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1. ACUTE LEUKEMIA DR. T T WAKAMA DEPT OF HAEMATOLOGY 21 ST NOVEMBER 2022

2. Learning Objectives

3. Outline General overview Introduction Epidemiology of acute leukaemias Etiology and pathogenesis of acute leukaemias Classification of acute leukaemias Clinical features of acute leukaemias Acute leukaemia diagnosis T reatment of acute leukaemias Prognosis of acute leukaemias Conclusion References

4. General Overview The term leukemia is derived from the Greek words  leukos   and  haima ,  which mean white and blood, respectively. In the mid-1800’s Rudolf Virchow, was the first to propose the word in more modern times, following the inspection of contaminated blood under a microscope. The pathological and anatomical descriptions of leukemia were first discussed in medical literature in the early 1800s by Alfred-Armand-Louis-Marie Velpeau who described the case of a 63-year-old florist that became ill with symptoms of weakness, fever, the presence of urinary stones and the enlargement of the spleen and liver.

5. General Overview Bennett, a pathologist at the Edinburgh Royal Infirmary, is often referred to as the person responsible for discovering leukemia due to his provision of complete and scientific descriptions. His discovery of the condition was made after performing an autopsy on a patient with reported abnormal blood consistency, which was later reported in the Edinburgh Medical and Surgical Journal in 1845.

6. General Overview Leukaemic transformation is assumed to occur in many cases at, or near, the level of the haemopoietic stem cell before it has embarked on any lineage commitment Clonal disease resulting from genetic mutations and transformation of a single early progenitor cell It is associated with chromosomal abnormalities, recurrent cytogenetic abnormalities, and disruptions in key signaling pathways

7. GENERAL OVERVIEW 7

8. General Overview

9. Introduction Acute leukaemias are a heterogeneous group of malignant disorders which are characterized by the uncontrolled clonal proliferation and accumulation of poorly differentiated blast cells in the bone marrow, blood and other tissues The leukemic cells are frequently but not always present in the bloodstream It is defined as the presence of over 20% blast cells in the blood or bone marrow or the presence of specific leukaemia-associated cytogenetic or molecular genetic abnormalities.

10. Epidemiology Leukaemias account for about 20-30% of haematologic malignancies Acute leukaemias account for 30-40% of leukamias in adults. Chronic leukaemias account for 60-70% of leukaemias in adults

11. Epidemiology- AML AML is the most common leukaemia among the adult population and accounts for about 80% of all cases Has an incidence of 2–3 per 100 000 per annum in children, rising to 15 per 100 000 in older adults. All ages affected- median:63 years Median age in our own environment is 34years ~10-15% of cases of leukaemia in children[5-9 years] AML is the most frequent leukaemia in the Neonates. Males have more predominance compared to females with a ratio of 5:3.

12. Epidemiology- ALL Bimodal age distribution: 2-5years and > 50years. Median age at diagnosis is 4years. Hispanics>Caucasians>Africans 19.7% of all childhood tumors seen in AKTH, Kano between January 2001 to December 2010. 15% of all childhood malignancies from 2015-2019 in NHA Despite increasing cure rates, it still remains an important cause of morbidity and mortality in children and adults. Overall survival of adults < children, but initial response to chemotherapy is almost same.

13. Aetiology and pathogenesis of acute leukemias Leukaemias result from the accumulation of acquired genetic mutations within a cell. This mutation can be acquired in utero or after birth Inherited factors and environmental influences contribute to the development of a malignancy.

14. Aetiology and pathogenesis of acute leukemias Down’s syndrome [20-30x] Fanconi’s anaemia Li Fraumeni syndrome Bloom’s syndrome Ataxia telangiectasia Neurofibromatosis Klinefelter syndrome Wiskott - Aldrich syndrome Chemicals ; Benzene Drugs ; alkylating [chlorambucil or mephalan ] Etoposide Radiation ; nuclear fall-out or diagnostic X-rays or therapeutic irradiations. Infectious agents ; Epstein –Barr virus [EBV] Inherited factors Environmental influences

15. GENETIC ASSOCIATIONS Malignant transformation occurs as a result of accumulation of genetic mutation in cellular genes Normal cell growth is maintained by proto-oncogene and tumor suppressor genes Proto-oncogene-These are genes that regulate cellular process They are involved in the pathway by which external signals are transduced to the cell nucleus Oncogene arises because of gain of function mutation in proto-oncogene. T umor suppressor genes- Are genes that regulate cell cycle Mutation in them result in loss of function 15

16. Pathology Loss of function of transcription factors needed for differentiation eg AML1-ETO CBF β -SMMHC PML-RAR α Gain of function mutations of Tyrosine Kinases eg FLT3, cKIT mutations N- and K-RAS mutations BCR-ABL TEL - PDGF β R Differentiation Block Enhanced Proliferation Acute Leukemia

17. GENETIC ASSOCIATIONS 17 CELL CYCLE

18. CONTROL OF HAEMOPOIESIS BY GROWTH FACTOR 18 Binding of GF to its receptor activates the JAK/STAT, MAPK and PI3K pathways which leads to transcriptional activation of specific c genes. E2F is a transcription factor needed for cell transition from G1 to S phase. E2F is inhibited by the tumour suppressor gene Rb (retinoblastoma) which can be indirectly activated by p53. The synthesis and degradation of different cyclins stimulates the cell to pass through the different phases of the cell cycle. The growth factors may also suppress apoptosis by activating AKT (protein kinase B).

19. GENETIC ASSOCIATIONS A mutation is a permanent change in DNA structure Classification: Gene mutation Chromosomal mutations 19

20. GENETIC ASSOCIATIONS AML development is a multistep process that requires the collaboration of at least two classes of mutations to obtain full-blown leukaemia Gilliland and Griffin presented a paradigm model for this process, designated the "two-hit model Class 1 mutations --- activate signal transduction pathways and increase cellular proliferation . Class 2 mutations ---- affect transcription factors and primarily serve to impair hematopoietic differentiation 20

21. GENETIC ASSOCIATIONS 21

22. PATHOPHYSIOLOGY AML is characterized by mutations of the genes involved in haematopoiesis. These malignant transformations usually occur at the pluripotent stem cell level , but sometimes involves a committed stem cell which has limited capacity for self renewal. In normal haematopoiesis the myeloblast will gradually differentiate and mature into specialized cells. In AML a single myeloblast with genetic mutation ‘’freeze’’ the cell in its immature state and prevent differentiation. 22

23. Classification of acute leukemias Acute leukaemias are broadly classified into Acute myeloid ( myeloblastic ) leukeamias [AML] Acute lymphoblastic leukaemias [ALL] Acute leukaemias are subclassified using; French-American-British(FAB) Classification ( 1976) Based on Morphology and cytochemical reactions World Health Organization(WHO) Classification(2008 and revised 2016) Based on Morphology, Immunophenotype, Cytogenetics and molecular studies

24. FAB Vs WHO Classifications Differences between FAB and WHO FAB-classification : 1 ) Morphologic Findings 2) Special staining (SBB, MPO, NSE, etc), if required For Diagnosis, Blast count in PB or BM is >30% . WHO-classification : 1) Morphologic findings 2) Special staining (decreased role) 3) Immunophenotyping (in the form of FC and IHC) heavily used. 4) Cytogenetics and Molecular genetics studies frequently used. For Diagnosis, Blast count in PB or BM is >20% .

25. FAB classification of AML(1976) M0 : undifferentiated M1: without maturation M2 : with maturation M3 : acute promyelocytic leukaemia M4 : acute myelomonocytic leukaemia M4Eo: acute myelomonocytic leukaemia with eosinophilia M5a: acute monoblastic M5b: acute monocytic M6: erythroleukaemia M7 : acute megakaryocytic leukaemia

26. AML M0 Large agranular blasts Platelets are decreased on film Blasts are negative for lymphoid antigens Positive for MPO and SBB under Electron microscope.

27. AML M1 90% or more of non erythroid cells are myeloblast <10% promyelocytes or more mature cells

28. AML M2 <90% of nonerythroid cells are blasts Auer rods typically present There is differentiation of at least 10% of the remaining cells into granulocytic series [promyelocytes to neutrophil] and at least 20% of non erythroid cells are monocytic

29. AML M3 Blast may be less than 30% of marrow nucleated cells There are large promyelocytes with abundant auer rods [faggot cells] in the cytoplasm. Nuclei are often bilobed or kidney shaped

30. AML M4 Monocytic component constituent at least 20% of the bone marrow cells with predominance of monoblast and promonocytes. Peripheral blood with monocytosis >5 x 10 9 /l

31. AML M5 (a-Monoblastic, b-Monocytic) M5a M5b ≥ 80% of cells have monocytic morphology Granulocytic component <20% Monoblastic leukemia: ≥ 80% leukemic cells are monoblasts Monocytic leukemia predominant cell type is promonocytes. Has <80% monoblasts

32. AML M6a (mixed erythroid/myeloid) ≥ 20% of nonerythroid cells are myeloblasts, ±Auer rods ≥ 50% of all nucleated cells are erythroid precursors Dysplastic erythroid precursors with megaloblastoid nuclei, round nuclei, fine chromatin, multiple nucleoli, nuclear bridging

33. AML M6b-Pure erythroid leukemia ≥ 80% erythroid precursors without evidence of a myeloid component Immature erythroid cells with deeply basophilic cytoplasm, round nuclei, one or more nucleoli, vacuoles

34. AML M7 ≥ 20% blasts ≥ 50% of blasts are megakaryoblasts Small blasts: resembling lymphoblasts, round nucleus, dense chromatin, scanty cytoplasm Large blasts: fine nuclear chromatin, nucleoli, cytoplasm abundant, basophilic, agranular, ±pseudopods

35. AML-WHO Classification(2008) AML with recurrent Genetic abnormalities AML with Myelodysplasia- related changes Therapy related myeloid dysplasia [t-AML] AML- Not otherwise specified Myeloid Sarcoma Myeloid proliferations related to Down’s syndrome

36. AML- WHO 2008 1]AML with recurrent genetic abnormalities • AML with t(8;21)(q22;q22); RUNX1-RUNX1T1 • AML with inv (16)(p13.1q22) or t(16;16)(p13.1q22); CBFB-MYH11 • Acute promyelocytic leukaemia with t(15;17)(q22;q12) PML-RARA • AML with t(9;11)(p22;q23); MLLT3-MLL • AML with t(6;9)(p23;q34); DEK-NUP214 • AML with inv (3)(q21;q26.2) or t(3;3)(q21;q26.2); RPN1-EVI1 • AML ( megakaryoblastic ) with t(1;22)(p13;q13); RBM15-MKL1

37. AML- WHO 2008 2] AML with myelodysplasia related changes There are microscopic features of dysplasia in at least 50% of cells in at least two cell lines 3] Therapy related myeloid neoplasms Arising in patients who have been treated previously with drugs such as Etoposides or alkylating agents

38. AML- WHO 2008 4] Acute myeloid leukaemia, not otherwise specified AML with minimal differentiation AML without maturation AML with maturation Acute myelomonocytic leukaemia Acute monoblastic and monocytic leukaemia Acute erythroid leukaemia Acute megakaryoblastic leukaemia Acute basophilic leukaemia Acute panmyelosis with myelofibrosis

39. AML- WHO 2008 5] Myeloid Sarcoma Solid tumour composed of myeloid blast cells. 6] Myeloid proliferation related to down’s syndrome Down’s syndrome increases the risk of development of AML

40. AML- WHO classification (2016) AML with recurrent Genetic abnormalities • AML with t(8;21)(q22;q22); RUNX1-RUNX1T1 • AML with inv (16)(p13.1q22) or t(16;16)(p13.1q22); CBFB-MYH11 • Acute promyelocytic leukaemia with t(15;17)(q22;q12) PML-RARA • AML with t(9;11)(p22;q23); MLLT3- KMT2A • AML with t(6;9)(p23;q34); DEK-NUP214

41. AML- WHO 20016 AML with inv (3)(q21;q26.2) or t(3;3)(q21;q26.2); GATA2, MECOM • AML ( megakaryoblastic ) with t(1;22)(p13;q13); RBM15-MKL1 . Provisional entity: AML with BCR-ABL1 • AML with mutated NPM1 • AML with mutated CEBPA . Provisional entity: AML with mutated RUNX1

42. AML with Myelodysplastic related changes Therapy related AML AML- Not otherwise specified (no changes) Myeloid Sarcoma Myeloid proliferations related to Downs syndrome Transient abnormal myelopoiesis (TAM) Myeloid leukemia associated with Down syndrome

43. Blastic plasmacytoid dendritic cell neoplasm Acute leukaemias of ambiguous lineage Acute undifferentiated leukaemia Mixed phenotype acute leukaemia (MPAL) with t(9;22)(q34.1;q11.2); BCR-ABL1 MPAL with t(v;11q23.3); KMT2A rearranged MPAL, B/myeloid, NOS MPAL, T/myeloid, NOS

44. ALL Classification French-American-British(FAB) Classification(1976) Based on MORPHOLOGY AND CYTOCHEMISTRY World Health Organization(WHO) Classification(2008/2016)

45. ALL, FAB L1 – PBF and BM This is the most common form found in children and it has the best prognosis. The cell size is small monomorphic type. Homogeneous blast with regular nuclear outline occasionally clefting or indented. The cytoplasm is scant, with slight to moderate basophilia and variable vacuoles.

46. ALL, L2 – PBF and BM This is the most frequent ALL found in adults. The cell size is large and heterogenous with variable nuclear chromatin The nucleus is irregular with clefting and indented and prominent nucleoli . The cytoplasm is variable and often moderate to abundant, the basophilia is variable and may be deep and vacuoles are variable

47. ALL, FAB L3 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

48. ALL-WHO classification of precursor lymphoid neoplasms (2008/2016) B lymphoblastic leukaemia/lymphoma B lymphoblastic leukaemia/lymphoma, NOS B lymphoblastic leukaemia/lymphoma with recurrent genetic abnormalities B lymphoblastic leukaemia/lymphoma with (9;22)(q34;q11.2); BCR-ABL1 B lymphoblastic leukaemia/lymphoma with t(v11q23); MLL rearranged B lymphoblastic leukaemia/lymphoma with t(12;21)(p13;q22) TEL-AML1* ( ETV6-RUNX1 ) *- removed

49. B lymphoblastic leukaemia/lymphoma with hyperdiploidy B lymphoblastic leukaemia/lymphoma with hypodiploidy B lymphoblastic leukaemia/lymphoma with t(5;14)(q31;q32) IL3-IGH B lymphoblastic leukaemia/lymphoma with t(1;19)(q23;p13.3); TCF3-PBX1 Provisional entity: B-lymphoblastic leukemia /lymphoma, BCR-ABL1–like Provisional entity: B-lymphoblastic leukemia /lymphoma with iAMP21

50. T lymphoblastic leukaemia/lymphoma Provisional entity: Early T-cell precursor lymphoblastic leukaemia Provisional entity: Natural killer (NK) cell lymphoblastic leukaemia/lymphoma

51. MIXED PHENOTYPE ACUTE LEUKEMIA These cases are rare Express two markers for both myeloid and lymphoid differentiation either on the same blast cells or on two different cell populations Have a poor prognosis

52. CLINICAL FEATURES- AML Usually due to BM infiltration or failure Anaemia Bleeding Recurrent Infections Bone pains Mild Splenomegaly Tissue infiltration with blasts- e.g. gums, skin (M4, M5) Disseminated Intravascular Coagulation- (M3)

53. CLINICAL FEATURES- AML Leukostasis & Hyperviscosity Confusion Visual Impairment/ Retinal Haemorrhage Dyspnoea (Lungs) Haemorrhage into Retina, Brain, Lungs

54. CLINICAL FEATURES- ALL Hepatosplenomegaly Fever Fatigue Lymphadenopathy Bleeding Bone or joint pain Anorexia Abdominal pain meningism

55. CLINICAL FEATURES- ALL Marked cervical lymphadenopathy in a boy Facial asymmetry in a 59 year old man due to a right lower motor neurone 7 th nerve palsy resulting from meningeal leukemic infiltration

56. DIAGNOSIS OF ACUTE LEUKEMIAS: flow of investigations 1. Morphology 2. Cytochemistry 3. Immunophenotyping 4. Cytogenetic analysis 5. Molecular studies

57. INVESTIGATIONS AND DIAGNOSIS Detailed History and physical examination Full Blood Count and Blood Film Bone Marrow Aspiration ± Trephine Bone Marrow Cytogenetics and Molecular analysis Immunophenotyping of Blood or Marrow Blasts CXR/Chest CT Scan Abdominal Ultrasound Scan/Abdominal CT Scan Lumbar Puncture – to detect occult CNS involvement Fundoscopy

58. Morphology-ALL R e d b l oo d c e ll s ; n orm o cy t i c normochromic/microcytic hypochromic red cells White blood cells : Leucocytosis with predominance of large mononuclear cells, loose nuclear chromatin pattern and nucleoli present with thin rim of pale blue cytoplasm. Platelets : decreased in number on film with normal morpho logy PBF

59. Morphology-ALL Cellularity : Hypercellular Erythropoiesis : Depressed Lymphopoiesis : marked increase with maturation arrest, majority of the cells which comprise >80% of marrow cells are large mononuclear cells with loose nuclear chromatin pattern containing 1-2 nucleoli having scanty or abundant basophilic cytoplasm Myelopoiesis : Depressed Megakaryopoiesis : markedly Depressed BMA

60. Morphology- AML Red blood cells : normocytic normochromic White blood cells : increased in number on film with predominance of large mononuclear cells, majority of which have loose nuclear chromatin pattern with nucleoli and abundant cytoplasm with auer rods. Neutrophils reduced in number on film Lymphocytes are small mature with thin rim of basophilic cytoplasm Platelets : reduced in number on film with normal morphology. PBF

61. Morphology-AML Cellularity : hypercellular M:E ratio > 30:1 Erythropoiesis: present but depressed Myelopoiesis : myeloid hyperplasia with maturation arrest; majority are large cells with open lacey nuclear chromatin pattern with nucleoli, deeply basophilic cytoplasm, some of which are granular with auer rods . Lymphopoiesis : present but reduced on film Megakaryopoiesis : markedly reduced on film Plasma cells <1% Foreign cells : not seen BMA

62. Cytochemistry

63. Immunophenotyping Antigens on the surface of cells are identified using specific antibodies Antigens on cells are named according to an internationally accepted cluster of differentiation [CD] with a unique number. This analysis gives information about the lineage and the stage of development of the cell and thus very useful for treatment modification and prognosis. Methods employed are immunoflourescence or immunoenzyme methods and flow cytometry Sample required: peripheral blood, marrow aspirate/biopsy, fresh or fixed tissue.

64. Immunophenotyping Primary panel : CD13, CD33,CD117,cyt [MPO] Secondary panel : Monocytic: CD11c, CD14, CD64 Erythroid : glycophorin [CD235a] Megakaryoblastic : CD41,CD42,CD61 Pro B ALL : HLA DR,TdT,CD19,CD22,CD79a Common ALL : HLA DR,TdT,CD19,CD22,CD79a,CD10 Pre B ALL: HLA DR,TdT,CD19,CD22,CD79a,CD10,CD20,Cty Igm B ALL : HLA DR,CD19,CD22,CD79a,CD10,CD20,SmIg Pro T ALL : CD7,CD3 Pre T ALL :CD7,cCD3, CD5/CD2 Cortical T ALL : CD7, cCD8, CD5,CD1a Mature T ALL: CD7, CD3, CD1a AML ALL

65. Cytogenetic analysis (Karyotyping) This is morphological analysis of chromosomes in metaphase under the microscope. Provides information concerning chromosome number and structure May provide an accurate diagnosis or recommend other studies such as FISH or molecular analysis. Cytogenetic analysis requires living cells [blood, marrow aspirate]

66. Molecular studies M olecular studies finds application in: Lineage of leukaemic blast the diagnosis of specific types of acute leukaemias through the identification of specific fusion genes formed due to genetic rearrangements Clonality Detection of MRD and early relapse Methods of molecular studies Southern blot analysis PCR-Based techniques Gene sequence analysis DNA micro-array platforms

67. A - Cytospin of CSF showing deposits of Blast Cells B - Indirect Immunofluorescent staining of CSF for Terminal deoxynucleotidyl ( TdT ) transferase A B

68. Thymic enlargement in T-cell ALL A-Before, B-After Chemotherapy

69. ALL: Radiographs of childrens ’ Skulls. A- Mottled appearance B- Multiple punched out lesion due to Leukaemic Deposits

70. DIFFERENTIAL DIAGNOSIS OF ACUTE LEUKEMIAS Infections: infectious mononucleosis, pertusis Aplastic anaemia Immune thrombocytopenic purpura Marrow infiltrations by other malignancies [ neuroblastoma, rhabdomyosarcoma, and Ewing’s sarcoma] Leukaemoid reaction Myelodysplastic Syndrome Blast crisis of Chronic Myeloid Leukemia

71. Definitions

72. TREATMENT OF ACUTE LEUKEMIAS

73. General supportive therapy Psychological support Blood product support Haemostasis support Management of tumor lysis syndrome Nutritional support Nursing care Pain management Prophylaxis and treatment of infection Reproductive issues

74. SPECIFIC TREAMENT IN ALL

75. Specific treatment -ALL Remission Induction Intensification (Consolidation) Therapy CNS Prophylaxis Maintenance Therapy Allogeneic Stem Cell Transplant

76. Treatment of ALL Remission Induction Goals: restore normal hematopoiesis, induce a complete remission rapidly Standard induction regimen 4 or 5 drugs: vincristine, prednisone, anthracycline, L- asparaginase, +/- cyclophosphamide Consolidation therapy Is given to patients in CR with the aim of eliminating residual leukaemia cells and to prevent the re-emergence of drug-resistant disease High doses of multiple agents not used during induction or re-administration of the induction regimen

77. Treatment of ALL CNS Prophylaxis/Treatment Given during induction and intensification Intrathecal: Methotrexate (MTX), Cytarabine, Corticosteroids – +/- Cranial Irradiation Maintenance Therapy -The aim of maintenance is to eliminate minimal residual disease -Daily po 6MP, weekly MTX, monthly pulses of vincristine and prednisone for 2-3 yrs.

78. Testicular leukemia Males with testicular involvement have historically received radiation to both testes. Recent studies suggest that radiation can be spared when testicular involvement resolves completely during the initial induction phase of therapy.

79. Allogeneic stem cell transplantation (SCT) Although relapse rates are lower after allogeneic SCT compared with chemotherapy, treatment-related mortality rates are higher after transplantation. Hence, SCT is rarely used for children in first remission (CR1) except within the context of clinical trials for individuals with extremely poor prognostic features. The indications for SCT in CR1 in adults with ALL continue to evolve toward recommendations based on early response to chemotherapy.

80. Allogeneic SCT When SCT is employed in the treatment of ALL, the conditioning regimen typically utilizes total body irradiation (TBI), which has been shown to decrease the relapse risk . Achieving MRD negativity prior to transplant increases the probability of a favourable outcome.

81. Emerging ALL Therapy/New Treatment Approaches Immunotherapy - using the patient’s own immune system to fight cancer Other Targeted therapies - targeting cancer related genes, proteins, tissue environment that contribute to its growth & survival Epigenetic therapies - regulate expression of genes

82. Management of Relapse in ALL The chance of cure decreases substantially after relapse. Attaining a second remission is critical and often times can be achieved with standard four-or five-drug reinduction regimens. The likelihood of prolonged DFS with standard regimens varies based in large part on immunophenotype, duration of the initial complete remission, and site of relapse. Curative salvage using standard chemotherapy and radiation is more likely in the setting of isolated extramedullary relapse.

83. Relapse in ALL For children with bone marrow or combined relapse and CR1 duration of more than 36 months, approximately 50% achieve prolonged DFS with intensive retreatment. Outcome is not encouraging with shorter CR1 durations, multiple relapses, T-cell ALL, or induction failure. Outcomes are dismal in adults with relapsed ALL with standard approaches; thus, these patients should be offered novel therapies on clinical trials.

84. Evaluation after treatment Follow-up evaluations to include history, physical examination, and routine laboratory studies (FBC, Chemistry panel) should be conducted to monitor for toxicity and recurrent disease until at least 5 years after completion of treatment on the following schedule (or as clinically indicated): Every 1 to 2 months during the first year Every 2 to 3 months during the second year Every 3 to 4 months during the third year Every 6 months during the fourth year Yearly thereafter.

85. Minimal/Measurable Residual Disease (MRD) Quantification MRD quantification is an essential component of caring for paediatric and adult patients with ALL MRD quantification is predictive of disease-free and overall survival at any timepoint Providers can choose between flow-based or NGS-based MRD quantification for assesment to 10⁻⁴ leukaemia burden Additional studies are needed to contextualize MRD for different genotypes and to determine optimal (and cost-effective) testing frequency.

86. SPECIFIC TREATMENT IN AML

87. Specific treatment in AML 1.Chemotherapy and or 2.Stem cell transplantation 3.Supportive therapy Induction Chemotherapy Anthracycline for 3 days and Cytosine Arabinoside (Ara-C) for 7 days (3+7, Younger/fit patients only ). Daunorubicin + AraC used for >30yrs Alternatives Idarubicin Adriamycin Mitoxantrone Thioguanine Etoposide

88. Response to Induction Remission status determined by bone marrow at end of month following induction therapy (e.g. Day 14 & 28) Complete remission: CR is defined Blood neutrophil count -1000/L Platelet count -100,000/L. Circulating blasts - absent. The bone marrow <2% blasts Auer rods -absent. Extramedullary leukemia –absent approx 2log reduction in tumour burden

89. Post-remission therapy : to reduce the risk of relapse , specific drug regimen is recommended based on the patient’s risk factors Better-Risk Patients with inv(16), t(16;16), t(8;21), or t(15;17) High dose Cytarabine 3g/m 2 IV over 3 hrs. every 12 hrs. on days 1, 3, and 5 for 4 cycles or High dose Cytarabine 3g/m 2 IV over 3 hrs every 12 hrs on days 1, 3, and 5 for 2 cycles plus SCT

90. Intermediate risk Patients with normal cytogenetics, trisomy 8, t(9;11), t(8;21), inv(16), t(16;16), c-kit mutation High dose Cytarabine 3g/m 2 IV over 3 hrs. every 12 hrs on days 1, 3, and 5 for 4 cycles or allogeneic SCT

91. High-risk patients with monosomy 5, 5q-, monosomy 7, 7q-, 11q23, inv(3), t(3;3), t(6;9), t(9;22) Allogeneic SCT, or High dose Cytarabine 3g/m 2 IV over 3 hrs every 12 hrs on days 1, 3, and 5 for 4 cycles plus SCT Elderly patients: who are older than 60 yrs are not eligible for intensive chemotherapy, because of its toxicity the use of single agent azacytidine has shown better overall survival and a reduced hospital stay

92. Standard treatment for APL All-trans-Retinoic Acid (ATRA), an analogue of vit. A, has been used to initiate therapy of APL since 1987. It induces remission in up to 80% of previously untreated patients Patients with APL may be stratified into 3 categories on the basis of WBC and platelet count i . Low risk: WBC < 10,000/mm 3 , Platelet >40,000mm 3 ii. Intermediate risk: WBC <10,000/ cmm , Platelet < 40,000/ cmm iii. High-risk: WBC> 10,000/ cmm

93. New formulations of Cytotoxic Drugs i . CPX-351 ( Vyxeos ) new formulation of Cytarabine and Daunorubicin combination packaged at a 5:1 molar ratio within liposomes ii. Vosaroxin a non-anthracycline quinolone derivative induces replication-dependent DNA damage minimally metabolised without production of free radicals that may cause cardiotoxicity

94. Targeted Therapy FLT3 mutation inhibitor FMS-like tyrosine kinase receptor 3 (FLT3) is the most frequently mutated gene in AML found in 20% of all AML patients and in 28 – 34% of those with normal cytogenetics Midostaurin is an oral FLT3 inhibitor Sorafenib ( an oral multi-kinase inhibitor (Raf-1 kinase, VEGFR, KIT, PDGFR, and FLT3) Quizartinib Crenolanib A selective pan-FLT3 inhibitor and can overcome Quizartinib resistance 5 . Gilteritinib

95. iv. IDH inhibitors Ivosidenib is an IDH1 inhibitor Enasidenib is an IDH2 inhibitor An important possible side effect of these drugs is known as differentiation syndrome Anti CD33 MoAb Gemtuzumab ozogamicin BCL-2 inhibitor Venetoclax Vii Hedgehog pathway inhibitor Glasdegib is a drug that targets a protein in this pathway used in newly diagnosed AML who are >=75 years

96. Management of Relapse in AML For relapsed/refractory AML, options include: -Clinical trial -Targeted therapy followed by matched sibling or other donor SCT Chemotherapy followed by matched sibling or other donor SCT -Repeat initial successful induction regimen if 12 months or more since induction regimen -Supportive care

97. COMPLICATIONS OF TREATMENT OF ACUTE LEUKEMIAS Bone marrow aplasia Cardiotoxicity [Anthracyclines] Neurotoxicity [Ara-C] Endocrine dysfunction [infertility, growth retardation Osteonecrosis [ Dexamethasone] Development of secondary malignancies Fulminant infections /Hospital acquired infections

98. DIFFERENTIATION SYNDROME 103 “Retinoid acid syndrome“ Occurs in 10–25% of APL patients within 2 to 21 days after initiation of treatment. More frequently in patients with a high wbc at diagnosis . Characterized by fever, peripheral edema , pulmonary infiltrates, hypoxemia, respiratory distress, hypotension, renal and hepatic dysfunction, and serositis resulting in pleural and pericardial effusions. Assc . hyperleukocytosis Early recognition &aggressive mgt with dexamethasone (10 mg IV every 12 hours for 3-5 days with a 2 week taper ) has been effective in most patients ATRA or ATO can be restarted in most cases once the syndrome has resolved.

99. Risk assessment-ALL

100. PROGNOSIS- ALL

101. PROGNOSIS- AML

102. PROGNOSIS- AML

103. CONCLUSION In the absence of treatment acute leukaemias are very aggressive, however with appropriate therapy and adequate blood product support morbidity and mortality associated with acute leukaemias are reduced. Management of acute leukaemias remains a big challenge in our environment due to delays in obtaining to absence of appropriate blood product support.

104. REFERENCES Hoffbrand’s essential Haematology 7 th edition by A. Victor Hoffbrand and Paul A.H. Moss Essentials of H aematology 2 nd edition Shirish M Kawthalkar Leukaemia diagnosis by Babra J Bain Post Graduate H aematology Victor Hoffbrand W illiam’s H aematology 9 th edition Robbin’s Pathology 9 th edition Clinical Haematology Atlas, 4 th edition, Rodak B.F and Carr J.H.

105. Johansson B, Mertens F, Mitelman F. Clinical and biological importance of cytogenetic abnormalities in childhood and adult acute lymphoblastic leukemia. Ann Med. 2004;36(7):492–503. Mrózek K, Heerema NA, Bloomfield CD. Cytogenetics in acute leukemia. Blood Rev. 2004;18(2):115–136. Swerdlow SH, Campo E, Harris NL, Harris NL, Jaffe ES, Pileri SA, Stein H, Thiele J, Vardiman JW, editors. WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues. Lyon, France: IARC; 200.