1. ACUTE LEUKAEMIA by DR. FATIMA AL-QAHTANI CONSULTANT HAEMATOLOGIST

2. ACUTE MYELOID LEUKAEMIA ETIOLOGICAL FACTORS GENETIC DISORDERS Congenital Defects Down syndrome Bloom Syndrome Monosomy 7 syndrome Klinefelter Syndrome Turner Syndrome Neurofibromatosis Congenital Dysmorphic Syndrome Marrow Failure Syndromes Fanconi Anaemia Dyskeratosis Congenita Schwachman – Diamond Syndrome Amegakaryocytic Thrombocytopenia Blackfan – Diamond Syndrome Kostmann Agranulocytosis Familial Aplastic Anaemia

3. ACUTE MYELOID LEUKAEMIA ETIOLOGICAL FACTORS Environmental Factors Solvents (benzene) Solvents (benzene) Smoking Smoking Ionizing radiation Ionizing radiation Atomic bomb exposure Atomic bomb exposure Nuclear power exposure Nuclear power exposure Medical radiation Medical radiation Non ionizing radiation Non ionizing radiation Chemotherapy Chemotherapy Alkylating agents Alkylating agents Topoisomerase II inhibitors Topoisomerase II inhibitors Other drugs Other drugs Chloramphenicol Chloramphenicol Phenylbutazone Phenylbutazone

4. Acute Myeloid Leukaemia CLINICAL FEATURES Increasing incidence with age. Median age at diagnosis is 50 years. Increasing incidence with age. Median age at diagnosis is 50 years. Symptoms are due to marrow failure (anaemia, infection, haemorrhage) or hyperleucocytosis. Symptoms are due to marrow failure (anaemia, infection, haemorrhage) or hyperleucocytosis. Rarely presenting symptoms are due to chloromas or CNS involvement. Rarely presenting symptoms are due to chloromas or CNS involvement.

5. Acute Lymphoblastic Leukaemia (ALL) Clinical Features ALL can occur at any age but has a peak incidence between 2 - 10 years. It is characterized by: bone marrow failure bone marrow failure lymphadenopathy lymphadenopathy thymic enlargement in T-lineage ALL thymic enlargement in T-lineage ALL bone pains which may be associated with radiological changes and fractures bone pains which may be associated with radiological changes and fractures tendency to relapse in the CNS and testis. tendency to relapse in the CNS and testis.

6. Acute Myeloid Leukaemia DEFINITION Acute Myeloid Leukaemia (AML) is currently defined by the FAB criteria. Acute Myeloid Leukaemia (AML) is currently defined by the FAB criteria.FAB The percentage of blasts, the presence of cytochemical myeloperoxidase, the major cell types present defined by morphology and esterase cytochemistry & the immunophenotype define the 8 FAB subtypes The percentage of blasts, the presence of cytochemical myeloperoxidase, the major cell types present defined by morphology and esterase cytochemistry & the immunophenotype define the 8 FAB subtypes

7. Acute Myeloid Leukaemia LABORATORY DIAGNOSIS MORPHOLOGY Myeloblasts are usually medium sized with an eccentric nucleus and open chromatin. Cytoplasm shows variable basophilia. Few granules or Auer rods may be present. Myeloblasts are usually medium sized with an eccentric nucleus and open chromatin. Cytoplasm shows variable basophilia. Few granules or Auer rods may be present. Maturing granulocytes may be normal or show the dysplastic features seen in MDS. Maturing granulocytes may be normal or show the dysplastic features seen in MDS.MDS Monoblasts are generally very large with abundant grey- blue or basophilic cytoplasm. Nuclei are round or lobulated, and are central in the cell. Fine azurophil granules may be present but Auer rods are rarely, if ever, present. Monoblasts are generally very large with abundant grey- blue or basophilic cytoplasm. Nuclei are round or lobulated, and are central in the cell. Fine azurophil granules may be present but Auer rods are rarely, if ever, present. Promonocytes and monocytes show abnormal nuclear maturation, granulation and loss of basophilia. Promonocytes and monocytes show abnormal nuclear maturation, granulation and loss of basophilia.

8. Acute Myeloid Leukaemia LABORATORY DIAGNOSIS MORPHOLOGY (Cont … ) Erythroid precursors may be normal or show varying degrees of dyserythropoiesis. Erythroid precursors may be normal or show varying degrees of dyserythropoiesis. Eosinophils may be present in varying numbers, with normal or abnormal morphology. Specific abnormal appearances are linked with cytogenetic abnormalities Eosinophils may be present in varying numbers, with normal or abnormal morphology. Specific abnormal appearances are linked with cytogenetic abnormalities (e.g. inv 16) Basophils are rarely increased in AML, and if present show abnormal or poor granule formation and nuclear maturation. Basophils are rarely increased in AML, and if present show abnormal or poor granule formation and nuclear maturation. Megakaryocytes may be reduced or increased. Dysplastic hyperlobated, hypolobated, multinuclear, small and blastic forms may be present Megakaryocytes may be reduced or increased. Dysplastic hyperlobated, hypolobated, multinuclear, small and blastic forms may be present

9. Acute Myeloid Leukaemia FAB Subtypes

11. M0-M5: >20% myelo/monoblasts by morphology or immunophenotype. morphology or immunophenotype. M6: >50% erythroid precursors, >20% blasts in non-erythroid cells. M7: >20% megakaryoblasts present. Note: Cytogenetics, molecular genetics, previous MDS or MPD, previous chemo- or radiotherapy and the presence of trilineage myelodysplasia do not have any place in the FAB system. All these features which contribute to the definition of prognostically important sub-groups is included in the new classification system. Cytogenetics, molecular genetics, previous MDS or MPD, previous chemo- or radiotherapy and the presence of trilineage myelodysplasia do not have any place in the FAB system. All these features which contribute to the definition of prognostically important sub-groups is included in the new classification system.new classification systemnew classification system

12. ACUTE MYELOID LEUKAEMIAS WHO CLASSIFICATION Acute myeloid leukaemia with reccurent genetic abnormalities Acute myeloid leukaemia with reccurent genetic abnormalities Acute myeloid leukaemia with t(8;21)(q22;q22); (AML1(CBFa)/ETO) Acute myeloid leukaemia with t(8;21)(q22;q22); (AML1(CBFa)/ETO) Acute myeloid leukaemia with abnormal bone marrow eosinophils Acute myeloid leukaemia with abnormal bone marrow eosinophils inv (16)(p13q22) or t(16; 16)(p13;q22); (CBFb/MYH11) inv (16)(p13q22) or t(16; 16)(p13;q22); (CBFb/MYH11) Acute promyelocytic leukaemia (AML with t(15; 17)(q22;q12)(PML/RARa) & variants Acute promyelocytic leukaemia (AML with t(15; 17)(q22;q12)(PML/RARa) & variants Acute myeloid leukaemia with 11q23 (MLL) abnormalities Acute myeloid leukaemia with 11q23 (MLL) abnormalities Acute myeloid leukaemia with multilineage dysplasia Acute myeloid leukaemia with multilineage dysplasia Acute myeloid leukaemia and myelodysplastic syndromes, therapy related Acute myeloid leukaemia and myelodysplastic syndromes, therapy related

13. ACUTE MYELOID LEUKAEMIAS WHO CLASSIFICATION Acute myeloid leukaemia not otherwise categorized Acute myeloid leukaemia not otherwise categorized Acute myeloid leukaemia minimally differentiated Acute myeloid leukaemia minimally differentiated Acute myeloid leukaemia without maturation Acute myeloid leukaemia without maturation Acute myeloid leukaemia with maturation Acute myeloid leukaemia with maturation Acute myelomonocytic leukaemia Acute myelomonocytic leukaemia Acute monoblastic and monocytic leukaemia Acute monoblastic and monocytic leukaemia Acute erythroid leukaemias Acute erythroid leukaemias Acute megakaryoblastic leukaemia Acute megakaryoblastic leukaemia Acute basophilic leukaemia Acute basophilic leukaemia Acute panmyelosis with myelofibrosis Acute panmyelosis with myelofibrosis Myeloid sarcoma Myeloid sarcoma Acute leukaemia of ambiguous lineage Acute leukaemia of ambiguous lineage Undifferentiated acute leukaemia Undifferentiated acute leukaemia Bilineal acute leukaemia Bilineal acute leukaemia Biphenotypic leukaemia Biphenotypic leukaemia

14. M0M1M2 M3M4 M5b M5a M6M7

15. Acute Myeloid Leukaemia LABORATORY DIAGNOSIS CYTOCHEMISTRY Myeloperoxidase (MPO): identify blast cells as myeloid. Auer rods are detected twice as frequently as on Romanowsky stains. Dysplastic neutrophils may be negative. Eosinophil granules are always positive. Monoblasts and promonocytes may be negative. Sudan Black B gives identical results. Myeloperoxidase (MPO): identify blast cells as myeloid. Auer rods are detected twice as frequently as on Romanowsky stains. Dysplastic neutrophils may be negative. Eosinophil granules are always positive. Monoblasts and promonocytes may be negative. Sudan Black B gives identical results. Myeloperoxidase (MPO)

16. Acute Myeloid Leukaemia LABORATORY DIAGNOSIS CYTOCHEMISTRY Chloroacetate Esterase (CAE) specifically identifies cells of the granulocyte lineage, from the early promyelocyte stage to mature neutrophils. Chloroacetate Esterase (CAE) specifically identifies cells of the granulocyte lineage, from the early promyelocyte stage to mature neutrophils. Chloroacetate Esterase

17. Acute Myeloid Leukaemia LABORATORY DIAGNOSIS CYTOCHEMISTRY α -Naphthyl Acetate (Nonspecific) Esterase (ANAE) stains monocytes and megakaryocytes at all stages of maturation. α -Naphthyl Acetate (Nonspecific) Esterase (ANAE) stains monocytes and megakaryocytes at all stages of maturation. Nonspecific Esterase

18. Acute Myeloid Leukaemia LABORATORY DIAGNOSIS CYTOCHEMISTRY Periodic Acid Schiff (PAS) stains many cell types. It is not lineage specific but the pattern of staining may be helpful, e.g. positive monoblasts, NRBC, megakaryoblasts … Periodic Acid Schiff (PAS) stains many cell types. It is not lineage specific but the pattern of staining may be helpful, e.g. positive monoblasts, NRBC, megakaryoblasts …

19. Acute Lymphoblastic Leukaemia Laboratory Diagnosis FAB Classification

20. Acute Lymphoblastic Leukaemia Laboratory Diagnosis

21. Acute Lymphoblastic Leukaemia Laboratory Diagnosis Morphology Blast morphology is variable some are small with high nuclear / cytoplasmic ratios and indistinct nucleoli (so-called L1 blasts) some are small with high nuclear / cytoplasmic ratios and indistinct nucleoli (so-called L1 blasts) while others are larger with more prominent nucleoli and more abundant cytoplasm (L2). while others are larger with more prominent nucleoli and more abundant cytoplasm (L2). A third type (L3) shows large blasts with moderately abundant highly vacuolated basophilic cytoplasm A third type (L3) shows large blasts with moderately abundant highly vacuolated basophilic cytoplasm Blast morphology does not correlate with cell lineage and cytochemistry is of little value.

22. ALL (L2) ALL (L3) Acute Lymphoblastic Leukaemia Laboratory Diagnosis - FAB Classification ALL (L1)

23. PASAc. Phos (T-ALL ) Acute Lymphoblastic Leukaemia Laboratory Diagnosis Acute Lymphoblastic Leukaemia Laboratory DiagnosisCYTOCHEMISTRY

24. Acute Myeloid Leukaemia LABORATORY DIAGNOSIS TREPHINE BIOPSY HISTOLOGY Helpful when there is severe cytopenia and a dry tap, e.g. in megakaryoblastic AML. Helpful when there is severe cytopenia and a dry tap, e.g. in megakaryoblastic AML. Useful for identifying megakaryocyte dysplasia and dyserythropoiesis. Useful for identifying megakaryocyte dysplasia and dyserythropoiesis. Immunophenotyping is possible when the diagnosis is in doubt. Immunophenotyping is possible when the diagnosis is in doubt. Not suitable for fine classification which is based on percentages of cell types and cytological detail. Not suitable for fine classification which is based on percentages of cell types and cytological detail.

25. Acute Myeloid Leukaemia LABORATORY DIAGNOSIS FLOW CYTOMETRY Myeloid blasts express combinations of CD34, CD13, CD33, CD117, HLA-DR, CD14, CD15. Glycophorin A and CD42b identify erythroid and megakaryocyte lineage blasts respectively. Myeloid blasts express combinations of CD34, CD13, CD33, CD117, HLA-DR, CD14, CD15. Glycophorin A and CD42b identify erythroid and megakaryocyte lineage blasts respectively. Essential to separate undifferentiated AML (M0) from ALL. May need supplementation with APAAP staining for cytoplasmic immunoreactive MPO. Essential to separate undifferentiated AML (M0) from ALL. May need supplementation with APAAP staining for cytoplasmic immunoreactive MPO.ALL

26. Acute Myeloid Leukaemia LABORATORY DIAGNOSIS FLOW CYTOMETRY (Cont … ) Essential for diagnosing biphenotypic leukaemias and detecting aberrant (promiscuous) antigen expression. Essential for diagnosing biphenotypic leukaemias and detecting aberrant (promiscuous) antigen expression. Can identify patient specific unique blast cell phenotypes. Can identify patient specific unique blast cell phenotypes. Can identify blasts of megakaryocyte, erythroid, monocyte and granulocyte lineages. Can identify blasts of megakaryocyte, erythroid, monocyte and granulocyte lineages. Can identify leukaemic contamination of 'remission' marrow harvests. Can identify leukaemic contamination of 'remission' marrow harvests. Can identify early relapse. Can identify early relapse.

27. Acute Lymphoblastic Leukaemia Laboratory Diagnosis Flowcytometry ALL is derived from precursor lymphocytes that are undergoing antigen receptor gene (Ig and TCR) rearrangement. B-lineage ALL The precursor nature of the cells is established by demonstrating lack of surface Ig, the presence of nuclear TDT and sometimes the expression of CD34. Sub classification is as follows: Pre-pre B-ALL: CD19+ CD10- cytoplasmic mu heavy chain negative. Common ALL: CD19+ CD10+ cytoplasmic mu present in <20% of cells Pre B-ALL: CD19+ CD10+ cytoplasmic mu present in >20% of cells Blasts of all subgroups will express cytoplasmic CD22 and CD79b.

28. T-lineage ALL The precursor nature of the cells is established by demonstrating TDT and sometimes CD34 positivity and the lack of surface TCR/CD3. The precursor nature of the cells is established by demonstrating TDT and sometimes CD34 positivity and the lack of surface TCR/CD3. T-cell lineage is demonstrated by the expression of CD7 and/or CD1a. T-cell lineage is demonstrated by the expression of CD7 and/or CD1a. Expression of the other pan-T cell markers is variable. Expression of the other pan-T cell markers is variable.

29. Acute Myeloid Leukaemia LABORATORY DIAGNOSIS IMMUNOHISTOCHEMISTRY / IMMUNOFLUORESCENCE APAAP staining for cMPO, cCD3 and cCD79 should be done in all cases of undifferentiated acute leukaemia. APAAP staining for cMPO, cCD3 and cCD79 should be done in all cases of undifferentiated acute leukaemia. Immunofluorescent staining for nuclear PML protein should be done in all cases of suspected acute promyelocytic leukaemia. A microparticulate pattern is diagnostic of APML. Immunofluorescent staining for nuclear PML protein should be done in all cases of suspected acute promyelocytic leukaemia. A microparticulate pattern is diagnostic of APML.

30. Acute Myeloid Leukaemia LABORATORY DIAGNOSIS CYTOGENETICS An abnormal karyotype is found in 50-60% of AML cases at presentation. An abnormal karyotype is found in 50-60% of AML cases at presentation. t(15;17), t(8;21) and inv/del/t(16) are associated with specific morphology, younger patients and a good prognosis. t(15;17), t(8;21) and inv/del/t(16) are associated with specific morphology, younger patients and a good prognosis. Complex karyotypes and abnormalities of chromosomes 5 and 7 are associated with older patients, trilineage dysplasia and a poor response to treatment. Complex karyotypes and abnormalities of chromosomes 5 and 7 are associated with older patients, trilineage dysplasia and a poor response to treatment. Other karyotypic abnormalities are prognostically neutral. Other karyotypic abnormalities are prognostically neutral.

31. Acute Myeloid Leukaemia LABORATORY DIAGNOSIS MOLECULAR GENETICS The 3 major good prognosis translocations are all detectable by RT-PCR, which can be used to detect up to 40% more cases than are found by metaphase cytogenetics. The 3 major good prognosis translocations are all detectable by RT-PCR, which can be used to detect up to 40% more cases than are found by metaphase cytogenetics. All translocations with cloned breakpoint genes are theoretically detectable by RT-PCR. All translocations with cloned breakpoint genes are theoretically detectable by RT-PCR. Real time multiplex PCR may become available for routine diagnosis. Real time multiplex PCR may become available for routine diagnosis. RT-PCR is used for monitoring speed of response to treatment and may be predictive for relapse RT-PCR is used for monitoring speed of response to treatment and may be predictive for relapse

32. Acute Lymphoblastic Leukaemia Laboratory Diagnosis CYTOGENETICS Hyperdiploidy is common. A number of balanced translocations have been identified in ALL: Hyperdiploidy is common. A number of balanced translocations have been identified in ALL: t(12;21) - this is the commonest translocation in ALL (30% of cases). It results in the TEL-AML fusion gene and is primarily associated with the common phenotype. t(12;21) - this is the commonest translocation in ALL (30% of cases). It results in the TEL-AML fusion gene and is primarily associated with the common phenotype. t(9;22) - this is commoner in adults and is associated with a very poor prognosis. t(9;22) - this is commoner in adults and is associated with a very poor prognosis. t(4;11) - this translocation results in the MLL-AF4 fusion gene. It is associated with pre-pre B-ALL and is associated with a poor prognosis. t(4;11) - this translocation results in the MLL-AF4 fusion gene. It is associated with pre-pre B-ALL and is associated with a poor prognosis. t(1;19) - associated with pre-B ALL and results in the formation of the E2A- PBX fusion gene. t(1;19) - associated with pre-B ALL and results in the formation of the E2A- PBX fusion gene. These translocations are demonstrable by RT-PCR techniques. These translocations are demonstrable by RT-PCR techniques. TAL-1 deregulation is the commonest genetic abnormality in T-ALL. This may occur as the result of the t(1;14) or more commonly due to chromosome 1p32 deletions. TAL-1 deregulation is the commonest genetic abnormality in T-ALL. This may occur as the result of the t(1;14) or more commonly due to chromosome 1p32 deletions.

33. Acute Lymphoblastic Leukaemia PROGNOSTIC FACTORS The following are poor prognostic factors in ALL: age 10 years age 10 years male sex male sex CNS disease at presentation CNS disease at presentation high white cell count high white cell count t(9;22) t(9;22) t(4;11) t(4;11) hypodiploidy hypodiploidy

34. Acute Lymphoblastic Leukaemia OUTCOME AND THERAPY The treatment of ALL consists of the following "phases": Remission induction - vincristine, prednisolone, daunorubicin, asparaginase. Remission induction - vincristine, prednisolone, daunorubicin, asparaginase. Consolidation - various combinations of chemotherapeutic agents. Consolidation - various combinations of chemotherapeutic agents. CNS directed therapy - high dose systemic and intrathecal methotrexate. CNS directed therapy - high dose systemic and intrathecal methotrexate. Maintenance therapy - vincristine, prednisolone, mercaptopurine and methotrexate for 2 years. Maintenance therapy - vincristine, prednisolone, mercaptopurine and methotrexate for 2 years. Childhood ALL is associated with 75% long term survival. Minimal residual disease assessment using PCR based strategies appear to be able to predict relapse although they are not yet in routine clinical use. Allogeneic transplantation is the treatment of choice at relapse. Childhood ALL is associated with 75% long term survival. Minimal residual disease assessment using PCR based strategies appear to be able to predict relapse although they are not yet in routine clinical use. Allogeneic transplantation is the treatment of choice at relapse. The outlook in adult ALL is poor with approximately 20% long-term survivors. Allogeneic transplantation is advisable in first remission. The outlook in adult ALL is poor with approximately 20% long-term survivors. Allogeneic transplantation is advisable in first remission.

35. ACUTE LEUKAEMIA CLASSIFICATION Acute lymphoblastic leukaemia Acute lymphoblastic leukaemia Early pre-B-cell ALL Early pre-B-cell ALL Pre-B-cell ALL Pre-B-cell ALL B-cell ALL B-cell ALL T-cell ALL T-cell ALL Acute nonlymphocytic leukaemia Acute nonlymphocytic leukaemia Acute myelocytic leukaemia, minimally differentiated (AML-M0) Acute myelocytic leukaemia, minimally differentiated (AML-M0) Acute myelocytic leukaemia, without maturation (AML-M1) Acute myelocytic leukaemia, without maturation (AML-M1) Acute myelocytic leukaemia, with maturation (AML-M2) Acute myelocytic leukaemia, with maturation (AML-M2) Acute promyelocytic leukaemia (APL, AML-M3) Acute promyelocytic leukaemia (APL, AML-M3) Acute myelomonocytic leukaemia, (AMMoL, AML-M4) Acute myelomonocytic leukaemia, (AMMoL, AML-M4) Acute monocytic leukaemia, (AMoL, AML-M5) Acute monocytic leukaemia, (AMoL, AML-M5) Acute erythroleukaemia, (AEL, AML-M6) Acute erythroleukaemia, (AEL, AML-M6) Acute megakaryocytic leukaemia, (AMegL, AML-M7) Acute megakaryocytic leukaemia, (AMegL, AML-M7) Biphenotypic (mixed lineage) leukaemia Biphenotypic (mixed lineage) leukaemia Acute undifferentiated leukaemia Acute undifferentiated leukaemia

36. ACUTE LYMPHOBLASTIC LEUKAEMIA Blast Cell Characteristics Early Pre-B Cell Pre-B Cell B Cell T Cell Early Pre-B Cell Pre-B Cell B Cell T Cell Gene rearrangement Heavy chain + * + + - Heavy chain + * + + - Light chain +/- +/- + - Light chain +/- +/- + - Immunologic features Cytoplasmic U - + - - Cytoplasmic U - + - - Membrane Ig - - + - Membrane Ig - - + - CD 10 (CALLA) + +/- +/- +/- CD 10 (CALLA) + +/- +/- +/- Ia/HLA-DR + + + - Ia/HLA-DR + + + - CD24, CD19, CD20 + + + - CD24, CD19, CD20 + + + - CD2, CD5, CD7 - - - + CD2, CD5, CD7 - - - + Cytochemical features Nuclear TDT + + - + Nuclear TDT + + - + 5’-Nucleotidase + + - + 5’-Nucleotidase + + - + Acid phosphatase - - - + Acid phosphatase - - - + Cytogenetic abnormalities t(12;21) t(1;19) t(8;14), t(2;8), t(8;22) t(1;14), t(11;14), del(9p) Morphology FAB L1 90% 90% 10% 95% FAB L1 90% 90% 10% 95% FAB L2 10% 10% 15% 5% FAB L2 10% 10% 15% 5% FAB L3 0 0 75% 0 FAB L3 0 0 75% 0

37. ACUTE NONLYMPHOBLASTIC LEUKAEMIA Blast Cell Characteristics AMegLAELAMoLAMMoLAPLAML M7 Cytoplasmic budding MyelofibrosisM6M5M4M3M0,M1,M2Morphology FAB classification FAB classification Associated features Associated features Cytochemical features Myeloperoxidase, Sudan black Myeloperoxidase, Sudan black Chloroacetate esterase Chloroacetate esterase Nonspecific esterase Nonspecific esterase PAS PAS Platelet peroxidase Platelet peroxidase --+/-++ -, +, ++ -, +, ++ ---++ --++-- ++---- +----- Abnormalities of 5, 7, 21 t(11q)del(11q)del(16)(q22)inv(16)(p13;q22)t(15;17)t(8;21)Cytogenetic abnormalities abnormalities

38. Myelodysplastic Syndrome (MDS) WHO Classification There are 8 categories of MDS in the WHO system. There are 8 categories of MDS in the WHO system. 1) Refractory anemia (RA) 2) Refractory anemia with ringed sideroblasts (RARS) 3) Refractory cytopenia with multilineage dysplasia (RCMD) 4) Refractory cytopenia with multilineage dysplasia and ringed sideroblasts (RCMD-RS) 5) Refractory anemia with excess blasts-1(RAEB-1) 6) Refractory anemia with excess blasts-2(RAEB-2) 7) Myelodysplastic syndrome, unclassified (MDS-U) 8) MDS associated with isolated del(5q)

39. Myelodysplastic Syndrome (MDS) WHO Classification Convert to AML Bone Marrow Blood%Type 6% Only erythroid dysplasia <5% blasts <15% ringed sideroblasts Anaemia No or rare blasts 5-10%RA ICD-O code 9980/3 1-2% Only erythroid dysplasia <5% blasts ≥15% ringed sideroblasts Anaemia No blasts 10-12%RARS ICD-O code 9982/3 11% ≥10% dysplasia of 2 or more myeloid cell lines <5% blasts, No Auer rods <15% ringed sideroblasts Cytopenias (2-3) No or rare blasts, No Auer rods <1×10 9 /L mono. 39% (24/15) RCMD ICD-O code 9985/3 ≥10% dysplasia of 2 or more myeloid cell lines <5% blasts, No Auer rods ≥15% ringed sideroblasts Cytopenias (2-3) No or rare blasts, No Auer rods <1×10 9 /L mono. RCMD -RS

40. Myelodysplastic Syndrome (MDS) WHO Classification 25% Uni/Multilineage dysplasia 5-9%blasts, No Auer rods Cytopenias <5% blasts, No Auer rods <1×10 9 /L mono. 40% (22/18) (affect pts > 50 years) pts > 50 years) RAEB I ICD-O code 9983/3 33% Uni/Multilineage dysplasia 10-19%blasts, Auer rods +/- Cytopenias 5-19% blasts, Auer rods +/- <1×10 9 /L mono. RAEB II ? Unilineage dysplasia <5% blasts, No Auer rods Cytopenias No or rare blasts, No Auer rods ? (0- 18%) MDS-U ICD-O code 9989/3 Uncommon Normal to increased megakaryocytes with hypolobated nuclei <5% blasts Isolated del(5q) cytogenetic abnormality No Auer rods Anaemia Normal or High Platelet Count <5% blasts (predo minantl y in middle age to older women) MDS-del(5q) ICD-O code 9986/3

41. Etiologic Factors in Acute Leukaemia ---------------------------------------------------- Chromosome Abnormalities Down’s syndrome Bloom’s syndrome Fanconi’s anaemia Radiation Exposure

42. Etiologic Factors in Acute Leukaemia (continued) ------------------------------------------------------------------------------------------------------------------------------------- Marrow Toxins 1.Benzene 2.Chloramphenicol 3.Phenylbutazone 4.Anticancer chemotherapeutic drugs, especially alkylating agents. Antecedent Hematopoietic Disorders 1.Paroxysmal nocturnal hemoglobinuria 2.Myelodysplastic syndromes (preleukemias) 3.Myeloproliferative disorders (chronic myelogenous leukaemia, polycythemia vera) -------------------------------------------------------------------------------------------------------------------------------------

43. Clinical Manifestations - - General - - Related to anaemia, decrease WBC, decrease Plt. - - Lymphadenopathy, hepatosplenomegaly: - - Uncommon Big Spleen: AML blast crisis of CML - - Organ infiltration - - Rare: Granulocytic sarcomas - - Uric Acid: Nephropathy, Gout - - DIC: All forms especially promyelocytic (M3)

44. Presenting manifestations of acute leukaemia ---------------------------------------------------------------------------------------------------------------------------------------------------- Common Anaemia Fever, malaise Haemorrhagic manifestations Less common Infection of the mouth and pharynx Pains in bones and joints (childhood especially) Upper respiratory tract infection (childhood especially) Superficial lymph node enlargement

45. Presenting manifestations of acute leukaemia (continued) -------------------------------------------------------------------------------------------------------------------------------------------- Occasional Diarrhoea and/or vomiting Acute abdominal pain Mediastinal pressure (childhood) Nervous system manifestations Skin rash

46. Acute Myelogenous Leukaemia (AML) Definition & Epidemiology ----------------------------------------------------- It is also known as: Acute non-lymphoblastic leukaemia A clonal malignant disease characterised by: -Proliferation of abnormal blasts in the BM. -Impaired production of normal blood cells.

47. Acute Myelogenous Leukaemia (AML) Definition & Epidemiology (Continued) ----------------------------------------------------- A neoplastic proliferation of: Haemopoietic stem cell. Constitutes around 80% of adult cases. There is no major differences in geographical incidence between urban and rural areas. Slightly more common in males than females.

48. Acute Myelogenous Leukaemia (AML) Diagnosis ----------------------------------------------------- - - Complete Blood Count (CBC): *WBC: High, Normal, Low 30% of cases > 10 X 10 9 /L Hypogranular neutrophils Blasts are usually seen *RBC & Hb: Low *Plat: Low

49. Acute Leukaemia Morphological (FAB) Classification ------------------------------------------------------------------------------------------------------------------------------------------------------------ A. A. Lymphoblastic (ALL): L1: Small, Monomorphic L2: Large, heterogenous L3: Burkitt-cell type B. B. Myeloid (AML): M1: Myeloblastic without maturation. M2: Myeloblastic with maturation. M3: Hypergranular promyelocytic M4: Myelomonocytic M5: Monocytic: Poorly differentiated (M5a) Well differentiated (M5b) M6: Erythroleukaemia. M7: Megakaryoblastic

50. Acute Leukaemia Cytochemical Reactions in AML & ALL ReactionM1M2M3M4M5M6M7L1-L2L3 Peroxidase Sudan Black +++ -/++ (BL) - (BL) -- ANA Ester-/+++/+++/++’++’-+’-/+- ChA Ester++ +/+++ -/+-- Lysozyme *---/++/++++---- Acid Phosph-/++++/++++++-/++ ▪ (Local.) - PAS-/++++ +++-/++- ( Diffuse ) (Dif & GR) (ER) ‘ ▪ NaF sensitive * ▪ T-ALL * ▪ Cytobacterial Test & /Or Serum Level

51. Cell markers in AML McAbMO*M1M2/M3M4/M5M6M7 CD34 (3C5)++± /- -± CD13 (MCS2) ¶++++++ CD33 (MY9)±+++±+ CD11b (OKM1)--+±-- CD14 (FMC17)---+-- Glycophorin----+- CD241/42-----+ TdT:-/+ ---- Undifferentiated myeloblastic leukaemia with negative light microscopy cyto- chemistry for AML: absence of lymphoid antigens: and positive peroxidase by electron microcsopy. ¶ More sensitive when tested on fixed cells (cytoplasmic expression) Oliveira et al. 1998). : Positive in up to 50% of M0/M1 cases and in less than 10% of other types of AML (M2 to M7) (Parreira et al. 1988).

52. Karyotypic Abnormalities in Acute Nonlymphocytic Leukemia * -------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ChromosomalApproximate AbnormalityFrequency (%) Association -------------------------------------------------------------------------------------------------------------------------------------------------------------------------- t 8;217-15 M2 subtype; low leukocyte alkaline phosphatase; good prognosis t 15;17low M3 subtype 11qlow M4, M5 subtypes -5, 5q-, -7, 7q-22 Preceding toxin exposure; more frequent in M1, M2 subtypes +817 inv (3)rare Megakryocytic leukemia T 4;11rare Younger patients; lymphoid-monocytoid features; leukocytosis; poor prognosis inv (16) 6 M4 subtype; abnormal marrow eosinophils; favourable prognosis t 6;9rare Marrow basophilia -------------------------------------------------------------------------------------------------------------------------------------------------------------------------- *Adapted from data in references 4,5,10,39,48,49,53,62,63,76, and 86. t= translocation; inv = inversion

53. Features of hypergranular promyelocytic leukaemia ------------------------------------------------------------ - *Incidence : 7% of all AML. *Age : predominantly < 40 years *Characteristic morphology (M3 of the FAB classification) *Pancytopenia common. *High incidence of D.I.C. *High levels of serum vitamin B12 binding protein (Transcobalamin I) *Unique chromosome abnormality: t(15q+; 17q-) all ≈ cases *Prolonged survival : 16% > 6 years

54. Clinical and laboratory features of monocytic (M5) leukaemia ----------------------------------------------------- *Lymphadenopathy *Gum hypertrophy > 50% of cases *Skin infiltrates *High serum and > 75% of cases urine lysozyme levels *Hypokalaemia *High WBC counts > 50% of cases (≥ 50 X 10 9 /1)

55. Classification of Childhood ALL -------------------------------------------------------------------------------------------------------------------------------------- Morphology B and T Anti-ALL Classification Incidence (FAB classification) markers serum -------------------------------------------------------------------------------------------------------- Positive Common – ALL 70% L1 in most cases Negative ---------------------------------------------------- Negative Null – ALL 90% --------------------------------------------------------------------------------------------------------- L1 or L2 T-markers Negative T - ALL 20% --------------------------------------------------------------------------------------------------------- L3 B-markers Negative B – ALL 1% (Burkitt type) --------------------------------------------------------------------------------------------------------

56. Classification of Adult ALL Morphology (FAB classification) B and T markers Anti-ALL serum Ph 1 Chromosome Classification Incidence L2 in most cases Negative Positive NegativeCommon ALL 30% PositivePh1(+)-ALL20% Negative Null-ALL30% L1 or L2T-markersNegative T-ALL8% L2 or L3B-markersNegative Leukaemic phase of B- cell lymphomas 12%

57. ----------------------------------------------------------------------------------------------------------------------------------------- Clinical and Haematological features of T-ALL ----------------------------------------------------------------------------------------------------------------------------------------- 1. 1. Blast cell count ≥ 100 X 10 9 /1 50% of cases 2. 2. Anterior mediastinal mass 3. 3. Median age : 6.5 years 4. 4. Male : female ratio 2.5 : 1 5. 5. Relatively less anaemia and thrombocytopenia than in common-ALL 6. 6. Short – lived complete remissions 7. 7. High incidence of meningeal relapse -----------------------------------------------------------------------------------------------------------------------------------------

58. Prognostic features in Childhood ALL BADGOOD WBC  20 X 10 9 /1, particularly > 100 x 10 9 /1 < 10 9 /1 Age 13 years3 – 7 years SexBoysGirls Cell markersT or BAll antigen OthersCNS leukaemia at presentation Complete remission in first 3 – 4 weeks

59. Acute Myelogenous Leukaemia (AML) Principles of Therapy --------------------------------------------------------------------------------------------------------------------------------------------------------- A. A. Remission induction: Daunorubicin Cytosine Arabinoside (ara-C) Thioguanine or etoposide B. B. Consolidation: As in (A) + 3 other drugs e.g. Maze or mace M-amssa (Amsacrine), Azacytidine or ara-C & Etoposide C. C. Consideration of BMT: Antologous (+/- BM purging) Allogeneic (HLA-Matched sibling) OR Further intensification e.g. 2 drug combination: Mitozantrone Moderately high dose ara-C

60. Acute Lymphoblastic Leukaemia (ALL) Principles of Therapy ------------------------------------------------------------------------------------------------------------------------------------------------------------- 1. 1. Remission induction ( 4 weeks) 2. 2. Consolidation (5 days) 3.Consideration of BMT (High Risk Cases) Vincristine Prednisolone Daunorubicin L- Asparaginase Vincristine, Daunorubicin Prednisolone, ara-C Etoposide, Thioguanine Allogenic Or Autologous

61. Acute Lymphoblastic Leukaemia (ALL) Principles of Therapy (Continued) ------------------------------------------------------------------------------------------------------------------------------------------------------------- 4.CNS Prophylaxix 5.Late Intensification 6.Maintenance Therapy (2 years) Cranial Irradiation Intrathecal Methotrexate (6 injections) Cyclophosphamide Methotrexate Intermediate Or High dose (etc.) Methotrexate 6-Mercaptopurine Vincristine Predinisolone

62. Clinical and Laboratory features of monocytic (M5) leukaemia --------------------------------------------------------------------------------------------------------------------------------------------------- *Lymphadenopathy *Gum hypertrophy > 50% of cases *Skin infiltrates *High serum and urine lysozyme levels > 75% of cases *Hypokalaemia *High WBC Counts > 50% of cases (50 X 10 9 /1)