Revision (D.E.C.I.S.T.

) of Acute Leukemia

Leukemia AML ALL

Definition - Malignant clonal disorder from hematopoietic stem cell characterized by
characterised by accumulation proliferation of poorly differentiated immature cells in BM and rapidly
of BLAST cell (myelo- or lympho- progressive fatal course if untreated
) in BM.
Etiology 1. Hereditary – Down 1. Same as AML
syndrome, Fanconi 2. But more common in children and
anemia male is more affected
2. Acquired – radiation,
chemical, virus
3. PNH
4. Myeloproliferative
disorder (Polycythemia
rubra vera, CML,
Myeloid metaplasia)
5. Common in adult and
both sex may be
affected
Clinical feature Pancytopenia and BM failure Pancytopenia and BM failure
1. Choloroma (M2)- Accumulation of malignant cells will
tumor-like (but its not spread to:
tumor) structure 1. Bone marrow – Pancytopenia,
caused by accumulation BM failure, bone problem
of blast cell arising from manisfestation
BM tissue 2. Peripheral blood – abnormal
2. DIC : AML M3 – Tissue characteristic in the blood smear
factor will activate 3. RES (Liver, Spleen, LN) –
coagulation cascade and hepatomegaly, splenomegaly and
release thrombin, when
there’s excess unregulated lymphadenopathy
release of thrombin, 4. Eye- pappiloedema and
plasminogen will convert to hemorrhage
plasmin to initiate
fibrinolysis. Fibrinolysis
causes excess of fibrin
degradation product that
lead to excessive bleeding.
Promyelocyte in M3 release
excess TF.
3. Gum hyperplasia in
AML-(M4/M5)

Investigation
1. Peripheral Blood Smear RBC: Normocytic Normochromic
WBC : 10k -> 100k (but all the cells are not functioning)
Plt: decrease (thrombocytopenia)
2. Bone Marrow Hypercellular, Myeloblast Hypercellular, Lymphoblast
Examination Blast morphology- Blast morphology-
1. Larger – because
immature 1. Size is smaller
2. Nucleus is indented or 2. Nucleus- rounded
folded – normally 3. Presence of nucleoli
mature neutrophil have 4. Chromatin dense coarse
segmentation 5. Scanty (a little) cytoplasm
3. Presence of nucleoli
4. May have presence of
Auer rod- they are linear
groups of azurophillic
granules, and this granules
made up from lysozyme
(important for phagocytosis
when the cell mature) the
granules are synthesized by
neutrophillic precursor. They
cannot be seen in normal
neutrophills. Only in AML.

3. Cytochemical Staining:
myeloperoxidase (MPO), stain AML ALL
MPO + -
Sudan Black (SB),
Periodic Acid Schiff (PAS) SB + -
PAS - +

4. Immunophenotyping
CD34+ (Stem cell)
CD13

CD2 CD10 CD33

cCD3 CD19 CD117
CD7 CD22 HLA-DR

T-ALL B-ALL
AML

By: Miya Wong

 5. FISH test In AML:
1. t(15; 17) – AML- M3
2. t(8; 21) – AML – M2
3. inv (16) – AML – M4

Stages: French American British

FAB stage
(FAB) indicate that’s the L1 Small cell + Homogenous
myeloblast cell is >30% M0 Myeloblast (all lymphoblast has the same size
undifferentiated of cell)
M1 Myeloblast w/o
maturation
L2 Large cell + Heterozygous
M2 Myeloblast w (not all lymphoblast has the same
maturation size)
M3 Promyelocytic
M4 Myelomonocytic L3 Burkit like large cell with
M5 Monocytic vacuolated cytoplasm
M6 Erythroleukemic
M7 Megakaryocytic

Treatment
1. Supportive/Palliative 1. Anemia: Red cell blood transfusion
treatment 2. Thrombocytopenia: Platelet infusion
3. Leucopenia(unfunction wbc) : Recurrent Infection – IV antibiotic
4. Hematopoietic GF
5. Monitor renal function
6. Psychological support
2. Systemic chemotherapy
a. Remission Induction Criteria of complete remission: 1. Vincristine + prednisone
for Complete 1. To kill most of the - Side drugs:
Remission (CR) tumor cell. athracycline and
2. <5% of blast in BM L-asparaginase
3. Normal PB count
4. S/S disappear Course: 4-6 weeks
Drugs:
1. Daunorubucin
2. Cytosine arabinoside
3. ATRA (all-trans retinoic
acid) for AML-M3

Course: minimal 4 cycles

By: Miya Wong

b. Post-Remission Eradication of residual leukemic
Therapy/Consolidati cells and prevent relapse
on 1. High Dose cytosine
arabinoside
2. HSCT transplantation-
a. Indicated after 1st
remission
b. Reserved for young
patient
2. Consolidation
3. Maintainence
1. CNS prophylaxis
- When cells enter CNS and the
chemo cant cross BBB so it
will cause leukemic meningitis
and relapse
- s/s: 3PB
1. Projectile vomiting
2. Pappiloedema
3. Persistent Headache
4. Blurry of vision
Prophylaxis:
- Cranial irradiation and
intrathecal methotrexate
a. High Dose methotrexate,
cytarabine
a. 2-3 years
b. 6-MP (daily)
c. Methothrexate (weekly)
By: Miya Wong