INTRODUCTION TO

LEUKEMIA
The Acute Leukemias

LEUKEMIAS - DEFINITION

Leukemias typically fill up the marrow with

abnormal cells, displacing normal
hematopoiesis. The marrow here is
essentially 100% cellular, but
composed almost exclusively of
leukemic cells. Normal hematopoiesis
is reduced via replacement (a
"myelophthisic" process) or by
suppressed stem cell division.

Leukemic cells are frequently present in the:

peripheral

blood
invade the reticulendothelial tissues

spleen, liver, and lymph nodes

may

also invade other tissues

untreated, eventually causes death

CLASSIFICATION

Classified according to cell type with regard to

both:
cell

maturity used to distinguish between acute and

chronic leukemia
if malignant cells are immature acute
rapidly aggressive
if predominantly mature - chronic
slow or indolent course

cell

lineage

Myeloid (granulocytic, monocytic, megakaryotic, and

erythrocytic )
Lymphoid

CATEGORIES OF LEUKEMIAS
Acute lymphoid leukemia (ALL)
Acute myeloid leukemia (AML) or acute
nonlymphoblastic leukemia (ANLL)
Chronic lymphocytic leukemia
Acute lymphocytic leukemia

ETIOLOGY/RISK FACTORS

Heredity

Congenital

chromosomal abnormalities
hereditary immunodeficiency states

Chronic marrow dysfunction

Drugs anticancer drugs
Ionizing radiation
Chemicals
Viruses

HTLV-1

causative agent of adult T-cell

leukemia/lymphoma

COMPARISON OF ACUTE AND

CHRONIC LEUKEMIA

Age
Clinical onset
Course (untreated)
Leukemic cells
Anemia
Thrombocytopenia
White cell count
Organomegaly

Acute

Chronic

All ages
Sudden
< 6 mo
Immature
Mild to
severe
Mild to
severe
Variable
Mild

Adults
Insidious
2 6 years
Mature
Mild
Mild
Increased
Prominent

ACUTE LEUKEMIA

Classification and Differentiation

CLINICAL FEATURES OF ACUTE LEUKEMIA

Pathogenesis

Clinical Manifestations

Bone Marrow Failure

Anemia

Fatigue, malaise, pallor

Thrombocytopenia

Bruising, bleeding

Granulocytopenia

Fever, infections

Organ Infiltration
Marrow expansion

Bone or joint pain

Spleen

Splenomegaly

Liver

Hepatomegaly

Lymph nodes

Lymphadenopathy

Central nervous system

Neurologic symptoms

Gums, mouth

Gingival hypertrophy,oral lesions

LABORATORY EVALUATION OF ACUTE

LEUKEMIA
Purpose: Confirm the diagnosis and distinguish
AML from ALL
Preliminary evaluation:

complete

blood count and peripheral blood

examination
bone marrow studies
morphologic examination
cytochemical staining
immunologic markers
cytogenetic studies
molecular genetic studies
electron microscopy ?

MORPHOLOGIC APPROACH TO CLASSIFICATION

Cytologic Features of Blasts in Acute ANLL and Acute Lymphocytic Leukemia

Feature

AML

ALL

Blast size

Larger, usually uniform

Variable, small to medium

size

Nuclear chromatin Usually finely dispersed

Coarse to fine

Nucleoli

1-4, often prominent

Absent or 1-2, often indistinct

Cytoplasm

Moderately, abundant, fine

granules often present

Usually scant, coarse

granules sometimes present
(~7%)

Auer rods

Present in 60-70% of cases Not present

Others

Often dysplastic changes

in maturing myeloid cells

Myeloid cells not dysplastic

Figure 1. A type I myeloblast has a large nuclus with prominent nucleoli

Maslak, P. ASH Image Bank 2003;2003:100726

Copyright 2003 American Society of Hematology. Copyright restrictions may apply.

Figure 3. Small number of granules are clustered in the cytoplasm of this myeloblast

Maslak, P. ASH Image Bank 2003;2003:100739

Copyright 2003 American Society of Hematology. Copyright restrictions may apply.

Figure 2. Type III blasts have greater than 20 granules but no centrosome

Maslak, P. ASH Image Bank 2004;2004:100953

Copyright 2004 American Society of Hematology. Copyright restrictions may apply.

Figure 1. Auer rods are distinctive cytoplasmic inclusion bodies which are found in
MDS and AML

Maslak, P. ASH Image Bank 2005;2005:101341

Copyright 2005 American Society of Hematology. Copyright restrictions may apply.

Figure 1. This lymphoid blast has a rounded, "regular" appearance without

cytoplasmic granules

Maslak, P. ASH Image Bank 2004;2004:101139

Copyright 2004 American Society of Hematology. Copyright restrictions may apply.

CYTOCHEMICAL REACTIONS USEFUL IN THE DIAGNOSIS OF

ACUTE LEUKEMIA
Special Stain

Site of Action

Cells Stained

Comment

Myeloperoxidase

Mainly primary
granules; Auer rods

Late myeloblasts,
granulocytes;
monocytes less
intensely

Separates AML (+)

from ALL (-)

Sudan black B

Phospholipids;
sterols, neutral fats

Late myeloblast,
granulocytes;
monocytes less
intensely

Parallels peroxidase,
but smears do not
need to fresh

Specific esterase
(Naphthol AS-D
chloroacetate

Cytoplasm

Neutrophilic
granulocytes; mast
cells

Parallels peroxidase,
but less sensitive;

Non-specific esterase Cytoplasm

(alpha-napththyl
acetate and butyrate)

Monocytes; focal
staining in T cells

Useful for
determining degree
of monocytic
differentiation;
separates mono (+)
from myelo (-) blasts

Periodic acid-Schiff

Lymphocytes,
granulocytes,
megakaryocytes

Helpful in supporting
diagnosis of
erythroleukemia

Glycogen and related

substances

IMMUNOLOGIC MARKERS USED IN THE

CLASSIFICATION OF ACUTE LEUKEMIA
Lineage

Antigen

B cell

CD19, CD20, CD21, CD22, CD23, D24

T cell

CD1, CD2, CD3, CD4, CD5, CD7, CD8

Lymphoid

TdT

Myeloid (granulocytic)

CD13, CD33, CD11b, CD15

Monocytic

CD14, CD11b

Erythroid

Glycophorin A

Megakaryocytic

CD41, CD42b, CD61

Lineage Independent Antigens

HLA-DR

HLA class II

CD45

Leukocyte common antigen

CD34

Stem cell antigen

CD10

Common ALL antigen (CALLA)

ACUTE MYELOID
LEUKEMIA
(AML)

Acute Nonlymphoid Leukemia

(ANLL)

DEFINITION

AML are clonal malignancies that are

characterized by the appearance of increased
numbers of immature myeloid cells in the
marrow and blood.

DEFINITION

AML is a clonal, malignant disease of the

hematopoietic tissue that is characterized by
accumulation

of abnormal (leukemic) blast cells,

principally in the marrow
impaired production of normal blood cells.

ETIOPATHOGENESIS

Risk factors

Environmental

radiation
benzenes
alkylating agents and other cytotoxic drugs therapyrelated AML

Evolution

from a chronic clonal hemopathy

Inherited syndromes

EPIDEMIOLOGY
AML is the predominant form of leukemia during
the neonatal period and
accounts for 15 to 20 percent of acute leukemia in
children and
80 percent of acute leukemia in adults.

REVISED CRITERIA FOR THE

CLASSIFICATION OF AML (FAB)
M0 with minimal differentiation
Large, agranular blasts (resemble ALL L2, rarely L1). Myeloperoxidase
negative or<3 percent positive; B-, T lineage markers negative; CD13 and/or
CD33 positive; myeloperoxidase positive by immunochemistry or electron
microscopy; TdT may be positive.

M1 with minimal maturation

1.
2.

Blast cells, agranular and granular types (type I and type II) >90 percent
of non erythroid cells. At least 3 percent of these are myeloperoxidase
or Sudan black positive.
Remaining 10 percent (or less) of cells are maturing granulocytes or
monocytes

REVISED CRITERIA FOR THE

CLASSIFICATION OF AML (FAB)
M2 with maturation
1.
2.
3.

Sum of agranular and granular blasts (types I and II) is from 30 to 89

percent of non-erythroid cells.
Monocytic cells, <20 percent.
Granulocytes from promyelocytes to mature polymorphs, > 10 percent.

M3 Promyelocytic
1.
2.

Majority of cells are abnormal promyelocytes with heavy granulation.

Characteristic cells containing bundles of Auer rods (faggots)
invariably present.
Note: Microgranular variant (M3v) also occurs. Promyelocytes have
marked nuclear irregularity that includes reniform, lobulated and
monocyte-like indented nuclei. The cytoplasm contains fine or
indistinct granules in contrast to the coarse azurophilic granules in
typical M3.

REVISED CRITERIA FOR THE

CLASSIFICATION OF AML (FAB)
M4 Myelomonocytic
1.
2.
3.
4.

In the marrow, blasts >30 percent of non-erythroid cells.

Sum of myeloblasts, promyelocytes, myelocytes and later granulocytes
is between 30 and 80 percent of non-erythroid cells.
> 20 percent of non-erythroid cells are monocyte lineage.
If monocytic cells exceed 80 percent, diagnosis is M5
Note: (a) If marrow findings as above and peripheral blood monocytes
(all types) are > 5.0 x 109/L, diagnosis is M4
(b) If monocyte count < 5 x 109/L, M4 can be confirmed on basis of
serum lysozyme, combined esterase, etc.
(c) Diagnosis of M4 confirmed if > 20 percent of marrow precursors are
monocytes (confirmed by special stains).

REVISED CRITERIA FOR THE

CLASSIFICATION OF AML (FAB)
M4 with eosinophilia
1.
2.
3.

Eosinophils > 5 percent of non-erythroid cells in marrow.

Eosinophils are abnormal.
Eosinophilis are chloroacetate and PAS positive.

M5 Monocytic
1.
2.
3.

80 percent of marrow non-erythroid cells are monoblasts,

promonocytes or monocytes.
M5a, 80 percent of monocytic cells are monoblasts.
M5b, < 80 percent of monocytic cells are monoblasts, remainder are
predominantly promonocytes and monocytes.

REVISED CRITERIA FOR THE

CLASSIFICATION OF AML (FAB)
M6 Erythroleukemia
1.
2.

The erythroid component of the marrow exceeds 50 percent of all

nucleated cells.
30 of the remaining non-erythroid cells are agranular or granular blasts
( types I and II).
Note: If > 50 percent erythroid cells but < 30 percent blasts, diagnosis
becomes myelodysplastic syndromes.
A rare form of erythoird neoplasia, erythremic myelosis, involves only the
red blood cell precursors. The erythroblasts, primarily pronormoblasts
and basophilic normoblasts, constitute 90% or more of the marrow cells.

M7 Megakaryocytic
1.
2.
3.

30 percent at least of nucleated cells are blasts.

Blasts identified by platelet peroxidase on electron microscopy, or by
monoclonal antibodies.
Increased reticulin is common.

Figure 1. Blasts are the predominant population in the bone marrow

AML (M1)

Maslak, P. ASH Image Bank 2003;2003:100838

Copyright 2003 American Society of Hematology. Copyright restrictions may apply.

Figure 2. Aspirate has a large number of blasts

AML (M2)

Maslak, P. ASH Image Bank 2003;2003:100722

Copyright 2003 American Society of Hematology. Copyright restrictions may apply.

Figure 1. The most common form of APL is easily recognized by the heavy
granulation of the abnormal promyelocytes (AML M3)

Maslak, P. et al. ASH Image Bank 2002;2002:100532

Copyright 2002 American Society of Hematology. Copyright restrictions may apply.

Figure 1. The granules in this morphologic variant of APL are less prominent than
those seen in the most common form of this disease

Maslak, P. et al. ASH Image Bank 2002;2002:100598

Copyright 2002 American Society of Hematology. Copyright restrictions may apply.

Figure 4. The increased number of blasts are noted with a prominent background of
eosinophils and abnormal eosinophilic myelocytes

Lazarchick, J. ASH Image Bank 2004;2004:101148

Copyright 2004 American Society of Hematology. Copyright restrictions may apply.

Figure 1. Monoblasts are large cells with ample cytoplasm

Maslak, P. et al. ASH Image Bank 2002;2002:100537

Copyright 2002 American Society of Hematology. Copyright restrictions may apply.

Figure 3. Erythroid elements comprise greater than or equal to 50% of the nucleated
cellular elements while the myeloblasts make up greater than or equal to 20% of the
nonerythroid population

Maslak, P. ASH Image Bank 2003;2003:100635

Copyright 2003 American Society of Hematology. Copyright restrictions may apply.

Figure 1. Blasts in acute megakaryoblastic leukemia may show cytoplasmic budding

reminiscent of the process where platelets are shed from normal megakaryocytes
(MacNeal Tetrachrome 400x)

Maslak, P. ASH Image Bank 2002;2002:100478

Copyright 2002 American Society of Hematology. Copyright restrictions may apply.

COMMON CYTOGENETIC ABNORMALITIES

ASSOCIATED WITH AML

Chromosome
Abnormality

Associated Disorder

t(8;21)
t(15;17)
16q abnormalities:
inv (16) and del (16)

AML (M2)
Unique to APL (M3)
AML with abnormal
eosinophilia (M4E)

t9;22)
t(9;11)

TREATMENT
Remission-induction therapy
Post-remission maintenance therapy
Stem cell transplant

ACUTE LYMPHOID
LEUKEMIA
acute lymphoblastic leukemia
acute lymphocytic leukemia

DEFINITION
ALL is a neoplastic disease that results from
multistep somatic mutations in a single lymphoid
progenitor at one of several discrete stages of
development.
The immunophenotype of leukemic cells at
diagnosis reflects the level of differentiation
achieved by the dominant clones.

ETIOPATHOGENESIS

Risk Factors
Genetic

syndromes
Environmental factors
Host pharmocogenetics
In utero development of ALL

EVENT-FREE AND OVERALL SURVIVAL IN ALL

FAB CLASSIFICATION OF ALL

Morphologic
Features

L1

L2

L3

Cell size

Small

Large

Large

Nuclear chromatin

Fine or clumped

Fine

Fine

Nuclear shape

Regular, may
have cleft of
indentation

Irregular, may
have cleft or
indentation

Regular, oval
to round

Nucleoli

Indistinct or not
visible

1 or more per
cell; large
prominent

1 or more per
cell; large
prominent

Amount of cytoplasm

Scanty

Moderately
abundant

Moderately
abundand

Cytoplasmic basophilia

Slight

Slight

Prominent

Cytoplasmic vacuoles

Variable

Variable

variable

ALL (L1)

ALL (L2)

ALL (L3)

ACUTE LEUKEMIA
A

heterogeneous group of neoplasms

affecting uncommitted or partially
committed hematopoietic stem cells.
The retained capacity of some
differentiation is the basis for the
phenotypic classification.
Broadly divided into (based on cell
origin)
Non-lymphoid

(Myeloid) leukemia
Lymphoid leukemia

CLASSIFICATION OF
LEUKEMIA
Acute

Myeloid (FAB classification)

Acute

myeloblastic leukemia

without differentiation (M0)

without maturation (M1)
with maturation (M2)

Acute

promyelocytic leukemia (M3) APL

Acute myelomonocytic leukemia (M4) AMML
Acute monocytic leukemia (M5) AMoL
Erythroleukemia (M6) Di Guglielmos
syndrome
Acute megakaryoblastic leukemia (M7)

CLASSIFICATION OF
LEUKEMIA
Acute

Lymphoblastic

Precursor

B-cell ALL

Early-Pre-B-cell ALL
Pre-B-cell ALL

B-cell

ALL
T-cell ALL

Chronic

Myeloid

Chronic

myelogenous leukemia (CML)

Chronic eosinophilic leukemia (CEL)
Chronic basophilic leukemia (CBL)

CLASSIFICATION OF
LEUKEMIA

Chronic Lymphoid
Chronic

lymphocytic leukemia (CLL)

B-cell CLL
T-cell CLL

Prolymphocytic

leukemia
Hairy cell leukemia
Plasma cell leukemia
Szary syndrome

ETIOLOGY AND RISK FACTORS

Host Factors
Heredity

Congenital

chromosomal abnormalities
Immunodeficiency
Chronic marrow dysfunction

Environmental Factors
Ionizing

radiation
Chemicals and drugs
Viruses