MED-341: Acute Leukaemia Professor Abdulkareem Almomen, MD, FRCPC (March 2011)

–Acute Myeloid Leukemia (AML) –Acute Lymphoblastic Leukemia (ALL) –Biphenotypic Acute Leukemia (BAL): My + Ly Acute Leukaemia: main subtypes

Clonal expansion of myeloid blasts in blood marrow (BM), peripheral blood (PB) or other tissue Minimum threshold of blast cells for defining AML (BM): – >20% blasts AML: definition / concept Proliferation + differentiation block / maturation arrest

Maturation arrest

Normal Bone Marrow: Cell Heterogeneity

BM in AML: Monomorphous Cell Appearance

AML5a AML4-eos

Incidence: pts / inhab - year Overall: 1.2% (US) Lineal increase with age: <35: < 1 / inhab - year >65: >10 / inhab - year Median age: year-old Not apparent increase during last years AML: epidemiology

Bone marrow failure –Anemia –Neutropenia –Thrombocytopenia Extramedullary involvement (skin, gums, CNS, other) Proliferative symptoms Coagulopathy Leukostasis Metabolic disorders (tumor lysis syndrome) AML: clinical presentation

AML: skin infiltration (granulocytic sarcoma)

AML: gums (gingival) infiltration

Acute Myeloid Leukemia (AML)

Cytology –PB –BM (BM aspirate ± BM biopsy) Cytochemistry –MPO (myeloperoxidase) & Sudan Black B (SBB) – Myeloid origin –Non-specific esterase (NSE):  -naphthyl acetate (ANA),  -naphthyl butyrate (ANB) – Monocytic origin Inmunophenotype –Hematopoietic precursors: CD34, HLA-DR, CD45 –My Ag: CD13, CD33, CD15, MPO, CD117 –Megakaryoblastic Ag: CD41, CD61 Cytogenetics Molecular biology –Fusion transcripts (RT-PCR): PML/RAR- , AML1/ETO, CBF-  /MYH11, MLL/..., BCR/ABL, DEK/CAN) –New mutations with prognostic impact: flt-3-ITD, CEBPalfa, NPM, … AML - diagnosis:

AML – Auer rod

MPO Naphtol-As-D-acetate esterase  -naphthyl acetate esterase AML : Cytochemistry

CD56 PE CD2 FITC NG2 PE CD34 FITC CD14 PE CD123 FITC AML : Flow cytometry

AML: Cytogenetics

Acute Promyelocytic Leukemia (APL, M3) bcr1 bcr3 RT-PCR PML/RAR-alpha FISH: PML/RARA fusion signal Anti-PGM3 pattern staining

Minimally differentiated (M0) AML w/o maturation (M1) AML with maturation (M2) Promyelocytic (M3) Myelomonocytic (M4) Monoblastic (M5a) Monocytic (M5b) Erythroleukemia (M6) Acute megakaryoblastic (M7) FAB classification for AML: lineage/differentiation- based Granulocytic diff Monocytic diff

I. AML with recurring genetic abnormalities –AML with t(8;21)(q22;q22) & (AML1/ETO) rearrangement –AML with abn BM eosinophils & inv(16)(p13q22)/t(16;16)(p13;q11) - CBF  /MYH11 rearrangement –Acute promyelocytic leukemia associated to t(15;17)(q22;q11-12) & PML/RAR-  rearr –AML with 11q23 (MLL) abn II. AML with multilineage dysplasia III. Therapy-related AML IV. AML not otherwise categorized WHO, 2001 WHO classification (AML): towards molecularly-based categories

–Favorable: t(15;17), t(8;21), inv(16) –Intermediate risk: normal karyotype –Unfavorable: abn 5 (del/-5), abn 7 (del/-7), inv(3q)/t(3;3), complex karyotype (≥5 abn), abn 11q, t(6;9), del(17p) AML: main cytogenetic abnormalities

AML (non-APL): standard approach Intensification CT Ara-C HD-based Post-remission tx AlloSCTAutoSCT CT Induccion CT Anthacycline + Ara-C /… CR~75% Long-term OS~35-40% (<60) Salvage therapy Refractory Relapse

Acute Lymphoblastic Leukemia (ALL)

ALL: definition –Clonal expansion of lymphoid (precursor lymphoid cells) in blood marrow (BM), peripheral blood (PB) or other tissue

ALL: main subtypes –B-cell ALL / precursor B lymphoblastic leukemia –T-cell ALL / precursor T lymphoblastic leukemia

Incidence: 2/ (inhab-year) 3/4 in children B-ALL: –80-85% –Predominance in children –10% presenting without BM involvement (B-cell lymphoblastic lymphoma) T-ALL: –15% of children ALL –25% of adult ALL –Predominance in adolescent / young male pts –Frequent presentation with exclusive extramedullary involvement (T-cell lymphoblastic lymphoma) ALL: epidemiology

Extramedullary involvement –CNS –Mediastinal (T-ALL) –Other (lymph node, testicular,...) B symptoms Bone marrow failure Metabolic disorder ALL: characteristic clinical features

T-ALL: mediastinal involvement

ALL – FAB1 subtype

ALL – FAB2 subtype

Common B-lineage antigens: HLA-DR, CD19, CD79a,CD22 Pro-B (B-cell progenitor, B-I): Tdt+, CD10(-), cyt Ig(-), CD20(-) Common (early pre-B, B-II): TdT(+), CD10(+), cyt Ig(-) Pre-B (B-III): Tdt(+), cyt Ig  (+) Mature B-ALL (B-IV): Tdt(-), s Ig  +, CD20(+) B-ALL: immunological classification

T-ALL/Common Ag: Tdt, CD3cyt, CD7 –Early T-ALL: CD1(-),CD2(-),CD3s(-), CD5(-),CD4(-), CD8(-) –Thymic T-ALL: CD1a(+),CD2(+),CD5(+) –Mature T-ALL: CD1a(-), CD2(+),CD5(+),CD3s(+) T-ALL: immunological classification

–Favorable: t(12;21), –Intermediate risk: normal karyotype, t(1;19) –Unfavorable: t(9;22), 11q23 abn [t(4;11) & other], hypoploid ALL: main cytogenetic abnormalities

ALL: current therapeutic approach Consolidation CT Post-remission AlloSCTAutoSCT CT (reinduction & maintenance) CR:  83% Induction Antr. / VCR / PDN L-ASA, ARA-C, CFM Surv * :   80% (children)  35% (adults)

Imatinib: molecular-targeted therapy for Ph-positive ALL Goldman et al, Lancet 2000 Y = Tyrosine P = Phosphate Bcr-Abl ATP Substrate P P P P Abl: a highly overexpressed tyrosine kinase protein in CML & Ph-pos ALL

Imatinib: molecular-targeted therapy for Ph-positive ALL Goldman et al, Lancet 2000 Bcr-Abl ATP Substrate P P P P Imatinib: blocks abl function by interfering with ATP binding Y = Tyrosine P = Phosphate

Outcome –Response criteria Complete response Cytogenetics response Molecular response –Failure: primary refractory, relapse –…

NCI criteria (Cheson et al, 1999) 1.<5% blasts in BM 2.Absence of extramedullary leukemia 3.Recovery of PB counts (ANC >1 & platelet >100x10 9 /L) 4.Minimum 4-week duration Definition of CR

CR (morphologic assessment) <5% of BM blast cells Low sensitivity Universally applicable Cytogenetic CR Absence of abnormal metaphases Low sensitivity Only in cases with cytogenetic abn (i.e., Ph-pos) Molecular response Clearance of molecular marker (bcr/abl, PML/RAR , AML1/ETO,...) Only in AL with known molecular marker High sensitivity (1 x ) Response assessment: types (degree) of response

Morphologic assessment of response CR Non-CR