Week 10: Leukemia
AMLAML ALLALL FAB classificationFAB classification WHO classificationWHO classification CytochemistriesCytochemistries MPOMPO SBBSBB PASPAS
OROORO CD markersCD markers FlowcytometryFlowcytometry CMLCML CLLCLL KaryotypeKaryotype Ph chromosomePh chromosome LAPLAP
Signs and Symptoms of AML
Insidious nonspecific onsetInsidious nonspecific onset Pallor due to anemiaPallor due to anemia Febrile due to ineffective WBCFebrile due to ineffective WBC Petechiae due to thrombocytopeniaPetechiae due to thrombocytopenia Mucus membrane and gum bleed in Mucus membrane and gum bleed in
M4 and M5M4 and M5 Bone painBone pain
Typical Labs of AML
LeukocytosisLeukocytosis BlastemiaBlastemia Leukemic hiatusLeukemic hiatus Auer rods in M2, M3, Auer rods in M2, M3,
M4M4 ThrombocytopeniaThrombocytopenia AnemiaAnemia >20% blasts in BM>20% blasts in BM
Other Findings
CD 13 and CD 33 in flowcytometryCD 13 and CD 33 in flowcytometry CytochemistriesCytochemistries
MyeloperoxidaseMyeloperoxidase Sudan black BSudan black B Choloroacetate esterase (specific)Choloroacetate esterase (specific) Nonspecific esteraseNonspecific esterase
FAB (1976) Classification
M0 -- Undifferentiated AMLM0 -- Undifferentiated AML M1 -- AML without maturationM1 -- AML without maturation M2 -- AML with maturationM2 -- AML with maturation M3 -- Acute Promyelocytic LeukemiaM3 -- Acute Promyelocytic Leukemia M4 -- Acute Meylomonocytic LeukemiaM4 -- Acute Meylomonocytic Leukemia M5 -- Acute Monocytic LeukemiaM5 -- Acute Monocytic Leukemia M6 -- Erythroleukemia (DiGuglielmo’s)M6 -- Erythroleukemia (DiGuglielmo’s) M7 -- Megakaryoblastic LeukemiaM7 -- Megakaryoblastic Leukemia
M1 and M2
Myeloperoxidase
(MPO)
p-Phenylene diamine + Catecol + H2O2
MPO > Brown black deposits
M3
M5
M4
Chloracetate (Specific) Esterase
Myeloid Cell Line
Naphthol-ASD-chloracetate CAE > Free naphthol compounds
+ Stable diazonium salt (eg, Fast Corinth) > Red deposit
Non-Specific Esterase
Monocytic Line
Naphthyl acetate ANAE > Free naphthyl compounds +Stable diazonium salt (eg, Fast blue RR) > Brown deposits
Double Esterase in M4
NSE with Fl inhibition
Histiocyte
FAB vs WHO Classifications of Hematologic Neoplasm FAB criteriaFAB criteria
MorphologyMorphology CytochemistryCytochemistry
WHO criteriaWHO criteria MorphologyMorphology ImmunophenotypingImmunophenotyping Genetic featuresGenetic features
KaryotypingKaryotyping Molecular testingMolecular testing
Clinical featuresClinical features
WHO Classification of AML
AML with recurrent cytogenic AML with recurrent cytogenic translocationstranslocations
AML with multi-lineage dysplasiaAML with multi-lineage dysplasia AML and myelodysplasia, therapy relatedAML and myelodysplasia, therapy related AML, not otherwise categorizedAML, not otherwise categorized
AML with Recurrent Cytogenetic Translocations (WHO 1995)
t(8;21) -- some maturation of neutrophilic line; t(8;21) -- some maturation of neutrophilic line; rare in older patients; AML1/ETO fusion protein; rare in older patients; AML1/ETO fusion protein; >90% FAB M2>90% FAB M2
t(15;17) -- APL (granular and microgranular t(15;17) -- APL (granular and microgranular variants); retinoic acid receptor (RAR) leukemias; variants); retinoic acid receptor (RAR) leukemias; middle aged adults; DICmiddle aged adults; DIC
inv(16) or t(16;16) -- monocytic and granulocytic; inv(16) or t(16;16) -- monocytic and granulocytic; abnormal eosinophilic componentabnormal eosinophilic component
11q23 -- monocytic; children; most common is 11q23 -- monocytic; children; most common is t(9;11)t(9;11)
FAB Classification of ALL
L1: Small homogeneous blasts; mostly in L1: Small homogeneous blasts; mostly in childrenchildren
L2: Large heterogeneous blasts; mostly in L2: Large heterogeneous blasts; mostly in adultsadults
L3: “Burkitt” large basophilic B-cell blasts L3: “Burkitt” large basophilic B-cell blasts with vacuoleswith vacuoles
L3L2
Periodic Acid Schiff
Periodic acid + Glycogen oxidation > Aldehyde + Schiff reagent
(para-rosaniline, Na metabisulfite) > Red deposit
ALL Cytochemistries
Oil Red OOil Red O: stains L3 vacuoles: stains L3 vacuoles Terminal deoxynucleotidyl transferaseTerminal deoxynucleotidyl transferase (Tdt): (Tdt):
DNA polymerase in early lymphoblastsDNA polymerase in early lymphoblasts Cell surface markersCell surface markers (CD’s) (CD’s) Cytoplasmic and surface immunoglobulinsCytoplasmic and surface immunoglobulins: :
B-cell lineB-cell line T-cell receptor T-cell receptor (TCR)(TCR)
WHO Classification of Lymphoproliferative Syndromes
Precursor B Lymphoblastic Leukemia/Lymphoma Precursor B Lymphoblastic Leukemia/Lymphoma (ALL/LBL) -- ALL in children (80-85% of (ALL/LBL) -- ALL in children (80-85% of childhood ALL); LBL in young adults and rare; childhood ALL); LBL in young adults and rare; FAB L1 or L2 blast morphologyFAB L1 or L2 blast morphology
Precursor T ALL/LBL -- 15% of childhood ALL Precursor T ALL/LBL -- 15% of childhood ALL and 25% of adult ALLand 25% of adult ALL
Burkitt Leukemia/Lymphoma (FAB L3)Burkitt Leukemia/Lymphoma (FAB L3)
•Antigens •B-Lineage •T-Lineage
•HLA Dr•Tdt•CD34
•+•+•+
•0 to +•+•0
•CD19•C 22•CD10•CD20•Cyt-•SIg
•+•cALL and older•cALL and older•Pre-B and older•Pre-B and older•B-ALL
•Pre-T•Pre-T•Pre-T•0•0•0
•CD7•CD3•CD5•CD2•CD1
•0•0•0•0•0
•+•+•+•T-ALL•T-ALL
IndicatorsIndicators FavorableFavorable PoorPoor
WBCWBC < 50,000/< 50,000/LL 50,000/50,000/LL
AgeAge 1 - 101 - 10 < 1 or < 1 or 1010
GenderGender FemaleFemale MaleMale
BlastBlast B-cellB-cell T-cell and mixedT-cell and mixed
KaryotypeKaryotype HyperploidyHyperploidy
Trisomy 4, 10, 17Trisomy 4, 10, 17
t(12;21) (TEL/AML1)t(12;21) (TEL/AML1)
HypoploidyHypoploidy
Trisomy 5Trisomy 5
t(1;19 (E2A/PBX1)t(1;19 (E2A/PBX1)
Mixed lineage leukemiaMixed lineage leukemia
T(9;22) (Ph)T(9;22) (Ph)
BM blast count BM blast count during inductionduring induction
Mkd reduction at day 7Mkd reduction at day 7 Mild reduction at day 7Mild reduction at day 7
Prognosis
Typical Labs in CML
Leukocytosis with blastemiaLeukocytosis with blastemia ThrombocytosisThrombocytosis BasophiliaBasophilia Micro-megakaryocytesMicro-megakaryocytes Low LAP score (intermediate if infected)Low LAP score (intermediate if infected) About 10% blasts in BMAbout 10% blasts in BM Philadelphia chromosomePhiladelphia chromosome
CML
Bone marrow aspirateand biopsy
Pseudo-Gaucher’s cells in BM
Leukocyte Alkaline Phosphatase (LAP)
Naphthol AS-MX phosphate LAP at pH8.6 >Naphthol AS-MX + Diazonium salt
(eg, Fast blue RR) > Insoluble pigment
LAP Score
Count 100 consecutive segs and bandsCount 100 consecutive segs and bands Score:Score:
0 = no granules0 = no granules
1+ = occasional diffuse granules1+ = occasional diffuse granules
2+ = moderate number of granules2+ = moderate number of granules
3+ = many strongly positive granules3+ = many strongly positive granules
4+ = confluent strongly positive granules4+ = confluent strongly positive granules
0 1+
2+ 3+ 4+
LAP Score
Example:
0 x 35 cells = 01+ x 30 cells = 302+ x 20 cells = 403+ x 10 cells = 304+ x 5 cells = 20
120 LAP Score
Philadelphia Chromosome
9 and 22 translocation almost specific to CML9 and 22 translocation almost specific to CML Karyotype to visualize Ph chromosomeKaryotype to visualize Ph chromosome Produces BCR/c-abl fusion oncogeneProduces BCR/c-abl fusion oncogene Gene product p190 is a hyperactive tyrosine Gene product p190 is a hyperactive tyrosine
kinasekinase Ph chromosome seen in ALL produces p210 and Ph chromosome seen in ALL produces p210 and
chronic neutrophilic leukemia produces p230chronic neutrophilic leukemia produces p230
Karyotype 46,XX,t(9;22)(q34;q11.2) -- Ph chromosome
FISH showing the BCR (green), ABL (orange), and BCR-ABL fusion signals (arrow): A=positive (contains a residual ABL signal), B=normal
FAB (1982) Classification of Myeloproliferative Disease (MPD)
Chronic Myelocytic Leukemia (CML)Chronic Myelocytic Leukemia (CML) Polycythemia Vera (PV)Polycythemia Vera (PV) Essential Thrombocythemia (ET)Essential Thrombocythemia (ET) Agnogenic Myeloid Metaplasia with or without Agnogenic Myeloid Metaplasia with or without
Myelofibrosis (AMM)Myelofibrosis (AMM) Benign Leukemoid ReactionBenign Leukemoid Reaction
WHO Classification of MPS (1997)
CML becomesCML becomes CML, Ph + t(9;22) BCR/ABLCML, Ph + t(9;22) BCR/ABL Chronic Neutrophilic Leukemia (CNL)Chronic Neutrophilic Leukemia (CNL) Chronic Eosinophilic Leukemia and Hyper-Chronic Eosinophilic Leukemia and Hyper-
eosinophilic Syndrome (CEL/HES)eosinophilic Syndrome (CEL/HES) PV remains PVPV remains PV ET remains ETET remains ET AMM becomesAMM becomes
Chronic Idiopathic MyelofibrosisChronic Idiopathic Myelofibrosis
Myelofibrosis
Myelofibrosis
Chronic Lymphocytic Leukemia
Exclusive in elderlyExclusive in elderly Lyphocytosis unrelated to viral infectionLyphocytosis unrelated to viral infection Hyper-mature lymphocytes with highly Hyper-mature lymphocytes with highly
condensed nucleicondensed nuclei Smudge cells: preventable with a drop of Smudge cells: preventable with a drop of
bovine albuminbovine albumin
CLLPB and BM
Bone Marrow
WHO Lymphoid Neoplasms
B cell neoplasmsB cell neoplasms T/NK cell neoplasmsT/NK cell neoplasms Hodgkin lymphoma (disease)Hodgkin lymphoma (disease)
Mature B Cell Neoplasms
B cell CLL/SLLB cell CLL/SLL B prolymphocytic B prolymphocytic
leukemialeukemia Burkitt’s lymphoma / Burkitt’s lymphoma /
leukemialeukemia Splenic marginal zone Splenic marginal zone
B lymphomaB lymphoma Extranodal marginal B Extranodal marginal B
lymphomalymphoma
Hairy cell leukemiaHairy cell leukemia Lymphoplasmocytic Lymphoplasmocytic
leukemialeukemia Mantle cell lymphomaMantle cell lymphoma Plasma cell myeloma / Plasma cell myeloma /
plasmacytomaplasmacytoma Follicular lymphomaFollicular lymphoma Diffuse large B Diffuse large B
lymphomalymphoma
T/NK Cell Neoplasms
T prolymphocytic T prolymphocytic leukemialeukemia
T granular T granular lymphocytic leukemialymphocytic leukemia
Aggressive NK cell Aggressive NK cell leukemialeukemia
Adult T lymphoma / Adult T lymphoma / leukemialeukemia
Mycosis fungoides Mycosis fungoides (Sezary syndrome)(Sezary syndrome)
Anaplastic large cell Anaplastic large cell lymphomalymphoma
Hepatosplenic T Hepatosplenic T lymphomalymphoma
Peripheral T lymphomaPeripheral T lymphoma Immunoblastic T Immunoblastic T
lymphomalymphoma
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