Leukemia 2009f

Today’s Quranic verse

And hold fast, all together, by the rope which God (stretches out for you), and be not divided among yourselves; and remember with gratitude God's favour on you; for ye were enemies and He joined your hearts in love, so that by His Grace, ye became brethren; and ye were on the brink of the pit of Fire, and He saved you from it. Thus doth God make His Signs clear to you: That ye may be guided. [003:103]

DISORDERS OF WHITE BLOOD CELLS

Palangka Raya UniversityJumat 21 April 2023

White blood cell types (WBC differential)

Neutrophils: 47%–77%

Band neutrophils: 0%–3%

Lymphocytes: 16%–43%

Monocytes: 0.5%–10%

Eosinophils: 0.3%–7%

Basophils: 0.3%–2%

White blood cell (WBC) count

4,000–11,000 per microliter (µL)

Name the different cells.

Neutrophil (Band Cell)

Platelet

Eosinophil

Monocyte

Lymphocyte

MatureNeutrophil

Basophil

Red Blood Cell (Mature Erythrocyte)

BENIGN DISORDERS OF LEUKOCYTES

• Leukocytosis Condition characterized by abnormally increased number of

WBC. It may be generalized or involve only individual granulocytes

or agranulocytes.

• Leukopenia: Condition characterized by abnormally reduced number of

WBC. It may be generalized or involve only neutrophils or

lymphocytes

Neutrophilic leukocytosis

Acute bacterial infections, especially those caused by pyogenic organisms; sterile inflammation caused by, for example, tissue necrosis (myocardial infarction, burns)

Eosinophilic leukocytosis

Allergic disorders such as asthma, hay fever, allergic skin diseases (e.g., pemphigus, dermatitis herpetiformis); parasitic infestations; drug reactions; certain malignancies (e.g.,Hodgkin disease and some non-Hodgkin lymphomas); collagen vascular disorders and some vasculitides; atheroembolic disease (transient)

Basophilic leukocytosis

Rare, often indicative of a myeloproliferative disease (e.g., chronic myelogenous leukemia)

Monocytosis Chronic infections (e.g., tuberculosis), bacterial endocarditis, rickettsiosis and malaria; collagen vascular diseases (e.g., systemic lupus erythematosus) and inflammatory bowel diseases (e.g., ulcerative colitis)

Lymphocytosis Accompanies monocytosis in many disorders associated with chronic immunologic stimulation(e.g., tuberculosis, brucellosis); viral infections (e.g., hepatitis A, cytomegalovirus, Epstein-Barr virus); Bordetella pertussis infection

LEUKOCYTOSIS

Reduced or ineffective production ofneutrophils

Accelerated removal of neutrophils

from the circulating blood

Leukemoid reaction

• Leukemoid reaction is defined as a reactive leukocytosis in excess of 50 000/μL. It is usually seen in response to infection, inflammation, or therapeutic agents such as growth factors and is less commonly caused by malignancy. Milder elevations in leukocyte count are common both in carcinoma and Hodgkin lymphoma.

• Cells are more mature than myelocytes in peripheral smear

• Leukocytic alkaline phosphatase activity is high

• Neutrophils contain toxic granules (Dohle bodies)

LEUKEMIAS

Neoplastic Proliferations of White Cells

Lymphoid neoplasms Myeloid neoplasms Histiocytoses

LymphomaChloroma

HEMOPOIESISMYELOID/ LYMPHOIDSTEM CELLS

(CD34)

LYMPHOID STEM CELLS

MYELOID STEM CELLS

LYMPHOCYTES OTHER BLOOD CELLS

HEMOPOIESISMYELOID/ LYMPHOIDSTEM CELLS

(CD34)

LYMPHOID STEM CELLS

MYELOID STEM CELLS

LYMPHOCYTES RBCOTHERWBC

PLATELET

HEMOPOIESIS

MYELOID/ LYMPHOIDSTEM CELLS

(CD34)

MYELOIDSTEM CELLS

PRO-NORMOBLAST

EARLYNORMOBLAST

INTERMEDIATENORMOBLAST

LATENORMOBLAST

RETICULOCYTE

RBC

MONOBLAST

PROMONOCYTE

MONOCYTE

MYELOBLAST

PRO-MYELOCYTE

MYELOCYTE

META-MYELOCYTE

BAND or STAB

GRANULOCYTES

MEGAKARYOCYTE

MEGAKARYOBLAST

PLATELET

HEMOPOIESISMYELOID/ LYMPHOID

STEM CELLS(CD34)

LYMPHOID STEM CELLS

Pre-T

Thymocyte

Peripheral T Cells

T-Helper

T-Supp.

Pro-B

Pre-B

B- Virgin

B- Mature

LPC

PLASMACELL

LEUKEMIAS

Leukemias are usually diseases of unknown etiology

Abnormal Uncontrolled

WidespreadWidespread

Proliferation of

WBCClonal

Leukemia

Etiology and Pathophysiology

• Associated with the development of leukemia – Chemical agents

– Chemotherapeutic agents

– Viruses

– Radiation

– Immunologic deficiencies

– Underlying hematologic disorders

– Hereditary/genetic conditions

– Idiopathic

LEUKAEMIAMYELOID/ LYMPHOIDSTEM CELLS

(CD34)

LYMPHOID STEM CELLS

MYELOID STEM CELLS

LYMPHOCYTES GRANULOCYTES

ACUTECHRONIC

Lymphoblasts

Lymphocytes Granulocytes

Myeloblasts

ALL AML

CMLCLL

HEMOPOIESISMYELOID/ LYMPHOID

STEM CELLS(CD34)

MYELOIDSTEM CELLSPRO-

NORMOBLAST

RBC

MONO-BLAST

MONOCYTE

MYELOBLAST

PRO-MYELOCYTE

MYELOCYTE

META-MYELOCYTE

BAND or STAB

GRANULOCYTES

MEGA-KARYO-BLAST

PLATELET

AMLCML

HEMOPOIESISMYELOID/ LYMPHOID

STEM CELLS(CD34)

LYMPHOID STEM CELLS

Pre-T

Thymocyte

Peripheral T Cells

T-Helper

T-Supp.

Pro-B

Pre-B

B- Virgin

B- Mature

LPC

PLASMACELL

ALL

CLL

Acute Leukemia means

Maturation Arrest

Sustained SELF-RENEWALAT THE EXPENSE OF

DIFFERENTIATION

Differentiation (Maturation)

Self-renewal

Maturation Arrest

Sustained self-renewal

Learn how to say “No” courteoulsy & Learn how to say “No” courteoulsy & promptlypromptly.

LEUKEMIAS

TYPES

INCIDENCE

AGE

PRESENTATION

BONE

MARROW

Anemia

Neutropenia

Thrombocytopenia

CNSBONESKIN

LYMPHATICSetc

OTHERS

ALL AML

CMLCLL

TYPES & AGE

CH

ILDR

EN

YOUNG ADULTSM

iddle Age

But ,also

any ageElderly

Acute Leukemias (AML/ALL)

Block in differentiation–“blasts” with prolonged generation time↓

Accumulation of “blasts’ (Result from a clonal expansion & Failure of maturation)

↓Suppress normal hematopoiesis

(↓ in normal RBCs, WBCs and PLTs)

Aim of TX is to reduce the leukemic clone to allow reconstitutionwith the progeny of remaining normal stem cells

Acute Leukemias (AML/ALL)

Clinical features

• Abrupt onset

• Symptoms related to BM depression– Fatigue from anemia, fever from infection, bleeding from thrombocytopenia

• Bone pain and tenderness– BM expansion with subperiosteal infiltration

• Generalized adenopathy, hepatosplenomegaly (ALL>AML)

• CNS manifestations (ALL>AML)– Headache, vomiting, nerve palsies

Acute Leukemias (AML/ALL)

• Laboratory– Leukocytosis (>100,000 or <10,000) with “blasts” in circulation & BM– Lymphoblasts: with + PAS aggregates– Myeloblasts: + myeloperoxidase– Thrombocytopenia

• Immunophenotyping– Tdt (DNA polymerase): + in 95% of ALL– Lineage specific markers: CD19, CD10 (B cell), CD1 CD2, CD5 CD7 (T cell)– CD33 & CD34 in AML

• Karyotyping (predictive of prognosis)– Usually nonrandom abnormalities– ALL; Pre - B: Hyperdiploidy assoc with t(12,21) - good & Ph chromosome – poor– AML; t(8;21) and inv(16 ) and t(15;17) Prognosis – > 60% of the patients achieve complete remission with chemotherapy, but only 15% to

30% remain free from disease for 5 years– >90% of children with ALL achieve complete remission, and 2/3 can be cured

Acute Leukemia

• Diagnosis: >20% blasts in the bone marrow• Categorized by

– H&E staining– Cytochemical stains (myeloperoxidase, NSE, PAS)– Flow cytometry– Cytogenetics

M1

M5

L2 LYMPHOBLAST

MYELOBLAST

MONOBLAST

SPECIAL STAINS

PAS

*Sudan Black*Myeloperoxidase*Specific Esterase

Non-Specific Esterase

Blasts

Features Myeloblasts Lymphoblasts

Cytoplasm Mod/abundant Scant/Mod

Cyt. Granules Common Uncommon

Nucleus (chromatin)

fine Coarse

Nucleoli Prominent Variable

Auer rods Present Absent

Shed hate and rancour, they hurt Shed hate and rancour, they hurt youyou more than they do more than they do others.others.

AML

ACUTE LEUKEMIASFAB CLASSIFICATION

M0

M1

M2

M3M4

M5

M6

M7L1

L2

L3

ALL

AML

ACUTE MYELOID LEUKEMIA

FAB CLASSIFICATION

M0

M1

M2

M3M4

M5

M6

M7

FAB Classification of AMLClass Morphology Comments

M0 Blasts lack cytologic markers

2-3%

M1 Very immature myeloblasts 20% (Ph chromosome worsens prognosis)

M2 Myeloblasts & promyelocytes 30%, t,(8;21) good prognosis

M3 Hypergranular promyelocytes“many auer rods”

5-10% DIC, t(15,17)Responds to ATRA

M4 Myelocytic & monocytic diff.

20-30%, inv16/del16q betterprognosis

M5 Monoblasts & promonocytes 10%, pediatric age-young adults, 11q23 abnormalities

M6 Erythroblasts > myeloblasts 5%, older adults

M7 Megakaryocytic blasts Myelofibrosis

Myeloid maturation

myeloblast promyelocyte myelocyte metamyelocyte band neutrophil

MATURATIONMATURATION

Adapted and modified from U Va website

M1M2

M3 M4 M5

M6 M7

AML

Auer rods in AML (M3)

Hypergranular promyelocytes,“many auer rods” 5-10% DIC, t(15,17), Responds to ATRA

CD M1/M2 M3 M4/M5 M6 M7

CD11b - + ++ - -

CD13 + + ++ + +

CD14 - - ++ - -

CD15 + + ++ - -

CD33 ++ + ++

+ +

CD34 ++ + + + +

Immunophenotyping of AML

ALLL1

L2

L3

FAB CLASSIFICATION

ACUTE LYMPHOBLASTIC LEUKEMIAS

L1

FAB CLASSIFICATION

ACUTE LYMPHOBLASTIC LEUKEMIAS

Lymphoblasts:Small & Monomorphic

ALL

ALL L2

FAB CLASSIFICATION

ACUTE LYMPHOBLASTIC LEUKEMIAS

Lymphoblasts:Large & Heterogeneous

L3

FAB CLASSIFICATION

ACUTE LYMPHOBLASTIC LEUKEMIAS

Burkitt ALL

ALL

Immunophenotyping of ALL

In the 10% to 20% of cases in which morphology and cytochemistry are inconclusive or insufficient to

Distinguish AML and ALL,

immunophenotype analysis provides the diagnosis in virtually all cases

Using a combination of CDs specifically recognizing B-cell, T-cell, and myeloid antigens, it is possible to distinguish

AML from ALL in 95% to 99% of cases

Beware of who has nothing to lose.Beware of who has nothing to lose.

Pallor

Purpura

Infection

Mucosal Bleeding

Oral CandidiasisPneumonia

Extensive Bruising

Gum Hypertrophy

Lymphadenopathy

Lymphadenopathy Leukemic Infiltrate

Retinal Bleed

Leukemic Infiltrate

Lytic Skull Lesions

Mediastinal Involvement

Chloroma

2% of AML have discrete tumors

Chloroma (Myeloblastoma)

Granulocytic SarcomaIn the Orbit, Para-nasal sinuses, Brain, Spinal cord, Bone, Breast

Skin & Subcutaneous tissues

Called chloromas because of greenish color from ↑MPO

A

B

C

Chloromas

NEJM 1998

Precursor B- and T- Cell Lymphoblastic Leukemia/Lymphoma

• Aggressive tumors of children/young adults• Composed of immature lymphocytes (lymphoblasts)• Lymphoblastic tumors are indistinguishable morphologically with

similar symptomatology– Pre-B: present as leukemias with extensive BM involvement (CD19+ and

CD10+) – Pre-T: mediastinal masses involving the thymus progress rapidly to a leukemic

phase or involve BM (CD1+, CD2+, CD5+, and CD7+)– Both pre-B/T lymphoblastic tumors have the clinical appearance of ALL at some

time during their course– Hyperploidy (>50 chromosomes), polyploidy, and t(12;21), t(9;22) and t(4;11)– >90% of children with ALL achieve complete remission, and 2/3 can be cured

• ALLs comprise 80% of childhood leukemia (peaks at age 4) and are usually pre-B phenotype

Acute Leukemia Treatment

The goal is to reduce and eventually eradicate the leukemic cell population while restoring normal hematopoiesis

Both normal and leukemic cells coexist & effective therapy will sufficiently reduce the leukemic cell burden to allow re-growth of normal myeloid progenitors.

Non-neoplastic cells repopulate the marrow after chemotherapy-induced remissions in most patients

The Future

• Clinical trials• New drug treatments• Vaccines• Immunotherapy• Leukemia type-specific therapy• Gene therapy

– Block encoding instructions of an oncogene– Target the oncoprotein

• Blood and marrow stem cell transplantation– Bone marrow transplantation provides long-term, disease-free survival

among patients in remission

Take a Break !…

Don’t lose control at any time; take a deep Don’t lose control at any time; take a deep breathbreath

Chronic Myeloproliferative Disorders

• Disorders of multipotent progenitor cells ( myeloid & Lymphoid precursor)• Increased, Functionally abnormal cells. • Extramedullary hemopoiesis - Organomegaly• End stage

– Progress to Leukemia– Myelofibrosis

• Chronic myelogenous leukemia (CML)• Polycythemia vera (PV)• Myeloid metaplasia with myelofibrosis (MMF)• Essential thrombocythemia

Chronic Myeloid Leukemia

The First Disease

The First Disease

The 1st disease for which the term leukemia was used (Virchow 1845; White Blood)

The 1st malignancy ~ with a recurring chromosomal abnormality (Philadelphia Chromosome)

The first disease in which the associated chromosomal abnormality was found to result fromthe translocation of genetic material from one chromosome to another to form fusion gene(BCR/ABL)

The first disease in which the fusion gene was recognized as giving rise to an abnormal fusion protein fundamental in the pathogenesis of the disease.

The first disorder in which a therapeutic agent “Glivec” has been designed to specifically targetthe molecular defect

Chronic myelogenous leukemia (CML)

• Adults, usually 40-50• Philadelphia chromosome• Clinical: slow onset, nonspecific symptoms, marked splenomegaly• Lab: leukocytosis (>100,000)

– PMNs, myelocytes, eosinophils, basophils, <5% “blasts”• BM: hypercellular (granulocytic/megakaryocytic)• D/D: leukemoid reaction (↑LAP)• Course: 50% accelerated phase

– ↑ anemia, ↓ PLTs, ++ cytogenetic abn, blastic crisis

CML

ChronicPhase

AcceleratedPhase

CML

BlastCrisis

STAGING OF CML

Three main stages, determined by percentage of blast cells in the blood

- Chronic Phase- Patient usually diagnosed- Fewer than 10% of cells in blood and bone marrow are blast- Prognosis: (with imatinib) 5yr: 70%, 10yr: 30-40%

- Accelerated Phase- 10-19% of cells in blood or bone marrow are blast, Basophilia ≥ 20%

- Blastic Phase, aka “blast crisis”- Fulminant symptoms of disease, multiple organ involvement- 20-30% or more blasts in bone marrow and blood- Prognosis: UNPROMISING, 2 months, may extend survival with newer

drugs or chemotherapy

Ph chromosomePh chromosome

BCR-ABLBCR-ABL (activated activated tyrosine kinase)tyrosine kinase)

BCRBCR ABLABL

CMLCML

The Philadelphia (Ph) Chromosome Leads to CML

bcr

abl

fusion 9abl/bcr

fusion 22bcr/abl

Practical Guidelines to Diagnose and Monitor CML

Test GuidelinesRoutine cytogenetic analysis

At diagnosis and every year

I-FISH Pretreatment to have baseline percent of Ph-positive cells, then every 2-3 mo until Ph <10%.

D-FISH As for I-FISH. Reliability for lack of false positivity when Ph 5-10% under investigation.

H-FISH As for I-FISH. No false-positives; can be used when Ph <10%

Southern blot At diagnosis, particularly if patient has morphologic CML but is Ph-negative by routine cytogenetics; does not detect p190 or p230.

PCR quantification Monitor minimal residual disease status in patients who are 0% Ph-positive; critical BCR-ABL to ABL ratio of 0.045 may be used for treatment decisions.a

Detection of p190 disease

Specific PCR primers.

Detection of p230 disease

Specific PCR primers.

D-FISH, double-probe fluorescence in situ hybridization; H-FISH, hypermetaphase fluorescence in situ hybridization; I-FISH, interphase fluorescent in situ hybridization; PCR, polymerase chain reaction

Treatment

• Chemotherapy:• Tyrosine kinase inhibitor:• Interferon-.• Stem cell transplant.

Own up to your Own up to your mistakes.mistakes.

Imatinib (Gleevec)

Normal Bcr-Abl Signaling

• The kinase domain activates a substrate protein, eg, PI3 kinase, by phosphorylation

• This activated substrate initiates a signaling cascade culminating in cell proliferation and survival PP P

ADP P

P

PP P

ATP

SIGNALING

Bcr-Abl

Substrate

Effector

ADP = adenosine diphosphate; ATP = adenosine triphosphate; P = phosphate.Savage and Antman. N Engl J Med. 2002;346:683Scheijen and Griffin. Oncogene. 2002;21:3314.

Imatinib Mesylate Mechanism of Action

• Imatinib mesylate occupies the ATP binding pocket of the Abl kinase domain

• This prevents substrate phosphorylation and signaling

• A lack of signaling inhibits proliferation and survival

P

PP P

ATP

SIGNALING

Imatinib mesylate

Bcr-Abl

Savage and Antman. N Engl J Med. 2002;346:683.

Impressive Results in CML ...

0102030405060708090

100

Late chronic phase Accelerated phase Blast crisis

Hematologic response Major cytogentic response (MCR)

(n=532) (n=235) (n=260)

89%

68%

55%

23%29%

15%

< 10% of patients on IFN have MCR1

1 Kantarjian, 1998

Don’t hesitate to lose a battle if it helps you win the war

Chronic Lymphoid Leukemia

Chronic Lymphocytic Leukemia (CLL)

• Most common form of leukemia in North America and Northern Europe• Essentially identical to small lymphocytic lymphoma (SLL)• M > F (2 : 1)• Elderly (>60 y/o)• Considered incurable• Mostly asymptomatic• Hepatosplenomegaly may be present (in later stages)• Symmetrical lymphadenopathy• Peripheral lymphocytosis (>200,000)• Increased susceptibility to bacterial infection (most frequent cause of

death)• May associated with autoimmune hemolytic anemia &

Thrombocytopenia

• Indolent clinical course• Median survival : 4-6 yrs• Occasional transformation to large non-Hodgkin’s

lymphoma (Richter’s syndrome) --- 3 to 5 %

Chronic Lymphocytic Leukemia (CLL)

CLL:

lymphocytes

‘smudge’ cells

CLL

Investigation:

• CBC:

– WBC:.

– Diff:lymphocytosis ,the absolute lymphocyte count is>5x109/l and may be up to 300x109/l or.

Blood film:

70-99% of white cells mature lymphocyte.

Smudge or smear cells also present.

Immunophenotyping:

Shows that the lymphocyte are B cells

(CD19) expressing one form of light chain

( or only) cells are also CD5 & CD23+ve.

• Bone marrow aspiration:

Lymphocytic replacement of normal marrow.

• Immunoglobulinelectrophoresis: of Ig, more marker with advance disease.

• Cytogenetic :

The 4 most common abnormalities are; deletion of13q14,trisomy 12, deletion of 11q23 & structural abnormality of 17p involving the p53 gene.

RaiStaging

CLL

CLL

Marrow

<20%

Lymph-ocytes

Lymphocyte1,500 to 4,000

/uL

NoPalpable

L.N.

NoPalpableDisease

NormalHb

NormalPlatelets

BLO

OD

MARROW

Ab

dom

en

L. N.

Hb.

Plate

let

SURVIVALGOK

CLL

Marrow

>40%

LC

LC>

15,000/uL

NoPalpable

L.N.

NoPalpableDisease

NormalHb

NormalPlatelets

SURVIVAL150

months

Stage “0”

CLL

Marrow

>40%

LC

LC>

15,000/uL

PalpableL.N.

NoPalpableDisease

NormalHb

NormalPlatelets

SURVIVAL101

months

Stage “I”

CLL

Marrow

>40%

LC

LC>

15,000/uL

PalpableL.N.

Hepato-Spleno-megaly

NormalHb

NormalPlatelets

SURVIVAL71

months

Stage “II”

CLL

Marrow

>40%

LC

LC>

15,000/uL

PalpableL.N.

Hepato-Spleno-megaly

Anemia NormalPlatelets

SURVIVAL19

months

Stage “III”

CLL

Marrow

>40%

LC

LC>

15,000/uL

PalpableL.N.

Hepato-Spleno-megaly

Anemia Thrombo-cytopenia

SURVIVAL19

months

Stage “IV”

BinetStaging

CLL

CLLGroup A

No anemia or thrombocytopenia, < three of five lymph node areas

Group BNo anemia or thrombocytopenia,

Three or more lymph node areas

Group CAnemia (Hb <10 g/dL) or

Thrombocytopenia (Platelets <100 x 109/L)

AxillaryL.N.

InguinalL.N.

CervicalL.N.

Liver

SpleenBinet Staging of CLL

Do onto others as you wish others did onto you.

Hairy Cell Leukemia

• Uncommon variant of peripheral B-cell neoplasm

• Clinically Middle age to elderly (younger than CLL)• splenic red pulp involvement• Histologically Lymphocyte with finger-like projections• Phenotypically TRAP (Tartrate Resistant Acid

Phosphatase)• CD19, CD20

Hairy Cell Leukemia clinical

• M > F (3-5 : 1)• Splenic red pulp involvement red pulp “lake”• Bone marrow & liver involvement• Tends to follow an indolent course

– Pancytopenia - most prominent feature• - Granulocytopenia recurrent bacterial infection• - Anemia fatigue• - Thrombocytopenia bleeding

• Good response to some chemotherapy regimen

Myelodysplastic Syndrome• Group of Clonal stem cell disorders characterized by ineffective

hematopoiesis, hypercellular marrow with left-shift (increase of blasts, 5- <20%) and peripheral cytopenias. Higher grade MDS (blasts >10%) may eventually transform into acute myeloid leukemia or progress into marrow failure.

• Types– Primary or Idiopathic = > 50yrs, Gradual in onset, risk of AML ↑– Rx ( RT or Drugs) related (t MDS) = after 2 -8 of RX, complication of Rx, Higher risk

of AML (↑ ↑ ↑)• Pathogenesis

– Unknown

• FAB classification (based on % blasts and ringed sideroblasts)

1. Refractory anemia(RA)2. Refractory anemia with ringed sideroblasts (RARS)3. Refractory anemia with excess blasts (RAEB)4. Refractory anemia with excess blasts in transformation (RAEB-T)5. CMML (chronic myelomonocytic leukemia)

• Cytogenetic abnormalities– Deletions (5q,7q,20q), Monosomy (5 & 7), Trisomy (8)

• Morphology– Marrow = usually Hypercellular,

• Erythroid precursors - ring Sideroblasts, budding nucleated cells, • Granulocytic – Megaloblastoid, Pseudo Pelger – Huet

neutrophils( two nuclear segments), • Megakaryocytes- Pawn ball type( multinucleate)

– Peripheral Blood = Cytopenias ( Pancytopenia)

• Patients present with Refractory Anemia’s (not responding to hematenics even after 6 months of Rx )

Myelodysplastic Syndrome

Don’t be afraid to say “I don’t know” and “I’m Don’t be afraid to say “I don’t know” and “I’m sorrysorry