Objective: The prognostic indictors of age-related poor outcomes in patients with acute myeloid leukemia (AML) are still controversial. The aim of this work was to provide comprehensive insights into the effect of different hemocytes and to investigate the association between age and clinical features in adult patients with AML. Study Design: A retrospective study was performed to determine the role of age in the therapeutic outcomes of AML. A total of 166 newly diagnosed adult patients’ data from January 2015 to November 2019 in Zhongshan Hospital of Xiamen University were collected and analyzed. Results: Older patients presented a poorer prognosis (p=0.001) with shorter overall survival, which is served as age-related outcomes. Binary logistic regression demonstrated that cytogenetic risk (OR=4.508, 95% CI 2.733–7.435), leukocyte (OR=7.410, 95% CI 1.139–5.910), and bone marrow blast cells (OR=3.261, 95% CI 1.075–5.615) were independent indictors for age-related prognosis. In addition, Kaplan-Meier curve also revealed that the above factors were associated with overall survival (all p values <0.001). Conclusion: Cytogenetic risk, leukocyte, and bone marrow blast cells are dominant factors which account for the age-related poor outcomes and shorter overall survival in AML. Keywords: acute myeloid leukemia, adult, cytogenetic risk, hemocyte, leukemia, overall survival

1. 216
Analytical and Quantitative Cytopathology and Histopathology®
0884-6812/21/4304-0216/$18.00/0 © Science Printers and Publishers, Inc.
Analytical and Quantitative Cytopathology and Histopathology®
OBJECTIVE: The prognostic indictors of age-related
poor outcomes in patients with acute myeloid leukemia
(AML) are still controversial. The aim of this work was
to provide comprehensive insights into the effect of differ-
ent hemocytes and to investigate the association between
age and clinical features in adult patients with AML.
STUDY DESIGN: A retrospective study was performed
to determine the role of age in the therapeutic outcomes
of AML. A total of 166 newly diagnosed adult patients’
data from January 2015 to November 2019 in Zhong-
shan Hospital of Xiamen University were collected and
analyzed.
RESULTS: Older patients presented a poorer progno-
sis (p=0.001) with shorter overall survival, which is
served as age-related outcomes. Binary logistic regres-
sion demonstrated that cytogenetic risk (OR=4.508,
95% CI 2.733–7.435), leukocyte (OR=7.410, 95% CI
1.139–5.910), and bone marrow blast cells (OR=3.261,
95% CI 1.075–5.615) were independent indictors for
age-related prognosis. In addition, Kaplan-Meier curve
also revealed that the above factors were associated with
overall survival (all p values <0.001).
CONCLUSION: Cytogenetic risk, leukocyte, and bone
marrow blast cells are dominant factors which account
for the age-related poor outcomes and shorter overall sur-
vival in AML. (Anal Quant Cytopathol Histpathol
2021;43:216–222)
Keywords: acute myeloid leukemia, adult, cyto-
genetic risk, hemocyte, leukemia, overall survival.
Acute myeloid leukemia (AML) is a group of he-
matological malignancies with clinical, cytogenet-
ic, and molecular heterogeneity. AML is the most
common leukemia among adults, especially in pa­
tients older than 60 years.1,2 Currently, the option
of appropriate regimen for AML mainly depends
on the age, gender, immunophenotype of patients,
and the risk stratification according to convention­
al molecular and cytogenetic features.3,4 However,
adult patients with AML who have none of the
adverse prognostic variables remain clinically het-
erogeneous with varied outcomes. Thus, the explo-
ration of new prognostic markers is critical to help
select the most effective therapeutic strategies for
these patients.
Cytogenetic Risk and Hemocyte Account for
the Age-Related Poor Prognosis in Adult Acute
Myeloid Leukemia Patients
Jiasheng Hu, M.D., Yanhong Zhuang, B.S., Jinzong Lin, B.S., Quanyi Lu, M.D., and
Zhe Li, B.S.
From the Departments of Hematology and Nephrology, Zhongshan Hospital of Xiamen University, Xiamen, Fujian, China.
Jiashen Hu is Deputy Chief Physician, Department of Hematology.
Yanhong Zhuang is Attending Physician, Department of Hematology.
Jinzong Lin is Attending Physician, Department of Hematology.
Quanyi Lu is Chief Physician, Department of Hematology.
Zhe Li is Nurse in Charge, Department of Nephrology.
Address correspondence to: Zhe Li, B.S., Department of Nephrology, Zhongshan Hospital of Xiamen University, Xiamen 361004, Fujian,
China (lizhexmzsh@163.com).
Financial Disclosure: The authors have no connection to any companies or products mentioned in this article.

2. Volume 43, Number 4/August 2021 217
Risk Factors for Poor Prognosis in Adult AML Patients
It has been demonstrated that increasing age
is strongly associated with poor therapeutic out-
comes of patients with AML, of which the reason
is unclear and likely to be complex. There are
several associated variables associated with age-
related prognosis, including types of AML, the
cytogenetic risk or mutations, the frequencies of
comorbidities, the therapeutic intensity, or dif-
ferent tolerance to therapy, which may affect the
clinical outcomes alone or combined. Ferrara et al
have reported that the change of genetic patterns
account for less than 40% of older AML patients,
and further large patient series and real-life studies
are needed to confirm the results.2
However, the majority of previous studies main­
ly focus on the dominant factors of therapeutic
effectiveness and clinical outcomes in AML pa­
tients, with little attention attached to the under-
lying mechanisms of age-related poor prognosis.
Only a few studies revealed the relevant indicators
of age-related poor prognosis so far. To accurately
predict clinical prognosis and effectively guide
therapy strategies, it is necessary to identify dom-
inant factors to optimize the risk stratification in
adult population, by which clinicians could better
estimate prognosis of adult patients with AML.
Identifying measurable patient characteristics that
contribute to suboptimal outcomes among older
adults can help individualize pretreatment assess-
ment and inform supportive management of those
patients.
One area of particular interest is the assess-
ment of comorbidities, because they are common
among older patients and can influence treatment
decision-making. The aim of this work was to
provide comprehensive insights into the effect of
different hemocytes and investigate the associa-
tion between age and clinical features in adult pa­
tients with AML.
Materials and Methods
Patients
This study was conducted by Zhongshan Hospital
of Xiamen University. A total of 166 patients new-
ly diagnosed with non-M3 AML from January 2015
to November 2019 with detectable hemocytes in
peripheral blood and bone marrow were enrolled
into this study.
The inclusion criteria used for selection of pa­
tients was as follows: age 18 years or older, newly
diagnosed non-M3 AML during the period Janu-
ary 2015 to November 2019, had available cytoge­
netic results, and was followed at our institution.
Subjects were followed until death or November
2019. AML was diagnosed and classified based
on the morphological, immunophenotypic, cyto-
genetic, and molecular features of myeloid blasts
according to French-American-British (FAB)5 and
World Health Organization (WHO) 2016 criteria.6
The real treatment selection was based on both
physician’s recommendation and the patient’s pref-
erence.
Source of Data
The demographic data included age and gender.
Variables such as white blood cell count, hemo­
globin (Hb), platelet (PLT) count, blast at periph-
eral blood, as well as bone marrow, immunophe-
notype, and cytogenetics. Cytogenetic risk groups
were classified according to the European Leu-
kemia Net (ELN) guidelines. Bone marrow aspi-
rate and peripheral blood samples were collected
from each patient at the time of diagnosis for the
following examination by microscopy or flow cy-
tometry. Overall survival was recorded from the
date of diagnosis and following treatment to the
time of death from any reasons. This study was
conducted in accordance with the Helsinki Dec-
laration, and it was approved by the Institutional
Review Zhongshan Hospital of Xiamen University.
Statistics
Clinical data were analyzed by utilizing the SPSS
21.0 software (IBM SPSS Statistics for Windows,
Armonk, New York, USA). Most of the analysis in
this study was comprised of descriptive statistics.
For comparison of numerical variables, the non-
parametric Mann-Whitney U test was used. For
comparison of categorical variables, two groups
were determined by χ2 test. Kaplan-Meier curves
were performed to analyze the overall survival,
and the log-rank test was used to demonstrate
the significant difference in overall survival of two
or three groups. Univariate and multivariate bina-
ry logistic regression were performed to explore
the factors predicting age-related prognosis. In all
analyses, p<0.05 was considered statistically sig-
nificant.
Results
Clinical Characteristics of Patients with AML
The baseline characteristics of patients with AML
are presented in Table I. A total of 166 patients
were enrolled in our study. The patients were cat-

3. 218 Analytical and Quantitative Cytopathology and Histopathology®
Hu et al
egorized into survival group and poor prognosis
group. The survival group included 63 (54.8%)
males and 52 (45.2%) females, while the poor
prognosis group included 28 (54.9%) males and 23
(45.1%) females. The cytogenetic risk significant-
ly differed between the survival group and poor
prognosis group. The results revealed that the
poor cytogenetic risk positively correlated with the
poor clinical outcomes (p=0.028). However, there
was no statistical significance of the adjuvant treat-
ment and FAB classification between these two
groups. Besides, we found that elder patients tend
to present a poor prognosis, while the age of
the survival group and poor prognosis group is
50.0±13.9 and 59.0±16.2 years, respectively. Thus,
we hypothesized that the poor outcomes may be
associated with the age of the patients.
The Risk Factors of Age-Associated Poor Outcomes
According to the above analysis, we wondered
whether age led to poor outcomes, so we divided
the patients into low-age (n=82) and high-age
(n=84) groups with the cutoff value of 60 years.
As is shown in Table II, higher rates of poor
outcomes were observed in older patient with
AML (p=0.001). Favorable cytogenetic risk was
the dominant type in the low-age group with 54
(64.3%) patients, while poor cytogenetic risk was
Table I The Baseline Characteristics
Poor
Survival prognosis
(n=115) (n=51) p Value
Gender 0.989
Female 52 (45.2%) 23 (45.1%)
Male 63 (54.8%) 28 (54.9%)
Age 50.0±13.9 59.0±16.2 0.0007
Cytogenetic risk 0.028
Favorable 12 (23.5%) 10 (8.7%)
Intermediate 30 (58.8%) 75 (65.2%)
Poor 9 (17.6%) 30 (26.1%)
Adjuvant treatment 0.935
Yes 30 (26.1%) 13 (25.5%)
No 85 (73.9%) 38 (74.5%)
FAB classification 0.792
M0 12 (10.4) 5 (9.8%)
M1 27 (23.5%) 13 (25.5%)
M2 26 (22.6%) 14 (27.5%)
M4 29 (25.2%) 12 (23.5%)
M5 15 (13.0%) 7 (13.7%)
M6 3 (2.6%) 0 (0%)
M7 3 (2.6%) 0 (0%)
FAB classification = French-American-British classification.
Table II Characteristics of Patients in Low-Age and High-Age Groups
Low-age group High-age group
(n=82) (n=84) p Value
Outcome 0.0010
Alive 35 (42.7%) 16 (19.0%)
Poor prognosis 47 (57.3%) 68 (81.0%)
Gender 0.543
Female 39 (47.6%) 36 (42.9%)
Male 43 (52.4%) 48 (57.1%)
Cytogenetic risk 0.008
Favorable 54 (64.3%) 34 (41.5%)
Intermediate 19 (22.6%) 20 (24.4%)
Poor 11 (13.1%) 28 (34.1%)
Bone marrow
Blast cell 31.95±29.539 44.93±33.287 0.0086
Promyelocyte 0.54±1.476 0.89±2.789 0.3121
Metamyelocyte 0.44±1.078 0.5±1.197 0.7350
Promonocyte 1.89±5.655 1.76±4.224 0.8667
Eosinophil 0.85±1.982 0.56±1.196 0.2541
Myelocyte 0.69±1.335 0.98±1.743 0.2299
Peripheral blood
Blast cell 65.99±21.80 66±23.289 0.9977
Hemoglobin 9.49±1.442 9.7±1.495 0.3585
Leukocyte 30.75±43.676 47.39±56.203 0.0344
Monocyte 13.61±17.665 13.58±17.22 0.9912
Platelet 71.061±62.70337 63.1905±42.84505 0.3454

4. Volume 43, Number 4/August 2021 219
Risk Factors for Poor Prognosis in Adult AML Patients
the least type, with 11 (13.1%) patients. On the
contrary, poor cytogenetic risk is likely to be ob­
served in the high-age group (p=0.008). Besides,
there was significant difference of bone marrow
blast cells and leukocytes in peripheral blood be-
tween the two groups. The high-age group tend-
ed to present high bone marrow blast cells and
peripheral leukocytes (p values 0.0086 and 0.0344,
respectively), while the promyelocyte, metamyelo-
cyte, promonocyte, eosinophil, myelocyte in bone
marrow, and blast cells, hemoglobin, monocyte,
and platelets in peripheral blood showed no sta-
tistical significance. The above results revealed the
possible reasons for age-associated poor outcomes,
and the factors of cytogenetic risk, bone marrow
blast marrow, and leukocytes need further analysis.
Logistic Regression Analysis of Age-Related Factors
As shown in Figure 1, the univariate analysis re-
vealed that cytogenetic risk (intermediate risk: OR=
4.456, p<0.0001; poor risk: OR=7.410, p<0.0001),
bone marrow blast marrow (OR=3.261, p=0.001),
and leukocytes (OR=3.203, p=0.001) are the dom-
inant factors associated with poor prognosis. The
Figure 1 Binary logistic regression of factors associated with age-related poor outcomes. (A) Univariate and (B) multivariate analysis of
cytogenetic risk, leukocyte, and bone marrow blast cells.

5. 220 Analytical and Quantitative Cytopathology and Histopathology®
Hu et al
odds ratio and 95% CI of the above characteris-
tics and factors were shown in forest plots. Factors
with a p value <0.05 were subsequently brought
into the multivariate model, which demonstrated
that cytogenetic risk (OR=4.508, p<0.0001), bone
marrow blast marrow (OR=7.410, p=0.023), and
leukocytes (OR=3.261, p=0.033), were independent
indicators for outcomes.
Taking into consideration the influences of cyto-
genetic risk, bone marrow blast marrow, and leu­
kocytes on overall survival, differences in overall
survival were assessed by Kaplan-Meier curves,
and the log-rank test of these three factors (all p<
0.05) was verified to be correlated with a shorter
overall survival (Figure 2).
Discussion
In this retrospective study of 166 adult patients
with AML, we found that age is a critical factor
associated with poor prognosis. AML is a malig-
nant cancer of elderly adults, with a median age
of 70 years.7 It has been reported that older age
is consistently associated with shorter overall sur-
vival time and higher morbidity.8,9 Poor clinical
prognosis for older adult patients with AML may
attribute to tumor biology and age-associated clin-
ical characteristics, which decrease treatment toler-
ance and inhibit therapy effect.10,11
Considerable data indicate that older patients
with AML are more likely to have biological and
clinical characteristics, such as high-risk cytoge-
netic and molecular abnormalities, leading to poor
prognosis.12 Buchner et al reported that age is the
independent risk factor for outcomes in patients
under 60 years old with intensive therapy, which
excludes the influence of reduced-intensity thera-
py in elder patients with AML.13 The progression
of aging is accompanied with a series of decline
of physiological and molecular processes which
are needed to maintain the body’s homeostasis.14
In addition, patients over 65 years present a major
adverse prognostic factor at the time of relapse,
which may be explained by excessive drug tox-
icity, higher AML resistance associated adverse
karyotype, and preferential involvement of early
hemopoietic precursors in the pathogenesis of the
disease.15
The landscape of AML therapy is undergoing
dramatic evolution with the awareness of the
molecular pathogenesis and the introduction of
new diagnostic and therapeutic methods. In this
regard, high-risk patients, especially in the older
population, represent an ideal field of clinical in-
vestigation. In addition, our results suggested that
high cytogenetic risk, leukocytes, and bone mar-
row blast cells may be dominant reasons for age-
associated poor prognosis. Similar to our results,
a few studies on adult patients with AML show-
ed association between cytogenetic risk and leuko-
cytes and outcomes.16
Various factors can affect the prognosis of AML,
including chromosomal mutation, molecular ab-
normality, and epigenetic alterations. According to
the European Leukemia Net (ELN), the interme­
diate risk group of AML was considered highly
heterogeneous. Thus, cytogenetic studies are rec-
ommended at diagnosis and follow-up of patients
with AML in common practice. In addition, ac-
cording to the FAB classification, six main types
of AML are defined with the direction of differen­
tiation along one or several cell lines and the de-
gree of maturation in cells.5 The blast cell, promy-
Figure 2 Kaplan-Meier analysis of factors associated with age-related poor outcomes. (A) Cytogenetic risk, (B) leukocyte, and (C) bone
marrow blast cells associated with the overall survival.

6. Volume 43, Number 4/August 2021 221
Risk Factors for Poor Prognosis in Adult AML Patients
elocyte, metamyelocyte, promonocyte, eosinophil,
myelocyte, and erythroblast in peripheral blood
and bone marrow were involved in the classifica-
tion and presentation of AML, which provide valu-
able information for clinical diagnosis and therapy.
Although it has been reported that the percent-
age of abnormal bone marrow cellularity was
demonstrated as an important predictive factor for
response in patients with AML,17 we did not found
a higher cellularity in the high-age group. The lack
of consistency in the literature in terms of hemo-
cytes in patient blasts and bone marrow may be in
part explained by different patient population and
therapeutic strategies. The sensitivity of hemocyte
measurement may differ, and the use of variable
cutoffs on each scale may affect the results.
There are several limitations to this study. Sim­
ilar to other retrospective studies of prognosis,
we limited our selection of mortality as clinical
outcomes to those well-represented in the cohort,
while leukemia-free survival and complete remis-
sion can also present clinical prognosis, which were
not well documented. Furthermore, our modest
sample size may have led to limited power to
demonstrate the correlations, especially among the
younger patients with lower mortality. Moreover,
further research should aim towards both valida­
tion of findings and exploration of dominant mo­
lecular mechanisms. The link between leukocyte
and cancer prognosis is particularly important, as
it may be amenable to novel and effective thera­
peutic strategies.
In summary, our results suggest that cytogenetic
risk, leukocytes, and bone marrow blast cells may
account for age-associated poor prognosis in adult
patients with AML. Moreover, when considering
individual mortalities, we revealed an association
of higher cytogenetic risk, leukocytes, and bone
marrow blast cells with more severe mortality
among older patients. These results provide evi­
dence for further exploration of the prognostic
significance of age-associated factors during AML
therapy, and the underlying mechanism may lead
to effective interventions.
Acknowledgements
We thank all the treating physicians for allowing
us to enroll their patients and the patients for al-
lowing us to analyze their data.
Disclosure Statement
The authors declare no potential conflicts of inter­
est with respect to the research, authorship, and/
or publication of this article.
Statement of Ethics
All procedures performed in studies involving
human participants were in accordance with the
ethical standards of the institutional and/or na­
tional research committee and with the 1964 Dec-
laration of Helsinki and its later amendments or
comparable ethical standards.
Author Contributions
Conception and design: Jiasheng Hu. Acquisition
of data: Yanhong Zhuang. Analysis and interpreta-
tion of data: Jinzong Lin, Quanyi Lu. Drafting the
article: Jiasheng Hu. Critically revising the article:
Zhe Li.
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