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LEUKEMIALeukemia, historic perspective, etiology, risk factors, incidence, classification and comparison of acute and chronic.pptx

Leukemia is a group of malignant disorders characterized by uncontrolled proliferation of leukocytes and their precursors in the bone marrow and blood, affecting all age groups and often resulting in anemia and infection due to bone marrow failure. It is classified into acute and chronic forms, with acute leukemia showing rapid progression and chronic leukemia demonstrating more gradual onset and symptoms. Diagnosis involves morphological examination of cells, cytochemistry, immunophenotyping, and cytogenetic analysis, while treatment varies based on the type and severity of the disease.

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LEUKEMIA BENJAMIN
Definition • Historic Perspective • Etiology and Risk Factors • Incidence • Classification • Comparison of Acute and Chronic
Definition • Leukemia is a disease of unknown etiology and fatal termination characterized by uncontrolled, abnormal and widespread proliferation of leukocytes and their precursors in bone marrow and blood.
Leukemia : • A group of malignant disorders affecting the blood and blood-forming tissues of • Bone marrow • Lymph system • Spleen • ● Neoplastic proliferation of abnormal WBCs. As these abnormal WBCs accumulate, they interfere with the • production of normal WBCs, as well as the production of erythrocytes and platelets, resulting in anemia and thrombocytopenia. • ● Occurs in all age groups • ● Results in an accumulation of dysfunctional cells because of a loss of regulation in cell division. In normal physiology we have controlled cell division “mitosis” and programmed cell death “apoptosis”, • if these are affected it will lead to excessive cell growth and division which will lead to cancer. Cancer in hematology is in the stem cells synthesis in the bone marrow = leukemia. • ● Fatal if untreated • ○ Progressive
Etiology: • No single causative agent • Most from a combination of factors • ○ Genetic and environmental influences Leukemia is not an inherited disease but a +ve family Hx indicates there is a genetic factor. • ● Associated with the development of leukemia • Chemical agents • Chemotherapeutic agents Hx of chemotherapy or radiation • Radiation • Viruses • Immunologic deficiencies • Down’s syndrome
Classification • This is based on the clinical course of the disease and the type of cell line that is involved. • In the early 1990s the French – American – British group introduced the FAB classification of acute leukemia based mainly on the morphological appearance of blasts in Romanowsky stained smears of peripheral blood and bone marrow.
• More recently (2002) the WHO classification of leukemia included in addition to morphology, immunophenotyping of the blasts and cytogenetic studies. • ACUTE LEUKEMIA is of sudden onset and rapid progression unless treated and is characterized by the presence of blast cells in peripheral blood and bone marrow. • CHRONIC LEUKEMIA is of gradual onset and slow progression and is characterized by the presence of more mature cells in the peripheral blood and bone marrow.
• ○ Acute leukemias • Acute versus chronic: • Cell • maturity • Nature of • disease • onset • ■ Acute lymphoblastic leukemia (ALL) • ■ Acute myelogenous leukemia (AML) (also "myeloid" or • "nonlymphocytic") • ○ Chronic leukemias • ■ Chronic lymphocytic leukemia (CLL) • ■ Chronic myeloid leukemia (CML) • (Within these main categories, there are typically several subcategories)
Clinical Manifestations of leukemia: • Relate to problems caused by: • Bone marrow failure • ● Overcrowding by abnormal cells • ● Inadequate production of normal marrow elements • ● Anemia, thrombocytopenia, ↓ number and function of WBCs Leading to ↑ incidence of infection. • Leukemic cells infiltrate patient’s organs: • ● Splenomegaly • ● Hepatomegaly • ● Lymphadenopathy • ● Bone pain, meningeal irritation, oral lesions (chloromas) Mostly with acute • In generale leukemia share the same symptoms the difference is the the severity and onset. Acute leukemia symptoms develop within days, whereas Chronic take many years and are usually asymptomatic at the time of the diagnosis, and the findings might be incidental. Patient with chronic leukemia might have constitutional symptoms “especially in CML” weight loss, fatigue.. Etc, and some signs of anemia, ↑infection ...etc but not severe enough to require ER visit.
Diagnostic Tools in the Diagnosis of Leukemia • A. Morphology of the blasts in peripheral blood and bone marrow. • B. Cytochemistry of blasts in the various leukemias • Leukocyte cytochemistry uses techniques to identify enzymes or other cytoplasmic products in cells. Cytochemistry is useful for • Identification of myeloid blasts from lymphoid blasts • Differentiation of granulocytic and monocytic components of acute myeloid leukemia • Detection of unusual lineages eg basophils. • Detection of the absence of certain enzymes in a malignant clone eg Leukocyte alkaline phosphatase in Chronic Myeloid Leukemia.
• The common Cytochemical stains used are • (a) Myeloperoxidase (MPO). This enzyme is present in primary and secondary granules of granulocytes. MPO splits H2O2 and in the presence of a chromogenic electron donor forms an insoluble reaction product. Substrates are benzidine substitutes. The reaction product is stable. MPO is not inhibited by heparin, oxalate or EDTA. The substrate is 3,3 diaminobenzidine with a phosphate buffer at pH 7.3. A brown granular deposit is seen in blasts of myeloid origin. • (b) Sudan Black B (SBB). This lipophilic dye binds with granule components in granulocytes and monocytes irreversibly. Staining reaction is comparable to MPO.
• (c) Periodic Acid Schiff reaction (PAS). Periodic acid oxidizes 1-2 glycol groups to produce dialdehydes. Dialdehydes give a red reaction when exposed to the Schiff reagent which is leucobasic fuchsin. A positive reaction is seen with carbohydrates especially glycogen polysaccharides, mucoproteins, glycoproteins etc. Blood smears are fixed with formali vapour, exposed to Periodic acid and then Schiff reagent and counter stained with Haematoxylin. WBC show diffuse, confluent red colour. ALL blasts show “block” positivit and the method can be used to differentiate ALL from AML
• (d) Acid phosphatase. This enzyme is present in haemopoietic cells. It is useful for the diagnosis of T cell ALL and Hairy cell leukemia. Air dried smears fixed in methanol, acetone, citric acid buffer are exposed to naptholAS-BI phosphate substrate at an acid pH of 5.0. • The reaction is detected with the use of hexazotised pararosanaline dye. • Nuclei are counter stained with haematoxylin. T cells show strong localized polar positivity. Other WBC also show variable positivity. • In hairy cell leukemia the cells react equally positive in the presence and absence of tartaric acid.
• (e) Esterase stains. WBC granules contain several types of esterases that hydrolyse acyl or chloroacyl esters of α naphthol or naphthol AS. • Specific esterase stain with naphthol AD chloroacetate ester (CAE) and is positive in the myeloid series and strong positive in promyelocytes including Auer rods. • Non specific esterase (NSE) stains with α naphthyl acetate ester (ANAE) or α naphthyl butyrate ester or (ANBE) and is positive in 80% of the monocyte cell line. • A stain combining the two substrates sequentially or in combination in one single step may be used to differentiate myeloblasts from monoblasts.
• (f) Neutrophils contain alkaline phosphatase enzyme in their granules. • The reaction between leukocyte alkaline phosphatase in cells, naphthol AS phosphate substrate, alkaline buffer at pH 9.0 is detected using a coupling azo dye (Fast Blue BB salt or Fast Garnet GBC) A counter stain is used for nuclei. The azo dye product is blue or brown granules in neutrophil cytoplasm. • The neutrophils are scored as 0 = negative, • 1+ = occasional granules in cytoplasm,2+ = moderate granulation, • 3+ = heavy granulation and 4+ = heavy granulation overlapping the nucleus. • A positive control that is used is usually from a pregnant female. The abnormal neutrophils in CML have markedly decreased levels of this enzyme. • In CML neutrophils stain negative for the enzyme
• (g) Toludine Blue stain is used to stain the metachromatic granules in • basophils and mast cells.
• C. Immunophenotyping is done to determine whether the cells are of myeloid or lymphoid origin and if lymphoid, whether they are of T or B cell origin. • The cells at various stages of development express antigens on the surface. • Monoclonal antibodies are available commercially to detect these antigens. • The antibodies are tagged with a fluorescent label. The test cells are incubated with a series of specific antibodies and by observing the degree of binding and the specificity of the antibody using a flow cytometer it is possible to identify and quantify the cells for diagnosis and for follow up of therapy. • Flow cytometry is also used to detect the presence of cytoplasmic or surface immunoglobulins and the presence of certain cytoplasmic enzymes eg myeloperoxidase.
• D. Cytogenetics. Many of the blasts show specific cytogenetic markers which help identify them as well as predict their behavior to chemotherapeutic drugs. Standard cytogenetics, RT-PCT, FISH are some techniques that are used. • E. Cytospin of Cerobrospinal Fluid is used to detect the presence of small numbers of lymphoblasts in CSF in ALL. The cytospin is a special centrifuge which is gentle on the cells and produces minimum distortion of the blast cells.
Acute Lymphocytic Leukemia (ALL) • ● Most common type of leukemia in children M > F • ● 15% of acute leukemia in adults • ● Immature lymphocytes proliferate in the bone marrow • ● Signs and symptoms may appear abruptly ○ Fever, bleeding • ● Insidious with progressive: • ○ Weakness, fatigue signs of anemia • ● Central nervous system manifestations. Must give CNS prophylaxis! “Prophylactic intrathecal drugs such as methotrexate” • ● Curable in 70% of children, and only in minority of adults
Clinical presentation • Of acute anemia both ALL & AML • Will present with sign or symptoms related to: • ● Pancytopenia: • ○ ↓ WBC → Infection. E.g Pneumonia, UTI • ○ ↓ Hb → Anemia. Dyspnea, Pallor, fatigue • ○ ↓ Platelets (thrombocytopenia)→ Bleeding. Epistaxis, easily bruised, petechiae • ● Organ infiltration: • ○ Lymphadenopathy, Splenomegaly, Hepatomegaly. • ● CNS: almost always in acute lymphocytic anemia • ○ 5-10% of patient with ALL • ○ Squint, Blurred vision, Headache.
ACUTE LYMPHOBLASTIC LEUKEMIA (ALL) • Clinical Presentation • ALL affects children in the 2 – 10 years age group commonly but is also seen in adults. The patient presents with fever, weakness, pallor, infections bleeding and enlarged lymph nodes and spleen. Childhood ALL is associated with a good prognosis.
Laboratory Diagnosis • 1. Haemoglobin, PCV, RBC count are decreased. • 2. MCV, MCH and MCHC are normal RDW is normal. There is normochromic normocytic anaemia. • 3. WBC count is elevated (20.0 – 100.0x109/L). Rarely the count may be low in subleukemic leukemia. • 4. Platelet count shows moderate to severe thrombocytopenia • 5. The blood film shows normochromic normocytic anaemia, leukocytosis with many blast cells and thrombocytopenia. • 6. The differential cells show many blast cells There is neutropenia
CLASSIFICATION • The FAB classification describes 3 types of ALL depending on the morphology of the blasts. They are;- • A. ALL L1 • The blast is small, 14 – 16µm in diameter, the cytoplasm is barely visible, the nucleus occupies the whole cell, has condensed chromatin and nucleoli are not seen.
• B. ALL L2 • The blast is 15 - 18µm in diameter, nucleus occupies most of the cell. The nuclear membrane is thick, chromatin is coarse, 1 – 2 nucleoli are seen. • The chromatin around the nucleolus is condensed. The cytoplasm is pale blue, forms a rim around the nucleus and does not contain any inclusions. • C. ALL L3 • The blast is 18 – 20 µm in diameter, nucleus has reticular chromatin, 1-2 prominent nucleoli, cytoplasm is moderate in amount blue in colour and there are punched out vacuoles in the cytoplasm and overlying the nucleus.
• 7. Cytochemistry. Special stains are done to differentiate ALL from AML. • These are • A. Myeloperoxidaes stain and Sudan Black B stains are negative in ALL. • B. Periodic Acid Schiff stain may show block positive staining in the cytoplasm of ALL blasts with no differentiation between T and B cells. • 8. Immunophenotyping differentiates the blasts into T and B cells. B cells are CD19+, CD10+ and may show cytoplasmic CD22. T cells are CD2+, CD5+, CD7+ • 9. Bone marrow examination shows solidly cellular marrow with suppression of normal erythropoiesis, myelopoiesis and megakaryocytes. The marrow is replaced by proliferating blasts. In the FAB classification there must be >30% blasts in the marrow and in the WHO classification there must be >20% blasts in marrow. • 10. Biochemical tests show raised serum uric acid levels, raised serum LDH and serum creatinine may be elevated
Myelogenous Leukemia: • Leukemia characterized by proliferation of myeloid tissue (as of the bone marrow and spleen) and an abnormal increase in the number of granulocytes, myelocytes, and myeloblasts in the circulating blood. • ● Myeloid tissue: • Is a biologic tissue with the ability to perform hematopoiesis. It is mainly found as the red bone marrow in bones and is often synonymous with this. However, • myeloid can also be present in the liver and spleen . • ● Myelocyte: • Is a young cell of the granulocytic series, occurring normally in bone marrow, but not in circulating blood (except when caused by certain diseases). • ● Granulocytes: • Are a category of white blood cells characterized by the presence of granules in their cytoplasm.They are also called polymorphonuclear leukocytes (PMN or PML) because of the varying shapes of the nucleus, which is usually lobed into three segments. • ● Myeloblast: • Is a unipotent stem cell, which will differentiate into one of the actors of the granular series.
Acute Myelogenous Leukemia (AML) • ● Leukemia characterized by proliferation of myeloid tissue (as of the bone marrow and spleen) and an abnormal increase in the number of granulocytes, myelocytes, and myeloblasts in the circulating blood • ● One fourth of all leukemias • ○ 85% of the acute leukemias in adults M > F Exposure to Benzene, Radiation play a major role. • ● Abrupt, dramatic onset • ○ Serious infections, abnormal bleeding • ● Uncontrolled proliferation of myeloblasts • ○ Hyperplasia of bone marrow and spleen • Curable in minority of adults • Important AML variant is Acute promyelocytic leukemia (M3): • ○ characterized by t(15;17) PML-RARα “ProMyelocytic Leukemia-Retinoic Acid Receptor α” • ○ Associated with DIC • ○ Presence of Auer rods • ○ treated with All-Trans retinoic acid “Vit A” with concurrent chemotherapy
ACUTE MYELOID LEUKEMIA (AML) • Clinical Presentation • AML affects young adults who present with fever, weakness, pallor, infections, bleeding, bone pains and splenomegaly.
Laboratory Diagnosis • 1. Haemoglobin, PCV, RBC count are decreased. • 2. MCV, MCH and MCHC are normal RDW is normal. There is normochromic normocytic anaemia. • 3. WBC count is elevated (20.0 – 100.0x10/L). Rarely the count may be low in subleukemic leukemia. • 4. Platelet count shows moderate to severe thrombocytopenia • 5. The blood film shows normochromic normocytic anaemia, leukocytosis with many blast cells and thrombocytopenia. • 6. The differential cell count shows many blast cells There is neutropenia.
CLASSIFICATION • The FAB classification describes 8 types of AML depending on the morphology of the blasts. They are
A. AML M0 • The blast is 15 - 18µm in diameter, nucleus occupies most of the cell, nuclear membrane is fine, chromatin is fine, 2 – 3 nucleoli are seen. • The cytoplasm is pale blue, forms a rim around the nucleus and does not contain any inclusions. These cells are CD 13+,CD 33+ and CD 117+ by flow cytometry <3% of cells show MPO/SBB positivity
B. AML M1 • The blast is 15 - 18µm in diameter, nucleus occupies most of the cell, nuclear membrane is fine, chromatin is fine, 2 – 3 nucleoli are seen. • The cytoplasm is pale blue, forms a rim around the nucleus and may contain thin rod like pink structures called Auer rods. This is formed by the condensation of primary granules and when present are diagnostic of AML.
C. AML M2 • The blast is 15 - 18µm in diameter, nucleus occupies most of the cell, nuclear membrane is fine, chromatin is fine, 2 – 3 nucleoli are seen. The cytoplasm is pale blue, forms a rim around the nucleus and contains fine early granulation and thin rod like pink structures called Auer rods. • Myeloperoxidase and Sudan Black B stains show positivity in 30 – 100% of cells.
D. AML M3 (Promyelocytic leukemia) • The blast is 18 – 20 µm in diameter, nucleus has reticular chromatin, 1-2 prominent nucleoli. The nucleus appears folded on itself or may be bilobed. The cytoplasm is moderate in amount and filled with fine pink azurophilic granules. Many Auer rods are seen and these cells are called faggot cells. • Sometimes the granulation is not prominent and the leukemia is called AML M3 Hypogranular variant . • The myeloperoxidase stain and SBB stains are strong positive. 90% of the cells show specific esterase positivity. AML M3 is associated with a cytogenetic abnormality namely T(15:17)
E. AML M4 (Myelomonocytic leukemia) • In this variant two types of blasts are present – myeloblasts as described above and up to 20% monocytes and monoblasts. • The monoblaste are 20– 22 µm in diameter, nucleus has reticular chromatin, 2-3 prominent nucleoli and the nucleus may be indented. • The cytoplasm is abundant, vacuolated and may contain few azurophilic granules and sometimes Auer rods. • MPO, SBB and non specific esterase are positive A variant of this leukemia with prominent eosinophilia and a cytogenetic abnormality inversion 16 is known.
F. AML M5 (Monocytic leukemia) • In this variant the predominant cell line is monocytoid and is a mixture of monocytes and monoblasts which make up >80% of the cells. • MPO, SBB and combined esterase are positive. In addition to cytochemistry there is also increase in serum and urinary lysozyme excretion
G. AML M6 (Erythroleukemia) • In this variant there are two cell lines involved erythroid which must be greater than 50% in marrow and myeloblasts which makes up greater than 20% of the non erythroid cells in marrow. • Auer rods and dysplasia may be seen. • PAS positivity is seen in erythroblasts.
H AML M7 (Megakaryoblastic leukemia) • In this variant the cell line involved is megakaryoblastic. The blasts superficially resemble lymphoblasts. • Flow cytometry is needed to identify these blasts which show positivity for CD 41 and CD 61 which are platelet markers.
• 7. Cytochemistry. Special stains are done to differentiate ALL from AML. These are • A. Myeloperoxidaes stain and Sudan Black B stains are negative in ALL. • B. Periodic Acid Schiff stain may show block positive staining in the cytoplasm of ALL blasts with no differentiation between T and B cells. • C. Esterase stains are done to differentiate the monocyte cell line • 8. Immunophenotyping is done to identify the myeloid, monocytoid, erythroid and megakaryocyte cell lines. • 9. Bone marrow examination shows solidly cellular marrow with suppression of normal erythropoiesis, myelopoiesis and megakaryocytes. The marrow is replaced by proliferating blasts. • 10. Biochemical tests show raised serum uric acid levels, raised serum LDH and serum creatinine may be elevated • 11. Cytogenetic studies are performed to demonstrate typical abnormalities in certain leukemias and to monitor response to treatment.
CHRONIC MYELOID LEUKEMIA (CML) • Clinical Presentation • This condition affects all age groups mostly young adults. There is anaemia, fever, weight loss, sweating, bone pain and enlarged spleen. • The leukemia runs a chronic course of 2 – 5 years unless treated and transforms into acute leukemia, myeloblastic or lymphoblastic as a terminal event.
Chronic Myelogenous Leukemia (CML) • ● Excessive development of mature neoplastic granulocytes in the bone marrow: • → Move into the peripheral blood in massive numbers • → Ultimately infiltrate the liver and spleen • ● Philadelphia chromosome • ○ Genetic marker. The chromosome abnormality that causes chronic myeloid leukemia (CML) (9 & 22) “BCR-ABL” • ○ It has tyrosine kinase activity and enhanced phosphorylation that result in altered cell growth • ○ That's why we treat it with oral tyrosine kinase inhibitors “Imatinib first line treatment in chronic phase” • ● Chronic, stable phase for many years followed by acute, aggressive (blastic Immature) phase (Blast crisis) end stage of the disease. • ● Massive splenomegaly is characteristic.
Laboratory Diagnosis • 1. Haemoglobin, PCV, RBC count are decreased. • 2. MCV, MCH and MCHC are normal RDW is normal. There is normochromic normocytic anaemia. • 3. WBC count is elevated (100.0 – 800.0x10 9/L). • 4. Platelet count is normal or increased. • 5. The blood film looks like a bone marrow preparation because of the marked leukocytosis. The red cells show normochromic normocytic anaemia. • The entire series of myeloid cells are seen. Myeloblast make up 2 -5% of the cells , myelocytes ~ 20%, neutrophils ~20%. There is an increase in basophils which make up 5 – 10% of the cells. Eosinophils may also be increased. • Lymphocytes are normal. Platelets may be normal or increased. • A falling haemoglobin, increasing blast percentage and increase in basophils indicate blast transformation.
• 6. The bone marrow is solidly cellular with no fat spaces, There is marked myeloid hyperplasia with all stages of maturation, basophilia and increased megakaryocytes. The erythroid series is normal • 7. Cytochemistry Leukocyte Alkaline phosphatase (LAP) Neutrophils contain alkaline phosphatase enzyme in their granules. The abnormal neutrophils in CML have markedly decreased levels of this enzyme. Blood smears made from finger prick are stained using a phosphate substrate, alkaline buffer at pH 9.0, a coupling azo dye and a counter stain. • In the presence of the enzyme the reaction product is seen as blue or brown (depending on azo dye used) granular deposit in neutrophil cytoplasm. In CML neutrophils stain negative for the enzyme.
• 8. Cytogenetics. A typical translocation between 19 :22 called the Philadelphia chromosome is demonstrated in CML. • 9. Biochemistry. Increased serum LDH, serum uric acid and serum vitamin B 12 are seen
CHRONIC LYMPHOCYTIC LEUKEMIA • Clinical Presentation • This condition affects older age groups and is common in Caucasians. • There is anaemia, fever, weight loss, sweating, enlarged lymph nodes and spleen. The leukemia runs a chronic course of 2 – 5 years unless treated and may be associated with frequent infections because of depressed immunity.
• disease of the old age >65 • ● Production and accumulation of functionally inactive but long-lived, • mature-appearing lymphocytes • ● B cell involvement • ● Lymph node enlargement is noticeable throughout the body • ○ ↑ incidence of infection • ● Complications from early-stage CLL is rare • ○ May develop as the disease advances • ○ Pain, paralysis from enlarged lymph nodes causing pressure.
Laboratory Diagnosis • 1. Haemoglobin, PCV, RBC count are mildly decreased or normal • 2. MCV, MCH and MCHC are normal RDW is normal. • 3. WBC count is elevated (50.0 – 250.0x109/L). • 4. Platelet count is normal. Rarely there may be immune thrombocytopenia. • 5. The blood film shows leukocytosis. The red cells are normochromic normocytic. 70 – 90 % of the WBC are mature lymphocytes. Many cells are smear cells. There is a persistent absolute lymphocytosis. Platelets are normal. • 6. The bone marrow is solidly cellular with no fat spaces. 90% of the cells • in the marrow are mature lymphocytes and a relative decrease in erythroid • and myeloid series. Megakaryocytes are normal.
• 7. Flow cytometry shows the presence of B cell markers with one aberrant T cell marker, namely CD5 • 8. Biochemistry Increased serum LDH, serum uric acid may be seen
CHRONIC MYELOPROLIFERATIVE DISORDERS • This is a group of disorders where there is proliferation of the various • components of the marrow leading to a chronic disease. These include:- • (a) Chronic myeloid leukemia – as described above • (b) Polycythemia rubra vera – erythrocytosis, leukocytosis and thrombocytosis • (c) Myelofibrosis - abnormal megakaryocyte proliferation leads to deposition of fibrous tissue in marrow. The normal haematopoiesis takes place in other organs like liver and spleen (extramedullary haematopoiesis) resulting in a leukoerythroblastic blood picture. • (d) Essential thrombocythemia – proliferation of abnormal megakaryocytes giving rise to thrombocytosis with abnormal platelets which also have platelet dysfunction • (e) Chronic myelomonocytic anaemia
Hairy Cell Leukemia : • ● Subtype of CLL • ● 2% of all adult leukemias • ● Usually in males > 40 years old • ● Chronic disease of lymphoproliferation • ● B lymphocytes cells that have a “hairy” appearance and infiltrate the bone • marrow and liver Can be Dx by blood morphology • ● Symptoms from • ○ Splenomegaly, Pancytopenia, Infection, Vasculitis production of autoantibodies that attack normal blood vessels → Autoimmune thrombocytopenia, Autoimmune hemolytic anemia • ● Treatment • ○ Alpha-interferon, Pentostatin, Cladribine
MYELODYSPLASTIC SYNDROMES OR PRELEUKEMIA • In this group of disorders the maturation of cells is abnormal and dysplastic and may involve one or more cell line in the marrow. These conditions usually progress to acute leukemia There are several types of MDS which include • (a) Refractory anaemia – persistent unexplained anaemia in older age group patients. Bone marrow shows evidence of erythroid hyperplasia with dysplastic maturation. • (b) Sideroblastic anaemia – persistent unexplained hypochromic microcytic anaemia in older patients with the presence of increased iron stores and ringed sideroblasts in marrow. • (c) Refractory anaemia with excess blasts (RAEB) .Marrow shows 5 - 20 % myeloblasts and the cell lines show dysplasia • (d) RAEB –T refractory anaemia with excess blasts in transformation. This condition is reclassified as AML with dysplasia in the WHO classification
Differential Diagnosis: • 1. Aplastic anemia • ● Autoimmune disease which cause complete deficiency of all types of blood cells • 2. Myelodysplastic syndromes • 3. Multiple myeloma • ● Malignancy in the plasma cells, leads to pancytopenia • 4. Lymphomas • ● Malignancy in the lymph nodes • 5. Severe megaloblastic anemia • ● Vitamin B12 deficiency *Extra “Pernicious anemia: diminished intrinsic factors → ↓B12 absorption • → megaloblastic anemia” • 6. Leukemoid reaction Neutrophilia; mostly in septicemia • ● How to to know benign leukemoid reaction from leukemia? *Extra from book • i. No splenomegaly • ii. History of precipitating event e.g., infection • iii. ↑Leukocyte alkaline phosphatase
Diagnostic Studies : Earlier Dx = Better prognosis • ● To diagnose and classify To know if Lymphoid or Myeloid • ○ Peripheral blood evaluation • ■ CBC • ● WBC count: • ○ Acute: might be normal, decrease or elevated. • ○ Chronic: mostly elevated • ● ↓Hg “Anemia” • ● ↓platelets “Thrombocytopenia” • ■ Blood smear • ● If acute it must show Blasts “ You may see blast in chronic leukemia but it should not exceeds 5%” • ● CLL: Smudge cells -- fragile leukemic cells that ruptures when placed on glass slide.
• ○ Bone marrow evaluation by biopsy Required for Dx • ■ ALL: • ● >20% Blasts of lymphoid lineage • ● +ve cALLa, +ve Tdt • ■ AML: • ● >20% Blasts of myeloid lineage • ● Auer rods if APL • ● +ve myeloperoxidase • ○ Flow cytometry • ■ Shows the receptors in each cell to know the clonality and determine whether Myeloid or • Lymphoid • ● To identify cell subtype and stage • ○ Morphologic, histochemical, immunologic, and “cytogenetic method To know the prognosis”
Collaborative Care Treatment • ● Goal is to attain remission (when there is no longer evidence of cancer cells in the body) • ○ What is remission? • - The main aim of treatment for acute lymphoblastic leukaemia is to give a remission. This means that the abnormal, immature white cells or blasts can no longer be detected in the blood or bone marrow, and normal bone marrow has developed again. • - For many people with acute lymphoblastic leukaemia the remission lasts indefinitely and the person is said to be cured. • ● Treatment of leukemia “especially acute” starts by treating emergencies first: • ○ Antibiotic: as necessary for infection. • ○ Blood transfusion: as necessary for anemia • ○ Platelet transfusion: as necessary for bleeding
Chemotherapy Regimens • ● ○ Combination chemotherapy • ■ Mainstay treatment • ■ 3 purposes • ● ↓ drug resistance • ● ↓ drug toxicity to the patient by using multiple drugs with varying toxicities • ● Interrupt cell growth at multiple points in the cell cycle
Bone Marrow and Stem Cell Transplantation • ● ○ Goal: Totally eliminate leukemic cells from the body using combinations of chemotherapy with or without total body irradiation • ○ Eradicates patient’s hematopoietic stem cells, replaced with those of an • HLA-matched (Human Leukocyte Antigen) • ■ Sibling (is a brother or a sister; that is, any person who shares at least one of the same parents ) • ■ Volunteer • ■ Identical twin • ■ Patient’s own stem cells removed before • ■ Parent’s
Case: • - 17 years lady presented to the ER with CBC: WBCs 50,000 HGB 10 PLT 15000 • - Abnormal circulating blasts 30% More Hx must be taken first!. • ● Hx: • ○ Patient presented with 10 Days of fever, diffuse erythematous skin rash, difficulty • breathing, inability to do hard effort, blurred vision. • ● PE: • ○ Hepatosplenomegaly, axillary lymphadenopathy. • From the abrupt presentation, short onset and the presence of blasts you know it is acute leukemia. • You can’t tell whether lymphoid or myeloid unless you do a bone marrow biopsy. • ● How to proceed with Diagnosis and Management? • ○ Bone marrow biopsy and flow cytometry • ■ for diagnosis and to determine whether lymphoid or myeloid
• ○ Cytogenetic test • ■ To know the prognosis • ● According to the results you will manage • ● Diagnosis and Risk stratification: • 1) Peripheral blood morphology • ● Abnormal blasts • 2) Peripheral blood flow cytometry to show clonality • ● 30 % blasts with CD33 Myeloid specific receptor, CD34 +ve • 3) BMBx for • ● Morphology (myeloblasts) • ● Cytogenetics for prognosis t(8:21) Acute myeloid leukemia translocation • ● Flow cytometry (50% blasts express M antigens) • ● Molecular (FLT3 –ITD +ve) • The results shows it is Acute Myeloid Leukemia
• ● Treatment: • ○ Goals: • 1) Remission induction (chemo for 28 days) • 2) Response assessment ( Day 28) • 3) Consolidation (chemo / SCT stem cell transplant) • 4) Maintenance. But if the patient is high risk consider stem cell transplant
summary:
LEUKEMIALeukemia, historic perspective, etiology, risk factors, incidence, classification and comparison of acute and chronic.pptx

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LEUKEMIALeukemia, historic perspective, etiology, risk factors, incidence, classification and comparison of acute and chronic.pptx

  • 1.
  • 2.
    Definition • Historic Perspective •Etiology and Risk Factors • Incidence • Classification • Comparison of Acute and Chronic
  • 3.
    Definition • Leukemia isa disease of unknown etiology and fatal termination characterized by uncontrolled, abnormal and widespread proliferation of leukocytes and their precursors in bone marrow and blood.
  • 4.
    Leukemia : • Agroup of malignant disorders affecting the blood and blood-forming tissues of • Bone marrow • Lymph system • Spleen • ● Neoplastic proliferation of abnormal WBCs. As these abnormal WBCs accumulate, they interfere with the • production of normal WBCs, as well as the production of erythrocytes and platelets, resulting in anemia and thrombocytopenia. • ● Occurs in all age groups • ● Results in an accumulation of dysfunctional cells because of a loss of regulation in cell division. In normal physiology we have controlled cell division “mitosis” and programmed cell death “apoptosis”, • if these are affected it will lead to excessive cell growth and division which will lead to cancer. Cancer in hematology is in the stem cells synthesis in the bone marrow = leukemia. • ● Fatal if untreated • ○ Progressive
  • 5.
    Etiology: • No singlecausative agent • Most from a combination of factors • ○ Genetic and environmental influences Leukemia is not an inherited disease but a +ve family Hx indicates there is a genetic factor. • ● Associated with the development of leukemia • Chemical agents • Chemotherapeutic agents Hx of chemotherapy or radiation • Radiation • Viruses • Immunologic deficiencies • Down’s syndrome
  • 6.
    Classification • This isbased on the clinical course of the disease and the type of cell line that is involved. • In the early 1990s the French – American – British group introduced the FAB classification of acute leukemia based mainly on the morphological appearance of blasts in Romanowsky stained smears of peripheral blood and bone marrow.
  • 7.
    • More recently(2002) the WHO classification of leukemia included in addition to morphology, immunophenotyping of the blasts and cytogenetic studies. • ACUTE LEUKEMIA is of sudden onset and rapid progression unless treated and is characterized by the presence of blast cells in peripheral blood and bone marrow. • CHRONIC LEUKEMIA is of gradual onset and slow progression and is characterized by the presence of more mature cells in the peripheral blood and bone marrow.
  • 8.
    • ○ Acuteleukemias • Acute versus chronic: • Cell • maturity • Nature of • disease • onset • ■ Acute lymphoblastic leukemia (ALL) • ■ Acute myelogenous leukemia (AML) (also "myeloid" or • "nonlymphocytic") • ○ Chronic leukemias • ■ Chronic lymphocytic leukemia (CLL) • ■ Chronic myeloid leukemia (CML) • (Within these main categories, there are typically several subcategories)
  • 14.
    Clinical Manifestations ofleukemia: • Relate to problems caused by: • Bone marrow failure • ● Overcrowding by abnormal cells • ● Inadequate production of normal marrow elements • ● Anemia, thrombocytopenia, ↓ number and function of WBCs Leading to ↑ incidence of infection. • Leukemic cells infiltrate patient’s organs: • ● Splenomegaly • ● Hepatomegaly • ● Lymphadenopathy • ● Bone pain, meningeal irritation, oral lesions (chloromas) Mostly with acute • In generale leukemia share the same symptoms the difference is the the severity and onset. Acute leukemia symptoms develop within days, whereas Chronic take many years and are usually asymptomatic at the time of the diagnosis, and the findings might be incidental. Patient with chronic leukemia might have constitutional symptoms “especially in CML” weight loss, fatigue.. Etc, and some signs of anemia, ↑infection ...etc but not severe enough to require ER visit.
  • 15.
    Diagnostic Tools inthe Diagnosis of Leukemia • A. Morphology of the blasts in peripheral blood and bone marrow. • B. Cytochemistry of blasts in the various leukemias • Leukocyte cytochemistry uses techniques to identify enzymes or other cytoplasmic products in cells. Cytochemistry is useful for • Identification of myeloid blasts from lymphoid blasts • Differentiation of granulocytic and monocytic components of acute myeloid leukemia • Detection of unusual lineages eg basophils. • Detection of the absence of certain enzymes in a malignant clone eg Leukocyte alkaline phosphatase in Chronic Myeloid Leukemia.
  • 16.
    • The commonCytochemical stains used are • (a) Myeloperoxidase (MPO). This enzyme is present in primary and secondary granules of granulocytes. MPO splits H2O2 and in the presence of a chromogenic electron donor forms an insoluble reaction product. Substrates are benzidine substitutes. The reaction product is stable. MPO is not inhibited by heparin, oxalate or EDTA. The substrate is 3,3 diaminobenzidine with a phosphate buffer at pH 7.3. A brown granular deposit is seen in blasts of myeloid origin. • (b) Sudan Black B (SBB). This lipophilic dye binds with granule components in granulocytes and monocytes irreversibly. Staining reaction is comparable to MPO.
  • 17.
    • (c) PeriodicAcid Schiff reaction (PAS). Periodic acid oxidizes 1-2 glycol groups to produce dialdehydes. Dialdehydes give a red reaction when exposed to the Schiff reagent which is leucobasic fuchsin. A positive reaction is seen with carbohydrates especially glycogen polysaccharides, mucoproteins, glycoproteins etc. Blood smears are fixed with formali vapour, exposed to Periodic acid and then Schiff reagent and counter stained with Haematoxylin. WBC show diffuse, confluent red colour. ALL blasts show “block” positivit and the method can be used to differentiate ALL from AML
  • 18.
    • (d) Acidphosphatase. This enzyme is present in haemopoietic cells. It is useful for the diagnosis of T cell ALL and Hairy cell leukemia. Air dried smears fixed in methanol, acetone, citric acid buffer are exposed to naptholAS-BI phosphate substrate at an acid pH of 5.0. • The reaction is detected with the use of hexazotised pararosanaline dye. • Nuclei are counter stained with haematoxylin. T cells show strong localized polar positivity. Other WBC also show variable positivity. • In hairy cell leukemia the cells react equally positive in the presence and absence of tartaric acid.
  • 19.
    • (e) Esterasestains. WBC granules contain several types of esterases that hydrolyse acyl or chloroacyl esters of α naphthol or naphthol AS. • Specific esterase stain with naphthol AD chloroacetate ester (CAE) and is positive in the myeloid series and strong positive in promyelocytes including Auer rods. • Non specific esterase (NSE) stains with α naphthyl acetate ester (ANAE) or α naphthyl butyrate ester or (ANBE) and is positive in 80% of the monocyte cell line. • A stain combining the two substrates sequentially or in combination in one single step may be used to differentiate myeloblasts from monoblasts.
  • 20.
    • (f) Neutrophilscontain alkaline phosphatase enzyme in their granules. • The reaction between leukocyte alkaline phosphatase in cells, naphthol AS phosphate substrate, alkaline buffer at pH 9.0 is detected using a coupling azo dye (Fast Blue BB salt or Fast Garnet GBC) A counter stain is used for nuclei. The azo dye product is blue or brown granules in neutrophil cytoplasm. • The neutrophils are scored as 0 = negative, • 1+ = occasional granules in cytoplasm,2+ = moderate granulation, • 3+ = heavy granulation and 4+ = heavy granulation overlapping the nucleus. • A positive control that is used is usually from a pregnant female. The abnormal neutrophils in CML have markedly decreased levels of this enzyme. • In CML neutrophils stain negative for the enzyme
  • 21.
    • (g) ToludineBlue stain is used to stain the metachromatic granules in • basophils and mast cells.
  • 22.
    • C. Immunophenotypingis done to determine whether the cells are of myeloid or lymphoid origin and if lymphoid, whether they are of T or B cell origin. • The cells at various stages of development express antigens on the surface. • Monoclonal antibodies are available commercially to detect these antigens. • The antibodies are tagged with a fluorescent label. The test cells are incubated with a series of specific antibodies and by observing the degree of binding and the specificity of the antibody using a flow cytometer it is possible to identify and quantify the cells for diagnosis and for follow up of therapy. • Flow cytometry is also used to detect the presence of cytoplasmic or surface immunoglobulins and the presence of certain cytoplasmic enzymes eg myeloperoxidase.
  • 23.
    • D. Cytogenetics.Many of the blasts show specific cytogenetic markers which help identify them as well as predict their behavior to chemotherapeutic drugs. Standard cytogenetics, RT-PCT, FISH are some techniques that are used. • E. Cytospin of Cerobrospinal Fluid is used to detect the presence of small numbers of lymphoblasts in CSF in ALL. The cytospin is a special centrifuge which is gentle on the cells and produces minimum distortion of the blast cells.
  • 24.
    Acute Lymphocytic Leukemia(ALL) • ● Most common type of leukemia in children M > F • ● 15% of acute leukemia in adults • ● Immature lymphocytes proliferate in the bone marrow • ● Signs and symptoms may appear abruptly ○ Fever, bleeding • ● Insidious with progressive: • ○ Weakness, fatigue signs of anemia • ● Central nervous system manifestations. Must give CNS prophylaxis! “Prophylactic intrathecal drugs such as methotrexate” • ● Curable in 70% of children, and only in minority of adults
  • 25.
    Clinical presentation • Ofacute anemia both ALL & AML • Will present with sign or symptoms related to: • ● Pancytopenia: • ○ ↓ WBC → Infection. E.g Pneumonia, UTI • ○ ↓ Hb → Anemia. Dyspnea, Pallor, fatigue • ○ ↓ Platelets (thrombocytopenia)→ Bleeding. Epistaxis, easily bruised, petechiae • ● Organ infiltration: • ○ Lymphadenopathy, Splenomegaly, Hepatomegaly. • ● CNS: almost always in acute lymphocytic anemia • ○ 5-10% of patient with ALL • ○ Squint, Blurred vision, Headache.
  • 26.
    ACUTE LYMPHOBLASTIC LEUKEMIA(ALL) • Clinical Presentation • ALL affects children in the 2 – 10 years age group commonly but is also seen in adults. The patient presents with fever, weakness, pallor, infections bleeding and enlarged lymph nodes and spleen. Childhood ALL is associated with a good prognosis.
  • 27.
    Laboratory Diagnosis • 1.Haemoglobin, PCV, RBC count are decreased. • 2. MCV, MCH and MCHC are normal RDW is normal. There is normochromic normocytic anaemia. • 3. WBC count is elevated (20.0 – 100.0x109/L). Rarely the count may be low in subleukemic leukemia. • 4. Platelet count shows moderate to severe thrombocytopenia • 5. The blood film shows normochromic normocytic anaemia, leukocytosis with many blast cells and thrombocytopenia. • 6. The differential cells show many blast cells There is neutropenia
  • 28.
    CLASSIFICATION • The FABclassification describes 3 types of ALL depending on the morphology of the blasts. They are;- • A. ALL L1 • The blast is small, 14 – 16µm in diameter, the cytoplasm is barely visible, the nucleus occupies the whole cell, has condensed chromatin and nucleoli are not seen.
  • 29.
    • B. ALLL2 • The blast is 15 - 18µm in diameter, nucleus occupies most of the cell. The nuclear membrane is thick, chromatin is coarse, 1 – 2 nucleoli are seen. • The chromatin around the nucleolus is condensed. The cytoplasm is pale blue, forms a rim around the nucleus and does not contain any inclusions. • C. ALL L3 • The blast is 18 – 20 µm in diameter, nucleus has reticular chromatin, 1-2 prominent nucleoli, cytoplasm is moderate in amount blue in colour and there are punched out vacuoles in the cytoplasm and overlying the nucleus.
  • 30.
    • 7. Cytochemistry.Special stains are done to differentiate ALL from AML. • These are • A. Myeloperoxidaes stain and Sudan Black B stains are negative in ALL. • B. Periodic Acid Schiff stain may show block positive staining in the cytoplasm of ALL blasts with no differentiation between T and B cells. • 8. Immunophenotyping differentiates the blasts into T and B cells. B cells are CD19+, CD10+ and may show cytoplasmic CD22. T cells are CD2+, CD5+, CD7+ • 9. Bone marrow examination shows solidly cellular marrow with suppression of normal erythropoiesis, myelopoiesis and megakaryocytes. The marrow is replaced by proliferating blasts. In the FAB classification there must be >30% blasts in the marrow and in the WHO classification there must be >20% blasts in marrow. • 10. Biochemical tests show raised serum uric acid levels, raised serum LDH and serum creatinine may be elevated
  • 31.
    Myelogenous Leukemia: • Leukemiacharacterized by proliferation of myeloid tissue (as of the bone marrow and spleen) and an abnormal increase in the number of granulocytes, myelocytes, and myeloblasts in the circulating blood. • ● Myeloid tissue: • Is a biologic tissue with the ability to perform hematopoiesis. It is mainly found as the red bone marrow in bones and is often synonymous with this. However, • myeloid can also be present in the liver and spleen . • ● Myelocyte: • Is a young cell of the granulocytic series, occurring normally in bone marrow, but not in circulating blood (except when caused by certain diseases). • ● Granulocytes: • Are a category of white blood cells characterized by the presence of granules in their cytoplasm.They are also called polymorphonuclear leukocytes (PMN or PML) because of the varying shapes of the nucleus, which is usually lobed into three segments. • ● Myeloblast: • Is a unipotent stem cell, which will differentiate into one of the actors of the granular series.
  • 32.
    Acute Myelogenous Leukemia(AML) • ● Leukemia characterized by proliferation of myeloid tissue (as of the bone marrow and spleen) and an abnormal increase in the number of granulocytes, myelocytes, and myeloblasts in the circulating blood • ● One fourth of all leukemias • ○ 85% of the acute leukemias in adults M > F Exposure to Benzene, Radiation play a major role. • ● Abrupt, dramatic onset • ○ Serious infections, abnormal bleeding • ● Uncontrolled proliferation of myeloblasts • ○ Hyperplasia of bone marrow and spleen • Curable in minority of adults • Important AML variant is Acute promyelocytic leukemia (M3): • ○ characterized by t(15;17) PML-RARα “ProMyelocytic Leukemia-Retinoic Acid Receptor α” • ○ Associated with DIC • ○ Presence of Auer rods • ○ treated with All-Trans retinoic acid “Vit A” with concurrent chemotherapy
  • 33.
    ACUTE MYELOID LEUKEMIA(AML) • Clinical Presentation • AML affects young adults who present with fever, weakness, pallor, infections, bleeding, bone pains and splenomegaly.
  • 34.
    Laboratory Diagnosis • 1.Haemoglobin, PCV, RBC count are decreased. • 2. MCV, MCH and MCHC are normal RDW is normal. There is normochromic normocytic anaemia. • 3. WBC count is elevated (20.0 – 100.0x10/L). Rarely the count may be low in subleukemic leukemia. • 4. Platelet count shows moderate to severe thrombocytopenia • 5. The blood film shows normochromic normocytic anaemia, leukocytosis with many blast cells and thrombocytopenia. • 6. The differential cell count shows many blast cells There is neutropenia.
  • 35.
    CLASSIFICATION • The FABclassification describes 8 types of AML depending on the morphology of the blasts. They are
  • 36.
    A. AML M0 •The blast is 15 - 18µm in diameter, nucleus occupies most of the cell, nuclear membrane is fine, chromatin is fine, 2 – 3 nucleoli are seen. • The cytoplasm is pale blue, forms a rim around the nucleus and does not contain any inclusions. These cells are CD 13+,CD 33+ and CD 117+ by flow cytometry <3% of cells show MPO/SBB positivity
  • 37.
    B. AML M1 •The blast is 15 - 18µm in diameter, nucleus occupies most of the cell, nuclear membrane is fine, chromatin is fine, 2 – 3 nucleoli are seen. • The cytoplasm is pale blue, forms a rim around the nucleus and may contain thin rod like pink structures called Auer rods. This is formed by the condensation of primary granules and when present are diagnostic of AML.
  • 38.
    C. AML M2 •The blast is 15 - 18µm in diameter, nucleus occupies most of the cell, nuclear membrane is fine, chromatin is fine, 2 – 3 nucleoli are seen. The cytoplasm is pale blue, forms a rim around the nucleus and contains fine early granulation and thin rod like pink structures called Auer rods. • Myeloperoxidase and Sudan Black B stains show positivity in 30 – 100% of cells.
  • 39.
    D. AML M3(Promyelocytic leukemia) • The blast is 18 – 20 µm in diameter, nucleus has reticular chromatin, 1-2 prominent nucleoli. The nucleus appears folded on itself or may be bilobed. The cytoplasm is moderate in amount and filled with fine pink azurophilic granules. Many Auer rods are seen and these cells are called faggot cells. • Sometimes the granulation is not prominent and the leukemia is called AML M3 Hypogranular variant . • The myeloperoxidase stain and SBB stains are strong positive. 90% of the cells show specific esterase positivity. AML M3 is associated with a cytogenetic abnormality namely T(15:17)
  • 40.
    E. AML M4(Myelomonocytic leukemia) • In this variant two types of blasts are present – myeloblasts as described above and up to 20% monocytes and monoblasts. • The monoblaste are 20– 22 µm in diameter, nucleus has reticular chromatin, 2-3 prominent nucleoli and the nucleus may be indented. • The cytoplasm is abundant, vacuolated and may contain few azurophilic granules and sometimes Auer rods. • MPO, SBB and non specific esterase are positive A variant of this leukemia with prominent eosinophilia and a cytogenetic abnormality inversion 16 is known.
  • 41.
    F. AML M5(Monocytic leukemia) • In this variant the predominant cell line is monocytoid and is a mixture of monocytes and monoblasts which make up >80% of the cells. • MPO, SBB and combined esterase are positive. In addition to cytochemistry there is also increase in serum and urinary lysozyme excretion
  • 42.
    G. AML M6(Erythroleukemia) • In this variant there are two cell lines involved erythroid which must be greater than 50% in marrow and myeloblasts which makes up greater than 20% of the non erythroid cells in marrow. • Auer rods and dysplasia may be seen. • PAS positivity is seen in erythroblasts.
  • 43.
    H AML M7(Megakaryoblastic leukemia) • In this variant the cell line involved is megakaryoblastic. The blasts superficially resemble lymphoblasts. • Flow cytometry is needed to identify these blasts which show positivity for CD 41 and CD 61 which are platelet markers.
  • 44.
    • 7. Cytochemistry.Special stains are done to differentiate ALL from AML. These are • A. Myeloperoxidaes stain and Sudan Black B stains are negative in ALL. • B. Periodic Acid Schiff stain may show block positive staining in the cytoplasm of ALL blasts with no differentiation between T and B cells. • C. Esterase stains are done to differentiate the monocyte cell line • 8. Immunophenotyping is done to identify the myeloid, monocytoid, erythroid and megakaryocyte cell lines. • 9. Bone marrow examination shows solidly cellular marrow with suppression of normal erythropoiesis, myelopoiesis and megakaryocytes. The marrow is replaced by proliferating blasts. • 10. Biochemical tests show raised serum uric acid levels, raised serum LDH and serum creatinine may be elevated • 11. Cytogenetic studies are performed to demonstrate typical abnormalities in certain leukemias and to monitor response to treatment.
  • 45.
    CHRONIC MYELOID LEUKEMIA(CML) • Clinical Presentation • This condition affects all age groups mostly young adults. There is anaemia, fever, weight loss, sweating, bone pain and enlarged spleen. • The leukemia runs a chronic course of 2 – 5 years unless treated and transforms into acute leukemia, myeloblastic or lymphoblastic as a terminal event.
  • 46.
    Chronic Myelogenous Leukemia(CML) • ● Excessive development of mature neoplastic granulocytes in the bone marrow: • → Move into the peripheral blood in massive numbers • → Ultimately infiltrate the liver and spleen • ● Philadelphia chromosome • ○ Genetic marker. The chromosome abnormality that causes chronic myeloid leukemia (CML) (9 & 22) “BCR-ABL” • ○ It has tyrosine kinase activity and enhanced phosphorylation that result in altered cell growth • ○ That's why we treat it with oral tyrosine kinase inhibitors “Imatinib first line treatment in chronic phase” • ● Chronic, stable phase for many years followed by acute, aggressive (blastic Immature) phase (Blast crisis) end stage of the disease. • ● Massive splenomegaly is characteristic.
  • 47.
    Laboratory Diagnosis • 1.Haemoglobin, PCV, RBC count are decreased. • 2. MCV, MCH and MCHC are normal RDW is normal. There is normochromic normocytic anaemia. • 3. WBC count is elevated (100.0 – 800.0x10 9/L). • 4. Platelet count is normal or increased. • 5. The blood film looks like a bone marrow preparation because of the marked leukocytosis. The red cells show normochromic normocytic anaemia. • The entire series of myeloid cells are seen. Myeloblast make up 2 -5% of the cells , myelocytes ~ 20%, neutrophils ~20%. There is an increase in basophils which make up 5 – 10% of the cells. Eosinophils may also be increased. • Lymphocytes are normal. Platelets may be normal or increased. • A falling haemoglobin, increasing blast percentage and increase in basophils indicate blast transformation.
  • 48.
    • 6. Thebone marrow is solidly cellular with no fat spaces, There is marked myeloid hyperplasia with all stages of maturation, basophilia and increased megakaryocytes. The erythroid series is normal • 7. Cytochemistry Leukocyte Alkaline phosphatase (LAP) Neutrophils contain alkaline phosphatase enzyme in their granules. The abnormal neutrophils in CML have markedly decreased levels of this enzyme. Blood smears made from finger prick are stained using a phosphate substrate, alkaline buffer at pH 9.0, a coupling azo dye and a counter stain. • In the presence of the enzyme the reaction product is seen as blue or brown (depending on azo dye used) granular deposit in neutrophil cytoplasm. In CML neutrophils stain negative for the enzyme.
  • 49.
    • 8. Cytogenetics.A typical translocation between 19 :22 called the Philadelphia chromosome is demonstrated in CML. • 9. Biochemistry. Increased serum LDH, serum uric acid and serum vitamin B 12 are seen
  • 50.
    CHRONIC LYMPHOCYTIC LEUKEMIA •Clinical Presentation • This condition affects older age groups and is common in Caucasians. • There is anaemia, fever, weight loss, sweating, enlarged lymph nodes and spleen. The leukemia runs a chronic course of 2 – 5 years unless treated and may be associated with frequent infections because of depressed immunity.
  • 51.
    • disease ofthe old age >65 • ● Production and accumulation of functionally inactive but long-lived, • mature-appearing lymphocytes • ● B cell involvement • ● Lymph node enlargement is noticeable throughout the body • ○ ↑ incidence of infection • ● Complications from early-stage CLL is rare • ○ May develop as the disease advances • ○ Pain, paralysis from enlarged lymph nodes causing pressure.
  • 52.
    Laboratory Diagnosis • 1.Haemoglobin, PCV, RBC count are mildly decreased or normal • 2. MCV, MCH and MCHC are normal RDW is normal. • 3. WBC count is elevated (50.0 – 250.0x109/L). • 4. Platelet count is normal. Rarely there may be immune thrombocytopenia. • 5. The blood film shows leukocytosis. The red cells are normochromic normocytic. 70 – 90 % of the WBC are mature lymphocytes. Many cells are smear cells. There is a persistent absolute lymphocytosis. Platelets are normal. • 6. The bone marrow is solidly cellular with no fat spaces. 90% of the cells • in the marrow are mature lymphocytes and a relative decrease in erythroid • and myeloid series. Megakaryocytes are normal.
  • 53.
    • 7. Flowcytometry shows the presence of B cell markers with one aberrant T cell marker, namely CD5 • 8. Biochemistry Increased serum LDH, serum uric acid may be seen
  • 54.
    CHRONIC MYELOPROLIFERATIVE DISORDERS •This is a group of disorders where there is proliferation of the various • components of the marrow leading to a chronic disease. These include:- • (a) Chronic myeloid leukemia – as described above • (b) Polycythemia rubra vera – erythrocytosis, leukocytosis and thrombocytosis • (c) Myelofibrosis - abnormal megakaryocyte proliferation leads to deposition of fibrous tissue in marrow. The normal haematopoiesis takes place in other organs like liver and spleen (extramedullary haematopoiesis) resulting in a leukoerythroblastic blood picture. • (d) Essential thrombocythemia – proliferation of abnormal megakaryocytes giving rise to thrombocytosis with abnormal platelets which also have platelet dysfunction • (e) Chronic myelomonocytic anaemia
  • 55.
    Hairy Cell Leukemia: • ● Subtype of CLL • ● 2% of all adult leukemias • ● Usually in males > 40 years old • ● Chronic disease of lymphoproliferation • ● B lymphocytes cells that have a “hairy” appearance and infiltrate the bone • marrow and liver Can be Dx by blood morphology • ● Symptoms from • ○ Splenomegaly, Pancytopenia, Infection, Vasculitis production of autoantibodies that attack normal blood vessels → Autoimmune thrombocytopenia, Autoimmune hemolytic anemia • ● Treatment • ○ Alpha-interferon, Pentostatin, Cladribine
  • 57.
    MYELODYSPLASTIC SYNDROMES OR PRELEUKEMIA •In this group of disorders the maturation of cells is abnormal and dysplastic and may involve one or more cell line in the marrow. These conditions usually progress to acute leukemia There are several types of MDS which include • (a) Refractory anaemia – persistent unexplained anaemia in older age group patients. Bone marrow shows evidence of erythroid hyperplasia with dysplastic maturation. • (b) Sideroblastic anaemia – persistent unexplained hypochromic microcytic anaemia in older patients with the presence of increased iron stores and ringed sideroblasts in marrow. • (c) Refractory anaemia with excess blasts (RAEB) .Marrow shows 5 - 20 % myeloblasts and the cell lines show dysplasia • (d) RAEB –T refractory anaemia with excess blasts in transformation. This condition is reclassified as AML with dysplasia in the WHO classification
  • 58.
    Differential Diagnosis: • 1.Aplastic anemia • ● Autoimmune disease which cause complete deficiency of all types of blood cells • 2. Myelodysplastic syndromes • 3. Multiple myeloma • ● Malignancy in the plasma cells, leads to pancytopenia • 4. Lymphomas • ● Malignancy in the lymph nodes • 5. Severe megaloblastic anemia • ● Vitamin B12 deficiency *Extra “Pernicious anemia: diminished intrinsic factors → ↓B12 absorption • → megaloblastic anemia” • 6. Leukemoid reaction Neutrophilia; mostly in septicemia • ● How to to know benign leukemoid reaction from leukemia? *Extra from book • i. No splenomegaly • ii. History of precipitating event e.g., infection • iii. ↑Leukocyte alkaline phosphatase
  • 59.
    Diagnostic Studies :Earlier Dx = Better prognosis • ● To diagnose and classify To know if Lymphoid or Myeloid • ○ Peripheral blood evaluation • ■ CBC • ● WBC count: • ○ Acute: might be normal, decrease or elevated. • ○ Chronic: mostly elevated • ● ↓Hg “Anemia” • ● ↓platelets “Thrombocytopenia” • ■ Blood smear • ● If acute it must show Blasts “ You may see blast in chronic leukemia but it should not exceeds 5%” • ● CLL: Smudge cells -- fragile leukemic cells that ruptures when placed on glass slide.
  • 60.
    • ○ Bonemarrow evaluation by biopsy Required for Dx • ■ ALL: • ● >20% Blasts of lymphoid lineage • ● +ve cALLa, +ve Tdt • ■ AML: • ● >20% Blasts of myeloid lineage • ● Auer rods if APL • ● +ve myeloperoxidase • ○ Flow cytometry • ■ Shows the receptors in each cell to know the clonality and determine whether Myeloid or • Lymphoid • ● To identify cell subtype and stage • ○ Morphologic, histochemical, immunologic, and “cytogenetic method To know the prognosis”
  • 61.
    Collaborative Care Treatment •● Goal is to attain remission (when there is no longer evidence of cancer cells in the body) • ○ What is remission? • - The main aim of treatment for acute lymphoblastic leukaemia is to give a remission. This means that the abnormal, immature white cells or blasts can no longer be detected in the blood or bone marrow, and normal bone marrow has developed again. • - For many people with acute lymphoblastic leukaemia the remission lasts indefinitely and the person is said to be cured. • ● Treatment of leukemia “especially acute” starts by treating emergencies first: • ○ Antibiotic: as necessary for infection. • ○ Blood transfusion: as necessary for anemia • ○ Platelet transfusion: as necessary for bleeding
  • 63.
    Chemotherapy Regimens • ●○ Combination chemotherapy • ■ Mainstay treatment • ■ 3 purposes • ● ↓ drug resistance • ● ↓ drug toxicity to the patient by using multiple drugs with varying toxicities • ● Interrupt cell growth at multiple points in the cell cycle
  • 64.
    Bone Marrow andStem Cell Transplantation • ● ○ Goal: Totally eliminate leukemic cells from the body using combinations of chemotherapy with or without total body irradiation • ○ Eradicates patient’s hematopoietic stem cells, replaced with those of an • HLA-matched (Human Leukocyte Antigen) • ■ Sibling (is a brother or a sister; that is, any person who shares at least one of the same parents ) • ■ Volunteer • ■ Identical twin • ■ Patient’s own stem cells removed before • ■ Parent’s
  • 65.
    Case: • - 17years lady presented to the ER with CBC: WBCs 50,000 HGB 10 PLT 15000 • - Abnormal circulating blasts 30% More Hx must be taken first!. • ● Hx: • ○ Patient presented with 10 Days of fever, diffuse erythematous skin rash, difficulty • breathing, inability to do hard effort, blurred vision. • ● PE: • ○ Hepatosplenomegaly, axillary lymphadenopathy. • From the abrupt presentation, short onset and the presence of blasts you know it is acute leukemia. • You can’t tell whether lymphoid or myeloid unless you do a bone marrow biopsy. • ● How to proceed with Diagnosis and Management? • ○ Bone marrow biopsy and flow cytometry • ■ for diagnosis and to determine whether lymphoid or myeloid
  • 66.
    • ○ Cytogenetictest • ■ To know the prognosis • ● According to the results you will manage • ● Diagnosis and Risk stratification: • 1) Peripheral blood morphology • ● Abnormal blasts • 2) Peripheral blood flow cytometry to show clonality • ● 30 % blasts with CD33 Myeloid specific receptor, CD34 +ve • 3) BMBx for • ● Morphology (myeloblasts) • ● Cytogenetics for prognosis t(8:21) Acute myeloid leukemia translocation • ● Flow cytometry (50% blasts express M antigens) • ● Molecular (FLT3 –ITD +ve) • The results shows it is Acute Myeloid Leukemia
  • 67.
    • ● Treatment: •○ Goals: • 1) Remission induction (chemo for 28 days) • 2) Response assessment ( Day 28) • 3) Consolidation (chemo / SCT stem cell transplant) • 4) Maintenance. But if the patient is high risk consider stem cell transplant
  • 68.