Chronic Leukemia

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Chronic Leukemia

• Dr.Huad alkarim.

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The definition of chronic leukemia
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What Are the Types of Chronic Leukemia?
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Classification of CL.

• There are two types
• 1-chronic myeloid leukemia.
• 2-chronic lymphoid leukemia.

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Chronic Myeloid Leukemia.
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Definition of CML

• Is a clonal disorder of a pluripotent stem cell
  and is classified as one of the
  myeloproliferative disorder.
• Constitute six different types of leukemia.
• See table.

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Types of Chronic CML
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Cont

• The disease accounts for around 15 of leukemia.
• May occur at any age.

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What Is Philadelphia Chromosome?
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Philadelphia

• Is the chromosome which result from the
  t(922)(q34q11)?part of the Abelson
  proto-oncogene ABL is moved to the BCR gene on
  chromosome 22 part of chromosome 22 moves to
  chromosome 9.
• The abnormal chromosome 22is the Ph.
• See fig.

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Fig
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How Would the Patient With CML Present?
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Clinical Presentation

• It can occur in any age .But the most age
  presentation is between 40-60.
• Symptoms related to hyper metabolism
• (weight loss,lassitude,anorexia or night sweats).
• (Gout or renal impairment caused by
  hyperuriceamia ).
• Bone marrow failure
• Anemia.

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Cont

• Bruising ,epistaxis,menorrhagia or hemorrhage
  from any site because of platelet dysfunction.
• Organ infiltration
• Splenomegally almost always present and is
  frequently massive.
• Rare symptoms include visual disturbance.

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How Would You Investigate the Patient With
Suspected CML?.
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Investigation

• CBC
• Wbc is usually gt50X10/l some times gt500X10/l.
• Normocytic normochromic anemia.
• Platelets ???.
• peripheral blood film
• circulating basophil.

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fig
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Cont

• Neutrophil alkaline phosphatase score is
  invariably low.
• BM is hyper cellular with granulopoietic
  predominance.
• Cytogenetics ph chromosome.
• Serum vitamin B12 vitamin b12-binding capacity
  are?.
• Serum uric acid is usually?.

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What Are the Phases of CML?
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Phases of CML

• Chronic phase
• Accelerated phase
• Blast phase

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How Would You Treat CML?
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Treatment

• Chemotherapy
• Tyrosine kinase inhibitor
• Interferon-?.
• Stem cell transplant.

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What Is the Course and Prognosis of CML?..
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Course prognosis

• Usually shows excellent response to chemtherapy
  in the chonic phase.
• Death usually occur from terminal acute
  trasformation ,hemorrhage or infection.

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Take a Break !
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Chronic lymphocytic Leukemia
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Introduction

• CLL is the most common of the chronic lymphoid
  leukemias.
• Peak incidence between 60-80yrs.
• It is characterize by chronic persistent
  lymphocytosis which later infiltrate different
  organs.

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What Is the Clinical Presentation?
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Clinical presentation

• The disease occurs in older subject,rare before
  40yrs.
• MF is 21.
• Many cases discover routinely.
• Symmetrical enlargement of superficial lymph node
  is the most frequent clinical sign.
• Feature of anemia.

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Fig(1)
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Cont

• Splenomegaly hepatomegaly usual in later stage.
• Repeated bacterial or fungal infection.
• Thrombocytopenia.

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Fig(2)
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How would you investigate patient with CLL?..
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Investigation

• CBC
• Wbc?.
• Difflymphocytosis ,the absolute lymphocyte count
  isgt5x109/l and may be up to 300x109/l or.
• More.
• Anemianormocytic normochromic anemia is present
  in later stages,autoimmune haemolysis.
• Platelets thrombocytepenia may occur.

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Cont

• Blood film
• 70-99 of white cells mature lymphocyte.
• Smudge or smear cells also present.
• Immunophenotyping
• Shows that the lymphocyte are B
  cells(CD19)expressing one form of light chain(?
  or? only)cells are also CD5CD23ve.

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Fig(3)
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Cont

• Bone marrow aspiration
• Lymphocytic replacement of normal marrow.
• Immunoglobulinelectrophoresis
• of Ig more marker with advance disease.
• Cytogenetic
• The 4 most common abnormalities are deletion
  of13q14,trisomy 12,deletion of11q23structural
  abnormality of 17p involving the p53 gene.

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What Is the Staging of CLL?
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Staging

• Staging is very important for prognosis and
  treatment.
• There are two staging system(Rai and Binet).
• See table.

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A-Rai Classification
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B-Binet Classification
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How Would You Treat Patient With CLL?
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Treatment

• Since cure is rare,the treatment aim is only
  symptoms control.
• Indication for treatment
• Troublesome organomegaly.
• Hemolytic episodes.
• Bone marrow suppression.

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Modality of Treatment

• 1-chemotherapy
• Chlorambucil 6mg/m2 daily for 10 days monthly
  for 2-4 month after which remission will be
  obtain.
• Fludarabinemore effective as single agent.
• Corticosteroid indicated in bone marrow
  failure,also indicated in autoimmune hemolytic
  anemia and thrombocytopenia.

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Cont

• 2-Radiotherapy
• Is useful in reducing the size of lymphnode not
  responsive to chemo.
• 3-Monoclonal antibody
• Both campath IH(anti CD52)and Rituximab(anti
  CD20)produce response in proportion of patient.

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Cont

• 4-Splenectomy
• For immune-mediated cytopenia or painful bulky
  splenomegally.
• 5-immunoglobulin replacement
• 250mg/kg /month by IV for patient with
  hypogammaglobulinemia and recurrent infection.

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Cont

• 5- Stem cell transplant
• Under clinical trial.

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Good Luck!..