ACUTE LEUKEMIAS

Curs 4
 Acute leukemias (AL)

A heterogeneous group of diseases characterized

by proliferation of immature (blastic) cells in bone
marrow and extramedullary tissues.
Normally, blasts are absent in peripheral blood (PB) and
are <5% in the bone marrow (BM)
The cytological criterium for AL diagnosis: >20% blasts
in BM

Blastic proliferation results in suppression of

normal clones and bone marrow failure:
Anemia
Infection
Hemorrhage
 Multipotential hematopoietic stem cell
Hematopoiesis in Humans (Hemocytoblast)

Common Common
myeloid lymphoid
progenitor progenitor

Proerythroblast Myeloblast Lymphoblast

Megakaryoblast
(Pronormblast)

Basophilic erythroblast B. promyelocyte N. promyelocyte E. promyelocyte Monoblast

Promegakaryoblast
Prolymphocyte

Polychromatic erythroblast B. myelocyte N. myelocyte E. myelocyte Promonocyte

Orthochromatic
erythroblast B. metamyelocyte N. metamyelocyte E. metamyelocyte
(Normoblast)
Megakaryocyte
Natural killer cell
Small lymphocyte

Polychromatic
erythrocyte B. band N. band E. band
(Reticulocyte)

T lymphocyte B lymphocyte

Thrombocytes Erythrocyte Basophil Neutrophil Eosinophil Monocyte

Mast cell Myeloid Lymphoid

 Acute leukemias (AL)

AL ~ 10% of hematological malignancies

The first cause of death by cancer in subjects <35
years old.

According to the origin of blastic cells, AL are

subdivided in 2 large groups:

A. Acute lymphoblastic leukemia (ALL), resulting

from the transformation of the multipotent lymphoid
stem cell.
B. Acute myeoid leukemia (AML) resulting from the
transformation of the multipotent myeloid stem cell
 Epidemiology
1. ALL
Incidence: 0,5-1,5/100.000/year.
ALL affects mostly children and young adults
It is the most frequent malignancy <15 years
Afterwards, ALL incidence decreases
gradually: in the elderly, ALL is very rare
2. AML
Incidence: 5-8/100.00/y increases with age
2/100,000/year < 40 years
10-12/100,000/year > 65 years
Currently, in developed countries, AML median
age at onset is ~ 65 years
 Etiology.

Unknown

Genetic factors:
AL is more frequent in children with congenital
diseases such as Down syndrome, Fanconi
anemia, Klinefelter syndrome.
Viral factors (HTLV1) - ATLL
Environmental factors
Exposure to radiation, solvents
Previous chemotherapy/radiotherapy for
other cancers
Secondary AML
 Pathogenesis
Genomic abnormalities appearing in a single stem
cell (leukemic stem cell).
Loss of differentiation capacity (maturation arrest)
Increased proliferative capacity

AL requires several
sequential genomic
abnormalities

Emergence of a
growth
advantage
for the leukemic
clone compared to
normal clones:
gradual
replacement of
hematopoiesis by
leukemic cells
 Clinical picture

Usually sudden onset - main symptoms:

Anemia
Bleeding: petechiae, echymoses, mucosal bleeding
Infections

Other frequently encountered symptoms:

Bone, joint pain
Lymphadenopathy, hepatosplenomegaly - ALL
Rarely cutaneous infiltration - purple nodules ALL, AML
(monocytic)
Neurologic symptoms due to CNS leukemic infiltration - ALL
Testicular infiltration more frequent in children, ALL
Gingival hypertrophy more common in AML (monocytic)
AL Clinical aspects
AL Clinical aspects
 Laboratory data

Blood counts:
Anemia
Thrombocitopenia
WBC: high, normal or low.

Peripheral blood
Presence of immature cells (blasts)
Usually low neutrophil count (<1500/l)

Bone marrow
Blasts >20%
Reduced normal precursors
 AL: Diagnosis Laboratory Data

FAB criteria:
1. Cytology (PB/BM)
2. Cytochemistry
3. Flow cytometry and
immunohistochemistry
4. Cytogenetics/Fluorescent in situ
hybridization (FISH)
5. PCR molecular byology
 AL: Diagnosis Laboratory Data
Cytology (PB/BM)

Cytology:
- recognize blasts
- number of blasts in BM:
> 20 % =acute leukemia
< 20 % = myelodysplastic syndrome
Leucemie acuta M1
Leucemie acuta limfoblastica
 AL: Diagnosis Laboratory Data
Cytochemistry

2. Cytochemistry :
- PAS
- Negru Sudan
- Myeloperoxidaze
- Esteraza
- TDT
Blasti PAS +
Blasti MPOX +
Blasti Esterazo +
AL: Diagnosis Laboratory Data
Flow cytometry
Flow-cytometry in AML: CD13, CD33, CD117 poz,
HLA-DR, CD10, CD7 neg
Monoclonal Atc
 AL: Diagnosis Laboratory Data
Flow cytometry
Immunophenotyping esential for
diagnosis
Lymphoid markers:
B lymphoid markers (CD10, CD19, CD20)
T lymphoid markers (CD3, CD7)
Early lymphoid markers (HLA-DR, TdT)

Mieloid markers
Granulocytic CD13, CD33
Monocytic CD14, CD68
Megacaryocytic CD41, CD61
Erythrocytic glycophorin 1 (CD235)
Stem cell marker - CD34
AL: Diagnosis Laboratory Data
Cytogenetics
 Cytogenetic aspects (karyotype).

ALL
Hyperdiploidia (>47 chromosomes) in
children no impact on prognosis.

Translocations:
t 8:14 (q24:q32) = ALL 3
t (9;22), (Ph1) ALL (bad prognosis)
t 15:17 (q22:q21) = AML3 (good prognosis)
t 8:21 (q22:q22) =AML (good prognosis)

Normal karyotype good prognosis

 AL: Diagnosis Laboratory Data
Fluorescent in situ hybridization (FISH)
 AL: Diagnosis Laboratory Data
Molecular genetics (PCR, sequencing

AML detects genomic abnormalities that are not

visible by karyotyping useful especially in normal
cytogenetic cases (NC-AML)
FLT3 (FMS-like tyrosine kinase-3) mutations
20-30% af all cases
25-40% of NC-AML
Bad prognosis.
NPM1 (nucleophosmin 1) mutations
20-30% of all cases
40-55% of NC-AML
Good prognosis (when not associated with FLT3
mutations)
Many other mutations..
!!! Minimal Residual Disease
(MDR)
 AL Classification

Acute lymphoblastic leukemia (ALL)

Acute myeloblastic leukemia (AML)
 ALL classification- morphologic criteria
 ALL classification Immunophenotipic criteria

B-cell ALL ~ 80% of cases

Precursor B type (pB)
proB - (5% of children, 10% of adults) HLA-DR+, TdT+,
CD19+, CD34+
common - (65% of children, 50% adults) HLA-DR+, TdT+,
CD19+, CD10+
preB (15% children, 10% adults) HLA-DR+, TdT+, CD19+,
CD10+/-, cytoplasmatic IgM (cIgM) +
Matur B type (3% of children, 5% of adults) HLA-DR+,
CD19+, CD20+/-, CD10+/-, sIgM + ; cytologically Burkitt-like

T-cell ALL ~ 20% of cases

Precursor T (1% of children, 7% of adults) TdT+, CD3+,
CD7+
Mature T (11% of children, 17% of adults) TdT+,
CD3+, CD1a+, CD5+
ALL classification
 AML 2 classifications are used;
Morphologic- FAB (French-American-British) classification
(the 80).

The FAB classification is no longer used:

Does not take into consideration cytogenetic abnormalities
Is not useful in taking decision (except APL - M3)
APL: Leucemia acuta promielocitara - particularitati:
- citologice corpi AUER
- biologice => CID
- citogenetic => t 15:17 (q22:q21) => onc PML / RAR alfa
2. The 2008 WHO AML classification
AML with recurrent genetic abnormalities
AML with t(8;21) (q22;q22 [RUNX1-RUNX1T1]
AML with inv(16)(p13.1;q22) or t(16;16)(p13.1;q22) - [CBF/MYH11]
Acute promyelocytic leukemia with t(15;17) (q12;q22) [PML/RARA]
AML with t(9;11)(p22;q23) [MLLT3-MLL]
Provisional entities molecularly defined:
AML with NPM1 mutations
AML with CEBPA mutations

AML with myelodysplasia - related changes (MRC)

AML and MDS, therapy related

AML not otherwise categorized

AML minimally differentiated
AML without maturation
AML with maturation
Acute myelomonocytic leukemia
Acute erythroid leukemia
Acute megakaryocytic leukemia
Acute basophilic leukemia
Acute panmyelosis with myelofibrosis

Vardiman et al. 2008

 Acute leukemia prognosis
1. ALL
Very good prognosis in children: 70-80% cure after
chemotherapy.
In adults prognosis is much worse:
20-30% cure after chemotherapy
40-50% after allogeneic stem cell transplant (SCT)
Prognostic factors in ALL
Bad:
WBC > 40.000/l
T and B mature phenotype
CNS involvement
Ph +
Good:
Common immunophenotype
2. AML bad prognosis median survival <1 year

Prognostic factors
Good cure in 30-50%:
Age <60 years
FAB M3 (APL) with t(15;17) 70-80% cure
t(8;21) and inv16 cure 40-60%
NPM1 mutations
Bad cure 5-10%:
Age >60 de ani
AML with myelodysplasia - related changes (MRC)
AML therapy related
Bad karyotype
FLT3 mutations
 AL treatment
Treatment is very complex: supportive measures,
chemotherapy, transplant
The first step towards cure: Complete Remission (CR)
CR can be defined as apparent cure (1000 X reduction of
number of tumor cells).

CR criteria:
No lymphadenopathy, no hepato/splenomegaly.
PB: neutrophils >1500/l, platelets >100.000/l, no blasts
<5% blasts n BM
Normal cerebrospinal fluid (CSF).
Normal karyotype

MRD !!!!
 General supportive measures:
Isolation
Hygene
Hyperuricemia prophylaxis: allopurinol,
rasburicase, alcalinisation.
Antibiotics, antifungals, antivirals
Transfusions:
Red cells : Hgb<7-8 g/dl
Platelets: Plt <10 000/l.
Growth factors.
In severe neutropenia (<500/l): G-CSF
 Chemotherapy

1. ALL standard chemotherapy

Several steps:
Remission induction
Combinations: antracyclines, vincristine, L-
asparaginase, corticoids
CNS prophylaxis
MTX, Ara-C i.t.
Consolidation
High dose MTX, Ara-C
Maintenance up to 3 years
Low dose 6MP, MTX
GMALL protocol HyperCVAD protocol
1. Induction 1. 1. Cycle A.
Vincristine (iv) 2mg, days 1, 8, 15, 22 Cyclophosphamide (iv, 3h, at 12 h) 300mg/m2, days
Doxorubicin (iv, 30 min), 25 mg/m2, days 1, 8, 15, 22 1,2,3
L-Asparaginase (iv, 30 min), 5 000 IU/m2, days
15,17,19,21,23,25,27 Methotrexate (i.t.) 15 mg, day 2
Prednisone (po) 60 mg/m2, days 1-28 Doxorubicin (iv, 30min) 50mg/m2, day 4
Methotrexate (i.t.) - 15 mg, day 1 Vincristine (iv) 2mg, days 4,11
2. Induction 2.
Dexamethasone (iv or po) 40mg days 1-4 and 11-14
Cyclophosphamide (iv) - 650 mg/m2, days 29, 43, 57
Ara-C (iv, 1 h) - 75 mg/m2, days 31-34, 38-41, 45-48, 52-55 Cytarabine (i.t.) - 70mg, day 7
6-Mercaptopurine (po) - 60 mg/m2, days 29-57
Methotrexat (i.t.) 15 mg, days 31, 38, 45, 52 2. Cycle B
3. Consolidation 1. (HDARAC+Mitox) + (HDMTX+Asp+6MP)
Methotrexate (iv, 24h) 1000mg/m2, day 1
Ara-C (iv, 3 h, at 12h) - 1 000 mg/m2, days 1-4
Mitoxantrone (iv, 30 min) 10 mg/m2, days 3-5, then, after Leucovorin (iv, 24 h after MTX) 6 doses every 6 h
hematological recovery: Ara-C (iv, 2 f, at 12 h) 3000mg/m2, days 2,3
Methotrexate (iv, 24 h) - 1 500 mg/m2, days 1, 15 + Leucovorin
L-Asparaginase (iv, 30 min) - 10 000 U/m2, days 2,16
A total of 8 cycles (4A + 4B)
6-Mercaptopurine (po) - 25 mg/m2, days 1-5, 15-19
4. Reinduction 1.
Vincristin (iv) 2mg, days 1, 8, 15, 22 3. Maintenance POMP 2 years
Doxorubicin (iv, 30 min) - 25 mg/m2, days 1, 8, 15, 22 Vincristine (iv) - 2mg, day 1
Prednison (po) 60 mg/m2, days 1-28
MTX 15 mg + Ara-C 50 mg + Dexamethasone 4 mg (i.t.) d 1
Prednisone (po) 60mg/m2, days 1-5
5. Reinduction 2. 6-Mercaptopurine (po) 60mg/m2, weekly, days 1-5
Cyclophosphamida (iv) - 650 mg/m2, day 29 Methotrexate (po) 12,5mg/m2, weekly, day 6
Ara-C (iv, 1 h) - 75 mg/m2, days 31-34, 38-41
6-Thioguanina (po) - 60 mg/m2, days 29-57
MTX 15 mg + Ara-C 50 mg + Dexametazona 4 mg (i.t.) day 29
6. Consolidation 2.
Etoposide (iv, 1 h) - 100 mg/m2, days 1-5
Ara-C (iv, 1 h) - 150 mg/m2, days 1-5, then, after hematological
recovery:
Cyclophosphamide (iv) - 1 000 mg/m2, day 1
Ara-C (iv, 24 h) - 500 mg/m2, day 1
MTX 15 mg + Ara-C 50 mg + Dexametasone 4 mg (i.t.) day 1
7. Maintenance 2 years.
6-Mercaptopurine (po) 60mg/m2, w eekly, days 1-5
Methotrexate (po) 12,5mg/m2, w eekly, day 6
Treatment of certain ALL subtypes:

Ph1-ALL [t(9;22)]: Tyrosine kinase

inhibitors - imatinib 600-800mg/day or
dasatinib 140mg/day are added, a la
longue.

B-ALL(Burkitt), CD20+: monoclonal anti-

CD20 antibodies (rituximab) are added
2. AML Standard chemotherapy (except M3):

Remission induction: 12 cycles 3/7 regimen

Idarubicin 12mg/m2 days 1,3,5
Cytarabine (Ara-C) 100-200mg/m2, days 1-7
Remission consolidation: High-dose Ara-C 3-4 cycles
Ara-C (iv 3h, every 12 ore) 3g/m2 days 1,3,5

M3 (Acute promylocytic leukemia, APL)

Induction:
All-trans retinoic acid (ATRA) 45mg/m2, p.o, day 1 till CR (usually 14-30 days)
induces leukemic cell differentiation
Idarubicin 12mg/m2, days 2, 4, 6, 8
Consolidation:
Idarubicin 5 mg/m2 days 1-4, repeated at 28 days, 3 cycles
Maintenance up to 2 years from onset
- 6MP 90 mg/m2/day, p.o. Days 1-5 of every week
- Methotrexate 15mg/m2, p.o., day 6
- ATRA 45mg/m2/day, p.o., days 1-15, every 3 months
 Stem cell transplant
Allogeneic stem cell transplant (allo-SCT)
Indicated as soon as possible, in 1st CR:
ALL
ALL Ph+
In adults with bad prognostic factors (<60 years)
AML
All intermediate/bad risk patients <60 years

In relapse/refractory disease all patients <60 ani

Autologous stem cell transplant (auto-SCT)

When no donor is found for allo-SCT
It is not clear if there is an advantage over chemotherapy
alone
 AL treatment

Leukemia free survival at 3 years

Allo SCT Chemotherapy

ALL
First CR 30-60 % 20-70 %
Second CR 30-50 % 10 %
AML
First CR 40-60 % 10-50 %
Second CR 30 % 10 %
Acute Leukemia
=
Emergency !!!