acute leukemia

1. Timeliness in diagnosis of Acute
Leukemia in paediatric age
group.

2. Epidemilogy
• Incidence rate of childhood cancer across the world varies between 50 and 200 per
million children
• Leukemia and lymphoma are the most prevalent cancers globally among children.
• In India, cancer is the ninth common cause of death among children between 5 and
14 years and approximately 45,000 children are diagnosed with cancer annually .
Preponderance of childhood leukemia and lymphoma cases is reported in boys as
against girls.
• Age specific rates were highest for lymphoid leukemia followed by myeloid and
unspecified leukemia. This trend is seen in all age groups and both sexes in all
regions of India.
S. Asthana et al. / Pediatric Hematology Oncology Journal 3 (2018) 115e12

3. How does acute leukaemia present in
children?
• Presentations of acute leukaemia relate to three main pathological processes
Chris M et al : BMJ 2009;338:b2285
Bone marrow failure due to
extensive infiltration by blast
cells
Infiltration of other tissues by
blasts
Systemic effects of cytokines
released by tumour cells.

4. How does acute leukaemia present in children?
contdd....
At present, there is no definitive evidence base enabling doctors, particularly GPs, to
discriminate with confidence between
• those children for whom wait and see is appropriate practice
• those for whom phlebotomy is advisable,
• those who should be referred urgently to the emergency department.
No studies conducted in primary care that evaluated the positive and negative predictive
value of signs and symptoms for the diagnosis ofacute leukaemia,
Although the appearance of the disease is often quite dramatic, there are many patients
who present much more indolently, creating a diagnostic dilemma for the primary care
pediatrician
Chris M et al : BMJ 2009;338:b2285

5. Presentations of acute leukaemia in children
UNDERLYING PATHOPHYSIOILOGY SIGNS AND SYMPTOMS
Systemic effects of
cytokines
Malaise,Fatigue,Nausea,Fever.
Bone marrow infiltration
Anaemia Pallor,Lethargy,Shortness of breath,Dizziness,
Palpitations,Reduced exercise tolerance.
Neutropenia Fever,Infection in general,Recurrent infection
Unusual infections, eg oral candida
Thrombocytopenia Bruising,Petechiae,Epistaxis
Reticuloendothelial
infiltration
Hepatosplenomegaly,Lymphadenopathy
Expiratory wheeze secondary to mediastinal
mass (due to lymphadenopathy, or thymic
infiltration or expansion)
Other organ infiltration
CNS Headaches,Vomiting,Cranial nerve palsie,Convulsions.
Testes Testicular enlargement
Leucostasis Headache,Stroke,Shortness of breath,Heart failure.
Chris M et al : BMJ 2009;338:b2285

6. Life Threatening Complications
Mechanism Complication
Neutropenia Infection: overwhelming, usually Gram-negative sepsis, with
or without
disseminated intravascular coagulation
Thrombocytopenia Bleeding: stroke, pulmonary haemorrhage, gastrointestinal
haemorrhage
Electrolyte imbalance Hyperkalaemia and hyperphosphataemia secondary to blast
cell lysis
Acute renal failure secondary to hyperuricaemic nephropathy
Reticuloendothelial infiltration Acute airway obstruction secondary to mediastinal thymic
mass
Leucostasis Stroke, acute pulmonary oedema, heart failure
Chris M et al : BMJ 2009;338:b2285

7. Tests for Childhood leukemia
Medical History and physical examination
• A thorough medical history to learn about the symptoms and how long the child has had them,
exposure to possible risk factors. A family history of cancer, especially leukemia.
• During the physical exam,look for any enlarged lymph nodes, areas of bleeding or bruising, or possible
signs of infection. The eyes, mouth, and skin will be looked at carefully, and a nervous system exam
may be done. The child's abdomen (belly) should be felt for signs of an enlarged spleen or liver.
Blood tests
• The first tests done to look for leukemia are blood tests. The blood samples are usually taken from a
vein in the arm, but in infants and younger children they may be taken from other veins (such as in the
feet or scalp) or from a “finger stick.”
• A complete blood count (CBC) is done to determine how many blood cells of each type are in the
blood.
The American Cancer Society medical and editorial content team. Last Revised: February 12, 2019

8. Tests for Childhood leukemia contd...
Bone marrow aspiration and biopsy
• A bone marrow aspiration and bone marrow
biopsy are tests that are usually done at the
same time. The samples are usually taken from
the back of the pelvic (hip) bones, but
sometimes they may be taken from the front of
the pelvic bones or from other bones.
• Bone marrow tests are used to diagnose
leukemia and its immunophenotype , but they
may also be repeated later to find out if the
leukemia is responding to treatment.
The American Cancer Society medical and editorial content team. Last Revised: February 12, 2019

9. Tests for Childhood leukemia contdd...
Lumbar puncture (spinal tap)
This test is used to look for leukemia cells in the
cerebrospinal fluid (CSF)
In children already diagnosed with leukemia, lumbar
punctures might also be used to give chemotherapy
drugs into the CSF to try to prevent or treat the
spread of leukemia to the spinal cord and brain. (This
is known as intrathecal chemotherapy.)
The American Cancer Society medical and editorial content team. Last Revised: February 12, 2019

10. Tests for Childhood leukemia contd...
Microscopic examination -Hyperleukocytosis (>100 × 103 WBC/mcL) occurs at diagnosis in about 12%
of white children and in about 23% of African-American children
Samples are sent for laboratory testing
Robert W M Clinical Chemistry 46:8(B)1252–1259 (2000)

11. Tests for Childhood leukemia contd...
Flow cytometry and
immunohistochemistry - The particular
immunophenotype is identified using flow
cytometry, a process by which cells are
stained with a panel of antibodies to
determine which markers are expressedon
the surface of the malignant cells
 In B-ALL, the tumors cells are positive
for terminal deoxynucleotidyl transferase
(TdT)B cell lineage proteins such as CD19,
CD22, CD20, and CD79a, and negative for
surface immunoglobulin, which appears
only on mature B cells.
In T-ALL,the tumors express TdT and
variable combinations of T-lineage antigens
such as CD1a, CD3, CD4, CD5, CD7, and
CD8
The leukemic cells (red) exhibit increased orthogonal
scatter indicative of cytoplasmic complexity, i.e.,
granules, and express CD13, CD33, myeloperoxidase
(MPO), and partial CD11b. They lack expression of
HLA-DR and CD34, which is typical of acute PML and
contrasts with most other types of AML.
Robert W M Clinical Chemistry 46:8(B)1252–1259 (2000)

12. Tests for Childhood leukemia contd...
Chromosomal tests - cytogenetics , FISH ,Next
Generation Sequencing Tests, - aid in risk
stratification
Bone marrow chromosome karyotype shows a single
abnormality, t(15;17)(q22;q21) (arrows). This
translocation involves the PML gene at band q22 on
chromosome 15 and the RARa gene on chromosome
17 band q21, producing a PML-RARa fusion gene.
This fusion gene is present in all cases of acute PML.
The karyotypic or molecular identification of this
translocation is necessary to consider treatment with
ATRA because leukemias with this molecular
translocation are the only ones that will respond.
Robert W M Clinical Chemistry 46:8(B)1252–1259 (2000)

13. Tests for Childhood leukemia contd...
Robert W M Clinical Chemistry 46:8(B)1252–1259 (2000)

14. Tests for Childhood leukemia contd...
Polymerase Chain Reaction-This test can be veryuseful in looking for small
numbers of leukemia cells (minimal residual disease, or MRD)
Imaging Tests
Chest x-ray -to assess for mediastinal mass
CT Scan
MRI
Ultrasound

15. WHO classification of Acute Leukemia 2000
AML ALL
Robert W M Clinical Chemistry 46:8(B)1252–1259 (2000)

16. WHO Classification of Acute Leukemia 2008
Myeloproliferative neoplasms(MPN)
Chronic myelogenous leukemia, BCR-ABL1-positive
Chronic neutrophillic leukemia
Polycythemia vera
Primary myelofibrosis
essential thrombocythemia
Chronic eosinophillic leukemiua, not otherwise specified
Mastocytosis
myeloproliferative neoplasma, unclassifiable
Myeloid and lymphoidneoplasms associated with eosinophilia and
abnormalities of PDGFRA,PDGFRB or FGFR1
myeloid and lymphoid neoplasms associated with PDGFRA
rearrangement
myeloid neoplasms associated with PDGRFB rearrangement
myeloid and lymphoid neoplasms associated with FGFR1abnormalities
Myelodysplastic/myeloproliferative neoplasms (MDS/MPN)
Chronic myelomonocytic leukemia
Atypical chronic myeloid leukemia, BCR-ABL1 negative
 Juvenile myelomonocytic leukemia
myelodysplasticmyeloprolferative neoplasm, unclassifiable
Myelodysplastic Syndrome (MDS)
Refractory cytopenia with unilineage dysplasis
refractory anemia
refractory neutropenia
refractory thrombocytopenia
refractory anemia with ring sideroblasts
refractory cytopenia with multilineage dysplasia
refratory anemia with excess blats
 myelodysplastic syndrome with isolated del(5q)
 myelodysplastic syndrome uclassifiable
 childhood myelodysplastic syndrome
Acute myeloid leukemia and related neoplasms
Acute myeloid leukemia with recurrent genetic abnormalities
 AML with t(8;21)(q22;q22); RUNX1-RUNX1T1
 AML with inv(16)(p13.1q22) or t(16;16)(p13.1;q22); CBFB-
MYH11
 APL with t(15;17)(q22;q12); PML-RARA
 AML with t(9;11)(p22;q23); MLLT3-MLL
 AML with t(6;9)(p23;q34); DEK-NUP214
 AML with inv(3)(q21q26.2) or t(3;3)(q21;q26.2); RPN1-EVI1
 AML (megakaryoblastic) with t(1;22)(p13;q13); RBM15-MKL1
 Provisional entity: AML with mutated NPM1
 Provisional entity: AML with mutated CEBPA
James W V et al, BLOOD, 30 JULY 2009, VOLUME 114, NUMBER 5

17. Acute myeloid leukemia with myelodysplasia-related
changes
 Therapy-related myeloid neoplasms
 Acute myeloid leukemia, not otherwise specified
 AML with minimal differentiation
 AML without maturation
 AML with maturation
 Acute myelomonocytic leukemia
 Acute monoblastic/monocytic leukemia
 Acute erythroid leukemia
 Pure erythroid leukemia
 Erythroleukemia, erythroid/myeloid
 Acute megakaryoblastic leukemia
 Acute basophilic leukemia
 Acute panmyelosis with myelofibrosis
 Myeloid sarcoma
 Myeloid proliferations related to Down syndrome
 Transient abnormal myelopoiesis
 Myeloid leukemia associated with Down syndrome
 Blastic plasmacytoid dendritic cell neoplasm
Acute leukemias of ambiguous lineage
 Acute undifferentiated leukemia
 Mixed phenotype acute leukemia with t(9;22)(q34;q11.2); BCR-ABL1
 Mixed phenotype acute leukemia with t(v;11q23); MLL rearranged
 Mixed phenotype acute leukemia, B-myeloid, NOS
 Mixed phenotype acute leukemia, T-myeloid, NOS
 Provisional entity: natural killer (NK) cell lymphoblastic leukemia/lymphoma
B lymphoblastic leukemia/lymphoma
 B lymphoblastic leukemia/lymphoma, NOS
 B lymphoblastic leukemia/lymphoma with recurrent genetic abnormalities
 B lymphoblastic leukemia/lymphoma with t(9;22)(q34;q11.2);BCR-ABL 1
 B lymphoblastic leukemia/lymphoma with t(v;11q23);MLL rearranged
 B lymphoblastic leukemia/lymphoma with t(12;21)(p13;q22) TEL-AML1
(ETV6-RUNX1)
 B lymphoblastic leukemia/lymphoma with hyperdiploidy
 B lymphoblastic leukemia/lymphoma with hypodiploidy
 B lymphoblastic leukemia/lymphoma with t(5;14)(q31;q32) IL3-IGH
 B lymphoblastic leukemia/lymphoma with t(1;19)(q23;p13.3);TCF3-PBX1
T lymphoblastic leukemia/lympho
WHO Classification of Acute Leukemia 2008
contdd...
James W V et al, BLOOD, 30 JULY 2009, VOLUME 114, NUMBER 5

18. FAB classification of Acutelymphoblastic
leukaemia
W.Ladines-Castro et alRevMedHospGenMéx.2016;79(2):107---113

19. FAB classification of acute myeloblastic leukaemia
W.Ladines-Castro et alRevMedHospGenMéx.2016;79(2):107---113

20. Initial Diagnostic Work-Up of Acute Leukemia:
ASCO Clinical Practice Guideline Endorsement
of the CAP and ASH Guideline
de Haas, et al.
www.asco.org/hematologic-malignancies-guidelines ©American Society of Clinical Oncology 2018. All rights reserved.

21. • Recommendation 1. The treating clinician should provide relevant clinical data or ensure that this is readily
accessible by the pathologist (Strong recommendation).
• Recommendation 2. The treating clinician should provide relevant physical examination and imaging
findings or ensure that those results are readily accessible by the pathologist.(Recommendation)
• Recommendation 3. The pathologist should review recent or concurrent complete blood cell (CBC) counts
and leukocyte differentials and evaluate a peripheral blood smear (Strong recommendation).
• Recommendation 4. The treating clinician or pathologist should obtain a fresh bone marrow aspirate for all
patients suspected of acute leukemia, a portion of which should be used to make bone marrow aspirate smears
for morphologic evaluation. If performed, the pathologist should evaluate an adequate bone marrow trephine
core biopsy, bone marrow trephine touch preparations, and/or marrow clots, in conjunction with the bone
marrow aspirates (Strong recommendation).
• Recommendation 5. In addition to morphologic assessment (blood and bone marrow), the pathologist or
treating clinician should obtain sufficient samples and perform conventional cytogenetic analysis (ie,
karyotype), appropriate molecular genetic and/or fluorescent in situ hybridization (FISH) testing, and flow
cytometric immunophenotyping (FCI). The flow cytometry panel should be sufficient to distinguish acute
myeloid leukemia (including acute promyelocytic leukemia), T-cell acute lymphoblastic leukemia (T-ALL)
(including early T-cell precursor leukemias), B-cell precursor ALL (B-ALL), and acute leukemia of
ambiguous lineage on all patients diagnosed with acute leukemia. Molecular genetic and/or FISH testing does
not, however, replace conventional cytogenetic analysis (Strong recommendation).

22. • Recommendation 6. For patients with suspected or confirmed acute leukemia, the pathologist may request
and evaluate cytochemical studies to assist in the diagnosis and classification of acute myeloid leukemia
(AML) (Expert consensus opinion)
• Recommendation 7. The treating clinician or pathologist may use cryopreserved cells or nucleic acid,
formalin fixed, nondecalcified paraffin-embedded (FFPE) tissue, or unstained marrow aspirate or peripheral
blood smears obtained and prepared from peripheral blood, bone marrow aspirate or other involved tissues
for molecular or genetic studies in which the use of such material has been validated. Such specimens must
be properly identified and stored under appropriate conditions in a laboratory that is in compliance with
regulatory and/or accreditation requirements.(recommendation)
• Recommendation 8. For patients with acute lymphoblastic leukemia (ALL) receiving intrathecal therapy, the
treating clinician should obtain a cerebrospinal fluid (CSF) sample. The treating clinician or pathologist
should ensure that a cell count is performed and that examination/enumeration of blasts on a cytocentrifuge
preparation is performed and is reviewed by the pathologist (Strong recommendation).
• Recommendation 9. For patients with acute leukemia other than those with ALL who are receiving
intrathecal therapy, the treating clinician may, under certain circumstances, obtain a cerebrospinal fluid (CSF)
sample when there is no clinical contraindication. The treating clinician or pathologist should ensure that a
cell count is performed and that examination/enumeration of blasts on a cytocentrifuge preparation is
performed and is reviewed by the pathologist (Expert consensus opinion).
• Recommendation 10. For patients with suspected or confirmed acute leukemia, the pathologist may use flow
cytometry in the evaluation of CSF (Recommendation).

23. • Recommendation 11. For patients who present with extramedullary disease without bone marrow or
blood involvement, the pathologist should evaluate a tissue biopsy and process it for morphologic,
immunophenotypic, cytogenetic, and molecular genetic studies, as recommended for the bone marrow
(Strong recommendation).
Note.—Additional biopsies may be indicated to obtain fresh material for ancillary testing.
• Recommendation 12. For patients with suspected or confirmed acute leukemia, the pathologist or
treating clinician should ensure that flow cytometry analysis or molecular characterization is
comprehensive enough to allow subsequent detection of minimal residual disease (MRD) (Strong
recommendation).
• Recommendation 13. For pediatric patients with suspected or confirmed B-ALL, the pathologist or
treating clinician should ensure that testing for t(12;21)(p13.2;q22.1); ETV6-RUNX1,
t(9;22)(q34.1;q11.2); BCR-ABL1,KMT2A (MLL) translocation, iAMP21, and trisomy 4 and 10 is
performed (Strong recommendation).
• Recommendation 14. For adult patients with suspected or confirmed B-ALL, the pathologist or
treating clinician should ensure that testing for t(9;22)(q34.1;q11.2); BCR-ABL1 is performed. In
addition, testing for KMT2A (MLL) translocations may be performed. [Strong recommendation for
testing for t(9;22)(q34.1;q11.2) and BCR-ABL1;Recommendation for testing for KMT2A (MLL)
translocations].

24. • Recommendation 15. For patients with suspected or confirmed ALL, the pathologist or treating
clinician may order appropriate mutational analysis for selected genes that influence diagnosis,
prognosis, and/or therapeutic management, which includes, but is not limited to, PAX5, JAK1, JAK2,
and/or IKZF1 for B-ALL and NOTCH1 and/or FBXW7 for T-ALL. Testing for overexpression of
CRLF2 may also be performed for B-ALL (Recommendation).
• Recommendation 16. For pediatric and adult patients with suspected or confirmed acute myeloid
leukemia (AML) of any type, the pathologist or treating clinician should ensure that testing for FLT3-
ITD is performed. The pathologist or treating clinician may order mutational analysis that includes, but
is not limited to, IDH1, IDH2, TET2, WT1, DNMT3A, and/or TP53 for prognostic and/or therapeutic
purposes. [Strong recommendation for testing for FLT3-ITD; Recommendation for testing for other
mutational analysis].
• Recommendation 17. For adult patients with confirmed core-binding factor (CBF) AML (AML with
t(8;21)(q22;q22.1); RUNX1-RUNX1T1 or inv(16)(p13.1q22)/t(16;16)(p13.1;q22); CBFB-MYH11), the
pathologist or treating clinician should ensure that appropriate mutational analysis for KIT is
performed. For pediatric patients with confirmed CBF-AML; RUNX1-RUNX1T1 or inv(16)(p13.1q22)
/ t(16;16)(p13.1;q22); CBFB-MYH11—the pathologist or treating clinician may ensure that appropriate
mutational analysis for KIT is performed. [Strong recommendation for testing for KIT mutation in
adult patients with CBF-AML; Expert consensus opinion for testing for KIT mutation in pediatric
patients with CBF AML].

25. Recommendation 18. For patients with suspected acute promyelocytic leukemia (APL), the pathologist
or treating physician should also ensure that rapid detection of PML-RARA is performed. The treating
physician should also order appropriate coagulation studies to evaluate for disseminated intravascular
coagulation (DIC) (Strong recommendation).
Recommendation 19. For patients other than those with confirmed core binding factor AML, APL, or
AML with myelodysplasia-related cytogenetic abnormalities, the pathologist or treating clinician should
also ensure that mutational analysis for NPM1, CEBPA, and RUNX1 is also performed (Strong
recommendation).
Recommendation 20. For patients with confirmed acute leukemia, no recommendation is made for or
against the use of global/gene-specific methylation, microRNA (miRNA) expression, or gene expression
analysis for diagnosis or prognosis (No recommendation).

26. • Recommendation 21. For patients with confirmed mixed phenotype acute leukemia (MPAL), the
pathologist or treating clinician should ensure that testing for t(9;22)(q34.1;q11.2); BCR-ABL1, and
KMT2A (MLL) translocations is performed (Strong recommendation).
• Recommendation 22. All laboratory testing performed for the initial workup and diagnosis of a
patient with acute leukemia must be performed in a laboratory that is in compliance with regulatory
and/or accreditation requirements (Strong recommendation).
• Recommendation 23. If after examination of a peripheral blood smear, it is determined that the patient
will require immediate referral to another institution with expertise in the management of acute
leukemia for treatment, the initial institution should, whenever possible, defer invasive procedures,
including bone marrow aspiration and biopsies, to the treatment center to avoid duplicate procedures,
associated patient discomfort, and additional costs (Strong recommendation).
• Recommendation 24. If a patient is referred to another institution for treatment, the primary institution
should provide the treatment center with all laboratory results, pathology slides, flow cytometry data,
cytogenetic information, and a list of pending tests at the time of the referral. Pending test results
should be forwarded when they become available (Strong recommendation).

27. • Recommendation 25. In the initial report, the pathologist should include laboratory, morphologic,
immunophenotypic, and, if performed, cytochemical data, on which the diagnosis is based, along
with a list of any pending tests. The pathologist should issue addenda/amended reports when the
results of additional tests become available (Strong recommendation).
• Recommendation 26. The pathologist and treating clinician should coordinate and ensure that all
tests performed for classification, management, predicting prognosis, and disease monitoring are
entered into the patient’s medical records (Strong recommendation).
Note.—This information should include the sample source, adequacy, and collection information,
as applicable.
• Recommendation 27. Treating physicians and pathologists should use the current World Health
Organization (WHO) terminology for the final diagnosis and classification of acute leukemia
(Strong recommendation).

28. Chris M et al : BMJ 2009;338:b2285

29. SUMMARY
• Presentation of acute leukaemia can be non-specific, and not always have the
classic signs and symptoms of anaemia, bruising, bleeding,
hepatosplenomegaly, and lymphadenopathy.
• Diagnosis can be difficult, and delays can contribute to additional, sometimes
life threatening problems during the period of initial treatment.
• Relatively simple, inexpensive tests—a full blood count and examination of
the blood film—will diagnose acute leukaemia in most cases.
• Overall survival has risen from less than 5% in the 1960s to over 85% today.
Chris M et al : BMJ 2009;338:b2285