PMC6541880_01
Bone marrow core biopsy: (A) low power (4x) sheets of malignant promyelocytes replacing the bone marow and (B) high power (40x) showing promyelocytes with varying size and shape, occasional kidney shaped nuclei, and dense cytoplasm with pink granules. (C) Clot: low power (4x) showing a monotonous population of myeloid cells, and (D) high power (40x) of the malignant promyelocytes with similar features as the above bone marrow core. (E) and (F) Aspirate at (100x, oil) shows the morphologic characteristics of acute promyelocyte leukemia, enlarged nuclei with nucleoli, moderate cytoplasm with dense azurophilic granules and occasional Auer Rods. (For interpretation of the references to color in this figure legend, the reader is referred to the web version of this article.)
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However, upon bone marrow examination (Fig. 1) by aspirate and touch-prep showed hypercellularity with virtual replacement by promyelocytes with nucleoli, cytoplasmic granules, and occasional Auer rods.
Flow cytometry of the bone marrow aspirate, showing a population of MPO+, CD117 dim +, CD33+, HLA-DR and TDT -, CD15-, CD64-, CD14-, CD13 dim+ and CD56- population of myeloid blasts (red), Consistent with APL. (For interpretation of the references to color in this figure legend, the reader is referred to the web version of this article.)
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Immunophenotyping of the bone marrow by flow cytometry revealed an immunophenotype consistent with APL, positive for CD33, low intensity CD15, myeloperoxidase (MPO), CD117, CD123, and CD38 and negative for DR (Fig. 2).
Cytogenetic analysis of bone marrow from initial diagnosis. (A) Karyotype showing translocation of chromosome 15 to chromosome 17. (B) FISH, Dual Color Dual Fusion probe (PML-15q22 Spectrum Orange, RARA-17q21.1 Spectrum Green) showing two fusion signals (t15; 17) (q22; q21). (For interpretation of the references to color in this figure legend, the reader is referred to the web version of this article.)
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FISH, Dual Color Dual Fusion probe (PML-15q22 Spectrum Orange, RARA-17q21.1 Spectrum Green) sowed two fusion signals (t15; 17) (q22; q21), (Fig. 3).
Cranial MR images (A) pre-treatment MRI, infiltrative lesion involving the clivus, the right maxilla, and right mandible without evidence of intracranial bleeding. AND (B), post-treatment MRI, complete resolution of these infiltrative lesions.
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Because of persistent headache, cranial magnetic resonance images (MRI) showed extensive infiltrative lesions involving the clivus, the right maxilla, and right mandible but no intracranial bleeding or mas formation (Fig. 4). Her intracranial disease resolved completely, Fig. 4B.
(A) Cytology examination of the CSF shows the presence of malignant promyeloblasts with prominent azurophilic granules in the CSF, Thin prep, (10x); and Thin prep, (100x). (B) Flow cytometry of CS, showing a population of MPO+, CD117 dim +, CD33+, HLA-DR and TDT -, CD15-, CD64-, CD14-, CD13 dim+ population of myeloid blasts (red), Consistent with APL. (For interpretation of the references to color in this figure legend, the reader is referred to the web version of this article.)
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CSF flow cytometry analysis demonstrated the same population of APL blasts as seen in the bone marrow, consistent with CSF involvement (Fig. 5A and B).