LEUKEMIA of LABORATORY

Sulistyo M Agustini
FK UMM
2015
• Abeloff D. M, Armitage O. J, Niederhuber E J, Kastan B M, McKenna
W.G, Childhood Leukemia in Clinical Oncology, 3rd edition, USA, Elsevier
Inc, 2004; 2731 – 2754
• Craig FE and Foon K A, Fow cytometric immunophenotyping for
hematologic neoplasms, Blood, 2008: 3941-3967
• Haferlach T, et al. 2005. Global approach the diagnosis of leukemia
using gene expression profiling, The American Society of Hematology;
1189-1198
• Hoffbrand AV, Pettit JE, Moss PA. H. 2001. Acute leukaemia. In Essential
Haematology. 4th ed. Victoria: Blackwell science ; p.1 – 11, 146, 162- 79
• Kumar, Hagler, Schneider. 2005. Tissue Renewal and Repair, Robbin and
Cotran In Pathologic Basis of Disease, 7th edition, Elsevier Sauders
Phildelphia; 87- 98 and 145 – 149.
• Vardiman JW, et al, The 2008 revision of the World Health Organization
(WHO) classification of myeloid neoplasms and acute leukemia:
rationale and important changes, Blood, 2009;114:937-951)
 PENDAHULUAN
• Leukemia akut: Keganasan hematologi yg bersifat
agresif dari haemapoitic progenitor (sel blast)
• Prevalensi terbanyak: usia anak-anak (usia < 7 th),
puncaknya 2-5 tahun, ♂ > ♀ dan berkulit putih, Prevalensi
leukemia akut pada anak di Malang cukup tinggi
• Etiologi : ?? Multifaktorial  perubahan genetik, kelainan
jumlah dan struktur kromosom
• Diagnosis & Klasifikasi: kreteria FAB & WHO
Classification of Acute Leukemia
• Diagnosis berdasarkan klinis dan laboratorium
• Berbagai metode pemeriksaan secara laboratorium al:
morfologi sel, histokimia, immunophenotyping & analisa
molekuler (genotyping) dikembangkan & digabung
mencapai akurasi & Efektifitas diagnosis, diharapkan
manajemen terapi yg tepat dan efektif pula
 Leukemia Akut
• Definisi” Leukemi merupakan keganasan
sistim hematopoitik (Stem cells disease /SIH)
yg mengalami hambatan diferensiasi-
maturasi berproliferasi scr tdk terkendali”

• Patogenesa:
 gangguan hematopoisis
(dishematopoisis, uneffective hematopoisis)
 proliferasi tak terkendali (uncontrolled proliferation)
 hambatan diferensiasi-maturasi (maturation arrest)
 kematian sel terhambat (delay apoptosis)
 ekspansi klonal (clonal expansion)
 supresi hematopoisis lainnya
 Diagnosis Leukemia Akut
Klinis dg berbagai manifestasi
• Kegagalan sumtul:
Anemia (pucat, lemah,sesak,
dsb)
Neutropenia (infeksi,
pharyngitis, dsb)
• Infitrasi sel2 leukemia ke jar/
organ: hepatomegaly,
splenomegaly,
lymphadenophaty, hypertropy
gum, bone pain
• Akibat akumulasi sel2 muda
(blas): leukositosis
Laboratorium dg metode
• Blood tests : CBC
(Autoanalizer Hema)
• Morfologi sel (Evaluasi
hapusan darah)
• Sitohistokimia (Periodic
acid shiff/PAS, Sudan black
B, esterase &
myeloperoksidase/MPO)
• Immunophenotyping
• Genotyping /Analisa genetic
Infiltrasi

largest
MANIFESTASI KLINIS ALL
 The French-American-British (FAB) Classification for Acute
Lymphoblastic Leukemia (ALL)

L1 L2 L3
Size of blasts Small,uniform Large,variable Medium-
large,uniform
Amount of cyplasm Scanty variable moderate
Cytoplasmic moderate variable intense
basophilia
Cytoplasmic moderate variable prominent
basophilia
Nucleus Regular,occasional Irregular, clefting Regular, nonclefted,
clefting, homogenous common, homogeneous,finely
chromatin heterogeneous stipped chromatin
chromatin

Nucleolus 0-1 inconspicuous ≥ 1,prominent 2-5, prominent

N/C ratio high low low

T Sun Tsieh, 2008 case 14, pag.137

Diagnosis and Classification of RSSA Malang Hospital
Differensial Count
 Cytomophology with Wright

Hapusan Darah Pada ALL Hapusan Darah Pada AML

Tsien Sun (2008)

Lymphoblastic Myeloblastic

Ukuran blast Beruba-ubah Biasanya besar & sama

Cytoplasms sedikit Jumlah sedang

Cytoplasmic granules Tidak ada Terdapat

Auer rod Tidak ada Tampak kira-2 1/5 kasus

Nuclear chromatin Tampak kasar Menyebar kasar

Nucleoli 0-2 terlihat sedikt 1 – 4 Sering menojol

Myelodysplastic changes negatif Kemungkinan tampak

Myeloperoxidase/Sudan black negatif Seringkali positif

Chloroacetate esterase Negatif Positif pda leukemia myeloid

Nonspecific esterase Negatif Positif pada leukemia monocystoid

Periodic acid-Schiff Sering posif Positif kira-2 10%-15 % kasus

Tdt Kebanyakan positif Kadang-2 Positif pd kasus

Common ALL antigen (CD10) Kebanyakan positif Negatif

Myeloid antigen Negatif Positf

Gene rearrangement Kebanyakan positif Kadang-2 posif

 Gambaran morphology ALL

L1. subtype (granulasi-) L2. blst langer cytoplasma penuh L3. (basophilic dg cytoplasma
vacuolation)

Staining PAS Indirect immunofluorescene

Sumber : Hoffbrand AV, 2001
AML
Chronic Lymphocytic Leukemia
Chronic Myelocytic Leukemia (CML)
A microscope slide of bone marrow cells photographed by Dr. Daniel Sabath,UW
Laboratory Medicine, in 1992, when UW researchers first began seeking genes for
inherited forms of leukemia, which comprises white blood cell production in bone marrow.
CLL
 Morfologi & Sitokimia
Romanowsky (wright-Giemsa) Sitokimia (Pewarnaan spesifik)
• Tidak spesifik • Non enzim : Periodic Acid
Hapusan Darah Pada ALL Hapusan Darah Pada AML
Schiff (PAS) Lymphosit /
ALL (+)
• Sudan Black BAML (+)
• Enzim : Myeloperoksidase
(MPO) AML (+) terlihat
multiple Auer rods
Neutophenia, trombocytophenia
 The French-American-British (FAB) Classification for AML
• AML undifferentiated (M0)
• AML without maturation (M1)
• AML with granulocytic maturation (M2)
• AML Acute promyelocytic (M3)
• AML granulocytic & monocytic maturation (M4)
• AML monoblastic (M5a) atau monocytic (M5b)
• AML erythroleukemia (M6)
• AML megakaryoblastic (M7)

Hoffbrand AV, 2003, cap 12;163

 WHO Classification of Acute Myeloid Leukemia
• Acute Myeloid Leukemia with recurrent Cytogenetic abnormalities
AML with t(8;21) (q22;q22),(AML1/ETO)
AML with inv(16)(q13q22) or t(16;16)(p13;22),(CBFß/MYH11)
Acute promyelocytic leukemia [AML with t(15;17)(q22;q12), (PML/RARα) & variants] (AML-M3)
AML with 11q23 (MLL) abnormal
• Acute Myeloid Leukemia with multilineage dysplasia
• Acute Myeloid Leukemia and myelodysplastic syndrome, therapy related
Alkylating agent related
Topoisomerase II inhibitor-related
• Acute Myeloid Leukemia not otherwise categorized
AML minimally differentiated (AML-M0)
AML without maturation (AML-M1)
Acute with maturation (AML-M2)
Acute Myelomonocytic leukemia (AML-M4)
Acute monoblastic and monocytic leukemia (AML-M5
Acute erytroid leukemia (AML-M6)
Acute megakaryoblastic leukemia (AML-m7)
Acute basophilic leukemia
Acute panmyellosis with myelofibrosis
Myeloid sarcoma
• Acute leukemia of ambiguous lineage Sun Tsieh, 2008
 History of Hematology Cell Counting

Manual
WBC, RBC PLT

Semi Automatis
WBC RBC, PLT

Otomatis
WBC RBC, PLT
A range of Data Presentation Formats are available… selection
depends on the question you are answering

Histogram
Dot plot
Contour plot
3D plot
Overlay plots
 Scatter pattern of Human Leukocytes
This is how a whole blood sample appears under
flow cytometry analysis
 Quantitative RT-PCR
start stop
promoter oncogen
Chromosomal
Fusion

ATG TGA

AAAA RNA
Reverse
Transcriptase
cDNA
2 1 cyclus
Fluorescent probe
4 2 cycli
quencher label
Taq-
Polymerase
8 3 cycli
94°C
72°C
60°C

16 4 cycli

2n n cycli
 Ringkasan
• Leukemia akut: malignansi hematologi ( clonal steam cells
haematopoietic) yg bersifat agresif, prevalensi terbanyak pd anak-
anak
• Diagnosis & klasifikasi berdasarkan gambaran klinis dan
Laboratorium, menurut kreteria WHO dan FAB classification of
acute leukemia di bagi tipe ALL & AML
• Metode pemeriksaan Laboratorium: gabungan morfologi sel,
sitokimia, immunophenotyping, genotyping, yg hingga saat ini
terus berkembang & direvisi dg berbagai perubahan penting &
rasionalisasi mencapai akurasi dan efektifitas diagnosis yg tepat,
sehingga dapat melakukakn manajemen yg tepat pula,
• Diharapkan dapat memperbaiki & dapat mengidentifikasi diagnosis
yg tepat, akurat dan efektif, sehingga menjadi strategi Diagnosis,
manajemen leukemia akut dan menentukan prognosisnya