ALL SEMINAR

1. ACUTELYMPHOBLASTICLEUKEMIA

2. LEUKEMIA
• Leukemia are the neoplastic proliferation of
hemopoietic cells.
• Acute leukemias are defined as neoplsam
• AML - more than 20 % blast
• ALL- more than 25% blast.

3. • Commonest form of malignancy in childhood.
• Peak incidence at 4 – 5 yrs of age.
• Acute onset with short history of duration.
• 85% are B cell , 15% are T cell.
ACUTE LYMPHOBLASTIC
LEUKEMIA

4. • HEREDITARY
• ACQUIRED
• Ionizing radiations
• Therapeutic radiations
• Nuclear fallout
• Diagnostic Xrays
• Chemical agents
• Viruses
PREDISPOSING FACTORS

5. • Activation of a proto-oncogene to an oncogene when it
is translocated to a transcriptionally active site
• Formation of a chimeric transcription factor
• Formation of a fusion protein with enhanced tyrosine
kinase activity
• Activation of FTL3 receptor
• Inactivation of tumour suppressor gene pathway
MECHANISM OF LEUKAEMOGENESIS

6. SYMPTOMS
• FEVER
• FATIGUE
• BONE /JOINTS PAIN
• WEIGHT LOSS
• PURPURA AND BLEEDING MANIFESTATION
• LYMPHADENOPATHY
• HEPATOSPLENOMEGALY
• STERNAL TENDERNESS
• MEDIASTENAL MASS

7. FAB CLASSIFICATION
• Based on morphology and cytochemistry.
•
stain AML ALL
MPO + -
SBB + -
NSE + IN M4, M5 AND M7 -
PAS FINE + IN M6 , M7 + , BLOCK
ACID PHOSPHATASE - +, T ALL

8. FAB CLASSIFICATION
 ALL L1
 ALL L2
 ALL L3
 In childhood – L1 is the most common type
 In adults – L2 is the most common type

9. FAB classification
Morphology L1 L2 L3
1 Size of blast Small Large
heterogeneous
Large
homogenous
2 Cytoplasm Scanty Moderate Moderate,
intensely
basophilic
3 N/C Ratio High Lower Lower
4 Cytoplasmic vacuoles +/- +/- Prominent
5 Nuclear membrane Regular Irregular with clef
ting
Regular
6 Nucleoli Invisible /
indistinct
Prominent 1-2 Prominent 1-2

10. CRITICISM OF FAB CLASSIFICATION
1- It dose not include
• Immunophenotyping
• Cytogentics
• Molecular characteristics
2- immunological subtype of ALL
3-biphenotypic leukemia
4- Limited relevance to therapeutic or
prognostic implications.

11. WHO CLASSIFIACTION OF ALL (2008)
1-B lymphoblastic leukemia/lymphoma nos
2- B lymphoblastic leukemia/lymphoma with recurrent
abnormalities
• t( 9; 22) , BCR ABL1
• t( v; 11q23) MLL rearangement
• t (12;21) ETV6-RUNX1
• With hypodiploidy
• With hyperdiploidy
• t (5;14) il3 –igh
• t ( 1;19) E2A-PBX1 (tcf3-pbx1)
3-T lymphoblastic leukemia/lymphoma

12. IMMUNOLOGICAL CLLASIFICATION
• 1- B ALL
• PRO B ALL
• EARLY PRE B ALL
• PRE B ALL
• MATURE B ALL
• 2- T ALL
• 3- MIXED LINEAGE ACUTE LEUKEMIA
• 4-Undifferentiated acute leukemia

13. IMMUNOLOGICAL CLLASIFICATION
SUBTYPE HLA DR TdT CD 10 cIg smIg
Pro B ALL +_ + - - -
COMMON ALL + + + - -
Pre BALL + - - + -
Mature B ALL - - - - +

14. T ALL
• PAS negative acid phosphatase positive
• CNS involvement and mediastenal mass
• CD3 ,2 and 7 positive

15. Scoring system for biphenotypic leukemia
points B lineage T lineage Myeloid
2.0 CD 79a
CD 22.
CD 3 MPO
1.0 CD 10 CD 1 CD 13
0.5 TdT TdT, CD 7 CD 11b
CD 11c
Score above 2 from two lineage is diagnostic of biphenotypic leukemia

16. Uncommon variants of ALL
• Small cell variant- blast cells are small and
may be mistaken for lymphocytes.
• Hand mirror variants- a subtype with
cytoplasmic protrusion .
• ALL with eosinophilia
• Granular cell ALL- The cells are large and
demonstrate azurophilic granulaes .

17. Hand mirror variants

18. • Peripheral Blood smear
• Bone marrow aspiration smear
• Cytochemistry
• Immunophenotyping
• Cytogenetic analysis
• Molecular genetic analysis
DIAGNOSIS OF ACUTE LEUKEMIA

19. PERIPHERAL BLOOD EXAMINATION
• Total leucocyte count raised , normal or low.
• Normocytic normochromic anaemia.
• Thrombocytopenia.

21. • Subleukemic leukemia-Total leukocyte count
is normal or low , but blast are seen in the
peripheral blood.
• Aleukemic leukemia- Blast are not seen in the
peripheral blood , but are demonstrable only
in bone marrow.

22. BONE MARROW EXAMINATION
• Hypercellular
• Normal hematopoietic elements diminished

23. ALL L1
Size – small.
Cytoplasm scanty basophilic.
N/C Ratio – high.
Nuclear membrane – regular.
Nucleoli – invisible or indistinct.

24. BONE MARROW SMEAR
BLAST

25. ALL L2
 Size of blast – large & heterogenous
 Cytoplasm – moderate
 N/C Ratio – lower
 Cytoplasmic vacuoles – variable
 Nuclear membrane – irregular with clefting
 Nucleoli – prominent ,1-2

26. BONE MARROW SMEAR

27. ALL L3
 Size of blast – large & homogenous
 Cytoplasm – moderate & intensely basophilic
 N/C Ratio – lower
 Cytoplasmic vacuoles – prominent
 Nuclear membrane – regular
 Nucleoli – prominent , 1-2

28. BONE MARROW SMEAR
LYMPHOBLAST WITH CYTOPLASMIC VACUOLES &
NUCLEOLI

29. STARRY SKY PATTERN

30. PAS STAIN
LYMPHOBLAST WITH BLOCK & COARSE GRANULAR STAINING

31. STAINS
METHYL GREEN PYRONINE OIL RED
O(VACUOLES)

32. • Diagnosis and classification.
• Assessment of prognosis.
• Monitoring of minimum residual disease.
IMMUNOPHENOTYPING

33. • Establishment of lineage-DNA analysis.
• Identification of translocation.
• Detection of relapse.
• Detection of minimum residual disease.
Molecular Genetics-

34. OTHER INVESTIGATIONS
• Lumbar puncture.
• Testicular biopsy.
• X-Ray chest.

35. DIFFERENTIAL DIAGNOSIS
• Leukemic phase of Non Hodgkins Lymphoma
• Reactive lymphocytosis due to infections
• Metastatic tumours in bone marrow
• AML

36. ALL Vs AML
ALL AML
Age Mainly children Mainly adults
Lymphadenopathy Usually present Usually absent
Hepatosplenomegaly +ve mild +ve mild
Gum hypertrophy -ve +ve in M4/M5
Skin infiltration -ve +ve in M4/M5
CNS involvement +ve in some +ve in some
Granulocytic sarcoma -ve +ve in few cases
Mediastinal mass +ve in T-ALL -
Associated DIC -ve +ve in M3
Serum muramidase Normal In M4/M5 (monocytic type)
Prognosis Good Bad

37. MorphologyLymphoblast Myeloblast
Nuclear chromatin Coarse Fine
Nucleoli 1-2 3-5
N:C ratio High High
Auer rod -ve +ve
Accompanying
cells
Lymphocytes Myeloid precursor
Myelo peroxidase -ve +ve
Sudan Black B -ve +ve
PAS stain Block positivity -ve in blast

38. AML ALL

39. PROGNOSTIC FACTORS
Factor Good prognosis Bad prognosis
Race White Black
Age 2-8 yrs <1yr.,adult, >10 yrs
Sex Female Male
Meningeal involvement - +
Lymphadenopathy, liver,
spleen
- Massively enlarged
Mediastinal mass - +
TLC <20x109
/L >50 x109
/L
Type of ALL L1 L2,L3
Cytogenetics Hyperdiploidy >50
chromosomes
Pseudodiploidy, t (4;11),t (9;22), BCR-ABL
fusion m RNA, MLL-AF4 fusion mRNA.
Immuno-phenotype B-ALL,CD 10+, Early pre-B
cell
T-ALL in children

40. Minimal residual disease detection
– ALL – B cell
– Cd20/cd10/cd19/cd45
– Cd9/cd34/cd19/cd45
– Cd58/cd10/cd38/cd19
– Cd20/cd10/cd19/cd34
– ALL –T cell
– TdT/CD5/CD3/CD7

42. • MODERATOR— Prof. Dr. C. V. KULKARNI
• SPEAKER- DR. NARMADA PRASAD TIWARI

43. • AML
• CD34/CD33/HLA-DR/CD45
• CD34/CD117/CD33/CD45
• CD115/CD117/CD33/CD34
• HLA-DR/CD117/CD33/CD34
• CLL
• CD20/CD79a/CD19/CD5

44. Factors Predisposing to Childhood
Leukemia
• GENETIC CONDITIONS
Down syndrome
• Fanconi syndrome
• Bloom syndrome
• Diamond-Blackfan
anemia
• Schwachman syndrome
• Klinefelter syndrome
• Turner syndrome
• Neurofibromatosis
• Ataxia-telangiectasia
• Severe combined
immune deficiency
• Paroxysmal nocturnal
hemoglobinuria
• Li-Fraumeni syndrome

45. • ENVIRONMENTAL FACTORS
• Ionizing radiation
• Drugs
• Alkylating agents
• Nitrosourea
• Epipodophyllotoxin
• Benzene exposure
• Advanced maternal age