HAEM - Acute & chronic leukaemia Flashcards by YA Park

From what do leukaemias arise from?

Stem cell & progenitor cell populations (e.g. multipotential progenitor, common lymphoiad progenitor, common myeloid progenitor, megakaryocyte erythrocyte progenitor)

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List (4) examples of lymphoid mature cells

NK cells
T cells
B cells
Dendritic cells

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List (8) examples of myeloid mature cells

Neutrophils
Eosinophils
Mast cells/Basophils
Megakaryocyte/Platelets!! 
Monocyte/macrophage/Kupffer cells
Dendritic cells
Erythrocyte

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Define leukaemia

Cancer that starts in blood forming tissue such as the bone marrow and causes large numbers of blood cells to be produced and enter the blood stream

Circulating malignant cells of hematopoietic origin in the blood or bone marrow

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Etiology of Leukemias

Unknown in majority

Etiological factors include:
–Previous cytotoxic therapy
–Exposure to ionizing radiation
–Chemical exposure e.g. benzene
–Infections e.g. adult T cell leukemia lymphoma and HTLV-1
–Genetics e.g. trisomy 21 (Down Syndrome) and high risk AML
–Rare familial syndromes e.g. fanconi’s anaemia 52% develop AML or MDS by age 50

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(4) Clinical Presentation of Acute Leukemia

–Anemia: Lethargy, dyspnoea, pallor, presyncope
–Neutropenia: Fevers / rigors, infections
–Thrombocytopenia: Bruising, bleeding
–B symptoms: Fevers, sweats, weight loss

–Less commonly: lymphadenopathy, hepatosplenomegaly, symtpoms of hyperleucocytosis

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Which leukaemia can occasionally have a mediastinal mass?

Acute lymphocytic leukaemia -> SVC obstruction -> red face, dyspnoea, cough

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(5) Key Investigations in Acute Leukemia

Full blood count and film
Bone marrow biopsy
Immunophenotyping
Cytogenetics
Molecular studies

Aim of these tests is to determine the type of leukaemia, the prognosis and how best to monitor response to therapy

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What (2) do you expect to see on blood film of AML?

Cytopaenia due to suppression of normal haematopoiesis

Blasts (large nucleus, little cytoplasm. Nucleus looks immature; big nucleoli)

Monomorphic. (looks pretty identical)

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What % of infiltration by malignant cells is classified as acute leukaemia?

> 20% blasts of nucleated cells

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What is Auer rod pathognomic for?

AML

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What markers of immunophenotyping do you look for in AML?

myelodi markers
immature markers

e.g. CD34, CD33, CD11

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What markers of immunophenotyping do you look for in ALL?

immature T&B cell markers -> determine subtype of ALL

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Discuss cytogenetics in AML

It determines the prognosis

Good risk: t(8;21), inv 16, t(15;17) -> can be cured with standard chemotherapy
Intermediate risk: (70% pts): mostly normal cytogenetics
Poor risk: monosomy 7, multiple complex abnormalities, chromosome 3 abnormalities -> must have transplant to have a chance of cure

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Discuss molecular testing in AML & its relationship to prognosis

especially important for intermediate risk group by cytogenetics (majority) to help better predict prognosis

molecular testings are more sensitive than cytogenetics (cytogenetics needs a lot of cells)

FLT3 internal tandem duplication: poor prognosis
nucleophosmin (NPM1) & CEBPA: good prognosis

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How (4) do you monitor response to therapy in acute leukaemia after chemotherapy?

Marrow aspirate and trephine:
- less than 5% = morphological remission
Cytogenetics:
- CG remission = disappearance of any previous abnormalities
Flow cytometry
- Remission = no detection of cells with aberrant phenotype
Molecular studies
- Remission = no detectable transcript if a quantifiable translocation eg AML1-ETO in t(8;21 ); serial zero levels c/w remission and likely cure but rising levels may impend relapse

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What are the principles of treatment in AML?

determine appropriate treatment according to age, condition, prognosis
palliative for elderly & poor prognosis
induction chemotherapy for fit pts (cytarabine & anthracycline)
determine response after marrow recovery
if good response, consolidation cycles (x2 in AML) with marrows after each cycle to check disease status
determine need of allogeneic transplant based on age (usually eligible if younger than 60yo) & prognostic features

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Differences in ALL therapy to the general principles of acute leukaemia

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maintenance therapy after consolidation without transplant
multiple drugs used. Important L-asparaginase
higher rate of CNS relapse -> intrathecal chemotherapy as prophylaxis

Discuss acute promyelocytic leukaemia (APML)

compared to AML
Px
coagulation studies

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the M3 subtype of acute myelogenous leukemia (AML)
abnormal accumulation of immature granulocytes called promyelocytes
good prognosis
Px: bruising, bleeding
coagulation studies: DIC with low fibrinogen due ot release of procoagulants from malignant promyelocytes

Describe APML morphology under microscope

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characteristic faggot cells containing many Auer rods

Ix of APML (acute promyelocytic leukaemia)

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Cytogenetics: t(15;17)

- PML-RAR alpha fusion

Discuss cytogenetics of acute lymphoblastic leukaemia

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A key determinant of prognosis

–Poor prognosis cytogenetics include t(4;11)
–Good prognosis: children with hyperdiploidy

Principles of treatment of ALL in older patients

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Palliative care

- steroids, vincristine

Eligibility of allogeneic transplant in ALL

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less than 50yo (c.f. 60yo in AML) + moderate-good prognostic features

If not receiving an allograft; maintenance chemotherapy for 2 years

(3) stages of CML

- chronic (majority; often asymptomatic+ incidental finding) - accelerated - blast Some may have symptoms from splenomegaly & feel vaguely unwell

What Px would you have in untreated CML?

High WCC, anaemia Fevers Increasing spleen

What would you see in CML blood film?

Hyperleukocytosis with ALL stages of myeloid development in the peripheral blood

(4) Ix of CML & what do you expect to see

•FBE: leukocytosis with spectrum of early myeloid cells, basophils, eosinophilia •Bone marrow –extremely hyperecellular –increased numbers of blasts in more advanced cases * Cytogenetics: Pathognomic finding is the Philadelphia chromosome t(9;22) * Molecular: BCR-ABL fusion gene

What is the cytogenetic pathognomic finding of CML?

Philadelphia chromosome t(9;22) -> BCR-ABL fusion

What is the key molecular abnormality of CML?

BCR-ABL fusion gene

Mx of CML

Standard therapy: tyrosine kinase inhibitors (Imatinib) - selective killing of CML cells -> remission - no longer need for allograft - in most no major toxicity If resistant to Imatinib due to mutation of binding sites -> use second generation tyrosine kinase inhibitors - e.g. dasatinib - niltoinib

How does Imatinib work in CML?

Imatinib blocks ATP binding of BCR-ABL protein -> reduces signalling that drives cell proliferation

How do you monitor response to therapy in CML?

Monitoring the amount of the abnormal bcr-abl transcript in the peripheral blood each 3 mths by PCR a rise in bcr-abl% may signify resistance to therapy, most often due to a mutation in the binding site of imatinib to abl

Describe chronic lymphocytic leukaemia

* By far the commonest leukaemia in adults * May be an asymptomatic finding on blood film Affects B cell lymphocytes -> grow out of control and accumulate in the bone marrow and blood, where they crowd out healthy blood cells. CLL is a stage of small lymphocytic lymphoma (SLL), a type of B-cell lymphoma, which presents primarily in the lymph nodes

(2) initial Ix of CLL & what you expect to see

•Morphology (blood and bone marrow) –small mature lymphocytosis with smear cells –cytopenias due to autoimmune phenomenon or marrow infiltration •Immunophenotype –B lymphocytes co-expressing CD5 ( they don’t normally! ) and CD19, CD23

What do you expect to see in blood film of CLL?

Small mature lymphocytosis, smear cells & thrombocytopaenia

How do you monitor response to therapy in CLL?

CT scans - by observing size of lymph nodes before and after

Do all CLL patients need treatment?

No. Criteria for need for treatment is based on symptoms (regardless of level of WCC), cytopenia, bulky glands or spleen Deletion of 17p (c.f. deletion of 13q for indolent course) & TP53 mutation are associated with more aggressive course. - Bone marrow biopsy & cytogenetics also often not necessary; may do in younger pts for prognosis - CT scans: not useful in asymptomatic - chemo in asymptomatic no benefits

What gives the diagnosis in CLL?

Flow cytometry

Discuss prognosis of CLL - factor for good prognosis - factor for poor prognosis

Many patients esp those with minimally raised WCC -> prolonged survival even w/o treatment Loss of p53 -> terminal phase more rapidly

Mx of CLL

Early stage disease & asymptomatic: - expectant Mx only - no benefit from therapy Symptomatic pts: - chemoimmunotherapy - monoclonal antibodies for relapsed disease Only curative option: allograft but majority are ineligible

FBE results of APML (acute promyelocytic leukaemia)

cytopaenia, increased APTT/INR Can also see characteristic faggot cells containing many Auer rods in blood film

Mx of APML

MEDICAL EMERGENCY: - correct coagulopathy with paltelets, cryoprecipitate & fibrinogen as needed. If not fixed -> people can die due to procoagulation - all trans retinoic acid (ATRA) to induce promylocyte differentiation - arsenic Can be cured with arsenic + ATRA upfront WITHOUT chemotherapy. Hence most curable now.

(2) Molecular markers of CLL

CD19 (present in B cells normally), CD5 (present in T cells normally)

HAEM - Acute & chronic leukaemia Flashcards

(44 cards)