2. INTRODUCTION
Leukaemia are the neoplastic proliferation of
hemopoietic cells
Divided into 2 broad categories depending
upon cell lineage-
MYELOID
LEUKAEMIA
LYMPHOID
LEUKAEMIA
3. Nuclear chromatin Coarse Fine
Nucleoli 1-2 3-5
N:C ratio
Auer rod
High
-ve
High
+ve
Accompanying
cells
Lymphocytes Myeloid precursor
Myelo peroxidase -ve +ve
Sudan Black B -ve +ve
PAS stain Block positivity -ve in blast
4. AML: the myeloblast is
a large blast with a
moderate amount of
granular cytoplasm, fine
lacy chromatin &
prominent nucleoli. Auer
rods may be seen
ALL: the
lymphoblast is a
small blast with scant
cytoplasm, dense
chromatin, indistinct
nucleoli, and no Auer
rods or granules.
5. ALL are neoplasm composed of immature B
(pre-B) or T (pre-T) cells
ALL is primarily a disease of children, 75% of
cases occurunder 6 yr.
B Cell (75-80%) orT Cell (15-20%)
B-ALL peak at 3yr while T-ALL
adolescence
Slight Male predominance is seen
peak at
6. Byconvention, the minimum numberof bone marrow
lymphoblasts required fordiagnosis is setat 20 %
In children - ALL the mostcommon malignant
disease.
8. PATHOGENESIS
Apprx 90% of ALLs have numerical or structural
chromosomal changes
MC is hyperploidy, but hypoploidy & variety of balanced
translocation also seen
These chromosomal aberrations dysregulate the expression
& function of transcription factors that are required for
normal B & T cell development.
These mutations disturb the differentiation of lymphoid
precursors & promote maturation arrest.
13. The blast havevaried appearance from a homogenous
population of small cells with a round to slightly
irregular nucleus, condensed chromatin &
inconspicuous nucleoli to large cells with irregular,
clefted or indented nuclei, variably distributed
chromatin & one or more distinct nucleoli.
Cytoplasm is scant to moderate & slight basophilic to
deeply basophilic as cell size increase
Compared with B- lymphoblast, T-lymphoblast
show greater nuclear convulation & significant
nuclear hyperchromasia.
19. MARKER FOR THE Dx OF ALL
LINEAGE ANTIGEN
Precursor-B ALL CD19, CD10, CD79a, TdT, cCD22,
HLA-DR, cCD79a
Precursor-T ALL CD1, CD2, CD3, CD4, CD5, CD7
CD8, TdT, cCD3
20. OTHER INVESTIGATIONS:
CSF examination for lymphoblast
Testicular biopsy-to ruleout residual disease
ChestX-ray
22. FAB CLASSIFICATION
BASED ON MORPHOLOGY
Blasts Morphology
Subtype Occ (%)
L1
Small round blasts, scant cytoplasm,round
nucleus, homogenous chromatin &
indistinct nucleolus
75%
L2
Pleomorphic larger blasts, moderate
amount of cytoplasm,irregular nuclei, fine
chromatin one or more often large distinct
nucleoli.
20%
L3
Large blasts, moderate amount of
basophilic vacuolated cytoplasm, round to
oval nucleus with stippled chromatin & one
or more, distinct nucleoli.
05%
28
23. Fig. 6.2 Bone marrow (BM)
aspirate, F
AB Ll ALL,showing a
uniform population of s1nall and
mediWll-sized blasts with a high
nucleocytoplasmic ratio. May
Griinwald-Giemsa (MGG) XlOO.
24. Fig. 6.3 BM aspirate, F
AB L2ALL,
showing large pleomorphic blasts.
MGG xlOO.
25. Bone marrow aspirate smear showing ALL-L3 blast with large
nucleus, basophilic cytoplasm with prominent vacuolization
(Burkitt type)
30. B-Lymphoblastic leukaemia, NOS
CRITERIA ≥ 25% blast, involving BM / PB committed to B cell
lineage
AGE •Common in Children
•75% cases below 6Yrs of age
INCIDENCE 1-4.75 / 1 lakh per year
MORPHOLOGY •Bone marrow aspiration : Blast may be small or large
•Small- scant cytoplasm, condensed chromatin,
indistinct nucleoli
•Large- moderate blue-grey cytoplasm, occasionally
vacuolated, dispersed nuclear chromatin with multiple
nucleoli
•Nuclei- round, irregular or convoluted
•10% blast with primary azurophilic granules
•BONE MARROW BIOPSY : relatively uniform
appearance with round to oval, indented or convoluted
42
nuclei, finely dispersed chromatin & inconspicuous to
prominent nucleoli
31. Pre B-ALL, BM smear with several lymphoblastwith high N:C and
Variablycondensed nuclearchromatin
32. Pre B-ALL showing medium size blastwith
numerous cytoplasmic coarseazurophilicgranules
33. B-Lymphoblastic leukaemia, NOS
IMMUNOPHENOTYPE
•CD19, CD79a, cyCD22 +ve
•CD10, sCD22, CD24, PAX5, Tdt
•CD20, CD34 variable expression
+ve in most cases
GENETICS •Nearly all cases with DJ rearrangement of IgH gene
•70% cases with TCR gene rearrangement
•Others- Del 6q, 9p & 12p
CYTOCHEMISTRY
•PAS +ve
•NSE +ve
•MPO –ve
•SBB –ve (granules if present may stain light grey but
less intense than myeloblast)
PROGNOSIS •Good in children
•Poor in adults
•Cure rate 80% in children
less than 50% in adults
45
34. Pre B-ALL,showing nuclearTdt positivity
in a bone marrow biopsy
Pre B-ALL : TdT positivity in a bone marrow biopsy
36. B-ALLwith t(9:22)
(q34;q11.2); BCR-
ABL 1
morphology morphology morphology
B-ALLwith
t(v:11q23);MLL
rearranged
B-ALLwith t(12;21)
(p13;q22); TEL-AML1
(ETV6-RUNX 1)
•Neoplasm of
lymphoblast with
trans b/w BCR-
ABL gene
•Translocation b/w
MLL gene at 11q and
any part of a large
No. of different
fusion partner
•WBC count very
high >1 lac/micro L
•CNS involvement
•. Translocation b/w
ETV 6 and RUNX 1
gene
•25 % of all B-ALL
AGE Common in adults
than children.
Accounting 25%
of adult ALL & 2-
4% of childhood
ALL
It is the most
common type of
leukaemia in <1 year
of age
Common in
children
Not seen in infants
Rare in Adults
MORPHOLOGY No unique No unique No unique
48
37. B-ALLwith t(9:22)
(q34;q11.2); BCR-
ABL 1
& adults •>90% cure rate
B-ALLwith
t(v:11q23);MLL
rearranged
B-ALLwith t(12;21)
(p13;q22); TEL-AML1
(ETV6-RUNX 1)
IMMUNO-
PHENOTYPE
•CD10+, CD19+,
Tdt+
•CD25+
•CD19+, CD10- & CD
24 –ve
•Pro B +ve for CD5
•Condroitin sulphate,
proteoglycan,
neuroglial Ag2
expressed
•CD19 +ve, CD10+ve
& CD34+ve
•CD13 Frequently
expressed
GENETICS •BCR gene fuse
with ABL 1 gene &
produce BCR-ABL
fusion protein
•190KD (children)
•210KD (adult)
•MLL gene have
many fusion partner
•m/c AF4 (4q21)
•Other ENL (19p13),
AF9 (9p22)
•ETV6-RUNX1
fusion protein
inhibit transcription
factor RUNX1
PROGNOSIS •Poor both in child •Poor •Good 49
38. Pre B-ALL with a t(9:22) abnormality BMA :
lymphoblast have moderate amount of cytoplasm
with numerous coarse azurophilicgranules
39. Bone marrow biopsy : marrow is replaced by
lymphoblast, mitotic figurealso seen in acase of
t(9:22) abnormality
40. B-ALL with
hyperdiploidy
B-ALL with
hypodiploidy
CRITERIA •Blast contains >50 & usually
<66 chromosomes
•No translocation
•No other structural
alteration
•Blast contain <46 or 45
chromosomes
AGE •Common in children
•Rare in adult
•Both in children & adults
•Haploid ALL (23-29 chrom)
seen in childhood
INCIDENCE •25% cases of B-ALL •5% if chromosomes<46
•1% if chromosomes<45
MORPHOLOGY •No unique morphological
feature
•No unique morphological
feature
52
41. B-ALL with
hyperdiploidy
B-ALL with
hypodiploidy
IMMUNO-
PHENOTYPE
CD19, CD10 +ve
CD34+ve
CD45-ve
•Blast have Pre-B phenotype
•CD19, CD10+ve
GENETICS •Numerical ↑se in chromosome
•No structural abnormalities
•21,X,14,4 chrom extra copies
(m/c)
•1,2,3 chrom (least common)
•Trisomy 4,10,17
•Loss of one or more chromo
having from 45 chrom to near
haploid
•Detect by standard
karyotyping FISH &
flocytometry
PROGNOSIS • Favourable Px
•Cure rate >90% in children
•Over all Poor Px
•45-46 chrom then better Px
53
42. B-ALL with
t(5:14)(q31:q32); IL3-IGH
B-ALL with
t(1:19);(q23:p13.3);E2A-
PBX1 (TCF3-PBX1)
•Blast having translocation b/w
IL3 gene & IGH gene
•Resulting in eosinophilia
Translocation in b/w E2A gene
& PBX1 gene
AGE •Both in children & adult •Common in children
•Also seen in adults
INCIDENCE •Rare disease
• <1% of all ALL
6% of all cases of B-ALL
MORPHOLOGY •Blast with typical morphology
•Increasing circulating
eosinophills
•No unique morphology
54
43. B-ALL with
t(5:14)(q31:q32); IL3-
IGH
B-ALL with
t(1:19);(q23:p13.3);E2A
-PBX1 (TCF3-PBX1)
IMMUNOPHE
NOTYPE
•CD19, CD10 +ve •CD19, CD10 +ve
•Cy μ heavy chain +ve
•CD9 strongly expressed in
absence of cy μ H chain
GENETICS •Functional rearrangement b/w
IL3 gene (5) & IGH gene (14)
•Resulting in over expression of
IL3 gene which results in
eosinophilia
•E2A-PBX1 translocation results
in a fusion protein that has an
oncogenic role
PROGNOSIS -------- •Poor
55
45. T-Lymphoblastic leukaemia
CRITERIA •Neoplasm of lymphoblast committed to T cell lineage involving
BM & PB
• >25% BM blast
AGE & SEX •Common in adolescents than young children
•Male >female
INCIDENCE •15 % of childhood ALL
•25 % of adult ALL
C/F •High leukocyte count
•Thymic infiltration is very common & may be associated with
pleural effusion, pericardial effusion, & SVC obstruction
•mediastinal mass
•Lymphadenopathy, hepatosplenomegaly
57
46. T-Lymphoblastic leukaemia
MORPHOLOGY •Composed of small to medium sized blast.
•Nuclear shape- round to irregular
•Small blast with scant cytoplasm ,condensed chromatin
& no prominent nucleoli
•Large blast with finely dispersed chromatin & relatively
prominent nucleoli
•Mitosis : higher than B-ALL
CYTOCHEMISTRY •Acid phosphatase +ve (Focal), not specific
IMMUNOPHENOTYPE •Tdt +ve
•CD99, CD34, CD1a most specific
• CD1a, CD2, CD3, CD4, CD5, CD7, CD8 variable +ve
•CD7, Cyt CD3 most often +ve
58
47. Blood smear : The lymphoblastvary in size from
large cell to small cell with high N:C ratio &
condensed chromatin, no nucleoli
48. Pre T-ALL (BMA) : numerous blast with delicate
chromatin round tooval nuclei & distinct nucleoli
49. B M aspiratesmear in Pre T-ALL showing numerous lymphoblastwith
nuclearirregularities,dispersed chromatin,occasionally
Distinct nucleoli ,and small amountof agranularbasophiliccytoplasm
53. T-Lymphoblastic leukaemia
GENETICS
•Clonal rearrangement of TCR gene
•20%cases with IgH gene rearrangement
•50-70%cases shows abnormal karyotype
•m/c involved gene include transcription factor TLX 1 &
TLX 3
•50% cases with mutation in NOTCH 1 & hCDC 4 gene
PROGNOSIS
Poor than B-ALL
•TLX1 positivity is favorable indicator
•NOTCH 1 mutation responsible for short survival
65
54. Prognosis in ALL
PARAMETERS GOOD POOR
WBC Low High(>50x10 9 /L)
GENDER Girls Boys
IMMUNOPHENOTYPE B-ALL T-ALL
AGE Child Adult Or Infant.
CYTOGENETIC Normal, hyperdiploid, Ph+,11q23rearrangements
.
TIME TO CLEAR BLAST
FROM BLOOD
< 1week >1week
TIME TO REMISSION <4weeks >4weeks
CNS DISEASE AT
PRESENTATION
Absent Present
MINIMAL RESIDUAL
DISEASE.
Negative At 1-3 Months Still Positive At 3-6
Months.
66
55. Risk Categories in ALL
Low Risk Intermediate Risk High Risk
Hyperdiploidy Age 1-10 year E2A/PBX Fusion
Very High Risk
BCR/ABL Fusion
with high TLC
TEL/AML1 fusion TLC<50,000/ cmm
without genetic risk
factor
T-ALL MLL Rearrangement
Age<1 year, >10 Year
and TLC>
50,000/cmm without
genetic risk factor
Induction Failure
56. DIFFERENTIAL DIAGNOSIS
AML minimallydifferentiated
Reactive lymphocytosisdue to infection
Small round cell tumorof the childhood that present
with marrow involvement
Hematogones
57. Mediastinal mass +vein T-A l l
Associated DIC -ve +vein M3
Serum muramidase Normal
i
Prognosis Good
Age
lymphadenopathy
Mainly children
Usually present
Mainly aduIts
Usually absent
Hepatosplenomegaly +ve mild +ve mild
Gum hypertrophy -ve +vein M4/MS
Skin infiltration -ve +vein M4/MS
CNS invotvement +vein some +vein some
Granulocytic sarcoma ve +ve in few cases
58. ALL v/s REACTIVE LYMPHOCYTOSIS
The atypical lymphocytescan bedistinguished from
leukemic blast by
1. Relatively maturechromatin pattern
2. Low N:C ratio
3. Prominent nucleoli
59. ALL v/s SMALL CELL TUMOR OF
THE CHILDHOOD
Immunophenotyping is helpful in arriving atcorrect
diagnosis
60. ALL v/s Hematogones
Hematogonesare the immature lymphoid cells
appearing like leukaemic blast
May be seen in infections, following chemotherapy, &
bone marrow transplantation
Theycan be differentiated from lymphoblast in having
higher N:C ratio, more homogeneouschromatin & no
discernible nucleoli
61. Bone marrow smear : lymphoid cells with high N:C ratio &
very homogeneous nuclearchromatin ,no or indistinct
nucleoli. Thesecells resembles the lymphoblast in ALL
64. INTRODUCTION
Acute leukemiasof ambiguous lineageare those leukaemias that
show noclearevidenceof differentiationalong a single lineage
1. Acute undifferentiated leukaemia(AUL)
2. Mixed phenotypeacute
leukaemia(MPAL)
(9:22)(q34;q11.2);BCR-ABL1
t(v;11q23);MLL rearranged
B/myeloid, NOS
T/myeloid,NOS
Mixed phenotypeacute leukaemia, NOS-rare types
Otherambiguous lineage
65. Requirement forassigning more than one lineage to asingle
blast population
MYELOID LINEAGE
Myeloperoxidase (f lowcytometry, IHC orcytochemistry)
or
Monocyticdifferentiation (atleast 2 of the following : NSE, CD11c, CD14, CD64,
lysozyme
T LINEAGE
cCD23 (f lowcytometry, IHC)
or
sCD23 (rare in mixed phenotype acute leukaemias)
B LINEAGE
Strong CD19 with atleastoneof the following stronglyexpressed :CD79a, cCD22,
CD10
or
Weak CD19 with atleast 2 of the following stronglyexpressed :CD79a,Ccd22, CD10
66. Ac undiff
leukaemia
t(9:22)(q34;q11.2);B
CR-ABL1
t(v;11q23);MLL
rearranged
incidence Very rare MC in mixed Rare ,common in
children
Clinical features Similaras Ac.
leukaemia
similar similar
morphology No morphologic
features of myeloid
diff
Showdimorphic
blastpopulation
Dimorphic:monobla
stic & lymphoblastic
cytochemistry MPO & esterase-ve -- --
immunophenotype Do not express B,T or
myeloid specific
marker
Blast meet criteria
for B & myeloid
lineage
CD19+,CD10-,CD15+
prognosis poor poor poor
67. B/myeloid,NOS T/myeloid,NOS
incidence Rare Rare
Clinical features similar similar
morphology May resembleALL or have
dimorphic population
May resembleALL or have
dimorphic population
cytochemistry MPO+ myeloblastor
monoblast,CD13+,CD33+,CD
117+,rare CD20+
MPO+ myeloblastor
monoblast,CD13+,CD33+,CD
117+,CD7+,CD5+,CD2+
immunophenotype Meetcriteria for both B &
myeloid lineage
Meetcriteria for both T &
myeloid lineage
prognosis poor poor
69. SUMMARY
ALL is the mostcommon leukaemia in childhood
ALL with MLL rearrangement is the mostcommon
leukaemia in infants
Ac leukaemiaof ambiguous lineage show noclear
evidenceof differentiation along a single lineage
The Dx of ambiguous lineage leukaemias is reston
immunophenotyping, f lowcytometry is the preffered
method
71. SCORING SYSTEM OF ACUTE BIPHENOTYPIC
LEUKEMIA
Score above 2 from two lineage is diagnosticof
biphenotypic leukemia
POINTS B-LINEAGE T-LINEAGE MYELOID
2.0 CD 79a,CD22,u CD3 MPO
1.0 CD 10 CD 1 CD 13
0.5 TdT TdT,CD7 CD11b,CD11c
