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Learning Objectives:
• Introduction
• Definition of CML
• Philadelphia Chromosome
• Normal Granulopoiesis
• Pathogenesis of CML
• Aetiology
• Incidence
• Clinical Features
• Phases of CML
• Lab Diagnosis of CML
• Course & Prognosis
• Differential Diagnosis
• Brief Overview of Treatment
Introduction

• Chronic myeloid leukaemia (CML), also known as

Chronic myelogenous leukemia, is a
myeloproliferative neoplasm characterized by
predominant proliferation of granulocytic cells.
• It is a clonal neoplastic disorder of
haematopoietic stem cell.
• The defining characteristic of CML is presence of
Philadelphia chromosome and/ or BCR/ABL
fusion gene in all the neoplastic cells.
Introduction

• What do we mean by myeloproliferative

neoplasm ?
• What do we mean by clonal neoplastic disorder ?
• What do we mean by Philadelphia
chromosome ?
Introduction

Myeloproliferative Neoplasms
• Clonal neoplastic disorders of pluripotent
haematapoietic stem cell.
• Characterized by excessive proliferation of one or
more of the myeloid cell lines like granulocytic,
erythroid, and megakaryocytic cells.
Introduction

Myeloproliferative Neoplasms (WHO 2008

Classification)
• Chronic myelogenous leukaemia, BCR‐ABL positive
• Chronic neutrophilic leukaemia
• Chronic eosinophilic leukaemia, not otherwise
specified
• Primary myelofibrosis
• Polycythaemia vera
• Essential thrombocythaemia
• Mastocytosis
• Myeloproliferative neoplasm, unclassifiable
Introduction

Clonal neoplastic disorder

• The initial development and growth is dependent
on a population of one single type of neoplastic
cells descended form one progenitor.
• These identical cells from a shared ancestry are
referred to as clonal cells.
Haematopoiesis
Multipotent Haematopoietic Stem Cell

Common Myeloid Progenitor Common Lymphoid Progenitor

Megakaryocyte-erythroid Granulocyte-macrophage Precursor Precursor

Progenitor Progenitor T/NK Cell B Cell

Platelets RBC T Cell NK Cell B Cell

Neutrophil Monocyte Basophil Eosinophil

Macrophage
Evidence for clonal origin of CML

• Clonal disorders arise from a single stem cell.

• All the neoplastic cells contain either G6PD A or
G6PD B enzyme.
• In CML erythroid, myeloid, and megakaryocytic
elements all contain a single G6PD enzyme.
Definition

• By WHO definition, CML is established by

identification of the clone of haematopoietic stem
cell that possesses the balanced reciprocal
translocation between chromosomes 9 and 22,
forming Philadelphia chromosome .
• Ref. Harsh Mohan Text Book of Pathology, 7th
Edition
Philadelphia Chromosome (Ph Chromosome)
• Formed by reciprocal translocation between
chromosome 22 and chromosome 9.
• ABL (Abelson) gene located on chromosome 9q34
is translocated to fuse with BCR (Breakpoint
Cluster Region) gene of chromosome 22q11.
• The Philadelphia chromosome refers to the
shortened chromosome 22 first described by
investigators in Philadelphia.
• The fusion product so formed is termed “Ph
chromosome t(9;22) (q34;11), BCR/ABL” which
should be positive for making the diagnosis of
CML.
Philadelphia Chromosome (Ph Chromosome)

ABL
Philadelphia Chromosome (Ph Chromosome)

• The site of breakpoint in BCR gene is variable.

• Therefore the size of BCR/ABL protein varies from
185 kDa to 230 kDa.
• Most patients with typical CML have 210 kDa
fusion protein.
Pathogenesis of CML

• BCR-ABL oncoprotein exhibits constitutive kinase

activity.
• It leads to excessive proliferation and reduced
apoptosis of CML cells.
• Ability of ABL to act as DNA-binding protein is
altered.
• Binding of ABL to actin microfilaments of the
cytoskeleton is increased.
Aetiology

• There are no familial associations in CML.

• The risk of developing CML is not increased in
monozygotic twins or in relatives of patients.
• No associations exist with exposures to benzene
or other toxins, fertilizers, insecticides or viruses.
Aetiology

• Exposure to ionizing radiation has increased the

risk of CML, which peaks at 5–10 years after
exposure and is dose-related.
• e.g. nuclear accidents, radiation treatment for
ankylosing spondylitis or cervical cancer.
• The median time to development of CML among
atomic bomb survivors of Hiroshima was 6.3 years.
• Following the Chernobyl nuclear accident, the
incidence of CML did not increase, suggesting that
only large doses of radiation can cause CML.
Incidence

• CML is primarily a disease of adults but also

occurs in children and adolescents.
• The peak incidence is in the fifth to sixth decades
of life.
Clinical Features

• Onset is insidious.
• Mild to moderate anaemia and hypermetabolism
leads to fatigability, weakness, anorexia and
weight loss.
• In case of splenomegaly dragging sensation in the
abdomen may be felt.
• In case of splenic infarct acute onset of left upper
quadrant pain may be present.
3 Phases of Chronic Myeloid Leukaemia

• Chronic Phase
• Accelerated Phase
• Acute Blast Crisis
Chronic Phase of CML

• Leukaemic cells retain the capacity for

differentiation and maturation and are largely able
to function normally.
• The disease is responsive to chemotherapy and
remains stable for variable period.
• The duration of this stage is 3 to 5 years.
Accelerated Phase of CML

• Leukaemic cells show increasing loss of

differentiation and maturation, increased
proliferation, and resistance to chemotherapy.
• Chronic phase gradually evolves into accelerated
phase in 70% of the cases.
• Disease becomes more aggressive.
• Majority of the cases may progress to acute blast
crisis phase within a span of few months.
Acute Blast Crisis Phase of CML

• This occurs when there is transformation to acute

leukaemia and the disease becomes extremely
resistant to chemotherapy.
• Median survival is 2 to 6 months.
• About 30% of patients progress to blastic phase
without intervening accelerated phase.
Lab Diagnosis of CML

• Peripheral Blood Examination

• Bone Marrow Examination
• Cytogenetic Analysis
Lab Diagnosis of Chronic Phase of CML

• A. Peripheral Blood Examination:

– Anaemia: Mild to moderate, normocytic and
normochromic.
– Total leucocyte count is moderately to markedly raised
and is commonly more than 1,00,000/cmm.
– All stages of maturation from myeloblast to segmented
neutrophils are present with ‘peaks’ of myelocytes and
segmented neutrophils.
– Blast cells are less than 10%.
– Basophilia is important for diagnosis of CML since it is
rarely seen in any other disorder.
Lab Diagnosis of Chronic Phase of CML

• B. Bone marrow examination:

– Cellularity: Hypercellular
– Myeloid : Erythroid Ration is 10:1 to 50:1 (normal ratio
is 2:1 to 4:1 )
– Myeloblast <10%
– Megakaryocytes are frequently increased in number
and are typically smaller in size with hypolobated
nuclei.
Lab Diagnosis of Chronic Phase of CML

• C. Cytogenetic Analysis:
– Cytogenetic analysis of bone marrow and peripheral
blood shows a characteristic abnormality, the Ph’
chromosome in more than 95% of the cases.
– In some cases of CML, Ph’ chromosome cannot be
demonstrated by cytogenetic analysis.
– However, in most such patients rearrangement of
BCR/ABL can be demonstrated by Southern blot
analysis, fluorescent in situ hybridisation or
polymerase chain reaction.
Lab Diagnosis of Accelerated Phase of CML

• According to WHO classification, accelerated

phase is characterized by presence of one or more
of the following features:
– Blast cells are 10–19% in the peripheral blood film and
bone marrow.
– Peripheral blood basophilia ≥20%.
– Persistence of thrombocytopaenia (<1 lac/cmm)
unrelated to therapy or persistent thrombocytosis (>10
lac/cmm) not responsive to therapy.
– Progressive splenomegaly and increase in leucocyte
count.
– Cytogenetic evidence of clonal evolution.
Lab Diagnosis of Blast Crisis Phase of CML

• According to WHO classification, blast crisis phase

is characterized by presence of one or more of the
following features:
– Blasts in peripheral blood or bone marrow ≥20%.
– Blast proliferation at a site other than bone marrow.
– Focal clustering of blasts in bone marrow.
• Blast crisis in CML may be myeloid (70%) or
lymphoid (30%).
Course & Prognosis of CML

• Chronic phase of CML may run a stable course

with a median duration of about 3.5 years.
• Chronic phase gradually evolves into accelerated
phase in 70% of the cases.
• About 30% of patients progress to blastic phase
without intervening accelerated phase.
• Median survival is 2 to 6 months in blast crisis
phase.
Course & Prognosis of CML

• At diagnosis, prognostic factors associated with

shorter duration of survival are –
– Older age
– Large spleen and liver size
– Increased number of blasts
– Increased number of basophils
– Fibrosis of bone marrow.
Differential Diagnosis of CML

• Non-neoplastic changes, particularly leukemoid

reaction
• Other myeloproliferative neoplasms, especially
primary myelofibrosis and essential
thrombocythaemia
• Myelodysplastic/myeloproliferative neoplasms,
particularly atypical CML and CMML
• Myelodysplastic syndrome with del(5q)
chromosome aberration
• De novo acute leukemia.
Differences between chronic myeloid leukaemia and
leukaemoid reaction
Traits CML Leukaemoid
Reaction
Clinical Features Splenomegaly According to
underlying cause
PBF WBC count Usually Usually
>1,00,000/cmm <50,000/cmm
Myelocyte and Present Absent
neutrophil ‘peaks’
‘Toxic’ granules Absent Present
Basophilia, Present Absent
eosinophilia,
monocytosis
Bone marrow Trilineage Myeloid hyperplasia
examination hyperplasia
Genetic analysis Ph’ chromosome or Normal
BCR/ABL gene
rearrangement
Traits CML Polycythae Essential Primary
mia vera thrombocytha myelofibros
emia is
Blood smears All stages of Thick smear Thrombocytosis Leuco-
myeloid due to with marked erythroblasti
maturation, erythrocytosi variation in size c reaction
‘peaks’ of s
myelocytes and
segmented
neutrophils.
Bone Marrow Trilineage Trilineage Numerous Predominant
hyperplasia with hyperplasia dispersed, large, granulocytic
granulocytic with erythroid mature hyperplasia;
predominance predominanc hyperlobated highly bizarre
e megakaryocytes megakaryocy
tes in tight
clusters
Predominant Granulocytic Erythroid Megakaryocytic Granulocytic
cell line and
affected megakaryocy
tic
Mutation BCR-ABL fusion JAK2V617F JAK2V617F JAK2V617F
(>95%) (50%); MPL (50%); MPL
Chronic myelomonocytic leukaemia (CMML):

• Usually presents with anaemia and splenomegaly

in elderly persons.
• There is moderate leucocytosis, neutrophils and
band forms are increased, and monocyte count is
in excess of 1000/cmm.
• Bone marrow typically shows trilineage dysplasia
and increase in monocytic cells.
• Basophilia, Ph’ chromosome, or BCR/ABL gene
rearrangement are absent.
Treatment of CML

• The treatment of CML was revolutionized in 1998

when imatinib mesylate, a potent and specific
inhibitor of tyrosine kinase became available.
(First line drug)
• 80% of patients with CML present in chronic phase.
• Majority of patients achieve a complete
haematologic response at 3 months and complete
cytogenetic response at 6, 12, or 24 months.
Treatment of CML

• Complete haematologic response means:

– Disappearance of all signs and symptoms of CML
– Disappearance of palpable splenomegaly
– Normalization of total leucocyte count and platelet
count
– No immature cells (myelocytes, promyelocytes, blasts)
on differential count.
Treatment of CML

• Complete cytogenetic response means:

– No Philadelphia chromosome positive metaphases
Treatment of CML

• For patients showing suboptimal response, options

include imatinib dose escalation or alternate
tyrosine kinase inhibitors like dasatinib or nilotinib.
• For accelerated phase, dasatinib or nilotinib are
recommended.
• For blast phase, tyrosine kinase inhibitor therapy
either alone or in combination with chemotherapy
followed by allogeneic haematopoietic
transplantation is recommended.
Closing Remarks

• Proper diagnosis of CML is vital for proper

management of the patient.
• Careful analysis of peripheral blood picture, bone
marrow examination and cytogenetic analysis
combined with multidisciplinary approach will
ensure the proper diagnosis and management of
CML.
Reference:
• Robbins & Cotran Pathologic Basis of Disease 9th Edition
• Harsh Mohan Text Book of Pathology 7th Edition
• de Gruchy’s Clinical Haematology in Medical Practice 6th Adapted
Edition
• Hoffbrand’s Essential Haematology 7th Edition
• Essentials of Haematology (Shirish M Kawthalkar) 2nd Edition
• Blood Cells : A Practical Guide 5th Edition
• Blood and Bone Marrow Pathology 2nd Edition
• Harrison's Haematology and Oncology 3rd Edition
• www.nhs.uk
• www.webmd.com
• www.wikipedia.org
• www.pathology.med.umich.edu
• Thank You!