Leukemia

Dr. Isbandiyah SpPD

Bag. Ilmu Penyakit Dalam UMM
Malang
 What Is Leukemia?
• Cancer of the white blood cells
• Acute or Chronic
• Affects ability to produce normal
blood cells
• Bone marrow makes abnormally
large number of immature white
blood cells called blasts
 Classification of leukemias

Acute Chronic

Myeloid Acute Myeloid Chronic Myeloid Leukemia

Leukemia (AML) (CML)
origin

Lymphoid Acute Lymphoblastic Chronic Lymphocytic Leukemia

Leukemia (ALL) (CLL)
origin
 Hematopoiesis
PLURIPOTENT MIXED COMMITTED RECOGNIZABLE MATURE
STEM CELL PROGENITOR PROGENITOR BONE MARROW BLOOD
CELL CELL PRECURSOR CELL CELL

BFU-E/CFU-E pronormoblast red cell

myeloblast neutrophil
CFU-GM
monoblast monocyte
CFU-Eos eosinophil
myeloid CFU-Baso basophil
progenitor
cell CFU-Meg megakaryocyte platelet
pluripotent
stem cell pre-T lymphoblast T-cell

pre-B lymphoblast B-cell

lymphoid & plasma cell
progenitor
cell
 Myeloid maturation
myeloblast promyelocyte myelocyte metamyelocyte band neutrophil

MATURATION
Adapted and modified from U Va website
 Acute Leukemia
• accumulation of blasts in the marrow
How to distinguish AML vs CML
from looking at peripheral
blood
Myeloid cell CML AML normal
blasts  
promyelocytes 
myelocytes 
metamyelocytes 
bands 
neutrophils   
 Classification of acute
leukemias
ALL AML
• mainly children • mainly adults
• M>F • M>F
• curable in 70% of
children • curable in minority
• curable in minority of adults
of adults
 Clinical manifestations
• symptoms due to:
– marrow failure
– tissue infiltration
– leukostasis
– constitutional symptoms

• usually short duration of symptoms

 Marrow failure
• neutropenia: infections, sepsis
• anemia: fatigue, pallor
• thrombocytopenia: bleeding
Infiltration of tissues/organs
• enlargement of liver, spleen, lymph
nodes
• gum hypertrophy
• bone pain
• other organs: CNS, skin, testis, any
organ
Gum hypertrophy
 Leukostasis
• accumulation of blasts in
microcirculation with impaired
perfusion
• lungs: hypoxemia, pulmonary
infiltrates
• CNS: stroke
• only seen with WBC >> 50 x 109/L
 Causes of acute leukemias
• idiopathic (most)
• underlying hematologic disorders
• chemicals, drugs
• radiation
• viruses
• hereditary/genetic conditions
 Constitutional symptoms
• fever and sweats common
• weight loss less common
 Laboratory features
• WBC usually elevated, but can be
normal or low
• blasts in peripheral blood
• normocytic anemia
• thrombocytopenia
 Bone marrow in acute
leukemia
• necessary for diagnosis
• useful for determining type
• useful for prognosis
• Acute leukemias are defined by the
presence of > 20% blasts in bone
marrow (% of nucleated marrow
cells)
Distinguishing AML from ALL
• light microscopy
– AML: Auer rods, cytoplasmic granules
– ALL: no Auer rods or granules.
• special stains (cytochemistry)
• flow cytometry
AML
ALL
Auer rods in AML
 Treatment of acute
leukemias
• Choice of Rx is influenced by:
– type (AML vs ALL)
– age
– curative vs palliative intent

• Chemotherapy
• Immunotherapy
• Radiation
• Bone marrow transplant
Principles of treatment
• combination chemotherapy
– first goal is complete remission
– further Rx to prevent relapse
• supportive medical care
– transfusions, antibiotics, nutrition
• psychosocial support
– patient and family
 Chemotherapy for acute
leukemias
• Phases of ALL treatment
– induction
– consolidation
post-remission therapy
– Maintenance

• AML treatment
– induction
– consolidation (post-remission therapy)
 Prognosis

Adult AML
Age CR DFS
< 60 75% ~ 30%
> 60 50% 5-15%

Adult ALL

similar to or worse than AML