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AML vs ALL 5th Semester

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MLT LECTURES BY TANVEER TARA
MLT LECTURES BY TANVEER TARA

This document provides information about acute leukemias. It begins by defining leukemia as a stem cell or precursor disorder characterized by malignant proliferation of immature blood cells. It then discusses the key points of acute leukemias, including that they are usually aggressive diseases that affect the ability to produce normal blood cells. The document goes on to describe the classification, pathogenesis, clinical manifestations, prognosis, and immunophenotypes of the different subtypes of acute myeloid leukemia. It also compares acute and chronic leukemias and discusses acute lymphoblastic leukemia.

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NCS University System A Project of NCS Education System Tanveer Tara Senior Lecturer Bachelor of Science in MLT Masters of Science in Hematology
Acute leukemias
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.
Conti… • 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
Comparison of acute and chronic leukemia 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
Pathogenesis of acute leukaemia • 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 a.an increased rate of proliferation; b.reduced apoptosis c. a block in cellular differentiation.
Acute Leukaemogenesis • 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
Clinical Manifestations • Symptoms due to: – Marrow failure – Tissue infiltration – Leukostasis – Other (DIC)
Marrow failure • Neutropenia: Infections, sepsis • Anemia: Fatigue, pallor • Thrombocytopenia: Bleeding
Infiltration of tissues/organs • 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
Constitutional symptoms • Fever and sweats………… common • Weight loss ……………less common
Acute Myeloid Leukaemia
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
Myeloid maturation myeloblast promyelocyte myelocyte metamyelocyte band neutrophil MATURATIONMATURATION Adapted and modified from U Va website
Classification of Leukemia WHO classification (Newer) • Incorporates and interrelates morphology, cytogenetics, molecular genetics, and immunologic markers. • 20% blast in blood and bonemarrow. FAB classification (Older) • 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.
FAB Classification of AML 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
WHO classification of AML 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 & myelodysplastic syndromes, therapy- related • Alkylating agent-related • Topoisomerase type II inhibitor-related (some may be lymphoid) • Other types
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
AML vs ALL 5th Semester
Immunophenotype of AML subtypes Antigen M0 M1 M2 M3 M4 M5 M6 M7 ALL HLA-DR ++ ++ + - ++ ++ + - + CD11b + + + - +++ +++ - - - CD13 +++ +++ +++ +++ +++ ++ ++ + +/- CD14 - + + - +++ +++ - - - CD15 - - +++ + + + - - - CD33 +++ +++ +++ +++ +++ +++ ++ + +/- CD41, CD61 - - - - - - - +++ - Glycophorin A - - - - - - +++ - - TdT ++ + + - - - - - +++ CD117 +++ +++ ++ + ++ ++ + - CD2 + + - ++ ++ - - - +++ CD7 + + - - - - - ++ ++ CD19 + ++ - - - - - ++++ CD34 +++ ++ ++ - + - - + ++
AML vs ALL 5th Semester
Prognostic Factors in AML • Favorable – younger age (<50) – WBC <30,000 – t(8;21) – seen in >50% with AML M2 – inv(16) – seen in AML M4 eos – t(15;17) – seen in >80% AML M3 • Unfavorable – older age (>60) – Poor performance status – WBC >100,000 – Elevated LDH – prior MDS or hematogic malignancy – CD34 positive phenotype, MRD1 postive phenotype – del (5), del (7) – trisomy 8 – t(6;9), t(9;22) – t(9;11) – seen in AML M5 – FLT3 gene mutation (seen in 30% of patients)
Peripheral Blood AML • 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 CHANGES IN AML 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
CYTOCHEMICAL FEATURES OF AML 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
Blast classification 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.
AML-MO • Distinguished by absence of visible granules in cytoplasm of blast. • Negative –ve reactions with cytochemical stains. • Positive +ve for myeloid lineage markers. CD13 CD33.
M0 AML
AML-M1 • 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.
PB film of a patient with M1 AML showing blasts,some of which are heavily vacuolated
AML-M2 • 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.
BM film of a patient with M2 AML showing unusually heavy granulation of neutrophils and precursors
AML-M3 • 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.
Auer rods • Auer rods are red staining, needle-like bodies seen in the cytoplasm of myeloblasts, and/or progranulocytes in certain leukemias. Auer rods are cytoplasmic inclusions which result from an abnormal fusion of the primary (azurophilic) granules. •
Faggot cells: Faggot cells: Cells with multiple auer rods sometime occuring in bundles.
AML-M4 • 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.
AML-M4
AML-M5 • 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 .
AML-M5
AML-M5a • 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.
AML-M5b • 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.
AML-M6 • 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 beyond basophilic normoblasts.
PB film in a patient with M6 AML showing an abnormal circulating erythroblast
AML-M7  Peripheral blood pancytopenia.  High peripheral blood blast count.  Micro megakaryocytes and undifferentiated blast.  Bone marrow reveals increased fibroblast.  Showing cytoplasmic budding.
AML-M7
Once again AML vs ALL
AML vs ALL 5th Semester
• Leukaemia is the most common childhood cancer and acute lymphoblastic leukaemia (ALL) is the most common subtype, accounting for 75 – 80% of all cases
FAB Classification of ALL • 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% FAB CLASSIFICATION ALL
• WHO has recognized just two groups of acute lymphoblastic leukemias, • precursor B-cell and • precursor T-cell lymphoblastic leukemia/lymphoma.
Precursor B lymphoblastic leukemia (B-ALL)/lymphoblastic lymphoma (B-LBL) • 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
Precursor T lymphoblastic leukemia/lymphoma • 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
AML vs ALL 5th Semester
AML vs ALL 5th Semester
Lymphoblast
Peripheral Blood ALL • WBCs – Total cont elevated 50-60 x 109 /L to 100 109 /L – Rarely more than 100 x 109 /L – Lymphoblasts in large numbers • RBCs – Normocytic normochromic anaemia. Thrombocytopenia.
BM CHANGES IN ALL Marrow aspirates show:  Blast cell predominace. They are lymphoblasts which are earliest identifiable precursor of lymphoid cells  Erythropeitic cells reduced  Dyserythropoiesis  Megakaryocytes reduced
ALL-L1 • This is the most common form found in children and it has the best prognosis.
ALL-L1
•This is the most frequent ALL found in adults. ALL-L2
ALL-L2
ALL-L3 • This is the rarest form of ALL. • Burkit lymphoma type cells
ALL-L3
AML vs ALL 5th Semester
 Aids in the diagnosis  Classification of the leukemias  Identification of the chemical components of cells - is conducted to distinguish different types of leukemia. Cytochemistry
Enzymatic Techniques  Myeloperoxidases  Esterases  Phosphatases Nonenzymatic Techniques  Periodic Acid-Schiff Stain  Sudan Black B  Toluidine Blue
Leukemia,White Blood 75 Cytochemical differences in ALL & AML blasts 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 76 Biochemical tests • Serum uric acid raised due to breakdown of leukemic cells. • Serum LDH may be raised • Hypocalcaemia • Hyperuricemia • Increase K+
Terminal Deoxynucleotidyl Transferase 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.
Significance of TdT • 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.
Imaging Studies 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
CSF • Look CSF for Blast cells
Karyotyping • 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.
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AML vs ALL 5th Semester

  • 1. NCS University System A Project of NCS Education System Tanveer Tara Senior Lecturer Bachelor of Science in MLT Masters of Science in Hematology
  • 3. 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.
  • 4. Conti… • 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.
  • 7. Comparison of acute and chronic leukemia 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
  • 8. Pathogenesis of acute leukaemia • 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 a.an increased rate of proliferation; b.reduced apoptosis c. a block in cellular differentiation.
  • 9. Acute Leukaemogenesis • 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
  • 10. Clinical Manifestations • Symptoms due to: – Marrow failure – Tissue infiltration – Leukostasis – Other (DIC)
  • 11. Marrow failure • Neutropenia: Infections, sepsis • Anemia: Fatigue, pallor • Thrombocytopenia: Bleeding
  • 12. Infiltration of tissues/organs • Enlargement of liver, spleen, lymph nodes • Gum hypertrophy • Bone pain • Other organs: CNS, skin, testis, any organ
  • 13. , • Accumulation of blasts in microcirculation with impaired perfusion. • Lungs: hypoxemia, pulmonary infiltrates • CNS: stroke
  • 14. Constitutional symptoms • Fever and sweats………… common • Weight loss ……………less common
  • 16. 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
  • 17. Myeloid maturation myeloblast promyelocyte myelocyte metamyelocyte band neutrophil MATURATIONMATURATION Adapted and modified from U Va website
  • 18. Classification of Leukemia WHO classification (Newer) • Incorporates and interrelates morphology, cytogenetics, molecular genetics, and immunologic markers. • 20% blast in blood and bonemarrow. FAB classification (Older) • 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.
  • 19. FAB Classification of AML 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
  • 20. WHO classification of AML 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
  • 21. 2 . AML with multilineage dysplasia • With previous myelodysplastic syndrome • Without previous myelodysplastic syndrome 3. AML & myelodysplastic syndromes, therapy- related • Alkylating agent-related • Topoisomerase type II inhibitor-related (some may be lymphoid) • Other types
  • 22. 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
  • 24. Immunophenotype of AML subtypes Antigen M0 M1 M2 M3 M4 M5 M6 M7 ALL HLA-DR ++ ++ + - ++ ++ + - + CD11b + + + - +++ +++ - - - CD13 +++ +++ +++ +++ +++ ++ ++ + +/- CD14 - + + - +++ +++ - - - CD15 - - +++ + + + - - - CD33 +++ +++ +++ +++ +++ +++ ++ + +/- CD41, CD61 - - - - - - - +++ - Glycophorin A - - - - - - +++ - - TdT ++ + + - - - - - +++ CD117 +++ +++ ++ + ++ ++ + - CD2 + + - ++ ++ - - - +++ CD7 + + - - - - - ++ ++ CD19 + ++ - - - - - ++++ CD34 +++ ++ ++ - + - - + ++
  • 26. Prognostic Factors in AML • Favorable – younger age (<50) – WBC <30,000 – t(8;21) – seen in >50% with AML M2 – inv(16) – seen in AML M4 eos – t(15;17) – seen in >80% AML M3 • Unfavorable – older age (>60) – Poor performance status – WBC >100,000 – Elevated LDH – prior MDS or hematogic malignancy – CD34 positive phenotype, MRD1 postive phenotype – del (5), del (7) – trisomy 8 – t(6;9), t(9;22) – t(9;11) – seen in AML M5 – FLT3 gene mutation (seen in 30% of patients)
  • 27. Peripheral Blood AML • 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.
  • 28. BM CHANGES IN AML 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
  • 29. CYTOCHEMICAL FEATURES OF AML 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
  • 30. Blast classification 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.
  • 31. AML-MO • Distinguished by absence of visible granules in cytoplasm of blast. • Negative –ve reactions with cytochemical stains. • Positive +ve for myeloid lineage markers. CD13 CD33.
  • 33. AML-M1 • 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.
  • 34. PB film of a patient with M1 AML showing blasts,some of which are heavily vacuolated
  • 35. AML-M2 • 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.
  • 36. BM film of a patient with M2 AML showing unusually heavy granulation of neutrophils and precursors
  • 37. AML-M3 • 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.
  • 38. Auer rods • Auer rods are red staining, needle-like bodies seen in the cytoplasm of myeloblasts, and/or progranulocytes in certain leukemias. Auer rods are cytoplasmic inclusions which result from an abnormal fusion of the primary (azurophilic) granules. •
  • 39. Faggot cells: Faggot cells: Cells with multiple auer rods sometime occuring in bundles.
  • 40. AML-M4 • 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.
  • 42. AML-M5 • 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 .
  • 44. AML-M5a • 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.
  • 45. AML-M5b • 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.
  • 46. AML-M6 • 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 beyond basophilic normoblasts.
  • 47. PB film in a patient with M6 AML showing an abnormal circulating erythroblast
  • 48. AML-M7  Peripheral blood pancytopenia.  High peripheral blood blast count.  Micro megakaryocytes and undifferentiated blast.  Bone marrow reveals increased fibroblast.  Showing cytoplasmic budding.
  • 50. Once again AML vs ALL
  • 52. • Leukaemia is the most common childhood cancer and acute lymphoblastic leukaemia (ALL) is the most common subtype, accounting for 75 – 80% of all cases
  • 53. FAB Classification of ALL • 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.
  • 54. 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% FAB CLASSIFICATION ALL
  • 55. • WHO has recognized just two groups of acute lymphoblastic leukemias, • precursor B-cell and • precursor T-cell lymphoblastic leukemia/lymphoma.
  • 56. Precursor B lymphoblastic leukemia (B-ALL)/lymphoblastic lymphoma (B-LBL) • 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
  • 57. • 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.
  • 58. • 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
  • 59. Precursor T lymphoblastic leukemia/lymphoma • 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
  • 60. • The lymphoblasts in T-ALL are TdT, cytoplasmic CD3, CD7, CD1, CD2, , CD5 positive
  • 64. Peripheral Blood ALL • WBCs – Total cont elevated 50-60 x 109 /L to 100 109 /L – Rarely more than 100 x 109 /L – Lymphoblasts in large numbers • RBCs – Normocytic normochromic anaemia. Thrombocytopenia.
  • 65. BM CHANGES IN ALL Marrow aspirates show:  Blast cell predominace. They are lymphoblasts which are earliest identifiable precursor of lymphoid cells  Erythropeitic cells reduced  Dyserythropoiesis  Megakaryocytes reduced
  • 66. ALL-L1 • This is the most common form found in children and it has the best prognosis.
  • 68. •This is the most frequent ALL found in adults. ALL-L2
  • 70. ALL-L3 • This is the rarest form of ALL. • Burkit lymphoma type cells
  • 73.  Aids in the diagnosis  Classification of the leukemias  Identification of the chemical components of cells - is conducted to distinguish different types of leukemia. Cytochemistry
  • 74. Enzymatic Techniques  Myeloperoxidases  Esterases  Phosphatases Nonenzymatic Techniques  Periodic Acid-Schiff Stain  Sudan Black B  Toluidine Blue
  • 75. Leukemia,White Blood 75 Cytochemical differences in ALL & AML blasts 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
  • 76. Leukemia,White Blood 76 Biochemical tests • Serum uric acid raised due to breakdown of leukemic cells. • Serum LDH may be raised • Hypocalcaemia • Hyperuricemia • Increase K+
  • 77. Terminal Deoxynucleotidyl Transferase 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.
  • 78. Significance of TdT • 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.
  • 79. Imaging Studies 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
  • 80. CSF • Look CSF for Blast cells
  • 81. Karyotyping • 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.