Acute promyelocytic leukemia differential diagnosis: Difference between revisions
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{{ | [[Image:Home_logo1.png|right|250px|link=https://www.wikidoc.org/index.php/Acute_promyelocytic_leukemia]] | ||
{{ | {{CMG}} {{shyam}} {{AE}} {{S.G.}}; {{GRR}} {{Nat}} | ||
==Overview== | |||
The differential diagnosis of acute promyelocytic leukemia includes a variety of other [[hematologic]] [[malignancies]], specifically [[acute myeloid leukemia]] (AML), [[acute lymphoblastic leukemia]] (ALL), [[Chronic myelogenous leukemia|chronic myeloid leukemia]] (CML), and [[chronic lymphocytic leukemia]] (CLL). Each of these conditions has distinct causes and therapies. There is some overlap between the causes and [[Medical laboratory|laboratory]] [[abnormalities]] amongst these [[Disease|diseases]]. | |||
==Differentiating Acute promyelocytic meukemia from other Diseases== | ==Differentiating Acute promyelocytic meukemia from other Diseases== | ||
The following table differentiates acute promyelocytic leukemia from other [[Leukemia|leukemias]] that may present with similar [[clinical]] features such as [[fever]], [[fatigue]], [[weight loss]], recurrent [[infections]] and elevated [[White blood cells|leukocyte]] counts. The following are the differentials: | |||
{| class="wikitable" | {| class="wikitable" | ||
!Characteristic | ! align="center" style="background:#4479BA; color: #FFFFFF;" + |Characteristic | ||
!Causes | ! align="center" style="background:#4479BA; color: #FFFFFF;" + |Causes | ||
!Laboratory abnormalities | ! align="center" style="background:#4479BA; color: #FFFFFF;" + |Laboratory abnormalities | ||
!Physical examination | ! align="center" style="background:#4479BA; color: #FFFFFF;" + |Physical examination | ||
!Therapy | ! align="center" style="background:#4479BA; color: #FFFFFF;" + |Therapy | ||
!Other associations | ! align="center" style="background:#4479BA; color: #FFFFFF;" + |Other associations | ||
|- | |- | ||
|Acute | |[[Acute myeloid leukemia|'''Acute myeloid leukemia''']] | ||
| | | | ||
* [[Chromosomal]] instability | |||
* Sporadic [[mutations]] | |||
* Prior exposure to [[benzene]] | |||
* Prior exposure to alkylating agents | * Prior exposure to alkylating agents | ||
* Prior exposure to topoisomerase II inhibitors | * Prior exposure to [[Topoisomerase II|topoisomerase II inhibitors]] | ||
* | * [[Germline]] ''[[RUNX1]]'' [[mutation]] | ||
| | | | ||
* | * [[Anemia]] | ||
* [[ | * [[Thrombocytopenia]] | ||
* [[Neutropenia]] | * [[Neutropenia]] | ||
* [[ | * Elevated [[LDH]] | ||
* | * Elevated [[uric acid]] | ||
* Elevated | * Elevated [[phosphorus]] | ||
* Elevated | * Elevated [[potassium]] | ||
* Low [[calcium]] | |||
* Greater than 20% [[myeloblasts]] on [[bone marrow]] aspirate<ref name="pmid27895058">{{cite journal| author=Döhner H, Estey E, Grimwade D, Amadori S, Appelbaum FR, Büchner T et al.| title=Diagnosis and management of AML in adults: 2017 ELN recommendations from an international expert panel. | journal=Blood | year= 2017 | volume= 129 | issue= 4 | pages= 424-447 | pmid=27895058 | doi=10.1182/blood-2016-08-733196 | pmc=5291965 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=27895058 }} </ref> | |||
| | | | ||
* [[ | * [[Pyrexia]] | ||
* Evidence of [[infection]] | |||
* [[Pallor]] | |||
* Evidence of infection | * [[Mucosal]] [[bleeding]] (less common than in [[acute promyelocytic leukemia]]) | ||
* Pallor | * [[Bruising]] (less common than in [[acute promyelocytic leukemia]]) | ||
* [[ | |||
| | | | ||
* [[Cytarabine]] | * [[Cytarabine]] | ||
* [[Anthracycline]] | * [[Anthracycline]] | ||
* [[Enasidenib]] | |||
* [[Liposomal]] [[daunorubicin]] plus [[cytarabine]] | |||
* [[Gemtuzumab ozogamicin|Gemtuzumab ozogamycin]] | |||
* [[Midostaurin]] | |||
* [[Enasidenib]] | |||
* Ivosidenib | |||
* [[Stem cell transplant]] | |||
| | | | ||
* | * Variable [[prognosis]] based on [[cytogenetic]] and molecular profile | ||
* | * Five new [[Food and Drug Administration|FDA]]-approved therapies became available in 2017-2018 | ||
|- | |- | ||
|Acute | |[[Acute promyelocytic leukemia|'''Acute promyelocytic leukemia''']] | ||
| | | | ||
* Prior exposure to alkylating agents | * Prior exposure to alkylating agents | ||
* Prior exposure to topoisomerase II inhibitors | * Prior exposure to [[topoisomerase II]] inhibitors | ||
* | * [[Chromosomal translocation|Translocation]] between [[Chromosome 15 (human)|chromosomes 15]] and [[Chromosome 17 (human)|17]] | ||
* Creation of PML-RAR''alpha'' [[gene]] product | |||
* [[Differentiation]] block in [[myeloid cells]] | |||
| | | | ||
* [[ | * Low [[white blood cell]] count (typically) | ||
* [[ | * [[Anemia]] | ||
* [[Neutropenia]] | * [[Neutropenia]] | ||
* | * [[Thrombocytopenia]] | ||
* | * Low [[fibrinogen]] | ||
* Elevated | * Elevated [[prothrombin time]] ([[Prothrombin time|PT]]) | ||
* Elevated | * Elevated [[partial thromboplastin time]] ([[Partial thromboplastin time|PTT]]) | ||
| | | | ||
* | * [[Mucosal bleeding]] | ||
* Evidence of infection | * [[Petechiae]] | ||
* Pallor | * [[Ecchymoses]] | ||
* | * Evidence of [[infection]] | ||
* [[Pallor]] | |||
* [[Thrombosis]] | |||
| | | | ||
* | * [[All-trans retinoic acid|All-''trans'' retinoic acid]] ([[ATRA]]) | ||
* | * [[Arsenic trioxide]] | ||
* | * [[Cytarabine]] | ||
* [[Anthracycline]] | |||
* [[ | |||
| | | | ||
* | * Presence of [[Auer rods]] in promyelocytes | ||
* | * High risk for early death from [[hemorrhagic]] [[Complication (medicine)|complications]]<ref name="pmid21993679">{{cite journal| author=McClellan JS, Kohrt HE, Coutre S, Gotlib JR, Majeti R, Alizadeh AA et al.| title=Treatment advances have not improved the early death rate in acute promyelocytic leukemia. | journal=Haematologica | year= 2012 | volume= 97 | issue= 1 | pages= 133-6 | pmid=21993679 | doi=10.3324/haematol.2011.046490 | pmc=3248942 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21993679 }} </ref> | ||
|- | |- | ||
|Acute lymphoblastic leukemia | |[[Acute lymphoblastic leukemia|'''Acute lymphoblastic leukemia''']] | ||
| | | | ||
* Chromosomal instability | * [[Chromosomal]] instability | ||
* Sporadic mutations | * Sporadic [[mutations]] | ||
| | | | ||
* [[Anemia]] | * [[Anemia]] | ||
* [[Thrombocytopenia]] | * [[Thrombocytopenia]] | ||
* [[Neutropenia]] | * [[Neutropenia]] | ||
* Elevated LDH | * Elevated [[LDH]] | ||
* Elevated uric acid | * Elevated [[uric acid]] | ||
* Elevated phosphorus | * Elevated [[phosphorus]] | ||
* Elevated potassium | * Elevated [[potassium]] | ||
* Low calcium | * Low [[calcium]] | ||
* Greater than 20% lymphoblasts on bone marrow aspirate | * Greater than 20% [[lymphoblasts]] on [[bone marrow]] aspirate | ||
| | | | ||
* Neurologic deficits | * [[Neurological|Neurologic]] deficits | ||
* Pallor | * [[Pallor]] | ||
* Lymphadenopathy | * [[Lymphadenopathy]] | ||
| | | | ||
* HyperCVAD (cyclophosphamide, vincristine, doxorubicin, dexamethasone)<ref name="pmid28665419">{{cite journal| author=Terwilliger T, Abdul-Hay M| title=Acute lymphoblastic leukemia: a comprehensive review and 2017 update. | journal=Blood Cancer J | year= 2017 | volume= 7 | issue= 6 | pages= e577 | pmid=28665419 | doi=10.1038/bcj.2017.53 | pmc=5520400 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28665419 }} </ref> | * HyperCVAD ([[cyclophosphamide]], [[vincristine]], [[doxorubicin]], [[dexamethasone]])<ref name="pmid28665419">{{cite journal| author=Terwilliger T, Abdul-Hay M| title=Acute lymphoblastic leukemia: a comprehensive review and 2017 update. | journal=Blood Cancer J | year= 2017 | volume= 7 | issue= 6 | pages= e577 | pmid=28665419 | doi=10.1038/bcj.2017.53 | pmc=5520400 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28665419 }} </ref> | ||
* R-HyperCVAD (inclusion of rituximab) | * R-HyperCVAD (inclusion of [[rituximab]]) | ||
* Peg-asparaginase | * Peg-asparaginase | ||
* Intrathecal methotrexate | * [[Intrathecal]] [[methotrexate]] | ||
* Intrathecal cytarabine | * [[Intrathecal]] [[cytarabine]] | ||
* Blinatumomab (bispecific T cell engager) | * [[Blinatumomab]] (bispecific [[T cell]] engager) | ||
* Inotuzumab ozogamycin (anti-CD22 antibody) | * [[Inotuzumab ozogamicin|Inotuzumab]] ozogamycin (anti-CD22 antibody) | ||
* Tisagenlecleucel (chimeric antigen receptor T (CAR-T) cell therapy) | * [[Tisagenlecleucel]] (chimeric antigen receptor T (CAR-T) cell therapy) | ||
* [[Stem cell transplant]] | * [[Stem cell transplant]] | ||
| | | | ||
* Sanctuary sites include the central nervous system (CNS) and testes<ref name="pmid23523389">{{cite journal| author=Inaba H, Greaves M, Mullighan CG| title=Acute lymphoblastic leukaemia. | journal=Lancet | year= 2013 | volume= 381 | issue= 9881 | pages= 1943-55 | pmid=23523389 | doi=10.1016/S0140-6736(12)62187-4 | pmc=3816716 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23523389 }} </ref> | * Sanctuary sites include the [[central nervous system]] ([[CNS]]) and [[testes]]<ref name="pmid23523389">{{cite journal| author=Inaba H, Greaves M, Mullighan CG| title=Acute lymphoblastic leukaemia. | journal=Lancet | year= 2013 | volume= 381 | issue= 9881 | pages= 1943-55 | pmid=23523389 | doi=10.1016/S0140-6736(12)62187-4 | pmc=3816716 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23523389 }} </ref> | ||
|- | |- | ||
|Chronic myeloid leukemia | |[[Chronic myelogenous leukemia|'''Chronic myeloid leukemia''']] | ||
| | | | ||
* Translocation between chromosomes 9 and 22 | * [[Translocation]] between [[Chromosome 9 (human)|chromosomes 9]] and [[Chromosome 22|22]] | ||
* Creation of BCR-Abl gene product | * Creation of [[Bcr-abl|BCR-Abl]] [[gene]] product | ||
| | | | ||
* Elevated [[white blood cell]] count | * Elevated [[white blood cell]] count | ||
* Presence of [[white blood cell]] precursors at various stages of maturation | * Presence of [[white blood cell]] precursors at various stages of maturation | ||
* Presence of excess metamyelocytes, basophils, eosinophils, and band cells | * Presence of excess metamyelocytes, [[basophils]], [[eosinophils]], and [[band cells]] | ||
| | | | ||
* Splenomegaly | * [[Splenomegaly]] | ||
* Abdominal tenderness | * [[Abdominal tenderness]] | ||
* Pallor | * [[Pallor]] | ||
* Evidence of infection | * Evidence of [[infection]] | ||
| | | | ||
* [[Imatinib]] | * [[Imatinib]] | ||
| Line 133: | Line 138: | ||
* [[Omacetaxine]]<ref name="pmid24516334">{{cite journal| author=Chen Y, Li S| title=Omacetaxine mepesuccinate in the treatment of intractable chronic myeloid leukemia. | journal=Onco Targets Ther | year= 2014 | volume= 7 | issue= | pages= 177-86 | pmid=24516334 | doi=10.2147/OTT.S41786 | pmc=3916637 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24516334 }} </ref> | * [[Omacetaxine]]<ref name="pmid24516334">{{cite journal| author=Chen Y, Li S| title=Omacetaxine mepesuccinate in the treatment of intractable chronic myeloid leukemia. | journal=Onco Targets Ther | year= 2014 | volume= 7 | issue= | pages= 177-86 | pmid=24516334 | doi=10.2147/OTT.S41786 | pmc=3916637 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24516334 }} </ref> | ||
| | | | ||
* High response rate to tyrosine kinase inhibitors | * High response rate to [[tyrosine kinase inhibitors]] | ||
* Risk for development of T315I kinase domain mutation | * Risk for development of T315I [[kinase]] domain [[mutation]] | ||
* Typically does not require [[stem cell transplant]] | * Typically does not require [[stem cell transplant]] | ||
* Three phases include chronic, accelerated, and blast phase | * Three phases include chronic, accelerated, and blast phase | ||
|- | |- | ||
|- | |- | ||
|[[Chronic lymphocytic leukemia]]<ref name="pmid28102226">{{cite journal| author=Kipps TJ, Stevenson FK, Wu CJ, Croce CM, Packham G, Wierda WG et al.| title=Chronic lymphocytic leukaemia. | journal=Nat Rev Dis Primers | year= 2017 | volume= 3 | issue= | pages= 16096 | pmid=28102226 | doi=10.1038/nrdp.2016.96 | pmc=5336551 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28102226 }} </ref> | |[[Chronic lymphocytic leukemia|'''Chronic lymphocytic leukemia''']]<ref name="pmid28102226">{{cite journal| author=Kipps TJ, Stevenson FK, Wu CJ, Croce CM, Packham G, Wierda WG et al.| title=Chronic lymphocytic leukaemia. | journal=Nat Rev Dis Primers | year= 2017 | volume= 3 | issue= | pages= 16096 | pmid=28102226 | doi=10.1038/nrdp.2016.96 | pmc=5336551 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=28102226 }} </ref> | ||
| | | | ||
* Chromosomal instability | * Chromosomal instability | ||
* Sporadic mutations | * Sporadic [[mutations]] | ||
* Infections | * [[Infections]] | ||
| | | | ||
* Elevated absolute lymphocyte count (in all stages) | * Elevated absolute [[lymphocyte]] count (in all stages) | ||
* Presence of >5000 clonal B cells per microliter in peripheral blood | * Presence of >5000 clonal [[B cells]] per microliter in peripheral blood | ||
* Anemia (in Rai stage III) | * Anemia (in Rai stage III) | ||
* Thrombocytopenia (in Rai stage IV) | * [[Thrombocytopenia]] (in Rai stage IV) | ||
| | | | ||
* [[Lymph node enlargement]] in Rai stage I | * [[Lymph node enlargement]] in Rai stage I | ||
| Line 167: | Line 172: | ||
* Associated with [[immune thrombocytopenia purpura]] | * Associated with [[immune thrombocytopenia purpura]] | ||
* Associated with [[pure red cell aplasia]] | * Associated with [[pure red cell aplasia]] | ||
* Treatment with corticosteroids or anti-leukemic therapy will correct the autoimmune complications of CLL | * Treatment with [[corticosteroids]] or anti-leukemic therapy will correct the autoimmune complications of CLL | ||
|} | |} | ||
Latest revision as of 16:15, 8 April 2019
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Shyam Patel [2] Associate Editor(s)-in-Chief: Sogand Goudarzi, MD [3]; Grammar Reviewer: Natalie Harpenau, B.S.[4]
Overview
The differential diagnosis of acute promyelocytic leukemia includes a variety of other hematologic malignancies, specifically acute myeloid leukemia (AML), acute lymphoblastic leukemia (ALL), chronic myeloid leukemia (CML), and chronic lymphocytic leukemia (CLL). Each of these conditions has distinct causes and therapies. There is some overlap between the causes and laboratory abnormalities amongst these diseases.
Differentiating Acute promyelocytic meukemia from other Diseases
The following table differentiates acute promyelocytic leukemia from other leukemias that may present with similar clinical features such as fever, fatigue, weight loss, recurrent infections and elevated leukocyte counts. The following are the differentials:
| Characteristic | Causes | Laboratory abnormalities | Physical examination | Therapy | Other associations |
|---|---|---|---|---|---|
| Acute myeloid leukemia |
|
|
|
| |
| Acute promyelocytic leukemia |
|
|
|
| |
| Acute lymphoblastic leukemia |
|
|
|
|
|
| Chronic myeloid leukemia |
|
|
|
| |
| Chronic lymphocytic leukemia[6] |
|
|
|
|
|
References
- ↑ Döhner H, Estey E, Grimwade D, Amadori S, Appelbaum FR, Büchner T; et al. (2017). "Diagnosis and management of AML in adults: 2017 ELN recommendations from an international expert panel". Blood. 129 (4): 424–447. doi:10.1182/blood-2016-08-733196. PMC 5291965. PMID 27895058.
- ↑ McClellan JS, Kohrt HE, Coutre S, Gotlib JR, Majeti R, Alizadeh AA; et al. (2012). "Treatment advances have not improved the early death rate in acute promyelocytic leukemia". Haematologica. 97 (1): 133–6. doi:10.3324/haematol.2011.046490. PMC 3248942. PMID 21993679.
- ↑ Terwilliger T, Abdul-Hay M (2017). "Acute lymphoblastic leukemia: a comprehensive review and 2017 update". Blood Cancer J. 7 (6): e577. doi:10.1038/bcj.2017.53. PMC 5520400. PMID 28665419.
- ↑ Inaba H, Greaves M, Mullighan CG (2013). "Acute lymphoblastic leukaemia". Lancet. 381 (9881): 1943–55. doi:10.1016/S0140-6736(12)62187-4. PMC 3816716. PMID 23523389.
- ↑ Chen Y, Li S (2014). "Omacetaxine mepesuccinate in the treatment of intractable chronic myeloid leukemia". Onco Targets Ther. 7: 177–86. doi:10.2147/OTT.S41786. PMC 3916637. PMID 24516334.
- ↑ Kipps TJ, Stevenson FK, Wu CJ, Croce CM, Packham G, Wierda WG; et al. (2017). "Chronic lymphocytic leukaemia". Nat Rev Dis Primers. 3: 16096. doi:10.1038/nrdp.2016.96. PMC 5336551. PMID 28102226.
- ↑ Al-Sawaf O, Fischer K, Engelke A, Pflug N, Hallek M, Goede V (2017). "Obinutuzumab in chronic lymphocytic leukemia: design, development and place in therapy". Drug Des Devel Ther. 11: 295–304. doi:10.2147/DDDT.S104869. PMC 5279834. PMID 28182141.