1. 1 Chronic Leukemia Ahmad Sh. Silmi, Msc, FIBMS

2. 2 The definition of chronic leukemia: Chronic leukemia is thought to arise from genetic defect in a single cell in B.M or in the peripheral tissue. When this cell success to proliferate gives rises to a clonal population that will give mass which when enlarged enough caused a serious disease. Chronic leukemia is thought to arise from genetic defect in a single cell in B.M or in the peripheral tissue. When this cell success to proliferate gives rises to a clonal population that will give mass which when enlarged enough caused a serious disease.

3. 3 What Are the Types of Chronic Leukemia?

4. 4 Classification of CL. There are two types: There are two types: 1- chronic myeloid leukemia. 2- chronic lymphoid leukemia.

5. 5 Chronic Myeloid Leukemia.

6. 6 Definition of CML: CML is defined as a stem cell disorder suggested as Philadelphia chromosome found in all stem cells. So there is replacement of normal B.M cells by cells with an abnormal chromosome – Philadelphia or (ph) chromosome CML is defined as a stem cell disorder suggested as Philadelphia chromosome found in all stem cells. So there is replacement of normal B.M cells by cells with an abnormal 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.

7. 7 Types of Chronic CML: Typename 1 (CML,Ph+)(chronic granulocytic leukemia) 2(CML,Ph-) 3 Juvenile CML 4 Chronic neutrophilic leukemia. 5 Esinophilic leukemia 6 Chronic myelomonocytic leukemia

8. Incidence CML comprises <20% of all leukaemia, its rarer than CLL. CML comprises <20% of all leukaemia, its rarer than CLL. The incidence rate is 1-2/100,000 -1 population; with a peak of incidence in the middle age people. The incidence rate is 1-2/100,000 -1 population; with a peak of incidence in the middle age people. The disease occur in either sex (male: female 1.4:1), however, it may occur in children, neonates and very old people. The disease occur in either sex (male: female 1.4:1), however, it may occur in children, neonates and very old people. 8

9. 9 What Is Philadelphia Chromosome?

10. 10 Philadelphia : Is the chromosome which result from the t(9;22)(q34;q11)  part of the Abelson proto- oncogene ABL is moved to the BCR gene on chromosome 22 & part of chromosome 22 moves to chromosome 9. Is the chromosome which result from the t(9;22)(q34;q11)  part of the Abelson proto- oncogene ABL is moved to the BCR gene on chromosome 22 & part of chromosome 22 moves to chromosome 9. The abnormal chromosome 22is the Ph. The abnormal chromosome 22is the Ph. See fig. See fig.

11. 11 Fig

12. 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

13. Pathogenesis Genetic abnormality Genetic abnormality CML is the result of an acquired genetic abnormality CML is the result of an acquired genetic abnormality A translocation between chromosome 9 and 22 [t(9;22)] – the Philadelphia chromosome A translocation between chromosome 9 and 22 [t(9;22)] – the Philadelphia chromosome The oncogene BCR-ABL encodes an enzyme – tyrosine phosphokinase (usually p210) The oncogene BCR-ABL encodes an enzyme – tyrosine phosphokinase (usually p210) The function of the normal abl gene product ( p145 abl ) is incompletely understood but it is known to have tyrosine kinase activity and may play a role in the regulation of several different growth factor receptors, including those for epidermal growth factor, platelet derived growth factor, and colony stimulating factor receptors. The function of the normal abl gene product ( p145 abl ) is incompletely understood but it is known to have tyrosine kinase activity and may play a role in the regulation of several different growth factor receptors, including those for epidermal growth factor, platelet derived growth factor, and colony stimulating factor receptors.

14. Pathogenesis The normal bcr gene product (p160 bcr ) is known to have serine/threonine kinase activity and shows considerable homology to a number of cell cycle proteins. It is thought to play an important role in cellular signal transduction. The normal bcr gene product (p160 bcr ) is known to have serine/threonine kinase activity and shows considerable homology to a number of cell cycle proteins. It is thought to play an important role in cellular signal transduction. The chimeric bcr-abl fusion gene produces a chimeric protein of molecular weight 210,000 daltons (p210 bcr- abl ). This protein has much more powerful tyrosine kinase activity than p145 abl and has been shown to interact with its substrates in an altered manner. The chimeric bcr-abl fusion gene produces a chimeric protein of molecular weight 210,000 daltons (p210 bcr- abl ). This protein has much more powerful tyrosine kinase activity than p145 abl and has been shown to interact with its substrates in an altered manner. (p210 bcr-abl ) has a great serine / threonine activity that enhance and push the proliferation and differentiation in a novel manner particularly in chronic phase. (p210 bcr-abl ) has a great serine / threonine activity that enhance and push the proliferation and differentiation in a novel manner particularly in chronic phase. 14

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

17. 17

18. 18 How Would the Patient With CML Present?

19. 19 Clinical Presentation: Increasing splenomegally, which is associated with discomfort, pain or indigestion. Increasing splenomegally, which is associated with discomfort, pain or indigestion. Refractory anaemia that include pallor, weakness and tachychardia. Refractory anaemia that include pallor, weakness and tachychardia. Bruising, epistaxis due to abnormal platelet functions. Bruising, epistaxis due to abnormal platelet functions. Gout or renal impairment due to hyperuricemia. Gout or renal impairment due to hyperuricemia. Visual disturbances. Visual disturbances. Increase requirement to chemotherapy to maintain remission. Increase requirement to chemotherapy to maintain remission. Massive increasing of circulating granulocytes. Massive increasing of circulating granulocytes.

20. 20 How Would You Investigate the Patient With Suspected CML? ….

21. 21 Investigation: CBC: CBC: Wbc is usually >50X10/l & some times >500X10/l. Normocytic normochromic anemia. Platelets . peripheral blood film: peripheral blood film:  circulating basophil.

22. 22

23. 23 fig

24. 24 Cont: Neutrophil alkaline phosphatase score is invariably low. Neutrophil alkaline phosphatase score is invariably low. BM: is hyper cellular with granulopoietic predominance. BM: is hyper cellular with granulopoietic predominance. Cytogenetics: ph chromosome. Cytogenetics: ph chromosome. Serum vitamin B12 & vitamin b12-binding capacity are . Serum vitamin B12 & vitamin b12-binding capacity are . Serum uric acid is usually . Serum uric acid is usually .

25. 25 What Are the Phases of CML? …

26. 26 Phases of CML: Chronic phase : Chronic phase : Accelerated phase: Accelerated phase: Blast phase: Blast phase:

27. 27 Chronic phase CML The three defining features of typical chronic phase are: Raised granulocytes. Raised granulocytes. The presence of Philadelphia chromosome. The presence of Philadelphia chromosome. Splenomegaly. Splenomegaly.

28. 28 Accelerated phase CML The transition to accelerated phase is accompanied by increasing refractoriness to treatment which may be reflected in one or 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 blood (blastic crisis), which is an evolution of CML that give rise to acute phase, this is manifested by progression of anaemia, neutropenia and thrombocytopenia. In blastic phase the blast should exceed 30% in the peripheral blood (blastic crisis), which is an evolution of CML that give rise to acute phase, this is manifested by progression of anaemia, neutropenia and thrombocytopenia.

29. 29 Blastic phase CML In most cases, establishment of the accelerated phase of CML is followed by a sustained refractory to treatment, the blast cell count rises and physical symptoms are worsening. The diagnostic criteria for blast crisis are that the circulating blast cell counts should exceed 30% of the total leukocyte count. In most cases, establishment of the accelerated phase of CML is followed by a sustained refractory to treatment, the blast cell count rises and physical symptoms are worsening. The diagnostic criteria for blast crisis are that the circulating blast cell counts should exceed 30% of the total leukocyte count. Progression of chronic phase to blastic phase has been likened to the evolution of chronic leukaemia into acute leukaemia. The accumulation of blast cells which results is accompanied by anaemia, neutropenia and thrombocytopenia Progression of chronic phase to blastic phase has been likened to the evolution of chronic leukaemia into acute leukaemia. The accumulation of blast cells which results is accompanied by anaemia, neutropenia and thrombocytopenia

30. 30

31. 31 How Would You Treat CML? …

32. 32 Treatment: Chemotherapy: Chemotherapy: Tyrosine kinase inhibitor: Tyrosine kinase inhibitor: Interferon- . Interferon- . Stem cell transplant. Stem cell transplant.

33. 33 Tyrosine kinase inhibitor

34. 34 What Is the Course and Prognosis of CML?..

35. 35 Course & prognosis: Usually shows excellent response to chemotherapy in the chronic phase. Usually shows excellent response to chemotherapy in the chronic phase. Death usually occur from terminal acute transformation,hemorrhage or infection. Death usually occur from terminal acute transformation,hemorrhage or infection.

36. 36 Take a Break ! …

37. 37 Chronic lymphocytic Leukemia:

38. CLL CLL is the most common of the chronic lymphoid leukemias. CLL is the most common of the chronic lymphoid leukemias. Is characterised by the accumulation of non- proliferation mature-appearing lymphocytes (Lymphocytosis) in the blood, marrow, lymph nodes, and spleen. Is characterised by the accumulation of non- proliferation mature-appearing lymphocytes (Lymphocytosis) in the blood, marrow, lymph nodes, and spleen. 38

39. CLL In most cases, the cells are monoclonal B lymphocytes that are CD5+ In most cases, the cells are monoclonal B lymphocytes that are CD5+ T cell CLL can occur rarely T cell CLL can occur rarely Peak incidence between 60-80yrs. Peak incidence between 60-80yrs. Is the most common form of leukemia in North America and Europe, but is extremely rare in the Orient Is the most common form of leukemia in North America and Europe, but is extremely rare in the Orient Affects men twice as often as women Affects men twice as often as women Incidence rate: 300 cases / 100,000 -1 population/ annually. Incidence rate: 300 cases / 100,000 -1 population/ annually. 39

40. Leukemogenesis Genetic factors have been postulated to play a role in high incidence of CLL in some families Genetic factors have been postulated to play a role in high incidence of CLL in some families Cytogenetics Cytogenetics – clonal chromosomal abnormalities are detected in approximately 50% of CLL patients – the most common clonal abnormalities are: trisomy 12 trisomy 12 structural abnormalities of chromosomes 13, 14 and 11 structural abnormalities of chromosomes 13, 14 and 11 – patients with abnormal karyotypes have a worse prognosis 40

41. 41 What Is the Clinical Presentation?

42. 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.

43. 43 Fig(1)

44. 44 Fig(2)

45. 45 How would you investigate patient with CLL?..

46. 46 Investigation: CBC: CBC: – Wbc:  – Diff: lymphocytosis,the absolute lymphocyte count is >5x10 9 /l and may be up to 300x10 9 /l or More. Anemia: normocytic normochromic anemia is present in later stages, autoimmune haemolysis. Platelets : thrombocytepenia may occur. Platelets : thrombocytepenia may occur.

47. 47 Cont: Blood film: 70-99% of white cells mature lymphocyte. Smudge or smear cells also present. Immunophenotyping: Shows that the lymphocyte are B cells(CD19)expressing one form of light chain(  or only)cells are also CD5&CD23+ve. Shows that the lymphocyte are B cells(CD19)expressing one form of light chain(  or only)cells are also CD5&CD23+ve.

48. 48 Fig(3)

49. 49 Cont: Bone marrow aspiration: Bone marrow aspiration: Lymphocytic replacement of normal marrow. Immunoglobulin electrophoresis: Immunoglobulin electrophoresis:  of Ig more marker with advance disease. Cytogenetic : Cytogenetic : The 4 most common abnormalities are; deletion of 13q14,trisomy 12, deletion of11q23&structural abnormality of 17p involving the p53 gene. The 4 most common abnormalities are; deletion of 13q14,trisomy 12, deletion of11q23&structural abnormality of 17p involving the p53 gene.

50. Cont: Clonal expansion of B (99%) or T(1%) lymphocyte Clonal expansion of B (99%) or T(1%) lymphocyte – In B-cell CLL clonality is confirmed by the expression of either  or light chains on the cell surface membrane the expression of either  or light chains on the cell surface membrane the presence of unique idiotypic specificities on the immunoglobulins produced by CLL cells the presence of unique idiotypic specificities on the immunoglobulins produced by CLL cells by immunoglobulin gene rearrangements by 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 hemolytic anemia, with a positive direct Coombs’ test 10 - 25% of patients with CLL develop autoimmune hemolytic anemia, with a positive direct Coombs’ test The marrow aspirates shows greater than 30% of the nucleated cells as being lymphoid The marrow aspirates shows greater than 30% of the nucleated cells as being lymphoid

51. Classification B CLL are CD5 +, CD19 +, CD20 +, CD21 +, CD22 + and HLA-DR. B CLL are CD5 +, CD19 +, CD20 +, CD21 +, CD22 + and HLA-DR. Typically, the antigen density on B-CLL is lower than normal lymphocyte. Typically, the antigen density on B-CLL is lower than normal lymphocyte. CLL cells also express CD25 (the IL-2 receptor) weakly&CD5 CLL cells also express CD25 (the IL-2 receptor) weakly&CD5 CD5 is a pan T cell marker, which is involved in T cell activation. CD5+ B lymphocytes are involved in the regulation of autoimmunity. CD5 is a pan T cell marker, which is involved in T cell activation. CD5+ B lymphocytes are involved in the regulation of autoimmunity. 51

52. 52

53. 53 What Is the Staging of CLL? …

54. 54 Staging : Staging is very important for prognosis and treatment. Staging is very important for prognosis and treatment. There are two staging system (Rai and Binet). There are two staging system (Rai and Binet). See table. See table.

55. 55 A-Rai Classification: Stagedefinition 0 Absolute lymphocytosis >15x10 9 /l. 1 Stage 0+enlarged lymph nodes. 11 Stage 0+liver or/and spleen   adenopathy. 111 Stage 0+anemia  organomegally or adenopathy. 1V Stage 0+thrombocytopenia  organomegally or adenopathy.

56. 56 B-Binet Classification: Stage. Organomegally. HbPlatelet. A(50-60%)0,1,or2areas B(30%) 3,4,or 5areas  10  100 C(<20%) Not considered <10 and /or <100 and /or <100

57. 57 How Would You Treat Patient With CLL? …

58. 58 Treatment : Since cure is rare, the treatment aim is only symptoms control. Since cure is rare, the treatment aim is only symptoms control. Indication for treatment: Indication for treatment: – Troublesome organomegaly. – Hemolytic episodes. – Bone marrow suppression.

59. 59 Modality of Treatment: 1-chemotherapy: 1-chemotherapy: Chlorambucil: 6mg/m 2 daily for 10 days monthly for 2-4 month after which remission will be obtain. Fludarabine:more effective as single agent. Corticosteroid :indicated in bone marrow failure, also indicated in autoimmune hemolytic anemia and thrombocytopenia.

60. 60 Cont: 2-Radiotherapy: 2-Radiotherapy: Is useful in reducing the size of lymph node not responsive to chemo. 3-Monoclonal antibody: 3-Monoclonal antibody: Both campath IH(anti CD52)and Rituximab(anti CD20)produce response in proportion of patient.

61. 61 Cont: 4-Splenectomy : 4-Splenectomy : For immune-mediated cytopenia or painful bulky splenomegally. 5-immunoglobulin replacement: 5-immunoglobulin replacement: 250mg/kg /month by IV for patient with hypogammaglobulinemia and recurrent infection.

62. 62 Cont: 5- Stem cell transplant: 5- Stem cell transplant: Under clinical trial.

63. 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.

64. Prolymphocyte leukemia

65. 65 Prolymphocyte leukemia The second most common type of CLL ( 10% ), largely B cell malignancy and afflicts the elderly people with incidence in male more than female. The T-PLL accounts 25% of PLL cases only. T-PLL accounts 25% of PLL cases only.

66. 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.

67. 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.

68. 68 Prolymphocytic leukemia

69. 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.

70. Immunophenotyping

71. 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.

72. 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.

73. 73 Hairy cell leukemia This is mainly a disease of elderly men This is mainly a disease of elderly men Patients present with marked splenomegaly, but not lymphadenopathy Patients present with marked splenomegaly, but not lymphadenopathy Patients have fatigue and malaise Patients have fatigue and malaise Pancytopenia Pancytopenia The peripheral smear shows atypical mononuclear lymphocytoid cells with hairy projections on their surfaces The peripheral smear shows atypical mononuclear lymphocytoid cells with hairy projections on their surfaces The bone marrow yields a dry tap because the malignant cells are often surrounded by fibrosis The bone marrow yields a dry tap because the malignant cells are often surrounded by fibrosis Splenectomy and interferon as well as new chemotherapeutic drugs are successful in promoting long lasting remissions Splenectomy and interferon as well as new chemotherapeutic drugs are successful in promoting long lasting remissions

74. 74 Hairy cell leukemia

75. 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.

76. 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.

77. 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.

78. 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.

79. 79 Good Luck! ……..