AMoL (Acute Monoblastic/Monocytic Leukemia) (M5)

Acute monocytic leukemia (AMoL, or AML-M5) is considered a type of acute myeloid leukemia (AML). In order to fulfill World Health Organization (WHO) criteria for AML-M5, a patient must have greater than 20% blasts in the bone marrow, and of these, greater than 80% must be of the monocytic lineage. A further subclassification (M5a versus M5b) is made depending on whether the monocytic cells are predominantly monoblasts (>80%) (acute monoblastic leukemia) or a mixture of monoblasts and promonocytes (<80% blasts).

Sample Cases

Click here for instructions on how to download the free FCS Express Reader to view and manipulate the sample cases.

Case Name (click on case name to open)	Comments	Size
M5_1	M5 AML	5.59 MB
M5_2	AML M5b	7.74MB

Epidemiology

Acute monoblastic leukemia comprises 5-8% of cases of AML. It may occur at any age but is most common in young individuals. In infancy, it is frequently associated with abnormalities of 11q23. Extramedullary lesions may occur. Acute monocytic leukemia conmprises 3-6% of cases; the male to female ratio is 1.8 to 1.0. It is more common in adults. The median age is 49 years.

Possible causes

None known.

Morphology

Monoblasts can be distinguished by having a roughly circular nucleus, delicate lacy chromatin, and abundant, often basophilic cytoplasm. These cells may also have pseudopods. By contrast, promonocytes have a more convoluted nucleus, and their cytoplasm may contain metachromatic granules.          

Example morphology of acute monocyticleukemia case. There is an admix of monoblasts and monocytes. (note granules)	Example morphology of an acutemonoblastic leukemia case. Monoblasts predominate.

Immunophenotyping

Neoplastic cells in AMoL can be initially identified using a SSC vs CD45 plot. Depending on the maturation of the cells of interest, they will fall into a characteristic region on the gating dot plot. Monoblasts have little to no granuoles and therefore have a lower side scatter than a monocytic leukemia which have a higher and more variable SSC. These cells may also have different fluorescent intensity of CD45. More mature monocytoid cells will have a brighter CD45 and fall closer to the monocyte region.  See examples below.        

This CD45 vs SSC plot corresponds to the above acute monocytic leukemia case. Abnormal monocytic population is green.  Note the higher SSC.	This CD45 vs SSC plot corrponds to the  above acute monoblastic leukemia case. Abnormal monocytic population is green.  Note the lower SSC.

Below is a list of immunophenotypic markers that are useful in the identification and classification of AMoL:                          

Marker	Prevalence in AMoL
CD2	10%
CD4	93%
CD7	11%
CD10	11%
CD11b	85%
CD11c	100%
CD13	77%
CD14	54%
CD16	13%
CD23	30%
CD33	100% (bright)
CD34	3%
CD45	100% (mod-bright)
CD56	80%
CD64	96%
CD117	14%
HLA Dr	93%

   Below are selected example dot plots from a AMoL case:    

CD64, CD11b and Lysosome are characteristically positive in AMoL. My4 can be partially expressed depending on the stage of maturity of the cells. (In this case My4 is variably expressed)	CD33 and CD64 are consistently expressed. (CD33 is generally bright). My4 and Mo2 are variably expressed depending on maturity of cells.	In this case CD4 is dimly expressed on these cells. CD34 is characteristically negative. Note the heterogenous population of MPO indicating a variety of maturity level of the cells in question.