Presentation on all

1. ACUTE LYMPHOBLASTIC LEUKEMIA
(ALL)
DRNILISHASHARMA
JR 1 PATHOLOGY

2. WHAT IS LEUKEMIA ??
DIVIDED INTO TWO BROAD CATEGORIES
• ACUTE MYELOID LEUKAEMIA
• ACUTE LYMPHOBLASTIC
LEUKAEMIA

5. FEATURES LYMPHOBLAST
NUCLEAR CHROMATIN COARSE FINE
NUCLEOLI 1-2 3-5
N:C RATIO HIGH HIGH
AUER ROD NEGATIVE POSITIVE
OTHER CELLS LYMPHOCYTES MYELOID PRECCURSOR
MYELO PEROXIDASE NEGATIVE POSITIVE
SUDAN BLACK B NEGATIVE POSITIVE
PAS STAIN BLOCK POSITIVITY NEGATIVE IN BLAST

6. CLASSIFICATION

7. ETIOLOGY
◦ HIGHER SOCIO-ECONOMIC STATUS
◦ GENATIC ABNORMALITY
◦ DOWN SYNDROME
◦ RADIATION EXPOSURE
◦ SMOKING
◦ INDUSTRIAL EXPOSURE TO CHEMICALS(BENZINE)

8. PATHOGENESIS
◦ APP 90% OFALLs HAVE NUMERICALOR STRUCTURALCHROMOSOMAL
CHANGES
◦ M/C IS HYPERPLOIDY, BUT HYPOPLOIDYAND VARIETY OF BALANCED
TRANSLOCATIONALSO SEEN
◦ THESE CHROMOSOMAL ABBERATIONS DYSREGULATE THE EXPRESSION AND
FUNCTION OF TRANSCRIPTION FACTORS THAT ARE REQUIRED FOR NORMAL
B AND T CELL DEVELOPMENT
◦ A HIHER FRACTION OF B- ALL HAVE LOSS OF FUNCTION MUTATION IN PAX5,
E2A, EBF
◦ UP TO 70% T-ALL HAVE GAIN OF FUNCTION MUTATION IN NOTCH1
◦ THESE MUTATIONS DISTURB THE DIFFERENTIATION OF LYMPHOID
PRECURSORSAND PROMOTE MATURATIONARREST
◦ SINGLE MUTATIONSARE NOT SUFFICIENTTO PRODUCEALL.

9. CLINICAL PRESENTATION
JOINT,EXTREMITYPAINS
CNS INVOLVEMENT
LYMPHADENOPATHY
SPLENOMEGALY
HEPATOMEGALY
GONADAL INVOLVEMENT
MEDIASTINAL MASS
ABRUPT ONSET
NON-SPECFIC SYMPTOMS
FATIGUE
PALLOR
EASY BRUISING
BLEEDING
FEVER
DYSPNOEA
DIZZINESS
WEIGHT LOSS

10. CLASSIFICATION OF ACUTE
LYMPHOBLASTIC LEUKEMIA
FAB CLASSIFICATION
IMMUNOLOGIC CLASSIFICATION
WHO CLASSIFICATION

11. FAB CLASSIFICATION(BASED ON MORPHOLOGY)
SUB TYPE MORPHOLOGY
L1
SMALL ROUND BLASTS, SCANT CYTOPLASM,
HOMOGENOUS CHROMATIN & INDISTINCT
NUCLEOLUS
L2
PLEOMORPHIC LARGER BLAST, MODERATEAMOUNT
OF CYTOPLASM, IRREGULAR NUCLEI, FINE
CHROMATIN ONE OR MORE OFTEN LARGE DISTINCT
NUCLEOLI
L3
LARGE BLASTS, MODERATEAMOUNT OF
BASOPHILIC VACUOLATED CYTOPLASM , ROUND TO
OVAL NUCLEUSWITH STIPPLED CHROMATIN & ONE
OR MORE , DISTINCT NUCLEOLI

12. L1, L2, L3 CELLSON BONE
MARROW ASPIRATION

13. DRAWBACKS OF FAB CLASSIFICATION
 IT DOES NOT INCLUDE –
a)MOLECULAR CHARACTERISTICS
b)CYTOGENETICS,
c) IMMUNOPHENOTYPING
IMMUNOLOGICAL SUB TYPE OF ALL
BIPHENOTYPIC LEUKEMIA
LIMITED RELEVANCE TO THERAPEUTIC OR PROGNOSTIC
IMPLICATION

14. IMMUNOLOGICAL CLASSIFICATION
1)B-ALL
2)T-ALL
3)MIXED –LINEAGE ACUTE LEUKEMIA
4)UNDIFFERENTIATED ACUTE LEUKEMIA

15. B-ALL
B LINEAGE MARKERS
PRO –B (8-10%) HLADR(+), Tdt(+), CD10(-),Cylg(-), Smlg(-)
COMMON(50%) HLADR(+), Tdt(+), CD10(+),Cylg(-), Smlg(-)
PRE –B(20%) HLADR(+), Tdt(+), CD10(-),Cylg(+), Smlg(-)
MATURE –B(1-2%) HLADR(+), Tdt(+), CD10(-),Cylg(-), Smlg(+)

16. T ALL
◦ PAS NEGATIVE
◦ ACID PHOSPHATE POSITIVE
◦ CD1(+), CD2(+), CD3(+), CD4(+),CD5(+),CD7(+),CD8(+),TdT,cCD3

17. MIXED LINEAGE ACUTE LEUKEMIA
(BIPHENOTYPIC LEUKEMIA )
◦ THESE COMPRISE 1-2% OF ACUTE LEUKEMIA
◦ THERE ARE TWO POPULATION OF CELLS
◦ (A) LARGE CELLS -WITH DIFFERENTIATION AS
MYELOBLAST ,WHICH ARE MPO +, SBB+ ,USUALLY
WITH AUER RODS ,OR MONOBLASTIC MORPHOLOGY
◦ (B) SMALLER BLASTS - WITH L1 MORPHOLOGY ,WITH
HAND MIRROR MORPHOLOGY .BLAST SHOWS
MIXTURE OF MYELOID &LYMPHOID ANTIGENS

18. UNDIFFERENTIATED ACUTE
LEUKEMIA
◦ BLASTS USUALLY HAVE L2 MORPHOLOGY BUT THERE
IS NO LINEAGE DIFFERENTIATION WITH EXPRESSION
OF HLA-DR , CD34, CD7 AND TdT

19. WHO CLASSIFICATION

20. B-LYMPHOBLASTIC LEUKEMIA, NOS
B LYMPHOBLASTIC LEUKEMIA ,NOS
CRITERIA
>25% blast, involving BM /PM COMMITED TO B CELL LINEAGE
AGE COMMAN IN CHILDREN
75% UNDER 6 YEARS
INCIDENCE 1_4.75/ 1 LAKH PER YEAR
MORPHOLOGY BONE MARROW ASPIRATION- BLASTS MAY BE SMALL OR LARGE
• SMALL – SCANT CYTOPLASM,CONDENSED CHROMATIN,INDISTINCT
NUCLEOLI
• LARGE MODERATE BLUE GRAY CYTOPLASM,OCCATIONALLY
VACUOLATED, DISPERSED NUCLEAR CHROMATINWITH MULTIPLE
NUCLEOLI
• 10% BLAST WITHAZUROPHILIC GRANULES
• BONE MARROW BIOPSY – RELATIVELY UNIFORM APPEARANCE WITH
ROUND TO OVAL , INDENTED OR CONVOLUTED NUCLEI ,FINELY
DISPERSED CHROMATIN & INCONSPICUOUS TO PROMINENT
NUCLEOLI.

21. IMMUNOPHENOTYPE CD19, CD79a, cyD22 +VE
CD10,Scd22, CD24,PAX5, Tdt +VE IN MOST
CASES CD20,CD34 VARIABLE EXPRESSION
GENETICS 70% CASES WITH TCR GENE
REARRANGEMENT
OTHERS- DEL6q, 9p&12p
CYTOCHEMISTRY PAS+VE,
NSE+VE
MPO –VE,
SBB -VE

24. B LYMPHOBLASTIC
LEUKEMIA WITH RECURRENT
GENETIC ABNORMALITIES

25. B-ALL WITH t(9:22)
(q34:q11.2); BCR-
ABL1
B-ALL WITH
t(V:11q23);KMT2a
REARRANGED
B-ALL WITH T(12:21)
(P13:Q22);TEL-kMT1
(ETV6-RUNX1)
NEOPLASM OF
LYMPHOBLASTWITH
TRANS B/W BCR- ABL
GENE
TRANSLOCATION
BETWEEN MLL GENE @
11q AND ANY PART OF
LARGE NO OF
DIFFERENT FUSION
PARTNER
WBC COUNT >
1LAC/MICRO LITRE
CNS INVOLMENT
TRANSLOCATION
BETWEEN ETV6 AND
RUNX1 GENE
25% OF ALL B-ALL
AGE COMMON IN ADULTS.
25% ADULT ALL
2.4%CHILDHOOD
MOST COMMON IN LESS
THAN 1 YR OF AGE
COMMON IN CHILDREN
NOT SEEN IN INFANTS
MORPHOLOGY NO UNIQUE
MORPHOLOGY
NO UNIQUE
MORPHOLOGY
NO UNIQUE
MORPHOLOGY

26. IMMUNOPHENOTYPE
S
CD10+,
CD19+,CD25+, Tdt+
CD19+, CD-,CD24-,
PRO-B+ FOR CD5
CD19+,CD10+,CD34,
CD13 FREQUENTLY
EXPRESSED
GENTICS BCR GENE FUSE
WITHABL1 GENE &
PRODUCE BCR-ABL
FUSION PROTEIN
190KD(CHILDREN)
210KD(ADULT)
MLL GENE HAVE
MANY FUSION
PARTNER
M/C AF4 (4q21)
OTHER ENL (19p14
AF9(9P22)
ETV6-RUNX1
FUSION PROTEIN
INHIBIT
TRANSCRIPTION
FACTOR RUNX1

28. B-ALL WITH HYPERDIPLOIDY B-ALL WITH HYPODIPLODY
CRITERIA BLAST CONTAIONS >50& <66
CHROMOSOMES
NO TRANSLOCATION
NO OTHER STRUCTURAL
ALTERATION
BLAST CONTAIN <46
CHROMOSOMES
AGE COMMONIN CHILDREN
RARE IN ADULT
BOTH IN CHILDRENAND
ADULTS
HAPLOID ALL (23-29 CHROM)
SEEN IN CHILDHOOD
INCIDENCE 25% 5% IF CHROMOSOME <46
1% IF CHROMOSOMES <45
MORPHOLOGY NO UNIQUE MORPHOLOGY NO UNIQUE MORPHOLOGY

29. B-ALL WITH HYPERPLOIDY B-ALL WITH HYPODIPLOIDY
IMMUNO-PHENOTYPE CD-19, CD-10+ BLAST HAVE PRE-B
CD34+ PHENOTYPE
CD45- CD19,CD10 +
GENETICS • NUMERICALINCREAS IN • LOSS OF 1 OR MORE
CHROMOSOME CHROMOSOME FROM 45
• NO STRUCTURAL CHROM TO NEAR
ABNORMALITY HAPLOID
• M/C EXTRA • DETECT BY STANDARD
CHROMOSOMESARE KARYOTYPING FISH &
21,X,14,4 FLOWCYTOMETRY.
• TRISOMY 4,10,17

30. 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
TRANSLOCATIO B/W IL3 GENE
&IGH GENE
RESULTING IN EOSINPHILIA
TRANSLOCATIONIN B/W E2A
GENE & PBX1 GENE
AGE BOTH IN CHILDRENAND
ADULT
COMMONIN CHILDREN
ALSO SEEN IN ADULTS
INCIDENCE RARE DISEASE <1% OF ALL 6% OF ALL CASES OF B- aLL
MORPHOLOGY BLAST WITH TYPICAL
MORPHOLOGY
INCRASING CIRCULATING
EOSINOPHIL
NO UNIQUE MORPHOLOGY
IMUNO PHENOTYPES C19,10 +
cyµ HEAVY CHAIN +
CD9 STRONGLY EXPRESSED
IN ABSENCE OF cyµ H CHAIN
C19,10 +
cyµ HEAVY CHAIN +
CD9 STRONGLY EXPRESSED
IN ABSENCE OF cyµ H CHAIN

31. T- LYMPHOBLASTIC LEUKAEMIA
CRITERIA NEOPLASM OF LYMPHOBLAST COMMITTED TO t-CELL LINEAGE
INVOLVING BM &PB
>25%BM BLAST
AGE AND SEX COMMONIN ADOLESCENTS THAN YOUNG CHILDREN
MALE > FEMALE
INCIDENCE 15% OF CHILDHOOD ALL
25% OF ADULT ALL
C/F • HIGH LEUCOCYTE COUNT
• THYMIC INFILTRATION IS VERY COMMON & MAY BE ASSOCIATED
WITH PLEURAL EFFUSION, PERICARDIAL EFFUSION & SVC
OBSTRUCTION
• MEDIASTINALMASS
• LYMPHADENOPATHY, HEPATOSPLENOMEGALY

32. MORPHOLOGY COMPOSED OF SMALL TO MEDIUM SIZED
BLAST.
NUCLEAR SHAPED – ROUND TO
IRREGULAR
SMALL BLAST WITH SCANT CYTOPLASM,
CONDENSED CHROMATIN & NO PROMINENT
NUCLEOLI
LARGE BLAST WITH FINELYDISPERED
CHROMATION& RELATIVELYPROMINENT
NUCLEOLI
MITOSIS: HIGHER THAN B- ALL
CYTOCHEMISTRY ACID PHOSPHATE POSITIVE
IMMUNOPHENOTYPE • Tdt +ve
• CD99,CD34,CD1a MOST SPECIFIC
• CD7,Cyt CD3MOSTSPECIFIC

33. IMMUNOPHENOTYPE INTRATHYMIC DIFFERENTIATION
• PRO T- cCD3+,CD7+,CD2-,CD1a -,CD34+
• PRE T- cCD3+,CD7+,CD2+,CD1a -,
CD34±ve
• CORTICAL T- cCD3+,CD7+,CD2+,CD1a+,
CD34-ve
• MEDULLARY T- cCD3+,CD7+,CD2+,CD1a-,
CD34 -,sCD3+
• CORTICAL T STAGE DOUBLE +VE FOR
CD4&8
GENETICS CLONAL REARRANGEMENT OF TCR GENE
20% OF CASES WITH IGH GENE
REARRANGEMENT
50-70% = ABNORMALKARYOTYPE
M/C INVOLVED GENE INCLUDE
TRANSCRIPTIONFACTOR TLX1 AND TLX3
50% CASES WITH MUTATION IN NOTCH1
AND HCDC4 gene

38. INVESTIGATION
◦ PERIPHERAL BLOOD SMEAR:
NORMOCYTIC NORMOCHROMIC ANAEMIA
TLC- DECREASED/ NORMAL/ INCREASE
LYMPHOBLASTS
GRANULOCYTOPENIA
THROMBOCYTOPENIA

40. ◦ BONE MARROW EXAMINATION:
1. HYPERCELLULAR d/t PROLIFERATION OF LEUKAEMIC BLASTS
2. B-ALL: THE BLAST HAVE VARIED 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 DISTINCTNUCLEOLI.
3. CYTOPLASM IS SCANT TO MODERATE & SLIGHT BASOPHILLIC TO DEEPLY
BASOPHILLICAS CELL SIZE INCREASE
4. TALL: COMPARED WITH B- LYMPHOBLAST, T-LYMPHOBLAST SHOW GREATER
NUCLEAR CONVULATION & SIGNIFICANT NUCLEAR HYPERCHROMASIA
5. MITOTIC FIGURE: HIGHER IN T-ALLTHAN B-ALL
6. MYELOID PRECURSORS: DECREASED
7. MEGAKARYOCYTES: DECREASED

42. STAIN AML ALL
MPO + -
SBB + -
NSE
+ IN M4, M5
-
PAS +(FINE BLOCK IN M6) BLOCK+
ACID PHOSPHATASE + IN M6 (DIFFUSED) +T- ALL

45. MARKER FOR THE DIAGNOSIS 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

46. OTHER INVESTIGATIONS:
◦ CSF EXAMINATION FOR LYMPHOBLAST
◦ TESTICULAR BIOPSY TO RULE OUT RESIDUAL DISEASE
◦ CHEST X-RAY

47. DIFFERENTIAL DX
◦REACTIVE LYMPHOCYTOSIS DUE TO INFECTION
◦SMALL ROUND CELL TUMOR OF THE CHILD
HOOD THAT PRESENT WITH MARROW
INVOLVEMENT
◦HEMATOGONES

48. ALL vs AML
ALL AML
AGE MAINLY CHILDREN MAINLYADULTS
LYMPHADENOPATHY USUALLY + USUALLY-ve
HEPATOSPLENOMEGALY +VE MILD +VE MILD
GUM HYPERTROPHY -VE +VE IN M4/M5
SKIN INFILTRATION -VE +VE IN M4/M5
CNS INVOLVEMENT +VE IN SOME CASES +VE IN SOME
GRANULOCYTIC SARCOMA -VE +VE IN FEW CASES
MEDIASTINALMASS +VE IN T- ALL -VE
ASSOCIATED DIC -VE +VE IN M3
SERUM MURAMIDASE NORMAL IN M4/M5(MONOCYTE TYPE)
PROGNOSIS GOOD BAD

49. ALL V/S REACTIVE LYMPHOCYTOSIS
◦ THE ATYPICAL LYMPHOCYTES CAN BE DISTINGUISHED FROM
LEUKEMIC BLAST BY
1. RELATIVELY MATURE CHROMATIN PATTERN
2. LOW N:C RATIO
3. PROMINENT NUCLEOLI
ALL v/S SMALL CELL TUMOR OF THE CHILDHOOD
IMMUNOPHENOTYPING IS HELPFUL IN ARRIVING AT CORRRECT
DIAGNOSIS

50. ALL V/S HEMATOGSONES
◦ HEMATOGONES ARE THE IMMATURE LYMPHOID CELLS
APPEARING LIKE LEUKAEMIC BLAST’MAY BE SEEN IN
INFECTIONS,FOLLOWING CHEMOTHERAPY AND BONE MARROW
TRANSPLANTATION
◦ THEY CAN BE DIFFERENTIATED FROM LYMPHOBLAST IN HAVING
HIGH N:C RATIO, MORE HOMOGENOUS CHROMATIN & NO
DISCERNIBLE NUCLEOLI

52. THANK YOU 