chronic leukemias csbrp

Chronic leukemias & Chronic leukemias & Myeloproliferative disorders Myeloproliferative disorders

- Chronic leukemia lymphoid malignancies- Chronic leukemia lymphoid malignancies- Chronic myeloid leukemia- Chronic myeloid leukemia

- Myelofibrosis- Myelofibrosis

Dr.CSBR.Prasad, M.D.

Differences – Differences – Acute and Chronic leukemiasAcute and Chronic leukemias

Feature Acute leukemia Chronic leukemiaTLC Vary Elevated - alwaysHGB Anemia Normal / AnemiaPlatelet count Low - always Normal / ElevatedBlasts 20% or more Absent or 1-2%

Leukemia / Lymphoma

• Leukemia (Blood & BM)• Lymphoma (Solid tissue)• Lymphoma / Leukemia (Solid tissue + Blood & BM)

Chronic leukemia lymphoid Chronic leukemia lymphoid malignanciesmalignancies

• B cell CLL• B cell Prolymphocytic Leukemia (B-PLL)• T cell Prolymphocytic Leukemia (T-PLL)• Hairy cell leukemia• Large granular lymphocytic leukemia (LGLL)• Sezary syndrome

Chronic lymphocytic leukemia / Chronic lymphocytic leukemia / Small Lymphocytic LymphomaSmall Lymphocytic Lymphoma

CLL / SLLCLL / SLL

CLL / SLLCLL / SLL

• Peripheral B-Cell Neoplasms • 4% of all NHLs• Diagnostic requirement for CLL:

Sustained Absolute lymphocyte count =/>5000 per mm3

Criteria for diagnosis of CLLA International CLL workshop (1989) criteria1-Sustained lymphocyte count of 5000 cells/cumm – mature lymphocytes

2-BM >30% lymphoctytes

3-B-cell phenotype

DiagnosisCriterion 1+Criterion 2 or 3 ORIf count is <10,000 then criteria 2+3 must be present

B The NCI-WG (1996) criteria1-Lymphocyte count >5000/cumm with <55% atypical cells. The cells should have

B-cell Ags CD19, 20, 23

CD 5 positivity

Kappa or Lambda sIg

Low density sIg

2-BM >30% lymphcoytes

CLL / SLL – CLL / SLL – Clinical featuresClinical features

• Older age group >60yrs• M:F=2:1• Painless lymphadenopathy• Autoimmune hemolytic anemia• Hepatosplenomegaly

CLL – Blood & BMCLL – Blood & BM• Small lymphocytes• No nucleoli• Smudge / basket cells• Prolymphocytes (having Nucleoli) <2%• Nodular / diffuse infiltrates in the BM• CD 5, 19, 20 +• Low level expression of sIg• CD 10 and cyclin D1 invariably negative• Trisomy 12• Richter’s transformation

B-CELL CLLB-CELL CLLBlood smear from an adult male with a marked lymphocytosis. The predominant lymphocytes have very sparse pale cytoplasm, round to slightly oval nuclei, and no evident nucleoli. Three damaged cells are present. This morphology is characteristic of the majority of cases of B CLL. (Wright-Giemsa stain)

These mature lymphocytes are increased markedly in number. They are indicative of chronic lymphocytic leukemia, a disease most often seen in older adults. This disease responds poorly to treatment, but it is indolent.

B-CELL CLL, MIXED CELL TYPEB-CELL CLL, MIXED CELL TYPE

Blood smear from a man with recently diagnosed B CLL and a leukocyte count of 175x109/L. There is variability in the size of the lymphocytes. The larger cells have abundant pale cytoplasm. Some cells have nucleoli that are not prominent. One cell has features of a prolymphocyte. (Wright-Giemsa stain)

B-CELL CHRONIC LYMPHOCYTIC LEUKEMIA: TRISOMY 12Karyotype of a lymphocyte from a patient with B CLL showing an extra copy of

chromosome 12. (G-banded, Wright-Giemsa stained)

Lymphnode / Liver / SpleenLymphnode / Liver / SpleenMorphology: • Lymph nodes are diffusely effaced by an

infiltrate of predominantly small lymphocytes• Proliferation centers: Pathognomonic for

CLL/SLL• Nodular / diffuse infiltrates in the BM• Infiltrates are also virtually always seen in the

splenic white and red pulp and the hepatic portal tracts

LN – Proliferation centers

SLL / CLL involving the liver

These infiltrates in the liver are composed of small lymphocytes. The involvement of tissues in cases of chronic lymphocytic leukemia (CLL) is known as small lymphocytic lymphoma (SLL). This disease, CLL/SLL, has an indolent course.

CHRONIC LYMPHOCYTIC LEUKEMIA: RICHTER TRANSFORMATIONA marrow biopsy from a patient with a history of B CLL with a recent onset of weight loss and fatigue. The marrow biopsy shows a large focus of pleomorphic cells which reacted with B-cell antibodies. The large cells are partially encircled by small lymphocytes. (Hematoxylin and eosin stain)

Molecular PathogenesisMolecular Pathogenesis

• Common: del of 13q14.3, 11q, and 17p• Trisomy 12• Deletions on Chr 13: Implicated two

microRNAs, miR-15a and miR-16-1, as possible tumor suppressor genes

Course and Prognosis• Indolent disease, incurable• Variable and depends on the clinical stage. • Median survival: 4 - 6 years, but over 10 years in

individuals with minimal tumor burden• Worse outcome seen in:

– the presence of deletions of 11q and 17p, – a lack of somatic hypermutation, and – the expression of ZAP-70, a protein that augments signals

produced by the Ig receptor

• Patients are generally treated with “gentle” chemotherapy to control symptoms

Target Tx

Immunotherapy with antibodies against CD20CD20 and CD52CD52, is finding

increasing use

Staging

• Rai staging – Lymphocytosis– Splenomegaly– Lymphadenopathy– Anemia– Thrombocytopenia

• Binet staging

HAIRY CELL LEUKEMIAHAIRY CELL LEUKEMIA


• B cell leukemia• Middle age• Men 7x• Massive splenomegaly• No lymphadenopathy


• B cell neoplasm• Extensive BM involvement - PANCYTOPENIA• Monocytopenia – Susceptible to TB• Hairy cells• BM – “fried egg” appearance of cells• BM – islands of neoplastic cells surrounded by

fibrosis – BM aspiration results in DRY TAP• Flow cytometry: CD 19, 20, 22, 25, 103, 11c• TRAP is positive

Hairy cellsHairy cells


Spleen:• Marked expansion of red pulp• “Fried egg” appearance• Pseudosinuses (Red cell lakes in between tumor

cells)


• Indolent disease• Long standing remissions with:

– 2-Chlorodeoxyadenosine (2-CDA/Cladribine)– Deoxycofromycin (Pentostatin)

OTHERSOTHERS

Prolymphocytic LeukemiaProlymphocytic Leukemia

B cell PLLB cell PLL• 70% PLL are B cell origin• Aggressive leukemia• Males 4x• May develop de novo or from CLL• DD: CLL Vs PLL

– PLL marked splenomegaly– PLL minimal lymphadenopathy– Prolymphocytes #

• <10% in CLL• >55% in PLL• Note: cases in between 10&55% are CLL/PLL. Course is unpredictable

B cell PLLB cell PLLDD: CLL Vs PLL

– PLL marked splenomegaly– PLL minimal lymphadenopathy– Prolymphocytes #

• <10% in CLL• >55% in PLL• Note: cases in between 10&55% are CLL/PLL. Course is

unpredictable• Strong sIg, CD20, 22, FMC-7• CD 23-• Trisomy12, 14q+, 6q-, p53 mutation.

B cell PLLB cell PLL• Absolute lymphocytosis• Anemia• Thrombocytopenia• Large granular lymphocytes

T cell PLLT cell PLL• Aggressive (survival 7months)• Marked lymphocytosis• Lymphadenopathy / hepatomegaly• Skin lesions• T cell PLL:

– Prominent nucleolus– Convoluted nucleus

• CD 2, 3, 4, 5, 7+ TdT-• Inv14, 11q-, trisomy 8q• Target Tx: anti-CD 52 (CAMPATH)

LARGE GRANULAR LARGE GRANULAR LYMPHOCYTIC LEUKEMIALYMPHOCYTIC LEUKEMIA

LGL LeukemiaLGL Leukemia


• T cell neoplasm• Large granular lymphocytes

• >15% of lymphocytes• NK like T cells (CD3+) or NK cells (CD3-)

• DD: Reactive lymphocytosis• By molecular diagnostics or• By cytogenetics


Two types:– T cell type [80%] [CD 2,3,5,7,8,16, 56+ & 4, 57-]– NK cell type

LGL LeukemiaLGL LeukemiaT cell type

• 80%• >50yrs • T-LGLL may have anemia, neutropenia,

thrombocytopenia• Lymphadenopathy and hepatomegaly – uncommon• 25% of patients may have Rhe.arthritis• Indolent course (10yr survival >80%)• CD 2,3,5,7,8,16, 57+ & 4, 56-

LGL LeukemiaLGL LeukemiaNK cell type

• 20%• ~40yrs • Presentation is like acute leukemia• Fever and hepatosplenomegaly • Neutropenia is rare• 25% of patients may have Rhe.arthritis

• Felty’s syndrome• Aggressive (Death with in 2months)• CD 2,7,16, 56+ & 3,4,8,57-

Chronic Myeloid LeukemiaChronic Myeloid LeukemiaCMLCML


Def: CML is a myeloproliferative disorder

originating from an abnormal pluripotent stem cell and

It’s associated consistently with Philadelphia chromosome (Ph’) and or BCR/ABL fusion gene.


Chronic myeloid leukemia (CML) is distinguished from other myeloproliferative disorders by the presence of a chimeric BCR-ABL gene derived from portions of the BCR gene on chromosome 22 and the ABL gene on chromosome 9.

CML – Clinical featuresCML – Clinical features• 15-20% of leukemias• 5th & 6th decade, can occur at any age• More common in males• Blood and BM is primarily involved• Most of the patients are asymptomatic• Night sweats, wt loss, anemia• Massive splenomegaly• Left quadrant abdominal pain

Hypermetabolism due to increased cell

turnover


Remember CML is a disease of “One MillionOne Million”

Parameter InterpretationOne million RBCs AnemiaOne million WBCs LeucocytosisOne million PLTs Thrombocytosis

CMLCML• White count 170k• Predominant cells are myelocytes and segmented

neutrophils• Blast count <2%• Basophilia • Eosinophilia• PLT count usually increased (1000k)• Mild anemia• BM: blasts <5%, paratrabacular polys 5-10 cell thick

CMLCMLPhases 1-Chronic phase (CML- CP) 2-Accelarated phase (CML- AP) 3-Blast phase (CML- BP)

CML - APCML - AP• Blasts 10-19% in blood / BM• Basophilia >20% • Thrombocytopenia not related to Tx• Increasing spleen size despite Tx• Cytogenetic evidence of clonal

evolutionNote: for diagnosis, one or more the above

findings should be present

Cytochemistry and immunophenotyping

• CML – CP markedly <NAP (LAP) score• CML – BP may show markers of myeloid

(CD 13, 33), monocytic (CD 15, lysozyme), MKc (CD41, 61) or erythroid (glcophorin-A, HGB-A)

• Lymphoblastic blast phase will express lymphoid markers (CD10,19,34 TdT et.c.)

• In 90-95% of cases - Characteristic t(9,22)(q34; q11) (Ph’)

Philadelphia chromosome Ph’Ph’• t(9,22)(q34; q11)• Fuses BCR gene on chr# 22 with ABL gene on chr# 9• Others may have variations in translocation

involving other chromosomes 3, 4 in addition to 9 & 22

• BCR (on 22), break occurs in major BCR (fusion protein p210) µ BCR (fusion protein p 190) m BCR (fusion protein p 230)• Products has Tyrosine kinase activity• Philadelphia chromosome is #22

Prognosis

• Age at diagnosis• Spleen size• # of blasts and basophils in BM• Marrow fibrosisTx: Imatinib Allogenic BM transplantation

This is a markedly enlarged spleen (the ruler is 15 cm long). Such massive splenomegaly is usually indicative of some myeloproliferative disease such as chronic myelogenous leukemia or myelofibrosis. There are subcapsular yellow-tan infarcts. Congestive splenomegaly (as with portal hypertension in cirrhosis of the liver) is unlikely to increase the size of the spleen over 800 gm. A spleen >1000 gm suggests a myeloproliferative, lymphoproliferative, or hematopoietic disorder.

Splenic rupture results most often from blunt abdominal trauma. Seen here are two large capsular lacerations in a patient who was involved in a motor vehicle accident. Note the hematoma resulting from the splenic rupture. Enlargement of the spleen from a condition such as malaria may render the spleen prone to rupture even with minor trauma.

The CBC here is from a patient with CML. Note the markedly increased WBC count.

740

CML case-1 Thrombocytosis Blood smear, May-Giemsa stain, x400

There are numerous granulocytic forms seen here, including immature myeloid cells and bands. This condition is one of the myeloproliferative states and is known as chronic myelogenous leukemia (CML) that is most prevalent in middle-aged adults. A useful test to help distinguish this disease is the leukocyte alkaline phosphatase (LAP) score, which should be low with CML and high with a leukemoid reaction.

Here is another view of a peripheral blood smear in a patient with CML. Often, the numbers of basophils and eosinophils, as well as bands and more immature myeloid cells (metamyelocytes and myelocytes) are increased. Unlike AML, there are not many blasts with CML.

CML case-2 BLAST CRISIS (Myeloid) Blood smear, MGG stain, x200

CML case-2 BLAST CRISIS (Myeloid) Blood smear, May-Giemsa stain, 1000x

A characteristic finding in CMLA characteristic finding in CML

Presence of scattered macrophages with abundant wrinkled, green-blue cytoplasm

so-called sea-blue histiocytes

Myeloid cells of CML are also characterized by the Philadelphia chromosome (Ph1) on karyotyping. This is a translocation of a portion of the q arm of chromosome 22 to the q arm of chromosome 9, designated t(9:22). This translocation brings the c-abl proto-oncogene on chromosome 9 in approximation with the bcr (breakpoint cluster) gene on chromosome 22. The hybrid bcr-c-abl gene encodes a tyrosine kinase that has growth promoting effects through nuclear stimulation.

FISH technique is diagrammed above with interphase nuclei. In the left panel, probes specific for the breakpoint regions of chromosome 8(q22) in green and chromosome 21(q22) in red identify a translocation t(8;21) in a patient with acute myelogenous leukemia. In the center panel, probes to chromosomes 11 (green) and 13 (red) identify a deletion of 11q23 in a patient with small lymphocytic lymphoma. In the right panel, a red fluorescent tag to the BCR gene of chromosome 22 and a green tag to the ABL gene of chromosome 9 are seen, but the yellow dot identifies the abnormal BCR-ABL fusion gene in a case of chronic myelogenous leukemia with the "Philadelphia chromosome".

AML t(8,21) SLL del 11q CML BCR-ABL fusion

Ph’

CML / CLL

• CML -- Women in beach• CLL -- Children in convent

Here is another view of a peripheral blood smear in a patient with CML. Often, the numbers of basophils and eosinophils, as well as bands and more immature myeloid cells (metamyelocytes and myelocytes) are increased. Unlike AML, there are not many blasts with CML.

B-CELL CHRONIC LYMPHOCYTICLEUKEMIABlood smear from an adult male with a marked lymphocytosis. The predominant lymphocytes have very sparse pale cytoplasm, round to slightly oval nuclei, and noevident nucleoli. Three damaged cells are present. This morphology is characteristic of the majority of cases of B CLL. (Wright-Giemsa stain)

CMLCML CLLCLL

The Philadelphia chromosome The Philadelphia chromosome in CML and ALLin CML and ALL

References

• Clinical laboratory hematology by McKenzie 2nd Edition.

• Robbin’s pathologic basis of disease 8th Edition.

chronic leukemias csbrp

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