Transcript Document
Week 10: Leukemia
AML
ALL
FAB classification
WHO classification
Cytochemistries
MPO
SBB
PAS
ORO
CD markers
Flowcytometry
CML
CLL
Karyotype
Ph chromosome
LAP
Signs and Symptoms of AML
Insidious nonspecific onset
Pallor due to anemia
Febrile due to ineffective WBC
Petechiae due to thrombocytopenia
Mucus membrane and gum bleed in
M4 and M5
Bone pain
Typical Labs
of AML
Leukocytosis
Blastemia
Leukemic hiatus
Auer rods in M2, M3,
M4
Thrombocytopenia
Anemia
>20% blasts in BM
Other Findings
CD 13 and CD 33 in flowcytometry
Cytochemistries
Myeloperoxidase
Sudan black B
Choloroacetate esterase (specific)
Nonspecific esterase
FAB (1976) Classification
M0 -- Undifferentiated AML
M1 -- AML without maturation
M2 -- AML with maturation
M3 -- Acute Promyelocytic Leukemia
M4 -- Acute Meylomonocytic Leukemia
M5 -- Acute Monocytic Leukemia
M6 -- Erythroleukemia (DiGuglielmo’s)
M7 -- Megakaryoblastic Leukemia
M1 and M2
Myeloperoxidase
(MPO)
p-Phenylene diamine + Catecol + H2O2
MPO
> Brown black deposits
M3
M4
M5
Chloracetate (Specific) Esterase
Myeloid Cell Line
Naphthol-ASD-chloracetate
CAE > Free naphthol compounds
+ Stable diazonium salt (eg, Fast Corinth)
> Red deposit
Non-Specific Esterase
Monocytic Line
Naphthyl acetate
ANAE > Free naphthyl compounds
+Stable diazonium salt (eg, Fast blue RR)
> Brown deposits
NSE with Fl inhibition
Histiocyte
Double Esterase in M4
FAB vs WHO Classifications of
Hematologic Neoplasm
FAB criteria
Morphology
Cytochemistry
WHO criteria
Morphology
Immunophenotyping
Genetic features
Karyotyping
Molecular testing
Clinical features
WHO Classification of AML
AML with recurrent cytogenic
translocations
AML with multi-lineage dysplasia
AML and myelodysplasia, therapy related
AML, not otherwise categorized
AML with Recurrent Cytogenetic
Translocations (WHO 1995)
t(8;21) -- some maturation of neutrophilic line;
rare in older patients; AML1/ETO fusion protein;
>90% FAB M2
t(15;17) -- APL (granular and microgranular
variants); retinoic acid receptor (RAR) leukemias;
middle aged adults; DIC
inv(16) or t(16;16) -- monocytic and granulocytic;
abnormal eosinophilic component
11q23 -- monocytic; children; most common is
t(9;11)
FAB Classification of ALL
L1: Small homogeneous blasts; mostly in
children
L2: Large heterogeneous blasts; mostly in
adults
L3: “Burkitt” large basophilic B-cell blasts
with vacuoles
L2
L3
Periodic Acid Schiff
Periodic acid + Glycogen
oxidation > Aldehyde + Schiff reagent
(para-rosaniline, Na metabisulfite)
> Red deposit
ALL Cytochemistries
Oil Red O: stains L3 vacuoles
Terminal deoxynucleotidyl transferase
(Tdt): DNA polymerase in early
lymphoblasts
Cell surface markers (CD’s)
Cytoplasmic and surface immunoglobulins:
B-cell line
T-cell receptor (TCR)
WHO Classification of
Lymphoproliferative Syndromes
Precursor B Lymphoblastic Leukemia/Lymphoma
(ALL/LBL) -- ALL in children (80-85% of
childhood ALL); LBL in young adults and rare;
FAB L1 or L2 blast morphology
Precursor T ALL/LBL -- 15% of childhood ALL
and 25% of adult ALL
Burkitt Leukemia/Lymphoma (FAB L3)
•Antigens
•B-Lineage
•T-Lineage
•HLA Dr
•Tdt
•CD34
•+
•+
•+
•0 to +
•+
•0
•CD19
•C 22
•CD10
•CD20
•Cyt-
•SIg
•+
•cALL and older
•cALL and older
•Pre-B and older
•Pre-B and older
•B-ALL
•Pre-T
•Pre-T
•Pre-T
•0
•0
•0
•CD7
•CD3
•CD5
•CD2
•CD1
•0
•0
•0
•0
•0
•+
•+
•+
•T-ALL
•T-ALL
Prognosis
Indicators
Favorable
Poor
WBC
< 50,000/L
50,000/L
Age
1 - 10
< 1 or 10
Gender
Female
Male
Blast
B-cell
T-cell and mixed
Karyotype
Hyperploidy
Trisomy 4, 10, 17
t(12;21) (TEL/AML1)
Hypoploidy
Trisomy 5
t(1;19 (E2A/PBX1)
Mixed lineage leukemia
T(9;22) (Ph)
BM blast count Mkd reduction at day 7
during induction
Mild reduction at day 7
Typical Labs in CML
Leukocytosis with blastemia
Thrombocytosis
Basophilia
Micro-megakaryocytes
Low LAP score (intermediate if infected)
About 10% blasts in BM
Philadelphia chromosome
CML
Bone marrow aspirate
and biopsy
Pseudo-Gaucher’s
cells in BM
Leukocyte Alkaline
Phosphatase (LAP)
Naphthol AS-MX phosphate LAP at pH8.6 >
Naphthol AS-MX + Diazonium salt
(eg, Fast blue RR)
> Insoluble pigment
LAP Score
Count 100 consecutive segs and bands
Score:
0 = no granules
1+ = occasional diffuse granules
2+ = moderate number of granules
3+ = many strongly positive granules
4+ = confluent strongly positive granules
0
2+
1+
3+
4+
LAP Score
Example:
0
1+
2+
3+
4+
x
x
x
x
x
35 cells
30 cells
20 cells
10 cells
5 cells
= 0
= 30
= 40
= 30
= 20
120 LAP Score
Philadelphia Chromosome
9 and 22 translocation almost specific to CML
Karyotype to visualize Ph chromosome
Produces BCR/c-abl fusion oncogene
Gene product p190 is a hyperactive tyrosine
kinase
Ph chromosome seen in ALL produces p210 and
chronic neutrophilic leukemia produces p230
Karyotype 46,XX,t(9;22)(q34;q11.2) -- Ph chromosome
FISH showing the BCR (green), ABL (orange), and BCR-ABL fusion
signals (arrow): A=positive (contains a residual ABL signal), B=normal
FAB (1982) Classification of
Myeloproliferative Disease (MPD)
Chronic Myelocytic Leukemia (CML)
Polycythemia Vera (PV)
Essential Thrombocythemia (ET)
Agnogenic Myeloid Metaplasia with or without
Myelofibrosis (AMM)
Benign Leukemoid Reaction
WHO Classification of MPS
(1997)
CML becomes
CML, Ph + t(9;22) BCR/ABL
Chronic Neutrophilic Leukemia (CNL)
Chronic Eosinophilic Leukemia and Hypereosinophilic Syndrome (CEL/HES)
PV remains PV
ET remains ET
AMM becomes
Chronic Idiopathic Myelofibrosis
Myelofibrosis
Myelofibrosis
Chronic Lymphocytic Leukemia
Exclusive in elderly
Lyphocytosis unrelated to viral infection
Hyper-mature lymphocytes with highly
condensed nuclei
Smudge cells: preventable with a drop of
bovine albumin
CLL
PB and BM
Bone Marrow
WHO Lymphoid Neoplasms
B cell neoplasms
T/NK cell neoplasms
Hodgkin lymphoma (disease)
Mature B Cell Neoplasms
B cell CLL/SLL
B prolymphocytic
leukemia
Burkitt’s lymphoma /
leukemia
Splenic marginal zone
B lymphoma
Extranodal marginal B
lymphoma
Hairy cell leukemia
Lymphoplasmocytic
leukemia
Mantle cell lymphoma
Plasma cell myeloma /
plasmacytoma
Follicular lymphoma
Diffuse large B
lymphoma
T/NK Cell Neoplasms
T prolymphocytic
leukemia
T granular
lymphocytic leukemia
Aggressive NK cell
leukemia
Adult T lymphoma /
leukemia
Mycosis fungoides
(Sezary syndrome)
Anaplastic large cell
lymphoma
Hepatosplenic T
lymphoma
Peripheral T lymphoma
Immunoblastic T
lymphoma