3. Clonal evolution of malignancy Most malignancies r the result of several sequentially acquired mutations rather than single catastrophic mutation.

6. Cell cycle CDK p53 is known as the ‘ guardian of the genome ‘

9. Usually point mutation or gene deletion (del.) One of the striking features of haemat.malign. ( in contrast to most solid tumours ) is high frequency of translocations ( t ) p53 the { guardian of the genome } is The most significant TSG in human cancer It is mutated or inactivated in > 50 % of malignant diseases including many haematological malignancies Examples of chromosomal translocations in haematological malignancies will be mentioned later on TSG may acquire loss-of-function mutation malignant transformation e.g. p53 (at 17p13 ) & Rb (at 13q14 ) Oncogenes arise because of gain-of-function mutation in the normal cellular genes ( proto-oncogenes ) TSG act in Cell cycle control (Checkpoint) ( G-1 S G-2 M ) DNA damage cell-cycle arrest for 1 of 2 1.DNA repair & continuation of cell cycle 2.Apoptosis by activating pro-apoptotic genes proto-oncogenes are often involved in transduction ( transfer of external signals to the nucleus to activate genes ) Tumour Suppressor Genes (TSG) (anti-oncogenes) Oncogenes

13. The most common Specific abnormality in childhood ALL is the t ( 12 ; 21 )

15. HAEMOPOIETIC STEM CELLS (HSC) (CD34+ ; CD38-) LYMPHOID STEM CELLS MYELOID STEM CELLS LYMPHOCYTES OTHER BLOOD CELLS

16. HAEMOPOIETIC STEM CELLS (HSC) LYMPHOID STEM CELLS MYELOID STEM CELLS LYMPHOCYTES RBC OTHER WBC PLATELET

17. HAEMOPOIETIC STEM CELLS LYMPHOID STEM cell MYELOID STEM CELLS LYMPHOCYTES ACUTE CHRONIC OTHER BLOOD CELLS

18. ACUTE CHRONIC HSC or early progenitors Maturing & mature cells usually aggressive & rapidly fatal if not rapidly treated x x some has high cure rate e.g. ALL( L1) in children X

19. HAEMOPOIETIC STEM CELLS LYMPHOID STEM CELL Lymphoblast MYELOID STEM CELL Myeloblast LYMPHOCYTES ACUTE CHRONIC M Y E L O I D L Y M P H O I D OTHER BLOOD CELLS

20. Lymphoblasts Lymphocytes Granulocytes Myeloblasts ALL AML CML CLL

21. LYMPHOID STEM CELLS Pre-T Thymocyte Peripheral T Cells T- Helper T- Supp. Pro-B Pre-B B- Virgin B- Mature LPC PLASMA CELL ALL CLL

22. MYELOID STEM CELLS PRO - NORMOBLAST RBC MONO- BLAST MONO- CYTE MYELOBLAST PRO-MYELOCYTE MYELOCYTE META-MYELOCYTE BAND or STAB GRANULOCYTES MEGA- KARYO- BLAST PLATELET AML CML

23. Acute Leukemia means Maturation Arrest Sustained SELF-RENEWAL at the expense of DIFFERENTIATION accumulation of BLAST CELLS Differentiation (Maturation) Self-renewal Maturation Arrest Sustained self-renewal Differentiation (Maturation) Acute Leukemia Normal

24. ACUTE LEUKEMIAS Types& Sub-types INCIDENCE Age Clinical presentation & Lab. Data B.M. failure Anaemia symptoms & signs of anaemia Neutropenia recurrent infections NB Total WBC count ( High; Normal or low ) Thrombocytopenia bleeding tendency Tissue Infiltration

25. Clinical presentation & Lab. Data Anaemia symptoms & signs of anaemia Neutropenia recurrent infections Thrombocytopenia bleeding tendency Tissue Infiltration: e.g. organomegaly (hepatosplenomegaly) ; lymphadenopathy ; meningeal syndrome ( headache, nausea, vomiting, blurring of vision & diplopia with blast cells in CSF) ; skin lesions ; testicular swelling -------- etc. B.M. failure caused by accumulation of BLAST cells

26. ALL AML TYPES & AGE mainly children ~ 4 yr mainly adults ALL the most common malignancy of childhood ( 25-30 % ) a second rise after the age of 40 yr AML incidence increase with age

29. AML FAB SUB-TYPES OF AL M0 M1 M2 M3 M4 M5 M6 M7 L1 L2 L3 ALL Morphological classification of AL

30. Burkitt’s Lymphoma is the Lymphomatous correlate of L- 3 ALL

31. LYMPHOBLASTS IN ALL FAB SUBTYPES large & homogeneous é marked Cy. basophilia & Cy. vacuoles Larger& heterogeneous é more abundant Cy. & more prominent Ni. small & monomorphic é large N/C ratio L3 L2 L1

32. ACUTE LEUKEMIAS SPECIAL STAINS M1-M4 M5 L2 LYMPHOBLAST MYELOBLAST MONOBLAST PAS Periodic acid- Schiff *Sudan Black-B’ SBB ’ * Myeloperoxidase’ MPO ’ * Specific Esterase Non-Specific Esterase

33. IPT of AL male predominance & Mediastinal mass CD14&CD15: M4 & M5 Glycophorin -A : M6 CD41a(GpIIb/IIIa) : M7 CD 14 & !% in M4& M5 Glycophorin A in M6 CD41a in( Myeloperoxidae in M0 CD14 &CD15 in M4 & M5 Glycophorin-A in M6 CD41a in M7 TdT ; Terminal deoxynucleotidyl transferase ~12% L1 or L2 ~ 3% L3 ~85% L1 or L2 ± ++ - cIg +ve Commonly child often infant CD 10 ( CALLA ) Pre-B common Pro-B sIg +v e B-ALL

34. Prognostic factors in ALL ( still + ve) at 3 - 6 months (- ve) at 1-3 months Minimal residual disease (MRD) > 4 week < 4 week Time to remission > 1 week < 1 week Time to clear b l asts from bl ood P h + ve , or P seudo-diploid Normal or Hyperdiploid Cytogenetics T-ALL ( in children ) C ALLA IPT High (> 50.000 /µL) Low WBC count ( + ) ( - ) CNS disease at presentation b oys (?) testes is a common site for relapse G irls Sex Adult ( or infant < 2 yr ) C hild Age P oor G ood

35. Myeloblast M0-M1 Monoblast M5 Pro-normoblast Megakaryo - blast M7 Promyelocyte M3 AML FAB-sub-types M0 - M7 M2 M4 M6 N.B. odd No.:- single cell even No.:- double cell Auer rods

36. M5a (monoblastic) M5b (monocytic) Pro-normoblast M7 Megakaryo - blastic M3 Ac. Promyelocytic L. (APL) AML FAB-sub-types M2 with granulocytic maturation M4 with granulocytic & monocytic maturation M6 ( Erythroleukaemia ) N.B. odd No.:- single cell even No.:- double cell M0 un differentiated M1 without maturation

37. M5 Megakaryo- blast M7 Promyelocyte M3 & M-3v AML Specific clinical. features M4 tissue infiltration Acute MF (no splenomegaly BM MK—blasts) DD:- MMM Myelofibrosis é Myeloid Metaplasia DIC

38. 0 0

39. ACUTE LEUKEMIAS SPECIAL STAINS M4 M5 MYELOBLAST MONOBLAST *Sudan Black-B’ SBB ’ * Myeloperoxidase’ MPO ’ *Specific Esterase Non-Specific Esterase DE M2-SBB+ve Auer rod M2-SBB+ve CG M2-MPO+ve CG M4-SBB+ve My Mo-ve

40. AML é. out M aturation M1 M2 AML é granulocytic Maturation

41. Myeloblast Promyelocyte C: Heavy azurophilic granulation (hypergranular) & Auer rods (rod-shaped granules) strongly positive for MPO Faggot cells : cells with bundles of Auer rods N: with nucleoli ( Ni ) APL M3 Classical

42. APL M3 Faggot cell

43. APL (M-3v) micro-granular variant Characterized by: paucity of myeloid granules & dumb-bell nucleus M-3v

44. AML (AMML) M4 AML with granulocytic & monocytic maturation Monoblast Myeloblast +

45. M5

46. Myeloblast Pro- normoblast > 50% of the nucleated marrow cells r erythroid &Myeloblasts < 30% BM NEC M6 AML Erythroleukemia M6

47. Myeloblast Megakaryo- blast Large and small megakaryoblasts with high N/C ratio C: is pale & a granular with blebs EM Platelets Peroxidase +ve AML M7 Megakaryoblastic L.

48. IPT of AL male predominance & Mediastinal mass CD14&CD15: M4 & M5 Glycophorin -A : M6 CD41a(GpIIb/IIIa) : M7 CD 14 & !% in M4& M5 Glycophorin A in M6 CD41a in( Myeloperoxidae in M0 CD14 &CD15 in M4 & M5 Glycophorin-A in M6 CD41a in M7 TdT ; Terminal deoxynucleotidyl transferase ~12% L1 or L2 ~ 3% L3 ~85% L1 or L2 ± ++ - cIg +ve Commonly child often infant CD 10 ( CALLA ) Pre-B common Pro-B sIg +v e B-ALL

49. M5 t ( 9 ; 11 ) t ( 11 ; 19 ) del (11q) M3 t ( 15 ; 17 ) AML Translocations (t) & other chromosomal changes M2 t ( 8 ; 21 ) M4-Eo inv ( 16 ) del ( 16q ) 11q23 abnormalities detected in 85 % of secondary AML

50. Prognostic factors in AML No Yes Complete remission after 1 course ? myeloid lymphoid CML-BC ( + ) ( - ) T rilineage Dysplasia ( + ) ( - ) Multi-drug resistance (MDR) del ( 5 or7 ) ; ( 11q23 ) t(8,21) ; t(15,17) & inv(16) T ranslocations ( + ve ) ( - ve ) IPT ( CD-34 ; HLA-DR & TdT ) High (> 50.000 µL) Low WBC count ( + ) ( - ) CNS or extra med. Disease at presentation ( + ) ( - ) i.e. denovo Previous MDS / MPD / Chemotherapy Adult ( > 60 yr ) or (infant < 2 yr ) Aged 40-60 yr induction remission 80% Age Poor Good

52. Up to 1993, the reported cases are 160 The 1 st reported case in Arab countries AML is the type often found in Cong. Leukaemia particularly M5&M7 Prognosis is extremely poor The Practitioner.Vol.10,No12,Dec.1999

53. Clinical presentation & Lab. Data Anaemia symptoms & signs of anaemia Neutropenia recurrent infections Thrombocytopenia bleeding tendency Tissue Infiltration: e.g. organomegaly (hepatosplenomegaly) ; lymphadenopathy ; meningeal syndrome ( headache, nausea, vomiting, blurring of vision & diplopia with blast cells in CSF) ; skin lesions ; testicular swelling -------- etc. B.M. failure caused by accumulation of BLAST cells

54. Pallor

55. Infections Pneumonia

56. Bleeding Tendency Extensive Bruising Mucosal Bleeding Purpura

57. Bleeding Tendency Retina Cerebral

58. Gum Hypertrophy Lymphadenopathy

59. Leukemic Skin Infiltrate Testicular Leukemia Leukemic Infiltrate

60. Mediastinal Involvement

62. Myelodysplastic Syndrome (MDS) Myelodysplasia of Haemopoietic cells Ineffective Haemopoiesis Anaemia symptoms & signs of anaemia Neutropenia recurrent infections Thrombocytopenia bleeding tendency ANT in various combinations : RA : Refractory anaemia RN : Refractory Neutropenia RT : Refractory Thrombocytopenia R Bicytopenia : ( e.g. A + N ; A + T ; N + T etc.---------------)

63. M D S L O W R I S K H I G H R I S K Any of the above with Promonocytes As any of the above with Persistent monocytosis > 1.0 X 10 3 / µL Chronic myelo-monocytic leuk. ( CMML ) 20% of MDS Tissue infiltr . ( gum hypertrophy; splenomeg.; skin rash & LAP) Blasts over 20 % or Auer rods present Blasts >5 % RAEB in transformation ( RAEB-t ) Blasts 5 - 20 % Blasts < 5 % RA with excess blasts ( RAEB ) Blasts < 5 % Ring sideroblasts > 15 % of total erythroblasts Blasts < 1 % RA with ring sideroblast ( RARS ) Blasts < 5 % Blasts < 1 % Refractory anaemia ( RA ) BM PB

64. Chronic Lymphocytic Leukaemia (CLL) Chronic Myeloid Leukaemia (CML) TYPES & AGE Peak incidence 70 ± 10 yr Male : female 2 : 1 Any age but most frequently at the age of 50 ± 10 yr Male : female 1.4 : 1 Only 15 % before the age of 50 yr

65. C hronic M yeloid L eukaemia (CML)

66. Anaemia symptoms & signs of anaemia High total WBC count : 50 – 500 X 10 3 / µL Hyper-Leucocytosis *..In up to 50 % of cases Dx. is made incidentally from the routine CBC bleeding tendency inspite thrombocytosis(?) Plt.dysfunction Clinical Presentation of CML Huge spleen Discomfort& Indigestion (small meals) Hyper-metabolism: #.weight loss #. Lassitude #.night sweat #.anorexia (?) mimic hyper-thyroidism Gout & Renal impairment Visual disturbances & Priapism 2ry to hyperleucocytosis & leuco-stasis with impaired microcirculation Urticaria

69. NAP score CML P regnancy Myelo p roliferative Disorders (MPD) - Polycythaemia (rubra) vera - PRV - Myelofibrosis ( MF ) P olymorphnuclear Leucocytosis ( Myeloid Leukaemoid Reaction ; Neutrophilia ; Neutrophil leucocytosis) Low Raised

71. The Philadelphia ( Ph’ ) chromosome: reciprocal translocation

72. BCR-ABL oncoprotein : 210 KDa in CML & some Ph’+ve ALL due to M-BCR: Major-BCR 190 KDa in other Ph’+ve ALL due to m-BCR: minor-BCR BCR-ABL = Breakpoint Cluster Region- Abelson Leukaemia

74. Chronic Phase Accelerated Phase CML Blast Crisis ( 70 % of CML ) inbetween more than 20 % less than 5 % BLAST CELLS

80. Glivec is the first line drug in the management of CML-chronic phase C omplete haematological response in virtually all patients , but the aim of treatment is C omplete c ytogenetic response { (-) Ph’ chromosome in BM in cytogenetic analysis }

82. Chronic Lymphocytic Leukaemia(s) *. B-Chronic Lymphocytic Leukaemia ( CLL ) The most common of Chronic Lymphoid Leukaemias

83. Chronic Lymphocytic Leukaemia (CLL) Chronic Myeloid Leukaemia (CML) TYPES & AGE Peak incidence 70 ± 10 yr Any age but most frequently at the age of 50 ± 10 yr only 15 % before the age of 50 yr Male : female 2 : 1 Male : female 1.4 : 1

85. Early: Bacterial infections Advanced Disease: viral & fungal infections Immuno suppression is significant Due to: 1. Hypo- gamma- globulin- aemia 2. Cellular immune dys- function Anaemia: Hb < 10 g/dL Thrombocytopenia: Plt < 100 x10 3 / µL Lymphadenopathy Symmetrical ; discrete & not tender (cervical ; axillary or inguinal) The most frequent clinical sign Hepatosplenomegaly Absolute Lymphocytosis ( > 5x10 3 /µL & sustained ) most cases Dx in routine CBC

86. Stage III : As stage 0 + Anaemia (Hb < 10 g/dL) ± Adenopathy ± Organomegaly Stage IV: As stage 0 + Thrombocytopenia (Plt < 100 x 10 3 / µL) ± Adenopathy ± Organomegaly Stage I : As stage 0 + Adeno-pathy Stage II: Stage 0: Absolute Lymphocytosis As stage 0 + Organomegaly ( Enlarged liver & / or spleen) ± Adeno-pathy Rai classification of CLL

87. Early: Bacterial infections Advanced Disease: viral & fungal infections reduced S. Ig conc. Anaemia Hb < 10 g/dL normocytic &normochromic Thrombocytopenia: Plt < 100 x10 3 / µL Lymphocytosis (5-300 x10 3 /µL) Smear: 70-99% small mature-looking lymphocytes with smudge (smear) cells BM aspiration : Lymphocytic replacement of normal marrow elements Lymphocytes comprise 60 ± 35 % Lab. Dx

88. Causes of anemia in CLL Primary ( Marrow Infiltration ) Hyper- splenism Immune Chemotherapy Folate Deficiency Elderly Nutritional Deficiency SECONDARY

89. Causes of thrombocytopenia in CLL Primary ( Marrow Infiltration ) Hyper- splenism Immune Chemotherapy SECONDARY

91. Bilateral inguinal lymphadenopathy Gross enlargement of the lymph nodes in both axillary regions in a 70-year-old female

93. C L L