Muhammad Asif Zeb
Lecuture IPMS (KMU)

Leukemia:
All leukemia's are stem cell/ and or precursor
of HSC disorders characterized by malignant neoplastic
proliferation and accumulation of immature and
nonfunctional haemopoietic cells in the blood and bone
marrow.

 Leukemia's are cancer found in the blood cells.
 Acute leukemia are usually aggressive disease.
 They are classified by how quickly they progress and
what type of cell they affect.
 Leukemia affects ability to produce normal blood cells.
 Bone marrow makes abnormally large number of
immature white blood cells called blasts.

Hematopoietic
stem cell
Neutrophils
Eosinophils
Basophils
Monocytes
Platelets
Red cells
Myeloid
progenitor
Lymphoid
progenitor
B-lymphocytesB-lymphocytes
T-lymphocytes
Plasma
cells
naïve
ALLALL
AMLAML

Leukemia
Acute
Chronic
ALL
AML
CML
CLL

FeaturesFeatures AcuteAcute ChronicChronic
AgeAge All agesAll ages AdultsAdults
Clinical onsetClinical onset SuddenSudden InsidiousInsidious
Course ofCourse of
diseasedisease
Week or monthsWeek or months Months to yearsMonths to years
Predominant cellPredominant cell Blast ,someBlast ,some
mature formsmature forms
Mature formsMature forms
AnemiaAnemia Mild – severeMild – severe MildMild
ThrombocytopeniaThrombocytopenia Mild – severeMild – severe MildMild
WBCWBC VariableVariable IncreasedIncreased

 Acute leukaemias are usually aggressive diseases
in which malignant transformation occurs in the
haemopoietic stem cell or early progenitors.
 Genetic damage is believed to involve several
key biochemical
 (i) an increased rate of proliferation;
 (ii) reduced apoptosis
 (iii) a block in cellular differentiation.

 Malignant transformation occurs as a result of the
accumulation of genetic mutations .
 Genes involved in the development of cancer are
divided broadly into two groups:
a. Oncogenes
b. Tumour-suppressor genes

 Symptoms due to:
◦ Marrow failure
◦ Tissue infiltration
◦ Leukostasis
◦ Other (DIC)

 Neutropenia:
Infections, sepsis
 Anemia:
Fatigue, pallor
 Thrombocytopenia:
Bleeding

 Enlargement of liver, spleen, lymph nodes
 Gum hypertrophy
 Bone pain
 Other organs: CNS, skin, testis, any organ

 Accumulation of blasts in microcirculation with
impaired perfusion.
 Lungs: hypoxemia, pulmonary infiltrates
 CNS: stroke

 Fever and sweats common
 Weight loss less common

Acute Myeloid Leukaemia

 Acute myeloid leukaemia (AML) has an incidence
of 2 – 3 per 100 000 per annum in children, rising
to 15 per 100 000 in older
adults

myeloblast promyelocyte myelocyte metamyelocyte band neutrophil
MATURATIONMATURATION
Adapted and modified from U Va website

WHO classification (Newer)
 Incorporates and interrelates morphology,
cytogenetics, molecular genetics, and immunologic
markers.
 20% blast in blood and bonemarrow.
FAB classification (Older)
 Solely based upon morphology as determined by
the degree of differentiation along different cell lines
and the extent of cell maturation.
 30% blast in blood and bone marrow.

M0: Minimally differentiated
M1: Myeloblastic leukemia without maturation
M2: Myeloblastic leukemia with maturation
M3: Hypergranular promyelocytic leukemia
M4: Myelomonocytic leukemia
M5: Monocytic leukemia
M6: Erythroleukemia (DiGuglielmo's disease)
M7: Megakaryoblastic leukemia

1.Acute myeloid leukemia with recurrent
genetic abnormalities
• AML with t(8;21)(q22;q22), AML1 (CBF-a)/ETO
• Acute promyelocytic leukemias [AML with t(15;17)
(q22;q11) and variants, PML/RAR-a]
• AML with abnormal bone marrow eosinophils
inv(16)(p13q22) or t(16;16)(p13;q11),
CBFb/MYH11X
• AML with 11q23 (MLL) abnormalities

2 . AML with multilineage dysplasia
• With previous myelodysplastic
syndrome
• Without previous myelodysplastic
syndrome
3. AML and myelodysplastic syndromes,
therapy-related
• Alkylating agent-related
• Topoisomerase type II inhibitor-related

4. AML not otherwise categorized
• AML minimally differentiated
• AML with maturation
• AML without maturation
• Acute myelomonocytic leukemia
• Acute monoblastic and monocytic
leukemia
• Acute erythroid leukemia
• Acute megakaryoblastic leukemia
• Acute basophilic leukemia
• Acute panmyelosis with myelofibrosis
5. Acute Biphenotypic Leukemias

 Most patients with AML present with anemia normocytic normochromic.
 Thrombocytopenia
 Leukocytosis white blood cell count up to 200x109
 Large, sometimes hypogranular platelets can be seen, and functional
defects can contribute to hemorrhagic manifestations.
 Most patients are neutropenic, and morphologic abnormalities
(hypogranulation, nuclear hyperlobulation, Pelger-Huët anomaly) are
often noted in the remaining neutrophils.
 Blasts are predominant cells.

BM aspirates show
 Hypercellularity
 Cells predominantly myeloblasts
 Immature granulocytes, erythroblasts, modest increase in
plasma cells, monocytes, megaloblastic erythroblasts,ring
sideroblasts.
 Erythropoeitic cells scanty, megaloblasts, ring sideroblasts found
 Megakaryocytes reduced
 Myelofibrosis can be seen

SUBTYPESUBTYPE MPO/SBMPO/SB
BB
SESE NSENSE
AML-M0AML-M0 __ __ __
AML-M1AML-M1 ++ ++ __
AML-M2AML-M2 ++ ++ __
AML-M3AML-M3 ++ ++ __
AML-M4AML-M4 ++ ++ ++
AML-M5aAML-M5a __ __ ++
AML-M5bAML-M5b __ __ ++
AML-M6AML-M6 ++ __ +/_+/_
AML-M7AML-M7 __ __ Strongly + using acetateStrongly + using acetate

Type 1
Typical myeloblast with open chromatin and
prominent nucleoli, immature deep blue cytoplasm
without granules.
Type 2
Similar to type one + presence of up to 20 discrete
azurophilic granules.
Type 3
Similar to type one + numerous azurophilic
granules.

 Distinguished by absence of visible granules in
cytoplasm of blast.
 Negative –ve reactions with cytochemical stains.
 Positive +ve for myeloid lineage markers.
CD13 CD33.

 AML variant and is most common in adults and in
infants less then 1 year.
 50% cases show leucocytosis.
 Lack of cellular maturation.
 Predominant cell in peripheral blood is poorly
differentiated myeloblast.
 Vacuoles may be present.
 Platelet are generally decreased.
 A few blast may have scanty azurophilic granules or
Auer rod is present.

 Presence of more differantiated cells in the bone marrow with
maturation.
 Condition is more common in adults.
 Leucocytosis in 50% of cases.
 Thrombocytopenia
 Myeloblast are predominant cell type in peripheral blood.
 Bone marrow is hypercellular.
 Azurophilic granules in variable amount.
 Auer rods a azurophilic granules are common.
Phi bodies:
Phi bodies are variant of auer rods but are smaller and not
necessarily in rod shaped.

 Typically seen in young adults.
 Sudden and severe progression.
 Cause acute DIC.
 DLC shows predominance of promyelocytes.
 Nucleus is very delicate sometime show foldings.
 Most common clinical finding is bleeding.
Faggot cells:
Cells with multiple auer rods sometime
occuring in bundles

 Both myelocytic and monocytic cells are present in
peripheral blood and bone marrow.
 Infilteration of leukemic cells in extramedullary sites is
more common.
 Serum and urine level of meuramidase are usually
elevated because of monocytic proliferation.
 Anemia
 Thrombocytopenia
 Cytochemical stains will demonstrate two cells
population in bone marrow.

 Usually seen in children and young adults.
 Degree of gum hypertrophy ,lymph node ,CNS and extra
medullary infiltrates seen.
 Occasional episods of DIC.
 Moderately elivated serum and urine muramidase.
 More then 80% of non erythroid cells seen in BM are
monocytic .

 Poorly differentiated.
 Monoblast account for 80% or more of all monocytic
cells.
 Remeining 20% are monocytes.
 The monoblast are larger.
 Azurophilic granules may be present.

 Well differentiated.
 More then 80% of monocytic cells in nonerythroid
marrow.
 The remaining cells are promonocytic or monocytic.
 The percentage of blast is less then 30%.
 Fine azeurophilic granules are present.

 Predominant cells in the bone marrow is erythroblast.
 Predominant feature is anemia with striking
poikilocytosis and anisocytosis.
 The diagnosis of erythroleucaemia can be done if more
then 50% of bone marrow cells are erythroid and 30%
of remaining are blast.
 True erythro leukemia occurs when BM is replaced by
proliferating normoblast showing no maturation byond
basophilic normoblasts.

 Peripheral blood pancytopenia.
 High peripheral blood blast count.
 Micro megakaryocytes and undifferentiated blast.
 Bone marrow reveals increased fibroblast.
 Showing cytoplasmic budding.

 Leukaemia is the most common childhood cancer
and acute lymphoblastic leukaemia (ALL) is the
most common subtype, accounting for 75 – 80%
of all cases

 L1—Mature-appearing lymphoblasts (T-cells or pre-B-
cells) small blast with High N:C ration.
 L2—Immature and pleomorphic (variously shaped)
lymphoblasts (T-cells or pre-B-cells) small and large
blast present with moderate N:C ration.
 L3— Lymphoblasts (B-cells; Burkitt's cells) are large and
uniform, deep basophilic cytoplasm, vaculation in
cytoplasm and low N:C ratio.

FeaturesFeatures L1L1 L2L2 L3L3
Cell sizeCell size Small, uniformSmall, uniform Large, oftenLarge, often
heterogeneousheterogeneous
Large, homogeneousLarge, homogeneous
NucleusNucleus Round, regularRound, regular Oval to round,Oval to round,
irregular cleftingirregular clefting
RoundRound
Amount ofAmount of
cytoplasmcytoplasm
ScantScant ModeratelyModerately
abundantabundant
Moderately abundantModerately abundant
Genetic materialGenetic material Dense, uniformDense, uniform variablevariable finely stippled andfinely stippled and
uniformuniform
NucleoliNucleoli Inconspicuous,Inconspicuous,
smallsmall
Prominent, largeProminent, large
1 - >11 - >1
Present, may bePresent, may be
prominentprominent
1- >1, vesicular1- >1, vesicular
cytoplasmcytoplasm
vacuolesvacuoles
OcassionalOcassional VariableVariable ProminentProminent
BasophiliaBasophilia SlightSlight VariableVariable PunctatePunctate
FrequencyFrequency 85%85% 15%15% 2%2%

 the WHO has recognized just two groups of acute
lymphoblastic leukemias,
 precursor B-cell and
 precursor T-cell lymphoblastic
leukemia/lymphoma.

 B-ALL comprises approximately 85% of all childhood ALL,
whereas B-LBL is a rare type of lymphoma and constitutes
approximately 10% of lymphoblastic lymphoma cases.
 is a malignancy where B lineage lymphoblasts predominate in the
bone marrow (B lymphoblastic leukemia).
 Sometimes there is primary involvement of lymph nodes or
extranodal sites (B lymphoblastic lymphoma).
 Greater than 20% of bone marrow cells
 ; however, the bone marrow aspirate typically consists of almost
entirely lymphoblasts at diagnosis.

 When the leukemic process is limited to a mass lesion and less than 20% or
fewer lymphoblasts are seen in the marrow, the designation lymphoma is
used.
 The blood and bone marrow contains lymphoblasts
 with L1 or L2 morphology
 B-ALL may also develop in adults, and the prognosis is generally much poorer
in adults
Immunophenotype
 The lymphoblasts in B-ALL/LBL are uniformly TdT
 positive and HLA-DR positive.
 The flow cytometric immunophenotype in most cases is positive for CD 10,
CD19, CD20, CD24, CD22, and CD79a

 is a malignancy of lymphoblasts with pre-T markers predominating
in the bone marrow (T-ALL).
 When there is primary involvement of lymph nodes or extranodal
sites, it is termed T lymphoblastic lymphoma.
 T-ALL represents approximately 15% to 20% of all childhood ALL, is
more prevalent in adolescents than young children, and is seen
more frequently in males than females.
 often have L2 morphology
 less frequently, have L1 morphology

 The lymphoblasts in T-ALL are TdT, cytoplasmic
CD3, CD7, CD1, CD2, , CD5 positive

 WBCs
◦ Total cont elevated 50-60 x 109
/L to 100 109
/L
◦ Rarely more than 100 109
/L
◦ Lymphoblasts in large numbers
 RBCs
◦ Normocytic normochromic anaemia.
 Thrombocytopenia.

Marrow aspirates show:
 Blast cell predominace. They are lymphoblasts which
are earliest identifiable precursor of lymphoid cells
 Erythropeitic cells reduced
 Dyserythropoiesis
 Megakaryocytes reduced

 This is the most common form found in children
and it has the best prognosis.

•This is the most frequent ALL found in adults.
–.

 This is the rarest form of ALL.
 Burkit lymphoma type cells

 Aids in the diagnosis
 Classification of the leukemias
 Identification of the chemical components of
cells - is conducted to distinguish different types
of leukemia.

Enzymatic Techniques
 Myeloperoxidases
 Esterases
 Phosphatases
Nonenzymatic Techniques
 Periodic Acid-Schiff Stain
 Sudan Black B
 Toluidine Blue

Leukemia,White Blood 69
CYTOCHEMICAL STAINCYTOCHEMICAL STAIN ALL BLASTSALL BLASTS AML BLASTSAML BLASTS
MPOMPO NegativeNegative PositivePositive
SUDAN BLACK BSUDAN BLACK B NegativeNegative PositivePositive
PASPAS PositivePositive NegativeNegative
NON SPECIFICNON SPECIFIC
ESTERASEESTERASE
NegativeNegative PositivePositive
ACID PHOSPHATASEACID PHOSPHATASE PositivePositive NegativeNegative

Leukemia,White Blood 70
 Serum uric acid raised due to breakdown of leukemic
cells.
 Serum LDH may be raised
 Hypocalcaemia
 Hyperuricemia
 Increase K+

Terminal deoxynucleotidyl transferase (TdT) is an
intranuclear enzyme found in stem cells and
immature lymphoid cells within the bone marrow,
but not in mature B lymphocytes.

 It is present in 90% of acute lymphoblastic leukemias.
 Only 5%-10% of acute myeloblastic leukemias.
 It has also been demonstrated in 1/3 of cases of the
blast crisis stage of chronic myelogenous leukemia and
is a good prognostic indicator in these patients.

It is likely that the physician will want to perform imaging studies to
determine whether the leukemia has invaded other organs within
the body. Such studies will include:
 X-rays
 Computed tomography (CT or CAT)
 Magnetic resonance imaging (MRI)
 Radionuclide (radioactive atom)
 Ultrasound

 Look CSF for Blast cells

 A karyotype is the characteristic chromosome
complement of a eukaryote species.
 Its study is called karyotyping.
 The preparation and study of karyotypes is part of
cytogenetics.