1. Acute Leukemia
Kristine Krafts, M.D.

3. Hematologic Malignancies
Leukemia
Malignancy of hematopoietic cells
Starts in bone marrow, can spread to blood, nodes
Myeloid or lymphoid
Acute or chronic
Lymphoma
Starts in lymph nodes, can spread to blood, marrow
Lymphoid only
Hodgkin or non-Hodgkin

4. Hematologic Malignancies
Leukemias
Acute leukemias
Chronic leukemias
Lymphomas
Hodgkin lymphoma
Non-Hodgkin lymphoma
Plasma cell disorders
Multiple myeloma

6. Hematologic Malignancies
Myeloid
Lymphoid
Acute myeloid leukemia
Chronic myeloid leukemia
Acute lymphoblastic leukemia
Chronic lymphocytic leukemia
Hodgkin lymphoma
Non-Hodgkin lymphoma
Multiple myeloma

7. How is a diagnosis made? Clinical setting Morphology Immunophenotyping
Molecular studies
Cytogenetics

9. Bone marrow biopsy needle

10. Bone marrow biopsy: cellularity

11. Normal bone marrow biopsy

12. Normal bone marrow biopsy

13. Bone marrow aspiration needle

14. Bone marrow aspiration

15. Normal bone marrow aspirate

16. Normal bone marrow aspirate

17. Acute leukemias

18. Chronic leukemias

19. Non-Hodgkin lymphoma

20. Hodgkin lymphoma

21. Myeloma

22. (Non-specific esterase)
Morphology
Regular stain
(Wright-Giemsa)
Cytochemical stain
(Non-specific esterase)

23. Immunophenotyping

24. Normal
chromosomes
Chromosomes
in CML

25. Cytogenetics

26. Molecular Studies
cut
paste
amplify

27. Hematologic Malignancies
Leukemias
Acute leukemias
Chronic leukemias
Lymphomas
Hodgkin lymphoma
Non-Hodgkin lymphoma
Plasma cell disorders
Multiple myeloma

28. Hematologic Malignancies
Leukemias
Acute leukemias
Chronic leukemias

29. Acute vs. chronic leukemia
Acute leukemia
Sudden onset
Can occur in either adults or children
Rapidly fatal without treatment
Composed of immature cells (blasts)
Chronic leukemia
Slow onset
Occurs only in adults
Longer course
Composed of mature cells

30. Acute
ALL
AML
Chronic
CLL
CML
Lymphoid
Myeloid

31. Acute
ALL
AML
Chronic
CLL
CML

33. Acute lymphoblastic leukemia Acute myeloid leukemia

35. Chronic myeloid leukemia Chronic lymphocytic leukemia

36. ALL
AML
CLL
CML
Lymphoid
Myeloid

39. Hematologic Malignancies
Leukemias
Acute leukemias

40. Pathophysiology of Acute Leukemia
Definition: malignant proliferation of immature myeloid or lymphoid cells in the bone marrow
Cause
Clonal expansion
Maturation failure
Badness
Crowd out normal cells
Inhibit normal cell function
Infiltrate other organs

42. Acute lymphoblastic leukemia Acute myeloid leukemia

43. Acute leukemia: bone marrow biopsy

44. Clinical Findings in Acute Leukemia
Sudden onset (days)
Symptoms of bone marrow failure
Fatigue
Infections
Bleeding
Bone pain (expanding marrow)
Organ infiltration (liver, spleen, brain)

45. Laboratory Findings in Acute Leukemia
Blasts/immature cells in blood
Leukocytosis
Anemia
Thrombocytopenia

46. Hematologic Malignancies
Leukemias
Acute leukemias
acute myeloid leukemia
acute lymphoblastic leukemia

47. Hematologic Malignancies
Leukemias
Acute leukemias
acute myeloid leukemia

48. Acute Myeloid Leukemia
Things you must know
Malignant proliferation of myeloid blasts in blood, bone marrow
20% cutoff for diagnosis
Many subtypes
Bad prognosis

50. Acute Myeloid Leukemia
M0 - acute myeloblastic leukemia, minimally differentiated
M1 - acute myeloblastic leukemia without maturation
M2 - acute myeloblastic leukemia with maturation
M3 - acute promyelocytic leukemia
M4 - acute myelomonocytic leukemia
M5 - acute monocytic leukemia
M6 - acute erythroblastic leukemia
M7 - acute megakaryoblastic leukemia

51. Acute Myeloid Leukemia
involve neutrophilic series
(myeloblasts, promyelocytes, etc.)
involve monocytic series (monoblasts, etc.)
involves erythroid series (erythroblasts)
involves megakaryocytic series (megakaryoblasts)

52. 20%
need at least
blasts

53. Acute myeloid leukemia: >20% blasts

54. Acute myeloid leukemia: >20% blasts

55. Acute myeloid leukemia

56. AML-M3 (acute promyelocytic leukemia)

57. AML-M6 (acute erythroblastic leukemia)

58. AML-M5 (acute monoblastic leukemia)

59. AML-M5: brain involvement

60. AML-M5: brain involvement

61. AML-M5: gum involvement

62. before (L) and after (R) treatment
AML: gum involvement
before (L) and after (R) treatment

63. AML-M0: Acute myeloid leukemia without differentiation

64. Auer rods

65. Treatment and Prognosis of AML
Chemo
Bone marrow transplant
Prognosis
Dismal
Some chromosomal abnormalities convert different prognosis
If therapy-related, worse prognosis

66. Myelodysplastic Syndrome
Dysmyelopoiesis ± increased blasts
May evolve into AML
Older patients, usually
Asymptomatic or marrow failure
Macrocytic anemia
Treatment depends on age, aggressiveness

67. Dyserythropoiesis (dysmyelopoiesis in red cells)

68. Dysgranulopoiesis (dysmyelopoiesis in neutrophils)

69. Hematologic Malignancies
Leukemias
Acute leukemias
acute myeloid leukemia
acute lymphoblastic leukemia

70. Acute Lymphoblastic Leukemia
Things You Must Know
Malignant proliferation of lymphoid blasts in blood, bone marrow
Classified by immunophenotype (B vs. T)
More common in children
Prognosis often good!

72. ALL

73. ALL

74. ALL Immunophenotype T-lineage ALL: worse prognosis.
B-lineage ALL: better prognosis.

75. children
most common in

76. Treatment and Prognosis of ALL
Chemo ± bone marrow transplant
Many children are cured!
Prognosis
Immunophenotype (T is worse)
Age (1-10 better)
WBC (<10,000 better)
Cytogenetics (hyperdiploidy better!)