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Chronic Leukemia

Ahmad Sh. Silmi, Msc, FIBMSAhmad Sh. Silmi, Msc, FIBMS

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The definition of chronic leukemia:

Chronic leukemia is thought to arise from genetic Chronic leukemia is thought to arise from genetic defect in a single cell in B.M or in the peripheral defect in a single cell in B.M or in the peripheral tissue. When this cell success to proliferate gives tissue. When this cell success to proliferate gives rises to a clonal population that will give mass rises to a clonal population that will give mass which when enlarged enough caused a serious which when enlarged enough caused a serious disease. disease.

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What Are the Types of Chronic Leukemia?

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Classification of CL.

There are two types:There are two types:

1- chronic myeloid leukemia.1- chronic myeloid leukemia.

2- chronic lymphoid leukemia.2- chronic lymphoid leukemia.

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Chronic Myeloid Leukemia.

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Definition of CML:

CML is defined as a stem cell disorder suggested CML is defined as a stem cell disorder suggested as Philadelphia chromosome found in all stem as Philadelphia chromosome found in all stem cells. So there is replacement of normal B.M cells cells. So there is replacement of normal B.M cells by cells with an abnormal chromosome – by cells with an abnormal chromosome – Philadelphia or (ph) chromosome Philadelphia or (ph) chromosome

t (9; 22)(q34; q11).t (9; 22)(q34; q11).

Constitute six different types of leukemia.Constitute six different types of leukemia.

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Types of Chronic CML:

Type Type namename

11 (CML,Ph+)(chronic granulocytic leukemia) (CML,Ph+)(chronic granulocytic leukemia)

22 (CML,Ph-)(CML,Ph-)

33 Juvenile CMLJuvenile CML

44 Chronic neutrophilic leukemia.Chronic neutrophilic leukemia.

55 Esinophilic leukemia Esinophilic leukemia

66 Chronic myelomonocytic leukemiaChronic myelomonocytic leukemia

Incidence CML comprises <20% of all leukaemia, its rarer CML comprises <20% of all leukaemia, its rarer

than CLL. than CLL.

The incidence rate is 1-2/100,000The incidence rate is 1-2/100,000-1 -1 population; population; with a peak of incidence in the middle age people.with a peak of incidence in the middle age people.

The disease occur in either sex (male: female The disease occur in either sex (male: female 1.4:1), however, it may occur in children, 1.4:1), however, it may occur in children, neonates and very old people. neonates and very old people.

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What Is Philadelphia Chromosome?

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Philadelphia :

Is the chromosome which result from the Is the chromosome which result from the t(9;22)(q34;q11)t(9;22)(q34;q11)part of the Abelson proto-part of the Abelson proto-oncogene ABL is moved to the BCR gene on oncogene ABL is moved to the BCR gene on chromosome 22 & part of chromosome 22 chromosome 22 & part of chromosome 22 moves to chromosome 9.moves to chromosome 9.

The abnormal chromosome 22is the Ph.The abnormal chromosome 22is the Ph.

See fig.See fig.

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Fig

Pathogenesis

Hematopoietic abnormality

● Expansion of granulocytic progenitors and a decreased sensitivity of the progenitors to regulation – increased white cell count

● Megakaryocytopoiesis is often expanded

● Erythropoiesis is usually deficient

● Function of the neutrophils and platelet is nearly normal

Pathogenesis

Genetic abnormalityGenetic abnormality CML is the result of an acquired genetic abnormalityCML is the result of an acquired genetic abnormality A translocation between chromosome 9 and 22 [t(9;22)] – A translocation between chromosome 9 and 22 [t(9;22)] – the Philadelphia chromosome the Philadelphia chromosome The oncogene BCThe oncogene BCRR-ABL encodes an enzyme – tyrosine -ABL encodes an enzyme – tyrosine phosphokinase (usually p210)phosphokinase (usually p210)The function of the normal abl gene product ( p145The function of the normal abl gene product ( p145ablabl ) ) is incompletely understood but it is known to have is incompletely understood but it is known to have tyrosine kinase activity and may play a role in the tyrosine kinase activity and may play a role in the regulation of several different growth factor receptors, regulation of several different growth factor receptors, including those for epidermal growth factor, platelet including those for epidermal growth factor, platelet derived growth factor, and colony stimulating factor derived growth factor, and colony stimulating factor receptors.receptors.

Pathogenesis The normal bcr gene product (p160The normal bcr gene product (p160bcrbcr ) is known to ) is known to

have serine/threonine kinase activity and shows have serine/threonine kinase activity and shows considerable homology to a number of cell cycle considerable homology to a number of cell cycle proteins. It is thought to play an important role in proteins. It is thought to play an important role in cellular signal transduction.cellular signal transduction.

The chimeric bcr-abl fusion gene produces a chimeric The chimeric bcr-abl fusion gene produces a chimeric protein of molecular weight 210,000 daltons (p210protein of molecular weight 210,000 daltons (p210bcr-bcr-

ablabl ). This protein has much more powerful tyrosine ). This protein has much more powerful tyrosine kinase activity than p145kinase activity than p145ablabl and has been shown to and has been shown to interact with its substrates in an altered manner. interact with its substrates in an altered manner.

(p210(p210bcr-ablbcr-abl ) has a great serine / threonine activity that ) has a great serine / threonine activity that enhance and push the proliferation and differentiation enhance and push the proliferation and differentiation in a novel manner particularly in chronic phase.in a novel manner particularly in chronic phase.

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Translocation t(9;22)(q34;q11)

Translocation t(9;22)(q34;q11)

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How Would the Patient With CML Present?

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Clinical Presentation: Increasing splenomegally, which is associated Increasing splenomegally, which is associated

with discomfort, pain or indigestion.with discomfort, pain or indigestion. Refractory anaemia that include pallor, weakness Refractory anaemia that include pallor, weakness

and tachychardia.and tachychardia. Bruising, epistaxis due to abnormal platelet Bruising, epistaxis due to abnormal platelet

functions.functions. Gout or renal impairment due to hyperuricemia.Gout or renal impairment due to hyperuricemia. Visual disturbances.Visual disturbances. Increase requirement to chemotherapy to Increase requirement to chemotherapy to

maintain remission.maintain remission. Massive increasing of circulating granulocytes.Massive increasing of circulating granulocytes.

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How Would You Investigate the Patient With Suspected CML?….

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Investigation:

CBC:CBC:

Wbc is usually >50X10/l & some times Wbc is usually >50X10/l & some times >500X10/l.>500X10/l.

Normocytic normochromic anemia.Normocytic normochromic anemia.

Platelets Platelets ..

peripheral blood filmperipheral blood film:: circulating basophil.circulating basophil.

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fig

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Cont:

Neutrophil alkaline phosphatase scoreNeutrophil alkaline phosphatase score is is invariably low.invariably low.

BM:BM: is hyper cellular with granulopoietic is hyper cellular with granulopoietic predominance.predominance.

CytogeneticsCytogenetics: ph chromosome.: ph chromosome. Serum vitamin B12 & vitamin b12-binding Serum vitamin B12 & vitamin b12-binding

capacity arecapacity are.. Serum uric acid is usuallySerum uric acid is usually..

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What Are the Phases of CML?…

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Phases of CML:

Chronic phase :Chronic phase : Accelerated phase:Accelerated phase: Blast phase:Blast phase:

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Chronic phase CML

The three defining features of typical chronic The three defining features of typical chronic phase are:phase are:

Raised granulocytes.Raised granulocytes. The presence of Philadelphia chromosome.The presence of Philadelphia chromosome. Splenomegaly.Splenomegaly.

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Accelerated phase CML The transition to accelerated phase is accompanied by increasing The transition to accelerated phase is accompanied by increasing

refractoriness to treatment which may be reflected in one or refractoriness to treatment which may be reflected in one or more of the following changes: more of the following changes:

>15% blasts in B.M or peripheral blood.>15% blasts in B.M or peripheral blood. >30% blasts + promyelocyte in peripheral blood.>30% blasts + promyelocyte in peripheral blood. >20% basophil in peripheral blood.>20% basophil in peripheral blood. <100,000/m3 platelet.<100,000/m3 platelet. Additional chromosome abnormality (+8) trisomy.Additional chromosome abnormality (+8) trisomy. Increase B.M fibrosis.Increase B.M fibrosis. In blastic phase the blast should exceed 30% in the peripheral In blastic phase the blast should exceed 30% in the peripheral

blood (blastic crisis) , which is an evolution of CML that give rise blood (blastic crisis) , which is an evolution of CML that give rise to acute phase, this is manifested by progression of anaemia , to acute phase, this is manifested by progression of anaemia , neutropenia and thrombocytopenia. neutropenia and thrombocytopenia.

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Blastic phase CML

In most cases, establishment of the accelerated In most cases, establishment of the accelerated phase of CML is followed by a sustained refractory phase of CML is followed by a sustained refractory to treatment, the blast cell count rises and physical to treatment, the blast cell count rises and physical symptoms are worsening. The diagnostic criteria for symptoms are worsening. The diagnostic criteria for blast crisis are that the circulating blast cell counts blast crisis are that the circulating blast cell counts should exceed 30% of the total leukocyte count.should exceed 30% of the total leukocyte count.

Progression of chronic phase to blastic phase has Progression of chronic phase to blastic phase has been likened to the evolution of chronic leukaemia been likened to the evolution of chronic leukaemia into acute leukaemia. The accumulation of blast cells into acute leukaemia. The accumulation of blast cells which results is accompanied by anaemia, which results is accompanied by anaemia, neutropenia and thrombocytopenianeutropenia and thrombocytopenia

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How Would You Treat CML?…

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Treatment:

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

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Tyrosine kinase inhibitor

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What Is the Course and Prognosis of CML?..

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Course & prognosis:

Usually shows excellent response to Usually shows excellent response to chemotherapy in the chronic phase.chemotherapy in the chronic phase.

Death usually occur from terminal acute Death usually occur from terminal acute transformation ,hemorrhage or infection.transformation ,hemorrhage or infection.

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Take a Break !…

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Chronic lymphocytic Leukemia:

CLL

CLL is the most common of the chronic lymphoid CLL is the most common of the chronic lymphoid leukemias.leukemias.

Is characterised by the accumulation of non-Is characterised by the accumulation of non-proliferation mature-appearing lymphocytes proliferation mature-appearing lymphocytes (L(Lymphocytosis) ymphocytosis) in the blood, marrow, lymph in the blood, marrow, lymph nodes, and spleen.nodes, and spleen.

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CLL

In most cases, the cells are monoclonal B In most cases, the cells are monoclonal B lymphocytes that are CD5+ lymphocytes that are CD5+

T cell CLL can occur rarelyT cell CLL can occur rarely Peak incidence between 60-80yrs.Peak incidence between 60-80yrs. Is the most common form of leukemia in North Is the most common form of leukemia in North

America and Europe, but is extremely rare in the America and Europe, but is extremely rare in the OrientOrient

Affects men twice as often as womenAffects men twice as often as women Incidence rate: 300 cases / 100,000Incidence rate: 300 cases / 100,000-1-1 population/ population/

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Leukemogenesis Genetic factors have been postulated to play a Genetic factors have been postulated to play a

role in high incidence of CLL in some families role in high incidence of CLL in some families CytogeneticsCytogenetics

– clonal chromosomal abnormalities are detected clonal chromosomal abnormalities are detected in approximately 50% of CLL patients in approximately 50% of CLL patients

– the most common clonal abnormalities are:the most common clonal abnormalities are: trisomy 12trisomy 12structural abnormalities of chromosomes 13, structural abnormalities of chromosomes 13,

14 and 1114 and 11– patients with abnormal karyotypes have a patients with abnormal karyotypes have a

worse prognosisworse prognosis

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What Is the Clinical Presentation?

Clinical presentation: The disease is slow progressive 25% of the cases are free of physical symptoms at

diagnosis. Unexplained absolute and persistent

lymphocytosis; cervical, supclavicular, and/or axillary lymphadenopathy; and splenomegaly are the earliest signs.

Chronic fatigue, recurrent or persistent infections, and easy bruising are consequences of anaemia, neutropenia, B-cell immunolgical dysfunction, and thrombocytopenia.

Hepatomegaly may accompanied splenomegaly. Leukaemic lymphocytes may invade unusual

locations such as the scalp, orbits, subconjunctivae, gums, pleural and lung parenchyma, prostate, and gonads.

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Fig(1)

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Fig(2)

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How would you investigate patient with CLL?..

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Investigation:

CBC:CBC:– WbcWbc::– DiffDiff: lymphocytosis ,the absolute lymphocyte : lymphocytosis ,the absolute lymphocyte

count is >5x10count is >5x1099/l and may be up to 300x10/l and may be up to 300x1099/l or /l or More.More.

AnemiaAnemia: normocytic normochromic anemia is : normocytic normochromic anemia is present in later stages, autoimmune haemolysis.present in later stages, autoimmune haemolysis.

PlateletsPlatelets : thrombocytepenia may occur. : thrombocytepenia may occur.

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Cont:

Blood film:Blood film:

70-99% of white cells mature lymphocyte.70-99% of white cells mature lymphocyte.

Smudge or smear cells also present.Smudge or smear cells also present.

ImmunophenotypingImmunophenotyping::

Shows that the lymphocyte are B Shows that the lymphocyte are B cells(CD19)expressing one form of light cells(CD19)expressing one form of light chain(chain( or or only)cells are also only)cells are also CD5&CD23+ve.CD5&CD23+ve.

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Fig(3)

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Cont:

Bone marrow aspiration:Bone marrow aspiration:

Lymphocytic replacement of normal marrow.Lymphocytic replacement of normal marrow. Immunoglobulin electrophoresis:Immunoglobulin electrophoresis: of Ig more marker with advance disease.of Ig more marker with advance disease.• Cytogenetic :Cytogenetic :

The 4 most common abnormalities are; deletion of The 4 most common abnormalities are; deletion of 13q14,trisomy 12, deletion of11q23&structural 13q14,trisomy 12, deletion of11q23&structural abnormality of 17p involving the p53 gene.abnormality of 17p involving the p53 gene.

Cont:

Clonal expansion of B (99%) or T(1%) lymphocyteClonal expansion of B (99%) or T(1%) lymphocyte– In B-cell CLL clonality is confirmed by In B-cell CLL clonality is confirmed by

the expression of either the expression of either or or light chains on the cell surface membrane light chains on the cell surface membrane the presence of unique idiotypic specificities on the immunoglobulins the presence of unique idiotypic specificities on the immunoglobulins

produced by CLL cellsproduced by CLL cells by immunoglobulin gene rearrangementsby immunoglobulin gene rearrangements typical B-cell CLL are unique in being CD19+ and CD5+typical B-cell CLL are unique in being CD19+ and CD5+

10 - 25% of patients with CLL develop autoimmune 10 - 25% of patients with CLL develop autoimmune hemolytic anemia, with a positive direct Coombs’ testhemolytic anemia, with a positive direct Coombs’ test

The marrow aspirates shows greater than 30% of the The marrow aspirates shows greater than 30% of the nucleated cells as being lymphoidnucleated cells as being lymphoid

Classification

B CLL are CD5B CLL are CD5++, CD19, CD19++,, CD20 CD20++, CD21, CD21++ , CD22 , CD22++ and HLA-DR. and HLA-DR.

Typically, the antigen density on B-CLL is lower Typically, the antigen density on B-CLL is lower than normal lymphocyte. than normal lymphocyte.

CLL cells also express CD25 (the IL-2 receptor) CLL cells also express CD25 (the IL-2 receptor) weakly&CD5weakly&CD5

CD5 is a pan T cell marker, which is involved in T CD5 is a pan T cell marker, which is involved in T cell activation. CD5+ B lymphocytes are involved cell activation. CD5+ B lymphocytes are involved in the regulation of autoimmunity.in the regulation of autoimmunity.

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Massive Adenopathy

Infiltration of Lymph

Impaired Accumulation of Splenomegaly Immunolgic Long-lived and Activity Poorly Functioning

Lymphocytes Hypersplenism Autoimmune Phenomenon Haemorrhage Hypogammaglobulinaemia Anaemia Thrombocytopenia Neutropenia Infection Bone Marrow Replacement Autoimmune Haemolytic anaemia (AIHA) ITP Immune Neutropenia

The Pathophysiology of Chronic Lymphocytic Leukaemia

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What Is the Staging of CLL?…

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Staging :

Staging is very important for prognosis and Staging is very important for prognosis and treatment.treatment.

There are two staging system (Rai and Binet).There are two staging system (Rai and Binet).

See table.See table.

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A-Rai Classification:

Stage Stage definitiondefinition

00 Absolute lymphocytosis >15x10Absolute lymphocytosis >15x1099/l./l.

11 Stage 0+enlarged lymph nodes.Stage 0+enlarged lymph nodes.

1111 Stage 0+liver or/and spleen Stage 0+liver or/and spleen adenopathy. adenopathy.

111111 Stage 0+anemia Stage 0+anemia organomegally or adenopathy.organomegally or adenopathy.

1V1V Stage 0+thrombocytopenia Stage 0+thrombocytopenia organomegally or adenopathy.organomegally or adenopathy.

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B-Binet Classification:

Stage .Stage . OrganomegallyOrganomegally..

HbHb Platelet.Platelet.

A(50-60%)A(50-60%) 0,1,or2areas0,1,or2areas

B(30%)B(30%) 3,4,or 5areas3,4,or 5areas 1010 100100

C(<20%)C(<20%) Not consideredNot considered <10<10 and /or and /or <100<100

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How Would You Treat Patient With CLL?…

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Treatment :

Since cure is rare, the treatment aim is only Since cure is rare, the treatment aim is only symptoms control.symptoms control.

Indication for treatment:Indication for treatment:– Troublesome organomegaly.Troublesome organomegaly.– Hemolytic episodes.Hemolytic episodes.– Bone marrow suppression. Bone marrow suppression.

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Modality of Treatment:

1-chemotherapy:1-chemotherapy:Chlorambucil: 6mg/mChlorambucil: 6mg/m22 daily for 10 days monthly for 2-4 daily for 10 days monthly for 2-4

month after which remission will be obtain.month after which remission will be obtain.

Fludarabine:more effective as single agent.Fludarabine:more effective as single agent.

Corticosteroid :indicated in bone marrow failure, also Corticosteroid :indicated in bone marrow failure, also indicated in autoimmune hemolytic anemia and indicated in autoimmune hemolytic anemia and thrombocytopenia.thrombocytopenia.

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Cont:

2-Radiotherapy:2-Radiotherapy:

Is useful in reducing the size of lymph node not Is useful in reducing the size of lymph node not responsive to chemo.responsive to chemo.

3-Monoclonal antibody:3-Monoclonal antibody:

Both campath IH(anti CD52)and Rituximab(anti Both campath IH(anti CD52)and Rituximab(anti CD20)produce response in proportion of patient.CD20)produce response in proportion of patient.

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Cont:

4-Splenectomy :4-Splenectomy :

For immune-mediated cytopenia or painful bulky For immune-mediated cytopenia or painful bulky splenomegally.splenomegally.

5-immunoglobulin replacement:5-immunoglobulin replacement:

250mg/kg /month by IV for patient with 250mg/kg /month by IV for patient with hypogammaglobulinemia and recurrent infection.hypogammaglobulinemia and recurrent infection.

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Cont:

5- Stem cell transplant:5- Stem cell transplant:

Under clinical trial.Under clinical trial.

Prognosis

50% of the patients will receive partial remission.

< 30% of the patients will got complete remission.

30% of the cases will transfer into PLL. 5% of the cases will have Richters syndrome in

which the blastic phase of CLL in lymph nodes.

Prolymphocyte leukemia

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Prolymphocyte leukemia

The second most common type of CLL ( 10% ), The second most common type of CLL ( 10% ),

largely B cell malignancy and afflicts the elderly largely B cell malignancy and afflicts the elderly

people with incidence in male more than female. Thepeople with incidence in male more than female. The

T-PLL accounts 25% of PLL cases only.T-PLL accounts 25% of PLL cases only.

Leukemogenesis The most common chromosomal rearrangement in

BPLL is t(11;14)(q13;q32) with frequency of (50-75%) which involves the translocation of BCL1 oncogene from 11q13 to the site of the immunoglobulin heavy chain gene locus at 14q32, thereby promoting expression of B lymphocyte growth factors.

Many other cytogenetic abnormalities have been described in BPLL, including +12 and rearrangement of 3p, 11p and 12p.

In contrast TPLL chromosomal abnormality commonly seen at 14q11, in which the locus of the T lymphocyte receptor a-chain gene is located. This abnormality has a frequency of more than 50% in all cases of TPLL.

Recognition and classification:

The presence of 55% of prolymphocyte at peripheral blood smear at presentation which has the following characteristics :

larger than normal lymphocyte . abundant cytoplasm . condensed chromatin material . prominent nucleolus .

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Prolymphocytic leukemia

Raised WBC < 100 X 103 and may reach 10X106 / m3 which is composed of more than 55% of prolymphocytes. TPLL mostly associated with higher WBC.

Most cases have thrombocytopenia and anaemia secondary to B.M infiltration and splenomegaly.

B.M is characteristic: B.M is not needed for diagnosis, however for prognosis, B-PLL has large pale blue, not granular cytoplasm, single nucleus with single nucleolus, while T-PLL is slightly smaller, irregular nucleus which is often cleft, and slightly more basophilic cytoplasm with azuophilic granules.

Immunophenotyping

CD number BPLL TPLL CD2 - +++ CD3 - +++

CD4 - ++ CD5 +/- +++ CD7 - +++ CD8 - ++ CD10 - - CD19 +++ - CD20 +++ - CD22 +++ - CD25 +/- - SIgM +++ - +++ -

Pathophysiology

Increase lymphocyte count with large immature blast like cells.

Immunophenotyping is only required to differentiate B and T cell types.

Progress much more rapidly than CLL. Swallow L.N is not seen. Spleen larger than in CLL.

Treatment

Aggressive treatment: irradiation or removal of spleen.

Leukophoresis can be used to remove WBC mass i.e. bulk reduction.

The remission after treatment is only short term.

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Hairy cell leukemia This is mainly a disease of elderly menThis is mainly a disease of elderly men Patients present with marked splenomegaly, but not Patients present with marked splenomegaly, but not

lymphadenopathylymphadenopathy Patients have fatigue and malaisePatients have fatigue and malaise PancytopeniaPancytopenia The peripheral smear shows atypical mononuclear The peripheral smear shows atypical mononuclear

lymphocytoid cells with hairy projections on their lymphocytoid cells with hairy projections on their surfacessurfaces

The bone marrow yields a dry tap because the The bone marrow yields a dry tap because the malignant cells are often surrounded by fibrosismalignant cells are often surrounded by fibrosis

Splenectomy and interferon as well as new Splenectomy and interferon as well as new chemotherapeutic drugs are successful in promoting chemotherapeutic drugs are successful in promoting long lasting remissionslong lasting remissions

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Hairy cell leukemia

Immunophenotyping

cell expresses CD19, CD20, CD22, HLA DR, SIgM and show immunoglobulin light chain restriction.

CD5 is absent, but express antigen not normally expected like CD11c, a monocyte-associated marker, and CD25, the IL2 receptor.

Cytochemistry

Staining peripheral blood with acid phosphatase is positive. The addition of tartaric acid to the reaction mixture inhibits all of the common isoenzymes of acid phosphatase, except isoenzyme 5, which is found in hairy cells. Tartrate resistance acid phosphatase (TRAP) is positive and is characteristic in HCL.

Pathophysiology

Fatigue, easy bruising. Repeated infection, which tend to be common

more than CLL. Enlarged spleen, if liver is increased, it's not

minimal. Rarely L.N swollen.

Treatment Removal of the spleen is the 1st step (especially in stage

II & I) and treatment depends on the reaction of spleen removal.

40% of patients will require chemotherapy after splenectomy that will be long term in order to maintain partial remission.

a - Interferon – available especially for HCL and possible to get complete remission, but still splenectomy required.

The problem is that antibodies to a-interferon will be produced leading to diminished response.

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Good Luck!……..