ACUTE LEUKEMIAS

1ST -2ND OF NOVEMBER 2019/ LE MERIDIAN

HOTEL

Prof. Heba Raslan

Consultant Hematopathology
King Fahd specialist hospital Dammam
 Acute Leukemia diagnosis
Clonal hematopoietic stem cell originating in BM characterized by proliferation of immature
lymphoid or myeloid cells, with blocking of maturation and replacement of trilineage
hematopoiesis.
• A complete diagnosis of acute leukemia requires knowledge of clinical information,
combined with morphologic evaluation, immunophenotyping and karyotyping and
molecular genetic testing.
• Cooperation between clinicians and pathologists is key to ensuring an accurate diagnosis.

Relevant Clinical Data: The data that should be provided or be made readily
accessible to the pathologist including:

• Age • Sex • Ethnicity • Prior malignancy

• History of any hematologic disorder or known predisposing conditions or syndrome
• Exposure to cytotoxic therapy, radiotherapy, or other possibly toxic substances.
• Any history of possible confounding factors, such as recent growth factor therapy,
transfusions, or other medications might obscure or mimic features of acute leukemia.
• Family history of any hematologic disorder or other malignancies
• Relevant physical examination findings, including neurologic exam findings
• Relevant imaging findings
• Presence of tumor masses (e.g., mediastinal), and/or organomegaly
• Any additional clinical findings deemed to have diagnostic or prognostic importance by the
attending physician
Initial diagnostic workup for acute leukemia, Melissa H.
Cessna, MD, Sa A. Wang, MD- From college of American
Initial diagnostic workup for acute leukemia, Melissa H. Cessna, MD, Sa A. Wang, MD- From
college of American pathologists and the American society of hematology-March 2017
 Acute leukemia
Blasts and Blast Equivalents: General Features

B-Lymphoblasts

T-Lymphoblasts

Lymphoblasts vary in size from small blasts with scant cytoplasm, condensed nuclear chromatin, and
indistinct nucleoli to larger cells with moderate amounts of light-blue to bluish-grey cytoplasm
(occasionally vacuolated), dispersed nuclear chromatin, and multiple variably prominent nucleoli.
The nuclei are round or show some convolutions.
 Myeloblasts

Myeloblasts with Auer rod

Agranular myeloblasts

Myeloblasts are small to medium sized cells,

occupied by a large oval nucleus composed of
very fine non-aggregated dispersed
chromatin, with multiple prominent nucleoli,
it has basophilic cytoplasm which in some
cells is devoid of granules, others show fine
granulation with Auer rod.
Granular myeloblasts
Monoblasts and Promonocytes: Large cells with fine delicate nuclear chromatin, irregular
folded nucleus with obvious nucleoli, abundant blue-gray cytoplasm with vacuolations and fine
azurophilic cytoplasmic granules.
Megakaryoblasts

Megakaryoblasts Medium in size with a round, slightly irregular, or indented nucleus

with fine reticular chromatin and 1-3 nucleoli. The cytoplasm is basophilic, mostly
agranular, and may show cytoplasmic blebs.
Promyelocytes (Malignant/Abnormal): Single or bilobed nuclei, hypo- or hypergranular
cytoplasm, may see cytoplasm packed with Auer rods “Faggot cells” (Counted in APL).

Erythroblasts: Medium-sized to large erythroblasts, usually with round nuclei, fine

chromatin, and one or more nucleoli (proerythroblasts); the cytoplasm is deeply basophilic
and agranular and frequently contains vacuoles.
 Morphology is the gold standard for accurate blast cells enumeration.
••Key diagnostic feature: Blast count?
• In AML it is Obligatory to count ≥ 20% blasts in PB &/or BM for diagnosis of
AML.
Yet the exception of cases with t(8;21), inv(16) or PML-RARA do not require 20% blast.

• Unlike myeloid leukemias, there is no agreed-upon lower limit for the

percentage of blasts required to establish a diagnosis of lymphoblastic
leukemia (ALL); in general, the diagnosis should be avoided when there are
< 20% blasts.

• It is recommended to count 200 cells in PB, 500 cells in the BM From different
slides, and to assess 5-6 intertrabecular areas in the biopsy section in different levels.

• Flow-cytometry:
- Is the diagnostic tool for acute leukemia.
- Confirm the blast nature and lineage.
- Allow determination of immunophenotypic aberrancies (1.Lineage infidelity.
2.Loss of lineage specific markers. 3.Asynchronous markers expression.4. Different
level of marker expression) which is important for future MRD assessment.
Why Flow cytometry is not used for blast enumeration?
1. Hemodilution which artificially decreases the blast percentage.
2. Partial Lysis of erythroid precursors which removes the erythroid precursors
from the denominator of the blast percentage artificially increase the blast
percentage.
3. In cases with blast equivalent, it is not found on the same known blast gate
(CD45dim/ Low SSC).

Common used antigen for flowcytometry evaluation in acute leukemias

• Progenitor cell (Primitive markers): CD34, CD117, Tdt, CD38, and HLA-DR.
• Myeloid markers: CD13, CD33, CD15, and MPO
• Monocytic markers:CD33, CD11b, CD11c, CD14, CD64, CD68, CD36, and
CD300e.
• Erythroid markers: CD235a Glycophorin A, and CD71.
• Megakaryocytic markers: CD41a, CD42a, CD42b, and CD61.
• B-Lymphoid markers: CD19, CD10, CD79a and CD22
• T-Lymphoid markers: CD3, CD2,CD4,CD5,CD7, and CD8.
 ALOT
Acute Leukemia Orientation Tube
V450 V500 FITC PE PerCP-Cy5 PE-Cy7 APC APC-H7
cyCD3 CD45 MPO cyCD79a CD34 CD19 CD7 SmCD3
A LOT 7UL 5UL 3UL 5UL 7UL 5UL 2UL 3UL

Lineage In case of negative

Lineage Lineage all lineage specific
specific specific specific markers; AML is
AML/MDS expected as CD7 is
T-ALL BCP-ALL the most aberrant
marker.

4 tubes 4 to 7 tubes 4 tubes 4 to 7 tubes

Panels used in our Flow. Lab.

 B-cell ALL Panel

V450 V500 FITC PE PerCP-Cy5PE-Cy7 APC APC-H7

CD20 CD58 CD66c CD10 CD38
1
1UL 7UL 10UL 5UL 3UL
SmIgM
SmIgk CyIgM CD33 10UL
2
4UL 10UL 5UL CD117 SmIgL
CD45 CD34 CD19 5UL 5UL
BCP-ALL
CD9 5UL TdT CD13 10UL 5UL CD22 CD24
3
4UL 10UL 7UL 5UL 5UL
CD15
CD21 10UL NG2
4
4UL CDw65 10UL CD123 CD81
7UL 7UL 5UL

B-cell Back bone markers

Panels used in our Flow. Lab
 T-cell ALL Panel

V450 V500 FITC PE PerCP-Cy5 PE-Cy7 APC APC-H7

unTdT CD99 CD5 CD10 CD1a
1
10ul 5ul 15ul 5ul 5ul
CD2 CD117 CD4 CD8 CD7
2
5ul 5ul 7ul 5ul 2ul
cyCD3 CD45 SmCD3
T-ALL TCRGD TCR AB CD33 CD56 cyTCRB
3 7ul 5ul 3ul
10ul 7ul 10ul 5ul 3
CD44 CD13 HLA-DR CD45RA CD123
4
7ul 7ul 7ul 5ul 7ul

T-cell Back bone markers

Panels used in our Flow. Lab

 AML-MDS Panel
V450 V500 FITC PE PerCP-Cy5PE-Cy7 APC APC-H7
CD16 CD13 CD11b CD10
1
20 UL 7UL 5UL 5UL
CD64 IREM-2
CD35 CD14
2 20UL (300e)
5UL 5UL
5UL
CD36 CD105 CD33 CD71
3
5UL 5UL 10UL 2UL
HLA-DR
nuTdT CD56 CD7 CD19
4 1UL CD45 CD34 CD117
AML/MDS 10UL 5UL 2UL 5UL
(1:5 5UL 10UL 5UL
CD15 NG2 CD22 CD38
5 dilution)
10UL 10UL 5UL 3UL
CD42a
1UL CD203c CD123 CD4
6
CD61 10UL 10UL 5UL
4UL
CD41a CD25 CD42b CD9
7
1UL 10UL 1UL 10UL

Back bone markers

Panels used in our Flow. Lab
 2017 WHO Classification of AML
Classification of myeloid neoplasms with germ line predisposition
Myeloid neoplasms with germline predisposition without a pre-existing disorder or organ dysfunction:
• Acute myeloid leukemia with germline CEBPA mutation.
• Myeloid neoplasms with germline DDX41 mutation.
Myeloid neoplasms with germline predisposition and pre-existing platelet disorders:
• Myeloid neoplasms with germline RUNX1 mutation
• Myeloid neoplasms with germline ANKRD26 mutation
• Myeloid neoplasms with germline ETV6 mutation
Myeloid neoplasms with germ line predisposition and other organ dysfunction:
• Myeloid neoplasms with germline GATA2 mutation.
• Myeloid neoplasms associated with bone marrow failure syndromes, Fanconi anemia, severe congenital
neutropenia, Shwachman-Diamond Syndrome, Diamond-Blackfan anemia.
• Myeloid neoplasms associated with telomere biology disorders.
• Juvenile myelomonocytic leukemia associated with neurofibromatosis, Noonan syndrome.
• Myeloid neoplasms associated with Down syndrome.
Acute myeloid leukemia and related precursor neoplasms
Acute myeloid leukemia with recurrent genetic abnormalities
• Acute myeloid leukemia with t(8;21 )( q22;q22.1 ); RUNX1-RUNXT1
• Acute myeloid leukemia with inv(16)(p13.1q22) or gene rearrangement t(16;16)(p13.1;q22); CBFB-MYH11
• Acute promyelocytic leukemia with PML-RARA
• Acute myeloid leukemia with t(9; 11 )(p21.3;q23.3); KMT2A-MLL
• Acute myeloid leukemia with t(6;9)(p23;q34.1 ); DEK-NUP214
• Acute myeloid leukemia with inv(3)(q21.3q26.2) t(3;3)(q21.3;q26.2); GATA2, MECOM
• Acute myeloid leukemia (megakaryoblastic) with t(1 ;22)(p13.3;q13.1); RBM15-MKL1
• Acute myeloid leukemia with BCR-ABL 1
 2017 WHO Classification of AML
Acute myeloid leukemia with gene mutations
• Acute myeloid leukemia with mutated NPM1
• Acute myeloid leukemia with biallelic mutation of CEBPA
• Acute myeloid leukemia with mutated RUNX1
Acute myeloid leukemia with myelodysplasia related changes
Therapy related myeloid neoplasm.
Acute myeloid leukemia, not otherwise specified:
• Acute myeloid leukemia with minimal differentiation
• Acute myeloid leukemia without maturation
• Acute myeloid leukemia with maturation
• Acute myelomonocytic leukemia
• Acute monoblastic and monocytic leukemia
• Pure erythroid leukemia
• Acute megakaryoblastic leukemia
• Acute basophilic leukemia
• Acute panmyelosis with myelofibrosis
Myeloid sarcoma
Myeloid proliferation associated with Down Syndrome:
• Transient abnormal myelopoiesis associated with Down syndrome
• Myeloid leukemia associated with Down syndrome
Blastic plasmacytoid dendritic cell neoplasm
Acute leukemia of ambiguous lineage
• Acute undifferentiated leukemia
• Mixed-phenotype acute leukemia t(9;22)(q34.1 ;q1 1 2); BCR-ABL 1
• Mixed-phenotype acute leukemia with t(v; 11 q23.3); KMT2A-rearranged
• Mixed-phenotype acute leukemia, B/myeloid, not otherwise specified
• Mixed-phenotype acute leukemia, T/myeloid, not otherwise specified
• Mixed-phenotype acute leukemia, not otherwise specified, rare types
• Acute leukemia of ambiguous lineage, not otherwise specified
Myeloid neoplasms with
germline predisposition
 Classification of myeloid neoplasms with germ line predisposition
RareMyeloid neoplasms with germline predisposition without a pre-existing
disorder or organ dysfunction:
• Acute myeloid leukemia with germline CEBPA mutation.
• Myeloid neoplasms with germline DDX41 mutation.
Myeloid neoplasms with germline predisposition and pre-existing platelet
disorders:
• Myeloid neoplasms with germline RUNX1 mutation
• Myeloid neoplasms with germline ANKRD26 mutation
• Myeloid neoplasms with germline ETV6 mutation
Myeloid neoplasms with germ line predisposition and other organ
dysfunction:
• Myeloid neoplasms with germline GATA2 mutation.
• Myeloid neoplasms associated with bone marrow failure syndromes. With
Fanconi anemia, severe congenital neutropenia, Shwachman-Diamond additional
Syndrome, Diamond-Blackfan anemia, Telomere biology disorder. non-
• Myeloid neoplasms associated with telomere biology disorders. hematological
• Juvenile myelomonocytic leukemia associated with neurofibromatosis, phenotypic
abnormalities
Noonan syndrome, or Noonan syndrome-like disorders.
• Myeloid neoplasms associated with Down syndrome.
 • Each of these neoplasms shows a specific germline mutation identified by
molecular genetic testing (including NGS).

• Routine cytogenetic analysis may be normal or may reveal non-defining

karyotypic alterations.

• The presence of additional organ dysfunction and abnormalities in platelet

number and function permit recognition and diagnosis of those patients as
they need proper clinical management and long-term follow-up.
Even if a patient has not developed malignancy,

• Clinical management of those patients often involves allogeneic SCT so

careful donor selection is critical in these families, to avoid re-introduction of
the mutation by unintentional use of affected donor stem cell, which will result
in failure of stem cell engraftment, or poor graft function, and donor-derived
leukemias.
 Acute myeloid leukemia and related precursor
neoplasms
Acute myeloid leukemia with recurrent genetic abnormalities
Acute myeloid leukemia with myelodysplasia-related changes
Therapy-related myeloid neoplasms
Acute myeloid leukemia, NOS
Myeloid sarcoma
Myeloid proliferations associated with Down syndrome
Acute myeloid leukemia with recurrent genetic abnormalities:
Acute myeloid leukemia with t(8;21)(q22;q22.1); RUNX1-RUNX1T1:
Morphology: AML showing predominantly neutrophilic maturation, eosinophilic and
basophilic precursors are increased in some cases.

Eosinophilic
precursor Salmon-Colored Granules
Blast in Granulocytes
Blast

Blast
Blast

Eosinophilic
precursor

Blasts and Eosinophilic precursors

Salmon-Colored Granules in Granulocytes
Acute myeloid leukemia with t(8;21)(q22;q22.1); RUNX1-RUNX1T1
 Erythroid Island

Megakaryocyte

Diffuse infiltration with sheets of myeloid blasts with suppression of trilineage hematopoiesis
Note: CD79a/ and or PAX5 is positive in AML with t(8;21 )( q22;q22.1) resulting from
RUNX1, rarely in other AML. Pathobiology2019;86:162166(DOI:10.1159/000493688)
Immunophenotyping:
Blasts of AML with t(8;21) strong positivity to: CD34, CD117, HLA-DR, MPO, and CD13, but
weak expression of CD33 (neutrophilic differentiation). Some cases are TdT-positive; Blasts
show aberrant CD15 and/or CD65 expression (Maturation asynchrony), CD19 or CD79a
(Lineage infidelity), and CD56 in a fraction of cases and may have adverse prognostic
significance in cases with KIT mutations.
 70%

31%

AML with t(8;21) shows

Positivity to:CD34, CD117,
Tdt, HLA-DR, MPO, CD13,
and CD33,
and the aberrant markers:
32% 23% CD15,CD56,
CD71, and CD123
The patient was positive to KIT
mutation.
 0.1%
0.23%

Positive MRD post induction

Acute myeloid leukemia with inv(16){p13.1q22) or t(16;16) {p13.1;q22); CBFB-
MYH11
Morphology: AML that usually shows Monocytic and Granulocytic differentiation , evident
morphological features of AMML. It is characterized by abnormal eosinophil component in the
BM, with immature eosinophilic granules at early stages, which are purple-violet in color, and in
some cells are so dense to obscure the cell morphology. Auer rods may be observed in myeloblasts

Eosinophils Eosinophils

Eosinophils
Blasts

Eosinophils

Blasts
 Myeloblasts

Monoblasts
Immunophenotyping:
Complex IPT showing: immature blasts with high CD34 and CD117 expression and
populations differentiating towards granulocytic lineage (positive for CD13, CD33, CD15,
CD65, and MPO) and the monocytic lineage (positive for CD14, CD4, CD11b, CD11c, CD64,
CD36, and lysozyme). Maturation asynchrony is often seen. Coexpression of CD2 has been
frequently documented, but it is not specific for this diagnosis.
Blasts are pos.to: CD34, CD117, HLA-DR B, CD33, MPO, CD4, CD11c, CD64, and CD15.
Acute promyelocytic leukemia with t(15;17) (q22;q11-12), PML-RARA.
1. Hypergranular APL Large cells showing irregular nuclear size and shape, some are rounded other are
kidney-shaped or bilobed, basophilic cytoplasm densely packed by large granules, staining bright red, or
purple, granules may be so large and numerous obscuring the nuclear-cytoplasmic margin. In some cells,
the cytoplasm is filled with fine dust-like granules. Some promyelocytes containing bundles of Auer rods
called “Faggot cell”.

Hypergranular Faggott
Promyelocyte cells

Hypergranular
Promyelocyte
 2. Microgranular (hypogranular) APL shows bilobed nuclei, hypogranular cytoplasm is due
to submicroscopic size of the azurophilic granules; causing confusion with acute monocytic
leukemia. TLC is markedly elevated in the microgranular variant of APL.

Hypogranular
Promyelocytes

Hypogranular
Promyelocytes

Hypogranular
Promyelocytes

DD with Acute monocytic Leukemia

3. Abnormal promyelocytes with deeply basophilic granules show convoluted nuclei,
abundant cytoplasm with numerous strongly basophilic coarse granules; Auer rods may be
identified.
Immunophenotyping:
Hypergranular variant: Absent expression of HLA-DR, &CD34, expression of CD117, bright expression
of CD33 and heterogeneous expression of CD13. Granulocytic differentiation markers CD15 and
CD65 are negative or only weakly expressed. Common aberrant expression of CD64.
Microgranular morphology: Expression of HLA-DR , CD34 and aberrant expression of CD2
(Associated with FLT3-ITD). 10% of APL express CD56 associated with a worse outcome.

Moderate to bright CD45

/High SSC

Hypergranular
Variant
HLA-DR,CD34
Are negative.
Acute myeloid leukemia with t(9;11)(p21.3;q23.3); KMT2A-MLLT3
Morphology: Acute myeloid leukemia (AML) with t(9;11)(p21.3;q23.3) resulting in
KMT2AMLLT3 fusion; KMT2A is best known by former gene name: MLL. It is usually
associated with monocytic differentiation with no significant eosinophilia.

Monoblasts Monoblasts

Immunophenotyping:
It is associated with strong expression of CD33, CD65, CD4, and HLADR, whereas expression
of CD13, and CD14 is usually low, express NG2, and some markers of monocytic differentiation:
CD4, CD11b, CD11c, CD64, and CD36. Primitive blast markers CD34, CD117 are negative.
Acute myeloid leukemia with t(6;9)(p23;q34. 1); DEK-NUP214
Morphology: -Increased basophils. - Multilineage dysplasia (especially erythroid and
granulocytic). -AML with maturation, it is strongly associated with (FLT3-ITD) mutation.

Immunophenotype: Expression of CD34, CD117, MPO, CD13, CD33, CD38, CD123, HLA-
DR. Half of the cases express Tdt . Aberrant expression of CD9, CD15; and CD64.; yet the
aberrant expression of Lymphoid markers are uncommon.
Acute myeloid leukemia with inv(3)(q21.3q26.2) or t(3;3)(q21.3;q26.2); GATA2, MECOM
-Morphology: Mostly in adult. Multilineage dysplasia of non-blast BM elements is a
frequent, the dysplastic megakaryocytes showing unilobed or bilobed nuclei.
-It show variable morphological features: AML without maturation, AMML and acute
megakaryoblastic leukemia morphology.

AML with inv(3).BM shows AML without maturation and atypical, non-lobated megakaryocytes.
 AML without
Maturation
Morphology
Associated with
monosomy 7 &/or
complex karyotype,
very poor prognosis. Dysplastic
Survival < 6 months megakaryocytes

CD34 CD117
Aberrant CD7
Expression

Immunophenotyping: Blasts shows

positivity to: CD34, CD33, CD13, CD117,
HLA-DR, and CD38, with aberrant CD7
expression. A subset of cases may express
megakaryocytic markers such as CD41 and
CD61
Acute myeloid leukemia (megakaryoblastic) with t(1;22) (p13.3;q13.1); RBM15-MKL1
Morphology: Uncommon in AML, in < 1% of all cases. It is restricted to infants and young
children ≤ 3 years, mostly occurring in the first 6 months, majority of cases present with
hepatosplenomegaly.
- Blasts are mostly megakaryoblasts admixed with more morphologically undifferentiated blast
cells resembling lymphoblasts. Micromegakaryocytes are common, but no other dysplastic
features. It is associated with increased fibrosis.
 In cases with fibrosis and dry tap:

IHC on BMB is important for

diagnosis. Megakaryoblasts can be
recognized by a positive reaction
with antibodies to Von Willebrand
factor, and the platelet
glycoproteins (CD61 and CD42b).

Immunophenotyping: Megakaryoblasts express one or more of the platelet glycoproteins:

CD41a, CD61, CD42a and CD42b (Better cytoplasmic). Myeloid-associated markers CD13
and CD33. Yet: CD34, CD45, and HLA-DR are often negative; Blasts are negative to MPO,
T&B Lymphoid markers and TdT.
Acute myeloid leukemia with gene mutations
Acute myeloid leukemia with mutated NPM1
-80-90 % of AMML and monoblastic show NPM1 mutation, yet NPM1 also detected in
AML with and without maturation and in pure erythroid leukemia.
-It occurs mainly in adult with low percentage in childhood.
-Dysplasia is common yet in the setting of NPM1 mutation, it does not result in a worse
prognosis; mostly with good prognosis unless associated with Flt3 mutation.

In cases of AMML the PB is the most diagnostic

 Immunophenotyping:
-AML with mutated NPM1 shows: pos. CD33, V-CD13, CD117, and CD123 are common.
- 2 Subgroups described: one with an immature myeloid IPT profile & one with a monocytic ITP profile.
-CD34 is negative in most cases. - CD34+ cases do occur and have been associated with an adverse prognosis.
-The CD34+/CD25+/CD123+/ CD99+ population is reportedly associated with FLT3-ITD mutations.

44%
44

14% 27%
25%

54% CD34-,CD117-,HLA-
DR+,CD25+,CD123+,
62% 57% CD56+,CD15+CD11b
CD64+CD35+Dim,
CD4+, CD13 +w
Acute myeloid leukemia with biallelic mutation of CEBPA
Morphology: AML with biallelic mutation of CEBPA showed AML with maturation or AML
without maturation features, but some show AMML or monoblastic features.

Immunophenotype: Blasts express: CD34, HLA-DR, CD13, CD33, with aberrant expression of
CD65, CD11b, CD15, and CD7 which by itself is present in 50-73% of cases.
AML with BCR-ABL1(a provisional entity in the current classification):
X
- It is de novo AML; patients show no evidence (either before or after therapy) CML.
- Note that cases meet criteria of MPAL, therapy-related AML or AML with recurrent genetic
abnormalities are excluded from this category.
- Less likely than CML to show basophilia and dwarf megakaryocytes (and splenomegaly).
- Most cases show the p210 form of the fusion protein, though p190 is also reported
- Poor prognosis, but TKI followed by allogeneic- SCT may improve survival.

AML with mutated RUNX1(a provisional entity in the current classification):

- It is a de novo AML with >20% in BM or PB blast cells that may have morphological features
of most AML, NOS, categories and has a higher frequency among cases with minimal
differentiation.
-Note: Cases fulfilling the criteria for specific AML subtypes: AML with recurrent genetic
abnormalities, therapy-related AML, or AML with MDS-related changes are excluded.
- Higher frequency in older adults (aged > 60 years).
-15- 65% of AML with minimal differentiation showed this mutation, the rest showed AML
with maturation and AML with monocytic or myelomonocytic features.
-MDS with mutated RUNX1 find a characteristic mutation signature involving SRSF2, EZH2,
STAG2, and ASXL1, which appears to be similar in AML with mutated RUNX1.
-Mutations of NPM1, CEBPA, and JAK2 are uncommon in this group.
-When RUNX1 mutation is detected, germline studies should be performed or careful family
histories obtained.
-Associated with worse overall survival
Acute myeloid leukemia with myelodysplasia-related changes
Diagnosis of AML-MRC requires the following 3 criteria are met: Complex karyotype (≥3 abnormalities)
1. ≥ 20% blood or marrow blasts. Unbalanced abnormalities
Loss of chromosome 7 or del(7q)
2. Any of the following: del(5q) or t(5q)
Isochromosome 17q or t(17p)
- History of MDS or MDS/MPN. Loss of chromosome13 or del(13q)
del(11q)
- Myelodysplastic syndrome-related cytogenetic abnormality. del(12p) or t(12p)
- Multilineage dysplasia (For an AML to be classified as having Idic (X)(q13)
Balanced abnormalities
myelodysplasia-related changes based on morphology, dysplasia must t(11 ;16)(q23.3;p13.3)
t(3;21)(q26.2;q22.1)
be present in ≥50% of the cells in at least two haematopoietic cell t(1 ;3)(p36.3;q21.2)
t(2;11)(p21 ;q23.3)
lines). t(5;12)(q32;p13.2)
3. Absence of both of the following: t(5;7)(q32;q11.2)
t(5;17)(q32;p13.2)
- Prior cytotoxic or radiation therapy for an unrelated disease t(5;10)(q32;q21)
t(3;5)(q25.3;q35.1)
- Recurrent cytogenetic abnormality described in AML with
recurrent genetic abnormalities.
Immunophenotyping: Heterogeneous IPT.
- Increase in CD14 is reported and related to a poor prognosis.
- An increased frequency of CD11b expression has been noted in patients with high-risk
- In cases with aberrations of chromosomes 5 and 7, a high incidence of CD34, TdT, and
CD7 expression has been reported.
-There is frequently aberrant expression of CD56 and/or CD7.
 Hypersegmented
AML-MRC: Condition mainly in elderly neutrophils
patients, and rare in children, yet Giant
happens in cases arising from MDS of Platelets
childhood, often presents with
pancytopenia, and less aggressive disease hyposegemented
hypogranular
course. Neutrophils

1st case, from MDS -EB

Dysplastic
Erythroid
Precursors
Defective Dysplastic
Granulation Erythroid
Precursors

Pegler huet
anomaly

Dysplastic
Erythroid
Precursors
 Defective megakaryocytes, and Defective megakaryocytes,
multinucleated erythroid precursors

Cases of AML-MRC with 20-29% blasts may have disease course more like MDS
 defective neutrophils

Promonocytes

Dysplastic
Erythroid
precursors Dysplastic
Erythroid
precursors

Increased
Blasts
Defective
Neutrophils

Giant platelets with

defective granulation
2nd case: A known case of CMML transformed to AML-MRC with increased blast cells,
promonocytes and abnormal neutrophilic precursors
 Dysplastic
Dysplastic erythroid Megakaryocytes
precursors

Dysplastic
Dysplastic Megakaryocytes
Megakaryocytes

Dysmegakaryopoesis and Dyserythropoiesis

 Therapy-related myeloid neoplasms (t-MNs):
• It includes t-AML, t-MDS, and t-MDS/MPN, occurring as a late complication almost
5- 10 yrs. of exposure to cytotoxic chemotherapy and/or Ionizing radiation therapy
administered for neoplastic or non-neoplastic disorders. Disease associated with poor
prognosis.

• 70% have treated for a solid tumour and 30% for a hematological neoplasm, with
cancer breast and NHL accounting for the largest numbers of cases.

• Any age group can be affected, yet increased incidence of cancer in older adults.

• (t-MNs) is a consequence of mutation events or changes in haematopoietic stem cells

and/or BM microenvironment induced by cytotoxic therapy /or Ionizing radiation by
selection of a myeloid clone with elevated risk for mutation events “heritable
predisposition” due to mutations in sensing or repair genes (e.g. BRCA1/2 or TP53)
or polymorphisms in genes that affect drug metabolism, drug transport or DNA-
repair mechanisms.

• PB and BM show dysplastic changes and it is labeled as t-MDS or t-AML depending

on the blast count.
Therapy related AML post follicular lymphoma treatment; t-AML - FL/AML

M2 Morphology and Immunophenotypically

M2 Morphology and Immunophenotypically
Acute myeloid leukemia, NOS
• AML-NOS, includes the cases that do not fulfill the criteria for inclusion in: AML with
recurrent genetic abnormalities, ML-MRC, or t-related AML with the possible
exception of pure erythroid leukemia.
• This classification define criteria for diagnosis of AML across a diverse morphological
spectrum, and include the specific diagnostic criteria for pure erythroid leukemia.
Acute myeloid leukemia with minimal differentiation
AML with no morphological or cytochemical evidence of myeloid differentiation.
Blast express typical early primitive
markers:CD34, CD38, CD117, and
lineage specific markers: MPO, CD13,
and CD33.
Acute myeloid leukemia without maturation :
-AML without maturation shows diffuse infiltration with blasts, the maturing cells of the
granulocytic lineage constitute < 10% of the nucleated bone marrow cells. It can occur at
any age, but mostly in adults
-Blasts expressing MPO, myeloid-associated antigens: CD13, CD33, and CD117. CD34 and
HLA-DR are positive in 70% of cases. No expression of markers associated with
granulocytic maturation (e.g. CD15 and CD65) or monocytic markers (e.g. CD14 and CD64).
Acute myeloid leukemia with maturation
-AML with maturation shows ≥20% blasts in BM or PB and evidence of maturation ≥10%
of maturing cells of granulocytic lineage in the BM; cells of monocyte lineage constitute
< 20% of bone marrow cells. It occurs in all age groups.
-Immunophenotype: As mentioned..
Acute myelomonocytic leukemia:
- AMML: Is characterized by proliferation of both neutrophil and monocyte precursors. PB or
BM has ≥:20% blasts (including promonocytes blast equivalent); neutrophils and their
precursors and monocytes and their precursors each constitute ≥20% of bone marrow cells.
- It occurs in all age groups, but is more common in older individuals.

Immunophenotyping: As mentioned in MLL

 Acute monoblastic and monocytic leukemia
- Acute monoblastic leukemia and acute monocytic leukemia are myeloid leukemias in which
PB or BM has ≥20% blasts including promonocytes(Blast equivalent) and in which ≥80% of
the leukemic cells are of monocytic lineage, including : Monoblasts, Promonocytes, and
Monocytes; a minor neutrophil component (< 20%) may be present.
-In acute monoblastic leukemia, most ≥80% of the monocytic cells are monoblasts. In acute
monocytic leukemia, most of the monocytic cells are promonocytes or monocytes.
- Acute monoblastic leukemia can occur at any age, but is most common in young individuals.
Acute monocytic leukemia more common in adults

Acute monoblastic leukemia

Acute monocytic leukemia
Acute Monocytic Leukemia
Pure erythroid leukemia
• Neoplastic proliferation of immature cells ( Proerythroblastic ) committed
exclusively to the erythroid lineage (> 80% of the bone marrow cells are erythroid,
with ≥30% proerythroblasts), with no evidence of a significant myeloblastic
component.

Note: Cases previously classified as erythroleukaemia on the basis of counting

myeloblasts as a percentage of non-erythroid cells when erythroid precursor cells
constituted ≥50% of the marrow cells are now classified on the basis of BM or PB blast
cell count as MDS-EB if blasts constitute < 20% of all marrow or blood cells, and as
AML-MRC if blasts constitute ≥20% of the cells, irrespective of the erythroid
precursor cell count.

• It can occur at any age, including in childhood. It can occur de novo, but more often
occurs as progression of a prior myelodysplastic syndrome.
Morphology:
-Sometimes due to haemodilution, erythroblasts may constitute < 80% of the cells on
an aspirate film; in such cases, the diagnosis of pure erythroid leukemia can be made if
the neoplastic erythroblasts occur in sheets and constitute > 80% of the cells in BMB.
- Background of dysmegakaryopoesis, ring sideroblasts are often present whereas
dysgranulopoiesis is infrequent.
In BMB sections of pure erythroid leukemia, the cells appear undifferentiated and are
arranged in a sheet-like pattern.
Immunophenotyping
Erythroblasts usually express: CD117, Glycophorin A and Hemoglobin A, and less
lineage-specific marker CD71. CD36 is positive but are not specific and can be expressed
by monocytes and megakaryocytes. Blasts are usually negative for HLA-DR and CD34.

Erythroblasts are positive to:

CD36, CD71, ,Glycophorin-
A, and negative to CD7,
CD45, HLA-DR, CD34, and
CD117
Acute megakaryoblastic leukemia
-Acute leukemia with ≥20% blasts, of which ≥50% are of megakaryocyte lineage; it is
uncommon disease, it occurs in both adults and children.
- Occasionally, the blasts occur in small clusters. Circulating micromegakaryocytes,
megakaryoblast fragments, dysplastic large platelets, and hypogranular neutrophils
may be present. Note: Micromegakaryocytes should not be counted as blasts.
- Immunophenotype as mentioned
Megakaryoblastic leukemias show two morphological pictures in BMB

BMB 1st: show a mixture of poorly differentiated blasts

and maturing dysplastic megakaryocytes.
BMB 2nd Or shows uniform population of poorly differentiated blasts
Acute panmyelosis with myelofibrosis
APMF is an acute panmyeloid proliferation with increased blasts ≥20% of cells in
BM or PB and accompanying fibrosis of the BM.
Morphology: PB shows marked pancytopenia, RBCs show no anisopoikilocytosis,
variable macrocytosis; and rare erythroblasts, but teardrop cells are not observed.
-Abnormal platelets may be noted. Bone marrow aspiration is frequently
unsuccessful; either no bone marrow can be obtained or the specimen is suboptimal.

Immunophenotyping: Blasts usually express CD34 and one or more myeloid associated
antigens: CD13, CD33, and CD117.

PB shows pancytopenia with blast and dysplastic neutrophils: Pseudo-Pelger-Huët.

Bone marrow biopsy supplemented with IHC is required for diagnosis. BM is hypercellular
and fibrotic. Reticulin staining shows markedly increased fibrosis with coarse fibers.

-Panmyelosis ‘ Increased trilineage hematopoiesis” with foci of blasts associated with dysplastic
megakaryocytes predominately of small size with variable degrees of cytological atypia,
including the presence of hyposegemented or non-lobated nuclei with dispersed chromatin.
Panel of antibodies that includes: Myeloid markers, Megakaryocyte markers, Erythroid
markers. To confirm the presence of panmyelosis

Increased Defective
erythroid megakaryocytes
precursors

Foci of Blasts
Foci of blasts positive CD34 immunostain Increased Reticulin stain +2
MPO is usually negative in the blasts.
 Myeloid proliferations associated with Down syndrome :
• Down syndrome have an increased risk to all leukemias, with 150-fold increase in AML.
• Acute megakaryoblastic leukemia accounts for 70% of cases of AML in children aged<4
years with Down syndrome, versus only 3- 6% in children without Down syndrome.
Two conditions associated with Down Syndrome.
1. Transient abnormal myelopoiesis associated with Down syndrome :
• It occurs in 10% of neonates with Down syndrome, which may be morphologically
indistinguishable form of AML; the disorder diagnosed at the age of 3-7 day and resolves
spontaneously over three months.
• Prognosis: the disorder is characterized by a high rate of spontaneous remission, non-
transient acute myeloid leukemia develops 1-3 years later in 20-30% of these children

2. Myeloid leukemia associated with Down syndrome:

• Condition occurs beyond neonatal period. AML follows a prolonged (MDS)-like phase.
• In DS there are no biological differences between MDS and overt AML; therefore,
differentiation is not relevant with no prognostic or therapeutic consequences; this type of
disease is distinctive to children with Down Syndrome, the term ‘Myeloid leukemia
associated with Down syndrome' includes both MDS and AML.

Morphology: Megakaryoblast morphology. Cytoplasm sometimes shows coarse granules

resembling basophilic granules. Dyserythropoiesis is evident yet Dysgranulopoiesis may be
present.
Dense blast cell infiltrate, some cases show dysplastic megakaryocytes; in other cases,
megakaryocytes may be markedly increased, with clusters of dysplastic small forms and
micromegakaryocytes
BMB shows a dense network of reticulin fibers.
Blasts are positive to CD45, CD117, CD42b, CD35, CD36, CD71, CD33, CD13, CD11b,
CD4 partial/dim, and CD7. Blasts are negative to CD34, HLA-DR, MPO, CD19, CD79a,
and CD3 surface and cytoplasmic.

Typical IPT profile

 Acute leukemias of ambiguous lineage
Leukemias that show no clear evidence of differentiation along a single lineage. They include:
1. Acute undifferentiated leukemias, which show no lineage specific antigens.(Rare entity )
2. Mixed-phenotype acute leukemias (MPALs), which have blasts that express antigens of more
than one lineage; MPALs can contain distinct blast populations each of a different lineage, one
population with multiple antigens of different lineages on the same cells, or a combination.

Requirements for assigning more than one lineage to a single blast population.
Myeloid lineage:
• MPO (by flow cytometry, immunohistochemistry, or cytochemistry) OR
• Monocytic differentiation (~2 of the following: non-specific esterase, CD11c, CD14,
CD64, lysozyme).
T-cell lineage:
• Strong Cytoplasmic CD3 (by flow cytometry with antibodies to CD3 epsilon chain using
a bright fluorophore as PE, or by lmmunohistochemistry. Note using polyclonal anti-CD3
antibody may detect CD3 zeta chain in NK cells, which is not T-cell-specific) OR
• Surface CD3 (rare in mixed-phenotype acute leukemias).
B·cell lineage: (Multiple antigens required).
• Strong CD19 with ~ 1 of the following strongly expressed: CD79a, cytoplasmic CD22,
CD10, PAX5 (PAX5 typically detected by immunohistochemistry). OR
• WeakCD19 with ~2 of the following strongly expressed: CD79a, cytoplasmic CD22,
CD10, PAX5 (PAX5 typically detected by immunohistochemistry).
• CD19 negative with three other B-cell markers present, but this is exceptionally rare.
CD79a
MPO
 A case of MPAL B/MYELOID

36%
Blasts are positive to: CD34,
Tdt, MPO (36%), CD19, CD79a,
CD22 surface and cytoplasmic
expression, CD38, CD58,
CD123, CD33 dim and CD13.
Blasts are negative to: CD10,
CD7, HLA-DR, surface and
cytoplasmic expression of CD3.
A case of MPAL B/Myeloid.
 Acute undifferentiated leukemia
Leukemia with no expression for lymphoid or myeloid lineage specific markers.
It is necessary to perform immunophenotyping with a comprehensive panel of monoclonal
antibodies in order to exclude leukaemias of unusual lineages, such as those derived from
plasmacytoid dendritic cell precursors (CD4, CD43, CD45RA, CD56, CD123, CD303,
TCL1A, CD2AP, Type I interferon), NK-cell precursors (CD2, CD7, cCD3, CD56, CD94 and
CD61), basophils (CD13, CD33, CD123, CD203c, CD117, CD9) or even non-haematopoietic
tumors(Pan-Cytokeratin).
Immunophenotype: Blasts often express: HLA-DR, CD34, and/or CD38 and may be Tdt and
CD7. Blasts are negative to T-cell and myeloid markers cCD3 and MPO and do not express B-
cell markers such as cCD22, cCD79a, or strong CD19. They also lack the specific features of
cells of other lineages, such as megakaryocytes or plasmacytoid dendritic cells.

Acute undifferentiated leukemia Blastic Plasmacytoid Dendritic Cell Neoplasm

Mixed-phenotype acute leukemia with t(9;22)( q34.1;q11.2); BCR-ABL1
It fulfills the criteria for MPAL and has blasts with t(9;22) and/or BCR-ABL 1 rearrangement.
Morphology: Many cases show a dimorphic blast population, with some blasts resembling
lymphoblasts and others myeloblasts, although other cases have no distinguishing features.
Immunophenotype: Blasts that meet the criteria for B-cell and myeloid lineage, other with T-
cell and myeloid lineage. Triphenotypic cases have also rarely been reported.
Myeloblast

Myeloblast

T-lymphoblast
B-lymphoblast

Myeloblast

T-lymphoblast
T-lymphoblast
Myeloblast

MPAL, T/Myeloid With 2 Blast Populations MPAL, B/Myeloid With 2 Blast Populations
Mixed-phenotype acute leukemia with t(v;11q23.3); KMT2A-rearranged
MPAL with t(v;11q23.3) fulfills the criteria for MPAL and has blasts with a translocation
involving KMT2A (previously called MLL).
Morphology: Dimorphic blast population, with some blasts clearly resembling monoblasts
and others resembling lymphoblasts; yet some cases appear as undifferentiated blast cells.
Immunophenotype: Lymphoblast population with a CD19+, CD10-, pro-B (B-cell precursor)
frequently positive for CD15. Expression of other B-cell markers, such as CD22 and CD79a, is
often weak. Cases also fulfill the criteria for myeloid lineage a separate population of myeloid
(usually monoblastic) leukemic cells.

MPAL, B/Myeloid (Monocytic)

Type With t(v;11q23.3);
*KMT2A* Rearranged
 X
MPAL, B/myeloid, NOS : Fulfills criteria for B/myeloid leukemia, but does not fulfill the
criteria for any of the genetically defined subgroups.
MPAL, T/myeloid, NOS: Fulfills criteria for both T-cell and myeloid lineage, but does not
fulfill the criteria for any of the genetically defined subgroups.
MPAL, NOS, rare types: Leukemic blasts show clear-cut evidence of both T-cell and B-cell
lineage commitment. (Very rare phenomenon). For assigning B-cell lineage to a case of T-
lymphoblastic leukemia, CD79a and CD10 should not be considered evidence of B-cell
differentiation.
-Too few cases with evidence of trilineage (B-cell, T-cell, and myeloid lineage) assignment.
- Up to date, no reports of mixed B- or T-cell and megakaryocytic or mixed B- or T-cell and
erythroid leukaemias. It has been assumed that erythroid and megakaryocytic lineages are the
earliest to branch off from the pluripotent haematopoietic stem cell, leaving progenitor cells
with T-cell, B-cell, and myeloid potential.
Acute leukaemias of ambiguous lineage, NOS:
Blasts express combinations of markers that do not allow for their classification as either acute
undifferentiated leukemia or mixed phenotype acute leukemia.
Immunophenotype: It include cases that express T-cell associated markers such as CD7 and
CD5 but lack cCD3, along with myeloid-associated antigens such as CD33 and CD13 without
MPO.
 Response criteria in AML
X
Category Definition Comment

BLOOD, 26 JANUARY 2017 x VOLUME 129, NUMBER 4

 2017 WHO Classification of B and T cell Lymphoblastic Leukemias
Precursor lymphoid neoplasms X

• B-lymphoblastic leukemia/lymphoma, NOS

• B-lymphoblastic leukemia/lymphoma with t(9; 22)( q34.1;q11.2); BCR-ABL 1
• B-lymphoblastic leukemia/lymphoma with t (v; 11 q23.3); KMT2A-rearranged
• B-lymphoblastic leukemia/lymphoma with t (12; 21)(p13.2;q22.1); ETV6-RUNX1
• B-lymphoblastic leukemia/lymphoma with hyperdiploidy
• B-lymphoblastic leukemia/lymphoma with hypodiploidy (hypodiploid ALL)
• B-lymphoblastic leukemia/lymphoma with t(5;14)(q31.1; q32.1); IGH/IL3
• B-lymphoblastic leukemia/lymphoma with t(1;19)(q23;p13.3); TCF3-PBX1
• B-lymphoblastic leukemia/lymphoma, BCR-ABL 1-like
• B-lymphoblastic leukemia/lymphoma with lymphoma iAMP
• T-lymphoblastic leukemia/lymphoma
• Early T-cell precursor lymphoblastic leukemia
• NK-lymphoblastic leukemia/lymphoma
B-lymphoblastic leukemia/ lymphoma, not otherwise specified (NOS)
Morphology:
• B-ALL/LBL is a neoplasm of precursor lymphoid cells committed to B cell lineage,
with B-cell lymphoblasts infiltration in the perpherial blood and bone marrow.
• Upon agreement, the term lymphoma is used when the process is confined to a mass
lesion with no or minimal evidence of blood and marrow involvement, in case of
marrow involvement many treatment protocols consider a value of > 25% marrow
blasts is used to define leukemia.

Exclusionary criteria:
• B-ALL should not be used to indicate Burkitt leukemia/lymphoma. OR
• Cases of B-ALL/LBL have specific recurrent genetic abnormalities that are
associated with distinctive clinical and phenotypic properties; these cases should not
be classified as B-ALL/ LBL, NOS, but rather according to their genetic
abnormalities.
Immunophenotyping:
• Lymphoblasts are positive for B-cell markers: CD19, cCD79a, surface and
cytoplasmicCD22, CD10, CD24, and TdT in most cases, whereas CD20 and CD34
expression is variable; CD45 may be absent or dimly expressed; aberrant expression
of myeloid-associated antigens CD13 and CD33 may be expressed.

• CD79a and PAX5 are most frequently used to demonstrate B-cell differentiation.
PAX5 is generally considered the most sensitive and specific marker for B-cell
lineage in tissue sections.

• The degree of differentiation has clinical and genetic correlates. In the earliest
stage (early precursor B-ALL or pro-B ALL), the blasts express CD19, cCD79a,
cCD22, and nuclear TdT. In the intermediate stage (common B-ALL), the blasts
express CD10.

• The most mature precursor B-cell differentiation stages include pre-B ALL, in which
the blasts express cytoplasmic mu chain, and occasional cases with surface heavy
chain without light chain may be seen in so-called Transitional pre-B ALL. Clonal
surface immunoglobulin light chain is characteristically absent.
The patient blasts are positive to CD34, CD10 B, CD19,
CD79a, CD38, CD58, CD24 D, CD81, CD9, and CD123 D
The blasts are negative to CD45, MPO, surface and cyCD3,
CD13, CD33, CD117, CD20, cyIgM, Tdt, and CD66c.
Aberrant markers:CD45 neg,CD10 B, and CD123 D
 How to differentiate between B cell lymphoblasts and marrow Hematogones?
-Both B-ALL and normal B-cell precursors (Hematogones) express CD10, yet their
immunophenotype always differ.
- Hematogones show a range of expression of markers of B-cell maturation, including
surface immunoglobulin, light chain, and show a reproducible pattern of acquisition and
loss of normal antigens.
- In contrast, B-ALL shows patterns that differ from normal, with either overexpression,
underexpression or loss of many markers, including CD10, CD45, CD38, CD58, and TdT;
together with the expression of aberrant markers in case of lymphoblastic leukemia.
These differences is useful in the evaluation of follow-up marrow for MRD.
Blast is pos. to: CD10
B, CD19, CD79a,
CD34CD58, CD38,
CD33, CD22, Tdt,
CD9, CD24, CD81,
&CD123
Aberrancy: CD45 neg,
CD10B, CD33, CD123
Positive MRD with 0.07%
Positive MRD with 0.07%
The patient relapsed after
5 months of MRD testing.
The patient relapsed after 5 months of MRD testing.
 B-lymphoblastic leukemia/lymphoma with recurrent genetic abnormalities
Group of diseases characterized by recurrent genetic abnormalities, including balanced
translocations and abnormalities involving chromosome number.
Why this genetic abnormalities specifically?
They have been chosen because they are associated with characteristic clinical, phenotypic
properties, prognostic effects.

B-lymphoblastic leukemia/lymphoma with t(9;22)(q34.1;q11.2); BCR-ABL1

• B-ALL with BCR-ABL 1 is relatively more common in adults than in children, it has the
worst prognosis in both children and adults.
• Therapy with tyrosine kinase inhibitors has a significant favorable effect on outcome
• Immunophenotype: B-ALL with BCR-ABL1 is typically positive for CD10, CD19, and TdT.
There is frequent expression of myeloid-associated antigens CD13 and CD33.
• CD25 is highly associated with B-ALL with BCR-ABL1.

B-lymphoblastic leukemia/lymphoma with t(v;11q23.3); KMT2A-rearranged

• B-ALL with KMT2A rearrangement is the most common leukemia in infants aged < 1 year
Patients with this leukemia present with very high white blood cell counts > 100 x 109 IL;
there is also a high frequency of CNS involvement at diagnosis.
• It has a poor prognosis.
• Immunophenotype: CD19+, and CD10- ,The NG2 is also characteristically expressed
and is relatively specific.
B-lymphoblastic leukemia/lymphoma with t(12;21)(p13.2;q22. 1); ETV6-RUNX1 X
- It is not seen in infants, but is common in children. It decreases with age, it is rare in adulthood.
- It has a very favorable prognosis.
- Immunophenotype: Blasts are positive to CD19, CD10, and CD34 positive; with complete
absence of CD9, CD20, and CD66c.
B-lymphoblastic leukemia/lymphoma with hyperdiploidy
-Neoplasm of lymphoblasts committed to B-cell lineage whose blasts contain > 50
chromosomes (usually < 66).
- Hyperdiploid B-ALL has a very favorable prognosis.
- Immunophenotype: Blasts are positive for CD19 and CD10, and express other markers typical
of BALL. Most cases are CD34 positive, and CD45 is often absent.

B-lymphoblastic leukemia/lymphoma with hypodiploidy

- Neoplasm of lymphoblasts committed to B-cell lineage whose blasts contain < 46
chromosomes. Consists of three subtypes: 1) near-haploid ALL (with 23-29 chromosomes}, 2)
low hypodiploid ALL (with 33-39 chromosomes), and 3) high hypodiploid ALL (with 40-43
chromosomes).
- Hypodiploid ALL has a poor prognosis.
- Immunophenotype: Blasts are positive to CD10 and CD19 with no specific phenotype
 B-lymphoblastic leukemia/lymphoma with t(5;14)(q31.1;q32.1); IGH/IL3
Typical morphology of lymphoblasts, but the striking finding of increase in circulating
eosinophils. This is a reactive population and not part of the leukemic clone
Blasts have a CD19+, CD10+ phenotype. The finding of even small numbers of blasts with
this phenotype in a patient with eosinophilia strongly suggests this diagnosis.
B-lymphoblastic leukemia/lymphoma with t(1;19)(q23;p13.3); TCF3-PBX1
X
- This leukemia is relatively common in children
- Blast are positive to: CD19, CD10, and cytoplasmic mu heavy chain, although not all
cases, strong expression of CD9 and lack CD34.
- Poor prognosis, and increased risk of CNS relapse.

B-lymphoblastic leukemia/lymphoma, BCR-ABL 1-like

- It have translocations involving other tyrosine kinases.
- Patients with BCR-ABL 1-like ALL have a poor prognosis
- These patients have shown dramatic responses to ABL-class tyrosine kinase inhibitors
such as Imatinib and Dasatinib

B-lymphoblastic leukemia/lymphoma with iAMP21

- Lymphoblasts committed to the B-cell lineage characterized by amplification of a
portion of chromosome 21, detected by FISH
-It is most often in older children who present with low white blood cell counts.
- ALL with iAMP21 has a relatively poor prognosis
 T-lymphoblastic leukemia/ lymphoma

• TALL/LBL is a neoplasm of lymphoblasts committed to the T-cell lineage.

• Blasts infiltrate the perpherial blood and the bone marrow (T-ALL) or presenting with
primary involvement of the thymus or of nodal or extranodal sites (T-LBL).
• The term lymphoma is used when the process is confined to a mass lesion with no or
minimal evidence of peripheral blood and bone marrow involvement, in case of
marrow involvement with a value > 25% bone marrow blasts is used to define
leukemia.
 Diffuse infiltration the lymphoblasts have a high N:C ratio, a thin nuclear membrane,
finely stippled chromatin, and inconspicuous nucleoli

CD3 Tdt
Immunophenotype: Lymphoblasts are variably expressing: CD1a, CD2, CD3, CD4, CD5, CD7, and
CD8. Of these markers, CD7 and CD3 (cytoplasmic) are most often positive, but only CD3 is
considered lineage specific. In addition to TdT and CD34, CD1a and CD99 may help to indicate the
precursor nature of T-lymphoblasts . CD79a positivity has been observed in approximately 10% of
some cases aberrantly express: CD13 and CD33. CD117 is positive with FLT3 mutations.

Blast are pos. to:

cyCD3,CD34,Tdt,CD99,
CD5,CD7, CD2,
Neg to CD4,CD8,sCD 3,
CD1a,
 Early T-cell precursor lymphoblastic leukemia
- Neoplasm composed of cells committed to the T-cell lineage but with a unique immunophenotype
indicating only limited early T-cell differentiation.
-This is an uncommon neoplasm found in both children and adults
-Immunophenotype: ETP-ALL expresses cytoplasmic, or in rare cases surface CD3, CD7 and may
express CD2 and/or CD4; but lacks CD8, CD5 and CD1a and is positive for one or more of the
myeloid/stem cell markers CD34, CD117, HLA-DR, CD13, CD33, CD11b, and CD65.
CD11b/CD33 Coexpression

CD34+

cyCD3+ CD45+
CD34+CD7+

ETP Phenotype
References:
• WHO classification of tumors of hematopoietic and
Lymphoid tissue - Revised edition 2017.

• Diagnostic Pathology: Blood and Bone Marrow- Second

Edition 2018 - Kathryn Foucar, MD.

• Bone marrow pathology- Fifth Edition 2019- Barbara J. Bain,

MD.