International Journal of Laboratory Hematology

The Official journal of the International Society for Laboratory Hematology

REVIEW

INTERNAT IONAL JOURNAL OF LABORATO RY HEMATO LOGY

Acute myeloid leukemia: advances in diagnosis and classification

R. P. HASSERJIAN

Department of Pathology,
Massachusetts General Hospital,
Boston, MA, USA
Correspondence:
Robert P. Hasserjian, Department of Pathology, Massachusetts General Hospital, 55 Fruit
Street, Boston, MA 02114, USA.
Tel.: +1 617 724 1445;
Fax: +1 617 726 7474;
E-mail: rhasserjian@partners.org
doi:10.1111/ijlh.12081

Received 3 January 2013;

accepted for publication 30
January 2013
Keywords
Acute myeloid leukemia,
cytogenetics, mutations, bone
marrow, myelodysplastic
syndrome

S U M M A RY

Acute myeloid leukemia is an aggressive myeloid neoplasm characterized by  20% myeloblasts in the blood or bone marrow. Current
treatment strategies for acute myeloid leukemia are based on both
patient-related parameters such as age and performance status as
well as the intrinsic characteristics of particular disease subtypes.
Subtyping of acute myeloid leukemia requires an integration of
information from the patients clinical history (such as any prior preleukemic myeloid neoplasm or cytotoxic potentially leukemogenic
therapy), the leukemia morphology, cytogenetic findings, and the
mutation status of particular genes (NPM1, FLT3, and CEBPA). In
recent years, a barrage of information has become available regarding gene mutations that occur in acute myeloid leukemia and their
influence on prognosis. Future therapies for acute myeloid leukemia
will increasingly rely on the genetic signatures of individual leukemias and will adjust therapy to the predicted disease aggressiveness
as well as employ therapies targeted against particular deregulated
genetic pathways. This article reviews current standards for diagnosing and classifying acute myeloid leukemia according to the 2008
WHO Classification. Data that have subsequently accumulated
regarding newly characterized gene mutations are also presented. It
is anticipated that future leukemia classifications will employ a combination of karyotypic features and the gene mutation pattern to
stratify patients to increasingly tailored treatment plans.

D I AG N O S I S O F AC U T E M Y E L O I D L E U K E M I A
Acute myeloid leukemia (AML) is an aggressive,
clonal myeloid neoplasm with maturation arrest of myelopoiesis, leading to an accumulation of myeloblasts in
bone marrow and/or blood. According to the current
WHO Classification, myeloblasts must comprise at
least 20% of nucleated cells in bone marrow or blood
to establish a diagnosis of AML. This cutoff is admittedly arbitrary and has been as high as 30% in the
prior French-American-British (FAB) classification
358

scheme. Conversely, some myeloid neoplasms with

smaller numbers of myeloblasts (such as acute
erythroid leukemia and some therapy-related myeloid
neoplasms) may exhibit aggressive behavior in spite of
lower blast counts.
In establishing a diagnosis of AML, it is critical to
obtain an accurate blast count performed on at least
500 nucleated bone marrow cells and at least 200
peripheral blood leukocytes. In instances of a dry tap,
it is acceptable to perform a myeloblast count on an airdried touch preparation. The blast count in well 2013 Blackwell Publishing Ltd, Int. Jnl. Lab. Hem. 2013, 35, 358366

R. P. HASSERJIAN | AML CLASSIFICATION

359

prepared aspirate smears or touch preparations usually

correlates with the blast estimate in the bone marrow
biopsy and the blast percentage obtained by flow
cytometry. However, the gold standard remains the
aspirate smear blast count: neither flow cytometry nor
biopsy blast estimate should be used in lieu of the aspirate blast count, unless the aspirate smears are compromised or otherwise appear to be not representative [1].
There are several exceptions to the requirement of
20% myeloblasts in blood or bone marrow to establish
a diagnosis of AML:
In cases with the cytogenetic abnormalities t(15;17),
inv(16)/t(16;16), or t(8;21), a diagnosis of AML can
be made irrespective of blast count.
In cases with monocytic differentiation, promonocytes (primitive monocytic cells with features intermediate between monocytes and monoblasts) are included
along with blasts in the blast count.
In cases where erythroid elements comprise at least
50% of the bone marrow nucleated cells and blasts
comprise  20% of the nonerythroid cells, a diagnosis
of acute erythroleukemia (erythroid-myeloid subtype)
is made.
In cases of pure erythroid leukemia, undifferentiated erythroblasts replace the marrow and comprise
 80% of the marrow cells, even though myeloblasts
are not increased.

lated genetic pathways, it has become increasingly critical to accurately classify individual cases to dictate the
appropriate therapy. The 2008 WHO Classification of
AML relies mainly on cytogenetic abnormalities and
mutations in three oncogenes (NPM1, FLT3, and
CEBPA) for genetic subclassification. Since 2008, there
has been an exponentially increasing application of
high-throughput sequencing to clinically annotated
AML cases. These studies have further validated the
importance of NPM1, FLT3, and CEBPA in establishing
AML prognosis and have also highlighted a number of
new oncogenes that supplement the prognostic information obtained by conventional karyotyping. These
mutations involve multiple genetic pathways and have
been grouped into the Class I oncogenes that confer
proliferative advantage to the leukemic cells and Class
II oncogenes that contribute to myeloid maturation
arrest; cooperation between mutations and/or translocations of both Class I and Class II oncogenes appears to
be critical to the development of AML [2]. As the classification of AML evolves, it is anticipated that a combination of karyotypic features and specific gene
mutations will be used to stratify patients to increasingly tailored treatment plans.

Myeloid lineage of blasts may be established by the

identification of Auer rods, presence of myeloperoxidase (MPO) cytochemical staining or, more commonly, by demonstrating expression of myeloid
markers such as CD13, CD33, CD117, or MPO by flow
cytometry. Leukemias with monocytic differentiation
display folded or indented nuclei and relatively abundant pale basophilic cytoplasm, often express the
monocytic enzyme nonspecific esterase by cytochemistry, and express one or more monocytic markers
(CD14, CD64, CD11c, or CD11b) by flow cytometry.

Acute promyelocytic leukemia with t(15;17)(q22;q12);

PML-RARA

P R O G N O S I S I N AC U T E M Y E L O I D L E U K E M I A :
I N T E G R AT I N G C Y TO G E N E T I C S W I T H
M O L E C U L A R G E N E T I C DATA
Provided well-prepared aspirate smears and full immunophenotyping are performed, a diagnosis of AML is
usually straightforward. The main challenge for the
diagnostician is to classify the leukemia with respect to
its expected clinical behavior and response to therapy.
As more therapeutic options for AML become available
and incorporate therapies targeted at specific dysregu 2013 Blackwell Publishing Ltd, Int. Jnl. Lab. Hem. 2013, 35, 358366

AC U T E M Y E L O I D L E U K E M I A W I T H
FAV O R A B L E G E N E T I C F E AT U R E S

Acute promyelocytic leukemia (APML) is considered

within the group of AML with recurrent genetic
abnormalities (AML-RGA) and has a favorable prognosis, with sustained long-term remissions and
excellent overall survival when treated appropriately.
Accurate identification of APML is critical, as it is
sensitive to treatment with all-trans retinoic acid
(ATRA) that targets the PML-RARA oncoprotein. The
addition of ATRA to the induction chemotherapy regimen is essential both to ensure effective therapy and
to protect against disseminated intravascular coagulation (DIC), a major cause of morbidity and mortality
in APML. Arsenic trioxide is also an effective therapy
for this specific type of AML, particularly for cases
that relapse or are refractory to ATRA therapy [3].
For any suspected diagnosis of APML, PML-RARA
rearrangement must be confirmed as soon as possible to
ensure that patients receive ATRA therapy, particularly
patients who present with DIC. The particular diagnostic
technique used differs in different laboratories; ideally,

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R. P. HASSERJIAN | AML CLASSIFICATION

a result confirming or reliably excluding PML-RARA

rearrangement should be obtained within 24 h, which
is possible for conventional bone marrow karyotyping
as well as FISH and RT-PCR testing for PML-RARA rearrangement. Some laboratories use an immunofluorescent method to detect altered nuclear staining of the
PML protein when translocated with RARA, which also
allows rapid diagnosis in a few hours [4].
The classic morphologic features of APML are a
proliferation of densely granulated promyelocytes in
the bone marrow; the granules vary from coarse to
fine and may be so abundant as to obscure the
nucleus, which is often bilobed (Figure 1a). Auer
rods, single or multiple, are typically present. In the
microgranular variant, the granules are indistinct on
Wright-Giemsa smear preparations, but the cells retain
frequently bilobed or dumbbell-shaped nuclei (Figure 1b) and careful search usually discloses some
blasts with Auer rods. MPO cytochemical stain is
strongly positive in the blasts and promyelocytes of
both microgranular and classic APML variants. Flow
cytometry findings can also support a diagnosis of
APML: the blasts and promyelocytes typically lack
expression of HLA-DR, CD34, CD11b, and CD11c,
unlike most other types of AML, which express most
or all of these antigens [5].
Rare cases of APML may show variant translocations between RARA and other genes, such as ZBTB16,
NUMA1, NPM1, and STAT5B; some of these variant
translocations may be resistant to ATRA therapy [6].
Neither the presence of additional chromosomal
aberrations nor gene mutations (including FLT3,
which is mutated in about 30% of APMLs), appear to
alter the favorable prognosis to APML [7]. A small
subset of APML cases (about 15%) are therapy
related, and these appear to have a good prognosis
similar to their de novo counterparts and unlike other
cases of therapy-related AML (see below) [8].
Acute myeloid leukemia with translocations involving
core-binding factor components
Two genetically defined subtypes of AML-RGA and
favorable prognosis involve rearrangements of two
genes (RUNX1 and CBFB) encoding the heterodimeric
components of core-binding factor (CBF), a hematopoietic transcription factor. These are AML with t
(8;21)(q22;q22); RUNX1-RUNX1T1 (Figure 1c) and
AML with inv(16)(p13.1q22) or t(16;16)(p13.1;q22);
CBFB-MYH11 (Figure 1d). Like APML, these CBF-rear-

ranged AML subtypes have relatively favorable outcomes. Although they are more frequent in younger
AML patients, their favorable prognosis is independent of age [7, 9]. Unlike APML, CBF-rearranged
AMLs are not currently treated with any specific targeted therapy and do not require rapid up-front identification prior to induction therapy, unless dictated
by specific clinical trial protocols.
The presence of additional chromosomal abnormalities does not confer adverse outcome to CBF-rearranged
AML subtypes [7]. However, approximately 1222% of
CBF-rearranged AMLs have a mutated KIT gene, usually involving either the activation domain in exon 17
or the dimerization domain in exon 8. KIT-mutated inv
(16)/t(16;16) and t(8;21) AML cases appear to exhibit a
higher relapse rate and reduced overall survival as
compared with KIT wild-type cases [10, 11]. Some studies have also suggested an adverse affect of FLT3 ITD
(see below) on CBF-rearranged AMLs [12]. RAS mutations occur in up to one-third of AML with inv(16)/t
(16;16) cases, but do not appear to be associated with
adverse outcome in this AML subtype, nor in other
AML cases [12].
Acute myeloid leukemia with mutated NPM1
One of the most common mutations in AML occurs in
the NPM1 gene, which encodes a nucleolar phosphoprotein that shuttles between the nucleus and
cytoplasm and is considered to represent a Class II
oncogene whereby mutation impairs maturation of
the leukemic blasts. NPM1 is mutated (usually due to
a 4-bp insertion at position 960, causing increased
nuclear export of the protein) in approximately 30%
of adult AML cases and about 50% of AMLs with normal karyotype. These are usually de novo AML cases
without therapy-related disease or history of any
antecedent myeloid neoplasm. About 85% of cases
have normal karyotype and the NPM1 mutation does
not occur together with t(15;17) or CBF gene rearrangements [13]. AML with mutated NPM1 often has
monocytic morphology, presents with high white
blood count with numerous circulating blasts, and is
frequently CD34 negative. Immunostaining with an
antibody to NPM1 demonstrates aberrant cytoplasmic
localization in the blasts of NPM1-mutated AML,
whereas staining of wild-type NPM1 is restricted to
the nucleus [14]. The rare AML cases with t(3;5),
resulting in translocation but not mutation of NPM1,
also show cytoplasmic NPM1 localization [15].
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R. P. HASSERJIAN | AML CLASSIFICATION

(a)

(b)

(c)

(d)

(e)

(f)

361

Figure 1. (a) Acute promyelocytic leukemia of classic type in bone marrow aspirate. Blasts are heavily granulated
and some contain Auer rods (center). (b) Acute promyelocytic leukemia, microgranular variant in peripheral
blood. Blast lack visible granules, but show a characteristically dumbbell-shaped nucleus, often with prominent
nucleoli. (c) Acute myeloid leukemia with t(8;21)(q22;q22); RUNX1-RUNX1T1 in bone marrow aspirate. Blasts are
large with prominent nucleoli and cytoplasmic granules as well as Auer rods. (d) Acute myeloid leukemia with inv
(16)(p13.1q22); CBFB-MYH11 in bone marrow aspirate. Blasts occur among numerous abnormal eosinophil
precursors with mixed eosinophilic-basophilic granules. (e) Acute myeloid leukemia with FLT3 ITD in bone
marrow aspirate. Blasts show monocytic features, and some have cup-shaped nuclear invaginations. (f) Acute
myeloid leukemia with myelodysplasia-related changes in bone marrow biopsy. A cluster of small, dysplastic
megakaryocytes with hypolobated nuclei is present amid numerous blasts (center).

The FLT3 oncogene is mutated in 2545% of AMLs

and is also associated with de novo disease, leukocytosis
and high numbers of circulating blasts; unlike the
NPM1 mutation, it occurs across all AML cytogenetic
subtypes, albeit with differing frequency. The two main
mutations that affect the FLT3 gene are internal tandem
duplication (ITD) of the juxtamembrane domain and
mutations in the tyrosine kinase domain (TKD), both of
which lead to constitutive activation of the FLT3 tyrosine kinase and enhance cellular proliferation. A subset
of AMLs with FLT3 ITD show cup-shaped nuclei with
a distinct nuclear invagination (Figure 1e) and lack
expression of CD34 and HLA-DR, potentially mimicking microgranular APML morphologically and immunophenotypically [16].
Acute myeloid leukemia (AML) patients with
mutant NPM1 that lack the FLT3 ITD have a favorable
prognosis similar to CBF-rearranged AML [17].
2013 Blackwell Publishing Ltd, Int. Jnl. Lab. Hem. 2013, 35, 358366

Emerging data suggest that additional mutations may

cooperate with NPM1 mutation in influencing patient
prognosis: for example, IDH1 and IDH2 mutations
appear to favorably influence the prognosis of NPM1mutated AML [11], while a concurrent FLT3 ITD
mutation adversely affects the prognosis, at least in
younger patients [9]. In contrast, neither multilineage
dysplasia nor cytogenetic aberrations appear to confer
an adverse prognosis to NPM1-mutated AML, and the
clinical features and gene expression profile of NPM1mutated AML are similar irrespective of the presence
or absence of karyotypic abnormalities or multilineage
dysplasia[18]. The use of NPM1 and FLT3 mutation
status to guide treatment is an area of intense
research. Some data suggest that NPM1-mutant/FLT3wild-type AML patients may not benefit from allogeneic stem cell transplant, while stem cell transplant
does reduce risk of relapse and death for AML patients

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R. P. HASSERJIAN | AML CLASSIFICATION

with FLT3 ITD [17]. Unlike the FLT3 ITD, the FLT3
TKD may not confer adverse prognosis in AML, and it
is unclear if these patients warrant more aggressive
treatment approaches.
Acute myeloid leukemia with mutated CEBPA
The CEBPA gene located on chromosome 19 encodes a
transcription factor within the Class II group of oncogenes: mutations in CEBPA block activation of granulocytic differentiation genes, leading to maturation arrest
[19]. Mutations in CEBPA occur in 510% of AML
cases and, similar to the NPM1 mutation, are mostly
seen in cytogenetically normal cases [20]. CEBPA mutations are associated with a favorable prognosis, particularly when both gene alleles are mutated [21].
Bialleleic CEBPA mutations are mutually exclusive with
NPM1 mutations and only infrequently occur with
FLT3 mutations [22]; it is uncertain if the FLT3 ITD
mutation influences the prognosis of CEBPA-mutated
AML [11, 22]. CEBPA-mutated AML exhibits a particular gene expression profile that includes downregulation of HOX genes and is also associated with
expression of CD7 and CD34 on leukemic blasts [23].

AC U T E M Y E L O I D L E U K E M I A W I T H
U N FAV O R A B L E G E N E T I C F E AT U R E S
Acute myeloid leukemia with myelodysplasia-related
changes
Acute myeloid leukemia with myelodysplasia-related
changes (AML-MRC) encompasses cases of AML that
bear some relationship to the myelodysplastic syndromes (MDS). According to the 2008 WHO Classification, this relationship may manifest in three ways
(i) A karyotype displaying specific abnormalities
shared with MDS and associated with inferior outcome (Table 1), (ii) A documented history of MDS or
myelodysplastic/myeloproliferative neoplasm, and (iii)
The presence of significant morphologic dysplasia in
the nonblast bone marrow cells, involving at least
50% of the maturing cells in at least two hemopoietic
lineages. AML-MRC is sometimes referred to as secondary AML, which also encompasses therapy-related
AML (see below) and AML following myeloproliferative neoplasms [24]. While this term may be accurate
for the subset of AML-MRC cases following MDS,
many AML-MRC patients present de novo, and it is

unclear if such patients had a clinically silent preceding MDS or truly presented with a de novo AML.
Acute myeloid leukemia with myelodysplasiarelated changes has a poor prognosis compared with
other types of AML, which may partly reflect older
patient age but is also largely related to the poorprognosis karyotypic abnormalities that are typically
associated with AML-MRC (Table 1) [9]. These abnormalities mostly overlap with the adverse karyotype risk
grouping of the United Kingdom Medical Research
Council, which was recently updated based on outcome
analysis of almost 6000 adult AML patients [7]. The
most common cytogenetic abnormalities in AML-MRC
include losses of chromosomes 5 and/or 7 or a complex
karyotype, defined as 4 or more independent cytogenetic aberrancies. Many cases bear a monosomal karyotype, defined as a loss affecting at least 2 chromosomes
or loss of 1 chromosome along with a structural karyotypic abnormality [25]. One possible reason for the
adverse prognosis of AML-MRC is fact that numerous
genetic abnormalities are present in the background
dysplastic nonblast cells, and these genetic abnormalities are shared with the leukemic blasts [26]. This clonally aberrant background hemopoiesis may be more
resistant to eradication by induction chemotherapy, and
indeed, AML patients with adverse karyotype appear to
benefit from more aggressive treatment regimens, such
as allogeneic bone marrow transplantation[27]. However, clonally abnormal background hemopoiesis may
not fully explain the aggressive behavior of AML-MRC,
because AML-related mutations have also been demonstrated in the background nonblast hemopoietic elements in favorable prognosis AML subtypes, such as
AML with mutated NPM1 [14]. Selection for more
aggressive clones and clonal diversification in the evolution from MDS to AML, perhaps in part influenced by
cytotoxic treatments of any prior MDS, may also contribute to the poor prognosis of AML-MRC [26].
As mentioned above, a diagnosis of AML-MRC may
be established by either a history of an antecedent
myeloid neoplasm, multilineage dysplasia or defining
karyotypic abnormality; one, two, or all three criteria
may be present in a given case. AML-MRC tends to affect
older patients and frequently presents with cytopenias
with relatively few circulating blasts. In contrast to the
10% threshold used to define a dysplastic lineage establishing a diagnosis of MDS, the threshold of dysplastic
cells to define a lineage as dysplastic for AML-MRC is
50% and at least two lineages must be affected. Due to

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363

Table 1. Cytogenetic abnormalities in acute myeloid leukemia: role in establishing the WHO Classification category
and prognostic risk grouping
Cytogenetic abnormality

Genes involved

WHO Category

UKMRC category

t(15;17)(q22;q21)*
t(8;21)(q22;q21)*
inv(16)(p13.1q22)/t(16;16)(p13.1;q22)*
t(9;11)(p22;q23)
t(6;9)(p23;q34)
t(1;22)(p13;q13)
inv(3)(q21q26)/t(3;3)(q21;q26)
t(3;21)(q26.2;q22.1)
t(1;3)(p36.3;q21.1)
t(3;5)(q25;q34)
-5, del(5q), -5, del(7q)
Abnormal 17p (translocation or deletion),
including i(17q)
t(11;16)(q23;p13.3)
t(2;11)(p21;q23)
Complex (  4 unrelated abnormalities)
t(5q33)
del(9q), del(11q), -13, del(13q), idic(X)(q13)
Abnormal 12p (translocation or deletion)
t(11;19)(q23;p13)
Other t(11q23) excluding t(9;11), t(11;19), t(11;16),
and t(2;11)
add(5q) or add(7q)
17
t(9;22)(q34;q11)

PML-RARA
RUNX1T1-RUNX1
CBFB-MYH11
MLLT3-MLL
DEK-NUP214
RBM15-MKL1
RPN1-EVI1
RUNX1-EVI1
PRDM16-RPN1
MLF1-NPM1
Unknown
TP53

AML-RGA
AML-RGA
AML-RGA
AML-RGA
AML-RGA
AML-RGA
AML-RGA
AML-MRC
AML-MRC
AML-MRC
AML-MRC
AML-MRC

Favorable
Favorable
Favorable
Intermediate
Intermediate
Intermediate
Adverse
Adverse
Adverse
Adverse
Adverse
Adverse

MLL-CBP
MLL
Variable
PDGFRB
Unknown
Unknown
MLL-ELL or MLL-MLLT1
MLL

AML-MRC
AML-MRC
AML-MRC
AML-MRC
AML-MRC
AML-MRC
AML-NOS
AML-NOS

Adverse
Adverse
Adverse
Intermediate
Intermediate
Intermediate
Intermediate
Adverse

Unknown
TP53
BCR-ABL

AML-NOS
AML-NOS
AML-NOS

Adverse
Adverse
Adverse

UKMRC, United Kingdom Medical Research Council; AML-RGA, acute myeloid leukemia with recurrent genetic
abnormalities; AML-MRC, acute myeloid leukemia with myelodysplasia-related changes; AML-NOS, acute myeloid leukemia, not otherwise specified.
*Cases are still classified as AML-RGA and considered to have favorable UKMRC karyotype even if other cytogenetic
abnormalities are present.
Cases can be classified as AML-MRC if there is significant morphologic dysplasia in nonblast cells and/or a history of
myelodysplastic syndrome or myelodysplastic/myeloproliferative neoplasm. Refs:[7, 30]

this strict definition, it is necessary to carefully examine

the nonblast cells (which may be relatively sparse in
high-blast count cases) in all new AML diagnoses (Figure 1f).
Therapy-related acute myeloid leukemia
The WHO defines therapy-related AML (t-AML) as any
AML occurring in patients who have received cytotoxic
chemotherapy and/or radiotherapy that exposed active
bone marrow sites. Cytotoxic chemotherapy encompasses agents that are capable of causing genetic mutations, including any alkylating agents, topoisomerase II
inhibitors, antimetabolites such as thiopurines or pur 2013 Blackwell Publishing Ltd, Int. Jnl. Lab. Hem. 2013, 35, 358366

ine/pyrimidine analogs and antitubulin agents such as

vincristine or paclitaxel [28]. The secondary AMLs
caused by these cytotoxic therapies have a very high
incidence of adverse karyotypes, in particular complex
karyotype and losses of chromosomes 7 and 5, genetic
features shared with AML-MRC. Both AML-MRC and
t-AML also have a relatively high incidence of TP53
mutations, and this is usually associated with complex
karyotype and multilineage dysplasia [2, 12]. The high
incidence of adverse karyotype appears to drive the
overall poor prognosis of t-AML, as the relatively few
cases of t-AML with favorable karyotypes (such as
translocations of CBF genes or PML-RARA) or normal
karyotype appear to have prognosis similar to de novo

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R. P. HASSERJIAN | AML CLASSIFICATION

disease [29]. Some cases of t-AML may present following antecedent MDS and/or progressive cytopenia,
while others (particularly those following therapy with
topoisomerase II inhibitors and/or with MLL rearrangement) develop de novo without antecedent MDS.
Unlike de novo AML and MDS, where prognosis is
highly dependent on both bone marrow blood blast
count and karyotype risk grouping, the prognosis of
t-AML and t-MDS reflects the karyotype risk, but is not
highly influenced highly by the blast count.
The diagnosis of t-AML is usually straightforward,
as any AML in which a history of cytotoxic therapy is
present is called t-AML, according to the WHO classification. The latency following the cytotoxic therapy is
highly variable, but can be 20 years or longer. Difficulties may arise with cases presenting with relatively
short latency, particularly if patients are still receiving
chemotherapeutic agents and growth factors that can
transiently elevate the blast count. Clinical correlation
is required in such cases to ensure that any increase
in blasts is not related to recent growth factor therapy.
The prognosis of the usual t-AML cases with adverse
karyotype is dismal, with allogeneic bone marrow
transplant affording the only reasonable chance of
cure. Cases of t-AML that lack adverse karyotype have
a more favorable outcome, although this may be
affected by comorbidity due to the other underlying
neoplasm and/or prior chemoradiotherapy.
Acute myeloid leukemia with other adverse karyotypes
Three relatively rare types of AML-RGA in the 2008
WHO Classification are those with t(6;9)(p23;q34);DEKNUP214, inv(3)(q21q26.2)/t(3;3)(q21;q26.2); RPN1EVI1, and t(1;22)(p13;q13); RBM15-MKL1 [30]. Unlike
the other types of AML-RGA discussed above, these
AML subtypes tend to have a poor prognosis. AML with
t(6;9) mostly affects children and young adults and is
associated with basophilia and multilineage dysplasia, a
high incidence of concurrent FLT3 ITD, and a generally
poor prognosis [31]. AML with inv(3)/t(3;3) is associated with multilineage dysplasia, particularly affecting
megakaryocytes, and thrombocytosis in some cases;
cases of inv(3)/t(3;3) myeloid neoplasms presenting
with <20% blasts appear to have an aggressive course
similar to those presenting as frank AML [32]. AML with
t(1;22) usually presents in young children as a megakaryoblastic leukemia, often with increased reticulin
fibrosis and hepatosplenomegaly [30].

Acute myeloid leukemia with MLL rearrangement

The MLL gene at the 11q23 locus is rearranged with a
wide variety of partners in AML. AML cases with an
MLL rearrangement and history of cytotoxic therapy
should be diagnosed as t-AML, and those with a history of MDS should be diagnosed as AML-MRC. The
prognosis of MLL-rearranged AML is highly dependent
on the particular partner gene: t(9;11) and t(11;19)
rearrangements, involving the MLLT3 and ELL or
MLLT1 genes respectively, show a relatively favorable
prognosis, while t(10;11) and t(6;11) rearrangements,
involving the MLLT10 and MLLT4 gene partners
respectively, have a very poor prognosis [7]. Only
AML with the t(9;11) MLLT3-MLL rearrangement is
considered to represent a specific AML-RGA subcategory. These cases occur more commonly in children
and are associated with monocytic morphology and
extramedullary disease. The prognostic influence of
MLL rearrangement may also partly depend on the
patient age, as one study found that AML with t(9;11)
had an unfavorable prognosis in older patients, but
not in the younger (<60 years) adult age group [9].
Another recent study suggested that AML patients
with MLL rearrangement may benefit from more
dose-intensive induction therapy [11]. These findings
underscore the complex interaction of the intrinsic
leukemia genetics with patient parameters such as age
and particular therapies administered, and emphasize
the pitfalls of applying information from mutational
analysis to individual patients in predicting prognosis
and determining the optimal therapeutic approach.

AC U T E M Y E L O I D L E U K E M I A W I T H N O R M A L
K A RYOT Y P E O R N O N S P E C I F I C K A RYOT Y P I C
ABNORMALITIES
Acute myeloid leukemia (AML) with normal karyotype, or with other karyotypic abnormalities associated with prognosis intermediate between the
UKMRC adverse and favorable groups, comprises
about 4050% of all AML cases [19]. The large subset
of cases with NPM1 or CEBPA mutations are discussed
above, and these represent provisional AML entities
in the 2008 WHO classification. The other AML cases
in this group are heterogeneous and usually bear
mutations in one or several oncogenes. In the absence
of a history of MDS, myelodysplastic/myeloproliferative neoplasm or prior cytotoxic therapy, they are

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R. P. HASSERJIAN | AML CLASSIFICATION

classified as AML, not otherwise specified (AML-NOS)

in the 2008 WHO Classification. Most studies have
shown that cases with FLT3 ITD have a poor prognosis
[12]. As more data emerge, it appears that that multiple mutations (in particular combinations of mutations in Class I and Class II oncogenes) contribute
to the pathogenesis of these normal karyotype AMLs,
and prognostic models will require the integrated
evaluation multiple oncogenes [2]. It is controversial
whether multilineage dysplasia in normal karyotype
AML is independently associated with outcome [33],
but one study found an association of multilineage
dysplasia with mutations in the ASXL1 gene and lack
of mutations of FLT3, NPM1, and DNMT3A, suggesting
that morphologic dysplasia may in part reflect the
underlying mutation pattern [34]. Many normal
karyotype AML cases bear mutations in genes that
affect epigenetic gene modification, such as DNA
methylation and chromatin structure. Mutations in
three of these genes, ASXL1, TET2, and DNMT3A, have

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