SUNY Upstate Medical University
Additional authors: Constance K. Stein, Ph.D., Theresa C.
Gentile, M.D., Ph.D., Bhuvaneswari Ramkumar, M.D.
History
• The patient is a 48 year old female who
presented to her doctor with symptoms
consistent with a sinus infection with head
congestion, shortness of breath and cervical
lymphadenopathy which did not improve with
antibiotics. She was found to have a white
blood cell count of 20,000 /ul with peripheral
blasts, anemia and thrombocytopenia.
Details
• RPIC bone marrow aspiration and biopsy.
• Aspirate films (push preps) and clot preparation prepared
at the bedside
• RPIC trephine biopsy and touch imprints made at the
bedside.
• The biopsy and clot were fixed in B5 fixative for two hours
and then transferred to 70% ETOH prior to processing.
• Peripheral blood in EDTA for CBC and blood films.
• Aspirate films and touch imprints stained manually with
Wright Giemsa; blood films with an automated stainer.
• Sections stained with H&E.
Blood
• WBC=20.2 K/ul
– 85.5% blasts
– 14.5% lymphocytes
– 8 NRBC/100 WBC
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•
•
•
Hgb=7.5 g/dl
RBC=2.24 M/ul
MCV=101.8 fl
plt=61 K/ul
– Blasts showed high N/C ratio, diffuse chromatin with 1-2
nucleoli and occasional Auer rods.
Blood film
BM aspirate
• Hypercellular marrow
– 41.4% erythroid precursors with moderate
megaloblastic/dysplastic features
– 50.8% blasts
• Auer rods were frequent and sometimes multiple.
– 6.8% lymphocytes
– 1.0% plasma cells
– Occasional megakaryocytes
BM aspirate
BM aspirate
Erythroid dysplasia
Biopsy/clot sections
IMMUNOHISTOCHEMISTRY AND FLOW
CYTOMETRY
• Flow cytometry:
– Blasts positive for:
• CD38, CD117, CD13, CD33, MPO (98%)
• dim/partial CD34 (29%) and CD15 (49%).
– negative for:
• CD14, CD64, cCD3, cCD79a, cCD22 and Tdt.
• Immunohistochemistry:
– Cytoplasmic and nuclear NPM
NPM
Karyotype:
47,XX,+4(9); 46,XX(11)
FISH
• chr. 4: nuc ish
(D4Z1x3)(64/100)
• FISH showed 64% of
cells with an additional
signal for chromosome
4 indicating trisomy 4.
MOLECULAR FINDINGS
• Positive for NPM1 (exon 12) mutation, 39.88%
• PCR amplification performed using NPM intron 11
forward primer and 6-fam-labeled NPM exon 12
reverse primer - Quest
• Negative for FLT3
• FLT3 length mutation (including internal tandem
repeats) as well as point mutations at D835 and I836
within the FLT3 tyrosine kinase domain– SUNY-UMU
INTERESTING FEATURES
• AML with trisomy 4 as the sole cytogenetic
abnormality is a rare to uncommon disease that
has been described but not classified among AML
with recurrent genetic abnormalities in the WHO
Classification. It often shows morphology of AML
without maturation or with minimal
differentiation (some cases described with varied
differentiation), with high blast proportions and
with a generally poor prognosis.
AML with NPM1 mutation
• AML with NPM1 mutation is classified within
AML with gene mutations in the WHO
Classification. It has a relatively good
prognosis, usually occurs in patients with
normal karyotype with monocytic or
myelomonocytic differentiation, occasionally
with erythroid differentiation or multilineage
dysplasia, has high blast proportions and is
often considered to be a primary abnormality
Concurrent trisomy 4 and NPM1
• In the few cases described of AML with trisomy 4, NPM1
mutation occurs at a similar frequency as in AML with
normal cytogenetics. In one publication, it was most often
also associated with FLT3-ITD (Bains). The simultaneous
occurrence of trisomy 4 and NPM1 in the current case
raises questions of whether either is the primary event or if
they are independent genetic abnormalities occurring
coincidentally to produce a unique disease. The case
initially suggests that in this situation the "worse" genetic
feature, trisomy 4, holds sway. This patient initially
achieved remission but suffered sustained pancytopenia
with possible early relapse after 6 months and has
undergone bone marrow transplantation.
Karyotypic abnormalities in NPM1
mutated AML
• The bulk of available evidence suggests strongly that NPM1
is a “founder” abnormality and that chromosomal
abnormalities are secondary events
• NPM1 mutation is not found as a secondary event
• NPM1 mutation is a stable marker of residual disease
• Presence of karyotypic abnormalities, including trisomies of
4, 8 and 11 may not adversely affect prognosis of NPM1
mutated AML
• While trisomy 4 has shown concurrent NPM1 mutation,
poor prognosis trisomy 11 has not
• It has recently been suggested that immune response to
mutated NPM1 may contribute to relatively favorable
prognosis
Clinical Course
• The patient was started on induction chemotherapy with
Cytarabine 100mg/m2 (milligram per square meter) for 7 days
along with Idarubicin 12mg/m2 for 3 days. She had neutropenic
fever with E. Coli bacteremia and was treated with antibiotics. Her
day 14 bone marrow did not show evidence of leukemia.
• After remission was confirmed, she received consolidation therapy
with high dose cytarabine. She developed cerebellar toxicity and
received only 5 out of 6 planned doses of cytarabine.
• Her second consolidation was with Mitoxantrone 10mg/m2 and
Etoposide 100mg/m2 daily for 5 days. She developed mucositis and
was treated supportively. She remained pancytopenic for 7 weeks.
A bone marrow examination was performed.
Follow-up marrow
• 13.2% blasts/blast-like cells, 15.6% immature monocytoid cells, 13%
monocytes and 28% mature/maturing neutrophils. No Auer rods.
• Flow Cytometry (blast gate): CD11b, CD13, CD15, CD33, CD64,
CD38, partial CD14 and CD41
• Cytogenetics:
– Karyotype: 46, XX
– FISH: No evidence of trisomy 4, del 5q, 7q or 20q12, or of trisomy 8.
• Immunohistochemistry: NPM cytoplasmic positivity in a minority of
scattered cells in clot section.
• Dx: Normocellular marrow with increased blasts and peripheral
pancytopenia, suggesting early relapse of AML but without genetic
evidence of recurrence; post-therapy dysplasia also possible.
Follow-up marrow
Follow-up NPM
Further follow-up
• She was referred to a transplant center and
underwent allogeneic stem cell
transplantation with a matched unrelated
donor.
• She is in bone marrow remission with no
cytogenetic or molecular abnormalities.
• She is in treatment for GVHD-related
complications.
Follow-up observations
• Post-treatment pancytopenia occurred with apparent
early relapse of AML but a smouldering course and
different than original phenotype (monocytic, CD34-).
• There was loss of trisomy 4, but some residual cells
showed cytoplasmic NPM, suggesting that the NPM1
mutation may have been the primary (founder)
abnormality, with the disease accelerated or altered by
trisomy 4 and persistent at low level after initial
therapy.
• There was no cytogenetic evidence of post-therapy
myeloid malignancy.
PROPOSED DIAGNOSIS
• Acute Myeloid Leukemia with recurrent
genetic abnormality
• Current terminology; AML with mutated
NPM1, and trisomy 4.
• Possible future terminology; AML with trisomy
4, and NPM1 mutation.
CONSENSUS DIAGNOSIS
• Acute myeloid leukemia, with NPM1 mutation
and trisomy 4
References
• Haferlach C, et al. AML with mutated NPM1 carrying a normal or aberrant
karyotype show overlapping biologic, pathologic, immunophenotypic, and
prognostic features. Blood 2009 Oct; 114(14): 3024-3032
• Falini B, et al. Acute myeloid leukemia with mutated nucleophosmin
(NPM1): is it a distinct entity? Blood 2011 Jan 27;117(4):1109-20
• Alseraye, et al. Trisomy 11 as an isolated abnormality in acute myeloid
leukemia is associated with unfavorable porgnosis but not with an NPM1
or KIT mutation. Int J Clin Exp Pathol 2011;4(4): 371-377
• Bains A, et al. Molecular and clinicopathologic characterization of AML
with isolated trisomy 4. Am J Clin Pathol 2012;137:387-394.
• Greiner J, et al. Immune responses against the mutated region of
cytoplasmic NPM1 might contribute to the favorable clinical outcome of
AML patients with NPM1 mutations (NPM1mut). Blood 2013;122(6):1087
• Jain P, et al. Mutated Nucleophosmin-1 (NPM1) in patients with Acute
Myeloid Leukemia (AML) in remission and relapse. Leuk Lymphoma 2013
[Epub ahead of print]