Acute leukemia-acute leukemia Irina.ppt

Acute leukemia-acute

1. Irina Datikashvili-David

2. Leukemia is a malignant disease characterized
by unregulated proliferation of one cell type.
It may involve any of the cell lines or a stem cell
common to several cell lines.
Leukemias are classified into 2 major groups
Chronic in which the onset is insidious, the disease is usually
less aggressive, and the cells involved are usually more
mature cells
Acute in which the onset is usually rapid, the disease is very
aggressive, and the cells involved are usually poorly
differentiated with many blasts.

3. Both acute and chronic leukemias are further classified
according to the prominent cell line involved in the
expansion:
If the prominent cell line is of the myeloid series it is a
myelocytic leukemia (sometimes also called granulocytic)
If the prominent cell line is of the lymphoid series it is a
lymphocytic leukemia
Therefore, there are four basic types of leukemia
Acute myelocytic leukemia – AML- (includes myeloblastic,
promyelocytic, monocytic, myelomonocytic, erythrocytic, and
megakaryocytic)
Acute lymphocytic leukemia – ALL- (includes T cell, B cell, and
Null cell)
Chronic myelocytic leukemia – CML - (includes myelocytic and
myelomonocytic)

4. Chronic lymphocytic leukemia – CLL - (includes plasmocytic
{multiple myeloma}, Hairy cell, prolymphocytic, large granular
cell lymphocytic, Sezary’s syndrome, and circulating
lymphoma)
Etiology – the exact cause is frequently not known,
but predisposing factors are known:
Host factors
Some individuals have an inherited increased
predisposition to develop leukemia
There is an increased incidence in those with an inherited
tendency for chromosome fragility or abnormality or those
with increased numbers of chromosomes (such as Down’s
syndrome).
Many of these diseases are characterized by chromosomal
translocations.

5. There is an increased incidence in those with hereditary
immunodeficiencies.
There is an increased incidence in those with chronic
marrow dysfunction such as those with myeloproliferative
diseases, myelodysplastic syndromes, aplastic anemia, or
paroxsymal nocturnal hemoglobinuria.
Environmental factors:
Exposure to ionizing radiation
Exposure to mutagenic chemicals and drugs
Viral infections

6. Incidence
Acute leukemias can occur in all age groups
 ALL is more common in children
AML is more common in adults
Chronic leukemias are usually a disease of adults
CLL is extremely rare in children and unusual before the
age of 40
CML has a peak age of 30-50

7. Comparison of acute and chronic leukemias:
Acute Chronic
Age all ages usually adults
Clinical onset sudden insidious
Course (untreated) 6 mo. or less 2-6 years
Leukemic cells immature >30% blasts more mature cells
Anemia prominent mild
Thrombocytopenia prominent mild
WBC count variable increased
Lymphadenopathy mild present;often prominent
Splenomegaly mild present;often prominent

8. Acute leukemia –
Is a result of:
Malignant transformation of a stem cell leading to
unregulated proliferation and
Arrest in maturation at the primitive blast stage. Remember
that a blast is the most immature cell that can be recognized
as committed to a particular cell line.
Clinical features
Leukemic proliferation, accumulation, and invasion of
normal tissues, including the liver, spleen, lymph nodes,
central nervous system, and skin, cause lesions ranging from
rashes to tumors.
A humoral mediator from the leukemic cells may inhibit
proliferation of normal cells.

9. Failure of the bone marrow and normal
hematopoiesis may result in pancytopenia with
death from hemorrhaging and infections.
Lab evaluation
The lab diagnosis is based on two things
Finding a significant increase in the number of immature
cells in the bone marrow including blasts, promyelocytes,
promonocytes (>30% blasts is diagnostic)
Identification of the cell lineage of the leukemic cells

10. Peripheral blood:
Anemia (normochromic, normocytic)
Decreased platlets
Variable WBC count
The degree of peripheral blood involvement determines
classification:
Leukemic – increased WBCs due to blasts
Subleukemic – blasts without increased WBCs
Aleukemic – decreased WBCs with no blasts
Classification of the immature cells involved may be
done by:

11. Morphology – an experienced morphologist can look at the
size of the blast, the amount of cytoplasm, the nuclear
chromatin pattern, the presence of nucleoli and the presence
of auer rods (are a pink staining, splinter shaped inclusion
due to a rod shaped alignment of primary granules found
only in myeloproliferative processes) to identify the blast
type:
AML – the myeloblast is a large blast with a moderate
amount of cytoplasm, fine lacey chromatin, and prominent
nucleoli. 10-40% of myeloblasts contain auer rods.

13. ALL – in contrast to the myeloblast, the lymphoblast is a
small blast with scant cytoplasm, dense chromatin,
indistinct nucleoli, and no auer rods

14. Cytochemistry – help to classify the lineage of a
leukemic cell (myeloid versus lymphoid)
Myeloperoxidase – is found in the primary granules of
granulocytic cells starting at the late blast stage.
Monocytes may be weakly positive.

15. Sudan black stains phospholipids, neutral fats and sterols
found in primary and secondary granules of granulocytic
cells and to a lesser extent in monocytic lysosomes. Rare
positives occur in lymphoid cells

16. Nonspecific esterase – is used to identify monocytic cells
which are diffusely positive. T lymphocytes may have
focal staining

17. Acid phosphatase may be found in myeloblasts and
lymphoblasts. T lymphocytes have a high level of acid
phosphatase and this can be used to help make a diagnosis
of acute T-lymphocytic leukemia.

18. Leukocyte alkaline phosphatase – is located in the
secondary granules of segmented neutrophils, bands and
metamyelocytes. The LAP score is determined by counting
100 mature neutrophils and bands. Each cell is graded
from 0 to 5. The total LAP score is calculated by adding
up the scores for each cell.

20. Immunologic markers (immunophenotyping) – these are
used mainly for lymphocytes, i.e., for determining B cell or T
cell lineage. These tests rely on antibodies made against
specific surface markers.
They constitute what we would call the primary antibody
and in an indirect assay they are allowed to react with the
cells and unbound antibody is then washed away.
Fluorescently labeled antibody (secondary antibody)
against the primary antibody is added and allowed to react
and then unbound secondary antibody is washed away.
The cells are then sent through a flow cytometer that will
determine the number of cells that have a fluorescent tag
and which are thus positive for the presence of the surface
marker to which the primary antibody was made.
In a direct assay, the primary antibody is fluorescently
labeled.

21. B or T Cell
marker
B or T cell
specific Ab
B or T cell
specific Ab
B or T Cell
marker

23. This is a unique DNA polymerase present in
stem cells and in precursor B and T lymphoid
cells.
High levels are found in 90% of lymphoblastic
leukemias.
It can also be detected using appropriate
antibodies and flow cytometry.

24. Cytogenetics – cytogenetics studies can now be used for
diagnosis and for prognosis of hematologic malignancies.
Many leukemias (and lymphomas) are characterized by
specific chromosomal abnormalities, including specific
translocations and aneuploidy. The specific type of
malignancy can be identified based on the specific
abnormality or translocation. These may be identified by
Looking at the karyotypes of the chromsomes from the
abnormal cells
DNA based tests – these tests are very useful for following the
course of the disease
RT-PCR
Southern blotting
A normal karyotype is usually associated with a better
prognosis.

27. Acute lymphoblastic leukemia –
They may be classified on the basis of the
cytological features of the lymphoblasts into;
L1 - This is the most common form found in children and
it has the best prognosis.
The cell size is small with fine or clumped homogenous
nuclear chromatin and absent or indistinct nucleoli.
The nuclear shape is regular, occasionally clefting or
indented.
The cytoplasm is scant, with slight to moderate
basophilia and variable vacuoles.
L2 – This is the most frequent ALL found in adults.
 The cell size is large and heterogenous with variable
nuclear chromatin and prominent nucleoli.
The nucleus is irregular, clefting and indented.
The cytoplasm is variable and often moderate to
abundant with variable basophilia and variable
vacuoles.


30. L3 – This is the rarest form of ALL.
The cell size is large, with fine, homogenous nuclear
chromatin containing prominent nucleoli.
The nucleus is regular oval to round.
The cytoplasm is moderately abundant and is deeply
basophilic and vacuolated.

32. ALL may also be classified on the basis of
immunologic markers into:
Early pre-B ALL
Pre-B ALL
B ALL
T ALL
Null or unclassified ALL (U ALL) - lack B or T markers
and may be the committed lymphoid stem cell)

35. Incidence – ALL is primarily a disease of young
children (2-5 years), but it can also occur in adults
Clinical findings – pancytopenia with resulting
fatigue, pallor, fever, weight loss, irritability,
anorexia, infection, bleeding, and bone pain.
L1 occurs in children, L2 in adults, and L3 is called
Burkitts leukemia

36. Prognosis – age, WBC count, and cell type are the
most important prognostic indicators
Patients younger then 1 and greater than 13 have a poor
prognosis
If the WBC count is < 10 x 10
9
/L at presentation, the
prognosis is good; If the WBC count is > 20 x 10
9
/L at
presentation the prognosis is poor
T cell ALL (more common in males) has a poorer prognosis
than any of the B cell ALLs which have a cure rate of 70%

37. Acute leukemias with mixed lineage –
occasionally there are acute leukemias that are
biphenotypic and display phenotypes for two
different lineages
B lymphoid/myeloid
T lymphoid/myeloid
B/T lymphoid
Myeloid/Natural killer
A rare trilineage leukemia has also been seen (was
B/T lymphoid/myeloid!)

38. Acute myeloid leukemia (also called acute
granulocytic leukemia) – classification depends
upon
Bone marrow blast morphology
Degree of cell maturation
Cytochemical stains
Immunophenotyping
AML is divided into 7 different classifications:
M1 – myeloblastic without maturation
The bone marrow shows  90% blasts and < 10%
promyelocytes
The disease occurs in older adults

39. Note the myeloblasts and the auer rod:

40. M2 – myeloblastic with maturation
The bone marrow shows 30-89% blasts and > 10%
promyelocytes;
This is characterized by an 8,21 chromosomal translocation
This occurs in older adults
M3 – hypergranular promyelocytic
This form of AML has a bone marrow with >30% blasts
Is more virulent than other forms
Occurs with a medium age of 39
The WBC count is decreased
Treatment causes a release of the granules and may send
the patient into disseminated intravascular coagulation
and subsequent bleeding
It is characterized by a 15,17 chromosomal translocation

41. Note myeloblasts and hypogranulated PMNs:

42. Note hypergranular promyelocytes:

43. M3m – hypogranular promyelocytic –
The bone marrow has > 30% blasts
The WBC count is increased.
Like the M3 type, treatment causes a release of the
granules and may send the patient into disseminated
intravascular coagulation and subsequent bleeding and
It is characterized by a 15,17 translocation
M4 – acute myelomonoblastic leukemia
Both myeloblasts and monoblasts are seen in the bone
marrow and peripheral blood
Infiltration of extramedullary sites is more common than
with the pure granulocytic variants

44. Note hypogranular promyelocytes:

45. Note monoblasts and promonocytes:

46. M5 – acute monoblastic leukemia
 >80% of the nonerythroid cells in the bone marrow are monocytic
There is extensive infiltration of the gums, CNS, lymph nodes and
extramedullary sites
This form is further divided into
M5A - Poorly differentiated (>80% monoblasts)
M5B - Well differentiated (<80% monoblasts)
M6 – erythroleukemia
This is rare and is characterized by a bone marrow having a
predominance of erythroblasts
It has 3 sequentially morphologically defined phases;
Preponderance of abnormal erythroblasts
Erythroleukemia – there is an increase in both
erythroblasts and myeloblasts
Myeloblastic leukemia – M1, M2, or M4
Anemia is common

47. Note monoblasts:

48. Note monoblasts, promonocytes, and
monocytes:

49. Note M1 type monoblasts

50. M7 - Acute megkaryoblastic leukemia
This is a rare disorder characterized by extensive
proliferation of megakaryoblasts, atypical megakaryocytes
and thrombocytopenia
Treatment of leukemias –
There are 2 goals:
Eradicate the leukemic cell mass
Give supportive care
Except for ALL in children, cures are not common
but complete remission (absence of any leukemia
related signs and symptoms and return of bone
marrow and peripheral blood values to within
normal values) is

51. There are four general types of therapy
Chemotherapy – usually a combination of drugs is
used
Bone marrow transplant
Radiotherapy
Immunotherapy – stimulate the patients own immune
system to mount a response against the malignant cells
Monoclonal antibodies – examples include Rituxan
SPECIAL - ATRA for AML M3