Leukaemia Lecture 01

Dr. Rabiul Haque

Lecturer, Department of Pathology
Holy Family Red Crescent Medical College, Dhaka
 Leukaemia Lecture 01
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 Leukaemia Lecture 01
Learning Objectives:
- Introduction
- Definition
- Classification
- Acute Leukaemia
- Predisposing Factors
- Acute Myeloid Leukaemia
- FAB & WHO Classification of AML
- Pathogenesis
- Clinical Features of AML
- Lab Diagnosis of AML
- Treatment of AML
Introduction
 Introduction
In the past the term leukaemia and lymphoma were
considered distinct entities.
But with increased understanding the divisions have
blurred.
 Introduction
The term leukaemia is used for neoplasms that
present with widespread involvement of the bone
marrow and (usually, but not always) the peripheral
blood.
The term lymphoma is used for lymphoid
proliferation that arise as discrete tissue masses.
The terms leukaemia and lymphoma merely reflect the
usual tissue distribution of each disease at the time of
presentation.
 Introduction
 Disorders of White Blood Cells

Proliferative Disorders Leukopenia

Reactive Neoplastic

Leukaemoid - Lymphoid neoplasms

Leukocytosis Reaction - Myeloid neoplasms
- Histiocytic neoplasms
 Introduction
Lymphoid neoplasms include leukaemias and
lymphomas of B, T or NK cell origin.
This group is divided into
 Precursor B-cell Neoplasms
 Peripheral B-cell Neoplasms
 Precursor T-cell Neoplasms
 Peripheral T-cell Neoplasms
 Hodgkin’s disease
 Introduction
Myeloid neoplasms include
 Acute myeloid leukaemias
 Myelodysplastic syndromes
 Chronic myeloproliferative disorders
 Definition of Leukaemia
Leukaemias are diseases in which abnormal
proliferation of haemopoietic cells causes
progressively increasing infiltration of the bone
marrow, although in certain forms the lymphatic
tissues are particularly affected.
 Leukaemoid Reaction
Defined as a reactive excessive leukocytosis in
the peripheral blood resembling that of leukaemia
in a subject who does not have leukaemia.
The clinical features of leukaemia such as
splenomegaly, lymphadenopathy and
haemorrhages are usually absent.
 Classification of Leukaemia
Historically, leukaemias have been classified on the
basis of cell types predominantly involved into
myeloid and lymphoid, and on the basis of natural
history of the disease, into acute and chronic.
Acute Myeloid Leukaemia or Acute Myeloblastic Leukemia
Acute Lymphoid Leukaemia or Acute Lymphoblastic Leukaemia
Chronic Myeloid Leukaemia or Chronic Myelocytic Leukaemia
Chronic Lymphoid Leukaemia or Chronic Lymphocytic Leukaemia
 Acute Leukaemia
Normally defined as presence of over 20 % of blast
cells in the bone marrow at clinical presentation.
However, it can be diagnosed with less than 20%
blasts if specific leukaemia associated cytogenetic
or molecular genetic abnormalities are present.
We can define the lineage of blast cells by
microscopic examination (morphology),
immunophenotypic, cytogenetic and molecular
analysis.
 Acute Leukaemia
 Usually aggressive diseases.
 Malignant transformation occur in haemopoietic stem cell (blasts) or
early progenitor cells.
 Genetic damage involves key biochemical steps:
 Increased rate of proliferation
 Reduced apoptosis
 Block in cellular differentiation
 If untreated, usually rapidly fatal.
 With modern treatments most younger patients are ultimately cured of
their disease.
 Acute Leukaemia
Self-renewal is maintained
or increased

Proliferative and
survival advantage
with block in
Apoptosis Proliferation is differentiation and
increased in apoptosis
leading to
accumulation of
undifferentiated
cells.

Differentiation
Predisposing Factors of Acute Leukaemia
 Predisposing Factors of Acute Leukaemia
Hereditary Factors
Acquired Factors
 Ionizing Radiation
 Chemical Agents
 Viruses
 Acquired Conditions
 Influence of Age & Sex
Hereditary Factors
• Evidence suggests that there is role of family
history, occurrence in identical twins and
predisposition of these malignancies in certain
genetic syndromes.
• Family History:
• Families with high incidence of leukaemia have been
identified.
• Identical Twins:
• High concordance rate is seen among identical twins if
acute leukaemia develops in the first year of life.
Hereditary Factors
• Association with Genetic Diseases:
• Down Syndrome (20 times increased incidence)
• Bloom Syndrome
• Klinefelter Syndrome
• Wiskott-Aldrich syndrome
• Fanconi’s anaemia
• Ataxia telangiectasia
Ionizing Radiation
• Nuclear Fall-out
• Therapeutic Irradiation
• Diagnostic X-Ray
Chemical Agents
• Occupational exposure to benzene has been
associated with increased risk of acute myeloid
leukaemia and aplastic anaemia.
• Alkylating agents used for chemotherapy of
cancer may induce acute myeloid leukaemia.
• Such secondary leukaemias develop about 5 to 6
years after chemotherapy and are usually preceded
by myelodysplastic syndrome.
• Treatment with drugs that inhibit topoisomerase II
(such as epipodophyllotoxins or etoposide) are
associated with AML.
Viruses
• The role of oncogenic viruses in human
leukaemogenesis is not established.
• Exception:
One virus Human T Lymphotropic Virus Type I
(HTLV-I) that is associated with adult T cell
leukaemia/lymphoma (ATLL).
Acquired Conditions
• Some acquired conditions may predispose to
acute leukaemia
• Myeloproliferative disorders
• Chronic Myeloid Leukaemia
• Polycythaemia vera
• Myelofibrosis
• Myelodysplastic syndromes
• Paroxysmal nocturnal haemoglobinuria
• Aplastic anaemia
Influence of Age and Sex
• Acute lymphoblastic leukaemia (ALL) is most
common form of leukaemia in children.
• Acute myeloid leukaemia is the predominant
form of leukaemia in adults, adolescents and
infants.
• AML has equal sex incidence.
• ALL has slightly higher incidence in males
compared to females.
 Acute Myeloid Leukaemia
Definition
Acute myeloid leukemia (AML) is a tumor of
hematopoietic progenitors caused by acquired
oncogenic mutations that impede differentiation,
leading to the accumulation of immature myeloid
blasts in the marrow.
 Ref: Robbins and Cortan Pathologic Basis of Disease 9th Edition
 Acute Myeloid Leukaemia
Incidence
It is the most common form of acute leukaemia
in adults.
The incidence rises throughout life.
Peak incidence after 60 years.
It forms only a minor fraction (10–15%) of the
leukaemias in childhood.
Classification of Acute Leukaemia
Currently, two main classification schemes for AML are followed:

French-American-British (FAB) Classification

World Health Organization (WHO) classification of acute
myeloid leukaemia (AML) and related precursor neoplasms,
2008
Depending upon available laboratory facilities both FAB and WHO
classification schemes for AML are followed in different settings.
Classification of Acute Leukaemia

French-American-British (FAB) Classification
 Based on morphology and cytochemistry.
 A leukaemia is considered acute if the bone marrow consists of more than 30% blasts.

World Health Organization (WHO) classification of acute myeloid leukaemia (AML)
and related precursor neoplasms, 2008
 Limited reliance on blast morphology and cytochemistry.
 Revised and lowered the cut off percentage of marrow blasts to 20% from 30% in the
FAB classification for making the diagnosis of AML.
 Reliance on clinical, cytogenetic and molecular abnormalities in different types.
French-American-British (FAB) Classification of Acute Leukaemia


Acute Lymphoblastic Leukaemias (ALL)
 ALL-L1 type
 ALL- L2 type
 ALL- L3 type
French-American-British (FAB) Classification of Acute Leukaemia


Acute Myeloid Leukaemia (AML)

Acute myeloblastic leukaemia minimally differentiated (M0)

Acute myeloblastic leukaemia without maturation (M1)

Acute myeloblastic leukaemia with maturation (M2)

Hypergranular promyelocytic leukaemia (M3)

– Hypo-or micro-granular promyelocytic leukaemia (M3 variant)

Acute myelomonocytic leukaemia (M4)

– Acute myelomonocytic leukaemia with bone marrow eosinophilia (M4 Eo)

Acute monocytic leukaemia (M5)

– Undifferentiated (monoblastic) (M5a)

– Well-differentiated (promonocytic-monocytic) (M5b)

Acute erythroleukaemia (M6)


Acute megakaryocytic leukaemia (M7)
World Health Organization (WHO) classification of acute
myeloid leukaemia (AML), 2008

I. AML with Recurrent Genetic Aberrations

II. AML with MDS-like Features
III. AML, therapy-related
IV. AML, Not Otherwise Specified
 I. AML with Genetic Aberrations
 AML with t(8;21)(q22;q22); RUNX1/ETO fusion gene
AML with inv(16)(p13;q22); CBFB/MYH11 fusion gene
AML with t(15;17)(q22;11-12); RARA/PML fusion gene
AML with t(11q23;v); diverse MLL fusion genes
AML with normal cytogenetics and mutated NPM
 AML with t(8;21)(q22;q22); RUNX1/ETO fusion gene
AML with inv(16)(p13;q22); CBFB/MYH11 fusion gene

t(8;21) gene rearrangement disrupts RUNX1 gene.

Inv(16) disrupts CBFB gene.

Under normal condition RUNX1 gene and CBFB gene encode
polypeptides that bind one another to form RUNX1/CBF1β
transcription factor which is needed for normal haematopoiesis.

t(8;21) and the inv(16) create chimeric genes encoding fusion
proteins that interfere with the normal function of RUNX1/CBF1β
and block the maturation of myeloid cells.
 AML with t(15;17)(q22;11-12); RARA/PML fusion gene

Translocation between chromosomes 15 and 17 leads to fusion of
gene for retinoic acid receptor α (RARα) on chromosome 15 with
the promyelocytic leukaemia (PML) gene on chromosome 17.

PML/RARα fusion protein favours recruitment of transcriptional
repressors.

This results in block in differentiation at promyelocyte stage.

This can be overcome by treatment with either all-trans retinoic
acid or arsenic trioxide.
 II. AML with MDS-like Features
With prior MDS
AML with multi-lineage dysplasia
AML with MDS-like cytogenetic aberrations
 III. AML, therapy-related
very poor prognosis
 IV. AML, Not Otherwise Specified
AML, minimally differentiated
AML without maturation
AML with myelocytic maturation
AML with myelomonocytic maturation
AML with monocytic maturation
AML with erythroid maturation
AML with megakaryocytic maturation
 Pathogenesis
Recurrent genetic aberrations seen in AML
disrupt genes encoding transcription factors
that are required for normal myeloid
differentiation.
Mutations that lead to activation of growth
factor signaling pathways collaborate with
transcription factor aberrations to produce AML.
 Clinical Features
Clinical features of AML can be divided into two
groups:
Due to bone marrow failure
Due to organ infiltration
Clinical Features Due to Bone Marrow Failure
Anaemia causing pallor, lethargy, dyspnoea.
Bleeding manifestations due to
thrombocytopenia producing spontaneous
bruises, petechiae, bleeding from gums and
other bleeding tendencies.
Infections of mouth, throat, skin, respiratory,
perianal and other sites are common.
Clinical Features Due to Bone Marrow Failure
Fever is generally attributed to infections in
acute leukaemia.
Sometimes no obvious source of infection can
be found and fever may occur in the absence of
infection.
 Clinical Features Due to Organ Infiltration
Pain and tenderness of bones (e.g. sternal
tenderness) occurs due to bone infarcts or
subperiosteal infiltration of leukaemic cells.
Lymphadenopathy and enlargement of the
tonsils may occur.
Splenomegaly may occur. Splenic infarction,
subcapsular haemorrhages and splenic rupture
may occur.
 Clinical Features Due to Organ Infiltration
Hepatomegaly is frequently present due to
leukaemic infiltration however the infiltrates
usually do not interfere with liver function.
Leukaemic infiltration of the kidney may
occur but usually does not interfere with renal
function.
 Clinical Features Due to Organ Infiltration
Leukaemic infiltration of the gingivae resulting in gum
hypertrophy is a frequent finding in myelomonocytic
(M4) and monocytic (M5) leukaemias.
Chloroma is a localized tumourforming mass
occurring in the skin or orbit due to local infiltration of
tissues by leukaemic cells. It is also known as
granulocytic sarcoma or myeloid sarcoma.
Rarely testis may be infiltrated by leukaemic cells
causing Testicular Myeloid Sarcoma.
 Lab Diagnosis
The diagnosis of AML is made by a
combination of routine blood picture and bone
marrow examination accompanied with
cytochemical stains and other special
laboratory investigations.
 Lab Diagnosis
Blood Picture:
Anaemia is almost always present.
Generally severe, progressive.
Normochromic.
Reticulocytosis up to 5%.
Few nucleated cells may be present.
 Lab Diagnosis
Platelet count is usually below 50,000/μl.l.
Spontaneous bleeding episodes develop in
patients with platelet count less than 20,000/μl.l.
In Acute promyelocytic leukaemia (M3)
disseminated intravascular coagulation (DIC)
may occur.
 Lab Diagnosis
Often there is progressive increase in the white
cell count.
In advanced cases white cell count may
exceed 100,000/μl.l.
Majority of leukocytes in the peripheral blood
are blasts.
Peripheral Blood Film of AML
Peripheral Blood Film of AML

Myeloblast
Peripheral Blood Film of AML

Nucleolus
Myeloblast
Peripheral Blood Film of AML

Nucleolus
Myeloblast
Auer’s Rod
Peripheral Blood Film of AML

Nucleolus
Myeloblast
Auer’s Rod

RBC
 Lab Diagnosis
Feature Myeloblast Lymphoblast

Size Larger Smaller

Nucleus Round or oval Round or oval

Nucleoli 2-5 1-2

Nuclear Membrane Very fine Fairly dense

Nuclear Chromatin Fine Coarse

Cytoplasm Moderate Scanty

 Lab Diagnosis
Bone Marrow Examination:
Cellularity: typically hypercellular.
A dry tap in AML may occur due to pancytopenia.
Sometimes the marrow is so much packed with
leukaemic cells that they cannot be aspirated as the
cells are adhesive and enmeshed in reticulin fibers.
 Lab Diagnosis
Leukaemic cells:
Bone marrow is generally tightly packed with
leukaemic blast cells.
 20% myeloblasts in the marrow is required for
labelling a case as AML.
Cytochemical stains may be used as an adjunct to
Romanowsky stain for determining the type.
 Lab Diagnosis
Erythropoiesis: reduced.
Dyserythropoiesis, ring sideroblasts and megaloblastic
features are common.
Megakaryocytes: usually reduced or absent.
 Lab Diagnosis
Cytogenetics:
 WHO classification gives special importance on the
categorization of AML on the basis of cytogenetic abnormalities.
In 75% of cases chromosomal analysis of dividing
leukaemic cells in the marrow shows karyotypic
abnormalities which may be related to prognosis.
 Lab Diagnosis
Immunophenotyping:
AML cells express CD13 and CD33 antigens.
 Lab Diagnosis
 Cytochemistry:
 Certain enzymes, fat, glycogen or other substances are
identified in blast cells by cytochemical techniques.
 Myeloperoxidase is positive in immature myeloid cells
containing granules and Auer rods.
 Sudan Black is positive in immature cells in AML.
 Periodic Acid-Schiff (PAS) is positive in erythroleukaemia.
 Non-specific esterase (NSE) is positive in monocytic series.
 Treatment
General supportive therapy
Specific therapy of AML
 General Supportive Therapy

Insertion of central venous catheter
 For patients who will need intensive treatment.
 Done via a skin tunnel from chest into superior vena cava.
 Provides ease of access for administering chemotherapy,
antibiotics, blood products and intravenous feeding.

 General Supportive Therapy

Blood Product Support
 Give red cell support when Hb less than 80 g/L.
 In patients needing both red cells and platelets, platelets are given first.
This reduces risk of further fall in platelet count.
 Platelet transfusion is required when typically a platelet count below 10 ×
109 /L but this should be doubled in the presence of active bleeding or
infection.
 Fresh frozen plasma may be needed to reverse coagulation defects.

 General Supportive Therapy

Tumour Lysis Syndrome
 Chemotherapy causes rapid lysis of tumour cells.
 This may trigger acute rise in plasma uric acid, potassium
and phosphate.
 Prevention: Allopurinol, intravenous fluid and electrolyte
replacement.

 General Supportive Therapy

Treatment and Prophylaxis of Infection
 Patient should be isolated and may be placed in
laminar airflow room to reduce exposure to airborne
particles and pathogens.
 Bowel sterilization, topical antiseptics, systemic
antibiotics and leukocyte concentrates are
considered.
 Specific Therapy For AML

Determined according to age, performance
status and genetic lesions within the tumor.

In younger patients treatment is primarily with
intensive chemotherapy usually given in three or
four blocks.

Each block is of approximately 1 week.
 Specific Therapy For AML

Commonly used drugs:
 Cytosine arabinoside
 Daunorubicin
 Idarubicin, mitoxantrone and etoposide are also
used in various regimens.
 Specific Therapy For AML

Stem Cell Transplant (SCT)
 Offered in selected intermediate and high risk cases in
first remission.
 Not used for patients in the favourable risk group unless
they have disease relapse.
 Reduced intensity conditioning regimens have raised
the age at which patients may be considered for SCT.
Thank You