AML: A Case of Myelodysplasia-Related Changes

Harry Erba, MD, PhD:We’re presented with a 68-year-old man who goes to the emergency room with dizziness and chest pain, and on evaluation, he’s found to have an acute myocardial infarction. He’s appropriately managed in the hospital for that. Routine blood counts, however, showed that he’s neutropenic with leukocytosis. He is stable from his myocardial infarction and then transferred to a hematologist-oncologist.

On evaluation there, he gives a history of about 2 months of fatigue and shortness of breath with exertion, a 6-month history of recurrent upper respiratory tract infections, and low-grade fevers that he thought were related to his prior history of tobacco abuse, but none of these infectious episodes actually improved dramatically with appropriate antibiotics.

In terms of a laboratory evaluation, he had a white blood cell count of 85,000. His neutrophil count though was around 600 with only about 1% neutrophils. And there was 25% blast on the peripheral blood smear. However, when you actually look at the peripheral blood smear, the majority of the cells are immature myeloid cells. So, I would assume that the remainder of that differential were atypical monocytes and promonocytes, and this patient had acute myelomonocytic leukemia. With over 25% blast, he clearly has AML, you don’t need to do a bone marrow to confirm that. Cytogenetic analysis shows that the long arm of chromosome 5 is missing, so he has deletion 5q in the karyotype. So, the final diagnosis is acute myeloid leukemia with myelodysplasia-related changes.

He receives induction chemotherapy with liposomal daunorubicin/cytarabine and achieves a complete remission. That’s followed with consolidation with the same agent. And then finally, allogeneic hematopoietic stem cell transplant.

Transcript edited for clarity.

Case: A 68-Year-Old Man With Newly-diagnosed AML

• A 68-year-old man went to the emergency room with complaints of dizziness and chest pain
  • Myocardial infarction diagnosed and managed in hospital
  • During stay, CBC revealed decreased neutrophils but increased total white blood cell count
  • When stable from MI, he was referred for specialist consultation
• Patient history and physical exam:
  • Reported fatigue, shortness of breath with minor exertion, and unexplained weight loss that have worsened over the past 2 months
  • Over the 6 months, has experienced three upper respiratory infections, often with mild fever, that were refractory to treatment, but which he attributed to being a former smoker
  • No history of cancer or cytotoxic treatment
• Laboratory findings:
  • Absolute neutrophil count: 600 cells/µL; WBC: 85,000 cells/µL
  • Peripheral blood shows poorly differentiated myeloid cells
  • 25% blasts in peripheral blood
  • Cytogenetic abnormalities: chromosome 5 (del[5q])
• Diagnosed with acute myeloid leukemia with myelodysplastic-related changes
• Received Vyxeos (CTX-351) induction therapy, followed by consolidation
  • Experienced complete response and underwent HSCT