Muhammad Asif ZebLecuture IPMS (KMU)

Leukemia:All leukemia's are stem cell/ and or

precursor of HSC disorders characterized by malignant neoplastic proliferation and accumulation of immature and nonfunctional haemopoietic cells in the blood and bone marrow.

Leukemia's are cancer found in the blood cells. Acute leukemia are usually aggressive disease. They are classified by how quickly they progress

and what type of cell they affect. Leukemia affects ability to produce normal blood

cells. Bone marrow makes abnormally large number of

immature white blood cells called blasts.

Hematopoieticstem cell

Neutrophils

Eosinophils

Basophils

Monocytes

Platelets

Red cells

Myeloidprogenitor

Lymphoidprogenitor

B-lymphocytesB-lymphocytes

T-lymphocytes

Plasmacells

naïve

ALLALL

AMLAML

Leukemia

Acute

Chronic

ALL

AML

CML

CLL

Features Features Acute Acute Chronic Chronic Age Age All ages All ages Adults Adults Clinical onset Clinical onset Sudden Sudden Insidious Insidious Course of Course of diseasedisease

Week or Week or monthsmonths

Months to Months to yearsyears

Predominant Predominant cell cell

Blast ,some Blast ,some mature formsmature forms

Mature formsMature forms

Anemia Anemia Mild – severeMild – severe Mild Mild Thrombocytopenia Thrombocytopenia Mild – severeMild – severe MildMildWBCWBC Variable Variable Increased Increased

Acute leukaemias are usually aggressive diseases in which malignant transformation occurs in the haemopoietic stem cell or early progenitors.

Genetic damage is believed to involve several key biochemical

(i) an increased rate of proliferation; (ii) reduced apoptosis (iii) a block in cellular differentiation.

Malignant transformation occurs as a result of the accumulation of genetic mutations .

Genes involved in the development of cancer are divided broadly into two groups:a. Oncogenesb. Tumour-suppressor genes

Symptoms due to:◦ Marrow failure◦ Tissue infiltration◦ Leukostasis◦ Other (DIC)

Neutropenia:Infections, sepsis

Anemia: Fatigue, pallor

Thrombocytopenia:Bleeding

Enlargement of liver, spleen, lymph nodes

Gum hypertrophy

Bone pain

Other organs: CNS, skin, testis, any organ

Accumulation of blasts in microcirculation with impaired perfusion.

Lungs: hypoxemia, pulmonary infiltrates

CNS: stroke

Fever and sweats common

Weight loss less common

Acute Myeloid Leukaemia

Acute myeloid leukaemia (AML) has an incidence of 2 – 3 per 100 000 per annum in children, rising to 15 per 100 000 in older

adults

myeloblast promyelocyte myelocyte metamyelocyte band neutrophil

MATURATIONMATURATION

Adapted and modified from U Va website

WHO classification (Newer) Incorporates and interrelates morphology,

cytogenetics, molecular genetics, and immunologic markers.

20% blast in blood and bonemarrow.

FAB classification (Older) Solely based upon morphology as

determined by the degree of differentiation along different cell lines and the extent of cell maturation.

30% blast in blood and bone marrow.

M0: Minimally differentiatedM1: Myeloblastic leukemia without maturationM2: Myeloblastic leukemia with maturationM3: Hypergranular promyelocytic leukemiaM4: Myelomonocytic leukemiaM5: Monocytic leukemiaM6: Erythroleukemia (DiGuglielmo's disease)M7: Megakaryoblastic leukemia

1.Acute myeloid leukemia with recurrent genetic abnormalities

AML with t(8;21)(q22;q22), AML1 (CBF-a)/ETO Acute promyelocytic leukemias [AML with

t(15;17)(q22;q11) and variants, PML/RAR-a] AML with abnormal bone marrow eosinophils

inv(16)(p13q22) or t(16;16)(p13;q11), CBFb/MYH11X

AML with 11q23 (MLL) abnormalities

2 . AML with multilineage dysplasia With previous myelodysplastic syndrome Without previous myelodysplastic

syndrome

3. AML and myelodysplastic syndromes, therapy-related

Alkylating agent-related Topoisomerase type II inhibitor-related

(some may be lymphoid) Other types

4. AML not otherwise categorized AML minimally differentiated AML with maturation AML without maturation Acute myelomonocytic leukemia Acute monoblastic and monocytic

leukemia Acute erythroid leukemia Acute megakaryoblastic leukemia Acute basophilic leukemia Acute panmyelosis with myelofibrosis

5. Acute Biphenotypic Leukemias

Most patients with AML present with anemia normocytic normochromic.

Thrombocytopenia Leukocytosis white blood cell count up to 200x109

Large, sometimes hypogranular platelets can be seen, and functional defects can contribute to hemorrhagic manifestations.

Most patients are neutropenic, and morphologic abnormalities

(hypogranulation, nuclear hyperlobulation, Pelger-Huët anomaly) are often noted in the remaining neutrophils.

Blasts are predominant cells.

BM aspirates show Hypercellularity Cells predominantly myeloblasts Immature granulocytes, erythroblasts, modest increase in plasma cells, monocytes, megaloblastic erythroblasts,ring sideroblasts. Erythropoeitic cells scanty, megaloblasts, ring sideroblasts found Megakaryocytes reduced Myelofibrosis can be seen

SUBTYPESUBTYPE MPO/MPO/SBBSBB

SESE NSENSE

AML-M0AML-M0 __ __ __AML-M1AML-M1 ++ ++ __AML-M2AML-M2 ++ ++ __AML-M3AML-M3 ++ ++ __AML-M4AML-M4 ++ ++ ++AML-M5aAML-M5a __ __ ++AML-M5bAML-M5b __ __ ++AML-M6AML-M6 ++ __ +/_+/_AML-M7AML-M7 __ _ _ Strongly + using Strongly + using

acetate as substrateacetate as substrate

Type 1Typical myeloblast with open chromatin and prominent nucleoli, immature deep blue

cytoplasm without granules.

Type 2Similar to type one + presence of up to 20

discrete azurophilic granules.

Type 3Similar to type one + numerous azurophilic granules.

Distinguished by absence of visible granules in cytoplasm of blast.

Negative –ve reactions with cytochemical stains.

Positive +ve for myeloid lineage markers.CD13 CD33.

AML variant and is most common in adults and in infants less then 1 year.

50% cases show leucocytosis. Lack of cellular maturation. Predominant cell in peripheral blood is poorly

differentiated myeloblast. Vacuoles may be present. Platelet are generally decreased. A few blast may have scanty azurophilic

granules or Auer rod is present.

Presence of more differantiated cells in the bone marrow with maturation.

Condition is more common in adults. Leucocytosis in 50% of cases. Thrombocytopenia Myeloblast are predominant cell type in peripheral blood. Bone marrow is hypercellular. Azurophilic granules in variable amount. Auer rods a azurophilic granules are common.Phi bodies:

Phi bodies are variant of auer rods but are smaller and not necessarily in rod shaped.

Typically seen in young adults. Sudden and severe progression. Cause acute DIC. DLC shows predominance of promyelocytes. Nucleus is very delicate sometime show

foldings. Most common clinical finding is bleeding.Faggot cells:

Cells with multiple auer rods sometime occuring in bundles

Both myelocytic and monocytic cells are present in peripheral blood and bone marrow.

Infilteration of leukemic cells in extramedullary sites is more common.

Serum and urine level of meuramidase are usually elevated because of monocytic proliferation.

Anemia Thrombocytopenia Cytochemical stains will demonstrate two cells

population in bone marrow.

Usually seen in children and young adults.

Degree of gum hypertrophy ,lymph node ,CNS and extra medullary infiltrates seen.

Occasional episods of DIC.

Moderately elivated serum and urine muramidase.

More then 80% of non erythroid cells seen in BM are monocytic .

Poorly differentiated. Monoblast account for 80% or more of all

monocytic cells. Remeining 20% are monocytes. The monoblast are larger. Azurophilic granules may be present.

Well differentiated.

More then 80% of monocytic cells in nonerythroid marrow.

The remaining cells are promonocytic or monocytic.

The percentage of blast is less then 30%.

Fine azeurophilic granules are present.

Predominant cells in the bone marrow is erythroblast.

Predominant feature is anemia with striking poikilocytosis and anisocytosis.

The diagnosis of erythroleucaemia can be done if more then 50% of bone marrow cells are erythroid and 30% of remaining are blast.

True erythro leukemia occurs when BM is replaced by proliferating normoblast showing no maturation byond basophilic normoblasts.

Peripheral blood pancytopenia.

High peripheral blood blast count.

Micro megakaryocytes and undifferentiated blast.

Bone marrow reveals increased fibroblast.

Showing cytoplasmic budding.

Leukaemia is the most common childhood cancer and acute lymphoblastic leukaemia (ALL) is the most common subtype, accounting for 75 – 80% of all cases

L1—Mature-appearing lymphoblasts (T-cells or pre-B-cells) small blast with High N:C ration.

L2—Immature and pleomorphic (variously shaped) lymphoblasts (T-cells or pre-B-cells) small and large blast present with moderate N:C ration.

L3— Lymphoblasts (B-cells; Burkitt's cells) are large and uniform, deep basophilic cytoplasm, vaculation in cytoplasm and low N:C ratio.

FeaturesFeatures L1L1 L2L2 L3L3Cell sizeCell size Small, Small,

uniformuniformLarge, often Large, often

heterogeneousheterogeneousLarge, homogeneousLarge, homogeneous

NucleusNucleus Round, Round, regularregular

Oval to round, Oval to round, irregular irregular cleftingclefting

RoundRound

Amount of Amount of cytoplasmcytoplasm

ScantScant Moderately Moderately abundantabundant

Moderately abundantModerately abundant

Genetic Genetic materialmaterial

Dense, Dense, uniform uniform

variable variable finely stippled and finely stippled and uniform uniform

NucleoliNucleoli InconspicuousInconspicuous,,

smallsmall

Prominent, largeProminent, large1 - >11 - >1

Present, may be Present, may be prominentprominent

1- >1, vesicular1- >1, vesicularcytoplasmcytoplasmvacuolesvacuoles

OcassionalOcassional VariableVariable ProminentProminent

BasophiliaBasophilia SlightSlight VariableVariable PunctatePunctate

FrequencyFrequency 85%85% 15%15% 2%2%

the WHO has recognized just two groups of acute lymphoblastic leukemias,

precursor B-cell and precursor T-cell lymphoblastic

leukemia/lymphoma.

B-ALL comprises approximately 85% of all childhood ALL, whereas B-LBL is a rare type of lymphoma and constitutes approximately 10% of lymphoblastic lymphoma cases.

is a malignancy where B lineage lymphoblasts predominate in the bone marrow (B lymphoblastic leukemia).

Sometimes there is primary involvement of lymph nodes or extranodal sites (B lymphoblastic lymphoma).

Greater than 20% of bone marrow cells

; however, the bone marrow aspirate typically consists of almost entirely lymphoblasts at diagnosis.

When the leukemic process is limited to a mass lesion and less than 20% or fewer lymphoblasts are seen in the marrow, the designation lymphoma is used.

The blood and bone marrow contains lymphoblasts with L1 or L2 morphology

B-ALL may also develop in adults, and the prognosis is generally much poorer in adults

Immunophenotype The lymphoblasts in B-ALL/LBL are uniformly TdT positive and HLA-DR positive. The flow cytometric immunophenotype in most cases is positive

for CD 10, CD19, CD20, CD24, CD22, and CD79a

is a malignancy of lymphoblasts with pre-T markers predominating in the bone marrow (T-ALL).

When there is primary involvement of lymph nodes or extranodal sites, it is termed T lymphoblastic lymphoma.

T-ALL represents approximately 15% to 20% of all childhood ALL, is more prevalent in adolescents than young children, and is seen more frequently in males than females.

often have L2 morphology less frequently, have L1 morphology

The lymphoblasts in T-ALL are TdT, cytoplasmic CD3, CD7, CD1, CD2, , CD5 positive

WBCs◦ Total cont elevated 50-60 x 109/L to 100

109/L◦ Rarely more than 100 109/L

◦ Lymphoblasts in large numbers RBCs

◦ Normocytic normochromic anaemia. Thrombocytopenia.

Marrow aspirates show: Blast cell predominace. They are lymphoblasts

which are earliest identifiable precursor of lymphoid cells

Erythropeitic cells reduced Dyserythropoiesis Megakaryocytes reduced

This is the most common form found in childrenand it has the best prognosis.

•This is the most frequent ALL found in adults.–.

This is the rarest form of ALL. Burkit lymphoma type cells

Aids in the diagnosis Classification of the leukemias

Identification of the chemical components of cells - is conducted to distinguish different types of leukemia.

Enzymatic Techniques Myeloperoxidases Esterases Phosphatases

Nonenzymatic Techniques Periodic Acid-Schiff Stain Sudan Black B Toluidine Blue

Leukemia,White Blood 69

CYTOCHEMICAL STAINCYTOCHEMICAL STAIN ALL BLASTSALL BLASTS AML BLASTSAML BLASTS

MPOMPO NegativeNegative PositivePositive

SUDAN BLACK BSUDAN BLACK B NegativeNegative PositivePositive

PASPAS PositivePositive NegativeNegative

NON SPECIFIC NON SPECIFIC ESTERASEESTERASE

NegativeNegative PositivePositive

ACID PHOSPHATASEACID PHOSPHATASE PositivePositive NegativeNegative

Leukemia,White Blood 70

Serum uric acid raised due to breakdown of leukemic cells.

Serum LDH may be raised

Hypocalcaemia

Hyperuricemia Increase K+

Terminal deoxynucleotidyl transferase (TdT) is an intranuclear enzyme found in stem cells and immature lymphoid cells within the bone marrow, but not in mature B lymphocytes.

It is present in 90% of acute lymphoblastic leukemias.

Only 5%-10% of acute myeloblastic leukemias. It has also been demonstrated in 1/3 of cases of

the blast crisis stage of chronic myelogenous leukemia and is a good prognostic indicator in these patients.

It is likely that the physician will want to perform imaging studies to determine whether the leukemia has invaded other organs within the body. Such studies will include:

X-rays Computed tomography (CT or CAT) Magnetic resonance imaging (MRI) Radionuclide (radioactive atom) Ultrasound

Look CSF for Blast cells

A karyotype is the characteristic chromosome complement of a eukaryote species.

Its study is called karyotyping.

The preparation and study of karyotypes is part of cytogenetics.