Acute Myeloid Leukemia Infiltration of the Stomach

Vinh-Quang Do Nguyen, DO
Corpus Christi Medical Center—Bay Area, Corpus Christi, Texas

Raghujit Singh, MD
Abdominal Specialists of South Texas, Corpus Christi, Texas

Aftab Mahmood, MD
Cancer Specialists of South Texas, Corpus Christi, Texas

A 41-year-old man with a past medical history of hypertension, type 2 diabetes mellitus, and acute myeloid leukemia (AML) presented with a 2-week history of abdominal pain, hematemesis, and melena. He also reported fatigue, decreased appetite, and weight loss. He denied fever, chills, chest pain, hemoptysis, and hematuria. He had completed induction chemotherapy with cytarabine and daunorubicin, and he had completed postremission therapy with bone marrow transplantation.

Physical examination. The patient’s vital signs were stable.

Diagnostic tests. Laboratory test results revealed a hemoglobin level of 5.8 g/dL (reference range, 14-18 g/dL) and a hematocrit of 18.8% (reference range, 42%-52%). Serologic test results were negative for acute hepatitis, Helicobacter pylori immunoglobulin G and M antibodies, and HIV-1 and -2 antigen and antibodies.

Computed tomography scans of the abdomen and pelvis (Figure 1) revealed an acute hemorrhage into the stomach.

The patient underwent an esophagogastroduodenoscopy. A 4-cm prepyloric lesion with adherent clot was found and biopsied (Figure 2). The lesion was examined histologically and immunohistochemically.

The patient received a diagnosis of AML infiltration of the stomach.

Treatment. The patient underwent aggressive fluid resuscitation, proton-pump inhibitor therapy, and blood transfusions to maintain hemodynamic stability.

Discussion. AML is a cancer of the blood and bone marrow with excess immature white blood cells. It is the most common acute leukemia in adults, and its incidence increases with age. In adults, the median age at diagnosis is approximately 65 years.¹ In the United States, the annual incidence has been stable at 3 to 5 cases per 100,000 population.² AML is cured in 35% to 40% of persons younger than 60 years and 5% to 15% of persons aged 60 years and older.² Older persons who are unable to withstand chemotherapy have an average survival of 5 to 10 months.³ 

Risk factors for developing AML include the presence of other blood disorders (eg, myelodysplastic syndrome), chemical exposures (eg, benzene, alkylating agents), ionizing radiation (eg, high levels of x-rays), and genetics (eg, Down syndrome).⁴

Patients with AML may present with fever, fatigue, weight loss or loss of appetite, shortness of breath, bone pain, anemia, easy bruising or bleeding, and frequent infections. The first clues to the diagnosis of AML are leukocytosis on a complete blood cell count and leukemic blasts on a peripheral blood smear.

A definitive diagnosis requires bone marrow aspiration and biopsy. Examination of the marrow or blood under light microscopy and flow cytometry helps to differentiate AML from other leukemias and to classify the subtype.⁴ AML commonly presents with extramedullary involvement including of the liver, spleen, lymph nodes, lungs, eyes, gingiva, skin, and central nervous system. Involvement of the digestive tract is rare. Leukemic infiltration of the stomach, as in our patient’s case, is extremely rare, with only 3 other cases reported in the literature.^5-7

The first-line treatment of AML is chemotherapy, divided into 2 phases: induction and postremission (or consolidation) therapy. The goal of induction therapy is to achieve a complete remission by reducing the number of leukemic cells to an undetectable level; the goal of postremission therapy is to eliminate any residual undetectable disease and achieve a cure.⁸ For patients with relapsed AML, hematopoietic stem cell transplant or a new chemotherapy regimen is advised.

Outcome of the case. The patient was discharged in stable condition, with a plan for follow-up with his oncologist and to start chemotherapy for the relapsed AML.

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