NEOPLASTIC DISEASES OF THE

BLOOD
Introduction
DEFINITION

The hematopoietic neoplasms are

clonal diseases that derive from a
single cell in the marrow or
peripheral lymphoid tissue that
has undergone genetic alteration
REPLACEMENT OF NORMAL MARROW CELLS BY NORMAL MARROW CELLS BY CLONAL
POPULATION OF NEOPLASTIC CELLS
EPIDEMIOLOGY OF BLOOD NEOPLASMS
EPIDEMIOLOGY OF BLOOD NEOPLASMS
RISK FACTORS
 Inherited factors
 Environmental factors
 Chemicals
 Drugs
 Radiation

 Infection
 Viruses
 Bacteria
 Protozoa
INFECTION ASSOCIATED WITH HEMATOPOIETIC
NEOPLASMS
Infection Neoplasms
Virus
HTLV-1 Adult T-cell leukemia/lymphoma
Epstein-Barr virus Burkitt’s and Hodgkin lymphomas; PTLD
HHV-8 Primay effusion lymphoma; Castleman disease
HIV-1 High-grade B-cell lymphoma
Bactera
H. pylori Gastric lymphoma (MALT)
Protozoa?
Malaria Burkitt’s lymphoma

PTLD, post-transplant lymphoproliferative disease

GENETICS OF BLOOD NEOPLASMS
Malignant transformation occurs as a result of the
accumulation of genetic mutations in cellular
genes. The genes that are involved can be divided
broadly into two (2) groups:

 Oncogenes

 Tumor-suppressor genes
COMMON GENETIC ABNORMALITIES IN HEMATOPOIETIC NEOPLASMS

Disease Genetic Oncogenes

abnormality involved
AML t(8;21) ETO/AML1 (CBFα)
t(15;17) PML, RARA
Nucleotide insertion NPM
Mutation, ITD FLT3
Mutation TET-2
Secondary AML 11Q23 translocations MLL
Myelodysplasia -5, del (5q) RPS 14
-7, del (7q) N RAS
CML t(9;22) BCR-ABL
Myeloproliferative Point mutation JAK-2
Point mutation TET-2
COMMON GENETIC ABNORMALITIES IN HEMATOPOIETIC NEOPLASMS

Disease Genetic abnormality Oncogenes involved

B-ALL t(12;21) TEL/AML1
t(9;22) BCR-ABL1
t(4;11) AF4/MLL
Follicular lymphoma t(14;18) BCL2
Mantle cell t(11;14) Cyclin D1
lymphoma t(8;14) MYC
Burkitt lymphoma
CLL 17P deletion P53
11q22-23 deletion ATM
 Multistep clonal
development of
malignancy and clonal
progression
CHROMOSOME NOMENCLATURE
GENETIC ABNORMALITIES THAT MAY LEAD HEMATOPOIETIC
MALIGNANCIES
GENETIC ABNORMALITIES THAT MAY LEAD HEMATOPOIETIC
MALIGNANCIES
GENETIC ABNORMALITIES THAT MAY LEAD HEMATOPOIETIC
MALIGNANCIES
GENETIC ABNORMALITIES THAT MAY LEAD HEMATOPOIETIC
MALIGNANCIES
OPERATIONAL CLASSIFICATION HL NEOPLASMS
INTRODUCTION TO LEUKEMIA
 LEUKEMIAS - DEFINITION

Leukemias are a group of

disorders characterized by
accumulation of malignant blood
cells in the bone marrow
and blood
 Leukemic cells are frequently present in the:
 peripheral blood
 invade the reticulendothelial tissues
 spleen, liver, and lymph nodes
 may also invade other tissues
 untreated, eventually causes death
CLASSIFICATION
 Classified according to cell type – with regard to
both:
 cell maturity – used to distinguish between acute and
chronic leukemia
 if malignant cells are immature – acute
 rapidly aggressive

 if predominantly mature - chronic

 slow or indolent course

 cell lineage
 Myeloid – (granulocytic, monocytic, megakaryotic, and
erythrocytic )
 Lymphoid
CATEGORIES OF LEUKEMIAS
 Acute lymphoid leukemia (ALL)
 Acute myeloid leukemia (AML) or acute
nonlymphoblastic leukemia (ANLL)
 Chronic myeloid leukemia

 Chronic lymphocytic leukemia

COMPARISON OF ACUTE AND CHRONIC
LEUKEMIA

Acute Chronic
Age All ages Adults
Clinical onset Sudden Insidious
Course (untreated) < 6 mo 2 – 6 years
Leukemic cells Immature Mature
Anemia Mild to severe Mild
Thrombocytopenia Mild to severe Mild
White cell count Variable Increased
Organomegaly Mild Prominent
ACUTE LEUKEMIAS - DIAGNOSIS
 the presence of over 20% blast cells in the blood or
bone marrow at clinical presentation.
 It can be diagnosed with even less than 20% blasts
if specific leukemia-associated cytogenetics or
molecular genetics are present
 Subdivided into acute myeloid leukemia (AML) and
acute lymphoid leukemia (ALL) on the basis of
whether the blasts are myeloblasts or lymphoblasts
 MORPHOLOGIC APPROACH TO
CLASSIFICATION

Cytologic Features of Blasts in Acute ANLL and Acute Lymphocytic Leukemia

Feature AML ALL

Blast size Larger, usually uniform Variable, small to medium
size
Nuclear chromatin Usually finely dispersed Coarse to fine

Nucleoli 1-4, often prominent Absent or 1-2, often indistinct

Cytoplasm Moderately, abundant, fine Usually scant, coarse

granules often present granules sometimes present
(~7%)
Auer rods Present in 60-70% of cases Not present

Others Often dysplastic changes Myeloid cells not dysplastic

in maturing myeloid cells
 Figure 1. A type I myeloblast has a large nuclus with prominent nucleoli

Maslak, P. ASH Image Bank 2003;2003:100726

Copyright ©2003 American Society of Hematology. Copyright restrictions may apply.

Figure 3. Small number of granules are clustered in the cytoplasm of this myeloblast

Maslak, P. ASH Image Bank 2003;2003:100739

Copyright ©2003 American Society of Hematology. Copyright restrictions may apply.

 Figure 2. Type III blasts have greater than 20 granules but no centrosome

Maslak, P. ASH Image Bank 2004;2004:100953

Copyright ©2004 American Society of Hematology. Copyright restrictions may apply.

 Figure 1. Auer rods are distinctive cytoplasmic inclusion bodies which are found in
MDS and AML

Maslak, P. ASH Image Bank 2005;2005:101341

Copyright ©2005 American Society of Hematology. Copyright restrictions may apply.

 Figure 1. This lymphoid blast has a rounded, "regular" appearance without
cytoplasmic granules

Maslak, P. ASH Image Bank 2004;2004:101139

Copyright ©2004 American Society of Hematology. Copyright restrictions may apply.

 CYTOCHEMICAL REACTIONS USEFUL IN THE DIAGNOSIS OF ACUTE LEUKEMIA
Special Stain Site of Action Cells Stained Comment
Myeloperoxidase Mainly primary Late myeloblasts, Separates AML (+)
granules; Auer rods granulocytes; from ALL (-)
monocytes less
intensely
Sudan black B Phospholipids; Late myeloblast, Parallels peroxidase,
sterols, neutral fats granulocytes; but smears do not
monocytes less need to fresh
intensely
Specific esterase Cytoplasm Neutrophilic Parallels peroxidase,
(Naphthol AS-D granulocytes; mast but less sensitive;
chloroacetate cells
Non-specific esterase Cytoplasm Monocytes; focal Useful for
(alpha-napththyl staining in T cells determining degree
acetate and butyrate) of monocytic
differentiation;
separates mono (+)
from myelo (-) blasts
Periodic acid-Schiff Glycogen and related Lymphocytes, Helpful in supporting
substances granulocytes, diagnosis of
megakaryocytes erythroleukemia
 IMMUNOLOGIC MARKERS USED IN THE
CLASSIFICATION OF ACUTE LEUKEMIA
Lineage Antigen
B cell CD19, CD20, CD21, CD22, CD23, D24

T cell CD1, CD2, CD3, CD4, CD5, CD7, CD8

Lymphoid TdT
Myeloid (granulocytic) CD13, CD33, CD11b, CD15
Monocytic CD14, CD11b
Erythroid Glycophorin A
Megakaryocytic CD41, CD42b, CD61
Lineage Independent Antigens
HLA-DR HLA class II
CD45 Leukocyte common antigen
CD34 Stem cell antigen
CD10 Common ALL antigen (CALLA)
IMMUNOLOGIC SUBCLASSES OF ACUTE
LEUKEMIA
WHO CLASSIFICATION AML
 AML with recurrent genetic abnormalities
 AML with t(8;21) (q22;q22); RUNX1/RUNX1T1
 AML with abnormal bone marrow eosinophils
[inv(16)(p13q22) or t(16;16)(p13;q22); CBFB/MYH11
 Acute promyelocytic leukemia [AML with
t(15;17)(q22;q12) (PML/RARα) and variants]
 AML with 11q23 (MLL) abnormalities
 AML with myelodysplasia-related changes
 Following a myelodysplastic syndrome or
myelodysplastic syndrome/myeloproliferative disorder
 Without antecedent myelodysplastic syndrome
WHO CLASSIFICATION AML
 Therapy-related myeloid neoplasms (t-AML)
 Alkylating agent-related
 Topoisomerase type II inhibitor-related
 Other types
WHO CLASSIFICATION AML
 AML not otherwise categorized
 AML minimally differentiated
 AML without maturation
 AML with maturation
 Acute myelomonocytic leukemia
 Acute monoblastic and monocytic leukemia
 Acute erythroid leukemia
 Acute megakaryoblastic leukemia
 Acute basophilic leukemia
 Acute panmyelosis with myelofibrosis
 Myeloid sarcoma
 Myeloid sarcoma

 Myeloid proliferation related to Down’s syndrome

REVISED CRITERIA FOR THE CLASSIFICATION
OF AML (FAB)

M0 with minimal differentiation

Large, agranular blasts (resemble ALL L2, rarely L1). Myeloperoxidase
negative or<3 percent positive; B-, T lineage markers negative; CD13 and/or
CD33 positive; myeloperoxidase positive by immunochemistry or electron
microscopy; TdT may be positive.
M1 with minimal maturation
1. Blast cells, agranular and granular types (type I and type II) >90 percent
of non erythroid cells. At least 3 percent of these are myeloperoxidase
or Sudan black positive.
2. Remaining 10 percent (or less) of cells are maturing granulocytes or
monocytes
REVISED CRITERIA FOR THE CLASSIFICATION
OF AML (FAB)

M2 with maturation
1. Sum of agranular and granular blasts (types I and II) is from 30 to 89
percent of non-erythroid cells.
2. Monocytic cells, <20 percent.
3. Granulocytes from promyelocytes to mature polymorphs, > 10 percent.
M3 Promyelocytic
1. Majority of cells are abnormal promyelocytes with heavy granulation.
2. Characteristic cells containing bundles of Auer rods (“faggots”)
invariably present.
Note: Microgranular variant (M3v) also occurs. Promyelocytes have
marked nuclear irregularity that includes reniform, lobulated and
monocyte-like indented nuclei. The cytoplasm contains fine or
indistinct granules in contrast to the coarse azurophilic granules in
typical M3.
REVISED CRITERIA FOR THE CLASSIFICATION
OF AML (FAB)

M4 Myelomonocytic
1. In the marrow, blasts >30 percent of non-erythroid cells.
2. Sum of myeloblasts, promyelocytes, myelocytes and later granulocytes
is between 30 and 80 percent of non-erythroid cells.
3. > 20 percent of non-erythroid cells are monocyte lineage.
4. If monocytic cells exceed 80 percent, diagnosis is M5
Note: (a) If marrow findings as above and peripheral blood monocytes
(all types) are > 5.0 x 109/L, diagnosis is M4
(b) If monocyte count < 5 x 109/L, M4 can be confirmed on basis of
serum lysozyme, combined esterase, etc.
(c) Diagnosis of M4 confirmed if > 20 percent of marrow precursors are
monocytes (confirmed by special stains).
REVISED CRITERIA FOR THE CLASSIFICATION
OF AML (FAB)

M4 with eosinophilia
1. Eosinophils > 5 percent of non-erythroid cells in marrow.
2. Eosinophils are abnormal.
3. Eosinophilis are chloroacetate and PAS positive.
M5 Monocytic
1. 80 percent of marrow non-erythroid cells are monoblasts,
promonocytes or monocytes.
2. M5a, 80 percent of monocytic cells are monoblasts.
3. M5b, < 80 percent of monocytic cells are monoblasts, remainder are
predominantly promonocytes and monocytes.
 REVISED CRITERIA FOR THE CLASSIFICATION
OF AML (FAB)

M6 Erythroleukemia
1. The erythroid component of the marrow exceeds 50 percent of all
nucleated cells.
2. 30 of the remaining non-erythroid cells are agranular or granular blasts (
types I and II).
Note: If > 50 percent erythroid cells but < 30 percent blasts, diagnosis
becomes myelodysplastic syndromes.
A rare form of erythoird neoplasia, erythremic myelosis, involves only the
red blood cell precursors. The erythroblasts, primarily pronormoblasts
and basophilic normoblasts, constitute 90% or more of the marrow cells.
M7 Megakaryocytic
1. 30 percent at least of nucleated cells are blasts.
2. Blasts identified by platelet peroxidase on electron microscopy, or by
monoclonal antibodies.
3. Increased reticulin is common.
FAB CLASSIFICATION OF ALL
Morphologic
Features L1 L2 L3
Cell size Small Large Large

Nuclear chromatin Fine or clumped Fine Fine

Nuclear shape Regular, may Irregular, may Regular, oval

have cleft of have cleft or to round
indentation indentation
Nucleoli Indistinct or not 1 or more per 1 or more per
visible cell; large cell; large
prominent prominent
Amount of cytoplasm Scanty Moderately Moderately
abundant abundand
Cytoplasmic basophilia Slight Slight Prominent

Cytoplasmic vacuoles Variable Variable variable

ALL (L1)
ALL (L2)
ALL (L3)
CLINICAL FEATURES OF ACUTE LEUKEMIA
Pathogenesis Clinical Manifestations
Bone Marrow Failure
Anemia Fatigue, malaise, pallor
Thrombocytopenia Bruising, bleeding
Granulocytopenia Fever, infections
Organ Infiltration
Marrow expansion Bone or joint pain
Spleen Splenomegaly
Liver Hepatomegaly
Lymph nodes Lymphadenopathy
Central nervous system Neurologic symptoms
Gums, mouth Gingival hypertrophy,oral lesions
LABORATORY EVALUATION OF ACUTE
LEUKEMIA
 Purpose: Confirm the diagnosis and distinguish
AML from ALL
 Preliminary evaluation:
 complete blood count and peripheral blood examination
 bone marrow studies
 morphologic examination
 cytochemical staining

 immunologic markers

 cytogenetic studies

 molecular genetic studies

 electron microscopy ?
ACUTE MYELOID LEUKEMIA
(AML)
Acute Nonlymphoid Leukemia
(ANLL)
EPIDEMIOLOGY
 AML is the predominant form of leukemia during the
neonatal period and
 accounts for 15 to 20 percent of acute leukemia in
children and
 80 percent of acute leukemia in adults.
PRIMARY AML VS SECONDARY AML
 Primary AML arise de novo
 Secondary AML develop from other chronic marrow
dysfunction or follow previous treatment with
chemotherapy
 associated with distinct genetic markers
 have different prognoses
 Figure 1. Blasts are the predominant population in the bone marrow
AML (M1)

Maslak, P. ASH Image Bank 2003;2003:100838

Copyright ©2003 American Society of Hematology. Copyright restrictions may apply.

 Figure 2. Aspirate has a large number of blasts
AML (M2)

Maslak, P. ASH Image Bank 2003;2003:100722

Copyright ©2003 American Society of Hematology. Copyright restrictions may apply.

 Figure 1. The most common form of APL is easily recognized by the heavy
granulation of the abnormal promyelocytes (AML M3)

Maslak, P. et al. ASH Image Bank 2002;2002:100532

Copyright ©2002 American Society of Hematology. Copyright restrictions may apply.

 Figure 1. The granules in this morphologic variant of APL are less prominent than
those seen in the most common form of this disease

Maslak, P. et al. ASH Image Bank 2002;2002:100598

Copyright ©2002 American Society of Hematology. Copyright restrictions may apply.

 Figure 4. The increased number of blasts are noted with a prominent background of
eosinophils and abnormal eosinophilic myelocytes

Lazarchick, J. ASH Image Bank 2004;2004:101148

Copyright ©2004 American Society of Hematology. Copyright restrictions may apply.

 Figure 1. Monoblasts are large cells with ample cytoplasm

Maslak, P. et al. ASH Image Bank 2002;2002:100537

Copyright ©2002 American Society of Hematology. Copyright restrictions may apply.

Figure 3. Erythroid elements comprise greater than or equal to 50% of the nucleated
cellular elements while the myeloblasts make up greater than or equal to 20% of the
nonerythroid population

Maslak, P. ASH Image Bank 2003;2003:100635

Copyright ©2003 American Society of Hematology. Copyright restrictions may apply.

Figure 1. Blasts in acute megakaryoblastic leukemia may show cytoplasmic budding
reminiscent of the process where platelets are shed from normal megakaryocytes
(MacNeal Tetrachrome 400x)

Maslak, P. ASH Image Bank 2002;2002:100478

Copyright ©2002 American Society of Hematology. Copyright restrictions may apply.

COMMON CYTOGENETIC ABNORMALITIES
ASSOCIATED WITH AML

Favorable Unfavorable
Cytogenetics t(15,17) Deletions of chromosome 5 or 7
t(8;21) Flt-3 mutation
inv (16) 11q23
NPM mutation t(6;9)
abn(3q)
Complex rearrangements
CLINICAL FEATURES
 Anemia and thrombocytopenia are often profound
 Disseminated intravascular coagulation (DIC) –
characteristics of the M3 variant
 Gum hypertrophy and infiltration, skin involvement
and CNS disease are characteristics of M4 and M5
types
 May present as isolated mass of leukemic blasts –
granulocytic sarcoma
TREATMENT
 Supportive treatment
 Specific treatment
 Intensive chemotherapy - all the AML FAB subtypes are
similarly treated except M3 variant
 All-transretinoic acid (ATRA) added to initial therapy

 Stem cell transplantation

PROGNOSTIC FACTORS
Favorable Unfavorable
BM response to <5% blasts after 1st >20% blasts after 1st
remission induction course course
Age <60 years >60 years
Onset Primary Secondary
ACUTE LYMPHOID LEUKEMIA
acute lymphoblastic leukemia
acute lymphocytic leukemia
EPIDEMIOLOGY
 The most common form of leukemia in child
 Has equal sex incidence

 T-cell ALL has male predominance

WHO CLASSIFICATION OF ALL (2008)
Precursor lymphoid neoplasms
B lymphoblastic leukemia/lymphoma
B lymphoblastic leukemia/lymphoma, NOS
B lymphoblastic leukemia/lymphoma with recurrent genetic
abnormalities
B lymphoblastic leukemia/lymphoma with t(9;22)(q34;q11.2); BCR-ABL
B lymphoblastic leukemia/lymphoma with t(v;11q23); MLL rearranged
B lymphoblastic leukemia/lymphoma with t(12;21)(p13;q22); TEL-
AML1
(ETV6-RUNX1)
B lymphoblastic leukemia/lymphoma with hyperdiploidy
B lymphoblastic leukemia/lymphoma with hypodiploidy (hypodiploid
ALL)
T lymphoblastic leukemia/lymphoma
NOS, not otherwise specified
FAB CLASSIFICATION OF ALL
Morphologic
Features L1 L2 L3
Cell size Small Large Large

Nuclear chromatin Fine or clumped Fine Fine

Nuclear shape Regular, may Irregular, may Regular, oval

have cleft of have cleft or to round
indentation indentation
Nucleoli Indistinct or not 1 or more per 1 or more per
visible cell; large cell; large
prominent prominent
Amount of cytoplasm Scanty Moderately Moderately
abundant abundand
Cytoplasmic basophilia Slight Slight Prominent

Cytoplasmic vacuoles Variable Variable variable

ALL (L1)
ALL (L2)
ALL (L3)
TREATMENT
CLINICAL FEATURES
 Bone marrow failure
 Anemia
 Neutropenia
 Thrombocytopenia

 Organ infiltration
 Tender bones
 Lymphadenopathy
 Hepato-splenomegaly
 Meningeal syndrome
 Less common
 Testicular swelling
 Signs of mediastinal compression (T-cell ALL)
CYTOGENETICS SUBSETS OF ALL
TREATMENT