A short presentation on the diagnostic procedure involved in Leukemia identification and possible treatment available currently. This presentation includes the types of leukemia, risk factors, symptoms, treatment methods, and advanced techniques.

1. Medical Diagnostics (BIT4002)
Faculty: Dr. Manjubala I.
Seminar by: Anamitra Mukherjee (20BBT0231)

2. Laboratory
Investigations in
Leukemia

3. SE
P
BLOOD CANCER
AWARENESS
MONTH

4. Myeloblast
Lymphoblast
Blood Stem Cell
MDS & MPN
Erythrocytes Platelets
Myeloid Stem Cell
AML &
CML
Lymphoid Stem Cell
NK cells
ALL
T
lymphocyte
B lymphocyte
CLL &
lymphomas
Granulocytes
Neutrophil, Basophil
& Eosinophil
Plasma cell
Myeloma
Leukocytes

5. Leukemia is a type of cancer affecting the blood
and bone marrow. It originates in bone marrow,
which is the spongy tissue of bones, where
haematopoiesis takes place. (Margo et al., 2023)
Leukemia is characterised by an uncontrolled
proliferation of leukocytes, specifically immature
or malfunctioning ones. These WBCs crowd out
healthy blood cells & interfere with the normal
functioning of the blood and immune system

6. Acute
Lymphoblastic
Leukemia
Acute
Myelogenous
Leukemia
Chronic
Lymphoblastic
Leukemia
Chronic
Myelogenous
Leukemia
Found in lymphoid cells
Grows Quickly
Common in children
6,000 caser per year
Found in myeloid cells
Grows Quickly
Common in adults & children
18,000 caser per year
Found in lymphoid cells
Grows Slowly
Common in adults 55+
15,000 caser per year
Found in myeloid cells
Grows Slowly
Common in adults
6,000 caser per year
4 major types of
leukemia

7. Risk factors for Leukemia
• Genetic disorders. Genetic abnormalities seem
to play a role in the development of leukemia.
Certain genetic disorders, such as Down
syndrome, are associated with an increased
risk of leukemia. (De Castro et al., 2021)
• Exposure to certain chemicals. Exposure to
certain chemicals, such as benzene and
formaldehyde, in the workplace or environment
is linked to an increased risk of some kinds of
leukemia. (Bassig et al., 2016)
• Smoking. Smoking cigarettes increases the risk
of acute myelogenous leukemia.
• Family history of leukemia. If members of your
family have been diagnosed with leukemia,
your risk of the disease may be increased.
• Previous cancer treatment. People who've
had certain types of chemotherapy for other
cancers have an increased risk of developing
certain types of cancers.
• Radiation Exposure: Prolonged exposure to high
levels of ionizing radiation, such as from nuclear
accidents or radiation therapy, can be a risk
factor.
• Viral Infections: In rare cases, infections with
certain viruses like the human T-cell leukemia
virus (HTLV-1) or Epstein-Barr virus (EBV) have
been linked to leukemia. (Tedeschi et al., 2006)
• Immune System Suppression: Having a
weakened immune system, either due to
medical conditions or medications, can be a risk
factor.

8. Step 1: Inquiry
Step 2: Physical Examination
Step 3: Laboratory Tests
Step 4: Result Analysis
Step 5: Treatment and Medication
Diagnostic Procedure
Inquiry - Patient’s history, Symptoms, how long they've been
happening, personal and family history of cancer, previous
exposure to chemicals, whether you smoke or used to smoke.

9. Signs and Symptoms
Headaches
Seizures
Psychological: fatigue,
loss of apetite
Bleeding
Systemic:
Weight Loss
Fever
Frequent Infections
Bone tenderness
Joint Pain
Bruising
Swollen Lymp Nodes
Coughing
Infection
Shortness of Breath
Enlargement
of Spleen or
Liver
Anemia
Muscular Weakness
Skin:
Purplish patches or
spots
Night Swaets
Easy bruising and
bleeding

10. Testing is essential to find out what type of leukemia it is, to what extent
has it spread, and what types of treatment will be most effective.
• BLOOD TESTS
• Blood Smear - Pathologists analyze the way the cells look in the smear.
Altered appearance of cells may indicate leukemia. (Dese et al., 2021)
• Complete Blood Count - A CBC measures number of red blood cells, white
blood cells and platelets in the blood.
• Differential - It counts the numbers of each type of white blood cell in the
blood. It can also detect abnormal cells.
• Flow Cytometry - It involves passing cells through a laser beam for analysis of
whether the tumor cells contain a normal or abnormal amount of DNA, to
analyze the proteins on their surface (immunophenotyping) and classify the
leukemia as lymphoid or myeloid.
How to test for
Leukemia?

11. Acute Myeloid Leukemia (AML) -
Blood tests of people with AML tend to
reveal high levels of immature white blood
cells and low levels of red blood cells and
platelets. Among the white blood cells,
many are myeloblasts, a type of white
blood cell that isn’t normally found in
healthy blood. Auer Rods observed.
Chronic Myeloid Leukemia (CML) -
People with CML tend to have high levels of
white blood cells, many of which are
myeloblasts. The cells appear abnormal
under a microscope. Red blood cells and
platelet counts may be low.
Acute Lymphocytic Leukemia (ALL) -
Blood tests of people with ALL often reveal
high levels of lymphoblasts (immature
white blood cells) and low levels of red
blood cells and platelets.
Chronic Lymphocytic Leukemia (CLL) -
The blood of people with CLL contains high
levels of lymphocytes (clonal expansion of
atleast 5000 B-Lymphocytes per micro-lt
of peripheral blood). Under a microscope,
these cells don’t look like normal, healthy
cells. The number of platelets and red
blood cells may be low.

12. • BIOPSY
• Bone Marrow Biopsy - Pathologists analyze the way the cells look in the smear.
Altered appearance of cells may indicate leukemia. (Dierickx et al., 2009)
• Aspiration - collects a sample of liquid bone marrow.
• Blood pressure and heart rate will be checked
• The area where the biopsy needles will be
inserted is marked and cleaned with an
antiseptic.
• Local anesthesia to numb the site where the
needles will be inserted.
• A small incision is made in the skin, then a
hollow needle is inserted through the bone and
into the bone marrow
• Using a syringe attached to the needle, a
sample of the liquid portion of the bone
marrow is withdrawn.
• It only takes a few minutes but several samples
may be taken

13. b. Biopsy - collects a small piece of the bone & bone marrow
• Blood pressure and heart rate will be checked
• The area where the biopsy needles will be inserted is marked and cleaned with an antiseptic.
• Local anesthesia to numb the site where the needles will be inserted.
• A larger needle is used to withdraw a sample of solid bone marrow tissue. The needle is twisted as
it’s inserted into the bone to help collect the sample.
• The biopsy needle is specially designed to collect a core (cylindrical sample) of bone marrow.
• Pressure will be applied to the area where the needle was inserted to stop the bleeding. Then a
bandage will be placed on the site.
• Recovery based on sedative and local anaesthetic applied.
c. Lymph Node Biopsy - removes all or part of a lymph node.
• Excisional (to remove an entire lymph node)
• Incisional (to remove part of a lymph node)
• The skin over the biopsy site is cleansed
• A local anesthetic is injected. You may be given a mild sedative in certain cases.
• The surgeon makes a small incision to remove part or all of the enlarged lymph node.
• Once the tissue sample is removed, he or she closes the opening with stitches. There's usually little
or no scarring.

14. • CHROMOSOME ANALYSIS
Examination through karyotyping or fluorescence in-
situ hybridization analyses to identify chromosomal
abnormalities and determine leukemia subtypes
e.g. Identification of Phladelphia chromosome (BCR-
ABL1 fusion gene) for the diagnosis of CML
t(8;21) - AML (M2)
t(15;17) - AML (M3)
Inv 16 - AML (M4)
t(8;14) - ALL
• MOLECULAR TESTING
Testing for specific mutations at DNA level through PCR analysis. Helps identify
leukemia subtypes, determine treatment and prognosis.

15. • X-ray:
⚬ Treatment planning
⚬ Identify changes in bone density
⚬ Identify lung infection
• CT-Scan:
⚬ Identify swelling of lymph
nodes, organ
⚬ Idea about staging
⚬ Monitoring Treatment Response
• PET Scan:
⚬ Often combined with CT scan
⚬ Idea about relapse
⚬ Extramedullary Involvement
• IMAGING
These techniques provide information about the extent of leukemia in the body, and
the presence of infections or other problems. They are done mostly during the period
of treatment. (Hearps et al., 2016)

16. • IMAGING
• MRI Scan:
⚬ Detecting complications (Tumors, abcess)
⚬ BM, organ imaging
⚬ CNS involvement
Lumbar Puncture (Spinal Tap)
If diseased cells are found in the bone marrow,
this test is done to check if leukemia cels are
present in the cerebrospinal fluid. During this
procedure, a needle is used to collect CSF from
the lower back. Lumbar punctures may also be
used to inject medications to treat the disease,
such as chemotherapy drugs.
• Ultrasound:
⚬ Guiding Biopsies
⚬ Assessment of enlarged organs
⚬ Evaluating Symptoms

17. 1. Chronic Myeloid Leukemia STAGES
2. Acute Lymphoid Leukemia STAGES
• Early pre-B ALL, Common ALL, Pre-B ALL, Mature B-cell ALL
• Pre-T ALL, Mature T-cell ALL
Staging
Chronic Phase Accelerated Phase Blast Phase
• <=9% blasts • 10%-19% myeloblasts in the peripheral
blood or bone marrow
• Persistent increase in WBCs
• Persistent splenomegaly unresponsive to
therapy
• Thrompocytosis unresponsive to therapy
• Thrombocytopenia
• >=20% basophils in peripheral blood
• >= 20% blasts in BM
or peripheral blood
• Extramedullary
blast proliferation

18. 3. Acute Myeloid Leukemia STAGES
Stage Definition
M0, myelogenous Undifferentiated blasts. AML otherwise not categorized
M1, myelogenous
Blasts and promyelocytes predominate without further maturation of
myelogenous cells
M2, myelogenous
Myelogenous cells demonstrate maturation beyond the Blasts and
promyelocytes stage
M3, promyelocytic Promyelocytes predominate in the bone marrow
M4, myelomonocytic
Both myelgenous and monocytic cells are present to the extent of atleast
20% of the total leukocytes
M5, monocytic
Most cells are monocytic, 2 subtypes are recognized: 1. large blasts in BM
and peripheral blood, 2. monoblasts, promonocytes, monocytes
M6, erythroleukemia
Known as DiGuglielmo syndrome, abnormal proliferation of boh erythroid
and granulocytic precursors, megakaryocytic and monocytic proliferation
M7, megakaryocytic
Large and small megakaryoblasts with a high nuclear-cytoplasmic ratio,
pale, agranular cytoplasm

19. 4. Chronic Lymphoid Leukemia STAGES
System Clinical Features Median Survval (yrs)
• A (Low Risk) • Fewer than 3 areas of lymphadenopathy
• no anemia or thrombocytopenia
• 12
• B (Intermediat
Risk)
• More than 3 involved node areas
• no anemia or thrombocytopenia
• 7
• C (High Risk) • Haemoglobin <100 g/L
• platelets <100 x 10^9 /L
• 2-4
System Clinical Features Median Survval (yrs)
• 0 (Low Risk) • Lymphocytes in blood and marrow only • >10
• I and II
(intermediate
risk)
• Lymphadenopathy
• Splenomegally +/-
• hepatomegaly
• 7
• iii an iV (High
Risk)
• Anemia
• Thrombocytopenia
• 0.75-4
RAI
SYSTEM
BINET
SYSTEM

20. Treatments
• CHEMOTHERAPY - is a common treatment for leukemia. It uses drugs to kill or control the
growth of leukemia cells. Chemotherapy can be given orally, intravenously, or through
intrathecal injections. (Kranjčec et al., 2022)
• TARGETED THERAPY -are drugs designed to target specific molecules or pathways
involved in the growth of leukemia cells. E.g.s include imatinib for CML and rituximab for
certain types of CLL.
• RADIATION THERAPY - uses high-energy X-rays or other particles to target and kill
leukemia cells.
• STEM CELL TRANSPLANTATION - involves replacing the patient's bone marrow with
healthy stem cells, either allogeneic transplant or autologous transplant.
• IMMUNOTHERAPY - stimulate the immune system to recognize and attack leukemia cells.
• GENE THERAPY - involves modifying a patient's genes to target & eliminate leukemia cells

21. CAR-T cell therapy https://youtu.be/mXADrg_ckhI?si=njcY-smXuvk1g-gj

22. • Bassig, B. A., Zhang, L., Vermeulen, R., Tang, X., Li, G., Hu, W., Guo, W., Purdue, M. P., Yin, S., Rappaport,
S. M., Shen, M., Ji, Z., Qiu, C., Ge, Y., Hosgood, H. D., Reiss, B., Wu, B., Xie, Y., Li, L., . . . Lan, Q. (2016).
Comparison of hematological alterations and markers of B-cell activation in workers exposed to
benzene, formaldehyde and trichloroethylene. Carcinogenesis, 37(7), 692–700.
https://doi.org/10.1093/carcin/bgw053
• Brown, G. (2022). Oncogenes and the origins of leukemias. International Journal of Molecular Sciences,
23(4), 2293. https://doi.org/10.3390/ijms23042293
• De Castro, C. P. M., Cadefau, M., & Cuartero, S. (2021). The mutational landscape of myeloid leukaemia
in Down Syndrome. Cancers, 13(16), 4144. https://doi.org/10.3390/cancers13164144
• Margo, C. E., Kang, L., & Filutowski, O. (2023). Leukemia. In Elsevier eBooks (pp. 341–346).
https://doi.org/10.1016/b978-0-323-95788-5.00041-8
• Tedeschi, R., Bloigu, A., Ögmundsdóttir, H. M., Marus, A., Dillner, J., DePaoli, P., Gudnadóttir, M.,
Koskela, P., Pukkala, E., Lehtinen, T., & Lehtinen, M. (2006). Activation of maternal Epstein-Barr virus
infection and risk of acute leukemia in the offspring. American Journal of Epidemiology, 165(2), 134–
137. https://doi.org/10.1093/aje/kwj332
Referrences

23. • Dese, K., Raj, H., Ayana, G., Yemane, T., Adissu, W., Krishnamoorthy, J., & Kwa, T. (2021). Accurate
Machine-Learning-Based classification of Leukemia from Blood Smear Images. Clinical Lymphoma,
Myeloma & Leukemia, 21(11), e903–e914. https://doi.org/10.1016/j.clml.2021.06.025
• Dierickx, D., De Rycke, A., Vandenberghe, P., Janssens, A., Evelyne, L., De Wolf-Peeters, C., Verhoef, G.,
& Evenepoel, P. (2009). Recipient-derived chronic lymphocytic leukaemia diagnosed shortly after
kidney transplantation on protocol biopsy. Nephrology Dialysis Transplantation, 24(12), 3886–3890.
https://doi.org/10.1093/ndt/gfp444
• Hearps, S., Seal, M. L., Anderson, V., McCarthy, M., Connellan, M., Downie, P., & De Luca, C. (2016). The
relationship between cognitive and neuroimaging outcomes in children treated for acute
lymphoblastic leukemia with chemotherapy only: A systematic review. Pediatric Blood & Cancer,
64(2), 225–233. https://doi.org/10.1002/pbc.26188
• Kranjčec, I., Matijašić, N., Abdović, S., Gašpar, I. H., La Grasta Sabolić, L., & Jadrijević-Cvrlje, F. (2022). A
challenging case of an adolescent and young adult patient with high-risk acute lymphoblastic
leukemia: the need for a multidisciplinary approach: a case report. Journal of Medical Case Reports,
16(1). https://doi.org/10.1186/s13256-022-03366-y
Referrences

24. THANK YOU