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LETTER TO THE EDITOR
Year : 2017  |  Volume : 13  |  Issue : 2  |  Page : 384

Significant plasmacytosis in an early induction marrow of acute myeloid leukemia: Diagnostic and therapeutic implications


1 Department of Pathology, RMLIMS, Lucknow, Uttar Pradesh, India
2 Department of Hematology and Immunology, Sahara Hospital, Lucknow, Uttar Pradesh, India

Date of Web Publication23-Jun-2017

Correspondence Address:
Sumaira Qayoom
Department of Pathology, RMLIMS, Lucknow, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.177498

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How to cite this article:
Awasthi NP, Qayoom S, Jaiswal A, Dabadghao S. Significant plasmacytosis in an early induction marrow of acute myeloid leukemia: Diagnostic and therapeutic implications. J Can Res Ther 2017;13:384

How to cite this URL:
Awasthi NP, Qayoom S, Jaiswal A, Dabadghao S. Significant plasmacytosis in an early induction marrow of acute myeloid leukemia: Diagnostic and therapeutic implications. J Can Res Ther [serial online] 2017 [cited 2019 Nov 15];13:384. Available from: http://www.cancerjournal.net/text.asp?2017/13/2/384/177498

Sir,

Acute myeloid leukemia (AML) with reactive plasmacytosis is a known, yet rare entity.[1],[2] Their significant presence in an early induction marrow, where blasts and other hematopoietic elements are sparse can lead to a diagnostic dilemma of a coexistent plasma cell (PC) dyscrasia.[3]

We present here a case of a 58-year-old female patient, presenting with complaints of easy fatigability for the past 1 month. Physical examination revealed pallor along with hepatosplenomegaly. Complete blood counts with peripheral blood (PB) smear showed leukocytosis with the presence of 68% myeloperoxidase (MPO) positive blasts. Bone marrow aspiration showed 1% PC and 70% blasts which on flow cytometric immunophenotyping expressed CD34, CD117, CD13, CD33, and MPO; suggesting a diagnosis of an AML. The patient was administered standard 3 + 7 (cytarabine + daunorubicin) induction regime. PB on day 14 showed the presence of pancytopenia with mild rouleaux formation, but no circulating blasts. Bone marrow aspiration showed hypoplastic marrow with 2% blasts and a significant plasmacytosis (78% of nucleated cells) [Figure 1]. These PCs appeared mature in morphology and were found to be entrapped around the endothelial cells, suggesting their perivascular location and hence, a reactive nature. In view of the presence of peripheral rouleax, very high proportion of PCs, and known incidence of concomitant AML and PC dyscrasia,[4],[5] a myeloma workup was done, which also confirmed the reactive nature of PC [Figure 2]. A repeat bone marrow on day 30 showed normocellular marrow with trilineage hematopoiesis, with 1% blasts and 3% PC. Further course of the patient was uneventful, and she is in remission for the last 3 years.
Figure 1: Microphotograph showing the presence of approximately 80% blasts at diagnosis (a and b). Day 14 marrow showing the presence of significant plasmacytosis. The plasma cells appear mature and are found surrounding the endothelial cells (periarteriolar arrangement) (c and d). Postinduction marrow showing reactive marrow with trilineage hematopoiesis. No excess of blast or plasma cells noted (e and f) (May–Grunwald–Giemsa)

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Figure 2: Images of serum electrophoresis (a) and immunofixation (b). The electrophoresis as well as immunofixaton show normal protein electrophoresis pattern. No M-band was noted (gel electrophoresis)

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Plasmacytosis seen in an early induction (day 14) marrow can be observed in some patients which is attributable to either some prior/concomitant infection or to the paracrine stimulation by the blasts mediated by cytokine interleukin-6 (IL-6).[1] One large study, which included 60 AML patients, showed the proportion of PC s to be 0.1–48.7%, and 15 (25%) patients to be having evidence of an antecedent or concomitant infection.[2] They also noted that mean PC proportion in cases having infection was significantly higher as compared to those who do not have any evidence of infection (18.1% vs. 10.7%, P= 0.039). Majority of the cases in this study were M4/M5 (50%) and were expected to be associated with increased IL-6 production and consequently plasmacytosis. In contrast, the present case neither had any clinical/laboratory evidence of infection nor had morphological evidence of monocytic differentiation. A proportion as high as 78%, as noted in our case, has never been reported. These cases with such a high PC proportion can very well masquerade as coexistent PC dyscrasias.[3] It is hypothesized that postinduction plasmacytosis may have an immunological role in maintaining remission. This was demonstrated in the study by Al-Shughair et al.[2] where the responders had higher PC proportion (14.3%) as compared with nonresponders (4.6%), predicting the likelihood of being free from leukemia. Similarly, the present case is also responding well and is in remission for the last 3 years. However, more studies are required to validate the clinical significance of this hypothesis.

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Nil.

Conflicts of interest

There are no conflicts of interest.

 
 > References Top

1.
Wulf GG, Jahns-Streubel G, Hemmerlein B, Bonnekessen K, Wörmann B, Hiddemann W. Plasmacytosis in acute myeloid leukemia: Two cases of plasmacytosis and increased IL-6 production in the AML blast cells. Ann Hematol 1998;76:273-7.  Back to cited text no. 1
    
2.
Al-Shughair N, Al-Dawsari G, Gyger M, Mohamed G, Roberts G. Clinical significance of plasmacytosis in the day+14 bone marrow of patients with acute myeloid leukaemia undergoing induction chemotherapy. J Clin Pathol 2007;60:520-3.  Back to cited text no. 2
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3.
Rangan A, Arora B, Rangan P, Dadu T. Florid plasmacytosis in a case of acute myeloid leukemia: A diagnostic dilemma. Indian J Med Paediatr Oncol 2010;31:36-8.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Attili S, Lakshmiah KC, Madhumati M. Simultaneous occurrence of multiple myeloma and acute myeloid leukaemia. Turk J Haematol 2006;23:209-11.  Back to cited text no. 4
    
5.
Kim D, Kwok B, Steinberg A. Simultaneous acute myeloid leukemia and multiple myeloma successfully treated with allogeneic stem cell transplantation. South Med J 2010;103:1246-9.  Back to cited text no. 5
    


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