all for student

1. MED-341:
Acute Leukaemia
Professor Abdulkareem Almomen, MD, FRCPC
(March 2011)

2. – Acute Myeloid Leukemia (AML)
– Acute Lymphoblastic Leukemia (ALL)
– Biphenotypic Acute Leukemia (BAL): My + Ly
Acute Leukaemia: main subtypes

3. • Clonal expansion of myeloid blasts in blood marrow
(BM), peripheral blood (PB) or other tissue
• Minimum threshold of blast cells for defining AML (BM):
– >20% blasts
AML: definition / concept
Proliferation + differentiation block / maturation arrest

4. Maturation arrest

5. Maturation arrest

6. Normal Bone Marrow: Cell Heterogeneity

7. BM in AML: Monomorphous Cell Appearance

8. AML5a
AML4-eos

9. • Incidence: 2 - 3 pts /100.000 inhab - year
• Overall: 1.2% (US)
• Lineal increase with age:
<35: < 1 /100.000 inhab - year
>65: >10 /100.000 inhab - year
• Median age: 60 - 70 year-old
• Not apparent increase during last years
AML: epidemiology

10. • Bone marrow failure
– Anemia
– Neutropenia
– Thrombocytopenia
• Extramedullary involvement (skin, gums, CNS, other)
• Proliferative symptoms
• Coagulopathy
• Leukostasis
• Metabolic disorders (tumor lysis syndrome)
AML: clinical presentation

11. AML: skin infiltration (granulocytic sarcoma)

12. AML: gums (gingival) infiltration

13. Acute Myeloid Leukemia (AML)

14. • Cytology
– PB
– BM (BM aspirate ± BM biopsy)
• Cytochemistry
– MPO (myeloperoxidase) & Sudan Black B (SBB) – Myeloid origin
– Non-specific esterase (NSE): -naphthyl acetate (ANA), -naphthyl
butyrate (ANB) – Monocytic origin
• Inmunophenotype
– Hematopoietic precursors: CD34, HLA-DR, CD45
– My Ag: CD13, CD33, CD15, MPO, CD117
– Megakaryoblastic Ag: CD41, CD61
• Cytogenetics
• Molecular biology
– Fusion transcripts (RT-PCR): PML/RAR-, AML1/ETO, CBF-/MYH11,
MLL/..., BCR/ABL, DEK/CAN)
– New mutations with prognostic impact: flt-3-ITD, CEBPalfa, NPM, …
AML - diagnosis:

16. AML – Auer rod

17. MPO
Naphtol-As-D-acetate esterase -naphthyl acetate esterase
AML : Cytochemistry

18. CD56
PE
100 101 102 103 104
CD2 FITC
10
0
10
1
10
2
10
3
10
4
NG2
PE
100 101 102 103 104
CD34 FITC
10
0
10
1
10
2
10
3
10
4
CD14
PE
100 101 102 103
104
CD123 FITC
10
0
10
1
10
2
10
3
10
4
AML : Flow cytometry

19. AML: Cytogenetics

20. Acute Promyelocytic Leukemia (APL, M3)
bcr1 bcr3
RT-PCR PML/RAR-alpha
FISH:
PML/RARA
fusion signal
Anti-PGM3 pattern staining

21. • Minimally differentiated (M0)
• AML w/o maturation (M1)
• AML with maturation (M2)
• Promyelocytic (M3)
• Myelomonocytic (M4)
• Monoblastic (M5a)
• Monocytic (M5b)
• Erythroleukemia (M6)
• Acute megakaryoblastic (M7)
FAB classification for AML:
lineage/differentiation- based
Granulocytic diff
Monocytic diff

23. I. AML with recurring genetic abnormalities
– AML with t(8;21)(q22;q22) & (AML1/ETO) rearrangement
– AML with abn BM eosinophils & inv(16)(p13q22)/t(16;16)(p13;q11) -
CBF/MYH11 rearrangement
– Acute promyelocytic leukemia associated to t(15;17)(q22;q11-12) &
PML/RAR- rearr
– AML with 11q23 (MLL) abn
II. AML with multilineage dysplasia
III. Therapy-related AML
IV. AML not otherwise categorized
WHO, 2001
WHO classification (AML): towards
molecularly-based categories

24. – Favorable: t(15;17), t(8;21), inv(16)
– Intermediate risk: normal karyotype
– Unfavorable: abn 5 (del/-5), abn 7 (del/-7),
inv(3q)/t(3;3), complex karyotype (≥5 abn),
abn 11q, t(6;9), del(17p)
AML: main cytogenetic abnormalities

25. AML (non-APL): standard approach
Intensification CT
Ara-C HD-based
Post-remission tx
AlloSCT AutoSCT CT
Induccion CT
Anthacycline + Ara-C /…
CR~75%
Long-term OS~35-40% (<60)
Salvage therapy
Refractory
Relapse

26. Acute Lymphoblastic Leukemia (ALL)

27. ALL: definition
– Clonal expansion of lymphoid (precursor
lymphoid cells) in blood marrow (BM),
peripheral blood (PB) or other tissue

28. ALL: main subtypes
– B-cell ALL / precursor B lymphoblastic leukemia
– T-cell ALL / precursor T lymphoblastic leukemia

29. • Incidence: 2/100.000 (inhab-year)
• 3/4 in children
• B-ALL:
– 80-85%
– Predominance in children
– 10% presenting without BM involvement
(B-cell lymphoblastic lymphoma)
• T-ALL:
– 15% of children ALL
– 25% of adult ALL
– Predominance in adolescent / young male pts
– Frequent presentation with exclusive extramedullary
involvement (T-cell lymphoblastic lymphoma)
ALL: epidemiology

30. • Extramedullary involvement
– CNS
– Mediastinal (T-ALL)
– Other (lymph node, testicular, ...)
• B symptoms
• Bone marrow failure
• Metabolic disorder
ALL: characteristic clinical features

31. T-ALL: mediastinal involvement

32. ALL – FAB1 subtype

33. ALL – FAB2 subtype

34. Common B-lineage antigens: HLA-DR, CD19, CD79a,CD22
• Pro-B (B-cell progenitor, B-I): Tdt+, CD10(-), cytIg(-), CD20(-)
• Common (early pre-B, B-II): TdT(+), CD10(+), cytIg(-)
• Pre-B (B-III): Tdt(+), cytIg(+)
• Mature B-ALL (B-IV): Tdt(-), sIg+, CD20(+)
B-ALL: immunological classification

35. T-ALL/Common Ag: Tdt, CD3cyt, CD7
– Early T-ALL: CD1(-),CD2(-),CD3s(-), CD5(-),CD4(-),
CD8(-)
– Thymic T-ALL: CD1a(+),CD2(+),CD5(+)
– Mature T-ALL: CD1a(-), CD2(+),CD5(+),CD3s(+)
T-ALL: immunological classification

36. – Favorable: t(12;21),
– Intermediate risk: normal karyotype, t(1;19)
– Unfavorable: t(9;22), 11q23 abn [t(4;11) & other],
hypoploid
ALL: main cytogenetic abnormalities

37. ALL: current therapeutic approach
Consolidation CT
Post-remission
AlloSCT AutoSCT CT (reinduction & maintenance)
CR:  83%
Induction Antr. / VCR / PDN
L-ASA, ARA-C, CFM
Surv*:  80% (children)
 35% (adults)

38. Imatinib: molecular-targeted therapy for
Ph-positive ALL
Goldman et al, Lancet 2000
Y = Tyrosine
P = Phosphate
Bcr-Abl
ATP
Substrate
P
P
P
P
Abl: a highly overexpressed
tyrosine kinase protein in CML
& Ph-pos ALL

39. Imatinib: molecular-targeted therapy for
Ph-positive ALL
Goldman et al, Lancet 2000
Bcr-Abl
Bcr-Abl
ATP
Substrate
P
P
P
P
Imatinib: blocks abl function by
interfering with ATP binding
Y = Tyrosine
P = Phosphate

40. Outcome
– Response criteria
• Complete response
• Cytogenetics response
• Molecular response
– Failure: primary refractory, relapse
– …

41. NCI criteria (Cheson et al, 1999)
1. <5% blasts in BM
2. Absence of extramedullary leukemia
3. Recovery of PB counts (ANC >1 & platelet >100x109/L)
4. Minimum 4-week duration
Definition of CR

42. CR (morphologic assessment) <5% of BM blast cells
Low sensitivity
Universally applicable
Cytogenetic CR Absence of abnormal metaphases
Low sensitivity
Only in cases with cytogenetic abn
(i.e., Ph-pos)
Molecular response Clearance of molecular marker
(bcr/abl, PML/RAR, AML1/ETO,...)
Only in AL with known molecular marker
High sensitivity (1 x 10-5)
Response assessment: types (degree) of response

43. Morphologic assessment of response
CR Non-CR