April - June, 2018/ Vol 4/ Issue 2 Print ISSN: 2456-9887, Online ISSN: 2456-1487

Original Research Article

A study of leukemias Profile in central India
Ahirwar R.1, Nigam R.K.2, Parmar D.3

1
Dr. Rajnikant Ahirwar, Assistant Professor, Department of Pathology, RKDF Medical College, Bhopal, 2Dr. Rajendra
Kumar Nigam, Professor, Department of Pathology, Gandhi Medical College, Bhopal, 3Dr. Deepankar Parmar, Professor,
Department of Pathology, RKDF Medical College, Bhopal, MP, India.

Corresponding Author: Dr. Rajnikant Ahirwar, A-2 Apartment, Flat No-301, Rchilifescape, Jatkhedi, Bhopal. E-mail:
[email protected]
………………………………………………………………………………………………………………………………...

Abstract
Introduction: Leukemia was considered as a rare disease few years back. However, it is increasing in incidence and
prevalence slowly and steadily. Leukemias are euplastic proliferations of haematopoietic cells and form a major
proportion of haematopoietic neoplasms that are diagnosed worldwide. Objective: To find out the incidence of four
major types of leukemias in central India. Methods: Total 73 cases were selected from in and out patient departments of
Gandhi Medical College and associated Hamidia Hospital Bhopal over a period from Oct 2013 to Nov 2014. Diagnosis
was based on peripheral blood count, peripheral blood smear and bone marrow examination for morphology along with
cytochemistry study whenever required. Results: Out of 73 cases on final diagnosis, 23 cases (31.51%) were of Acute
Lymphoblastic Leukemias, 11 cases (15.07%) were of Acute Myeloblastic Leukemias, 35 cases (47.97%) were of
Chronic Myeloid Leukemias, 1 case (1.37%) is of Chronic Lymphocytic Leukemia and 3 cases (4.11%) were
Undiagnosed which were referred to higher centers. Conclusion: The present study revealed that Chronic leukemia was
more common than acute leukemia with Chronic Myeloid Leukemias being the most common type, followed by Acute
Lymphoblastic Leukemias, Acute Myeloblastic Leukemias and Chronic Lymphocytic Leukemia.

Keywords: Acute Lymphoblastic Leukemias, Incidence, Leukaemia.

………………………………………………………………………………………………………………………………...

Introduction
Leukemia was considered as a rare disease few years As per available information from population-based
back. However, it is increasing in incidence and surveys, the incidence of leukemia in India varies from
prevalence slowly and steadily. Leukemias are the 10th 0.8/1, 00,000 in Barshi (Rural area of Maharashtra) to
most common cancer in men and 12th most common in 5/1,00,000 in Delhi.
women and constitute 3% of the global cancer burden
[1]. These figures are comparably lower than rest of the
world but under diagnosis and under-reporting cannot
Developing countries bear more than half of global be ruled out [4]. The cell type distribution of leukemias
cancer burden, because 75% of the world population observed in India is different from that observed in
lives in these countries [2]. The incidence of Leukemia developed world.
is highest in North America and Australia/New-Zealand
and lowest in sub-Saharan Africa [3]. Myeloid leukemias predominate in India while
lymphoid leukemias dominate in western world mainly
In India,lympho-haematopoietic malignancies constitute because of higher incidence of chronic lymphatic
9.5% of all cancers in men and 5.5% in women [4]. leukemia [5].
Manuscript received: 4th April 2018
Reviewed: 14th April 2018 Despite being relative uncommon, leukemias have been
Author Corrected: 20th April 2018
Accepted for Publication: 25th April 2018 studied more extensively because of easy accessibility
of involved tissue [1].

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April - June, 2018/ Vol 4/ Issue 2 Print ISSN: 2456-9887, Online ISSN: 2456-1487
Original Research Article
The incidence of CML was noted highest (45.3%) and Place of study- Department of Pathology, Gandhi
that was lowest of CLL (5.7%) in Capital of India i.e. Medical College, Bhopal
Delhi during a period of 1970-1979.19 Similar
Type of study- prospective
observations were noted in Chandigarh and other metro
cities like Mumbai and Calcutta [6,7,8]. Sampling methods- Selected from in and out patient
departments of Gandhi Medical College and associated
There was exception for incidence of ALL (39.2%) Hamidia
which was highest observed in Kerala state during a Sample collection- Blood, bone marrow smear
period of 1980-1983 [9]. The leukemias are defined as
diseases in which abnormal proliferation of Inclusion criteria- having provisional diagnosis of
haematopoetic cells cause progressively increasing acute leukemia and leucoproliferative disorder.
infiltration of bone marrow, although in certain forms
the lymphatic tissues are particularly affected [10]. The study was conducted after approval from
institutional ethical committee in the Department of
Malignant proliferation of haematopoietic cells Pathology, Gandhi Medical College, Bhopal from Oct
(leukemia) constitutes major proportion of 2013 to Nov 2014.
haematopoietic neoplasm’s worldwide. Leukemias are
classified into myeloid and lymphoid subtype [11]. Total 73 cases were selected from in and out patient
departments of Gandhi Medical College and associated
Typing of leukemia is essential for effective therapy Hamidia Hospital Bhopal having provisional diagnosis
because prognosis and survival rate are different for of acute leukemia and leucoproliferative disorder so on
each type and sub-type [12]. Leukemia are of two types; basis of leishman stained smears-Peripheral/bone
acute and chronic. marrow along with cytochemistry study whenever
required.
Acute leukemias are; acute lymphoblastic leukemia
(ALL) and acute myeloid leukemia (AML). In Thorough case history and clinical examination as per
childhood, ALL is most common type than AML. In predefined Performa with Hemoglobin estimation,
India, the incidence of ALL and AML are 35% and WBC count, Platelet count and various hematological
15% of all hematological malignancies respectively. indices were evaluated using automated analyzer.

Chronic leukemias are classified into chronic myeloid Peripheral blood/bone marrow smear was made on
leukemia (CML) and chronic lymphocytic leukemia clean glass slides with fresh blood samples; smears
(CLL) [13,14]. Due to the lack of any nationwide were fixed and stained by leishman stain.
leukemia screening program, most of the population of
India is still unaware of this blood disorder. Leishman stain was poured on air dried unfixed smears
for a period of 5-7 minutes, then added twice quantity
Lack of awareness also plays a role in underlying late of buffered distilled water for next 10 minutes. Smears
presentation and noncompliance with screening prepared on clean glass slides, fixed by methanol and
guidelines [15]. stained for various cytochemical stains (MPO, PAS,
NES, and NAP).
Hence it is important to determine the current incidence
of leukemia’s in India as well as to understand how the For all the special stains, commercially available kits
occurrence and outcome of the disease differs across the (Leucognost) were used. FAB classification of acute
whole country. leukemia was applied for sub-typing.

Materials and Methods

Results
The present study comprises 73 cases of Leukemia. The observations made in this study are as follows.

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Original Research Article
Table No-1: Type of Leukemia’s, including Age, sex distribution.

Age (yrs) No of Patient

ALL (23) AML (11) CML (35) CLL (1) Undiagnosed (3)
& Sex

0-15 13 56.52% 2 18.18% 3 8.57% 0 0 0 0

16-30 5 21.74% 4 36.36% 9 25.71% 0 0 2 67.00%

31-45 3 13.04% 4 36.36% 13 37.14% 0 0 1 33.00%

>45 2 8.70% 1 9.09% 10 28.57% 1 100% 0 0

Male 15 65.22% 4 36.36% 10 28.57% 0 0 2 67.00%

Female 8 34.78% 7 63.64% 25 71.43% 1 100% 1 33.00%

Out of 73 cases on final diagnosis, 23 cases (31.51%) were of Acute Lymphoblastic Leukemias, 11 cases (15.07%) were
of Acute Myeloblastic Leukemias, 35 cases (47.97%) were of Chronic Myeloid Leukemias, 1 case (1.37%) is of Chronic
Lymphocytic Leukemia and 3 cases (4.11%) were Undiagnosed.

In Our study Out of 73 cases - 31cases (42.47%) were Male and 42cases (57%) were Female. which shows female
predominance it may be due to sample size. Out of 73 cases – 18 cases (24.66%) were of age group 0 to 15 years, 21
cases (28.77%) were of age group 16 to 30 years, 19 cases (26.03%) were of age group 31 to 45 years and 15 cases
(20.55%) were of above 45 years.

Hemoglobin Distribution: In Acute Lymphoblastic Leukemia and Acute Myeloblastic Leukemia most of the cases
(56.52% and (72.73%) had less than 6 gm% Hb. In Chronic Myeloid Leukemia only 5.71% cases had severe anemia,
while 34.29% and 51.43% had moderate and mild anemia. In Chronic Lymphocytic Leukemia patient had mild anemia.

Total Leukocyte Count Distribution: In Acute Lymphoblastic Leukemia and Acute Myeloblastic Leukemia 39.13%
and 63.64% of cases showed countless then 4000/cu mm. While in Chronic Myeloid Leukemia most of cases (91.43%)
showed leukocytosis and 100.00% cases of Chronic lypmphocytic leukemia showed leukocytosis.

Platelet Count Distribution: Most of the cases (82.61% and 100%) of acute lymphoblastic leukemia (ALL) acute
myeloid leukemia (AML) had moderate to severe thrombocytopenia. Whereas in chronic myeloid leukemia (CML) and
chronic lypmphocytic leukemia (CLL) most of cases had platelet above 1lakh/cu mm.

Sub-classification Acute Myeloblastic Leukemia: On by morphological and cytochemical method. sub classification of
Acute Myeloblastic Leukemia is done. Most common subtype of Acute Myeloblastic Leukemia was M3 subtype which
comprised of 36.36% cases.

Whereas M1, M2, M5, M6, M7 comprised of 18.18%, 9.09%, 9.09%, 9.09%, 18.18% respectively. In present study there
were no cases belonging to M0 and M4 subtype.

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Original Research Article
Table-2: Frequency (in percentage) of various Leukemias in India.

Reference Region (Period of Study) No of cases ALL AML CML CLL

Chatterjee et al Calcutta (1949–1961) 544 22.5 32.5 35.9 5.9

Advani et al Mumbai (1960–1975) 1126 30 13 40 9

Prakash et al Pondicherry (1970–1979) 278 35 29.5 30.8 3.2

Rani et al Delhi (1970–1979) 490 15.5 30.8 45.3 5.7

Verghese et al Kerala (1980–1983) 1016 39.2 19.6 16.4 1.9

Kushawaha et al Lucknow (1971–1984) 970 9.3 38.7 48 2.6

Shome et al Chandigarh (1975–1983) 820 24 29.3 36.7 8.8

Dicosta et al Mumbai (1975–1984) 242 36 22 38 2

Rathee et al Haryana (2008-2012) 650 17.2 33.8 39 10

Jaya Bhaskar Loni, Maharashtra 156 26.28 23.07 33.97 15.38

(2006 and 2011)

Our study Bhopal (2013-2014) 73 31.51 15.07 47.97 1.37

Discussion
The incidence of leukemia has increased considerably In Chronic Lymphocytic Leukemia patient had mild
and this rise is noticeable because of improved anemia In Acute Lymphoblastic Leukemia and Acute
statistics, better case findings with novel technologies Myelo-blastic Leukemia 39.13% and 63.64% of cases
which lead to better diagnosis and treatment methods. showed count less then 4000 /cu mm. While in Chronic
Myeloid Leukemia most of cases (91.43%) showed
This incidence varies in different geographical regions leukocytosis and 100.00% cases of chronic
according to varying life styles, economic conditions, lypmphocytic leukemia showed leukocytosis.
and poverty rate [16].
Most of the cases (82.61% and 100%) of acute
In India the incidence of various hematological cancers lymphoblastic leukemia (ALL) acute myeloid leukemia
is different as compared to western countries. This can (AML) had moderate to severe thrombocytopenia.
be attributable to less health awareness and poor Whereas in chronic myeloid leukemia (CML) and
availability of health care delivery system in India [17, chronic lypmphocytic leukemia (CLL) most of cases
18]. In present study 73 cases of leukemias were studied had platelet above 1lakh/cu mm.
34 cases (46.58%) and 36 cases (49.32%) were of acute
and chronic leukemias respectively and 3 cases (4.11%) In present study four special staining procedures were
were undiagnosed. done after making a provisional diagnosis of leukemias
by leishman stain (Stain used Myeloperoxidase,
Out of 73 cases – 18 cases (24.66%) were of age group Periodic acid Schiff, Non-specific Esterase and alkaline
0 to 15 years, 21 cases (28.77%) were of age group 16 phosphates). On special staining we found Myeloblasts
to 30 years, 19 cases (26.03%) were of age group 31 to of AML and CML showed positive (coarse brown black
45 years and 15 cases (20.55%) were of above 45 years. granules) staining with MPO in more than 3% of blasts
In Acute Lymphoblastic Leukemia and Acute in all cases except one in which NSE stain was positive.
Myeloblastic Leukemia most of the cases (56.52% and
(72.73%) had less than 6 gm% Hb. In Chronic Myeloid Whereas ALL and CLL were negative for MPO stain.
Leukemia only 5.71% cases had severe anemia, while The lymphoblasts of ALL and CLL showed positive
34.29% and 51.43% had moderate and mild anemia. (block positive) PAS staining.

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Original Research Article
Whereas myeloblasts of AML and CML were negative. any developed country. It should be stressed that there
The NAP scoring was done in all (35) cases of CML are not many cancer registry data’s in India despite a
and the range of NAP score was 0 to 10. Undiagnosed 3 large population, so better development of regional and
cases were negative for all (MPO, PAS, NSE) stain. national registries is the need of the hour.
They were advised for flow cytometry,
immunophenotyping for which they referred to higher Conclusion
center.
Present study concluded that the incidence of different
types of leukaemia in central India doesn’t differ
Among all leukemias the incidence and prevalence of
markedly from rest of the Indian populations. Chronic
chronic myeloid leukemia (CML) remains higher due to
leukemia was more common than acute leukemia with
chronicity, earlier diagnosis because of accurate and
chronic myeloid leukemia being the most common type,
cheaper diagnostic tool and greater physician
followed by Acute Lymphoblastic Leukemias, Acute
awareness.
Myeloblastic Leukemias and Chronic Lymphocytic
Leukemia.
The studies done by various authors also observed
[6,8,19-23] higher incidence of chronic myeloid
Chronic myeloid leukemia which came out to be more
leukemia (CML) than ours while the findings of
common in our study, is mainly a leukemia of adults
Menzes and Malik [24] and Verghese et al [9]vary from
affecting the myeloid series while AML occurring in
the above studies (Table 2).
younger age group is characterized by presence of
>20% blasts in marrow, as per the WHO criteria.
Our study revealed chronic myeloid leukemia (CML)
(47.95%) as the most common type of leukemia (Table
This incidence varies in different geographical regions
1). The varying findings of Menzes and Malik [24] and
according to varying life styles, economic conditions,
Verghese et al [9] can be attributable to geographical
and poverty rate. It should be stressed that there are not
variation and population bias.
many cancer registry data’s in India despite a large
population, so better development of regional and
The incidence of acute lymphoblastic leukemia was
national registries is the need of the time.
higher in studies by Prakash et al [25] and Verghese et
al [9]. In our study the cases of acute lymphoblastic
Addition to existing knowledge: Though numerous
leukemia were the second predominant (31.51%) which
studies of leukemia have been done in various regions
correlates with study of Advani et al [26], Dicosta et al
of India but this study is exclusively the first one which
[7], Modak H et al [27], Chen et al [28] and Shome et al
details the leukemia profile in central part of India.
[6] (Table 1).
Funding: Nil, Conflict of interest: None initiated
The incidence of Acute myeloid leukemia (AML) in our Permission from IRB: Yes
study was the third most common. Similar findings are
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How to cite this article?

Ahirwar R, Nigam R.K, Parmar D. A study of leukemias Profile in central India.Trop J Path Micro 2018;4(2):181-187.
doi: 10.17511/jopm.2018.i2.12
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