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    Diagnosis and classificationof acute leukaemia

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    The acute leukemias are a heterogeneous group ofneoplasms arising from transformation ofuncommitted or partially committedhematopoietic stem cells

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    DIAGNOSTIC EVALUATION

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    Morphologychromatin (fine in myeloblasts, often clumped in

    lymphoblasts),

    nucleoli (distinct in myeloblasts, variable in

    lymphoblasts),cytoplasm (moderate or abundant, often with

    granules in myeloblasts; scant to moderate,granules uncommon in lymphoblasts)

    The granules of standard APL are large andreddish violet; in the microgranular variant ofAPL, they are indistinct

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    Auer rods,

    The appearance of more differentiated myeloidcells in the marrow may provide a clue to myeloid

    lineageErythroid and maturing myeloid precursors may

    be megaloblastoid in AML, but normal in ALL.

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    Cytochemistry

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    myeloperoxidase (MPO)

    Sudan black B (SBB)

    nonspecific esterase (NSE)

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    Immunophenotyping

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    Panel of monoclonal

    antibodies to differentiateAML & ALL

    Myeloid Anti-MPO; CD13; CD33; CDw65; CD117B lymphoid CD19; cytoplasmic CD22; CD79a;

    CD10

    T lym phoid Cytoplasmic CD3; CD2; CD7

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    Immunophenotypic patternsin AML subtypes

    Undifferentiated (M0) Anti-MPO; CD13;CD33; CD34; CDw65; CD117; negativecytochemistry; lymphoid markers

    Myelomon ocytic (M1-M5): anti-MPO; CD13;CD33; CDw65; CD117

    Monocytic (M4 & M5) Stronger expression ofCD11b & CD14

    Erythroid (M6) Anti-glycophorin AMegakaryocytic (M7) CD41; CD61

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    Cytogenetic analysis

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    patients with AML can be assigned to three broad

    prognostic groups and their treatment can bemodified accordingly;

    specific categories of AML requiring very specifictherapeutic strategies can be identified(particularly M3 and M3 variant);

    it facilitates the recognition of therapy-relatedacute leukaemia and the distinction betweenalkylating agent-related and topoisomerase II-interactive drug-related leukaemia.

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    Favourable r isk

    cytogeneticst(8;21)(q22;q22): FAB M2; 58% adults

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    Interm ediate r iskcytogeneticsNormal karyotype: any FAB type; 1520% adults.

    + 8: any FAB type; 10% adults.

    abnormal 11q23: >50% infant AML cases; 57%

    adults; fusion gene MLL.Others: del(9q); del(7q); +6; +21; +22; Y and 3

    5 complex abnormalities plus other structural ornumerical defects not included in the good risk or

    poor risk groups

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    Poor r isk cytogenetics 5/del(5q): any FAB type; >10% adults >45years.

    7/del(7q): any FAB type; >10% adults >45years.

    Complex karyotypes (>5 abnormalities)Others: t(6;9)(p23;q34); t(3;3)(q21;q96); 20q;

    21q; t(9;22); abn 17p.

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    Molecular genetic analysis

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    PMLRARA fusion in AML

    Use of all-trans-retinoic acid and possibly arsenic

    trioxide; good prognosis so overtreatment shouldbe avoided

    AML1ETO fusion in AML

    Good prognosis, overtreatment should be avoided

    High hyperdiploidy in ALL

    Good prognosis, overtreatment should be avoided

    BCRABL fusion in AML, ALL

    Poor prognosis in AML and ALL, intensivetreatment may be justified and

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    FRENCH/AMERICAN/BRITISH DESCRIPTIONS

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    Acute Lym phoblasticLeukemiaL1

    L2

    L3

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    Acute Myeloid Leukem iaM0AML with minimal differentiation

    M1AML without maturation

    M2 AML with maturation

    M3 Acute promyelocytic leukaemiaM4 Acute myelomonocytic leukaemia

    M5a M5b Acute monoblastic/monocytic leukaemia

    M6 Acute erythroleukaemia

    M7 Acute megakaryoblastic leukaemia

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    W HO CLASSIFICATION

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    WHO criteria for the diagnosis ofacute myeloid leukaemiaBlast cells are 20% or more in either peripheral

    blood or bone marrow

    Presence of

    t(8;21)(q22;q22) or AML1ETO fusion gene inv(16)(p13q22) or t(16;16)(p13;q22) or CBFB

    MYH11 fusion gene

    t(15;17)(q22;q12) and variants or PMLRARA

    fusion gene or variantsTranslocation with an 11q23 breakpoint and MLL

    gene rearrangement

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    The AML classification includesfour groups:

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    ACUTE M YELOID LEUKEM IA WITHRECURRENT CYTOGENETIC

    ABNORMALITIESrecurring balanced translocations and

    inversions;;

    lack multilineage background dysplasia;

    tend to respond favorably to cytotoxicchemotherapy;

    unrelated pathogenetically to MDS

    They comprise approximately 85% of AML in

    young patients but only a small percent of cases inthe elderly.

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    ACUTE MY ELOID LEUK EMIA WITH MULTILINEAGE DYSPLASIA

    cytogenetic abnormalities shared with MDS;

    an exponentially increasing incidence withadvancing age (similar to MDS), with median agein the 70s;

    tend to have multilineage background dysplasia;

    clonal background and remission hematopoiesis;

    respond poorly to cytotoxic chemotherapy,

    related pathogenetically to MDS

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    ACUTE MYELOID LEUKEMIA,THERAPY RELATED

    Alkylating agentrelated AML.Peak incidence isapproximately 5 years after exposure. It is oftenpreceded by MDS.

    Topoisomerase II inhibitorrelated AML.

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    ACUTE MYELOID LEUKEMIA NOTOTHERW ISE CATEGORIZED

    Acute basophilic leukemia

    Acute panmyelosis with myelofibrosis

    Myeloid sarcoma

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    Acute Lym phoblasticLeukemiaPRECURSOR B-LYMPHOBLASTIC

    PRECURSOR T-LYMPHOBLASTIC

    BURKITT LYMPHOMA/LEUKEMIA

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    Acute Leukemia of Ambiguous

    Lineage

    cases with apparent differentiation to more thanone lineage, usually T/myeloid or B/myeloid(biphenotypic acute leukemia),

    cases with no discernible further differentiation beyond hematopoietic stem cells using currenttechniques (undifferentiated acute leukemia) .

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    Conclusion

    The diagnosis and further classification of acuteleukaemia requires:

    1. a full assessment of the medical history, familyhistory and physical findings,

    2. assessment of cytological features in blood andbone marrow

    3. cytochemistry is selective

    4. Application of immunophenotyping can be

    selective but is tending to become universal5. cytogenetic analysis should be universally

    applied, with molecular analysis being usedselectively.