1. Myelodysplastic syndrome and acute myeloid leukaemia
Dr. Edmond S. K. Ma
Division of Haematology
Department of Pathology
The University of Hong Kong

2. Leukaemia classification
FAB
MIC 1987
EGIL 1996
REAL
Proposed by ILSG in 1994
Lymphoma classification, but principles extended to other haemic neoplasms
Encompasses all available information
Consensus approach

3. WHO Classification Collaborative project of: Started in 1995
European Association for Haematopathology
Society for Haematopathology
Started in 1995
Steering Committee
Working Group Meeting in Lyon, France, November 8 – 11, 2000
Clinical Advisory Committee

4. Myelodysplastic syndrome
A group of clonal haemopoietic stem cell disorder characterized by dysplasia and ineffective haemopoiesis in one or more major myeloid cell line
< 20% blasts in blood and bone marrow

5. Myelodysplastic syndrome
A disease of the elderly
Incidence : 3 – 20 /100,000
Increasing number of therapy related MDS
Clinical features: related to cytopenia
Etiology: prior chemoradiotherapy, benzene exposure, cigarette smoking, inherited syndromal disorders (e.g. Fanconi’s anaemia)

6. Dyserythropoiesis Nuclear budding Inter-nuclear bridging Karyorrhexis
Multinuclearity
Megaloblastoid maturation
Ringed sideroblast
Vacuolation
PAS +ve

7. Dyserythropoiesis

8. Dyserythropoiesis

9. Dysgranulopoiesis Small size
Nuclear hypolobulation (pseudo-Pelger Heut)
Hypersegmentation
Hypogranularity
Pseudo-Chediak Higashi granules

10. Dysgranulopoiesis

11. Dysgranulopoiesis

12. Dysmegakaryocytopoiesis
Hypolobulated micro-megakaryocyte
Non-lobulated nuclei in megakaryocyte of all sizes
Multiple, widely separated nuclei

13. Megakaryocyte dysplasia

14. Megakaryocyte dysplasia

15. Abnormal localization of immature precursors
Presence of 3 or more small clusters of myeloblasts and promyelocytes (5 – 8 cells) in marrow trephine biopsy in the central portion of the marrow away from the vascular structure and the endosteal surface of the bone trabeculae

16. Abnormal localization of immature precursors

17. Genetics
5q- syndrome
del (17p), small hypolobulated or vacuolated neutrophils, p53 mutations, poor prognosis
-5/5q-
-7/7q-
del(20q)
3q21q26 abnormality

18. Cytogenetics and prognosis
Good risk
Normal, isoloted 5q-, isolated 20q-, -Y
Poor risk
Complex changes (> 3 abnormalities)
Chromosome 7 abnormalities
Intermediate risk
All other changes

19. International Prognostic Scoring System
Score
% blasts <
Karyotype Good Intermediate Poor
Cytopenia
Cytopenia: Hb < 10 g/dL; neutrophils < 1.5 X 109/L; plt < 100 X 109/L
Risk groups
Low = 0; Intermediate-1 = 0.5-1; Intermediate-2 = 1.5-2; High = 2.5

20. Refractory anaemia PB anaemia, no or rare (<1%) blasts MB
Unilineage dysplasia, restricted to erythroid lineage,
< 5% blasts,
< 15% ringed sideroblasts

21. Refractory anaemia
Exclusion of known secondary causes of dyserythropoiesis
If no cytogenetic abnormality present, reassess after 6 months
Protracted clinical course, median survival is 66 months, leukaemic transformation 6%

22. Giant pronormoblast is parvovirus infection

23. Refractory anaemia with ringed sideroblastsPB
Anaemia
No blast MB
 15% ringed sideroblasts
Erythroid dysplasia only
<5% blasts

24. Ringed sideroblast Erythroid precursor
One third or more of the nucleus
Encircled by 10 or more siderotic granules

25. Refractory anaemia with ringed sideroblasts
Indolent clinical course
Median survival = 6 years
Leukaemic transformation 1 – 2 %

26. Refractory cytopenia with multilineage dysplasiaPB
Bicytopenia or pancytopenia
No or rare blasts
No Auer rod
< 1 X 109/L monocytes MB
Dysplasia in  10% of cells in two or more myeloid cell lines
< 5% blasts
No Auer rod
< 15% ringed sideroblasts

27. Refractory cytopenia with multilineage dysplasia

28. Refractory cytopenia with multilineage dysplasia

29. Refractory cytopenia with multilineage dysplasia

30. Refractory cytopenia with multilineage dysplasia and ringed sideroblastsPB
Bicytopenia or pancytopenia
No or rare blasts
No Auer rod
< 1 X 109/L monocytes MB
Dysplasia in  10% of cells in two or more myeloid cell lines
< 5% blasts
No Auer rod
 15% ringed sideroblasts

31. Refractory cytopenia with multilineage dysplasia
Cytogenetic abnormality seen in 50% +8
Monosomy 7
del(7q)
Monosomy 5
del (5q)
del (20q)
Complex karyotype

32. Refractory cytopenia with multilineage dysplasia
Leukaemic transformation 11%
Overall median survival 33 months
RCMD and RCMD-RS are similar in clinical course
Patients with complex karyotype have similar clinical course to RAEB

33. Refractory anaemia with excess blasts-1PB
Cytopenia
<5% blasts
No Auer rod
<1% monocytes MB
Unilineage or multilineage dysplasia
5-9% blasts
No Auer rod

34. Refractory anaemia with excess blasts-2PB
Cytopenia
5-19 % blasts
Auer rod ±
<1% monocytes MB
Unilineage or multilineage dysplasia
10-19% blasts
Auer rod ±

35. Refractory anaemia with excess blasts-2

36. Refractory anaemia with excess blasts
Blast cells show myeloid phenotype
Leukaemic transformation
RAEB-1 25%
RAEB-2 33%
Median survival
RAEB-1 18 months
RAEB-2 10 months

37. Myelodysplastic syndrome, unclassifiablePB
Cytopenias
No or rare blasts
No Auer rods MB
Unilineage dysplasia, one myeloid cell line
(non-erythroid)
<5% blasts
No Auer rod

38. 5q- syndrome PB Anaemia Usually normal or increased platelet count
<5% blasts MB
Normal or increased megakaryocytes with hypolobulated nuclei
<5% blasts
Isolated 5q- abnormality
No Auer rod

39. 5q- syndrome

40. Acute myeloid leukaemia
Acute myeloid leukaemia with recurrent genetic abnormalities
Acute myeloid leukaemia with multilineage dysplasia
Acute myeloid leukaemia and myelodysplastic syndrome, therapy-related
Acute myeloid leukaemia not otherwise categorized

41. Acute myeloid leukaemia

42. Acute myeloid leukaemia

43. Acute myeloid leukaemia
The blast % is lowered from 30% (FAB) to 20% (WHO)
Median age of onset = 60 yrs
Incidence 4 –10 / 100,000
Etiology

44. Myeloblasts versus lymphoblasts

45. Acute myeloid leukaemia

46. Acute lymphoblastic leukaemia

47. Acute myeloid leukaemia: cytochemistry
Myeloperoxidase
Sudan Black B
Non-specific esterase
a-naphthyl butyrate
a-naphthyl acetate

48. Cytochemistry: MPO

49. Cytochemistry: NSE

50. Cytochemistry

51. Acute myeloid leukaemia: role of immunophenotyping
Distinction of minimally differentiated AML from acute lymphoblastic leukaemia
Recognition of AML-M7
Recognition of specific AML sub-categories (e.g CD56+ve AML)
Diagnosis of biphenotypic leukaemia
However, immunophenotyping is not mandatory in typical cases of AML, unlike in ALL where a phenotypic diagnosis is needed in every case

52. Acute myeloid leukaemia: role of immunophenotyping

53. Panel of monoclonal antibodies in classification of acute leukaemia
Haemopoietic precursors: CD34, HLA-DR, Tdt, CD45
B-lineage: CD19, CD20, CD22, CD79a
T-lineage: CD2, CD3, CD5, CD7
Myeloid: CD13, CD33, CD117, anti-MPO
Megakaryocytic: CD41, CD61

54. Acute myeloid leukaemia with recurrent genetic abnormalities
Acute myeloid leukaemia with t(8;21)(q22;q22); AML1/ETO
Acute myeloid leukaemia with abnormal bone marrow eosinophils and inv(16)(p13q22) or t(16;16)(p13;q22); CBFb/MYH11
Acute promyelocytic leukaemia (AML with t(15;17)(q22;q12); PML/RARa and variants
Acute myeloid leukaemia with 11q23 (MLL) abnormalities

55. Acute myeloid leukaemia with t(8;21)(q22;q22); AML1/ETO
t(8;21) is the commonest translocation in AML
Associated with AML-M2 morphology
Tumour masses (granulocytic sarcoma)

56. Acute myeloid leukaemia with t(8;21)(q22;q22); AML1/ETO
Morphology
Large blasts, heavily granulated
Frequent Auer rods
Variable dysplasia in granulocytic series
Rare cases with blast count < 20%
Immunophenotype
CD13+ CD33+ anti-MPO+
CD19+ CD34+ CD56±

57. Acute myeloid leukaemia with t(8;21)(q22;q22); AML1/ETO

58. Acute myeloid leukaemia with t(8;21)(q22;q22); AML1/ETO

59. Acute myeloid leukaemia with t(8;21)(q22;q22); AML1/ETO

60. Acute myeloid leukaemia with t(8;21)(q22;q22); AML1/ETO

61. Detection of fusion genes by FISH

62. Detection of fusion genes by FISH

63. Acute myeloid leukaemia with t(8;21)(q22;q22); AML1/ETO
Prognosis
Good response to chemotherapy and high complete response rate
Long term disease free survival
Adverse factors
additional chromosomal changes e.g. 9q-
CD56 +ve

64. Granuolocytic and monocytic features
Acute myeloid leukaemia with inv(16)(p13q22) or t(16;16)(p13;q22); CBFb/MYH11
Granuolocytic and monocytic features
AML-M4 (acute myelomonocytic leukaemia) morphology
Abnormal eosinophils with coarse basophilic granules

65. Acute myeloid leukaemia with inv(16)(p13q22) or t(16;16)(p13;q22); CBFb/MYH11

66. Cytochemistry Immunophenotype Prognosis
Acute myeloid leukaemia with inv(16)(p13q22) or t(16;16)(p13;q22); CBFb/MYH11
Cytochemistry
Abnormal eosinophils are CAE +ve
Immunophenotype
Granulocytic and monocytic markers
Co-expression of CD2 in blast population
Prognosis
Favourable

67. Acute myeloid leukaemia with inv(16)(p13q22) or t(16;16)(p13;q22); CBFb/MYH11

68. Acute promyelocytic leukaemia
AML with t(15;17)(q22;q12); PML/RARa and variants
Characteristic morphology
Associated with disseminated intravascular coagulation

69. Acute promyelocytic leukaemia

70. Acute promyelocytic leukaemia

71. Acute promyelocytic leukaemia
Immunophenotype
CD33+ CD13+
HLA-DR and CD34 negative
Co-expression of CD2 and CD9
Genetics
t(15;17)(q22;q12)
Variants: t(11;17)(q23;q12) PLZF/RARa; t(5;17)(q32;q12) NPM/RARa; t(11;17)(q13;q12) NuMA/RARa

72. Acute promyelocytic leukaemia

73. Acute promyelocytic leukaemia
Treatment
All-trans retinoic acid (ATRA)
Arsenic for relapse cases
RARa variants: resistant to ATRA
Prognosis
Favourable when treated optimally with ATRA followed by anthracyclines

74. Acute myeloid leukaemia with 11q23 abnormalities
Infant leukaemia
Therapy related AML after exposure to DNA topoisomerase II inhibitors
Acute monocytic and myelomonocytic leukaemia
Associated with MLL rearrangement

75. Acute myeloid leukaemia with multilineage dysplasia
Following MDS or MDS/MPD
Without antecedent MDS
Dysplasia in  50% of cells in at least 2 lines
Poor prognosis

76. AML and MDS, therapy related
Alkylating agent related
Topoisomerase type II inhibitor related

77. Acute myeloid leukaemia not otherwise categorized
Equivalent to FAB classification
AML minimally differentiated
AML without maturation
AML with maturation
Acute myelomonocytic leukaemia
Acute monoblastic and monocytic leukaemia
Acute erythroid leukaemia
Acute megakaryoblastic leukaemia
Acute basophilic leukaemia
Acute panmyelosis with myelofibrosis
Myeloid sarcoma

78. AML without maturation

79. Acute myeloid leukaemia with maturation

80. Acute monocytic leukaemia

81. Erythroleukaemia

82. Acute leukaemia of ambiguous lineage
Mixed myeloid and lymphoid characteristics
Biclonal (two clones)
Biphenotypic (two characteristics on same blast cell)