LEUKAEMIAS

Leukaemias

A group of disorders characterized by the

accumulation of abnormal white cells in the
bone marrow
 LEUKAEMIAS

Accumulation of abnormal white cells in the bone marrow

Capable of further division

Bone Marrow Failure  Circulating WBC Organ infiltration

Liver
Spleen
Lymph Nodes
Anaemia
Meninges
Neutropenia
Brain
Thrombocytopenia
Skin
Testis
Gums
 Aetiology
 Ionizing radiation
 Atomic bobs, post radiotherapy
 Chemotherapy:
 Alkylating agents myeloid leukaemia
 Exposure to benzene
 Viral infections
 Retrovirus T cell leukaemia
 Genetic:
 Identical twins
 Down’s syndrome
 Immunological
 Immune deficiency   risk of hematological malignancies
 Classification of leukemias
 Acute leukemias ‘blast cells >30% in BM’
 Acute lymphoblastic leukemia ‘ALL’
 Acute myeloid leukkemia ‘AML’

 Chronic leukemias ‘blast cells <20% in BM’

 Chronic lymphocytic leukemia ‘CLL’
 Chronic myeloid leukemia ‘CML’
Acute Leukemias
 Acute Leukaemias
 Epidemiology:
 Not a common disease
 50% of all leukaemias
 ALL
Commonst leukaemia in children
Age 3-4 yrs and > 40 yrs

 AML
Commonst acute leukemia in adult
Any age
 Males > Females
 Clinical presentation of Acute Leukemia
 A- due to bone marrow failure
 Anaemia:
 Pallor, fatigue, exertional dyspnea, palpitaion
 Neutropenia  infection:
 Sore throat, malaise, fever, skin and perianal or respiratory infection, septicaemia
 Thrombocytopenia:]
 Spontaneous bruises, purpura, bleeding gums, menorrhagia, bleeding from puncture
sites
 DIC in AML (M3)  life threatening bleeding
 B- due to organ infiltration:
 ALL
 Bony tenderness and joint pain
 Superficial lymphadenopathy
 Hepato-spleenomegaly
 Meningeal involvement
 Testicular involvement
 Mediastinal disease(T-Cell)
 AML
 Hepatosplenomegaly
 Gum hypertrophy(M5)
 Skin infiltration (M5)
 Meningeal involvemnt (M4,M5): headache, nausea, vomitting, convulsions,
papilloesema
Clinical features of acute leukemia

Anemia
Clinical features of acute leukemia

Infection due to neutropenia

 Clinical presentation of acute leukemia

Bleeding
due to thrombocytopenia or DIC(AML-M3)
 Investigations

 Aim:
 Confirm diagnosis
 Assess patients performance
 Assess complications
Reaching the diagnosis of acute leukemia

Is
it acute leukemia?
myeloid or lymphoblastic?
What is the FAB classification?
 Laboratory Investigations

 FullBlood Counts
 Blood film:
 Bone marrow aspiration cytology
 Flow cytometry
 Cytogenetics
 others
Reaching the diagnosis of acute leukemia

Is
it acute leukemia?
myeloid or lymphoblastic?
What is the FAB classification?
 Investigations of acute leukemia
a- Full blood count
 Hb
Anaemia:

Normocytic or macrocytic
 WBC:
normal, high up to 200 x109/l
or low (aleukaemic
leukaemia)
 Platelets
Thrombocytopenia:

more sever in AML nemia

 ESR
 Investigations of acute leukemia
b- peripheral blood smear
 Myeloblasts
 Moderat to large
 Abundant cytoplasm
 Granules in cytoplasm
 Aur’s rods
 > 2 nucleoli

 Lymphoblasts
 Small to moderate
 Scanty cytoplasm
 No cytoplasmic granules
 1-2 nucleoli
 Investigations of acute leukemia
c- bone marrow examination
 Bone marrow
aspiration cytology:
 Hyper cellular bone
marrow
 Blast cells >30%

Dry tap: in ALL some times

it is difficult to aspirate the
marrow due to presence of
reticulin fibres
Reaching the diagnosis of acute leukemia

Is
it acute leukemia?
myeloid or lymphoblastic?
What is the FAB classification?
 Bone marrow aspiration cytology
AML or ALL?
i- morphology:
 Myeloblasts  Lymphoblasts
 Moderat to large
 Abundant cytoplasm
 Small to moderate
 Granules in cytoplasm  Scanty cytoplasm
 Aur’s rods  No cytoplasmic granules
 > 2 nucleoli  1-2 nucleoli
 Bone marrow aspiration cytology
AML or ALL?
ii- Cytochemistry :
AML ALL T-ALL
Myeloperoxidase + - -

Sudan Black + - -
+ +
PAS -
(fine, except M6) (coarse)
+
Non-specific esterase - -
(M4,M5)

Acid phosphatase - - +
Myeloperoxidase positivity

AML
Sudan Black and Chloroacetate
esterase positivity

AML
Bone marrow aspiration cytology
AML or ALL?
iii- Immuno-chemistry :
AML ALL
TdT - +
CD10 - +
CD19 - +
CD7 - + (T-ALL)
CD22 - +
CD13 + -
CD33 + -
CD41 +(M7) -
 ALL-
Indirect immune-flourescence
staining for tdt using
flourescin labelling
and CD10 antigen using
avidin labelling

 AML-M7
CD41 positive
 d- flow cytometry

ALL ALL
CD10 positive CD34 positive
Reaching the diagnosis of acute leukemia

Is
it acute leukemia?
myeloid or lymphoblastic?
lymphoblastic
What is the FAB classification?
 AML- FAB classification
 M0 minimal differentiation
 M1 AML without maturation
 M2 AML with granulocytic maturation
 M3 promylocytic
 M4 myelomonocytic
 M5 monocytic
 M6 erythroleukemia
 M7 megakaryocytic
 M0

Large, agranular blasts.

Myeloperoxidase negative or <3%
 M1- myeloblastic leukemia without
maturation

 Cells show some granulocytic differentiation.

 3% or more of blasts are myeloperoxidase positive
 Blasts contain few azurophilic granules, Auer rods or both.
 Further maturation not seen.
 M2- myeloblastic leukemia with
maturation

 Presence of maturation at or beyond the promyelocyte stage.

 Cells are nucleated and have varying amounts of cytoplasm, usually
with many azurophilic granules
 Auer rods
 Myelocytes,metamylocytes and mature granulocytes may be found
 t(8;21) is frequently associated with M2.
 AML-M2

AML-M2 myeloperoxidase

AML-M2 sudan black AML-M2 t(8;21)

 M3-Promyelocytic leukemia

 Most of cells are abnormal promyelocytes with heavy granulation.

 Nucleus vary greatly in size and shape, it is often reniform or bilobed.
 DIC
 t(15;17) are invariable
M3-Promyelocytic leukemia
M3-Promyelocytic leukemia
 M3-Promyelocytic leukemia

Typical bilobed nuclei seen in M3 variant. The basophilic

cytoplasm is packed with granules too small to resolve by light
microscopy, but which give the typical cytochemical reactions of
M3
M4-Myelomonocytic leukemia
AML-M4
M5- monocytic leukemia
 AML-M5

Large monoblasts with central nuclei and abundant cytoplasm.

The inset shows the monoblasts positive with alpha-napthyl
acetate esterase (brown), and one blue chloroacetate esterase
positive myelocyte.
M6-erythroleukemia
AML-M6
AML-M6
 AML-M6

Giant multinucleate late normoblasts (left). Granular

PAS positivity in proerythroblasts and homogeneous
positivity in the later normoblasts.
AML-M6
PAS
M7
M7
 AML-M7

Trephine biopsy showing fibrosis, blast cells and

atypical small megakaryocytes.
 FAB classification of ALL

 L1 small, scanty cytoplasm, cytoplasmic

eosimophilia and vaculations are minimal
 L2 in between
 L3 moderate, moderate cytoplasm, marked
cytoplasmic vaculations and basophilia,
prominent neucleoli
ALL-L1

•small,

•scanty cytoplasm,

•cytoplasmic
eosimophilia

•vaculations are
minimal
ALL-L2
L3

moderate cytoplasm,

marked cytoplasmic
vaculations

basophilia,

prominent neucleoli
 Classification of acute leukemaia

 Acute lymphoblastic leukemia

 Common type pre-B 70%
 T-cell
 B-cell
 undifferentiated
 ALL
common-ALL
 ALL
T-ALL subtype
 Acute leukemia
Other Investigations
 Biochemistry:
 uric acid
  LDH
  Na K
 Chromosomal studies:
 For prognostic reasons
 Ph chromosome positivity in ALL  poor prognosis

 Others:
 FDP fibrin  in M3 AML (DIC)
 LP  ALL with suspected meningeal involvement
 CXR, CT-Scan for mediastinal leukemia (T-ALL)
 Management of Acute Leukemia
 A- Supportive:
 Correct anaemia:
 Packed cell transfusion to raise Hb level to > 10g/dl
 Control bleeding:
 Platelet transfusion if;
 Bleeding
 Platelet count < 20 000/cmm
 DIC: fresh frozen plasma + heparin + ranexemic acid
 Treat infection:
 Febrile neutropenia: a fever > 38oC for > 1 hour in a patient with a
neutrophil count < 1000/cmm, it is an oncological emergency, treat with
antibiotics once suspected.
 Commmon organisms:
 Bacteria:specially the normal flora in throat, skin and gut
 Skin: Gm+ve, staph and strep
 Gut: gm –ve, ps, areugonosa, E-Coli,and anerobes
 Viral: herps virus
 Fungi: candida, aspergillus
 Protozoa: toxoplasma
 Treatment of infection:
 Once suspected, examine patient thouroughly looking
for site of infection.
 Send cultures:
 Blood and all suspected sources
 eg, throat swab, iv catheter tip, perianal swab, etc
 CXR, urine, C/S
 Start antibiotic treatment once infection is suspected
 Aminoglycosides + antipseudomonal or 3 rd generation
cephalosporin
 If no response after 48 hours, add an antifungal
 Vancomycin  infested iv catheters or once staph is
suspected
 Fluconazole  oral and pharyngeal
candidiasis#Amphotericin B  systemic fungal infection
 Acyclovir  herpes infection
 Management of Acute Leukemia
 Supportive care, cont’d
 Prevent infection:
Isolation
Decontamination of gut and skin
 Treat hyperuricemia:
Allopuranol
Proper hydration
Keep lvel < 7 mg /dl
Management of Acute Leukemia
Specific treatment

 Aim of treatment
Controlof BM and systemic disease
Treatment of sanctuary site disease CNS
 Acute lymphoblastic leukemia

 Treatment phases:
Remission induction
CNS prophylasix
Remission continuation or maintenance

 Average length of treatment

is 1.5-3 years in order to eradicate the
leukemic cell population.
 ALL
 Induction of remission
 Phase I
 Anthracyclin + prednisolone + vincristine
 IT methotrexate
 Phase II
 Cyclophosphamide + cytosar + 6 mercaptopurine
 Intensification phase
 High dose methotrexate
 Cranial irradiation
 Consolodation phase
 Etoposide, vincristine, cytosar, daunorubicin, cyclophosphamide,
6 thioguanine
 Maintenance phase
 Vincrisitine, prednisolone, 6mercaptopurine, methotrexate,
interferon alfa
 BMT in ALL

 Indications:
 High risk ALL
Ph chromosome positive ALL
Very high peripheral WBC at presentation
CD 10 – patients

 Relapsed ALL
 AML

 Phases of treatment:
 Inductionof remission
 Postremission treatment
 No maintenance therepy is given
 No CNS prophylaxis is given
CNS disease occurs in < 5% of patients
 AML specific treamtnet
 Induction of remission:
 Anthracycline +
 cytosine arabinoside +
 6 thipguanine
 Require intensice supportive measures
 M3
 low dose heparin
 Retinoic acid

 Postremission treamtnent
 Same regimen
 BMT in AML

 Indications:
 High risk group
Deletion of 5q and 7q, trisomy 8, t(6;9), t(9;22)
History of myelodysplasia

 Early first relapse

 Chronic leukaemias

Chronic myelogenous
leukaemia
Chronic lymphocytic leukaemia
 Chronic leukaemias

Chronic myelogenous
leukaemia
Chronic lymphocytic leukaemia
 Chronic myelogenous leukaemia
A Myeloproliferative disorder
 A clonal disorder where 95% of patients
have a distinctive cytogenetic abnormality
“the Philadelphia (Ph) chromosome”
 Median age of ph+ CML is 67 yrs(30-
80yrs)
 Medial survival is 4-6 yrs, (range 1-10yrs)
 Curative only by BMT
Myeloproliferative disorders

 Chronic myelogenous leukaemia

 Polycythemia Vera
 Myelofibrosis
 Essential thrombocythemia
 CML – Natural History
 Chronic phase:
 Disease respond to treatment
 < 5% of blasts and promylocytes in the peripheral blood and
bone marrow

 Accelerated phase
 > 5% in either peripheral blood or bone marrow and < 30% in
both peripherla blood and bone marrow.
 Blast crisis  acute leukaemia
 > 30% blasts are present in peripheral blood or bone marrow
 70% AML
 30% ALL
 CML- Symptoms
 Fatigue
 Abdominal fullness and discomfort
 Symptoms of anaemia
 Night sweating
 Low grade fever
 When WBC count is very high
“leukostasis”
•Blurred vision
•Respiratory distress
•priapism
 CML- Signs
 Splenomegaly ;
 mildto gross, usually
marked
 10% have normal spleen

 Sternaltenderness
 Signs of anaemia
 Philadelphia chromosome
 A cytogenetic abnormality
 Due to reciprocal translocation
between the long arm of
chromosomes 9(9q) and
22(22q) (9:22 translocation)
 It is found in all haematopoietic
precursors of CML patients.
 This result in the transfer of the
Abelson's (abl) oncogene to an
area of chromosome 22
termed the break-point cluster
region (bcr)
 This results in a fused bcr-abl
gene and production of and
abnormal tyrosine kinas
protein.
 This protein causes disordered
myelopoiesis in CML
 CML- Investigations
 Complete blood count
 Peripheral blood film smear
 Bone marrow aspiration
 Southern Blot analysis
 Ph chromosome analysis
 NAP score
 Others
 CML- Investigations
 Complete blood count
 Peripheral blood film smear
 Bone marrow aspiration
 Southern Blot analysis
 Ph chromosome analysis
 NAP score
 Others
 Complete blood count

 WBC counts
 It
may reach up to 500.000/cmm
 Usually around 150.000

 Anaemia
 Platelets N or 
 CML- Investigations
 Complete blood count
 Peripheral blood film smear
 Bone marrow aspiration
 Southern Blot analysis
 Ph chromosome analysis
 NAP score
 Others
 Peripheral blood film smear
 Shift to left of myeloid series with more myelocytes in PBF
than mature WBCs

 Blast cells are < 5%

 Basophilia
PBF in CML
 CML- Investigations
 Complete blood count
 Peripheral blood film smear
 Bone marrow aspiration
Assess cellularity
Assess fibrosis
Cytogenetic studies for Ph chromosome analysis

 SouthernBlot analysis
 NAP score
 Others
 CML - Bone marrow aspiration
 Hyper cellular bone marrow
 Shift in the myeloid series to immature forms,
this increase in number as patients progress to
blastic phase of the disease.
 Myeloblast count <5% of myeloid cells.
 Increased number of eosinophils or basophils
are often present.
 Monocytes are seen
 Megakaryocytes are often found in the marrow
 Reduced percentage of lymphocytes
 Elevated myeloid/ erythroid ratio in the marrow.
 CML- Investigations
 Complete blood count
 Peripheral blood film smear
 Bone marrow aspiration
 Southern Blot analysis
 NAP score
 Others
 CML- Southern Blot analysis
 It is a quantitative test
 Used for breakpoint cluster region gene
rearrangement.
 It may substitute bone marrow sampling to
monitor response to therapy.
 CML- Investigations
 Complete blood count
 Peripheral blood film smear
 Bone marrow aspiration
Assess cellularity
Assess fibrosis
Cytogenetic studies for Ph chromosome analysis

 SouthernBlot analysis
 NAP score  LOW
 Others
 CML- Investigations
 Complete blood count
 Peripheral blood film smear
 Bone marrow aspiration
 Assess cellularity
 Assess fibrosis
 Cytogenetic studies for Ph chromosome analysis

 SouthernBlot analysis
 NAP score
 Others
 Vitamin B12 level due to  secretion of
transcobolamin III
  Uric acid
 Management of CML

 Types of response:
 Hematological response:
Absence of abnormal cells in peripheral blood and
bone marrow.
 Cytogenetic response:
Absence of philadelphia chromosome positivity
and abl-bcr gene
 Management of Chronic CML
 Allogenic BMT
 Is the only curative treatment available of
CML so far
 It should be considered in the first year of
diagnosis if the patient is <40 yrs of age and
has an HLA matched donor.
 Interferon α
 Used for patients who are not eligible for BMT
 May induce a cytogenetic response in 20% of
patients.
 Management of Chronic CML
 Gleevec® (Imatinib mesylate)
A tyrosine kinase inhibitor
 Tyrosine kinase is required for transforming
functioin of the bcr-able fusion protein
 It induces hematological remission in almost
all patients with interferon resistent CML
 Cytogenetic response is seen in 50% of
patients.
 Management of Chronic CML
 Hydroxurea
 Uses:
 Initialtreatment to lower WBC count prior to interferon
therapy.
 Palliative treatment of patients failing other treatment.

 Busulfan
 Rarely used
 Splenectomy
 Hypersplemism
 discomfort
 Accelerated phase of CML
 Features
 Bone pain
 Spleenomegaly
 Resistance to current treatment
 Progressive anaemia
 Thrombocytopenia or thrombocytosis
 Blast cells >5% in either PB or BM and <30%
of both PB and BM.
 Accelerated phase of CML
 Treatment
 Bone marrow transplantation
Autologus
Allogenic

 Imatinib mesylate
 Interferon α
 High dose cytarabine
 hydroxurea
 Blastic phase of CML
 Features
 Fever
 Malaise
 Progressive splenomgaly
 Blast cells >30% in PB or BM
 Blastic phase of CML
 Treatment
 Imatinib mesylate
myeloidcrisis
Ph chromosome positive ALL

 Vincrisitneand prednisolone + anthracycline

 Allogenic BMT
Of benefit in <10% of patients
 Hydroxurea for palliative care
 High dose cytarabine
 Chronic lymphocytic leukemia
 Itis a disease of
morphologically mature but
immunologically less mature
lymphocytes.
 Manifested be progressive
accumulation of lymphocytes
in the blood, bone marrow
and lymphatic tissues.
 CLL
 Epidemiology
 The most common leukemia in adult
 males >females
 > 45 yrs
 Here mature lymphocytes fail to respond to
Ag stimulation
95% are B cell type
5% are T cell type

 The overall 5 year survival is 60%

 CLL
Clinical presentation
 Indolentlymphocytosis (asymptomatic)
 Generalized lymphadenopathy
 Hepato-splenomegaly
 Pancytopenia
 Anaemia
 Coombs positive hemolysis
 Hypoplastic

 Bleeding
 Production thrombocytopenia
 Immune thrombocytopenia

 Infection
 Depressed immunoglobulin levels
enlarged lymphatic tissue
 Infection
herpes zoster
 CLL
investigations

 CBC
 PBF
 BM aspiration
 Immunochemistry
 Total protein and Ig level
 CLL
investigations

 CBC
 PBF
 BM aspiration
 immunochemistry
 Total protein and Ig level
 Complete blood counts

 WBC:
 Increased counts
 Mainly lymphocytes
 Lymphocyte count >=10.000 cmm Hb: Low or N

 Hb:
 Normalor low
 Hemolytic anaemia

 Platelets:
 Normal or low
 CLL
investigations

 CBC
 PBF
 BM aspiration
 Immunochemistry
 Total protein and Ig level
 Perioheral blood film
 Predominantly
lymphocytosis
 Normallylooking
 Presence of smudge cells
 CLL
investigations

 CBC
 PBF
 BM aspiration
 Immunochemistry
 Total protein and Ig level
 Bone marrow aspiration
 Not essential for diagnosis
 Infiltration of the bone marrow by
lymphocytes.
 CLL
investigations

 CBC
 PBF
 BM aspiration
 Immuno chemistry
 Total protein and Ig level
 Immuno-chemistry
•CD19 positive
•CD20 positive
•CD5 positive

Immunoglobulin levels
 Low immunoglobulin levels
CLL- staging
 CLL
whom to treat?
 Stage A
 Observation only
 Stage B
 Observation
only for asymptomatic
 Chemotherapy for symptomatic
lymphadenopathy
 Stage C
 Should be treated
 CLL
treatment
 Supportive treatment
 Treat infection
 Herpes zoster
 Pseudomonas carinii
 Candida albicans
 Proper hydration + allopurinol
 Specially in patients with large lymph nodes (bulky disease)
to prevent tumour lysis syndrome
 Automimmune anaemia or thrombocytopenia
 corticosteroids
 Blood transfusion
 High dose immuneglobulin
 Cyclosporine
 Splenectomy
 Low dose radiation to the spleen
 CLL
Treatment options
 Oral alkylating agents with or without corticosteroids
 Chlorambucil + prednisolone
 Purine analogues: Fludrabine, 2-chlorodeoxyadenodine
or pentostatin
 Better response, no advantage in survival and more side effects
 Combination chemotherapy:
 CVP: cyclophosphamide, vincristine, prednisolone
 CHOP: cyclophosphamide, doxorubicin, vincristine, prednisolone
 Involved field radiotherapy: for lymph node areas
 Splenic radiation for palliation of hypersplenism
 Monoclonal antibodies: CAMPATH-1H and rituximab
under trial
 Bone marrow transplantation and peripheral stem cell
transplantaion