A Diagnosis of Acute Monocytic Leukemia – Cancer Example

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"A Diagnosis of Acute Monocytic Leukemia"  is a great example of a paper on cancer. A 74-year-old Caucasian male presented with an intermittent rash that had been ongoing for 7 years. A skin biopsy proved to be suggestive of Mycosis Fungoides (Cutaneous T-cell lymphoma). Oral and topical steroids including prednisone, triamcinolone, and fluocinonide were used to treat the condition. The patient’ s laboratory investigations started portraying a picture of anemia during the last two years. Hemoglobin (10.3 g/dl) accompanied by thrombocytopenia of unknown origin was noted. Other labs including reticulocyte count, serum B12 and folate levels, ferritin and TIBC were normal.

Bone marrow revealed hypercellular marrow with trilineage hematopoiesis, dysplastic megakaryocytes, normal blasts; a picture suggestive of myelodysplastic syndrome (MDS). Anemia was treated with Procrit. The patient presented with acute aggravation of his skin condition four months ago. Physical examination revealed the presence of patchy erythematous papules and dry scaling plaques spread over the right aspect of the face. A punch biopsy of the skin was performed (Braun-Falco 21). Flow cytometry immunophenotypic studies of bone marrow revealed the presence of a heterogeneous population of cells including increased CD14+ monocytes.

A myeloid predominance (M: E ratio 4.1:1) was detected in Bone marrow aspirate. Nuclear cytoplasmic asynchrony was observed in the erythroid and myeloid series. Increased monoblasts and mature monocytes were observed, whereas bone marrow biopsy was 80% cellular; marrow spaces were filled with immature cells containing convoluted nuclear and prominent nucleoli resembling monoblasts and monocytes that were CD68 positive and CD20, CD3, CD30, S100, and pan-cytokeratin negative. A few maturing myeloid cells along with decreased megakaryocytes that appeared dysplastic were prevailing. A diagnosis of Acute Monocytic Leukemia (AML-M5) co-existing with Mycosis Fungoides was made.

The diagnostic criteria for AML include the following (Tallman et al); 80% of leukemic cells from the monocytic lineage (monoblasts, promonocytes, and monocytes) Presence of granulocytic component Monoblasts> 80%, majority monocytic cells being promonocytes (in FAB M5a) Peripheral blood monocyte count greater than 5000/L At least 30% bone marrow blasts As far as the specific markers of AML-M5 are concerned, CD13, CD33, CD4, and HLA-DR are all positive in this type. A strong expression of CD45 is also seen. CD64 demonstrates a high level of sensitivity whereas reactions with CD14, CD16 and CD24 display high specificity related to monocytic lineage (Bain 84). The recent aggravation was associated with the presence of hypercellular bone marrow containing monoblasts and marrow spaces were filled with immature cells which is a characteristic feature of cancerous cells.

A common condition associated with Mycosis Fungoides is the Sezary syndrome, which was perhaps the first suspicion of physicians in this case. The clinical and pathological findings were however not consistent with Sezarysyndrome. The diagnosis of this case was not difficult, but since the co-occurrence of the ultimately diagnosed disease entities is a rare finding, the diagnosis was missed earlier which delayed the process of diagnosis.

Anemia that appeared earlier in the course of the disease was treated with Procrit, which is a reflection of the fact that the underlying pathological phenomena were being ignored at that time. At the time of diagnosis, however, the disease had become full-blown which resulted in the worst prognosis i. e. death of the patient.

References

Bain, Barbara J. Leukaemia Diagnosis. Chichester, West Sussex: Wiley-Blackwell, 2010. Internet resource.

Braun-Falco, Otto. Dermatology: With 281 Tables. Berlin [u.a.: Springer, 2000. Print.

Tallman, MS, HT Kim, E Paietta, JM Bennett, G Dewald, PA Cassileth, PH Wiernik, and JM Rowe. "Acute Monocytic Leukemia (french-American-British Classification M5) Does Not Have a Worse Prognosis Than Other Subtypes of Acute Myeloid Leukemia: a Report from the Eastern Cooperative Oncology Group." Journal of Clinical Oncology : Official Journal of the American Society of Clinical Oncology. 22.7 (2004): 1276-86. Print.

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