Understanding Leukemia

from a Lab Perspective

Mohamed Salama M.D.

Medical Director, Hematopathology
ARUP National Reference Laboratories
Outline
• Basic concepts
• Acute Myeloid Leukemia: overview
• Diagnosis and Classification
• Prognostic factors
• Acute lymphoblastic leukemia
• Chronic leukemias
Basic concepts
• Leukemia vs lymphoma
– Leukemias are systemically distributed neoplasms of white
cells

• Lymphomas are solid tumors of the hematopoietic

system. Neoplasms of lymphoid origin, typically causing
lymphadenopathy
Very important concept……

 lymphomas and leukemias are clonal expansions

of cells at certain developmental stages
Leukemia
• Divided into:
• acute v. chronic

• lymphoblastic v. myeloid (non-lymphoblastic)

Acute

Chronic
Acute Leukemia
• Divided into:
• acute v. chronic

• lymphoblastic v. myeloid (non-lymphoblastic)

Acute
Myeloid Lymphoid

Chronic
Myeloid Lymphoid
 Leukemia

Acute Chronic

Acute Myeloid Acute lymphoblastic Chronic Myeloid Chronic lymphocytic

leukemia (AML) Leukemia (ALL) leukemia (CML) Leukemia (CLL)
Acute Myeloid Leukemia
• Diagnosis:
– No evidence of maturation within blood or marrow

– >20% blasts
Diagnostic Process

Morphology

Clinical
Data Phenotype

Genetic /
molecular

Diagnosis

Biology
Acute Leukemia
• Each type of leukemia has:
– Phenotypic and genetic differences.

– A different presentation, natural history, prognosis, and

treatment.
Acute Myeloid Leukemia
• Age: Adults
• Incidence increases with age
• Median age = 60 years
• Incidence = 10/100,000 per year in those> 60 years of
age
• 12,000 cases per year in USA
• Prognosis
– Untreated~ six weeks
– With treatment - median survival = 18 months

– Some long term survivors

Acute Myeloid Leukemia
• Diagnosis:
– No evidence of maturation within blood or marrow

– >20% blasts

• Requires all the following diagnostic components

– Documentation of bone marrow infiltrate

– Myeloid origin of the leukemic cells

– FAB/WHO classification of the leukemia
– Karyotype analysis / FISH
Documentation of bone marrow infiltrate

Aspirate Smear Core Biopsy

Myeloid origin of the leukemic cells
– Wright’s staining Auer
Rod

Myeloblast

– Cytochemical stains
myeloperoxidase Non specific

(MPO) estrase
+ in Myeloid + in Monocytic

– Flow cytometry
• MPO – in myeloid lineage
Flow-cytometry
Cytogenetics
Classification based on the type of cell and degree of
maturity. FAB (French American British)
• M0 acute myeloblastic leukemia with minimal differentiation
• M1 AML without maturation
• M2 AML with maturation
– t(8;21)
• M3 Acute promyelocytic leukemia
– t(15;17)
• M4 Acute myelomonocytic leukemia
• M4 eos Acute myelomonocytic leukemia with
eosinophilia
– inv (16)
• M5 Acute monocytic leukemia
– t(9;11)
• M6 Acute erythroid leukemia
• M7 Acute megakaryoblastic leukemia
FAB
M0: AML with minimal differentiation
<3% MPO

Blasts

MPO
M1: AML without maturation
>3% MPO

MPO
M2: AML with maturation
t(8;21)(q22;q22)AML1 / ETO

Auer
Rod

Myeloblast
M2
Courtesy of Dr. Shashi Shetty

Karyotype: 45,X,-Y,t(8;21)(q22;q22),del(9)(q13q31),t(12;14)(p13;q11.2)[18]/46,XY[2]
M3: Acute Promyelocytic Leukemia

MPO +

t (15;17)

Promyelocytes
M3
M3

Karyotype: 46,XY,t(15;17)(q24;q21)[20]

Courtesy of Dr. Shashi Shetty

M4e: Acute Myelomonocytic Leukemia with eosinophilia

Abnormal
granules
M4e
M5: Acute Monocytic Leukemia
t(9;11)(p21;q23)
AML
• Clinical Correlates
– M3: disseminated intravascular coagulation
– M4, M5: skin & gum infiltration, hypokalemia
WHO classification (Risk Adapted)-2008
• Recognizes three sub groups
– AML with recurrent genetic abnormalities
• AML with t(8;21)
• AML with t(16;16) or inv 16
• APML or AML with t(15;17)
• Favorable response to therapy
– AML with multilineage dysplasia
• Includes secondary AML (MDS, therapy related)
– AML not otherwise categorized
WHO classification
• AML, not otherwise categorized
• Defined almost identically as in the FAB classification
• Based on identification of major cell lineage(s) involved
and degree of maturation
WHO classification (Risk Adapted)
• AML with recurrent genetic abnormalities
– AML with t(8;21)
– AML with inv(16),
– AML with t(15;17)
– AML with t(9;11)
– AML with t(6;9)
– AML with inv (3)
– AML (megakaryoblastic) with t(1;22)
– Provisional entity: AML with mutated NPM1
– Provisional entity: AML with mutated CEBPA
• AML with myelodysplasia-related changes
• Therapy related myeloid neoplasms
• AML not otherwise specified
– AML with minimal differentiation
– AML without maturation
– AML with maturation
– acute myelomonocytic leukemia
– acute monocytic leukemia
– acute erythroid leukemia
– acute megakaryoblastic leukemia
– acute basophilic leukemia
– acute panmyelosis with myelofibrosis
– myeloid sarcoma (also known as granulocytic sarcoma or chloroma)
Treatment
• Remission induction chemotherapy
– Aims to reduce total body leukemia cell population

• Remission consolidation
– One or more courses of chemo or BMT. Eradicate residual
leukemia
– Stem cell transplantation in certain cases with appropriate
physiology, age, and match.
Induction
• Most common regimen is Cytarabine IV x 7 days plus
duanorubicin x3 days. This is the 7+3 regimen. 60-80%
achieve complete remission.

• Toxicities include myelo-supression, mucositis and

diarrhea
 Acute promyelocytic leukemia (M3)
All trans retinoic acid (ATRA) induces Myelocytic
differentiation

PML-RARA fusion Ptn

Production of abnormal retinoic acid receptors
↓
ATRA Blocked myeloid differentiation
↓

X
APL (M3)

Myeloblast

Promyelocyte Myelocyte Metayelocyte Band Seg

WHO classification (Risk Adapted)

• Prognostic factors in AML are useful for the

prediction of relapse and failure of induction
therapy.

Age & Karyotype

Powerful prognostic
at diagnosis
factor in AML
to Predicts clinical
outcome
Early blast clearance after induction
chemotherapy
AML Risk Stratification
Favorable-Risk Group

Balanced structural rearrangements t(15;17)(q22;q12-21)

t(8;21)(q22;q22)
inv(16)(p13q22)/t(16;16)(p13;q22)
Intermediate-Risk Group
Normal Karyotype
Balanced structural rearrangement: t(9;11)(p22;q23)
Unbalanced structural rearrangements del(7q)
del(11q)
del(20q)
Numerical aberrations -Y, +8, +1, +13, +21
Unfavorable-Risk Group
Complex karyotype
Balanced structural rearrangements: inv(3)(q21q26)/t(3;3)
(q21;q26)
t(6;9)(p23;q34)
t(6;11)(q27;q23)
t(11;19)(q23;p13.1)
Unbalanced structural rearrangement: del(5q)
Numerical aberrations: -5
-7
Intermediate Cytogenetics Risk Group
• ~40% of AML patients shows no chromosomal
aberrations (normal karyotype) and hence they lack
diagnostic/or prognostic information.

• A range of molecular abnormalities might confer

considerable heterogeneity in patients, resulting in a
different response to chemotherapy or transplantation.

• Additional molecular markers in diagnostic evaluations of

AML may improve the efficacy of routine genetic
characterization and allow assignment of patients to
better-defined risk categories.
AML with normal cytogenetics
• Good
– Nucleophosmin (NPM 1) mutations without FLT3 ITD

• Bad
– FLT3 (Fms-like Tyrosine Kinase-3)
Acute Lymphoblastic Leukemia (ALL)
• Age: Children (75% < 6 years of age) &Less common in
adults
• 3200 cases/year
• Prognosis
– Potential for cure is high in children
– Long term remissions possible in adults but less common

• Treatment
– Induction therapy: vincristine + prednisone + other agents
– Consolidation and maintenance therapy
– CNS prophylaxis mandatory
Acute Lymphoblastic Leukemia (ALL)

Lymphocyte

Lymphoblast
ALL
• Most cases are tdt positive
• Most express CD10 (common ALL antigen)
• B cell ------- CD20
• 15-20% T-cell lineage ----- CD3
ALL
• With induction therapy, complete remission (CR) is
attained in 90% of patients.
• Therapy usually lasts about 3 years
• Without CNS prophylaxis, CNS relapse is common and
devastating
ALL
• High risk features
– Philadelphia chromosome +
– Leukocyte count > 30 x 109/L for pre-B ALL
– Leukocyte count > 100 x 109/L for pre-T ALL
– Time to remission > 28 days
Favorable prognostic markers
• An age of 2 to 10 years
• A low white cell count
• Hyperploidy
• Trisomy of chromosomes 4, 7, and 10
• t(12;21)
ALL
• Stem cell transplant in first remission if high risk
features (e.g. Philadelphia Chromosome)

• Patients of all ages should receive a stem cell

transplant in second remission, if appropriate (age,
performance status, donor availability)
Thank you
© 2014 ARUP Laboratories