1. Chronic Leukemias S. Sami Kartı, MD, Prof.

2. What are the Leukemias? • Cancers of leukocytes or their precursors • Accumulation or proliferation of leukocytes in the bone marrow • May or may not have increased leukocyte count in the peripheral blood

3. Types of Leukemia

4. The peripheral blood white cell count in leukemia

5. Chronic lymphocytic leukemia

6. Introduction • Is characterised by the accumulation of nonproliferating mature-appearing lymphocytes in the blood, marrow, lymph nodes, and spleen • In most cases, the cells are monoclonal B lymphocytes that are CD5+ • T cell CLL can occur rarely

7. Introduction • Is the most common form of leukemia in North America and Europe • Typically occurs in older patients, with the highest incidence being in those aged 50 to 55 years • Affects men twice as often as women

8. Etiology • The cause of CLL is unknown • Radiation is not a cause • Genetic factors have been postulated to play a role in high incidence of CLL in some families

9. Etiology • Cytogenetics • clonal chromosomal abnormalities are detected in approximately 50% of CLL patients • the most common clonal abnormalities are: • trisomy 12 • structural abnormalities of chromosomes 13, 14 and 11 • Oncogenes • in most cases of CLL is overexpressed the proto-oncogene c-fgr 9a member of the src gene family of tyrosine kinases

10. CLL - Pathology • Genetic change in B-cell clone • Slow proliferation exceeds apoptosis • Gradual accumulation of neoplastic B-lymphocytes

11. CLL - pathology • Neoplastic B-lymphocyte accumulation • blood lymphocytosis • marrow failure • lymphadenopathy (lymphocytic lymphoma) • splenomegaly

12. lymphocytes

13. lymphocytes ‘smudge’ cells

14. Clinical findings • Approximately 40% of CLL patients are asymptomatic at diagnosis • In symptomatic cases the most common complaint is fatigue • Less often the initial complaint are enlarged nodes or the development of an infection (bacterial)

15. Clinical findings • Most symptomatic patients have enlarged lymph nodes (more commonly cervical and supraclavicular) and splenomegaly • The lymph nodes are nontender • Hepatomegaly

16. Clinical findings • Less common manifestation are infiltration of tonsils, mesenteric or retroperitoneal lymphadenopathy, and skin infiltration • Patients rarely present with features of anemia, and bruising or bleeding

17. Laboratory findings • The blood lymphocyte count above 5,000/µL • In most patients the leukemic cells have the morphologic appearance of normal small lymphocytes • In the blood smears are commonly seen ruptured lymphocytes (“basket” or “smudge” or “smear”cells)

18. Laboratory findings • Careful examination of the blood smear can usually differentiate CLL, and the diagnosis can be confirmed by immunophenotyping • Clonal expansion of B (99%) or T(1%) lymphocyte • In B-cell CLL clonality is confirmed by • the expression of either  or  light chains on the cell surface membrane • the presence of unique idiotypic specificities on the immunoglobulins produced by CLL cells • by immunoglobulin gene rearrangements • typical B-cell CLL are unique in being CD19+ and CD5+

19. Laboratory findings • Hypogammaglobulinemia or agammaglobulinemia are often observed • 10 - 25% of patients with CLL develop autoimmune hemolytic anemia, with a positive direct Coombs’ test • The marrow aspirates shows greater than 30% of the nucleated cells as being lymphoid

20. The diagnostic criteria for CLL 1) A peripheral blood lymphocyte count of greater than 5000/µL 2) The cell should have the presence of Bcell-specific differentiation antigens (CD19, CD20) and be CD5(+) 3) A bone marrow aspirates showing greater than 30% lymphocytes

21. Differential diagnosis • Infectious causes • bacterial (tuberculosis) • viral (mononucleosis) • Malignant causes • leukemic phase of non-Hodgkin lymphomas • Hairy-cell leukemia • Waldenstrom macroglobulinemia • large granular lymphocytic leukemia

22. Investigations • Pretreatment studies of patients with CLL should include examination of: • complete blood count • peripheral blood smear • reticulocyte count • Coomb’s test • renal and liver function tests • serum protein electrophoresis • immunoglobulin levels • plasma 2 microglobulin level • If available immunophenotyping should be carried out to confirm the diagnosis • Bone marrow biopsy and cytogenetic analysis is not routinely performed in CLL

23. Staging • Rai Classification for CLL • 0 - lymphocytosis (>5,000/µL) • I - lymphocytosis + lymphadenopathy • II - lymphocytosis + splenomegaly +/-lymphadenopathy • III - lymphocytosis + anemia (Hb <11g%) +/-lymphadenopathy or splenomegaly • IV - lymphocytosis + thrombocytophenia (Plt <100,000/µL) +/- anemia +/-lymphadenopathy +/- splenomegaly

24. Staging • Binet Classification for CLL • A. < 3 involved areas, Hb > 10g/dL, Plt > 100,000/µL • B. > 3 involved areas, Hb > 10g/dL, Plt > 100,000/µL • C. - any number of involved areas, Hb < 10g/dL, Plt < 100,000/µL

25. Rai classification stage median survival (years) 0 >10 I > 8 II 6 III 2 IV < 2 Binet classification stage median survival (years) A > 10 B 7 C 2 Prognosis

26. Markers of poor prognosis in CLL • Advanced Rai or Binet stage • Peripheral lymphocyte doubling time <12 months • Diffuse marrow histology • Increased number of prolymphocytes or cleaved cells • Poor response to chemotherapy • High 2- microglobulin level • Abnormal karyotyping

27. Treatment • Treatment is reserved for patients with low- or intermediate risk disease who are symptomatic or have progressive disease (increasing organomegaly or lymphocyte doubling time of less than 12 months) and patients with high -risk disease • Alkylating agents (chlorambucil, cyclophosphamide) • Nucleoside analogs (cladribine, fludarabine) • Biological response modifiers • Monoclonal antibodies • Bone marrow transplantation • Systemic complications requiring therapy • antibiotics • immunoglobulin • steroids • blood products

28. Chronic Myeloid Leukemia

29. Definition • A neoplasm of hemopoietic stem cells caused by the ‘Philadelphia’ chromosome t(9;22) • A three-phase disease • chronic • accelerated • blastic

30. CML - pathology • Chronic Phase • Accumulation of myeloid cells • bone marrow • peripheral blood • spleen and liver • elsewhere • Accelerated Phase • Further genetic changes in the stem cell leading eventually to acute transformation (ie acute leukemia) and death

34. 1960 “The findings suggest a causal relationship between the chromosome abnormality observed and chronic granulocytic leukemia.” Peter Nowell

35. The Philadelphia Chromosome

36. 1973 Janet Rowley

38. The bcr/abl fusion protein • Uncontrolled kinase activity • Deregulated cellular proliferation • Decreased adherence of leukemia cells to the bone marrow stroma • Leukemic cells are protected from normal programmed cell death (apoptosis)

39. Clinical features • 30 percent of patient are asymptomatic at the time of diagnosis • Symptoms are gradual in onset • easy fatigability, malaise, anorexia, abdominal discomfort, weight loss, excessive sweating • Less frequent symptoms: • Night sweats, heat intolerance- mimicking hyperthyroidism, gouty arthitis, symptoms of leukostasis (tinnitus, stupor), splenic infarction (left upper-quadrant and left shoulder pain), urticaria (result of histamine release)

40. Clinical features • Physical signs: • Pallor • Splenomegaly • Sternal pain • Hepatomegaly

42. blast basophil neutrophils and precursors

43. Laboratory features • The hemoglobin decreased • Nucleated red cells in blood film • The leukocyte count above 25,000/μl (often above 100,000/μl), granulocytes at all stages of development • Hypersegmentated neutrophils • The basophiles increased • The platelet count is normal or increased • Neutrophils alkaline phosphatase activity is low or absent (90%)

44. Laboratory features • The marrow is hypercellular (granulocytic hyperplasia) • Reticulin fibrosis • Hyperuricemia and hyperuricosuria • Serum vitamin B12-binding proteine and serum vitamin B12 levels are increased • Pseudohyperkalemia, and spurious hypoxemia and hypoglycemia • Cytogenetic test- presence of the Ph chromosome • Molecular test – presence of the BCR-ABL fusion gene

45. Differential diagnosis • Polycythemia vera • Myelofibrosis • Essential thrombocytemia • Extreme reactive leukocytosis

46. CML - diagnosis • Blood count • Genetic analysis (RT-PCR or FISH) • Bone marrow aspiration and biopsy

47. CML - accelerated phase • Was inevitable – now prevented by imatinib • 1/3 ALL; 2/3 AML • Clinical features • sweats, weight loss, bone pain, enlarging spleen • bone marrow failure, and blasts in the blood • Onset and course rapid, outcome fatal.

48. CML-principles of treatment • Imatinib mesylate to achieve a ‘Major Molecular Remission’ (by Q-RT-PCR) • Dasatinib • Nilotinib • Allogeneic transplantation • Hydroxyurea