85

CLINICAL SECTION

CLI ICO - PATHOLOGICAL CONFERENCE-No. 1 *

4JOnocytic Leukaemia in an Adult treated with Aminopterin

Clinical History (Dr. Russell Fraser)The patient, a housewife aged 28, was admitted

to hospital on June 9, I949, with a diagnosis ofacute leukaemia and the suggestion that she mightbe treated by Aminopterin. Her preceding periodof illness had been short and non-specific. Shewas married, had three children and until threemonths ago had had excellent health. Then shebegan to notice increasing tiredness, accompaniedby morning nausea or vomiting, loss of weight and-appetite and slight menorrhagia (5/2I instead of4/28). Two weeks before admission she suddenlydeveloped a sore throat which was successfullytreated with penicillin.On examination. T. ioo, P. go, R. 20. She

was pale, slightly wasted and looked listless andill. She weighed 84 stones instead of her normalsII stones. Her extremities felt warm and herpulse was bounding and regular; her bloodpressure was i;o'6o. Her jugular venous pressurewas at the level of the sternal angle, i.e. raised.An apical systolic murmur was heard over theheart but no other physical signs were noted in thechest. Her tongue was dry and furred, her throatslightly reddened and both tonsils enlarged; theaxillary and inguinal glands were palpable but notclearly abnormal. A firm spleen was felt threefinger-breadths and a firm liver edge one finger-breadth below the costal margin. No oedema orrash was noted. Several haemorrhages but noother abnormalities were seen in the optic fundi.The chmst X-ray was normal. The E.C.G. was oflow voltage, probably due to anaemia, but other-wise normal. The peripheral blood findings(Fig. i) were diagnostic of acute monocytic leu-kaemia.

Progress. Transfusions were given to bring herhaemoglobin to ioo per cent.; three pints onJune i6 and two pints on June 20, of packed cells.Following this her low intermittent fever ceasedand she felt well. A course of oral Aminopterinwas given from June 2I to July 2 (I5 mgm. in all).

* Held at the Postgraduate Medical School of Lon-don, Hammersmith Hospital, November i6, 1949. Weare most grateful to Dr. Bernard Lennox by whose carethis report was assembled.

This was terminated because of the developmenton July i of a generalized purpuric rash, somereddening and soreness of the palate with stomalulcers, epistaxis and progressive anaemia. Cessa-tion of the drug and a further transfusion of fourpints of packed cells on July I3 brought her to acondition where *she felt practically in normalhealth; she was up and able to follow her normalactivities.

She was therefore discharged home wherefurther progress was watched. Fair health con-tinued for a further month when vaginal bleedingcommenced and led to a return of weakness andmorning sickness. Two transfusions arrested thebleeding but gave only partial relief to her feelingof weakness; since then she also noticed ankleoedema in the evenings.

She was readmitted on August 3o, 1949, and stilllooked anaemic though rather more ill. T. 102,P. 0OO, R. 22, B.P. I05/55. She had no rash buthad a frequent unproductive cough. There wereshallow I in. ulcers on the palate and gums; hertongue was furred, her gums spongy and herpalate reddened. The tonsils were enlarged andall other glands were more palpable. No fingerclubbing was noticed; there was little change inher chest and abdominal signs, though the spleenwas now slightly larger (four finger-breadths) andsoft and the liver slightly larger (two finger-breadths). The optic fundi showed many old andrecent haemorrhages. The blood picture wasmore grossly leukaemic (Fig. 2). A transfusion offour pints was given, followed by a second courseof oral aminopterin from September 3 to 14 (i6mgm. in all). On this occasion her fever did notintermit as with the previous treatment.The aminopterin was interrupted on September

iI because of the onset of severe diarrhoea andvomiting; blood and mucus were not observed inthe stools and culture showed no pathogens.Despite penicillin and morphia these symptomspersisted and her condition deteriorated. By theI7th generalized petechia appeared and an ulcera-tive stomatitis. A further transfusion on this dategave little relief and her condition deteriorated todeath on the 2ISt.

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86 POSTGRADUATE MEDICAL JOURNAL February 1950

The final clinical diagnosis was:-i. Acute monocytic leukaemia with2. Terminal acute colitis due probably to the

anti-folic acid effects of aminopterin and granulo-cytopaenia, and possibly to leukaemic bowelinfiltration.

Haematology (Dr. J. C. White)This case presents interesting features regarding

diagnosis of the type 'of acute leukaemia. Thesigns and symptoms, the blood picture and sternalmarrow puncture biopsy (Fig. i), clearly indicatedan acute leukaemia. Determination of the' exacttype presented a more difficult problem, however.The, severe' anaemia '(with normal M.C.V. andM.C.H.C.) was accompanied by an initial whitecell count of only io,ooo per cm.; but primitiveblast cells comprised'24 per cent. of the latter, andabnormal monocyte-like cells 55 per cent. Thesternal '`marrow contained a' predominance ofprimitive blast cells, of which many were haemo-'cytoblasts and myeloblasts, whilst others- werequite unlike any normal 'counterparts, but wereconsidered to be paramyeloblasts; there was somedifferentiation towards 'both granulocytes andabnormal 'monocytoid ' or monocyte-like cells.In supravital preparations of the marrow, motilitywas seen in the older granulocytes and sometimesa very sluggish motility in more primitive cells.The primitive cells showed fine, scattered mito-chondria and groups of neutral red bodies, butboth these cells and their older derivatives werequite unlike normal monocytes. With the peroxi-dase reaction it was found that the youngest cellswere negative, whilst the older cells showed varyingdegrees of positive reaction which increased withmaturity. An interesting feature in the marrowwas the occurrence of a type of erythropoiesisclosely resembling the megaloblastic form.

In view of these features the case was consideredto be probably a 'variant of acute myeloblasticleukaemia giving a monocytic blood picture.Downey (I938) has called such cases ' Naegeli-type monocytic leukaemia,' since Naegeli (1931)considered most cases of so-called monocytic leu-kaemia to be unusual myeloblastic or 'para-myeloblastic ' forms. In contrast to these types,Downey distinguishes as ' Schilling-type mono-cytic Ieukaemia' those rarer cases in which thereis a reticulosis-like overgrowth of 'the reticulum,cells of monocytic-type appearing in the peripheralblood (leukaemic reticulo-endotheliosis). Cazal(i949) has recently given further data on thesedifferent forms.

Therapy. 6o ,ug. of vitamin B12 were first in-jected, but without effect on the megaloblasticerythropoiesis in the marrow as seen in the sternalmarrow films taken the day before aminopterin

therapy was commenced. In the first course oftherapy I5 mg. of aminopterin were given bymouth in daily doses of i mg., and later 2 mg., overa period of I2 days. Evidence of response becameapparent after nine days, when fall in the blastcells and monocytoid cells in the peripheral bloodoccurred, and the marrow showed fewer primitivecells and more older forms. The peripheral bloodleucocytes fell rapidly to about 2,000, then roseagain to 7,ooo, but the blast cells and monocytoidcells remained low, whereas mature polymorphsincreased (Fig. 4j. The marrow showed a steadyincrease in degrees of maturation towards normidgranulopoiesis, and 23 days from the start oftherapy there was very active granulopoiesis, butsome primitive cells and monocytoid cells werestill present and megaloblastic erythropoiesispersisted (Fig. 2).

Subsequent Relapse. The remission lasted onlyabout one month, and on. readmission the bonemarrow and peripheral blood again showed frankevidence of leukaemia (Fig. .3). The' marrowpicture now appeared even more ' para-myelo-blastic,' and primitive cells formed about 40 percent. of the total. Response to a second' course ofaminopterin, i8 mg. in 2 mg. doses daily, was notsatisfactory, although the spleen diminished a littleand the peripheral leucocytes fell (Fig. 4). Sternalpuncture was not repeated. Terminally, blastcells appeared again in large numbers in the peri-pheral blood (Fig. 4).-

Resistance to Further Therapy. The reason whya good initial response to aminopterin is oftenfollowed by resistance in subsequent relapses isnot yet clear. It is possible that a line of re-sistant cells develop from leukaemic cells whichescape destruction during the first course. It isalso possible that the leukaemic cells may developalternative metabolic pathways, enabling them togrow despite the presence of a folic-acid antagonist,but good evidence for such a view is not easy tocome by. Certainly in resistant relapses other bodytissues remain equally prone to the toxic effects ofthe antagonist. Normally developing blood cellprecursors are also readily damaged.

Toxic Effects of Aminopterin. Toxic effects inthis case were prominent. During the firsf course,buccal ulceration and congestion, a generalizedpurpuric rash, epistaxis and progressive anaemiaoccurred, though recovery- soon followed onwithholding the drug. The platelets were neverbelow ioo,ooo per cm. during this period (Fig. 4)3,and it is possible that the haemorrhagic toxiceffects of aminopterin may in certain cases be due-to some interference with the coagulationmechanism other than via diminished platelet pro-duction. In" the final course of aminopterintherapy, stomatitis and petechial' haemorrhages

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February I950 Clinical Section 87

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FIG. I.-Sternal marrow film before therapy.

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FIG. 2.-Sternal marrow film after first course ofaminopterin therapy.

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FIG. 3.-Sternal marrow film in relapse

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POSTGRADUATE MEDICAL JOURNAL February 1956

O 2

884 - 3850 ML. 2200 2200 2200II U11

4 Do AMINOPTERINc11111111111 15MG. 11111111IB18MG.

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100- 3.0-

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FIG. 4.-Chart of haematological data (prepared by Dr. E. Dresner).

occurred, and finally severe diarrhoea, all of whicheffects may have resulted from toxic action of thedrug.

BIBLIOGRAPHY

CAZAL, P. (i949), ' La Reticulose Histiomonocytaire,' Masson,Paris.

DOWNEY, H. (1938), 'Monocytic Leucemia and LeucemicReticutlo-Endotheliosis,' in Handbook of Hematology, Ed. H.Downey, Hoeber, N.Y., p. 1275.

NAEGELI, 0. (I931), 'Blutkrankheiten und Blutdiagnostik,'Springer, Berlin, p. 469.

Autopsy Findings (Prof. J. H. Dible)At post-mortem the body was that of a thin,

pale young woman with petechial haemorrhagesover the upper arms and thighs. Apart from somemild fatty infiltration of the heart, and oedema andemphysema of the lungs, no noteworthy changeswere found in the cardiovascular or respiratorysystems.There was general enlargement of the lymph

glands throughout the body, the largest being the

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February 1950 Clinical Section 89-

para-aortic glands, which measured up to 3 cm. indiameter. The glands were pink and fleshy inappearance.The spleen was greatly enlarged, weighing I,235

gm. and giving a positive haemosiderin reaction.The alimentary tract was normal down to the

lower ileum, where a single Peyer's patch was en-larged. The caecum and ascending colon werethickened, oedematous and markedly inflamed onthe mucous surface, which was covered with afibrinous exudate resembling the appearance seenin severe bacillary dysentery. This conditiondiminished in the transverse colon, and thedescending colon and rectum were healthy.The liver showed marked enlargement. It

weighed 3,110 gm. The cut surface was pale andslightly brownish and gave a positive haemo-siderin reaction. A few small nodules of whitetissue could be seen scattered through the liver.The kidneys were pale and showed scatteredleukaemic nodules, some of them haemorrhagic.The bone marrow was everywhere hyperplastic

and of greyish-buff colour. Of the long bones thetibia, fibula and femur were divided from end toend and found to be filled with hyperplasticmarrow. The other organs showed no changes ofnote.

Histology. The lymph glands showed a generalextensive infiltration with cells, which exhibitedconsiderable pleomorphism. The predominatingcell was rounded with abundant cytoplasm and alarge, pale nucleus, often indented and resemblingthe blood monocyte. In addition, there were manygiant cells, some typical megakaryocytes, otherswith two or more pale nuclei resembling cells ofthe Steinberg-Reed type. Lymphocytes, eosino-phils and possibly cells of the erythroblastic seriescould be seen. A characteristic of the glands wasthe continued existence of germ-centres, thoughthese were reduced in size. The neoplastic tissueinvaded the gland capsule and periglandular fattytissue. In these situations it appeared to showcytological differences from the appearance seenin the substance of the gland; there was anabsence of giant cells and an apparent differentia-tion towards fibroblastic types of cell, with a pro-duction of reticulin and young blood vessels, re-sembling the appearance of granulation tissue.The changes in the marrow were similar to

those in the parenchyma of the glands. Largemononuclear primitive cells predominated, butwith very considerable numbers of megakaryo-cytes, most of which were smaller and moreprimitive than normal.The spleen showed changes similar to those in

the glands, but in addition there were areas ofhaemorrhage and necrosis.

The liver and kidneys showed focal infiltrationswith leukaemic cells, which in the former wereconcentrated in the portal tracts. Some of theseinfiltrations were of macroscopic size and showedcentral necrosis.The heart showed a little patchy fatty infiltration

and the lungs some slight accumulations of leu-kaemic cells in the perivascular tissues.The lesion in the large intestine was a superficial

ulceration, associated with diffuse infiltration ofthe coats of the bowel with leukaemic cells whichwere concentrated more especially in the sub-mucosa and the sub-peritoneal coats. Many of theinfiltrating cells were grouped in the perivascularregion of the sub-mucosal vessels which showedmarked activity of their proper cells, suggestingthat they were participating in the production ofthe leukaemic accumulations.

Summary. From the histological point of viewthe case was one of a malignant overgrowth ofpluripotential cells of the reticulo-endothelialsystem.The cells showed considerable pleomorphism

and were differentiating in different directions,apparently in relationship to their environment,giving in the blood a leukaemic picture and in thetissues one of a pleomorphic malignant reticulosis.

Professor Dible also showed sections of thelymph nodes of a case of monocytic leukaemiawhich had been the subject of an earlier con-ference, demonstrating a remarkable similarity be-tween the lesions in the two cases.

DiscussionDR. DACIE: This is our second case of mono-

cytic leukaemia with Hodgkin-sarcoma-likechanges in the lymph-nodes. The first of thesewe confidently diagnosed as a Schilling-type ofleukaemia from the point of view of the bloodchanges, whereas this we diagnosed as a Naegeli-type. It alt tends to show that the distinction be-tween these two kinds of leukaemia is ratherartificial. Aminopterin has been used now ex-tensively in the treatment of leukaemia, especiallyin America, but really satisfactory remissions haveonly been produced in children. Very few peoplehave seen good responses in adults. The responseseen in this case is as good as any. Of seven oreight adults treated here, only two have responded,this and another; the other case also was a mono-cytic leukaemia.

DR. COPE: Professor Dible made a point thatthe cells in lymph-nodes and marrow were show-ing multipotent powers of differentiation. Arenot these sections equally compatible with pro-gressive undifferentiation in a variety of cell typesrather than differentiation in one single kind ofcell ?

F

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POSTGRADUATE MEDICAL JOURNAL February 1950

PROF. DIBLE: I think that this is a reasonablesuggestion. I regard this as multicentric inorigin and I agree that the perivascular accumula-tions appearing in various organs do look as thoughthey were originating on the spot.

DR. WHITE: The pleomorphic nature of theabnormal cells is most interesting. It is quiteobvious that lymph-nodes, spleen and bonemarrow showed an overall cellular proliferationwithout very much laying down of reticulin, whichis in marked contrast to the infiltrated capsularareas of the lymph-nodes.

DR. CROFTON: May I ask if the colon was cul-tured ? Some gram-negative bacteria requirefolic acid -and it is possible that aminopterin mightaIter the flora of the intestine in some way, enoughto produce these lesions.

PROF. MCMICHAEL: Are the bowel lesions dueto a direct effect of the aminopterin, or is thelocalization due to the action of aminopterin onleukaemic infiltrations in the alimentary tract ?

PROF. DIBLE: It is very difficult to say. Notonly are there leukaemic infiltrations to be con-sidered, but there are vascular lesions and themucosal changes might be ischaemic. On theother hand, there is no doubt that certain of thehepatic infiltrations are undergoing necrosis. Thewhole picture is very complicated.

DR. FRASER: There may be a pointer to this inthe mouth lesions. These began as a submucoushaemorrhage which ulcerated. This occurred I4days before she died. Possibly the intestinallesions began then as submucous haemorrhages.

DR. DACIE: On the other hand, the folic acidantagonists may have interfered with the nutritionof intestinal epithelial cells, just as they do withthe bone marrow cells, and the intestinal lesionsmay be attributed to that.

DR. WHITE: In normal rats and chicks, aminop-terin and other folic acid antagonists producedirect toxic changes in the cells of the intestinalepithelium. These occur at the same time aschanges in the bone marrow. In the small materialwhich we have been able to examine from patientstreated with aminopterin, leukaemic infiltrationhas not always played a prominent part in thecommon bowel lesions.

DR. SHERLOCK: Necrotic lesions are often foundin -the liver, in Hodgkin's disease and other

reticuloses, even in the untreated case where thereis no question of their being due to aminopterin orother treatment.

PROF. DIBLE: I know that in Hodgkin's diseasenecrosis of the liver does occur. I think that inthis case you cannot say the intestinal lesion is dueto aminopterin alone.

DR. DACIE: From post-mortems many peoplehave been struck by the frequency of intestinallesions occurring in cases treated by aminopterin.I know that at Great Ormond Street a good deal ofit has been seen in their children.

DR. LEWES: Can Professor Dible indicatewhether there is any essential difference in thegross or microscopic appearance between the bowellesions of treated and untreated cases of acuteleukaemia ?

PROF. DIBLE: I do not know.DR. DONIACH: I wonder if Professor Dible has

any ideas on the mode of origin of splenic infarctsin leukaemia. The picture looked like haemor-rhagic necrosis occurring in tumour rather thanthe picture of arterial or venous occlusion.

PROF. DIBLE: I agree that it looked very likehaemorrhagic necrosis in tumour, and of courseyou can regard this as tumour in the spleen. Itis stated that splenic infarcts in leukaemia are dueto vascular thromboses but I have never seen bigthrombi in the vessels-one can always find littlethrombi if one looks for them.

PROF. MCMICHAEL: Suppose you had a glandsent to you for diagnosis without knowing any-thing of the history, or say in the early stages of thiscase the blood changes were equivocal, what wouldyour histological diagnosis be ?

PROF. DIBLE: Pleomorphic reticulo-sarcoma.DR. DACIE: One of the first children we treated

with aminopterin (for a myeloblastic leukaemia)seemed in all respects a typical case and had avery good remission but eventually died at anotherhospital, and the pathologist there, not knowing theprevious history, diagnosed it as an undifferentiatedreticulo-sarcoma.

DR. WHITE: In view of the probable differencesin susceptibility to the action of various growth-inhibitors, the accurate determination of cell typesin the leukaemias may well prove to be of muchmore than theoretical interest.

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