LEUKEMIAS

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LEUKEMIAS

• Definition
• Molecular biology
• Chromosomal abnormalities
• Etiology
• Acute leukemias (AML and ALL).

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Molecular biology of Leukemogenesis

• Inappropriate expression of genes that regulate
  basic steps in cell proliferation.
• Proto-oncogenes?Oncogenes.
• Point mutations, Gene amplification,,
  translocation.
• Philadelphia chromosome in CML ALL.
• ABL on Chr-9, BCR on Chr-22.

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Chromosomal abnormalities

• Very common in leukemias.
• Diagnosed by banding techniques.
• t (821), t(922), inv(16), t(1517).
• gt50 of cases of leukemias have Chr.
  abnormalities.
• Helps in diagnosis, prognosis, treatment
  outcome.. Etc.

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Etiology

• Radiation Ionizing, Non ionizing.
• Chemicals Benzene, alkyalating agents.
• Viruses Leukemogenic viruses with RT enzyme,
  HTLV-1.
• Genetic factors Downs, Blooms, Fanconis,
  Ataxia talengiectasia.

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Acute leukemias

• Aggressive course.
• High mortality.
• Dominant cell is the Blast.
• Classification based on morphology of PS, BM,
  Cytochemistry,Immunophenotyping.
• Criteria is more than 20 blasts in BM or PS
• 8 AML morphological types 3 ALL types.

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ACUTE MYELOID LEUKEMIAS (AML)

• AML with Recurrent Cytogenetic Abnormalities.
• AML with Multilineage Dysplasia.
• AML MDS Therapy related.
• AML not otherwise Categorized (M0-M7)
• AML with Ambiguous Lineage.

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Clinical features of AML

• Primarily in adults and in infants less than 1 yr
• 15 to 20 of all leukemias
• More No. of cases after age 50 yrs.
• Abrupt onset of symptoms.. Within weeks to months.

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• Palor, fatigue, weakness, anaemia.
• Bleeding, bruising, petichial hemorrhages.
• Infections, pneumonia, meningitis
• Spleenomegaly, hepatomegaly, lymphadenopathy.
• DIC in AML-M3, skin infiltration soft tissue
  masses in AML- M5 etc.

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Diagnosis of AML

• High index of clinical suspicion
• Family history, past history.
• Simple PS examination.
• PS, Bone marrow, Cytochemistry,
  Immunophenotyping, Cytogenetics,
• Other lab tests Serum uric acid, LDH, RFT,
  Sr.Ca, electrolytes

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Cytochemistry

• Sudan black B, Myeloperoxidase (MPO)
• Periodic acid schiff (PAS)
• Non- specific esterase (NSE)
• Acid phosphatase

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MONOCLONAL Ab IN THE CLASSIFICATION OF ACUTE
LEUKEMIAS

• Hematopoetic precursors CD 34, HLA-DR, TdT, CD
  45
• B-LineageCD 19, CD 20, Cyto CD 22, CD79a.
• T Lineage CD 2, Cyto CD 3, CD 5, CD 7.
• Myeloid MPO, CD 117, 13, 33, 15.
• Monocytic CD 14, 116, 11c, 36, Lysozyme
• Megakaryocytic CD 41, 61
• Erythroid CD 36, 71, Glcophorin A.

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Blood picture

• Anaemia, Thrombocytopenia,
• WBC Range from 10,000 to more than 1 lakh /
  cumm.
• Leukemia presenting as pancytopenia!!!
• Blasts in PS and neutropenia.
• Buffy coat smear may be useful.
• Predominantly immature stages of maturation.

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AML not otherwise CATEGORISED

• AML-Minimally differentiated M0
• AML without Maturation M1
• AML with Maturation M2
• Acute promyelocytic leukemia M3
• Acute Myelomonocytic Leukemia M4
• Acute Monocytic Leukemia M5
• Acute Erythroid Leukemia M6
• Acute Megakaryocytic Leukemia M7

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AML-Minimally Differentiated M0

• No evidence of Myeloid differentiation on Light
  microscopy.
• Immunophenotyping EM-Cytochemistry.
• Adults, 5 of AML.
• Cytochem MPO, SBB, NSE ve or
• MPO in lt3, EM-MPO .
• DDs ALL, AML-M7, Mixed Leukemia, Leukemic phase
  of LCL.

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AML-Minimally Differentiated M0

• Immunophenotyping
• Panmyeloid markers CD 13, 33, 117 .
• BT Lymphoid markers CD 3, 22, 79a ve.
• Stem cell Markers CD 34, 38 HLA-DR
• Myelomonocytic markers CD 11b,15,14,65-ve.
• TdT Positive in 30 of Pts.
• Genetics- Nothing Unique
• PrognosisPoor, Low remission, Increased Relapse,
  Shorter survival.

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AML without MATURATION M1

• 10 of AML, Adults.
• Increased BM Blasts
• No significant evidence to show Maturation
• gt 90 Blasts are Non-Erythroid.
• Morphology Auer rods?, MPO, SBB gt3
• IPT At least two Myelomonocytic antigens CD13,
  33, 117 or MPO are . CD34 often
• Negative for Monocytic Ag CD 11b, 14.
• Ab to MPO Positive.
• Prognosis Aggressive course

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AML with MATURATION M2

• Bimodal age presentation.
• 30-45 of AML
• Criteria gt20 Blasts in PS/BM, gt10 Neutrophils
  in Diff. Stg of Maturation, lt20 Monocytes.
• MorphologyBlasts with or without Azurophilic
  granules. Auer rods .
• Cytogenetics del 12p, t(69) assoc. with BM
  Basophilia. T(816) assoc. with Hemophagocytosis.

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AML with MATURATION M2

• IPT One or more Myeloid Ag CD13, 33, 15 are .
• Many express CD117, 34, HLA-DR
• Prognosis Responds to Aggressive treatment.
  Survival rates vary.
• t(821)- Favorable prognosis.
• t(69)- Poor prognosis.

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AML M3

• Hypergranular or Typical APL
• Hypogranular APL.
• 5-8 of AML, Middle aged Adults.
• Hypogranular Assoc. with High WBC count
  increased Doubling Time.
• Morphology FAB-AML-M3.
• MPO Strongly , NSE weakly in 25.
• Homogenous CD33, Heterogeneous CD13
• Sensitive to Rx with ATRA

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ACUTE MYELOMONOCYTIC LEUKEMIA (AMMoL) M4

• 15-25 of AML.
• All ages, MC in older persons. Few Pts are with
  H/O CMML.
• Criteria Blasts in PS/BM gt20, Neutrophil
  precursors gt20, Monocytes gt20.
• Cytochemistry MPO in gt3, NSE .
• IPT Myeloid markers CD 13, 33, Monocytic
  markers CD14,11b,11c,64,36
• Prognosis Increased BM Eosinophils are assoc.
  with inv16- Good prognosis.

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ACUTE MONOCYTIC LEUKEMIA (AMoL) M5
Morphology Auer rods rare, NSE is Intense
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ACUTE MONOCYTIC LEUKEMIA (AMoL) M5

• IPT Variable expression of Myeloid markers CD
  13, 33, 117. Monocytic markers are CD 14, 4,
  11b, 11c, 64, 68. CD 34 -Ve.
• Genetics AMoL with del 11q23 (MLL).
• t(816)- M5b assoc. with Hemophagocytosis
  Coagulopathy.
• Prognosis Both types have aggressive clinical
  course.

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ACUTE ERYTHROID LEUKEMIA M6
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ACUTE ERYTHROID LEUKEMIA M6

• Morphology Iron stain shows RS. PAS diffuse
  pattern in Erythroid precursors. MPO/SBB in
  Myeloblasts.
• IPTMyeloid markers ve.Anti MPO is ve.
  Glcophorin A, Hb-A Ab . Myeloblasts show CD13,
  33, 177 .
• Genetics No specific
• Prognosis 6a- Aggressive clinical course.
• 6b- Rapid clinical course.

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ACUTE ERYTHROID LEUKEMIA M6

• What to Do?
• Differential count of all the Nucleated cells to
  be done.
• If Erythroid precursors are gt50 of the cells
  then
• Do Separate DC of all Non-Erythroid cells.
• If ?20 are Non Erythroid blasts----M6a
• If lt20 are Non Erythroid blasts---RAEB

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ACUTE MEGAKARYOCYTIC LEUKEMIA (AMgL) M7

• 3-5 of cases of AML.
• gt50 cells in BM are Megakaryocytic lineage.
• Can present as Denovo, Rx related, Post MPD/MDS.
• Dry marrow is common, Osteolysis/ osteosclerosis,
  Raised LDH.
• EM shows Platelet peroxidase .

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ACUTE MEGAKARYOCYTIC LEUKEMIA (AMgL) M7

• IPT Most of Myeloid Lymphoid markers are ve.
  Rarely CD 33, 34.
• Megkaryocyte lineage markers CD 41, 42b,
  61,Factor VIII related Ag .
• Genetics t(122)- Infants with Extensive
  organomegaly.
• Prognosis Downs syndrome do well. Pts with
  Myeloscerosis- Bad. t(122) Poor prognosis.

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AML WITH RECURRENT CYTOGENETIC ABNORMALITIES

• AML with t(821), (AML1/ETO)
• AML with inv16 or t(1616) (CBF?/MYH11)
• AML with t(1517) (PML/RAR?)
• AML with 11q23 (MLL) abnormalities.

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AML WITH RECURRENT CYTOGENETIC ABNORMALITIES

• Mainly Balanced Translocations also are seen
  Inversions and Deletions.
• Associated with High rate of Complete Response
• Favorable prognosis
• Cytogenetics have low sensitivity.
• Molecular genetics ( RT-PCR) shows high yield.

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AML with Multilineage Dysplasia

• AML with gt20 blasts in PS/BM Dysplasia in 2 or
  more cell lines including Megakaryocytes.
• gt50 cells to show Dysplasia
• 1. With prior MDS 2. With out Prior MDS
• These features to be present in Pre Treatment
  specimen.
• Terminology AML Evolving from a MDS

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AML MDS Therapy related

• 1. Alkylating agents
• 2. Topoisomerase II inhibitors
• Diagnosis is appropriate if Specific morphology,
  Genetic category Therapy is present.
• ALL can also be seen ( with Topoisomerase II
  Inhibitors)

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Prognostic Factors in AML-Clinical
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Prognostic Factors in AML-Morphology
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Prognostic Factors in AML-IPT, GENETIS
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