Download presentation
Presentation is loading. Please wait.
1
MED-341: Acute Leukaemia Professor Abdulkareem Almomen, MD, FRCPC (March 2011)
2
–Acute Myeloid Leukemia (AML) –Acute Lymphoblastic Leukemia (ALL) –Biphenotypic Acute Leukemia (BAL): My + Ly Acute Leukaemia: main subtypes
3
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
4
Maturation arrest
6
Normal Bone Marrow: Cell Heterogeneity
7
BM in AML: Monomorphous Cell Appearance
8
AML5a AML4-eos
9
Incidence: 2 - 3 pts /100.000 inhab - year Overall: 1.2% (US) Lineal increase with age: <35: < 1 /100.000 inhab - year >65: >10 /100.000 inhab - year Median age: 60 - 70 year-old Not apparent increase during last years AML: epidemiology
10
Bone marrow failure –Anemia –Neutropenia –Thrombocytopenia Extramedullary involvement (skin, gums, CNS, other) Proliferative symptoms Coagulopathy Leukostasis Metabolic disorders (tumor lysis syndrome) AML: clinical presentation
11
AML: skin infiltration (granulocytic sarcoma)
12
AML: gums (gingival) infiltration
13
Acute Myeloid Leukemia (AML)
14
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:
16
AML – Auer rod
17
MPO Naphtol-As-D-acetate esterase -naphthyl acetate esterase AML : Cytochemistry
18
CD56 PE 10 0 10 1 10 2 10 3 10 4 CD2 FITC 10 0 10 1 10 2 10 3 10 4 NG2 PE 10 0 10 1 10 2 10 3 10 4 CD34 FITC 10 0 10 1 10 2 10 3 10 4 CD14 PE 10 0 10 1 10 2 10 3 10 4 CD123 FITC 10 0 10 1 10 2 10 3 10 4 AML : Flow cytometry
19
AML: Cytogenetics
20
Acute Promyelocytic Leukemia (APL, M3) bcr1 bcr3 RT-PCR PML/RAR-alpha FISH: PML/RARA fusion signal Anti-PGM3 pattern staining
21
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
23
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
24
–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
25
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
26
Acute Lymphoblastic Leukemia (ALL)
27
ALL: definition –Clonal expansion of lymphoid (precursor lymphoid cells) in blood marrow (BM), peripheral blood (PB) or other tissue
28
ALL: main subtypes –B-cell ALL / precursor B lymphoblastic leukemia –T-cell ALL / precursor T lymphoblastic leukemia
29
Incidence: 2/100.000 (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
30
Extramedullary involvement –CNS –Mediastinal (T-ALL) –Other (lymph node, testicular,...) B symptoms Bone marrow failure Metabolic disorder ALL: characteristic clinical features
31
T-ALL: mediastinal involvement
32
ALL – FAB1 subtype
33
ALL – FAB2 subtype
34
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
35
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
36
–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
37
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)
38
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
39
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
40
Outcome –Response criteria Complete response Cytogenetics response Molecular response –Failure: primary refractory, relapse –…
41
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
42
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 10 -5 ) Response assessment: types (degree) of response
43
Morphologic assessment of response CR Non-CR
Similar presentations
© 2024 SlidePlayer.com Inc.
All rights reserved.