Blood Malignancies-IBlood Malignancies-I

Prof. Herman Hariman,SpPK (KH). Ph.D.(U.K)Prof. Herman Hariman,SpPK (KH). Ph.D.(U.K)o e a a a ,Sp ( ) (U )o e a a a ,Sp ( ) (U )Prof. Dr. Adikoesoema Aman, SpPK (KH)Prof. Dr. Adikoesoema Aman, SpPK (KH)

Dept. Clinpath, FKDept. Clinpath, FK--USUUSUDept. Clinpath, FKDept. Clinpath, FK USUUSU

First do the Full Blood CountFirst do the Full Blood CountFirst do the Full Blood CountFirst do the Full Blood CountHb, WBCS, PlateletsHb, WBCS, PlateletsM h l !! S h bl b l lM h l !! S h bl b l lMorphology !! Such as blasts, abnormal mononuclears, Morphology !! Such as blasts, abnormal mononuclears, ordinary cells which shows abnormal appearancesordinary cells which shows abnormal appearancesUnexplained drop of platelet numbersUnexplained drop of platelet numbersUnexplained drop of platelet numbersUnexplained drop of platelet numbersUnexplained drop of HbUnexplained drop of HbUnexplained drop or increase of WBCsUnexplained drop or increase of WBCs

Cell Counter

2nd step do Bone Marrow Study2nd step do Bone Marrow Study2 step do Bone Marrow StudyIf possible both the aspiration and

bi

2 step do Bone Marrow StudyIf possible both the aspiration and

bibiopsy biopsy AspirationAspirationAspirationAspirationBiopsyBiopsyCytogeneticsCytogeneticsImmunophenotypingImmunophenotypingp yp gp yp gTissue typing (HLA)Tissue typing (HLA)

DASAR DIAGNOSA LEUKEMIA

MORFOLOGI CELL

RUTIN STAININGSPESIAL STAINING ( SITOSTAINING )( SITOSTAINING )

ISLAM aspiration needleISLAM aspiration needle

ISLAM biopsy needle set

CytostainingCytostaining

Sudan Black (SBB), Myeloperoxidase Sudan Black (SBB), Myeloperoxidase (MPO), neutrophil alkaline phosphatse(MPO), neutrophil alkaline phosphatse( ), p p p( ), p p pThey are They are oudatedoudated by immunophenotyping by immunophenotyping (flowcytometer) and cytogenetics (qRT(flowcytometer) and cytogenetics (qRT--(flowcytometer) and cytogenetics (qRT(flowcytometer) and cytogenetics (qRTPCR) especially in the implementation of PCR) especially in the implementation of WHO classification of blood malignanciesWHO classification of blood malignanciesWHO classification of blood malignanciesWHO classification of blood malignancies

MPO stain, myeloblast but negative for neutrophil

Sudan Black B

Flowcytometer together with PCR can be used for cytogenetics

KLASIFIKASI LEUKEMIAKLASIFIKASI LEUKEMIAWHO ( 1997 ) WHO ( 1997 ) The European Association of PathologistThe European Association of Pathologistp gp gAnd the Society for HematopathologyAnd the Society for HematopathologyFAB ( MIC )

-Lymphoid Neoplasma

Myeloid Neoplasma

-Morfologi

I h t i -Myeloid Neoplasma

-Histiocytic Neoplasma

-Immunophenotyping

-Cytogenetic

-Mast Cell Neoplasma

IMMUNOPHENOTYPINGIMMUNOPHENOTYPINGIMMUNOPHENOTYPING( IMMUNOLOGI MARKERS ) SEL :IMMUNOPHENOTYPING( IMMUNOLOGI MARKERS ) SEL :

DEFINISI :DEFINISI :Pertanda Immunologi dari struktur / antigenPertanda Immunologi dari struktur / antigenPertanda Immunologi dari struktur / antigen Pertanda Immunologi dari struktur / antigen permukaan sel baik sel normal maupun sel permukaan sel baik sel normal maupun sel LeukemiaLeukemia

Immunophenotyping

( Cluster Differentiation )1 t I i l W k h d H L1st International Workshop and Humen Leucocyte

Differentiation Antigen ( 1982 ) di Paris

Nomenclature CD 151 CD

5th Boston Workshop ( 1993 ) Update CD

6th Workshop on HLDA( Tadamatsu Kishimoto dari Osaka University Medical School )

1000 CD

Classification of myeloidClassification of myeloidClassification of myeloid malignancies

Classification of myeloid malignancies

FABFABChronic Chronic

l lif til lif timyeloproliferative myeloproliferative diseasesdiseases

Myelodysplastic Myelodysplastic syndromessyndromesAcute myeloid Acute myeloid leukaemiasleukaemiasleukaemiasleukaemias

W H O Classification ofW H O Classification ofW.H.O Classification of Myeloid Malignancies

W.H.O Classification of Myeloid Malignancies

Chronic myeloproliferative diseasesChronic myeloproliferative diseasesChronic myeloproliferative diseasesChronic myeloproliferative diseasesMyelodysplastic/myeloproliferative Myelodysplastic/myeloproliferative diseasesdiseasesdiseasesdiseasesMyelodysplastic syndromesMyelodysplastic syndromesAcute myeloid leukaemiasAcute myeloid leukaemias

Classification of myeloidClassification of myeloidClassification of myeloid malignancies

Classification of myeloid malignancies

FABFABChronic Chronic

l lif til lif ti

WHOWHOChronic Chronic

l lif til lif timyeloproliferative myeloproliferative diseasesdiseases

myeloproliferative myeloproliferative diseasesdiseasesMyelodysplastic/myelopMyelodysplastic/myelop

Myelodysplastic Myelodysplastic

Myelodysplastic/myelopMyelodysplastic/myeloproliferative diseasesroliferative diseasesMyelodysplastic Myelodysplastic

ddsyndromessyndromesAcute myeloid Acute myeloid leukaemiasleukaemias

syndromessyndromesAcute myeloid Acute myeloid leukaemiasleukaemiasleukaemiasleukaemias leukaemiasleukaemias

Chronic MyeloproliferativeChronic MyeloproliferativeChronic Myeloproliferative Disorders

Chronic Myeloproliferative Disorders

FABFABChronic myelogenous Chronic myelogenous leukemia (CML)leukemia (CML)

WHOWHOCML Ph+: t(9;22)(qq34;q11), CML Ph+: t(9;22)(qq34;q11), BCR/ABLBCR/ABL

Agnogenic myeloid Agnogenic myeloid metaplasia with metaplasia with

l fib i (MF)l fib i (MF)

Chronic neutrophilic Chronic neutrophilic leukemialeukemiaChronic eosinophilic Chronic eosinophilic l k i /h i hilil k i /h i hilimyelofibrosis (MF)myelofibrosis (MF)

(Idiopathic myelofibrosis)(Idiopathic myelofibrosis)leukemia/hypereosinophilic leukemia/hypereosinophilic syndromesyndromeChronic idiopathic Chronic idiopathic myelofibrosismyelofibrosis

Polycythemia vera (EV)Polycythemia vera (EV)Essential thrombocytemia Essential thrombocytemia (ET)(ET)

myelofibrosismyelofibrosisPolycythemia veraPolycythemia veraEssential thrombocytemiaEssential thrombocytemia

(ET)(ET)

(French American British) F.A.B(French American British) F.A.B

Based on MORPHOLOGYBased on MORPHOLOGY> 30% blasts = ACUTE LEUKAEMIA> 30% blasts = ACUTE LEUKAEMIA> 30% blasts ACUTE LEUKAEMIA> 30% blasts ACUTE LEUKAEMIA< 5% = normal or Chronic Leukaemia< 5% = normal or Chronic Leukaemia66 29% MYELODYSPLASTIC29% MYELODYSPLASTIC66--29% = MYELODYSPLASTIC 29% = MYELODYSPLASTIC SYNDROME with the exception of SYNDROME with the exception of E h l k i b 6E h l k i b 6 29% bl b29% bl bErythroleukaemia can be 6Erythroleukaemia can be 6--29% blasts but 29% blasts but the blast/NEC ratio > 30%the blast/NEC ratio > 30%

CHRONIC CHRONIC MYELOPROLIFERATIVE

DISODERSMYELOPROLIFERATIVE

DISODERSDISODERSDISODERS

CML Ph+: t(9;22)(qq34;q11), BCR/ABLCML Ph+: t(9;22)(qq34;q11), BCR/ABL( )(qq q )( )(qq q )Chronic neutrophilic leukemiaChronic neutrophilic leukemiaChronic eosinophilic Chronic eosinophilic ppleukemia/hypereosinophilic syndromeleukemia/hypereosinophilic syndromeChronic idiopathic myelofibrosisChronic idiopathic myelofibrosisp yp yPolycythemia veraPolycythemia veraEssential thrombocytemiaEssential thrombocytemiayy

Laboratory testsLaboratory tests

FBCs: leucocytosis (>100 x 109/l) with FBCs: leucocytosis (>100 x 109/l) with immature neutrophil (myelocytes immature neutrophil (myelocytes p ( y yp ( y y+metamyelocytes)+metamyelocytes)BasophiliaBasophiliaBasophiliaBasophiliaNeutrophil Alk Phosphatase: reducedNeutrophil Alk Phosphatase: reducedBMP PhBMP Ph11 d BCR/Abl dd BCR/Abl dBMP: PhBMP: Ph11and BCR/Abl oncogene + do and BCR/Abl oncogene + do HLA typingHLA typing

New Chimeric Fusion ProteinNew Chimeric Fusion ProteinNew Chimeric Fusion ProteinBCR/Abl oncogene

New Chimeric Fusion ProteinBCR/Abl oncogene

BCR/Abl TYROSINE KINASEBCR/Abl TYROSINE KINASEBCR/Abl TYROSINE KINASEBCR/Abl TYROSINE KINASE

PROLIFERATIVE EFFECTPROLIFERATIVE EFFECTARREST OF DIFFERENTIATIONARREST OF DIFFERENTIATION

ARREST OF APOPTOSISARREST OF APOPTOSIS

CMLCML

The most important change is, that The most important change is, that only the only the Ph+ cases are called CMLPh+ cases are called CML by the WHO. by the WHO. yyThe The PhPh-- casescases (which show myelodysplastic signs, (which show myelodysplastic signs, and are known to have significantly worse and are known to have significantly worse

i ) ll di ) ll d CMLCML ( t i l CML) d( t i l CML) dprognosis) are called prognosis) are called aCMLaCML (atypical CML), and (atypical CML), and belong to the newly created belong to the newly created myelodysplastic / myelodysplastic / myeloproliferative groupmyeloproliferative group. The aCML term is . The aCML term is y p g py p g psomewhat misleading, because somewhat misleading, because it is not CMLit is not CML at at all, but it was kept, having no better alternative.all, but it was kept, having no better alternative.

Chronic phase CML Low power view of this bone marrow aspirate reveals an increased ME ratio. Eosinophils and larger immature myeloid elements

are also evident.

CML accelerated phase, leukocytosis with abnormal lobulation nuclei blasts less 20%

CML BLASTIC CRISIS

Hypereosinophilic syndrome/CEL

Idiopathic Myelofibrosis

Myelodysplastic / MyeloproliferativeMyelodysplastic / MyeloproliferativeMyelodysplastic / Myeloproliferative Disorders

Myelodysplastic / Myeloproliferative Disorders

Atypical myelogenous leukemia (aCML)Atypical myelogenous leukemia (aCML) same same morphology, Ph (morphology, Ph (--)ve, BCR/Abl (+)ve)ve, BCR/Abl (+)veChronic myelomonocytic leukemia (CMML)Chronic myelomonocytic leukemia (CMML)Chronic myelomonocytic leukemia (CMML)Chronic myelomonocytic leukemia (CMML)same morphology with > 20% monocytessame morphology with > 20% monocytesJuvenile myelomonocytic leukemia (JMML)Juvenile myelomonocytic leukemia (JMML)

h l b t i hild 2 ldh l b t i hild 2 ldsame morphology but in children < 2 ys oldsame morphology but in children < 2 ys old

CMML belonged to the MDS in the FAB classification. About oneCMML belonged to the MDS in the FAB classification. About oneCMML belonged to the MDS in the FAB classification. About one CMML belonged to the MDS in the FAB classification. About one half of the cases show proliferative, the other dysplastic signs, half of the cases show proliferative, the other dysplastic signs, but it looks like these are just different forms of the same but it looks like these are just different forms of the same disease.disease.

MYELODYSPLASTICMYELODYSPLASTICMYELODYSPLASTIC SYNDROME

MYELODYSPLASTIC SYNDROME

Refractory anemia (RA) Refractory anemia (RA) R f t i ith i d id bl tR f t i ith i d id bl tRefractor anemia with ringed sideroblasts Refractor anemia with ringed sideroblasts (RARS)(RARS)Refractory cytopenia with multilineage Refractory cytopenia with multilineage y y p gy y p gdysplasiadysplasia (new)(new)Refractory anemia with excess blasts (FAB: Refractory anemia with excess blasts (FAB: RAEB)RAEB)RAEB)RAEB)5q5q-- syndromesyndrome (new)(new)unclassifiableunclassifiable (new)(new)( )( )

No granules

PSEUDO-PELGER (no granules) as sign of dysmyelopoiesis

DYSERYTHROPOIESIS

DYSMEGAKARYOPOIESISDYSMEGAKARYOPOIESIS

Ring SideroblastRing Sideroblast

RCMD

Refractory Cytopenia with Multilineage Dysplasia (RCMD)

Refractory Cytopenia with Multilineage Dysplasia (RCMD)

RAEB-1

RAEB-2

BELGIAN ANAEMIA 5q- syndrome

ACUTE MYELOID LEUKAEMIAACUTE MYELOID LEUKAEMIA

AML with recurrent cytogenetic translocationsAML with recurrent cytogenetic translocationsAML with t(8;21)(q22;q22) AML1/CBFalpha/ETOAML with t(8;21)(q22;q22) AML1/CBFalpha/ETOAcute promyelocytic leukemia:AML withAcute promyelocytic leukemia:AML withAcute promyelocytic leukemia:AML with Acute promyelocytic leukemia:AML with t(15;17)(q22;q12) and variants PML/RARalphat(15;17)(q22;q12) and variants PML/RARalphaAML with abnormal bone marrow eosinophils AML with abnormal bone marrow eosinophils inv(16)(p13;q22) vagy t(16;16)(p13;q22) inv(16)(p13;q22) vagy t(16;16)(p13;q22) CBFbeta/MYH1CBFbeta/MYH1AML with 11q23 MLL abnormalitiesAML with 11q23 MLL abnormalitiesqq

Acute myeloid LeukaemiaAcute myeloid LeukaemiaAcute myeloid Leukaemia (continued)

Acute myeloid Leukaemia (continued)

AML with multilineage dysplasiaAML with multilineage dysplasiaWith prior MDSWith prior MDSWithout prior MDSWithout prior MDSAML with myelodysplastic syndrome, therapy relatedAML with myelodysplastic syndrome, therapy relatedy y p y , pyy y p y , pyAlkylating agent relatedAlkylating agent relatedEpipodophyllotoxin relatedEpipodophyllotoxin relatedAML not otherwise categorizedAML not otherwise categorizedAML minimally differentiatedAML minimally differentiatedyyAML without maturationAML without maturationAML with maturationAML with maturationAcute myelomonocytic leukemiaAcute myelomonocytic leukemiaAcute monocytic leukemiaAcute monocytic leukemiayyAcute erythroid leukemiaAcute erythroid leukemiaAcute megakaryocytic leukemiaAcute megakaryocytic leukemiaAcute basophilic leukemiaAcute basophilic leukemiaAcute panmyelosis with myelofibrosisAcute panmyelosis with myelofibrosis

A.M.L-M1

A.M.L-M2; 25% of M2 may contain t-8:21

AML-M3 hypergranular can be found in t-15:17

M3 folding nuclei

INV(16)/AMLM4EoINV(16)/AMLM4Eo

AML-M5

AML-M6

AML-M7

AML de Novo or secondary

Investigation of risk factors

Good Risk Standard/ Poor Riskt(8;21), t(15;17) IntermediateRisk Relapsed( ; ), ( ; ) p

Inv(6) w/wo other No favourable nor unfavourable >15% blasts after C1Cytogenetic cytogenetic abnormalities -5, -7, abn(3q), complex abnormalities 5-15% blasts after C1 genetic abnormalities

Induction-C1 Induction-C1

Induction-C2 Induction-C2

2 CoursesConsolidation Consolidation ADE FLA

±G-CSF ±G-CSFCourse-4 BMT Course-4 ±ATRA ±ATRA

Course-5 BMT Course-5 Off BMT Consolidation

Cytogenetic, the most significant factors

Good Risk Standard/ Poor Riskt(8;21), t(15;17) IntermediateRisk Relapsed( ; ), ( ; ) p

Inv(6) w/wo other No favourable nor unfavourable >15% blasts after C1Cytogenetic cytogenetic abnormalities -5, -7, abn(3q), complex abnormalities 5-15% blasts after C1 genetic abnormalities

CN-AML (Cytogenetically Normal)± 50% patients are assigned p g

In the intermediate group

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