INTRODUCTION TO LEUKEMIA

Acute leukemias
INTRODUCTION TO LEUKEMIA
 Leukemia is a malignant disease
characterized by unregulated proliferation
of one cell type.
 It may involve any of the cell lines or a stem
cell common to several cell lines.
 Leukemias are classified into 2 major groups
 Chronic in which the onset is insidious, the disease is
usually less aggressive, and the cells involved are
usually more mature cells
 Acute in which the onset is usually rapid, the disease
is very aggressive, and the cells involved are usually
poorly differentiated with many blasts.
INTRODUCTION TO LEUKEMIA
 Both acute and chronic leukemias are further
classified according to the prominent cell line involved
in the expansion:
 If the prominent cell line is of the myeloid series it is a
myelocytic leukemia (sometimes also called granulocytic)
 If the prominent cell line is of the lymphoid series it is a
lymphocytic leukemia
 Therefore, there are four basic types of leukemia

 Acute myelocytic leukemia – AML- (includes

myeloblastic, promyelocytic, monocytic,
myelomonocytic, erythrocytic, and megakaryocytic)
 Acute lymphocytic leukemia – ALL- (includes T cell, B
cell, and Null cell)
 Chronic myelocytic leukemia – CML - (includes
myelocytic and myelomonocytic)
INTRODUCTION TO LEUKEMIA
 Chronic lymphocytic leukemia – CLL - (includes
plasmocytic {multiple myeloma}, Hairy cell,
prolymphocytic, large granular cell lymphocytic,
Sezary’s syndrome, and circulating lymphoma)
 Etiology – the exact cause is frequently not
known, but predisposing factors are known:
 Host factors
 Some individuals have an inherited increased
predisposition to develop leukemia
 There is an increased incidence in those with an
inherited tendency for chromosome fragility or
abnormality or those with increased numbers of
chromosomes (such as Down’s syndrome).
 Many of these diseases are characterized by
chromosomal translocations.
INTRODUCTION TO LEUKEMIA
 There is an increased incidence in those with hereditary
immunodeficiencies.
 There is an increased incidence in those with chronic

marrow dysfunction such as those with

myeloproliferative diseases, myelodysplastic syndromes,
aplastic anemia, or paroxsymal nocturnal
hemoglobinuria.
 Environmental factors:

 Exposure to ionizing radiation

 Exposure to mutagenic chemicals and drugs

 Viral infections
INTRODUCTION TO LEUKEMIA
 Incidence
 Acute leukemias can occur in all age groups
 ALL is more common in children
 AML is more common in adults

 Chronic leukemias are usually a disease of

adults
 CLL is extremely rare in children and unusual
before the age of 40
 CML has a peak age of 30-50
INTRODUCTION TO LEUKEMIA
 Comparison of acute and chronic leukemias:
Acute Chronic
Age all ages usually adults
Clinical onset sudden insidious
Course (untreated) 6 mo. or less 2-6 years
Leukemic cells immature >30% blasts more mature cells
Anemia prominent mild
Thrombocytopenia prominent mild
WBC count variable increased
Lymphadenopathy mild present;often prominent
Splenomegaly mild present;often prominent
INTRODUCTION TO LEUKEMIA
 Acute leukemia –
 Is a result of:
 Malignant transformation of a stem cell leading to
unregulated proliferation and
 Arrest in maturation at the primitive blast stage.
Remember that a blast is the most immature cell that
can be recognized as committed to a particular cell
line.
 Clinical features
 Leukemic proliferation, accumulation, and invasion of
normal tissues, including the liver, spleen, lymph
nodes, central nervous system, and skin, cause lesions
ranging from rashes to tumors.
 A humoral mediator from the leukemic cells may
inhibit proliferation of normal cells.
INTRODUCTION TO LEUKEMIA
 Failure of the bone marrow and normal
hematopoiesis may result in pancytopenia
with death from hemorrhaging and
infections.
 Lab evaluation
 The lab diagnosis is based on two things
 Finding a significant increase in the number of
immature cells in the bone marrow including
blasts, promyelocytes, promonocytes (>30% blasts is
diagnostic)
 Identification of the cell lineage of the leukemic

cells
INTRODUCTION TO LEUKEMIA
 Peripheral blood:
 Anemia (normochromic, normocytic)
 Decreased platlets

 Variable WBC count

 The degree of peripheral blood involvement determines

classification:
 Leukemic – increased WBCs due to blasts

 Subleukemic – blasts without increased WBCs

 Aleukemic – decreased WBCs with no blasts

 Classification of the immature cells involved

may be done by:
INTRODUCTION TO LEUKEMIA
 Morphology – an experienced morphologist can look
at the size of the blast, the amount of cytoplasm, the
nuclear chromatin pattern, the presence of nucleoli
and the presence of auer rods (are a pink staining,
splinter shaped inclusion due to a rod shaped
alignment of primary granules found only in
myeloproliferative processes) to identify the blast
type:
 AML – the myeloblast is a large blast with a moderate
amount of cytoplasm, fine lacey chromatin, and
prominent nucleoli. 10-40% of myeloblasts contain auer
rods.
MYELOBLASTS WITH AUER RODS
INTRODUCTION TO LEUKEMIA
 ALL – in contrast to the myeloblast, the lymphoblast is a
small blast with scant cytoplasm, dense chromatin,
indistinct nucleoli, and no auer rods
INTRODUCTION TO LEUKEMIA
 Cytochemistry – help to classify the lineage of a leukemic
cell (myeloid versus lymphoid)
 Myeloperoxidase – is found in the primary granules of

granulocytic cells starting at the late blast stage.

Monocytes may be weakly positive.
SUDAN BLACK
 Sudan black stains phospholipids, neutral fats and
sterols found in primary and secondary granules of
granulocytic cells and to a lesser extent in monocytic
lysosomes. Rare positives occur in lymphoid cells
NONSPECIFIC ESTERASE
 Nonspecific esterase – is used to identify monocytic cells
which are diffusely positive. T lymphocytes may have
focal staining
ACID PHOSPHATASE
 Acid phosphatase may be found in myeloblasts and
lymphoblasts. T lymphocytes have a high level of acid
phosphatase and this can be used to help make a
diagnosis of acute T-lymphocytic leukemia.
LEUKOCYTE ALKALINE
PHOSPHATASE
 Leukocyte alkaline phosphatase – is located in the
secondary granules of segmented neutrophils, bands and
metamyelocytes. The LAP score is determined by
counting 100 mature neutrophils and bands. Each cell is
graded from 0 to 5. The total LAP score is calculated by
adding up the scores for each cell.
LEUKOCYTE ALKALINE
PHOSPHATASE
INTRODUCTION TO LEUKEMIA
 Immunologic markers (immunophenotyping) – these
are used mainly for lymphocytes, i.e., for determining
B cell or T cell lineage. These tests rely on antibodies
made against specific surface markers.
 They constitute what we would call the primary antibody
and in an indirect assay they are allowed to react with
the cells and unbound antibody is then washed away.
 Fluorescently labeled antibody (secondary antibody)
against the primary antibody is added and allowed to
react and then unbound secondary antibody is washed
away.
 The cells are then sent through a flow cytometer that will
determine the number of cells that have a fluorescent tag
and which are thus positive for the presence of the
surface marker to which the primary antibody was made.
 In a direct assay, the primary antibody is fluorescently
labeled.
 DIRECT VERSUS INDIRECT LABELING OF
ANTIGENS

B or T cell B or T cell
specific Ab specific Ab
B or T Cell
marker

B or T Cell
marker
FLOW CYTOMETER
TERMINAL DEOYXTIDYL TRANSFERASE
 This is a unique DNA polymerase present in
stem cells and in precursor B and T lymphoid
cells.
 High levels are found in 90% of lymphoblastic
leukemias.
 It can also be detected using appropriate
antibodies and flow cytometry.
INTRODUCTION TO LEUKEMIA
 Cytogenetics – cytogenetics studies can now be used
for diagnosis and for prognosis of hematologic
malignancies.
 Many leukemias (and lymphomas) are characterized by
specific chromosomal abnormalities, including specific
translocations and aneuploidy. The specific type of
malignancy can be identified based on the specific
abnormality or translocation. These may be identified by
 Looking at the karyotypes of the chromsomes from the
abnormal cells
 DNA based tests – these tests are very useful for
following the course of the disease
 RT-PCR
 Southern blotting
 A normal karyotype is usually associated with a better
prognosis.
CHROMOSOMAL TRANSLOCATION
CHROMOSOME KARYOTYPING
ACUTE LEUKEMIAS
 Acute lymphoblastic leukemia –
 They may be classified on the basis of the
cytological features of the lymphoblasts into;
 L1 - This is the most common form found in children
and it has the best prognosis.
 The cell size is small with fine or clumped homogenous
nuclear chromatin and absent or indistinct nucleoli.
 The nuclear shape is regular, occasionally clefting or
indented.
 The cytoplasm is scant, with slight to moderate basophilia
and variable vacuoles.
 L2 – This is the most frequent ALL found in adults.
 The cell size is large and heterogenous with variable
nuclear chromatin and prominent nucleoli.
 The nucleus is irregular, clefting and indented.

 The cytoplasm is variable and often moderate to abundant

with variable basophilia and variable vacuoles.


ALL-L1
ALL-L2
ACUTE LEUKEMIAS
 L3 – This is the rarest form of ALL.
 The cell size is large, with fine, homogenous nuclear
chromatin containing prominent nucleoli.
 The nucleus is regular oval to round.

 The cytoplasm is moderately abundant and is deeply

basophilic and vacuolated.
ALL-L3
ACUTE LEUKEMIAS
 ALL may also be classified on the basis of
immunologic markers into:
 Early pre-B ALL
 Pre-B ALL

 B ALL

 T ALL

 Null or unclassified ALL (U ALL) - lack B or T markers

and may be the committed lymphoid stem cell)
B CELL MATURATION
T CELL MATURATION
ACUTE LEUKEMIAS
 Incidence – ALL is primarily a disease of young
children (2-5 years), but it can also occur in adults
 Clinical findings – pancytopenia with resulting
fatigue, pallor, fever, weight loss, irritability,
anorexia, infection, bleeding, and bone pain.
 L1 occurs in children, L2 in adults, and L3 is called
Burkitts leukemia
ACUTE LEUKEMIAS
 Prognosis – age, WBC count, and cell type are
the most important prognostic indicators
 Patients younger then 1 and greater than 13 have a
poor prognosis
 If the WBC count is < 10 x 109/L at presentation, the
prognosis is good; If the WBC count is > 20 x 109/L at
presentation the prognosis is poor
 T cell ALL (more common in males) has a poorer

prognosis than any of the B cell ALLs which have a

cure rate of 70%
ACUTE LEUKEMIAS
 Acuteleukemias with mixed lineage –
occasionally there are acute leukemias
that are biphenotypic and display
phenotypes for two different lineages
 B lymphoid/myeloid
 T lymphoid/myeloid
 B/T lymphoid
 Myeloid/Natural killer
 A rare trilineage leukemia has also been seen
(was B/T lymphoid/myeloid!)
ACUTE LEUKEMIAS
 Acutemyeloid leukemia (also called acute
granulocytic leukemia) – classification
depends upon
 Bone marrow blast morphology
 Degree of cell maturation
 Cytochemical stains
 Immunophenotyping
 AML is divided into 7 different classifications:
 M1 – myeloblastic without maturation
 The bone marrow shows  90% blasts and < 10%
promyelocytes
 The disease occurs in older adults
AML – M1
 Note the myeloblasts and the auer rod:
ACUTE LEUKEMIAS
 M2 – myeloblastic with maturation
 The bone marrow shows 30-89% blasts and > 10%
promyelocytes;
 This is characterized by an 8,21 chromosomal
translocation
 This occurs in older adults

 M3 – hypergranular promyelocytic
 This form of AML has a bone marrow with >30% blasts
 Is more virulent than other forms

 Occurs with a medium age of 39

 The WBC count is decreased

 Treatment causes a release of the granules and may send

the patient into disseminated intravascular coagulation
and subsequent bleeding
 It is characterized by a 15,17 chromosomal translocation
AML – M2
 Note myeloblasts and hypogranulated PMNs:
AML – M3
 Note hypergranular promyelocytes:
ACUTE LEUKEMIAS
 M3m – hypogranular promyelocytic –
 The bone marrow has > 30% blasts
 The WBC count is increased.

 Like the M3 type, treatment causes a release of the

granules and may send the patient into disseminated
intravascular coagulation and subsequent bleeding and
 It is characterized by a 15,17 translocation

 M4 – acute myelomonoblastic leukemia

 Both myeloblasts and monoblasts are seen in the bone
marrow and peripheral blood
 Infiltration of extramedullary sites is more common than

with the pure granulocytic variants

AML – M3M
 Note hypogranular promyelocytes:
AML – M4
 Note monoblasts and promonocytes:
ACUTE LEUKEMIAS
 M5 – acute monoblastic leukemia
 >80% of the nonerythroid cells in the bone marrow are
monocytic
 There is extensive infiltration of the gums, CNS, lymph nodes
and extramedullary sites
 This form is further divided into
 M5A - Poorly differentiated (>80% monoblasts)
 M5B - Well differentiated (<80% monoblasts)

 M6 – erythroleukemia
 This is rare and is characterized by a bone marrow having a
predominance of erythroblasts
 It has 3 sequentially morphologically defined phases;
 Preponderance of abnormal erythroblasts
 Erythroleukemia – there is an increase in both erythroblasts
and myeloblasts
 Myeloblastic leukemia – M1, M2, or M4
 Anemia is common
AML – M5A
 Note monoblasts:
AML-M5B
 Note monoblasts, promonocytes, and monocytes:
AML – M6
 Note M1 type monoblasts
ACUTE LEUKEMIAS
 M7 - Acute megkaryoblastic leukemia
 This is a rare disorder characterized by extensive
proliferation of megakaryoblasts, atypical
megakaryocytes and thrombocytopenia
 Treatment of leukemias –
 There are 2 goals:
 Eradicate the leukemic cell mass
 Give supportive care

 Except for ALL in children, cures are not

common but complete remission (absence of
any leukemia related signs and symptoms and
return of bone marrow and peripheral blood
values to within normal values) is
ACUTE LEUKEMIAS
 There are four general types of therapy
 Chemotherapy – usually a combination of drugs is used
 Bone marrow transplant

 Radiotherapy

 Immunotherapy – stimulate the patients own immune

system to mount a response against the malignant cells
 Monoclonal antibodies – examples include Rituxin