Sukati P.

M Page 1

VAAL UNIVERSITY OF TECHNOLOGY
APPLIED AND COMPUTER SCIENCES:
N. DIPLOMA BIOMEDICAL
TECHNOLOGY
HAEMATOLOGY III PRACTICAL
LEUKAEMIAS

SUKATI P.M
206007981
PRACTICAL PORTFOLIO
OCTOBER 2012
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Dedications
I dedicate this hard work to my daughter Nowethu Mukelo Sibusisiwe Blessing Sukati.
I love you princess.


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ACUTE LYMPHOBLASTIC LEUKAEMIA



Introduction
Acute lymphoblast Leukemia is caused by an accumulation of lymphoblast in the bone marrow. ALL
causes damage and death by crowding out normal cells in the bone marrow and by spreading to other
organs. ALL is most common in children with a peak incident at 3-7 years of age and the other peak is at
old age.
Acute refers to the relatively short term course of the disease. It is interchangeably referred to as
Lymphocytic or Lymphoblastic. This refers to the cells to the cells that are involved, which if they were
normal would be referred to as lymphocytes but are seen in this disease in a relatively immature.


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Pathogenesis
ALL is the most common form of leukaemia in children. Highest incident at 3-7 years fall by 10 years with
a secondary rise after the age of 40 years. The common CD10+ precursor B type which is most used I
children has an equal sex incident, there is a male predominance for T cell ALL/ ALL T cell.
The pathogenesis is varied in a proportion of cause the first event occurs in the fetus in utero, infection
in children. In other cases the disease seems to arise as a post natal mutation in an early lymphoid
progenitor cell.
Clinical Features
The clinical features are a result of the following ;
Bone marrow failure; Anemia ( pallor lethargy and dypnoea) neutropenia (fever malaise features
of mouth, throat, skin, respiratory, perianal or other infections and thrombocytopenia (
spontaneous bruising, purpura, bleeding gums and menorrhagia
Organ infiltration; Tender bones, lymphadenopathy, moderate splenomegaly, hepatomegaly
and meningeal syndrome (headache nausea and vomiting blurring vision and diplopia. Fundal
examination may reveal papilloedema and sometimes haemorrhage. Many patients have a fever
which is usually resolved after starting chemotherapy, less common manifestations include
testicular swelling or signs of medianal compression in T ALL.
Laboratory findings
Haematological Investigations
Normochromic
Normocytic anaemia
Total white cell count may increase (>200X 10
9
/L
Morphology
Blast cells are seen on blood smear and should be greater than 20%
Bone marrow
It is hypercellular with >20% leukaemic blasts characterized by morphology, immunological tests and
cytogenetic analysis
Special tests for Acute Lymphoblastic leukaemia (ALL)
ALL
Cytochemistry -
Myeloperoxidase -
Suden Black -
Non specific esterase +(coarse black positivity in ALL)
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Periodic Acid Schiff +( Course block positivity in ALL
Acid Phosphatase + in T ALL (golgi staining)
Immunoglobulins and TCR genes Precursor B-ALL; clonal rearrangement of immune
globulin gene
T-ALL; clonal rearrangement TCR genes

Immunological markers of acute lymphoblastic leukaemia
Markers ALL Precursor B+ T
Myeloid
CD13
CD33
CD117
Glycophorin
Platelet Antigen
Myeloperoxidase
B Lineage
CD19
cCD22
cCD79a
CD10
clg
Slg
TdT
T Lineage
CD7
cCD3
CD2

-
-
-
-

-


+
+
+
+ or
+ (pre B)
-(early pre B)
+

-
-
-

-
-
-
-
-


-
-
-
-
-
-
+
+
+
+
+
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TdT + +


Cytogenetics Translocation Molecular genetics abnormality %
Crptic t(12,21) TEL-AML1 fussion
(6)
25.4%
T(1:19)(q23q13) E2A-PBX (PBX1) FUSION
(8)
4.8%
T(9;22)(q34;q11) BCR-ABL fusion(P185)
(9)
1.6%
T(4;11)(q21;q23) MLL-AF4 fusion
(18)
1.6%
T(8;14)(q24;q32) IGH-MYC fusion
(11)

T(11;14)(p13;q11) TCR-RBNT2 fusion
(12)


Biochemistry Tests
Serum uric acid
Serum Lactate Dehydrogenase
Less commonly, hypercalcaemia
Others
A Lumber puncture will tell if the spinal column and brain has been invaded
Classification
FAB
Subtyping of the various forms of ALL used to be done according to the French American British (FAB)
Classification which was used for all acute leukaemias
ALL-L
1
blast cells small uniform, high nuclear to cytoplasmic ratio
ALL-L
2
blast cells large, heterogeneous, low nuclear to cytoplasmic ratio
ALL-L
3
vacuolated blasts, basophilic cytoplasm (usually B-ALL)
WHO classification
Proposed world health organization (WHO) classification of lymphoid neoplasm
B-CELL NEOPLASMS
Precursor B-cell neoplasm
Precursor B lymphoblastic leukaemia/lymphoma (precursor B-cell acute lymphoblastic
leukaemia)

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Mature (peripheral) B-cell neoplasm
B-cell chronic lymphocytic leukaemia/ small lymphocytic lymphoma
B-cell prolymphocytic leukaemia
Lymphoplasmacytic lymphoma
Splenic marginal zone B-cell lymphoma (+/- villous lymphocytes
Hairy cell leukaemia
Plasma cell myeloma/ plaamacytoma
Extranodal marginal zone B-cell lymphoma of MALT type
Nodal marginal zone B-cell lymphoma (+/- monocytoid B cells)
Follicular lymphoma
Mantle cell lymphoma
Diffuse large B cell lymphoma
Mediastinal large B cell lymphoma
Primary effusion lymphoma
Burkitts lymphoma /burkitts cell leukaemia
T AND NK-CELL NEOPLASMS
Precursor T-cell neoplasm
Precursor T-lymphoblastic lymphoma/ leukaemia (precursor T-cell lymphoblastic leukaemia)
Mature ( peripheral) T-cell neoplasm
T-cell lymphocytic leukaemia
T-cell granular lymphocytic leukaemia
Aggressive NK-cell leukaemia
Adult T-cell lymphoma/leukaemia (HTLV1+)
Extranodal NK/T-cell lymphoma, nasal type
Enteropathy-type Tcell lymphoma
Hepatosplenic gamma ,delta,T-cell lymphoma
Subcutaneous pannicullitis-like T-cell lymphoma
Prognosis
Good Poor
WBC Low High( eg >50X10
9
/L)
Sex Girls Boys
Immunophenotype B-ALL T-Cell (in children)
Age children Adults( or infants <2 years)
Cytogenetics Normal or Hyperdiploidy >50
TEL rearrengement
Ph+,11q23 rearrengements
Time to clear blasts from blood <1 week >1 week
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Time to remission <4 weeks >4 weeks
CNS disease at presentation Absent Present
Minimal residual disease Negative at 1-3 months Still positive at 3-6 months

Treatment
This may be divided into supportive and specific treatment
1. General supportive therapy
2. Specific therapy
Chemotherapy
Radiotherapy
3. Remission induction
4. Intensificatio ( consolidation)
Vincristine
Cyclophosphamide
Cytostine
Arabinoside
Daunorubicin
Etoposide
Thioguanine
Mercaptopurine
5. Central nervous system directed therapy
Methotrexane
Cytocine arabinoside
Cranial irradiation
6. Maintenance
Daily oral Mercaptopurine
Weekly- Oral methotraxane
Intravenous vincristine with a short course ( 5 days ) of oral corticosteroid











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ACUTE MYELOID LEUKAEMIA



INTRODUCTION
Acute myeloid leukaemia (AML) is also known as Acute myelogenous leukaemia is the cancer of the
myeloid line of blood cells characterized by the rapid growth of abnormal white Blood Cells that
accumulate in the bone marrow and interferes with the production of normal blood cells. AML is the
most common leukaemias affecting adults and its incidence increases with age. Although AML is a
relatively rare disease accounting for approximately 1.2% of Cancer deaths in the United States. Its
incidence is expected to increase as the population ages.
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The symptoms of AML are caused by replacement of normal bone marrow with leukaemic ells which
causes a drop in red blood cells, platelets and normal white blood cells. These symptoms include fatigue,
shortness of breath, easy bruising and bleeding and increased risk of infection. Although several risk
factors for AML have been identified, the specific cause of the disease remains unclear. As an acute
leukaemia, AML, progresses rapidly and its typically fatal within weeks or months if left untreated.
AML has several subtypes: treatment and prognosis varies among subtypes. Five year survival varies
from 15-70% and relapse rate 33-78% depending on subtypes. AML is treated initially with
chemotherapy aimed at inducing a remission; patients may go on to receive additional chemotherapy or
hematopoietic stem cell transplant. Recent research into the genetics of AML has resulted in the
availability of tests that can predict which drug or drugs may work best for a particular patient as well as
how long that patient is likely to survive.
Incidence and Pathogenesis
AML occurs in all age groups. It is the most common form of acute leukaemia in adults and is
increasingly common with age. AML forms only a minor fraction (10-15%) of the leukaemias in
childhood. An important distinction is between primary AML which appears to rise de novo and
secondary AML which can develop from myelodysplasia and other haematological diseases such as
myeloproliferative diseases or follow previous treatment with chemotherapy. The two types are
associated with distinct genetic markers and have different prognosis Cytogenetic abnormalities and
response to initial treatment have a major influence on prognosis.
The most common genetic abnormality is the presence of internal tandem repeat of the FLT-3 gene
whose expression is normally tightly regulated in healthy CD34
+
cells. Some cases of primary AML
demonstrate the chromosomal translocations inv(16) and t(8;22) which generate fusion proteins
involving the cord binding factor (CBF) genes. These together with the t(15;17) variant exhibit a good
prognosis. Many cases Of the AML, with the apparently normal karyotype carry mutations in the
nucleophosmin (NPM) gene and these also carry a favorable prognosis. This mutation leads to
dysregulated cytoplasmic expression of NPM protein which normally acts as a nucleocytoplasmic
shutting protein and regulates the p53 pathway. On the other hand other chromosomes abnormalities
carry unfavorable prognosis. Those with normal karyotype may also be subdivided into favorable or
poor prognosis on the bases of DNA microarray analysis.
Clinical Features
Clinical features resembles those of ALL, Anaemia and thrombocytopenia are often profound. A bleeding
tendency caused by thrombocytopenia and disseminated intravascular coagulation DIC is characteristic
of the M
3
varia nt of AML. Tumor cells can infiltrate a variety of tissues. Gum hyperthrophy and
infiltration, skin involvement and CNS disease are characteristic of the myelomonocytic M
4
and
monocytic (M
5
) types. An isolated mass of leukaemic blasts is usually referred to as a granulocytic
sarcoma

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Laboratory findings
The general haematology and biochemical findings are similar to those seen in ALL. Tests for DIC are
often positive in patients with the promyelocytic (M
3
) variant of AML. Cytogeneic and molecular analysis
is critical for determining the prognosis and developing a treatment plan.
Haematological Investigations
Normochromic
Normocytic anaemia with thrombocytopenia
Total white cell count may increase >200X10
9
/l decreased or stay normal
AML can also present with isolated decreases in platelet, red blood cells or even with low white
blood cell count (leukopenia)
Morphology
Myeloblasts with auer rods seen
Diagnosis of AML is established by demonstrating involvement of more than 20% of the blood
and / or bone marrow by leukaemic myeloblasts
Bone marrow
Marrow or blasts is examined via light microscopy as well as flow cytometry to diagnose the
presence of leukaemia to differentiate AML from other types of leukaemia (eg acute
lymphoblastic leukaemia) and to classify the subtypes of disease.
A sample of marrow or blood is typically also tested for chromosomal translocation by routine
cytogenetics or fluorescent in situ hybridization. Genetic studies may also be performed to look
for specific mutations in genes such as FLT3, nucleophosmin and KIT which may influence the
outcome of the disease.
It is hypercellular with >20% leukaemic blasts characterized by morphology, immunological tests
and cytogenetic analysis.
Cytochemistry tests
The single most important prognostic factor in AML is cytogenetics or the chromosomal structure of the
leukaemic cell. Certain cytogenetic abnormalities are associated with very good outcomes ( for example,
the t(15;17) translocation in acute promyelocytic leukaemia. About half of AML patients have normal
ctogenetics they fall into the intermediate risk group. A number of other cytogenetic abnormalities are
known to associate with poor prognosis and a high risk to relapse after treatmet.
Risk catagory Abnormalities 5- year survival Relapse rate
Favorable T(821), t(15;17), inv(16) 70% 33%
Intermediate Normal,+8,+21,+22,
del(9q),abnormal 11q23,
all other structural or
48% 50%
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numerical changes.
Adverse -5, -7,del(5q),abnormal
3q, complex cytogenetics
15% 78%

Special tests for acute myeloid leukaemia AML
AML
Cytochemistry
Myeloperoxidase
Suden black
Non-specific esterase
Periodic acid-schiff
Acid phosphatase
Immunoglobulin and TCR genes


+( including auer rods )
+( including auer rods )
+ in M
4
,M
5
+(fine blocks in M
6
)
+ in M
6
(diffuse)
Germline configuration of immunoglobulin and
TCR gene



Immunological Markers for classification of acute myeloid leukaemia
Marker AML
Myeloid
CD13
CD33
CD117
Glycophorin
Platelet antigens (eg CD41)
Myeloperoxidase
B lineage
CD19
cCD22
cCD79a
CD10
Clg
Slg
TdT
T lineage
CD7
Ccd7
CD2
Tdt

+
+
+
+ (M
6
)
+(M
7
)
+(M
0
)

+
+
+
+or
+(preB)
-(early pre B)
+

-
-
-
+



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Genetic abnormalities Acute myeloid Leukaemia (AML)
Disease Genetic abnormality Oncogenes involved
Myeloid
AML M
2

AML M
3
AML M
4

AML M
%

AML (all types)

MDS


Secondary myeloid leukaemia

T(8;21)
T(6;9)
T915;17)
Inv(16)
Del(16q)
Del(11q); t(9;11)
T(11;19)
Nucleotide insertion
Mutation ,ITD
-5/DEL(5q)
-7/det(7q)
Point mutation
11q23 translocations

ETO AND CBF alpha (AML1)
DEK,CAN
RAR alpha,PML
CBF beta MYTH1

MLL

Nucleophosmin
Flt3
Unclear

N-RAS
MLLgene

Biochemical Tests
Raised serum Uric acid
Serum Lactate dehydrogenase (LDH) raised
Hypercalcaemia less common
DIC tests are positive in patients with promyelocytic (M
3
) variant of AML
FAB Classification
The French American British (FAB) classification system divides AML into 8 subtypes,M
0
through to M
7,

based on the type of cell from which the leukaemia developed and its degree of maturity. This is done
by examining the appearance of the malignant cells under light microscopy and /or by using
cytogenetics to charecterise any underlining chromosomal abnormalities. This subtypes have varying
prognosis and responses to therapy. Although the World Health Organisation classification may be more
usefull.
There are eight FAB subtypes
Type Name Cytogenetics
M
0
Undifferentiated
M
1
Without maturation
M
2
With granulocytic mutation T(8;21)
M
3
Acute promyelocytic T(15;17)
M
4
Granulocytic and monocytic
maturation
Inv(16)
M
5
Monoblastic (M
5a
) or Monocytic
(M5b)

M
6
Erythroleukaemia
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M
7
Megakaryoblastic

World Health Organization (WHO) Classification of Acute Myeloid Leukamia (AML)
Acute myeloid leukaemia with recurrent cytogenetic translocations
AML with t(8;21)(q22;q22), AML1(CBF alpha )/ETO
Acute promyelocytic leukaemia (AML with t(15;17)(q22;q11-12) and variants, PML/RAX alpha)
AML with abnormal bone marrow eosinophils (inv(16)(p12q22) or t(16;16)(p13;q11), CBF betta /
MYH1X)
AML with 11q23 (MLL) abnormalities
Acute myeloid leukaemia with multilineage dysplasia
With prior myelodysplastic syndrome
Without myelodysplastic syndrome
Acute Myeloid leukaemia and myelodysplastic syndrome ,therapy related
Alkylating agent related
Epipodophyllotoxin related
Other types
Acute myeloid leukaemia not otherwise catagorised
AML minimally differentiated
AML without maturation
AML with maturation
Acute myelomonocytic leukaemia
Acute monocytic leukaemia
Acute erythroid leukaemia
Acute negakaryocytic leukaemia
Acute basophilic leukaemia
Acute penmyelosis with myelofibrosis





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Prognosis
Prognosis of acute myeloid leukaemia
Favorable Unfavorable
Cytogenetic T(15;17)
T(8;21)
Inv(16)
NPM mutation
Deletions of chromosome 5 or 7
Flt -3 mutation
11q23
T(6;9)
Abn(3q)
Complex rearrengements
Bone marrow response to
remission induction
<5% blast after first course >20% blasts after first course
Age <60 years >60 years
Onset Primary Secondary

Treatment
1. Supportive Treatment
All-trans retinoic acid (ATRA)
Dexamethasone 10mg
2. Specific chemotherapy for AML
Cytosine arabinoside
Daunorubucin
Idarubicin
Mitoxathrone
Etopocide










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CHRONIC MYELOID LEUKAEMIA

INTRODUCTION
Chronic leukaemias are distinguished from acute leukaemias by their slow progression. Paradoxically,
they are also more difficult to cure. Chronic leukaemias can be broadly subdivided into myeloid and
lymphoid.
Chronic myeloid leukaemia (CML) is a clonal disorder of a pluripotent stem cell. The disease accounts for
around 15% of leukaemias and may occur at any age. The diagnosis of AML is rarely difficult and is
assisted by the characteristic presence of the Ph chromosome. This results from the t(9;22)(q34;q11)
translocation between chromosome 9 and 22 as a result of which part of the proto oncogene cABL is
moved to the BCR gene on chromosome 22 and part of chromosome 22 moves to chromosome 9. The
abnormal chromosome 22 is the Ph chromosome. In the Ph translocation 5 axons of BCR are fused
To 3 axons of ABL. The resulting chimeric BCR-ABL gene codes for a fusion protein of size 210kDa. This
has a tyrosine kinase activity in excess of the normal 145 kDa ABL product. The Ph Translocation is also
seen in a minority of cases of acute lymphoblastic leukaemia and In some of these the breaking point in
BCR occurs in the same region as in CML. However, in other cases the break point in BCR is further
upstream in the intron between the first and second axon leaving only the first BCR axon intact. This
chimeric BCR-ABL gene is expressed as a p190 protein which like p210 enhanced tyrosine kinase activity.
In a minority of patients, the Ph abnormality cannot be seen by microscopic karyotypic analysis but the
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same molecular rearrangement is detectable by more sensitive techniques for example fluorescence in
situ hybridization (FISH) or polymerase chain reaction (PCR). The Ph negative BCR-ABL positive CML
behaves clinically like Ph positive CML. As the Ph chromosome is an acquired abnormality of
haemopoietic stem cell it is found in cells of both the myeloid (granulocytic, erythroid and
megakaryocytic ) and lymphoid (B and T cells ) lineages.
Clinical features
This disease occurs in either sex (male: female ratio of 1:4), most frequently between the ages of 40 and
60 years. However, It may occur in children and neonates, and in the very old. In most cases there are
no predisposing factors but the incidence was increased in survivors of the atomic bomb exposures in
Japan. Its clinical features include the following:
1. Symptoms related to hypermetabolism (eg weight loss, lassitude, anorexia or night sweats)
2. Splenomegaly is nearly always present and is frequently massive. In some patients, splenic
enlargement is associated with considerable discomfort, pain or indigestion.
3. Features of anaemia may include pallor, dyspnea and tachycardia.
4. Bruising, epistaxis, menorrhagia or haemorrhage from other sites because of abnormal platelet
function.
5. Gout or renal impairment caused by hyperuricaemia from excessive purine breakdown maybe a
problem.
6. Rare symptoms include visual disturbances and priapism.
7. In up to 50% of cases the diagnosis is made incidentally from routine blood count.
Laboratory findings
1. Leukocytosis is usually >50X10
9
/L and sometimes >500X10
9
/L. A complex spectrum of myeloid
cells seen in the peripheral blood. The level of neutrophils and myelocytes exceeds those of
blast cells and promyelocytes
2. Increased circulating basophils
3. Normochromic, Normocytic anaemia is usal.
4. Platelet count maybe increased (most frequently ), Normal, or decreased
5. Neutrophilic Alkaline Phosphatase score is invariably low. It is raised in the myeloproliferative
diseases
6. Bone marrow is hypercellular with granulopoietic predominance.
7. Ph chromosome on cytogenetic analysis, conventional (or FISH) of blood or bone marrow
8. Serum uric acid is usually raised.




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Classiications
FAB Classification of Chronic Myeloid Leukaemias AML
Chronic Myeloid Leukaemia, Ph positive (CML,Ph+)
(Chronic Granulocytic leukaemia, Ph Negative, CGL)
Chronic Myeloid leukaemia, Ph negative (CML,Ph-)
(Atypical)
Juvenile chronic myeloid leukaemia
Chronic neutrophilic leukaemia
Eosinophilic leukaemia
Chronic Myelomonocytic leukaemia (CMML)

World Health Organization classification of Myeloid Neoplasm
Myeloproliferative disease (MPD)
Chronic Myelogenous Leukaemia, Philadelphia chromosome (Ph1)[t(9;22)(qq34;q11),
BCR/ABL]+
Chronic neutrophilic leukaemia
Chronic eosinophilic leukaemia/ hypereusinophilic syndrome
Chronic idiophathic myelofibrosis
Polycythea vera
Essential thrombocythaemia
Myeloproliferative disease
Myelodysplastic/ myeloproliferative disease
Chronic myelomonocytic leukaemia (CMML)
Atypical Chronic myelogenous leukaemia (aCML)
Juvenile myelomonocytic leukaemia (JMML)
Myelodysplastic Syndrome (MDS)
Refractory anaemia (RA)
o With ringed sideroblasts (RARS)
o Without ringed sideroblasts
Refractory cytopenia (myelodysplastic syndrome) with mutilineage dysplasia (RCMD)
Refractory anaemia ( myelodysplastic syndrome) with excess blasts (RAEB)
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5q-syndrome
Myelodysplastic syndrome, unclear


Course and Prognosis
CML usually shows an excellent response to imatinib in the chronic phase. Survival is now much
prolonged by imatinib. It is possible but not yet established that the best the best responders to imatinib
may never relapse. If death occurs it is usually from terminal acute transformation or from intercurrent
haemorrhage or infection. The patients may be divided into prognostic groups according to age, spleen
size, platelet count, peripheral blood or bone marrow blast cells on presentation. These are only rough
guides to outcome. Ease the response to imatinb is most important
Treatment
Treatment of chronic phase
Tyrosine kinase inhibitors Imatinib ( Glivec) at a dose of 400 mg/day
Cytosine arabinoside
Allopurinol is used in the initiation phase of treatment to prevent hyperurecaemia and gout
Busulfan is also effective in controlling the disease but considerable long term side effects
Paracetamol











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CHRONIC LYMPHOID LEUKAEMIA

Introduction
Chronic Lymphocytic Leukemia (CLL) and Related Diseases
A chronic lymphocytic leukemia, can sometimes be clinically diagnosed with some certainty. An
example is the case of a patient (usually older) with clearly enlarged lymph nodes and significant
lymphocytosis (in 60% of the cases this is greater than 20 000/l and in 20% of the cases it is greater
than 100 000/l) in the absence of symptoms that point to a reactive disorder. The lymphoma cells are
relatively small, and the nuclear chromatin is coarse and dense. The narrow layer of slightly basophilic
cytoplasm does not contain granules. Shadows around the nucleus are an artifact produced by
chromatin fragmentation during preparation (Gumprechts nuclear shadow). In order to confirm the
diagnosis, the B-cell markers on circulating lymphocytes should be characterized to show that the cells
are indeed monoclonal. The transformed lymphocytes are dispersed at varying cell densities throughout
the bone marrow and the lymph nodes. A slowly progressing hypogammaglobulinemia is another
important indicator of a B-cell maturation disorder.
Transition to a diffuse large-cell B-lymphoma (Richter syndrome) is rare: B-prolymphocytic leukemia (B-
PLL) displays unique symptoms. At least 55% of the lymphocytes in circulating blood have large central
vacuoles. When 1555% of the cells are prolymphocytes, the diagnosis of atypical CLL, or transitional
CLL/PLL is confirmed. In some CLL-like diseases, the layer of cytoplasm is slightly wider. B-CLL was
defined as lymphoplasmacytoid immunocytoma in the Kiel classification. According to the WHO
classification, it is a B-CLL variation (compare thiswith lymphoplasmacytic leukemia, p. 78). CLL of the T-
lymphocytes is rare. The cells shownuclei with either invaginations orwell-defined nucleoli (T
prolymphocytic
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leukemia). The leukemic phase of cutaneous T-cell lymphoma (CTCL) is known as Szary syndrome. The
cell elements in this syndrome and T-PLL are similar.
Pathogenesis
Chronic Lymphocytic Leukaemia (CLL) is by far the most common of the chronic lymphoid leukaemias
and has a peak incidence between 60 and 80 years of age. The aetiology is unknown but they are
geographical variations in incidence. It is the most common of the leukaemias in the western world but
rare in the far east. In contrast to other forms of leukaemia there is no higher incidence after previous
chemotherapy or radiotherapy. There is a seven fold increase risk of CLL, in the close relatives of
patients. The tumour cells appears to be relatively mature B Cell with weak surface expression of the
immunoglobulin (Ig) M or IgD. The cells accumulate in the blood, bone marrow, liver, spleen and lymph
nodes as a result of a prolonged lifespan with impaired apoptosis.
Clinical features
1. The disease occurs in older subjects with only 15% of cases before 50 years of age. The male to
female ratio is 2:1.
2. Most cases are diagnosed when a routine blood test is performed. With routine medical check
ups.
3. Symmetrical enlargement of cervical, axillary or inguinal lymph nodes is the most frequent sign.
The nodes are usually discrete and non- tender. Tonsillar enlargement may be a feature.
4. Features of anaemia may be present. Patient with thrombocytopenia may show bruising or
purpura.
5. Splenomegaly and less commonly hepatomegaly are common in later stages.
6. Immunosuppression is a significant problem resulting from hypogammaglobulinaemia and
cellular immune dysfuction. Early in the disease course bacterial infections predominate but
with advanced disease viral and fungal infections such as herpes zoster are also seen.
Laboratory findings
1. Lymphocytosis-The absolute lymphocyte count is >5X10
9
/L and maybe up to 300X10
9
/L or more
between 70 and 99%of white cells in the blood film appear as small lymphocytes. Smudge or
smear cells are also present.
2. Immunophenotyping of the lymphocytes shows them to be B-cells (surface CD19), weakly
expressing surface immunoglobulin (IgM or IgD). This is shown to be monoclonal because of
expression of only one form of light chains (kappa,lambda). Characteristically, The cells are also
surface CD5+ and CD23+ but CD796- and FMC7-. Similar clones are found in some healthy
subjects but with a normal total lymphocyte clunt.
3. Normocytic, normochromic anaemia is present in later stages as a result of marrow infiltration
or hypersplenism. Autoimmune haemolysis may also occur. Thrombocytopenia occurs in many
patients.
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4. Bone marrow aspiration shows lymphocytic replacement of normal marrow elements.
Lymphocytes comprises 25-95% of all the cells. Trephine biopsy reveals nodular diffuse or
interstitial involvement by lymphocytes.
5. Reduced concentration of serum immunoglobulins are found and this becomes more marked
with advanced disease. Rarely a paraprotian is present.
6. Autoimmunity directed against cells of the haemopoietic system is common. Autoimmune
haemolytic anaemia is most frequent but immune thrombocytopenia, neutropenia and red cell
aplasia are also seen.
Classification
FAB Classification of the chronic Lymphoid leukaemia (CLL)/ Lymphoma syndrome
B-Cell T-Cell
Chronic lymphoid leukaemia
Chronic Lymphocytic Leukaemia (CLL)
Prolymphocytic leukaemia (PLL)
Hairy cell leukaemia (HCL)
Plasma cell leukaemia

Large granular lymphocytic leukaemia
T-cell prolymphocytic leukaemia (T-PLL)
Leukaemia/lymphoma syndromes
Splenic lymphoma with villous lymphocytes
Follicular lymphoma
Mantle cell lymphoma
Lymphoplasmacytic lymphoma
Large cell lymphoma

Sezary syndrome , Adult T cell leukaemia/
lymphoma
Large cell lymphoma

World Health Organisation (WHO) Classification of lymphoid neoplasms
B-Cell Neoplasms
Precursor B cell neoplasm
Precursor B-lymphoblastic leukaemia/lymphoma(precursor B cell acute lymphoblastic leukaemia
Mature (peripheral) B-cell neoplasms
B-cell chronic lymphocytic leukaemia/ small lymphocytic lymphoma
B-cell prolymphocytic leukaemia
Lymphoplasmacytic lymphoma
Splenic marginal zone B-cell lymphoma(+/- villous lymphocytes)
Hairy cell leukaemia
Plasma cell myeloma/ plasmacytoma
Extranodal marginal zone B-cell lymphoma of MALT type
Nodal marginal zone B-cell lymphoma (+/-monocytoid B cells)
Follicular lymphoma
Mantle cell lymphoma
Diffuse large B-cell lymphoma
Mediastinal Large B cell lymphoma
Primary effusion lymphoma
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Burkitts lymphoma/ Burkitt cell leukaemia
T AND NK CELL NEOPLASMS
Precursor T-cell neoplasm
Precursor T- lymphoblastic lymphoma/leukaemia (precursor T-cell acute lymphoblastic
leukaemia)
Mature (peripheral) T-cell neoplasm
T-cell prolymphocytic leukaemia
T-cell granular lymphocytic leukaemia
Aggressive NK-cell leukaemia
Adult T-cell lymphoma/leukaemia (HTLV1+)
Extranodal NK/T-cell lymphoma, nasal type
Enteropathy-type T-cell lymphoma
Hepatosplenic gamma delta T-cell lymphoma
Subcutaneous panniculitis-like T-cell lymphoma
Mycosis fungiodes/ sezary syndrome
Anaplastic large cell lymphoma, T/null cell, primary cutaneous type
Peripheral T-cell lymphoma, not otherwise characterized
Angioimmunoblastic T-cell lymphoma
Anaplastic large cell lymphoma T/null cell, primary splenic type
HODGKINS LYMPHOMA (HODGKINS DISEASE
Nodular lymphocytes predominance Hodgkins lymphoma
Classic Hodgkins lymphoma
Nodular sclerosis Hodgkins lymphoma (grades 1 and 2)
Mixed cellularity Hodgkins lymphoma
Lymphocyte depletion Hodgkins lymphoma

Prognosis
Prognostic factors in chronic lymphocytic leukaemia (CLL)
Good Bad
Stages Binet A( Rai 0-1) Binet B (Rai II-IV)
Sex Female Male
Lymphocyte doubling time Slow Rapid
Bone Marrow Biopsy
Appearance
Nodular Diffuse
Chromosomes Deletion 13q14 Trisomy 12,deletion 17p,deletion
11q23
VH immunoglobulin genes Hypermutated Unmutated
ZAP expression Low High
CD38 expression Negative Positive
CLLU 1 Expression Low High
LDH Normal Raised


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Staging of chronic lymphocytic leukaemia
Rai Classification
Stage
0 Absolute lymphocytosis >15X10
9
/L
1 As stage 0 +enlarged lymph nodes (adenopathy)
2 As stage 0 + enlarged liver and /or spleen adenopathy
3 As stage 0 +anaemia (Hb<10.0X10gidL)
+
adenopathy organomegaly
4 As stage 0 + thrombocytopenia (platelets<100X10
9
/l adenopathy organomegaly

International Working Party Classification (from).J.L.Binet et al.1981
Stage Organ enlargement Haemoglobin (g/dL) Platelet (X10
9
/L)
A(50-60%) 0,1 or two areas
B ( 30%) 3,4 or 5 areas 10 100
C (<20%) Not considered <10 And/ or <100

Treatment
Cures are rare
Chemotherapy
o Chlorambucin given orally with DOSAGE OF 4-6MG/DAY
o Purine anologues
o Fludarabine
o Combination of fludarabine and cyclophosphamide
o Rituximab
o Monoclonal antibodies Campath-H1 (antiCD52)
o Corticosteroid
Other forms of treatment
o Radiotherapy
o Combined chemotherapy
o Splenectomy
o Immunoglobulin replacement
o Stem cell transplant




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Bibliography
A.V.Hoffbrand,P.A.H. Moss and J.E. Pettit.2006. Essential Haematology, Fifth edition. Blackwell
publishers.
H. Thelm. H.Diem. T. Haferlac.2004. Colour Atlas Haematology Practical microscopic and Clinical
Diagnosis