The acute leukaemias

Acute leukaemia is a clonal (that is,

derived from a single cell) malignant
disorder affecting all age groups.
- annual incidence rate of 4-7 people per
100 000.
It is characterised by the accumulation of
immature blast cells in the bone marrow,
which replace normal marrow tissue,
including haemopoietic precursor cells.
This results in bone marrow failure,
reflected by peripheral blood cytopenias
and circulating blast cells. Infiltration of
various organs is also a feature of some
forms of leukaemia.
In most cases the aetiology is not obvious,
but internal and
external factors associated with damage to
DNA can predispose to acute leukaemia.
Over 50 years, progressive advances in
the treatment of acute leukaemia have
converted an incurable
disease to one in which complete
remissions can be obtained in up to 95%

of selected patients treated with curative

intent.
This has largely been the result of ongoing
clinical trials, improved supportive
treatment and the development of bone
marrow transplantation for those in higher
risk categories.
Aetiological factors in acute leukaemia
Unknown (usually)
Hereditary
Downs syndrome
Blooms syndrome
Fanconis anaemia
Ataxia telangiectasia
Kleinfelters syndrome
Osteogenesis imperfecta
Wiskott-Aldrich syndrome
Leukaemia in siblings
Chemicals
Chronic benzene exposure
Alkylating agents (chlorambucil, melphalan)
Radiation
Predisposing haematological diseases
(myeloproliferative disorders, myelodysplasia, and
aplastic anaemia)
Viruses (HTLV-I causing adult T cell
leukaemia/lymphoma)

Acute leukaemia is subdivided into

(a) acute lymphoblastic leukaemia
(ALL),
in which the abnormal proliferation is in
the lymphoid progenitor cells (that is,
immature lymphocytes) and
(b) acute myeloid leukaemia (AML),
which involves the myeloid lineages (that
is, cells from which neutrophils,
eosinophils, monocytes, basophils,
megakaryocytes, etc. are derived).
The distinction between the two
leukaemias is based on morphological,
cytochemical, immunological and
cytogenetic differences and is of
importance as the
treatment and prognosis are usually
different.
Both acute lymphoblastic leukaemia and
acute myeloid leukaemia are currently
further subdivided on the basis of
morphological criteria:
acute lymphoblastic leukaemia into
FAB

(French-American-British) subtypes L1,

L2, and L3, and
Acute myeloid leukaemia into FAB
subtypes M0 to M7.

FAB* Classification of acute myeloid

leukaemia
M0 Acute myeloblastic leukaemia without
maturation
M1 Acute myeloid leukaemia with minimal
evidence of myeloid differentiation
M2 Acute myeloblastic leukaemia with
maturation
M3 Acute promyelocytic leukaemia
M4 Acute myelomonocytic leukaemia
M5 Acute monocytic/monoblastic
leukaemia
M6 Acute erythroleukaemia
M7 Acute megakaryoblastic leukaemia
*French-American-British

Figure -1 Blood film of patient with acute

lymphoblastic leukaemia

Figure -2 Blood film of patient with acute

myeloid leukaemia

Incidence
Acute lymphoblastic leukaemia

Acute lymphoblastic leukaemia is most

common in the age range 2-10 years, with
a peak at 3-4 years.
The incidence then decreases with
increasing age, though there is a
secondary rise after 40 years.
In children it is the most common
malignant
disease and accounts for 85% of
childhood leukaemia.

Acute myeloid leukaemia

Acute myeloid leukaemia accounts for 1015% of childhood leukaemia, but it is the
commonest leukaemia of adulthood,
particularly as chronic myeloproliferative
disorders and preleukaemic conditions
such as myelodysplasia usually progress
to acute myeloid leukaemia rather than
acute lymphoblastic leukaemia.
The incidence increases with age,
and the median age at presentation is 60
years.

Acute leukaemia is always serious

and life threatening,
and all patients suspected of having this
condition should be immediately referred
for urgent assessment.
Common symptoms and signs at
presentation result from
bone marrow failure or, less commonly,
organ infiltration.
Anaemia can result in pallor, lethargy,
and dyspnoea.
Neutropenia results in predominantly
bacterial infections of
the mouth, throat, skin, chest or perianal
region.
Thrombocytopenia may present as
spontaneous bruising, menorrhagia,
bleeding from venepuncture sites, gingival
bleeding, or prolonged nose bleeds.
A common presenting feature resulting
from organ
infiltration in childhood acute
lymphoblastic leukaemia is
Bone pain, but acute lymphoblastic
leukaemia can also present with

superficial lymphadenopathy,
abdominal distension due to abdominal
lymphadenopathy and
Hepatosplenomegaly,
respiratory embarrassment due to a large
mediastinal mass,
testicular enlargement, or a meningeal
syndrome. Gum hypertrophy and skin
infiltration are more commonly seen in
acute myeloid than in acute lymphoblastic
leukaemia.
Investigations
Full blood count usually shows reduced
haemoglobin concentration and platelet
count.
The white cell

count can vary from _1.0x109/l to

_200x109/l, and the
differential white cell count is often
abnormal, with
neutropenia and the presence of blast
cells.
The anaemia is a normochromic,
normocytic anaemia, and the
thrombocytopenia may be severe (platelet
count <10x109/l).

Coagulation screening may yield

abnormal results, particularly
in promyelocytic leukaemia (acute
myeloid leukaemia M3)
when granules from the leukaemic blasts
can have
procoagulant activity and trigger a
consumptive coagulopathy.
Biochemical screening is particularly
important if the leucocyte count is very
high, when there may be evidence of renal
impairment and hyperuricaemia.
Chest radiography is mandatory to
exclude the presence of a mediastinal
mass, which is present in up to 70% of
patients with
T cell acute lymphoblastic leukaemia.
In childhood acute lymphoblastic
leukaemia lytic bone lesions may also be
seen.
Bone marrow aspiration with or
without trephination is essential to
confirm acute leukaemia.
The marrow is usually hypercellular,
with a predominance of immature
(blast) cells.

Immunophenotyping of the antigens

present on blasts isolated from the bone
marrow or peripheral blood is the most
reliable method of determining whether
the leukaemia is lymphoid or myeloid, and
cytochemistry helps to confirm myeloid or
monocytic origin.

Cytogenetics and molecular studies

often detect abnormalities within the
leukaemic clone that can have diagnostic
or prognostic valuefor example,
the Philadelphia chromosome,
which is the product of a translocation
between chromosomes 9 and 22, the
presence of which confers a very poor
prognosis
in cases of acute lymphoblastic leukaemia.
Atraumatic lumbar puncture with
cerebrospinal fluid cytospin is an
important initial staging investigation in
ALL or AML with neurological symptoms to
detect leukaemic cells in the cerebrospinal
fluid, indicating involvement of the central
nervous system.

Management

supportive care to ameliorate or correct

the effects of the leukaemia and to
facilitate treatment.
Supportive care
Chemotherapy
The aim of chemotherapy for leukaemia is
initially to induce a remission (<5% blasts
in the bone marrow) and then to eradicate
the residual leukaemic cell population by
further courses of consolidation therapy.
The drugs damage the capacity of the
leukaemic cells to divide and replicate,
and
using cyclical combinations of three or
more drugs .
Management of acute leukaemia
Immediate (same day) referral to
specialist
Prompt diagnosis
Early treatment
Intensive supportive care
Systemic chemotherapy
Treatment directed at central nervous
system (in children and in adult acute
lymphoblastic leukaemia)

 Minimising early and late toxicity of

treatment
- Pseudomonas infection of skin and nail
bed in patient having treatment for acute
myeloid leukaemia
Adequate hydration and allopurinol
are essential at the start of
treatment to reduce the risk of
hyperkalaemia,
hyperuricaemia, and renal damage
Psychological and social support to
patients and families .
Treatment directed at the central
nervous system
The treatment or prevention of leukaemic
cells in the central nervous system is part
of all treatment protocols in childhood
leukaemia and adult acute lymphoblastic
leukaemia.

Bone marrow transplantation

Up to 85% of patients who initially
achieve a complete remission will

subsequently relapse. Transplantation

reduces
relapse risk but has been associated with
high procedural mortality.
The development of peripheral rather than
bone marrow stem cell harvest has
reduced procedural mortality.
Table 23.2 The association of morphology (FAB group) with cytogenetics and
immunophenotype in AML.
MIC group FAB
Immunological markers
Karyotype
CD7 CD19 CD13 CD33 GPA CD41
M2/t(8;21) M2
+
+
t(8;21)
(q22;q22)
M3/t(15;17) M3, M3v
+
+
t(15;17)
(q22;q12)
M5a/del(11q23) M5a (M5b, M4)
+
+
t/del(11)(q23)
M4Eo/inv(16) M4Eo
+
+
del/inv(16)(q23)
M1/t(9;22) M1 (M2)
+
+
t(9;22)
(q34;q11)
M2/t(6;9) M2 or M4 with basophilia
+
+
t(6;9)(p21
22;q34)
M1/inv(3) M1 (M2, M4, M7) with
thrombocytosis
+
+
inv(3)(q21;q26)
M5b/t(8;16) M5b with phagocytosis
+
+
t(8;16)
(p11;p13)
M2Baso/t(12p) M2 with basophilia
+
+
t/del(12)(p11
13)
M4/+4 M4 (M2) +
+ +4
+, Positive; , negative; no symbol, not specified by MIC Workshop.
.FAB, French American British classifi cation; GPA, glycophorin A

Chronic myeloid leukaemia

Pathogenesis
All leukaemia cells in patients with chronic
myeloid leukaemia contain a specific
cytogenetic marker, described originally in

1960 by workers in Philadelphia and now

known as the
Philadelphia or Ph chromosome.
The Ph chromosome is derived from a
normal 22
chromosome that has lost part of its long
arm as a result of a
balanced reciprocal translocation of
chromosomal material involving one of the
22 and one of the 9 chromosomes.
The translocation is usually referred to as
t(9;22)(q34;q11).
The Ph chromosome carries a specific
fusion gene known as BCR-ABL, which
results from juxtaposition with part of the
ABL proto-oncogene (from chromosome 9)
with part of the
BCR gene on chromosome 22.
This fusion gene is expressed as
a protein called p210BCR-ABL. This protein
perturbs stem cell kinetics, resulting in the
chronic phase of chronic myeloid
leukaemia, although the exact mechanism
remains unclear.
Researchers have recently developed a
drug (imatinib

mesylate) that blocks the action of the

BCR-ABL gene and
thereby reverses the leukaemic phenotype
in chronic myeloid leukaemia cells.
Clinical features in patients with
chronic
myeloid leukaemia at diagnosis
Common
Fatigue
Weight loss
Sweating
Anaemia
Haemorrhageeg easy bruising,
discrete ecchymoses
Splenomegaly with or without
hepatomegaly
Rare
Splenic infarction
Leucostasis
Gout
Retinal haemorrhages
Priapism
Fever
Survival from chronic myeloid
leukaemia
The average survival from diagnosis is 56 years, but the range is wide

 Occasionally patients die within one year

of diagnosis
About 3% of patients may live more than
15 years without radical therapy

Figure -2 Patient with massive

splenomegaly in chronic phase chronic
myeloid leukaemia
The spleen may be greatly enlarged
before onset of symptoms. Treatment
that reduces leucocyte count to
normal usually restores the spleen to
normal size
Table 27.4 Criteria for distinguishing the chronic,
accelerated
and blastic phases of CML based on proposals
published by
WHO (2001).
Chronic phase

Ability to reduce spleen size and restore and

maintain a normal
blood count with appropriate therapy
Accelerated phase (defined by one or more of the
following features)
Blasts 10 19% of white blood cells in peripheral
blood and/or of
nucleated bone marrow cells
Peripheral blood basophils20%
Persistent thrombocytopenia ( 10010 9 /L)
unrelated to
therapy, or persistent thrombocytosis ( 1000 10
9
/L)
unresponsive to therapy
Increasing spleen size and increasing white blood cell
count
unresponsive to therapy
Megakaryocyte proliferation in sheets or clusters in
association
with marked reticulin or collagen fibrosis
Blastic phase (defined by one or more of the
following features)
Blasts 20% of peripheral blood leucocytes or of
nucleated bone
marrow cells
Extramedullary blast proliferation
Large foci or clusters of blasts in the bone marrow
biopsy
Note: In this classification, unlike some other
classifications, the
acquisition of new cytogenetic abnormalities in
addition to the
Ph chromosome is not by itself a criterion for
promoting a

chronic - phase patient to accelerated phase.

Chronic phase disease

Presentation
The characteristic symptoms at
presentation include fatigue,
weight loss, sweating, anaemia,
haemorrhage or purpura, and
the sensation of a mass in the left upper
abdominal quadrant (spleen).
Often the disease is detected as a result of
routine
blood tests performed for unrelated
reasons, and a fifth of patients are totally
asymptomatic at the time of diagnosis.
The spleen may be greatly enlarged
before onset of symptoms.
Treatment that reduces the leucocyte
count to normal usually restores the
spleen to normal size.
Rare features include ;
Non-specific fever,
lymphadenopathy,
visual disturbances due to leucostasis (a
form of hyperviscosity
retinal haemorrhages,
splenic pain due to infarction, gout, and
occasionally priapism.

The commonest physical sign at diagnosis

is an enlarged spleen, which may vary
from being just palpable at the left costal
margin to filling the whole left side of the
abdomen and extending towards the right
iliac fossa.
The liver may be enlarged.
Spontaneous and excessive bruising in
response to minor trauma is common.
Diagnosis in chronic phase;
Peripheral blood film,
shows greatly increased numbers of
leucocytes with many immature forms
(promyelocytes and myelocytes);
The marrow is usually examined to
confirm the diagnosis.
Marrow examination shows increased
cellularity. The
distribution of immature leucocytes
resembles that seen in the blood film.
Red cell production is relatively reduced.
Megakaryocytes, are plentiful but may be
smaller than usual.
Cytogenetic study of marrow shows the
presence of the Ph chromosome in all dividing
cells.

Lactate dehydrogenase is usually raised.

Serum urate concentration may be raised.

Figure -3

Peripheral blood film from patient with

chronic myeloid leukaemia showing many mature
granulocytes, including two basophils (arrow); a blast
cell is prominent (double arrow)

Investigations to confirm suspected

chronic
myeloid leukaemia
Routine
Full blood count including blood film
Neutrophil alkaline phosphatase
Urea, electrolytes
Serum lactate dehydrogenase
Bone marrow aspirate (degree of
cellularity, chromosome analysis)
Optional
Bone marrow trephine biopsy (extent of
fibrosis)
BCR-ABL chimeric gene by fluorescent in
situ

hybridisation or by polymerase chain

reaction
Vitamin B12 and B12 binding capacity
HLA typing for patient and family
members
Management
Treatment with hydroxyurea
Hydroxyurea inhibits the enzyme
ribonucleotide reductase
and acts specifically on cells of the
myeloid series
It is useful for rapid reduction of the
leucocyte count in newly diagnosed
patients
Many haematologists start treatment
with hydroxyurea then
switch to interferon _ once the patients
symptoms are relieved and the leucocyte
count is restored to normal
Hydroxyurea is also valuable for
controlling chronic phase disease in
patients who cannot tolerate interferon _
It is usually started at 2.0 g daily by
mouth; the usual maintenance dose is 1.01.5 g daily, titrated against the leucocyte
count

 Treatment with hydroxyurea does not

eradicate cells with the Ph chromosome
Side effects are rare but include rashes,
mouth ulceration, and gastrointestinal
symptoms.
The drug causes macrocytosis and
megaloblastoid changes in the marrow
Imatinib mesylate (STI571)Imatinib
mesylate has just become generally
available and seems already to be the
treatment of choice for chronic myeloid
leukaemia presenting in chronic phase.
It acts by specifically inhibiting the
enhanced
protein tyrosine kinase activity of the BCRABL oncoprotein
and thus reversing the pathologically
perturbed signal
transduction.
Preliminary clinical studies show that it
induces
complete haematological remission in
_95% of previously untreated patients and
at least 50% of these will achieve a
complete cytogenetic remission. Toxicity
seems to be relatively mild.

It is too early to say whether the drug will

prolong life in comparison with interferon _
used alone or in conjunction with
cytarabine.
Interferon _Interferon _
is a member of a family of naturally
occurring glycoproteins with antiviral and
antiproliferative actions.
It was until recently the drug of choice
for managing chronic myeloid leukaemia
in the chronic phase.
It restores spleen size and blood counts to
normal in 70-80% of patients.
Some 10-20% of patients achieve a major
reduction or
complete disappearance of cells with the
Ph chromosome from their bone marrow
(tantamount to complete cytogenetic
remission).
Interferon _ initially causes flu-like
symptoms, but
these usually subside.
Other more persistent side effects include
anorexia, weight loss, depression,
alopecia, rashes,
neuropathies, autoimmune disorders, and
thrombocytopenia.

Currently interferon _ should be

considered for chronic phase patients
resistant to imatinib mesylate.
Allogeneic stem cell transplantation
Patients under the age of 60 years who
have siblings with identical HLA types may
be offered treatment by high dose
cytoreduction (chemotherapy and
radiotherapy) followed by transplantation
of haemopoietic
stem cells collected from the donors bone
marrow or
peripheral blood.
With typical family size in western Europe,
about 30% of patients will have matched
sibling donors.
In selected cases transplants may also be
performed with HLAidentical unrelated
donors.
Allogeneic stem cell transplants are
associated with an appreciable risk of
morbidity and mortality,
and in general, older patients (aged 4060) fare less well than younger patients.
Nevertheless, the projected cure rate after

allogeneic stem cell transplantation is

about 60-70%.
Autologous stem cell transplantation

For patients up to the age of 65 years for

whom an allograft is excluded,
autografting may be considered. For this
purpose haemopoietic stem cells are
collected from the patients blood or
marrow and
cryopreserved.
The patient then receives high dose
cytoreductive chemotherapy, followed by
reinfusion of the thawed stem cells.
The procedure may prolong life in some
cases, and remains experimental.
Advanced phase disease
Presentation
The patient may have excessive
sweating, persistent fever, or otherwise
unexplained symptoms of anaemia,
splenic enlargement or splenic infarction,
haemorrhage, or bone pain.
In most cases the blast crisis is myeloid
(that is, resembling acute myeloid

leukaemia), and in a fifth of cases

lymphoid blast crisis occurs.
Occasionally patients progress to a
myelofibrotic phase of the disease, in
which intense marrow fibrosis
predominates,
blast cells proliferate less aggressively,
and the clinical picture is
characterised by splenomegaly and
pancytopenia consequent on marrow
failure.
Management
Patients in accelerated phase may derive
considerable benefit
from imatinib mesylate, which can reestablish chronic phase disease and even
Ph-negative haemopoiesis in some cases.
They may also respond to hydroxyurea or
busulphan if they have not previously
received these agents. Splenectomy may
be useful to
improve thrombocytopenia or symptoms
due to splenomegaly.
Patients in a blastic phase respond only
transiently to imatinib mesylate.

It is probably preferable to rely on the use

of
combination chemotherapy .
Criteria for advanced phase disease
Increasing splenomegaly despite full
doses of cytotoxic drugs
Rapid white blood cell doubling time
White blood cell count poorly responsive
to full doses of cytotoxic drugs
Anaemia or thrombocytopenia
unresponsive to cytotoxic drugs
Persistent thrombocytosis (>1000x109/l)
>10% blasts in peripheral blood or
marrow
>20% blasts plus promyelocytes in
blood or marrow
Acquisition of non-random
chromosomal changes in addition to
presence of Philadelphia chromosome
Development of myelofibrosis
At times the advanced phase can be
difficult to distinguish from the chronic
phase and can be diagnosed with
confidence only in retrospect

Chronic lymphocytic leukaemia

and other B-cell disorder

Introduction
Within the broad term of B-cell
lymphoproliferative disorders we include a
number of disease entities arising from
mature B lymphocytes and which involve
primarily the blood, bone marrow and
other lymphoid organs such as the spleen.
Their clinical course is often chronic and
they affect mainly adults.
All show, early in their course, circulating
leukaemic cells in various degrees.
Some of these conditions could be
considered as primary leukaemias .
Others represent the leukaemic phase of
low-grade non-Hodgkins lymphomas
(NHL) and their recognition is important
for the purpose of differential diagnosis
and patient management.
The study of lymphoid leukaemias has
been enriched with the advent of
monoclonal antibodies (MAbs) which
define antigenic determinants that are
specific for the B- and T-cell lineages.
Characterization of these malignancies is
not possible without the use of these

reagents and/or other membrane markers

which define the cell lineage and the
maturation stage of the leukaemic cell.
DNA analysis for the detection of
immunoglobulin
and T-cell receptor gene rearrangements
has been
incorporated as another diagnostic test for
cell lineage and clonality and for
monitoring minimal residual disease
(MRD) after therapy.
Chromosome abnormalities which
characterise some
of the genetic changes in the lymphoid
leukaemias are now also important for
diagnostic and prognostic purposes and
are routinely studied by fluorescence in
situ hybridization (FISH) as it is not easy to
obtain metaphases in slowly dividing
lymphocytes.
The primary B-cell leukaemias include ;
-chronic lymphocytic leukaemia (CLL),
which is by far the most common,
-the rare B-prolymphocytic leukaemia (BPLL) and
-hairy cell leukaemia (HCL).

The B-NHLs which most frequently affect

the blood and bone marrow include;
- splenic marginal zone lymphoma (SMZL)
or splenic lymphoma with circulating
villous lymphocytes (SLVL),
-mantle cell lymphoma (MCL), which not
infrequently has lymphocytosis,
particularly in the splenomegalic or
nonnodal form, and
-follicular lymphoma which, in its
generalized or
systemic form (stage IV), regularly affects
the bone marrow and may spill over to the
peripheral blood.
Methodology for diagnosis
Examination of the morphology of
leukaemic cells in wellprepared peripheral
blood and bone marrow films stained with
Romanowsky dyes is the first diagnostic
procedure.
Details which are helpful in the analysis of
cell types are: cell size, nucleocytoplasmic
(N/C) ratio, regularity or irregularity of the
nuclear outline, the characteristics of the
cytoplasm such as the presence and
length of any villus formations, the degree
of basophilia, the presence or absence of

cytoplasmic granules, the degree of

nuclear chromatin condensation and its
pattern, and the prominence,frequency
and localization of the nucleolus.
The second crucial element for the
diagnosis of any type of lymphocytosis is
to use a small battery of membrane
markers to define the immunophenotype
(B or T) and whether the process is clonal
or polyclonal.
Once a monoclonal B-cell proliferation is
established by light-chain restriction, e.g.
kappa or lambda, one can clarify the
problem further by using a restricted
panel of monoclonal antibodies to define a
particular disease immunophenotype.
Table -1 The immunophenotype of CLL:
tests used as basis for a scoring system.
Marker (result)
Score
SmIg (weak)
1
CD5
()
1
CD23 ()
1
FMC7 ()*
1
CD79b (or /)
1
Total 5

*Epitope of CD20 but CD20 not useful for

scoring.
Table -2 CLL score in B-cell disorders.
Disease
Score
CLL
Typical
45
Atypical; CLL/PL
35
B-prolymphocytic leukaemia
01
Hairy cell leukaemia
01
NHL with leukaemia*
02
*Follicular, mantle, splenic marginal zone.
(Table -1)define the typical
immunophenotype
of CLL. Also indicates in brackets after
each of the five markers used the
expected result in CLL.
(Table -2) summarizes the results of
applying the panel of markers of the CLL
score to the B-cell disorders.
High scores are,by definition, expected in
CLL; low scores are the feature in the
other B-cell leukaemias and B-cell NHL.
The data refer mainly to results in
peripheral blood samples. There are,
however, a number of issues which may
present problems;

-First, as shown in Table -2, some cases of

CLL with atypical morphology, e.g. clefted
or cleaved nucleus, plasmacytoid features,
and cases with more than 10%
prolymphocytes (CLL/PL) may have scores
lower than 4 or 5.
Rare cases of NHL may approach scores of
2 or 3;
thus, reliance only on the
immunophenotype may be misleading.
-Second, the important distinction
between CLL and MCL,another CD5positive disease, may require other tests,
e.g. FISH.
In our experience of 60 cases of MCL with
lymphocytosis studied with this panel of
MAb, the highest score was 2.
Recently, we have also identified a group
of patients with CD5-positive leukaemia in
which MCL was excluded by FISH and
which also gave scores of 1 or 2. We have
provisionally described them as very
atypical CLL as we are not sure of the
exact nature of this condition.
An important consideration when using
membrane markers is the distinction
between CD20 and FMC7. FMC7 has now

been recognized as binding to a

conformational epitope of the CD20
molecule. Despite this, FMC7 does not
correlate with
CD20 staining in CLL.
Most cases of CLL and other B-cell
disorders express CD20, hence its value as
a pan-B-cell marker and as a target for the
monoclonal antibody rituximab.
We have reexamined the possible use of
CD20 instead of FMC7 for the scoring of
CLL (as suggested by some authors) in
close to 1000 cases and concluded that
FMC7 is of greater diagnostic value to
distinguish CLL (where it is negative) from
the other B-cell disorders in which it is
strongly expressed.
The findings with CD20 and FMC7 are very
similar only in the non-CLL B-cell
disorders.
When considering the possibility of a
diagnosis of NHL, it is essential to obtain
tissue for histology to confirm this
suspicion and facilitate the classification of
the disease.
When the WBC is high (e.g. above 50
109/L) and the blood film shows

unequivocal features of CLL or B-PLL,

lymph node histology may not be
essential, and not infrequently it is not
available.
Bone marrow trephine biopsies are always
required as they provide important
diagnostic and prognostic information.
The pattern of bone marrow infiltration
paratrabecular, diffuse,nodular or
interstitial the cell morphology, the
status of the normal haemopoietic
elements, the presence of fibrosis,
proliferation centres, etc., are all features
which can help to confirm a diagnosis of
CLL or NHL, provide indications about the
mechanism of anaemia or
thrombocytopenia and help predict the
outcome of splenectomy.
The pattern and degree of lymphocytic
infiltration in CLL have been considered an
important prognostic variable independent
of the clinical stage.
For disorders with an enlarged spleen, e.g.
B-PLL, HCL, splenic lymphoma with
circulating SLVLs and some forms of MCL,
spleen histology is often of diagnostic
value.

The difficulties in eliciting metaphases for

cytogenetic analysis in CLL and other
small lymphocytic disorders has
emphasized the value of FISH analysis
which can be assessed on interphase
cells.
There is, however, no specific genetic
abnormality in CLL and the current FISH
studies are valuable as prognostic
indicators .
FISH is important to exclude the two NHLs
which have characteristic abnormalities,
MCL with t(11;14)(q13;q32) and follicular
lymphoma with t(11;14)(q32;q21).
Other abnormalities, e.g. deletions 6q21,
11q23, 13q14 and 17p21 (the p53locus)
and trisomy 12, are seen in variable
degree in most types of B-cell NHL as well
as in CLL.
As stated above (Table -1), a combination
of membrane markers is often diagnostic
of CLL, distinguishing it not only from Tcell disorders but also from other Blymphoproliferative disorders (Table -2).
The diseases which are often confused
with CLL are follicular lymphoma, splenic

marginal zone lymphoma or SLVL and MCL

when they present with lymphocytosis.
The pattern of bone marrow infiltration
may also help in the differential diagnosis
with other lymphomas.
For example, true paratrabecular deposits
are common in follicular lymphoma and
may be seen in SLVL and MCL, but not in
CLL.
Proliferation centres, a classic feature of
CLL and small lymphocytic lymphoma
(SLL), are seen in lymph node biopsies,
and in very active CLL also in bone
marrow biopsies, not infrequently
associated with an increased proportion of
prolymphocytes (CLL/PL) in blood and
bone marrow films.
The proliferating centres have a high
proliferation index as detected by
immunocytochemistry staining for Ki-67 or
MIB-1 and show prolymphocytes and
blasts (para-immunoblasts). There is also
a high expression of CD23 in the
proliferating centres of lymph nodes and
spleen greater than in the small
lymphocytes. This may explain the high

levels of soluble CD23 in the serum of

patients with active CLL and its correlation
with adverse prognosis.
Proliferation centres are unique to CLL and
SLL and are absent in NHL, particularly
cases of MCL, which may otherwise
resemble CLL.
CHAPTER 38

Chronic lymphocytic leukaemia

Chronic lymphocytic leukaemia accounts
for about 25% of all leukaemias.
In adults over the age of 50 years it is the
most common form, particularly in the
West.
CLL affects twice as many males as
females, with a peak incidence between
60 and 80 years.

Several factors may be involved in the

pathogenesis of CLL,including
antigen stimulation within specific
microenvironments and failure to undergo
apoptosis.
The protein BCL2 is consistently
overexpressed and prevents or delays the
death of CLL lymphocytes.
Clinical and laboratory features
In approximately 50% of patients, the
disease is diagnosed by chance following
blood examination.
In others, the presentation is
Symptoms of anaemia or by the discovery
of
painless lymph node enlargement.
Systemic symptoms such as pyrexia,
sweating or weight loss are rare.
Not infrequently, prolonged chest infection
or pneumonia is the first manifestation of
CLL.
The diagnosis of CLL requires evidence of
lymphocytosis, at least 10X109/L, and
lymphocytic infiltration in the bone
marrow of at least 40%.
With immunological methods, particularly

the detection of monoclonal B-cell

populations by light-chain restriction, it is
possible to diagnose the disease with
lymphocyte counts below this threshold.
Morphologically, the lymphocytes in blood
films are small and show scanty cytoplasm
and a characteristic
pattern of nuclear chromatin clumping;
the nucleolus is inconspicuous (Figure
38.3).
The presence of smear cells, which
correlates with the level of WBC, is of
diagnostic value.
A proportion of prolymphocytes (15%)
are nearly always seen with counts
30109/L.
If the proportion of prolymphocytes is
greater than 10%, it represents a variant
designated CLL/PL (Figure 38.4).
As reported by the FrenchAmerican
British (FAB) group, some patients have
a mixed pattern of small and large cells
and others have lymphoplasmacytoid
features or even cells with nuclear clefts.
These are often associated with other
atypical features .

Figure 38.3 Blood film of a typical case of

.CLL

Figure 38.4 Blood film from a case of

CLL/PL.

Note the dual population of small

lymphocytes and larger nucleolated
prolymphocytes.
Anaemia and thrombocytopenia are
important prognostic features in CLL and
form part of the information used for
staging.
In advanced CLL, there is heavy
lymphocytic infiltration resulting in bone
marrow failure. Hypogammaglobulinaemia
is the rule in advanced CLL and is
responsible for the high incidence of upper
respiratory tract infections.
Small monoclonal (M) bands, often
immunoglobulin
M (IgM), are seen in less than 10% of
.cases
Bone marrow examination (Table 38.4)
After the examination of peripheral blood
films and the five markers for defining the
immunophenotype, a bone marrow
examination is the next most important
test in CLL.
Although it is common practice to perform
an aspirate and a trephine biopsy,
the latter is probably more informative.

Aspirates are useful to confirm the cell

morphology, to assess residual
haemopoiesis
and to ascertain any myelodysplastic
features (in heavily treated patients).
They are, however, not as informative as
the core
biopsy regarding overall cellularity and
.degree of infiltration
Staging systems
The Rai system has five stages:
0, no anaemia, thrombocytopenia or
physical signs;
I, lymphadenopathy only;
II, splenomegaly and/or hepatomegaly
with or without lymph node enlargement
and without anaemia or
thrombocytopenia;
III, anaemia below 11 g/dL, irrespective of
physical signs; and
IV, thrombocytopenia below 100 109/L,
with or without any of the above features.
Binet modified this system following
extensive multivariate analysis from two
French studies.

This system is simpler, has only three

stages
(A, B and C) and is probably more
accurate
with respect to the prognosis for patients
with Rai stages I and II.
For these patients, a subdivision according
to the number of involved sites (as in
Binets staging) shows prognostic
advantages over the subdivision in I and II.
The Binet system groups together patients
with anaemia (Hb 10 g/dL) and
thrombocytopenia (platelets 100 109/L)
as group C.
The remainder of patients are staged
according to the number of lymphoid
organs involved, considering as one each
of the following areas: neck, axillae and
inguinal regions, spleen and liver.
Group A patients have no organ
enlargement or up to two areas;
group B patients have 35 involved areas.
The International Workshop on CLL
proposed to retain the Rai stages as
substages for group A,
,as A(0), A(I) and A(II)

In practice, staging is necessary to predict

prognosis
Table_Agents used alone or in
combination for the treatment of CLL.
Chlorambucil (oral)
Cyclophosphamide (oral/i.v.)
Prednisolone (standard/high dose)
Fludarabine (oral/i.v.)
Cladribine (2-CdA; i.v./s.c.)
Pentostatin (DCF; i.v.)
Rituximab (anti-CD20)
Campath-1H (anti-CD52; i.v./s.c.)
Genasense (BCL2 antisense)
Zevalin (rituximab yttrium-90)