A case of myelodysplastic syndrome with acute myeloid leukemia or excess blasts

A 57-year-old man presented with pancytopenia and hepatosplenomegaly. Peripheral smear revealed a leukoerythroblastic picture. Bone marrow aspirate smears revealed marked dysplasia in all three hematopoietic lineages. The morphological changes varied from hyposegmented Pelger–Huet, ring forms to gigantic flower-like forms in neutrophils. The erythroblasts showed budding yeast-like and branching tree-like nuclei [Figure 1]. Blasts and myelocytes were enormously large in size and the bespectacled nucleus of eosinophils had transformed into a telephone receiver like shape. The biopsy revealed paratrabecular aggregates of large blast-like cells having large prominent nucleoli [Figure 2] which were positive for CD117 but negative for CD34 and HLADR on both flow cytometry and immunohistochemistry. CD34 positivity was found only in 3% of the blasts scattered elsewhere. Cytogenetics for MDS revealed del(7q). Therefore, the case was diagnosed as a myelodysplastic syndrome with excess blasts-1 (2016 WHO Criteria)^[1] with a differential of acute myeloid leukemia with myelodysplasia-related changes expressing aberrant phenotypes^[2] in view of paratrabecular cell aggregates showing characteristic myeloblast-like morphology.

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Figure 1:

High-power view of dyspoietic changes observed in erythroid series and granulocytic series of cells marked with stars (black=neutrophil, red=erythroblasts, brown=eosinophil, green=myeloblast, and white=myelocyte) (H&E, ×400).

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Figure 2:

(a) High-power view of bone marrow biopsy showing dyspoietic features in megakaryocytes (black), eosinophils (brown) and (b) paratrabecular aggregate of blast-like cells (green) (H&E, ×400).

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