????????(CML)

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Leukemia (???)
??(Xie yi) Dep.Hematology,Huashan Hospital
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Concept of leukemia

• Definition
• It is the results of the tumor proliferation of
  heamotopoietic stem cells.(?????)
• Leukemia is a malignant blood disorder. (not
  solid tumor)

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Heamatopoietic stem cell

• reproduction HSC
• 
  lymphoid HSC
• HSC
• differentiation early
  progenitor
• 
  CFU-GEMM
• 
  myeloid HSC
• Heamatopoietic Stem Cell (HSC) is the primary
  cell of Heamatopoietic system and immune system.

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(No Transcript)
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Tumor proliferation of HSC

• Differentiation of HSC is blocked.
• Leukemia cells are stopped on a differentiation
  stage of HSC lack of the normal function .
• Proliferation is out of control and apoptosis is
  inhibited.
• Leukemia cell is cloned and accumulated in a
  great quantity.
• infiltration and metastasis

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malignant blood disorders

• HSC differentiation is blocked.
• Normal blood cells are decreased and leukemia
  cell is increased.
• The function of Blood and immune system are
  short of.
• Fever ,bleeding ,anemia

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malignant blood disorders

• Proliferation is out of control ,apoptosis is
  inhibited and leukemia cell is accumulated in a
  great quantity.
• Leukostasis(?????)
• Abnormal morphology pictures of blood and bone
  marrow
• Liver,spleen,lymph nods, skin,CNS are infiltrated
  and dysfunctional frequently.

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the tradition classification (FAB)of leukemia

• According to the acute myeloid leukemia(AML)
• Differentiation M0 M1 M2 .. M7
• Kind of cell blast crisis of CML,mast
  cell leukemia,
• acute eosinophilic
  leukemia,basophilic
• leukemia acute lymphocyte
  leukemia(ALL)
• L1,L2,L3
• T-ALL?B-ALL
• chronic leukemia CML?P-LL?CLL?HCL?

leukemia
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WHO classification (2001)

• 1, Acute myeloid leukemia(AML)
• (1), AML with recurrent cytogenetic abnormalities
• AML with t(821)(q22q22),(AML1/ETO)
• AML with t(1517)(q22q12),(PML/RAR?)
• AML with inv(16)(p13q22) or
• t(1616)(p13q22) ,CBF?/MYH11
• AML with 11q23 (MLL) abnormalities

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WHO classification (2001)

• (2), AML with multilineage dysplasia
• With prior myelodysplastic syndrome
• Without prior myelodysplastic syndrome
• (3),AML and myelodysplastic syndrome,
• therapy related
• Alkylating agent related
• Topoisomerase ll inhibitor-related

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WHO classification (2001)

• (4) AML not otherwise categorized
• AML minimally differentiation
• AML without maturation
• AML with maturation
• Acute myelomonocytic leukemia
• Acute monoblastic and monocytic leukemia
• Acute erythroid leukemia
• Acute megakaryoblastic leukemia
• Acute basophilic leukemia
• Acute panmyelosis with myelofibrosis
• Myeloid sarcoma
• (5) Acute leukemia of ambiguous lineage

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WHO classification (2001)

• 2, chronic myeloid leukemia
• (1), chronic myeloproliferative disease
• chronic myelogenous leukemia
• Chronic neutrophilic leukemia
• Chronic eosinophilic leukemia/hypereosinophilic
  syndrome
• (2), myelodysplastic/myeloproliferative disease
• Chronic myelomonocytic leukemia
• Atypical chronic myeloid leukemia
• Juvenile myelomonocytic leukemia

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WHO classification (2001)

• 3, B-cell neoplasms
• (1), Precursor B-cell neoplasm
• Precursor B lymphoblastic leukemia
• (2), Mature B-cell neoplasm
• Chronic lymphocytic leukemia/Small lymphocytic
  lymphoma (CLL/SLL)
• B-cell prolymphocytic leukemia
• Hairy cell leukemia
• Burkitt lymphoma/leukemia

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WHO classification (2001)

• 4, T-cell and NK-cell neoplasms
• (1), Precursor T-cell neoplasm
• Precursor T lymphoblastic leukemia
• (2), Mature T-cell and NK-cell neoplasms
• T-cell prolymphocytic leukemia
• T-cell large granular lymphocytic leukemia
• Aggressive NK leukemia/lymphoma
• Adult T-cell leukemia/lymphoma

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Epidemiology incidence

• 3/105 , increase with years?
• acutegtchronic , AMLgtALL
• Special distribution
• Sex manfemale21
• Age ALL, adolescent 80lt20y AML, adult
• CML, 2050 years old CLL ,5070
  years old
• Area adult T lymphocytic leukemia
• CML, eastern countries
• CLL, western countries

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Epidemiology mortality

• 2.51/105
• Area
• city gt the countryside
• ChinaltSingaporeltJapanltUSAltunited Kingdom
  ltSweden(7.59/105)
• In order of the mortality of malignant tumors
• in114y,leukemia is most high
• in1544y,leukemia is third high(ltstomach Calt
  liver Ca)
• in all person, leukemia is sixth or eighth high

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Etiology

• radiation
• 1?atom bomb (? ?)1Km 1.5km 2km
• 100 22
  2.6
• 2?high dose X radiation?32P therapy

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Etiology

• chemicals
• benzene
• Therapy-related leukemia 47/440000

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Etiology

• virus
• ATLV ,1981,Japan(???)
• electric microscopevirus C
• The serum antibody titer of ATLV
• decrease with the distance from ???

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Etiology

• Genetics
• twin(same egg )
  0.20.25
• sibling
  10/105
• Downs syndrome (21) 40-60/105
  Fanconi anemia
  4/66

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Etiology

• from other blood disorders
• Myeloproliferative Disease
• chronic myeloid leukemia(CML)
• polycythemia vera(PV)
• primary thrombocythemia(PT)
• myelofibrosis(MF)
• myelodysplastic syndrome(MDS)
• paroxysmal nocturnal hemoglobinuria(PNH)
• lymphoma or myeloma

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Mechanism

• Radiation, chemicals, virus, genetics other
  blood disorders
• Chromosome translocation
• Fusion gene formation
• Fusion protein(enzyme )
• Malignant biologic behaviors
• Malignant blood disorders

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Acute leukemia Clinical manifestation 1,
fever?bleeding?anemia 2?infiltration 3?Abnormal
morphology pictures of blood and bone marrow
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1, fever?bleeding?anemia

• normal WBC??immune? ( AIDS) ?fever
• The place where skin and mucosa meet respiratory
  tube, mouth, perineum, anus
• Inflammatory reaction is weakly
• G-B(psuedomonas aeruginosa), interstitial
  pneumonia (peumosystis arinii, CMV,herpes virus),
  candida
• PLT?? bleeding
• skin , mucosa or cranial cavity
• RBC?? anemia

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2?infiltration

• Hepatomegaly, splenomegaly, lymphadenopathy,
• sternal tenderness
• Special infiltration area
• Chloromasskin ,orbit (granulocytic sarcoma)
• Painless enlargement of testicle( ALL)
• CNS involvement, paraplegia(ALL,M4,M5)
• gingivitis(M4,M5)

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3?Abnormal morphology pictures of blood and bone
marrow

• Blood WBC from lt 1109/L(non leukemoid) to
  gt100109/L ( hyperleukocytosis ), blasts are
  present, anemia, PLT?
• BMproliferative(or hypoplastic),blastsgt30,
  Auers rods(), erythropoiesis ?,megakaryocytopoie
  sis?

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Normal bone marrow cell
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leukemia cells ( show Auers rods )
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Clinic Diagnosis of AL

• The normal blood cell?and luekemia cell?
• are shown by clinical signs, symptoms,
  laboratory features and special examinations.
• blast more than 30
• in non erythrocytic cells(NEC) of bone marrow
  smear

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MICM TYPING DIAGNOSIS

• MICM
• Morphology
• Immunology
• Cytogenetics
• Molecular

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morphology

• lymphoblast myeloblast
  monoblast
• plasma ?,?? ?,Auers ?,???
• chromatin ?? ?? ?
• chromosome ?? ??
  ?
• Accompany ??C, ?? ?? ??, ???
• POX - /??
  -/??
• NSE - -/,NaF???
  ,NaF??
• PAS ??-?? ????? ????

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IMMUNO-PHENOTYPING

• mab M1 M2 M3 M4 M5 M6 M7
• CD13 - -
• CD33 - -
• CD14 - - - -
• CD41 - - - - - -
• Ret - - - - - -
• Lectoferrin - - - - -
• CD19 CD7 HLA-DR CD2 MPO
• T - - -
• B - - -

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Chromosome translocation

• M1 8,-5,-7 inv(3)
• M2 t(821) t(69)
• M3 t(1517)
• M4 inv(16)
• M5 t(411), t(816)
• M6
• M7

ALL t(922) (B) t(814)
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Fusion gene molecular

• AML1/ETO
• PML/RAR?
• CBF?/MYH11
• MLL abnormalites
• BCR/ABL

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MICM TYPING DIAGNOSIS

• We could use traditional typing diagnosis as what
  FAB asked.
• If the situation permit, we could use FCM,
  chromosome, PCR or FISH in a WHO typing diagnosis
  way.

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Differential Diagnosis

• Myelodysplastic syndrome (MDS)
• refractory anemia or pancytopenia, BM
  dysplasia, blastslt30
• Leukemoid reaction
• mature leukocytes proliferative would play a
  main role, NAP?, if progenitor increase, only
  shortly on time
• CML mature progenitors ?
• E??B?, NAP0, ph'(),bcr-abl()
• Stomatitis,Infectious mononucleosis,ITP,
  AA,agranulocytopenia
• There is no blasts in bone marrow

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principle early,combine,full,interval,by stages

• why early ?
• The over hyperplasia infiltration could bring
  the difficulty on therapy
• Tumor lysis
• Leukemia cell enter into the area protected by
  the barrier between blood and brain
• Could make anti-infection, support and
  chemotherapy to be done at same time if it were
  necessary

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principle early,combine,full,interval,by stages

• use Combination regimen of these drugs which have
  different action,
• typing and toxicity
• to increase curative effect and decrease
  toxicity

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Different Action of Drugs

• ??? ???
• 6MP 6TG MTX ????
• ???
• MTX
  HU
• ?????
• VM26 Ara-C,CC
• ?????? DNA ?? ???,CCNU AMSA
• RNA DNA
• L-ASP VCR
  ,VM26
• protein ???DNA
• ??????,????,??,???,????
• ???CTX,??,BU,CB1348,CCNU,BCNU

VP16
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Cell cycle and chemotherapy
G2

• end cell
• apoptosis
• Go (source of relapse)
• sensitive insensitive

M
S
G1
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The drug typing

• CCSA CCNSA
• Antimetabolic drugs alkylating drugs
• S, 6MP, 6TG mustine,CTX,BU
• Ara-C, CC, MTX CB1348,CCNU
• HU, VP16 anthracycline antibiotics
• M, VCR, VDS, VM26 bleomycin A5(????)
• G1, L-ASP, prednisone harringtonine(???)
• G2, VP16

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The drug s effect

• CCSA CCNSA
• effect
• dosage
  dosage
• the effect is increased by time the effect
  increased by dosage

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The toxicity of the drugs

• ??? ???? VCR ???
  ?? ???
• BM?? -
  -
• ??
  
• ????
• ????
• ??N?
• ??
• ????
  
• ???? v v v v
  v v
• ??????
• ??

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principle early,combine,full,interval,by stages

• full
• the drug should work in all period of cell cycle
• the dosage should be full
• The regimen would be used repeatedly
• ,

Killing the cells in all period of cell cycle
repeatedly could make G0? cycle control the
source of relapse(MRD)
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principle early,combine,full,interval,by stages

• Interval for 34 weeks before next therapy
• Leukemia cell
  normal cell
  
• When get disease the greater part of cells
  hyperplasia is inhibited
• is not in G0 period
• easily killed by chemotherapy
  in G0 period or not?
• doubling time long
  short
• Recover in interval not easy to recover
  easy to recover

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principle early,combine,full,interval,by stages
Reduce MRD step by step Keep the DFS for long
time

• remission consolidation
  maintenance
• induction
• 10111012 1068
  104(MRD)
• prevent CNS leukemia
• 6 cycles 35years

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(1) remission induction

• Regimen for ALL
• VP VCR 12mg
• (classical) NS 20cc V qw
• Prednisone 2030mg/d p.o
• use it till CR
• would be more effective,but relapse easily

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Induction remission Regimen for ALL

• 1) VDLP
• VCR 12mgNS20cc V qw(1,8,15,21d)
• DNR 3040mg V gtt qd 13d, 1517d
• Pred 40mg60mg p.o 114d
• L-ASP 10,000u V gtt 19-28d

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Induction remission Regimen for ALL

• 2) VP16 0.2 V gtt qd 3d
• Ara-C 0.10.15 V gtt qd7d
• MTX 23g V gtt 24h
• after 12h, leucovorin 69mg m q8h 2d
• hydrotherapy alkalize
• leukemia in CNS could be treated

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Induction remission Regimen for ANLL

• HOAP(classical)
• VCR 12mg V
• harringtonine 14mg V gtt qd5-7d
• Ara-C 50-100mg V gtt Bid5-7d
• Prednisone 30-60mg p.o qd5-7d
• interval 14d

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Induction remission Regimen for ANLL

• HA
• harringtonine 2-4mg V gtt7
• Ara-C 0.10.2 V gtt7
• HD Ara-C
• Ara-C 2.0 V gtt q12h3
• DA
• DNR 30 40mg V gtt3
• Ara-C 0.10.2 V gtt7

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Induction remission Regimen for ANLL

• PML(M3) retinoid acid(ATRA)60-80mg p.o
• Use chemotherapy in consolidation stage
• When relapse As2O3 5mg V gtt28d
• Hypoplastic leukemia
• Ara-C 12.5mg M qd21d
• harringtonine 1mg M qd21d

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CR

• there are not anemia fever hemorrhage and
  infiltration
• Hb gt100g/L WBC lt10109/L
• PLT gt100109/L
• BM blastslt5

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(2)The regimen in consolidation remission stage

• Using a induction remission regimen for six
  cyclesz
• Using different induction remission regimen
  alternately for six cycles

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(3)maintenance remission regimen

• treatment with extended interval using the
  different induction remission regimen alternately
  for 35Y
• in interval time the patients with ALL will take
  CTX,6-MP,6-TG MTX, P.O
• Not maintain therapy unless leukemia relapse
  Protect the capacity of body immunity, improve
  quality of life

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supportive care

• conponent transfusion therapy
• RBC ,rhEPO
• platelet
• antibiotics(???),IVIG, rhG-CSF
• Vein high nutrition
• protect heart, liver kidney

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others

• Therapeutic Leukapheresis
• To treat the Leukostasis (WBCgt105)
• To prevent tumor lysis syndrome
• immunotherapy
• monoantibody to CD33 drug

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others

• Hemapoietic stem cell transplantation
• Could be curable
• Expensive and high risk
• Acute myelomonocytic leukemia with DIC
• Use the low molecular heparin to improve prognosis

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CNS leukemia

• Incidence of ALL 10-40,ANLL 2-4
• Could be found in youth age, who
  suffered from infiltration, easily
  onset in remission stage always

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The clinical manifestation diagnosis of
CNS leukemia

• Clinical examination
• Intracranial hypertension
• The signs of meninges stimulated
• the signs of nerves injure
• CSF examination
• presuregt200mmH20, sugar ?,protein(gt40mg/dl),WBCgt1
  0/mm3
• could find leukemia cells

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The treatment of CNS leukemia

• High dose MTX injection
• MTX 5-10mg sheath enjection Biw-qw
• (dilution with injection water 3ml,
  add. dexamethasome 5mg)
• 2.4Gy 60Co radiation to head

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The prevention of CNS leukemia

• After CR
• MTX 5-10mg sheath rejection qw6
• Incidence of CNS leukemia?,lt5

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Chronic Myelogenous Leukemia (CML)

• a Clonal proliferative disorder of pluripotent
  stem cell
• Consistently associated with the Ph chromosome
  and BCR-ABL fusion gene
• About 1525 of all cases of leukemia
• 2560 years, slightly more in men than women

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MECHANISM Ph CHROMOSONE
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MECHANISMPh CHROMOSONE
2
1
ABL
BCR-ABL Fusion gene
1 2 3
BCR
8.5Kb mRNA(b3a2 or b2a2)
210Kd protein(P210)
CML
7.5kb mRNA (b1a2) ? 190Kd(p190) ?Ph()ALL
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CML development

• Initial indolent chronic phase(CML-CP,34
  years)is followed by accelerated phase(CML-AP)and
  blast phase(CML-BP,as acute leukemia)

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Clinical manifestation

• Weight loss?fatigue ,excessive sweating
• sternal tenderness, splenomegaly
• WBC?
• gt200109/L, Leukostasis(?????)

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Clinical manifestation

• WBC 101000109/L
• Granulocytes at all stages of development are
  present in blood(??????)
• or PLT gt1000109/L or anemia
• NAP(neutrophil alkaline phosphatase activity)0
• BM proliferate ?,Granulopoiesis is dominent .
  blastlt10, B E?
• ph1() 90 pcr, BCR/ABL fusion gene()

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CML diagnosis

• Symptoms are vague and nonspecific
• Splenomagly,90sternal tenderness
• WBC 101000109/L
• Granulocytes at all stages of development are
  present in blood, NAP0
• BM proliferate ?,Granulopoiesis is dominent
• blastlt10, B E? and Erythropoiesis ?
• megakaryocytopeoiesis ? and reticulin fibrosis ?
• ph1() ,bcr-abl ()

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CML by stages

• Chronic phase accelerative phas blast
  phase
• Asymptomatic, anemia,hemorrhage, like as acute
• splenomegaly splenomegaly
  leukemia
• eosinophilia basophilic cell
  
• basophlia gt20
• blast blast
  blast
• lt 10 1020
  gt20
• PLTlt100109/L
• gt 1000109/L

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CMLdifferentiation diagnosis

• 1?leukemoid reaction
• infection,cancer etc
• WBC ? ,there isnt splenomegaly
• NAP ? ,absence of Blast, ph1, bcrabl
• 2?myelofibrosis
• WBC ? Splenomegaly
• teardrop poikilocytes,nucleared red cell in blood
• BMaspiration is often unsuccessful NAP ?
  ,absence of Blast, ph1 and bcrabl
  biopsycollagen fibrosis

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CMLdifferentiation diagnosis

• 3?acute leukemia
• ph1 in 2 AML
• ph1 in 525 ALL
• 4?acute abdomen
• Absence of splenomegaly and the fricative in left
  hypochondrial region

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CML treatment

• 1, keep WBC 4.010.0109/L
• (1) Hydroxyurea (???) 0.52.0 tid
• Busulfan (???)110mg qd
• ????????????????
• (2)Interferon a-2b 500?u H qd
• Ara-C 25mg H qd 1421?
• (3) Grivec (Greevec,??? ,STI 571 ) 400600mg/d

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CMLs THERAPY

• 2, WBCgt200109/L, Leukostasis
• therapeutic luekopheresis
• 3, Blast Phase
• Like as acute leukemia , difficultly
• 4, Allo-BMT, Allo- PBSCT, CBT)
• curabale

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Chronic lymphocytic leukemia(CLL)

• CLL is neoplastic disease
• The apoptosis of lymphocyte is inhibited
• Accumulation of small mature appearing CD5 B
  lymphocytes in blood ,marrow and lymphoid tissues
  
• immunodeficiency
• incidence 20/ 105 in western country, 2/ 105 in
  China
• 90gt50y male female21

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CLLdiagnosis

• 25 patients are asymptomatic
• Maybe nontender lymphadenopathy, splenomegaly and
  hepatomegaly
• Unexplained absolute lymphcytosis
• WBC 10200, lymphocytesgt 50, gt 5109/L (5000/mm3
  ) , gt4 weeks
• BM lymphocytes gt40

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CLLdiagnosis

• Lymphocyte surface immunologic marker can
  determine monoclonality
• immunophenotyping
• B,surface or cytoplasmic immunoglobuline , ? or
  ? light chains ,CD5 ,CD19 ,CD20
  
• T (fewer) ,CD2,CD3,CD8,CD5

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CLL Rai staging diagnosis

• 
  median survival 0 L gt15109/L
  gt150 month
• I 0lymphadenopathy 105
• II Ispleno-hepatomegaly 71
• III IHb lt110g/L
  19
• IV IPlt lt100109/L 19

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CLLdifferentiation diagnosis

• With reactive lymphocytosis
• Mononucleosis syndrome
• Epstein Barr virus
• Cytomegalovirus
• HIV
• With other lymphoproliferative disorders
• Prolymphocytic leukemia, hairy cell leukemia,
  lymphoma,Waldenström macroglobulinemia,

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CLL therapy

• O observe, if WBC?, Lymphapheresis
• I / II Chlorambucil(CB1348),CB1348prednisone
• III / IV
• COP / Fludarabine(????)
• Cladribin ( 2-CdA ,2-?????)
• Pentostatin(Deoxycoformycin,??????)
• mabthera (CD20 mab,???), FCR regimen
• radiotherapy