1. Approach to Acute Leukemia
Dr. Nikhil Patkar
Clinician Scientist & Asst Professor
Hematopathology Laboratory
Tata Memorial Centre

2. History 59 year old female, easy fatiguability
Leucocytosis, decrease in platelets
TLC:90,000/mm3
Platelet counts: 54,000/mm3
Suspected to have acute leukemia and referred to TMH

4. Questions to ask when faced with acute leukemia
Is there an increase in blasts or blast equivalents?
Are there abnormal promyelocytes?
Are there Auer rods?
Is cytochemical MPO positive?
Is cytochemical NSE positive?
Must send for immunophenotyping.
YES?
NO?
NO?
NO?
NO?

5. Cytochemical MPO

7. Summary Morphology Immunophenotype Myeloid Blasts Strong MPO positive
CD34 Negative
HLA-DR Negative
CD13,CD33positive, CD117 dim-negative

8. Diagnosis?

9. Questions to ask when faced with acute leukemia
Is there an increase in blasts or blast equivalents?
Are there abnormal promyelocytes?
Are there Auer rods?
Is cytochemical MPO positive?
Is cytochemical NSE positive?
Must send for immunophenotyping.
YES?
NO?
NO?
NO?
NO?

10. Is this acute promyelocytic leukemia?
Yes / No Is this distinction important? How urgent is the report ?

11. APL with t(15;17)(q22;q12); PML-RARA

12. How does this determine treatment?
AML with t(15;17)
Treated with
All Trans Retinoic Acid
Or Arsenic Trioxide
Excellent survival
High mortality if not detected early & treated correctly
DIC and bleeding complications eg intracranial bleeding
Practical working algorithm in a pathology lab
AML M3 or non M3 AML

13. Overall survival (top) and disease-free survival (bottom) curves of 14 relapsed APL patients after As2O3-induced CR.
Overall survival (top) and disease-free survival (bottom) curves of 14 relapsed APL patients after As2O3-induced CR.
Shen Z et al. Blood 1997;89:
©1997 by American Society of Hematology

15. Cup Shaped Blasts
Cytochemical MPO Positive

16. Typical morphology of myeloid blasts with cup-like nuclear invagination in AML. (A) The “cup” seems to be a part of the nucleus in Pappenheim staining, however it is positive for myeloperoxidase (MPO) in reactive blasts.
Typical morphology of myeloid blasts with cup-like nuclear invagination in AML. (A) The “cup” seems to be a part of the nucleus in Pappenheim staining, however it is positive for myeloperoxidase (MPO) in reactive blasts. (B) MPO-positive and MPO-negative cup-like blast cells in a patient with AML FAB M1.
Kroschinsky F P et al. Haematologica 2008;93:
©2008 by Ferrata Storti Foundation

17. Cup shaped blasts are often associated with NPM1 Mutations
NPM WT
169bp
NPM Mutant
173 bp
FLT3-WT
330bp

18. NPM1 Mutated AML, FAB AML M1
Final Diagnosis
NPM1 Mutated AML, FAB AML M1