leukemia 2009f
DESCRIPTION
yTRANSCRIPT
Today’s Quranic verse
And hold fast, all together, by the rope which God (stretches out for you), and be not divided among yourselves; and remember with gratitude God's favour on you; for ye were enemies and He joined your hearts in love, so that by His Grace, ye became brethren; and ye were on the brink of the pit of Fire, and He saved you from it. Thus doth God make His Signs clear to you: That ye may be guided. [003:103]
DISORDERS OF WHITE BLOOD CELLS
Palangka Raya UniversityJumat 21 April 2023
White blood cell types (WBC differential)
Neutrophils: 47%–77%
Band neutrophils: 0%–3%
Lymphocytes: 16%–43%
Monocytes: 0.5%–10%
Eosinophils: 0.3%–7%
Basophils: 0.3%–2%
White blood cell (WBC) count
4,000–11,000 per microliter (µL)
Name the different cells.
Neutrophil (Band Cell)
Platelet
Eosinophil
Monocyte
Lymphocyte
MatureNeutrophil
Basophil
Red Blood Cell (Mature Erythrocyte)
BENIGN DISORDERS OF LEUKOCYTES
• Leukocytosis Condition characterized by abnormally increased number of
WBC. It may be generalized or involve only individual granulocytes
or agranulocytes.
• Leukopenia: Condition characterized by abnormally reduced number of
WBC. It may be generalized or involve only neutrophils or
lymphocytes
Neutrophilic leukocytosis
Acute bacterial infections, especially those caused by pyogenic organisms; sterile inflammation caused by, for example, tissue necrosis (myocardial infarction, burns)
Eosinophilic leukocytosis
Allergic disorders such as asthma, hay fever, allergic skin diseases (e.g., pemphigus, dermatitis herpetiformis); parasitic infestations; drug reactions; certain malignancies (e.g.,Hodgkin disease and some non-Hodgkin lymphomas); collagen vascular disorders and some vasculitides; atheroembolic disease (transient)
Basophilic leukocytosis
Rare, often indicative of a myeloproliferative disease (e.g., chronic myelogenous leukemia)
Monocytosis Chronic infections (e.g., tuberculosis), bacterial endocarditis, rickettsiosis and malaria; collagen vascular diseases (e.g., systemic lupus erythematosus) and inflammatory bowel diseases (e.g., ulcerative colitis)
Lymphocytosis Accompanies monocytosis in many disorders associated with chronic immunologic stimulation(e.g., tuberculosis, brucellosis); viral infections (e.g., hepatitis A, cytomegalovirus, Epstein-Barr virus); Bordetella pertussis infection
LEUKOCYTOSIS
Reduced or ineffective production ofneutrophils
Accelerated removal of neutrophils
from the circulating blood
Leukemoid reaction
• Leukemoid reaction is defined as a reactive leukocytosis in excess of 50 000/μL. It is usually seen in response to infection, inflammation, or therapeutic agents such as growth factors and is less commonly caused by malignancy. Milder elevations in leukocyte count are common both in carcinoma and Hodgkin lymphoma.
• Cells are more mature than myelocytes in peripheral smear
• Leukocytic alkaline phosphatase activity is high
• Neutrophils contain toxic granules (Dohle bodies)
LEUKEMIAS
Neoplastic Proliferations of White Cells
Lymphoid neoplasms Myeloid neoplasms Histiocytoses
LymphomaChloroma
HEMOPOIESISMYELOID/ LYMPHOIDSTEM CELLS
(CD34)
LYMPHOID STEM CELLS
MYELOID STEM CELLS
LYMPHOCYTES OTHER BLOOD CELLS
HEMOPOIESISMYELOID/ LYMPHOIDSTEM CELLS
(CD34)
LYMPHOID STEM CELLS
MYELOID STEM CELLS
LYMPHOCYTES RBCOTHERWBC
PLATELET
HEMOPOIESIS
MYELOID/ LYMPHOIDSTEM CELLS
(CD34)
MYELOIDSTEM CELLS
PRO-NORMOBLAST
EARLYNORMOBLAST
INTERMEDIATENORMOBLAST
LATENORMOBLAST
RETICULOCYTE
RBC
MONOBLAST
PROMONOCYTE
MONOCYTE
MYELOBLAST
PRO-MYELOCYTE
MYELOCYTE
META-MYELOCYTE
BAND or STAB
GRANULOCYTES
MEGAKARYOCYTE
MEGAKARYOBLAST
PLATELET
HEMOPOIESISMYELOID/ LYMPHOID
STEM CELLS(CD34)
LYMPHOID STEM CELLS
Pre-T
Thymocyte
Peripheral T Cells
T-Helper
T-Supp.
Pro-B
Pre-B
B- Virgin
B- Mature
LPC
PLASMACELL
LEUKEMIAS
Leukemias are usually diseases of unknown etiology
Abnormal Uncontrolled
WidespreadWidespread
Proliferation of
WBCClonal
Leukemia
Etiology and Pathophysiology
• Associated with the development of leukemia – Chemical agents
– Chemotherapeutic agents
– Viruses
– Radiation
– Immunologic deficiencies
– Underlying hematologic disorders
– Hereditary/genetic conditions
– Idiopathic
LEUKAEMIAMYELOID/ LYMPHOIDSTEM CELLS
(CD34)
LYMPHOID STEM CELLS
MYELOID STEM CELLS
LYMPHOCYTES GRANULOCYTES
ACUTECHRONIC
Lymphoblasts
Lymphocytes Granulocytes
Myeloblasts
ALL AML
CMLCLL
HEMOPOIESISMYELOID/ LYMPHOID
STEM CELLS(CD34)
MYELOIDSTEM CELLSPRO-
NORMOBLAST
RBC
MONO-BLAST
MONOCYTE
MYELOBLAST
PRO-MYELOCYTE
MYELOCYTE
META-MYELOCYTE
BAND or STAB
GRANULOCYTES
MEGA-KARYO-BLAST
PLATELET
AMLCML
HEMOPOIESISMYELOID/ LYMPHOID
STEM CELLS(CD34)
LYMPHOID STEM CELLS
Pre-T
Thymocyte
Peripheral T Cells
T-Helper
T-Supp.
Pro-B
Pre-B
B- Virgin
B- Mature
LPC
PLASMACELL
ALL
CLL
Acute Leukemia means
Maturation Arrest
Sustained SELF-RENEWALAT THE EXPENSE OF
DIFFERENTIATION
Differentiation (Maturation)
Self-renewal
Maturation Arrest
Sustained self-renewal
Learn how to say “No” courteoulsy & Learn how to say “No” courteoulsy & promptlypromptly.
LEUKEMIAS
TYPES
INCIDENCE
AGE
PRESENTATION
BONE
MARROW
Anemia
Neutropenia
Thrombocytopenia
CNSBONESKIN
LYMPHATICSetc
OTHERS
ALL AML
CMLCLL
TYPES & AGE
CH
ILDR
EN
YOUNG ADULTSM
iddle Age
But ,also
any ageElderly
Acute Leukemias (AML/ALL)
Block in differentiation–“blasts” with prolonged generation time↓
Accumulation of “blasts’ (Result from a clonal expansion & Failure of maturation)
↓Suppress normal hematopoiesis
(↓ in normal RBCs, WBCs and PLTs)
Aim of TX is to reduce the leukemic clone to allow reconstitutionwith the progeny of remaining normal stem cells
Acute Leukemias (AML/ALL)
Clinical features
• Abrupt onset
• Symptoms related to BM depression– Fatigue from anemia, fever from infection, bleeding from thrombocytopenia
• Bone pain and tenderness– BM expansion with subperiosteal infiltration
• Generalized adenopathy, hepatosplenomegaly (ALL>AML)
• CNS manifestations (ALL>AML)– Headache, vomiting, nerve palsies
Acute Leukemias (AML/ALL)
• Laboratory– Leukocytosis (>100,000 or <10,000) with “blasts” in circulation & BM– Lymphoblasts: with + PAS aggregates– Myeloblasts: + myeloperoxidase– Thrombocytopenia
• Immunophenotyping– Tdt (DNA polymerase): + in 95% of ALL– Lineage specific markers: CD19, CD10 (B cell), CD1 CD2, CD5 CD7 (T cell)– CD33 & CD34 in AML
• Karyotyping (predictive of prognosis)– Usually nonrandom abnormalities– ALL; Pre - B: Hyperdiploidy assoc with t(12,21) - good & Ph chromosome – poor– AML; t(8;21) and inv(16 ) and t(15;17) Prognosis – > 60% of the patients achieve complete remission with chemotherapy, but only 15% to
30% remain free from disease for 5 years– >90% of children with ALL achieve complete remission, and 2/3 can be cured
Acute Leukemia
• Diagnosis: >20% blasts in the bone marrow• Categorized by
– H&E staining– Cytochemical stains (myeloperoxidase, NSE, PAS)– Flow cytometry– Cytogenetics
M1
M5
L2 LYMPHOBLAST
MYELOBLAST
MONOBLAST
SPECIAL STAINS
PAS
*Sudan Black*Myeloperoxidase*Specific Esterase
Non-Specific Esterase
Blasts
Features Myeloblasts Lymphoblasts
Cytoplasm Mod/abundant Scant/Mod
Cyt. Granules Common Uncommon
Nucleus (chromatin)
fine Coarse
Nucleoli Prominent Variable
Auer rods Present Absent
Shed hate and rancour, they hurt Shed hate and rancour, they hurt youyou more than they do more than they do others.others.
AML
ACUTE LEUKEMIASFAB CLASSIFICATION
M0
M1
M2
M3M4
M5
M6
M7L1
L2
L3
ALL
AML
ACUTE MYELOID LEUKEMIA
FAB CLASSIFICATION
M0
M1
M2
M3M4
M5
M6
M7
FAB Classification of AMLClass Morphology Comments
M0 Blasts lack cytologic markers
2-3%
M1 Very immature myeloblasts 20% (Ph chromosome worsens prognosis)
M2 Myeloblasts & promyelocytes 30%, t,(8;21) good prognosis
M3 Hypergranular promyelocytes“many auer rods”
5-10% DIC, t(15,17)Responds to ATRA
M4 Myelocytic & monocytic diff.
20-30%, inv16/del16q betterprognosis
M5 Monoblasts & promonocytes 10%, pediatric age-young adults, 11q23 abnormalities
M6 Erythroblasts > myeloblasts 5%, older adults
M7 Megakaryocytic blasts Myelofibrosis
Myeloid maturation
myeloblast promyelocyte myelocyte metamyelocyte band neutrophil
MATURATIONMATURATION
Adapted and modified from U Va website
M1M2
M3 M4 M5
M6 M7
AML
Auer rods in AML (M3)
Hypergranular promyelocytes,“many auer rods” 5-10% DIC, t(15,17), Responds to ATRA
CD M1/M2 M3 M4/M5 M6 M7
CD11b - + ++ - -
CD13 + + ++ + +
CD14 - - ++ - -
CD15 + + ++ - -
CD33 ++ + ++
+ +
CD34 ++ + + + +
Immunophenotyping of AML
ALLL1
L2
L3
FAB CLASSIFICATION
ACUTE LYMPHOBLASTIC LEUKEMIAS
L1
FAB CLASSIFICATION
ACUTE LYMPHOBLASTIC LEUKEMIAS
Lymphoblasts:Small & Monomorphic
ALL
ALL L2
FAB CLASSIFICATION
ACUTE LYMPHOBLASTIC LEUKEMIAS
Lymphoblasts:Large & Heterogeneous
L3
FAB CLASSIFICATION
ACUTE LYMPHOBLASTIC LEUKEMIAS
Burkitt ALL
ALL
Immunophenotyping of ALL
In the 10% to 20% of cases in which morphology and cytochemistry are inconclusive or insufficient to
Distinguish AML and ALL,
immunophenotype analysis provides the diagnosis in virtually all cases
Using a combination of CDs specifically recognizing B-cell, T-cell, and myeloid antigens, it is possible to distinguish
AML from ALL in 95% to 99% of cases
Beware of who has nothing to lose.Beware of who has nothing to lose.
Pallor
Purpura
Infection
Mucosal Bleeding
Oral CandidiasisPneumonia
Extensive Bruising
Gum Hypertrophy
Lymphadenopathy
Lymphadenopathy Leukemic Infiltrate
Retinal Bleed
Leukemic Infiltrate
Lytic Skull Lesions
Mediastinal Involvement
Chloroma
2% of AML have discrete tumors
Chloroma (Myeloblastoma)
Granulocytic SarcomaIn the Orbit, Para-nasal sinuses, Brain, Spinal cord, Bone, Breast
Skin & Subcutaneous tissues
Called chloromas because of greenish color from ↑MPO
A
B
C
Chloromas
NEJM 1998
Precursor B- and T- Cell Lymphoblastic Leukemia/Lymphoma
• Aggressive tumors of children/young adults• Composed of immature lymphocytes (lymphoblasts)• Lymphoblastic tumors are indistinguishable morphologically with
similar symptomatology– Pre-B: present as leukemias with extensive BM involvement (CD19+ and
CD10+) – Pre-T: mediastinal masses involving the thymus progress rapidly to a leukemic
phase or involve BM (CD1+, CD2+, CD5+, and CD7+)– Both pre-B/T lymphoblastic tumors have the clinical appearance of ALL at some
time during their course– Hyperploidy (>50 chromosomes), polyploidy, and t(12;21), t(9;22) and t(4;11)– >90% of children with ALL achieve complete remission, and 2/3 can be cured
• ALLs comprise 80% of childhood leukemia (peaks at age 4) and are usually pre-B phenotype
Acute Leukemia Treatment
The goal is to reduce and eventually eradicate the leukemic cell population while restoring normal hematopoiesis
Both normal and leukemic cells coexist & effective therapy will sufficiently reduce the leukemic cell burden to allow re-growth of normal myeloid progenitors.
Non-neoplastic cells repopulate the marrow after chemotherapy-induced remissions in most patients
The Future
• Clinical trials• New drug treatments• Vaccines• Immunotherapy• Leukemia type-specific therapy• Gene therapy
– Block encoding instructions of an oncogene– Target the oncoprotein
• Blood and marrow stem cell transplantation– Bone marrow transplantation provides long-term, disease-free survival
among patients in remission
Take a Break !…
Don’t lose control at any time; take a deep Don’t lose control at any time; take a deep breathbreath
Chronic Myeloproliferative Disorders
• Disorders of multipotent progenitor cells ( myeloid & Lymphoid precursor)• Increased, Functionally abnormal cells. • Extramedullary hemopoiesis - Organomegaly• End stage
– Progress to Leukemia– Myelofibrosis
• Chronic myelogenous leukemia (CML)• Polycythemia vera (PV)• Myeloid metaplasia with myelofibrosis (MMF)• Essential thrombocythemia
Chronic Myeloid Leukemia
The First Disease
The First Disease
The 1st disease for which the term leukemia was used (Virchow 1845; White Blood)
The 1st malignancy ~ with a recurring chromosomal abnormality (Philadelphia Chromosome)
The first disease in which the associated chromosomal abnormality was found to result fromthe translocation of genetic material from one chromosome to another to form fusion gene(BCR/ABL)
The first disease in which the fusion gene was recognized as giving rise to an abnormal fusion protein fundamental in the pathogenesis of the disease.
The first disorder in which a therapeutic agent “Glivec” has been designed to specifically targetthe molecular defect
Chronic myelogenous leukemia (CML)
• Adults, usually 40-50• Philadelphia chromosome• Clinical: slow onset, nonspecific symptoms, marked splenomegaly• Lab: leukocytosis (>100,000)
– PMNs, myelocytes, eosinophils, basophils, <5% “blasts”• BM: hypercellular (granulocytic/megakaryocytic)• D/D: leukemoid reaction (↑LAP)• Course: 50% accelerated phase
– ↑ anemia, ↓ PLTs, ++ cytogenetic abn, blastic crisis
CML
ChronicPhase
AcceleratedPhase
CML
BlastCrisis
STAGING OF CML
Three main stages, determined by percentage of blast cells in the blood
- Chronic Phase- Patient usually diagnosed- Fewer than 10% of cells in blood and bone marrow are blast- Prognosis: (with imatinib) 5yr: 70%, 10yr: 30-40%
- Accelerated Phase- 10-19% of cells in blood or bone marrow are blast, Basophilia ≥ 20%
- Blastic Phase, aka “blast crisis”- Fulminant symptoms of disease, multiple organ involvement- 20-30% or more blasts in bone marrow and blood- Prognosis: UNPROMISING, 2 months, may extend survival with newer
drugs or chemotherapy
Ph chromosomePh chromosome
BCR-ABLBCR-ABL (activated activated tyrosine kinase)tyrosine kinase)
BCRBCR ABLABL
CMLCML
The Philadelphia (Ph) Chromosome Leads to CML
bcr
abl
fusion 9abl/bcr
fusion 22bcr/abl
Practical Guidelines to Diagnose and Monitor CML
Test GuidelinesRoutine cytogenetic analysis
At diagnosis and every year
I-FISH Pretreatment to have baseline percent of Ph-positive cells, then every 2-3 mo until Ph <10%.
D-FISH As for I-FISH. Reliability for lack of false positivity when Ph 5-10% under investigation.
H-FISH As for I-FISH. No false-positives; can be used when Ph <10%
Southern blot At diagnosis, particularly if patient has morphologic CML but is Ph-negative by routine cytogenetics; does not detect p190 or p230.
PCR quantification Monitor minimal residual disease status in patients who are 0% Ph-positive; critical BCR-ABL to ABL ratio of 0.045 may be used for treatment decisions.a
Detection of p190 disease
Specific PCR primers.
Detection of p230 disease
Specific PCR primers.
D-FISH, double-probe fluorescence in situ hybridization; H-FISH, hypermetaphase fluorescence in situ hybridization; I-FISH, interphase fluorescent in situ hybridization; PCR, polymerase chain reaction
Treatment
• Chemotherapy:• Tyrosine kinase inhibitor:• Interferon-.• Stem cell transplant.
Own up to your Own up to your mistakes.mistakes.
Imatinib (Gleevec)
Normal Bcr-Abl Signaling
• The kinase domain activates a substrate protein, eg, PI3 kinase, by phosphorylation
• This activated substrate initiates a signaling cascade culminating in cell proliferation and survival PP P
ADP P
P
PP P
ATP
SIGNALING
Bcr-Abl
Substrate
Effector
ADP = adenosine diphosphate; ATP = adenosine triphosphate; P = phosphate.Savage and Antman. N Engl J Med. 2002;346:683Scheijen and Griffin. Oncogene. 2002;21:3314.
Imatinib Mesylate Mechanism of Action
• Imatinib mesylate occupies the ATP binding pocket of the Abl kinase domain
• This prevents substrate phosphorylation and signaling
• A lack of signaling inhibits proliferation and survival
P
PP P
ATP
SIGNALING
Imatinib mesylate
Bcr-Abl
Savage and Antman. N Engl J Med. 2002;346:683.
Impressive Results in CML ...
0102030405060708090
100
Late chronic phase Accelerated phase Blast crisis
Hematologic response Major cytogentic response (MCR)
(n=532) (n=235) (n=260)
89%
68%
55%
23%29%
15%
< 10% of patients on IFN have MCR1
1 Kantarjian, 1998
Don’t hesitate to lose a battle if it helps you win the war
Chronic Lymphoid Leukemia
Chronic Lymphocytic Leukemia (CLL)
• Most common form of leukemia in North America and Northern Europe• Essentially identical to small lymphocytic lymphoma (SLL)• M > F (2 : 1)• Elderly (>60 y/o)• Considered incurable• Mostly asymptomatic• Hepatosplenomegaly may be present (in later stages)• Symmetrical lymphadenopathy• Peripheral lymphocytosis (>200,000)• Increased susceptibility to bacterial infection (most frequent cause of
death)• May associated with autoimmune hemolytic anemia &
Thrombocytopenia
• Indolent clinical course• Median survival : 4-6 yrs• Occasional transformation to large non-Hodgkin’s
lymphoma (Richter’s syndrome) --- 3 to 5 %
Chronic Lymphocytic Leukemia (CLL)
CLL:
lymphocytes
‘smudge’ cells
CLL
Investigation:
• CBC:
– WBC:.
– Diff:lymphocytosis ,the absolute lymphocyte count is>5x109/l and may be up to 300x109/l or.
Blood film:
70-99% of white cells mature lymphocyte.
Smudge or smear cells also present.
Immunophenotyping:
Shows that the lymphocyte are B cells
(CD19) expressing one form of light chain
( or only) cells are also CD5 & CD23+ve.
• Bone marrow aspiration:
Lymphocytic replacement of normal marrow.
• Immunoglobulinelectrophoresis: of Ig, more marker with advance disease.
• Cytogenetic :
The 4 most common abnormalities are; deletion of13q14,trisomy 12, deletion of 11q23 & structural abnormality of 17p involving the p53 gene.
RaiStaging
CLL
CLL
Marrow
<20%
Lymph-ocytes
Lymphocyte1,500 to 4,000
/uL
NoPalpable
L.N.
NoPalpableDisease
NormalHb
NormalPlatelets
BLO
OD
MARROW
Ab
dom
en
L. N.
Hb.
Plate
let
SURVIVALGOK
CLL
Marrow
>40%
LC
LC>
15,000/uL
NoPalpable
L.N.
NoPalpableDisease
NormalHb
NormalPlatelets
SURVIVAL150
months
Stage “0”
CLL
Marrow
>40%
LC
LC>
15,000/uL
PalpableL.N.
NoPalpableDisease
NormalHb
NormalPlatelets
SURVIVAL101
months
Stage “I”
CLL
Marrow
>40%
LC
LC>
15,000/uL
PalpableL.N.
Hepato-Spleno-megaly
NormalHb
NormalPlatelets
SURVIVAL71
months
Stage “II”
CLL
Marrow
>40%
LC
LC>
15,000/uL
PalpableL.N.
Hepato-Spleno-megaly
Anemia NormalPlatelets
SURVIVAL19
months
Stage “III”
CLL
Marrow
>40%
LC
LC>
15,000/uL
PalpableL.N.
Hepato-Spleno-megaly
Anemia Thrombo-cytopenia
SURVIVAL19
months
Stage “IV”
BinetStaging
CLL
CLLGroup A
No anemia or thrombocytopenia, < three of five lymph node areas
Group BNo anemia or thrombocytopenia,
Three or more lymph node areas
Group CAnemia (Hb <10 g/dL) or
Thrombocytopenia (Platelets <100 x 109/L)
AxillaryL.N.
InguinalL.N.
CervicalL.N.
Liver
SpleenBinet Staging of CLL
Do onto others as you wish others did onto you.
Hairy Cell Leukemia
• Uncommon variant of peripheral B-cell neoplasm
• Clinically Middle age to elderly (younger than CLL)• splenic red pulp involvement• Histologically Lymphocyte with finger-like projections• Phenotypically TRAP (Tartrate Resistant Acid
Phosphatase)• CD19, CD20
Hairy Cell Leukemia clinical
• M > F (3-5 : 1)• Splenic red pulp involvement red pulp “lake”• Bone marrow & liver involvement• Tends to follow an indolent course
– Pancytopenia - most prominent feature• - Granulocytopenia recurrent bacterial infection• - Anemia fatigue• - Thrombocytopenia bleeding
• Good response to some chemotherapy regimen
Myelodysplastic Syndrome• Group of Clonal stem cell disorders characterized by ineffective
hematopoiesis, hypercellular marrow with left-shift (increase of blasts, 5- <20%) and peripheral cytopenias. Higher grade MDS (blasts >10%) may eventually transform into acute myeloid leukemia or progress into marrow failure.
• Types– Primary or Idiopathic = > 50yrs, Gradual in onset, risk of AML ↑– Rx ( RT or Drugs) related (t MDS) = after 2 -8 of RX, complication of Rx, Higher risk
of AML (↑ ↑ ↑)• Pathogenesis
– Unknown
• FAB classification (based on % blasts and ringed sideroblasts)
1. Refractory anemia(RA)2. Refractory anemia with ringed sideroblasts (RARS)3. Refractory anemia with excess blasts (RAEB)4. Refractory anemia with excess blasts in transformation (RAEB-T)5. CMML (chronic myelomonocytic leukemia)
• Cytogenetic abnormalities– Deletions (5q,7q,20q), Monosomy (5 & 7), Trisomy (8)
• Morphology– Marrow = usually Hypercellular,
• Erythroid precursors - ring Sideroblasts, budding nucleated cells, • Granulocytic – Megaloblastoid, Pseudo Pelger – Huet
neutrophils( two nuclear segments), • Megakaryocytes- Pawn ball type( multinucleate)
– Peripheral Blood = Cytopenias ( Pancytopenia)
• Patients present with Refractory Anemia’s (not responding to hematenics even after 6 months of Rx )
Myelodysplastic Syndrome
Don’t be afraid to say “I don’t know” and “I’m Don’t be afraid to say “I don’t know” and “I’m sorrysorry