Acute Leukaemia-

Update
Dr Niranjan N. Rathod
DM (Hem), MD (Med), FACP (USA)
Fellowship in BMT, FHCRC, USA

Consultant in Haematology , Haemato-Oncology &

Bone Marrow Transplantation

Jupiter Hospital, Thane

Global Hospitals, Mumbai
LTMHG & LT Medical College, Sion, Mumbai
Outline of talk
 Introduction
 Leukaemiogenesis
 Classification of acute leukaemias
 Clinical features
 Diagnosis
 Treatment
 Induction therapy
 Post remission therapy
 Role of Bone marrow Transplant
Definition: Acute Leukaemia

 Acute leukemias are clonal / malignant

disorders that arise from hematopoietic
progenitors developing either in the
lymphoid or myeloid pathway or from
primitive stem cells with multilineage
potential.
 Classification of leukemias

Acute Chronic

Myeloid Acute Myeloid Chronic Myeloid Leukemia

Leukemia (AML) (CML)
origin

Lymphoid Acute Lymphoblastic Chronic Lymphocytic Leukemia

Leukemia (ALL) (CLL)
origin
 ALL
naïve

B-lymphocytes
Plasma
Lymphoid cells
progenitor T-lymphocytes

AML
Hematopoietic Myeloid Neutrophils
stem cell progenitor
Eosinophils

Basophils

Monocytes

Platelets

Red cells
 Myeloid maturation
AML AML-M3- APML CML

myeloblast promyelocyte myelocyte metamyelocyte band neutrophil

MATURATION
Lymphoid maturation

Lymphoblast - ALL Mature Lymphocytes-CLL

MATURATION
Two-hit model of
Leukemogenesis
Loss of function of Gain of function mutations of
transcription factors tyrosine kinases
needed for differentiation
eg. FLT3, c-KIT mutations
eg. AML1-ETO N- and K-RAS mutations
CBF-SMMHC BCR-ABL
PML-RAR TEL-PDGFR

differentiation enhanced Acute

block + proliferation Leukemia
Regulation of
Haematopoiesis
 Development of Leukemia in
the Bloodstream

Stage 1- Normal Stage 2- Symptoms Stage 3- Diagnosis

Legend
White Cell Stage 5a- Anemia

Red Cell
Platelet Stage 4- Worsening
Blast
Germ Sources from Leukemia, by D. Newton and D. Siegel
Stage 5b- Infection
WHO Classification

 Acute Myelogenous Leukaemia (AML)

 Acute promyelocytic Leukaemia (APML)
 Acute Lymphoblastic Leukaemia (ALL)
 Ph +ve ALL
 Burkitt Leukaemia
 Acute Leukaemia of ambiguous lineage
 Undifferentiated
 Mixed phenotype
 With BCR-ABL
 With MLL
 NOS
 NK Cell
WHO 2008 classification-AML

Acute myeloid leukemia with recurrent genetic

abnormalities

 AML with t(8;21)(q22;q22); RUNX1-RUNX1T1

 AML with inv(16)(p13.1q22) or t(16;16)(p13.1;q22); CBFB-
MYH11
 APL with t(15;17)(q22;q12); PML-RARA
 AML with t(9;11)(p22;q23); MLLT3-MLL
 AML with t(6;9)(p23;q34); DEK-NUP214
 AML with inv(3)(q21q26.2) or t(3;3)(q21;q26.2); RPN1-EVI1
 AML (megakaryoblastic) with t(1;22)(p13;q13); RBM15-MKL1
 Provisional entity: AML with mutated NPM1
 Provisional entity: AML with mutated CEBPA
WHO 2008 classification-AML
 Acute myeloid leukemia with myelodysplasia-related
changes
 Therapy-related myeloid neoplasms
 Acute myeloid leukemia, not otherwise specified
 AML with minimal differentiation
 AML without maturation
 AML with maturation
 Acute myelomonocytic leukemia
 Acute monoblastic/monocytic leukemia
 Acute erythroid leukemia
 Pure erythroid leukemia
 Erythroleukemia, erythroid/myeloid
 Acute megakaryoblastic leukemia
 Acute basophilic leukemia
 Acute panmyelosis with myelofibrosis
WHO 2008 classification-AML
 Myeloid sarcoma
 Myeloid proliferations related to Down syndrome
Classification ALL

Immunologic
Subtype FAB Type % of Cases Cytogenetic Abnl

Pre-B cell ALL L1, L2 75 t(9:22) t(4:11) t(1:19)

T-cell ALL L1, L2 20 14q11 or 7q34

B-cell ALL L3 5 t(8:14) t(8:22) t(2:8)

WHO 2008 classification-ALL

Lymphoblastic leukemia/lymphoma
B lymphoblastic leukemia/lymphoma, NOS
B lymphoblastic leukemia/lymphoma with recurrent genetic
abnormalities
 B lymphoblastic leukemia/lymphoma with t(9;22)(q34;q11.2);BCR-ABL 1
 B lymphoblastic leukemia/lymphoma with t(v;11q23);MLL rearranged
 B lymphoblastic leukemia/lymphoma with t(12;21)(p13;q22) TEL-AML1
(ETV6-RUNX1)
 B lymphoblastic leukemia/lymphoma with hyperdiploidy
 B lymphoblastic leukemia/lymphoma with hypodiploidy
 B lymphoblastic leukemia/lymphoma with t(5;14)(q31;q32) IL3-IGH
 B lymphoblastic leukemia/lymphoma with t(1;19)(q23;p13.3);TCF3-PBX1
T lymphoblastic leukemia/lymphoma
EPIDEMIOLOGY :Incidence
 Incidence: 5% of all new cancer cases.
 AML common in adult
 ALL most common in children

ALL
others
11%
17%

CML CLL
15% 26%

AML
31%
EPIDEMIOLOGY : Etiology
 Etiology:
 Ionizing radiation.
 Benzene.
 Chemotheraputic agent(alkylating agent,topoisomerase II
inhibitor)
 Human T-lymphocyte leukemia virus (HTLV1) & EBV
infections.
 Congenital disorder:
 Down syndrome.
 Immunodeficiency syndrome.
 Fanconi’s anaemia
 Progession from clonal diseases
 PNH
 MDS
 Aplastic anaemia
Acute Myeloid Leukaemia

 Median age- 67 years

 Incidence is 2-3 per 100,000
 In younger patients, the incidence is 2-3 per
100,000, which rises to 13 to 15 per 100,000 in
6-7th decade
AML-heterogeneous disease

 Highly heterogeneous disease or set of

diseases in terms of
 morphology,
 cytochemistry of the leukemic population,
 immunophenotype,
 cytogenetics, and
 molecular abnormalities
Acute Promyelocytic Leukemia

 FAB: AML M3
 WHO 2008: AML with recurrent genetic
abnormalities
 APL with t(15;17)(q22;q12);(PML-RARA)
 10-15% of all AML cases (~1300/year in US)
 80-90% cure rate, though morbidity and
mortality is high before and during induction
Unique Features of APL
 Disseminated intravascular coagulation
relatively common at diagnosis
 Highly sensitive to anthracyclines
 t(15;17) and PML-RARa fusion gene required
 All-trans retinoic acid (ATRA) targets RARa
 Arsenic trioxide (ATO) targets PML
 Patients have high cure rates, once they
survive induction
Molecular Features of APL
 PML/RARa gene product
forms homodimer
 Homodimer represses
target genes needed for
differentiation
 Mechanisms act via
aberrant histone
modification and DNA
methylation
 Proliferation via FLT3 and
KIT as well are required

Wang, Blood,
2008
APL
 Early diagnosis is key!
 If APL is considered, start ATRA first, ask
questions later
 The hematopathologist may not always be
around to help
Acute Lymphoid Leukemia (ALL):

• Approximately 3,000 new cases per year

• Mostly affects children, accounts for 2/3 of

childhood leukemia (peak age 4 years)

• Comprises less than 20% of leukemia in young

adults

• May be B-cell, T-cell, or null-type (non-B, non-

T cell)
Childhood ALL

 Success story of haematological

malignancies- cure rates reaching to >90%

 Risk stratification approach

 CNS directed therapies

 Importance schedule & methodological

protocol approach
Pediatrics-ALL
Adult-ALL
Clincal manifestations

 Symptoms due to:

 Marrow failure
 Tissue infiltration
 Leukostasis
 Constitutional symptoms
 Other (DIC)
 Usually short duration of symptoms
Marrow failure

 Neutropenia: infections, sepsis

 Anaemia: fatigue, pallor
 Thrombocytopenia: bleeding
Infiltration of
tissues/organs
 Gum hypertrophy
 Bone pain
 Other organs: CNS,
skin, testis, any organ
Leukaemia cutis
Enlargement of liver, spleen,
lymph nodes
Lymphadenopathy Splenomegaly
Leukostasis

 Accumulation of blasts
in microcirculation with
impaired perfusion
 Only seen with WBC >>
50 x 109/L
 Lungs: hypoxemia,
pulmonary infiltrates
 CNS: stroke
DIC

Echymotic skin patch Bleeding gums

Differential diagnosis of Acute
leukemias:
 Aplastic anemia
 Severe megaloblastic anaemia due to B12
deficiency.
 Myelodysplastic syndrome.
 Severe lymphocytosis due to infections.
 Lymphoma
 Multiple myeloma- plasma cell leukaemia
Diagnosis of acute
leukaemia
 Blood
 Bone Marrow
 Cytochemistry
 Flow cytometry
 Cytogenetics
 FISH
 Molecular
Blood count/ smear

 WBC usually elevated, but can be normal or

low
 Blasts in peripheral blood
 Acute leukaemias are defined by the presence
of > 20% blasts in blood/ bone marrow
 Normocytic anemia
 Thrombocytopenia
 Neutropenia
 Pictures Of Blood
Platelet Platelet
White Cell Red Cell Red Cell Blasts
White Cell

Normal human blood Blood with leukemia

Sources from beyond2000.com
Sources from Arginine.umdnj.edu
Bone Marrow Aspirate/ Biopsy

 Diagnosis- 20% blasts

 Determining type-
 Morphology
 Immunophenotype
 Cytogentics
 Molecular
Distinguishing AML from ALL

 Light microscopy
 AML: Auer rods, cytoplasmic granules
 ALL: no Auer rods or granules.
 Special stains (cytochemistry)- MPO, NSE etc
 Flow cytometry (Immunophenotype)
Auer rods in AML
ALL
Cytochemistry

MPO-AML NSE- M4/5

Cytochemistry

Sudan Black-AML PAS-ALL

AML

M0 M1
AML

M2 M4eo
AML

M 5a 5b
AML

M6 M7
APML- AML-M3

Classical Variant
ALL

L1 L2
ALL-L3
Flow cytometry
Flow Cytometry

APML AML
ALL
BM cytogenetic-metaphase

45 XX t(9,22)
AML t(8;21)
APML- t(15;17)
FISH- interphase

 t (15;17)- APML
Molecular- Polymerase chain
reaction (PCR)
Molecular-NPM1,CEBPA,FLT3-ITD,
MLL,IDH 1/2
Gene expression profile
Treatment & prognosis

 Supportive
 Chemotherapy
 AML
 APML
 ALL
 Role of transplant
Emergency treatment

 Acute leukaemias are true oncologic

emergencies; prompt initiation of therapy is
crucial.
 Treatment delays > 5 days from diagnosis
resulted in a decreased response rate and
overall survival (OS) in patients *

*Sekeres MA et al. Blood 2009

Supportive care- NCCN
guidelines
Gradual improvement-better
supportive treatment
Principle of chemotherapy

 Induction therapy – goal of complete

remission
 Post-remission therapy- goal of preventing
relapse
AML- Treatment- age <6o
years
Induction therapy-
7 + 3 chemotherapy
 Daunomycin (60-90
mg/m2) for 3 days
 Cytosine Arabinoside (100-
200 mg/m2 continuous
infusion) for 7 days

CR rates- 70-80%
AML- Treatment

Post-remission therapy-

Determined by risk stratification

 HIDAC +/- Auto HSCT- Favorable + Normal

cytogenetic with NPM1 + & CEBPA + /FLT3 –

 Allogeneic HSCT- t(8;21) with c-KIT, Normal or

Unfavorable cytogenetic
Risk stratification-AML
Genetic group Subsets
t(8;21)(q22;q22); RUNX1-RUNX1T1

inv(16)(p13.1q22) or t(16;16)(p13.1;q22); CBFB-MYH11

Favorable
Mutated NPM1 without FLT3-ITD (normal karyotype)

Mutated CEBPA (normal karyotype)

Mutated NPM1 and FLT3-ITD (normal karyotype)

Intermediate-I• Wild type NPM1 and FLT3-ITD (normal karyotype)

Wild type NPM1 without FLT3-ITD (normal karyotype)

t(9;11)(p22;q23); MLLT3-MLL
Intermediate-II Cytogenetic abnormalities not classified as favorable
or adverseΔ

inv(3)(q21q26.2) or t(3;3)(q21;q26.2); RPN1-EVI1

t(6;9)(p23;q34); DEK-NUP214
Adverse
t(v;11)(v;q23); MLL rearranged

-5 or del(5q); -7; abnl(17p); complex karyotype◊

Overall survival in AML
AML- Treatment-age >6o
years
 Induction
 Intensive chemotherapy
 Low dose chemotherapy
 Low dose cytarabine
 Hydroxyurea
 Supportive
 Azacytidine/ Decitabine
APML treatment

 Early treatment to prevent DIC-

 Induction chemotherapy
 Daunomycin + ATRA
 ATRA + Arsenic trioxide (Older or comorbid)
 Arsenic trioxide alone
 CR rates of 95%
 Overall survival – 80-90%
Risk stratification-APML

Risk WBC Platelet

count
Standard < 10,000 > 20,000
Intermediate < 10,000 < 20,000
High > 10,000 any
APML treatment

 Post-remission therapy
 Low risk/ Intermediate- Daunomycin/Ida + ATRA
 High risk- addition of cytosine arabinoside

 Maintenance therapy
 PML-RARA- Negative-ATRA + MTX+ 6-MP
 PML-RARA- Positive- Autologous BMT
Treatment results in ALL

 Adults
 Complete remission (CR) 80-85%
 Leukemia-free survival (LFS) 40-50%

 Children
 Complete remission (CR) 95-99%
 Leukemia-free survival (LFS) 80-90%
ALL treatment
 Induction therapy
 Daunomycin
 Vincristine
 Steroids
 L-asparginase
 +/- Cyclophosphamide
 Post-remission therapy- determined by risk
stratification (6 months)
 CNS directed therapy- IT chemo +/- CNS RT
 Maintenance chemotherapy (2-3 years)
ALL-BFM 95
Risk stratification-childhood ALL

Recommended
Risk Group Features Percent
Therapy
Hyperdiploid or Conventional
20
Lesser trisomies 4, 10, 17 anti-metabolite-
t(12,21) 20 based therapy
WBC
<50,000/microL Intensified
Standard 15 antimetabolite
Age 1 to 9.9 therapy
years
T-cell phenotype 15
Age >10 years or 15 Intensive multi-
High
WBC>50,000/micr agent therapy
6
oL, t(1;19)
t(9;22) 3 Consider
t(4;11); age <1 allogeneic
4
year hematopoietic
Very High
Induction failures cell
and slow 2 transplantation
responders in first remission
Risk stratification-adult ALL
ALL-L3 (Burkitt’s)

 Highly aggressive disease

 High TLS
 C-myc or chromosome 8 abnormalities
Rx
 Intensified short interval chemotherapy
regimen -CALGB or CODOX-M/IVAC
 TLS prophylaxis, Rasburicase
 Changed prognosis from bad to good
Ph +ve ALL treatment

 Dasatinib / Imatinib+ Induction

chemotherapy
 Allogeneic BMT (HSCT)
MRD as tool

 Assessment of minimal residual disease

(MRD) may prove useful to modulate the
intensity of post-remission therapy in Acute
leukaemia*
 Multi-parametric flow cytometry -80%
 PCR- 20-40%
 BM or Blood #

* Venditti A et al, Blood 2000

* Buccisano F et al, Leukemia 2006
# Luca Maurillo et al, Haematologica 2007
Minimal Residual Disease (MRD)

Technique Marker Detection

Limits

Routine pathology Cellular morphology 10-1 to 10-2

Cytogenetics Chromosome 10-1 to 10-2

morphology
FISH Chromosome 10-2
structure
FACS analysis (Flow) Surface Antigen 10-3 to 10-4
profile
PCR DNA/RNA structure 10-5
AML-MRD-PCR

 Acute myeloid
leukemia and inv(16)
 CBFβ-MYH11

 Also useful in APML &

ALL
AML MRD- flow
Role of Bone Marrow
Transplant
 Haematopoietic Stem Call Transplant (HSCT)
 Indications
 AML with t(8;21) with c-KIT, Normal without
NPM1/CEBPAor Unfavorable cytogenetic
 AML in CR2
 APML in CR2
 High risk ALL
 ALL in CR2
 Thank you
Dr Niranjan N. Rathod
DM (Hem), MD (Med), FACP (USA)
Fellowship in BMT, FHCRC, USA

Consultant in Haematology , Haemato-Oncology &

Bone Marrow Transplantation

Jupiter Hospital, Thane

Global Hospitals, Mumbai
LTMHG & LT Medical College, Sion, Mumbai

Mobile- 9930767546
Email- drniranjanrathod@gmail.com