Module 4

Leukemia and its classification, WHO and FAB

classification, AML, ALL, CML, CLL, its aetiology,
clinicalfeatures, laboratory investigations. Cytochemistry
involved in diagnosis of various types of leukemia.
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Leukemia

Leukemia is classified by the type of white blood cells affected and by how quickly the
disease progresses:

• Lymphocytic leukemia (also known as lymphoid or lymphoblastic leukemia) develops

in the white blood cells called lymphocytes in the bone marrow.
• Myeloid leukemia (also known as myelogenous leukemia) may also start in white
blood cells other than lymphocytes, as well as red blood cells and platelets.

In terms of how quickly it develops or gets worse, leukemia is classified as either acute (fast-
growing) or chronic (slow-growing):

• Acute leukemia is rapidly progressing and results in the accumulation of immature,

functionless blood cells in the bone marrow. With this type of leukemia, cells
reproduce and build up in the marrow, decreasing the marrow’s ability to produce
enough healthy blood cells.
• Chronic leukemia progresses more slowly and results in the accumulation of
relatively mature, but still abnormal, white blood cells. It tends to take longer to start
causing noticeable problems than acute leukemia. However, chronic, slower-growing
leukemia may be more difficult to treat.

What are the common types of leukemia?

According to data from the National Cancer Institute Surveillance, Epidemiology, and End
Results (SEER) Program, the most common types of leukemia in the United States are, in
this order:

• Chronic lymphocytic leukemia

• Acute myeloid leukemia
• Chronic myeloid leukemia
• Acute lymphocytic leukemia

The four types of leukemia explained

Acute lymphocytic leukemia (ALL) progresses rapidly, replacing healthy cells that produce
functional lymphocytes with leukemia cells that can't mature properly. The leukemia cells are
carried in the bloodstream to other organs and tissues, including the brain, liver, lymph
nodes and testes, where they continue to grow and divide. The growing, dividing and
spreading of these leukemia cells may result in a number of possible symptoms, some of
which may resemble the flu. They include fatigue, shortness of breath, fever, and
easy bruising or bleeding, among other symptoms.

ALL develops when changes in DNA (mutations) cause the bone marrow to produce too
many abnormal lymphocytes (a type of white blood cell). Lymphocytes are supposed to help
fight infections, but the ones produced in people with ALL are unable to do so properly. The
proliferation of these abnormal cells also crowds out other types of healthy blood cells.

It’s unknown what exactly causes the mutations that lead to ALL, but certain factors may
increase one’s risk. Risk factors for ALL include:

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• Being male, white and older than 70 years old

• Having a history of chemotherapy or radiation exposure .

ALL may be diagnosed with blood tests and a bone marrow aspiration and biopsy, which
involve extracting a sample of bone marrow and a tiny piece of bone, then studying the cells
under a microscope.

Some of the common treatment options for ALL include:

• Chemotherapy
• Radiation therapy
• Stem cell transplant
• Targeted therapy

Learn more about ALL

Acute myeloid leukemia (AML), also known as acute myelogenous leukemia, acute
myeloblastic leukemia, acute granulocytic leukemia or acute nonlymphocytic leukemia, is a
fast-growing form of cancer of the blood and bone marrow.

Like ALL, AML causes the bone marrow to overproduce abnormal white blood cells,
crowding healthy blood cells and affecting the body’s ability to fight infections.

Risk factors for AML include:

• Being male
• Smoking
• Having past chemotherapy treatment or radiation exposure

Some symptoms may resemble the flu—such as fever, fatigue and night sweats. Others
include easy bruising or bleeding and weight loss. Blood tests and bone marrow aspiration
and biopsy are among the tests that may be done to diagnose this cancer.

Treatment may include:

• Chemotherapy
• Radiation therapy
• Stem cell transplant
• Targeted therapy

Learn more about AML

Chronic lymphocytic leukemia (CLL) is a typically slow-growing cancer that begins in

lymphocytes in the bone marrow and extends into the blood. It may also spread to lymph
nodes and organs such as the liver and spleen. CLL develops when too many abnormal
lymphocytes grow, crowding out normal blood cells and making it difficult for the body to fight
infection.

About 25 percent of all cases of leukemia are CLL, and approximately one in every 175
people may develop CLL in their lifetime, according to the American Cancer Society (ACS).
CLL is like ALL, but it’s chronic instead of acute, meaning that it’s more slow-growing and
takes longer to start causing symptoms.

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When it does cause symptoms, these may include swelling in the lymph nodes (neck,
underarm, stomach or groin), fatigue, fever, infection, weight loss and more. Various blood
tests may be used to help diagnose CLL.

CLL may not need to be treated immediately, but rather monitored for any problems and
changes, at which point the need for treatment may be reassessed. Common treatment
options include:

• Targeted therapy
• Chemotherapy
• Radiation therapy
• Immunotherapy

Learn more about CLL

Chronic myeloid leukemia (CML), also known as chronic myelogenous leukemia, begins in
the blood-forming cells of the bone marrow and then, over time, spreads to the blood.
Eventually, the disease spreads to other areas of the body.

CML is slow-growing, but once it starts causing symptoms, these may include fatigue, fever,
weight loss and an enlarged spleen. Around half of CML cases are diagnosed by a blood
test before symptoms have begun. About 15 percent of leukemias are CML, according to
the ACS.

Treatment options include:

• Targeted therapy
• Chemotherapy
• Immunotherapy
• Stem cell transplant

Rare types of leukemia

Among the many different types of leukemia, some are less common than others. Three
rarer leukemia types—prolymphocytic leukemia (PLL), large granular lymphocyte leukemia
(LGL) and hairy cell leukemia (HCL)—share some of the same characteristics as
lymphocytic leukemias and are sometimes considered subtypes of chronic or acute
lymphocytic leukemia (CLL and ALL). Myelodysplastic syndromes are conditions related to
leukemia that are also rare.

Prolymphocytic leukemia (PLL) may develop along with CLL or on its own, but it usually
progresses faster than typical CLL. It’s marked by a proliferation of immature lymphocytes. If
it causes symptoms, they may be similar to other types of leukemia (flu-like symptoms, easy
bruising, unexplained weight loss). Diagnosis may include blood tests as well as bone
marrow aspiration and biopsy. PLL tends to respond well to treatment, and options may
resemble those used to treat CLL. However, relapse is common.

Large granular lymphocytic (LGL) leukemia is a chronic type of leukemia that causes the
body to produce abnormally large lymphocytes. By the time patients are diagnosed with this
condition, symptoms tend to be present and include flu-like symptoms, frequent infections
and unexplained weight loss. People with autoimmune diseases tend to be more at risk for
developing LGL. Diagnosis may include blood tests and bone marrow aspiration and biopsy.
Most patients require treatment shortly after diagnosis, which may include drugs that
suppress the immune system. Others may be able to hold off on treatment to see whether

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problems arise. Treatment for LGL isn’t standardized, and patients may require different
options, depending on their condition.

Hairy cell leukemia (HCL) is a rare subtype of chronic lymphocytic leukemia (CLL) that
progresses slowly. About 700 people are estimated to be diagnosed with HCL every year,
according to the American Society of Clinical Oncology. HCL is caused when bone marrow
makes too many B cells (lymphocytes), a type of white blood cell that fights infection. As the
number of leukemia cells increases, fewer healthy white blood cells, red blood cells and
platelets are produced. The word “hairy” comes from the look of the cells produced. Under a
microscope, HCL cells appear to have thin, hair-like outgrowths.

Symptoms of HCL may be similar to other types of leukemia and resemble the flu. Bone
marrow aspiration and biopsy and blood tests are the primary diagnostic tools.

HCL often doesn’t need to be treated immediately, and patients are monitored for
problematic changes that require treatment. When complications related to HCL do occur—
such as low blood cell counts, frequent infections or lymph node swelling—chemotherapy is
typically used.

Myelodysplastic syndromes (MDS) are a group of closely related diseases in which the
bone marrow produces too few functioning red blood cells (which carry oxygen), white blood
cells (which fight infection), or platelets (which prevent or stop bleeding), or any combination
of the three. The different types of myelodysplastic syndromes are diagnosed based on
certain changes in the blood cells and bone marrow. The cells in the blood and bone marrow
(also called myelo) usually look abnormal (or dysplastic), hence the name myelodysplastic
syndromes.

More than 10,000 people a year are diagnosed with MDS, according to the ACS. In the past,
MDS was commonly referred to as a preleukemic condition (and it is still sometimes called
preleukemia) because some people with MDS develop acute leukemia as a complication of
the disease. However, most patients with MDS never develop acute leukemia.

By convention, MDS are reclassified as acute myeloid leukemia (AML) with myelodysplastic
features when blood or bone marrow blasts reach or exceed 20 percent.

Classification of Leukemia - WHO

The current approach to classifying leukemia is based on the 2016 World Health
Organization (WHO) system (classification for hematopoietic neoplasms). The WHO
classification is based on a combination of clinical, morphologic, immunophenotypic, and
genetic features. Other less commonly used classification systems include the French-
American-British (FAB) system, which is based on the morphology of the abnormal
leukocytes.
Leukemias are commonly also categorized as

• Acute or chronic: Based on the percentage of blasts or leukemia cells in bone

marrow or blood

• Myeloid or lymphoid: Based on the predominant lineage of the malignant

cells

The four most common leukemias and their distinguishing features are summarized in the
table Findings at Diagnosis in the Most Common Leukemias.

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For 2022, the American Cancer Society estimates the distribution of new US cases by
leukemia type as follows (1):
• Acute myeloid leukemia (AML): 33%
• Acute lymphoblastic leukemia (ALL): 11%
• Chronic myeloid leukemia (CML): 15%
• Chronic lymphocytic leukemia (CLL): 33%
• Other leukemias: 8%

Acute leukemias
Acute leukemias consist of predominantly immature, poorly differentiated cells (usually
blast forms). Acute leukemias are divided into
• Acute lymphoblastic leukemia (ALL)
• Acute myeloid leukemia (AML)
Chronic leukemias
Chronic leukemias have more mature cells than do acute leukemias. They usually
manifest as leukocytosis with or without cytopenias in an otherwise asymptomatic person.
Findings and management differ significantly between

• Chronic lymphocytic leukemia (CLL)

• Chronic myeloid leukemia (CML)
Myelodysplastic syndromes
Myelodysplastic syndromes are a group of clonal hematopoietic stem cell disorders unified
by the presence of distinct mutations of hematopoietic stem cells. They involve progressive
bone marrow failure but with an insufficient proportion of blast cells (< 20%) for making a
definite diagnosis of acute myeloid leukemia; 40 to 60% of cases evolve into acute myeloid
leukemia.
Leukemoid reaction
A leukemoid reaction is a neutrophil count > 50,000/mcL (> 50 × 109/L) not caused by
malignant transformation of a hematopoietic stem cell. It can result from a variety of
causes, particularly other cancers or systemic infection. Usually the cause is apparent, but
apparent benign neutrophilia can be mimicked by chronic neutrophilic leukemia or chronic
myeloid leukemia.
FAB Classification of Leukemia
Acute Lymphoblastic Leukemia
The FAB classification of ALL was based initially on morphology and cytochemistry (Table
2). The cytochemical stains needed were SBB or chloroacetate esterase plus an NSE stain
to exclude myeloid differentiation and a periodic acid–Schiff (PAS) and an acid
phosphatase stain to provide supporting evidence of lymphoid differentiation. The PAS
stain identifies glycogen in the cytoplasm of cells; in ALL, there may be solid blocks of PAS-
positive material, whereas in AML, there is more likely to be a negative result or granular
positivity. The pattern of reactivity on acid phosphatase staining can support a diagnosis of
T-lineage ALL, strong focal positivity in the paranuclear Golgi zone being typical. However, it
must be recognized that cytochemical staining is not a totally reliable means of
demonstrating lymphoid lineage, and it is highly desirable that morphology and
cytochemistry are supplemented by immunophenotyping to make a positive identification of
B-lineage and T-lineage ALL (as well as to permit the recognition of the M0 and M7
categories of AML). An important advance in knowledge that has occurred since the
publication of the FAB classification of acute leukemias is the recognition that FAB L3
morphology often (but not always) represents the leukemic phase of Burkitt lymphoma.
Observation of these cytological features should lead not only to immunophenotyping being
performed but also to molecular analysis (e.g., fluorescence in situ hybridization) to detect
the t(8;14) or variant translocation that is typical of this condition. Such cases are now
classified as non-Hodgkin lymphoma, not as ALL; their recognition is important because
treatment differs from that of ALL.

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What Is Acute Myeloid Leukemia (AML)?

Cancer starts when cells in a part of the body begin to grow out of control. There are many
kinds of cancer. Cells in nearly any part of the body can become cancer. To learn more
about cancer and how it starts and grows, see What Is Cancer?

Leukemias are cancers that start in cells that would normally develop into different types of
blood cells. Most often, leukemia starts in early forms of white blood cells, but some
leukemias start in other blood cell types. There are several types of leukemia, which are
divided based mainly on whether the leukemia is acute (fast growing) or chronic (slower
growing), and whether it starts in myeloid cells or lymphoid cells.

Acute myeloid leukemia (AML) starts in the bone marrow (the soft inner part of certain
bones, where new blood cells are made), but most often it quickly moves into the blood, as
well. It can sometimes spread to other parts of the body including the lymph nodes, liver,
spleen, central nervous system (brain and spinal cord), and testicles.

Most often, AML develops from cells that would turn into white blood cells (other than
lymphocytes), but sometimes AML develops in other types of blood-forming cells. The
different types of AML are discussed in Acute Myeloid Leukemia (AML) Subtypes and
Prognostic Factors.

Acute myeloid leukemia (AML) has many other names, including acute myelocytic leukemia,
acute myelogenous leukemia, acute granulocytic leukemia, and acute non-lymphocytic
leukemia.

acute myeloid leukemia Aetiology

Acute myeloid leukemia (AML) is a type of cancer that begins in the bone marrow, where
blood cells are made. The exact cause of AML is not known. However, certain factors may
increase a person’s risk of developing the condition,

including:

• Exposure to high doses of radiation

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• Exposure to certain chemicals, such as benzene

• Inherited genetic risk factors, such as Down syndrome or Li-Fraumeni syndrome

• Previous cancer treatment with chemotherapy or radiation

• Having a genetic disorder, such as myeloproliferative disorders

• Having a family history of AML

Laboratory investigations of acute myeloid leukemia

Laboratory investigations used to diagnose acute myeloid leukemia (AML) include blood
tests, bone marrow tests, genetic tests, and imaging tests.

Blood tests: Blood tests are used to measure the levels of white and red blood cells,
platelets, or abnormal blasts in the blood. The results of these tests help determine if there is
an abnormality in the number of cells and can also show if there are any mutations in the
DNA of the cells.

Bone marrow tests: A bone marrow biopsy is used to look for the presence of leukemia cells
in the bone marrow. This can confirm the diagnosis of AML and can also help determine the
type of AML. A bone marrow aspiration is also used to measure the amount of leukemia
cells in the bone marrow.

Genetic tests: Genetic tests are used to identify genetic mutations that are associated with
AML. These tests can also help predict how the disease will progress and can help guide
treatment decisions.

Imaging tests: Imaging tests such as X-rays, CT scans, and MRIs are used to look for the
spread of leukemia to other parts of the body. They can also help identify any enlarged
organs or other abnormalities.

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What Is Acute Lymphocytic Leukemia (ALL)?

Cancer starts when cells in the body begin to grow out of control. There are many kinds of
cancer. Cells in nearly any part of the body can become cancer. To learn more about cancer
and how it starts and spreads, see What Is Cancer?

Leukemias are cancers that start in cells that would normally develop into different types of
blood cells. Most often, leukemia starts in early forms of white blood cells, but some
leukemias start in other blood cell types.

There are several types of leukemia, which are divided based mainly on whether the
leukemia is acute (fast growing) or chronic (slower growing), and whether it starts in myeloid
cells or lymphoid cells. Knowing the specific type of leukemia helps doctors better predict
each person’s prognosis (outlook) and select the best treatment.

Acute lymphocytic leukemia (ALL) is also called acute lymphoblastic leukemia. “Acute”
means that the leukemia can progress quickly, and if not treated, would probably be fatal
within a few months. "Lymphocytic" means it develops from early (immature) forms
of lymphocytes, a type of white blood cell.

ALL starts in the bone marrow (the soft inner part of certain bones, where new blood cells
are made). Most often, the leukemia cells invade the blood fairly quickly. They can also
sometimes spread to other parts of the body, including the lymph nodes, liver, spleen,
central nervous system (brain and spinal cord), and testicles (in males). Some cancers can
also start in these organs and then spread to the bone marrow, but these cancers are not
leukemia.

Other types of cancer that start in lymphocytes are known as lymphomas (either non-
Hodgkin lymphoma or Hodgkin lymphoma). While leukemias like ALL mainly affect the bone
marrow and the blood, lymphomas mainly affect the lymph nodes or other organs (but may
also involve the bone marrow). Sometimes it can be hard to tell if a cancer of lymphocytes is
a leukemia or a lymphoma. Usually, if at least 20% of the bone marrow is made up of
cancerous lymphocytes (called lymphoblasts, or just blasts), the disease is considered
leukemia.

Aetiology of Acute Lymphocytic Leukemia

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Acute lymphocytic leukemia (ALL) is a type of cancer that affects the white blood cells
known as lymphocytes. It is caused by a genetic mutation that leads to an overproduction of
immature white blood cells. This mutation is thought to be caused by a combination of
environmental factors and inherited genetic mutations. Examples of environmental factors
that may increase the risk of ALL include exposure to radiation, certain chemicals, and viral
infections. Inherited genetic mutations that may increase the risk of ALL include mutations in
certain genes associated with the immune system.

Laboratory investigations of Acute Lymphocytic Leukemia

(ALL) may involve a variety of tests, such as complete blood count (CBC) and differential,
blood chemistry tests, peripheral blood smear, bone marrow aspirate and biopsy,
cytogenetic analysis, and various laboratory tests to determine the presence of leukemia
cells.

CBC and differential: This test provides information about the number of white blood cells,
red blood cells, and platelets in the blood. Abnormalities in the types and numbers of these
cells can indicate the presence of leukemia.

Blood chemistry tests: These tests measure the levels of sugar, electrolytes, enzymes, and
other substances in the blood. Abnormal levels can indicate the presence of leukemia.

Peripheral blood smear: This test examines the shape and size of different types of blood
cells. Abnormalities in the shape and size of cells can indicate the presence of leukemia.

Bone marrow aspirate and biopsy: Bone marrow contains immature cells that can become
red blood cells, white blood cells, and platelets. These tests involve taking a sample of bone
marrow from the pelvis and examining it under a microscope. Abnormalities in the type and
number of cells can indicate the presence of leukemia.

Cytogenetic analysis: This test examines the chromosomes

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What Is Chronic Myeloid Leukemia?

Cancer starts when cells in the body start to grow out of control. Cells in nearly any part of
the body can become cancer, and can spread to other parts of the body. To learn more
about how cancers start and spread, see What Is Cancer?

Chronic myeloid leukemia (CML) is also known as chronic myelogenous leukemia. It's a
type of cancer that starts in certain blood-forming cells of the bone marrow.

In CML, a genetic change takes place in an early (immature) version of myeloid cells -- the
cells that make red blood cells, platelets, and most types of white blood cells (except
lymphocytes). This change forms an abnormal gene called BCR-ABL, which turns the cell
into a CML cell. The leukemia cells grow and divide, building up in the bone marrow and
spilling over into the blood. In time, the cells can also settle in other parts of the body,
including the spleen. CML is a fairly slow growing leukemia, but it can change into a fast-
growing acute leukemia that's hard to treat.

CML occurs mostly in adults, but very rarely it occurs in children, too. In general, their
treatment is the same as for adults.

Aetiology of Chronic Myeloid Leukemia

Chronic myeloid leukemia (CML) is caused by a genetic mutation in the bone marrow, which
is the soft, inner core of the bones that produces blood cells. This mutation results in the
production of an abnormal form of a protein called BCR-ABL. This protein causes the bone
marrow to produce too many white blood cells, which can lead to an enlarged spleen,
anemia, and other complications. The exact cause of this mutation is unknown, but it is
thought to be related to environmental factors, such as radiation exposure or certain
chemicals, or to genetic factors, such as mutations in the BCR-ABL gene.

Laboratory investigations of Chronic Myeloid Leukemia

Laboratory investigations used to diagnose and monitor Chronic Myeloid Leukemia (CML)
include the following:

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1. Complete Blood Count (CBC): This test looks at the number and types of cells in the
blood, including red blood cells, white blood cells, and platelets. An increased number of
white blood cells and a specific type of white blood cell called the basophil is a common
indication of CML.

2. Bone Marrow Aspiration and Biopsy: A sample of bone marrow is taken from the hip or
chest and examined under a microscope. This test is used to check for the presence of
abnormal white blood cells and confirm the diagnosis of CML.

3. Cytogenetic Analysis: A sample of cells is taken and examined for any genetic
abnormalities associated with CML. The most common abnormality is the Philadelphia
chromosome, which is an abnormal exchange of genetic material between chromosomes 9
and 22.

4. Molecular Tests: Tests that look for the presence of specific genetic mutations associated
with CML, such as the BCR-ABL fusion gene, can help with diagnosis and treatment.

5. Flow Cytometry: This test looks for specific markers on the surface of cells, which can
help

What Is Chronic Lymphocytic Leukemia?

Cancer starts when cells start to grow out of control. Cells in nearly any part of the body can
become cancer and can spread to other parts of the body. To learn more about how cancers
start and spread,

Chronic lymphocytic leukemia (CLL) is the most common leukemia in adults. It's a type of
cancer that starts in cells that become certain white blood cells (called lymphocytes) in the
bone marrow. The cancer (leukemia) cells start in the bone marrow but then go into the
blood.

In CLL, the leukemia cells often build up slowly. Many people don't have any symptoms for
at least a few years. But over time, the cells grow and spread to other parts of the body,
including the lymph nodes, liver, and spleen.

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Aetiology of Chronic Lymphocytic Leukemia

Chronic Lymphocytic Leukemia (CLL) is a type of cancer of the blood and bone marrow
caused by an abnormal proliferation of mature B-lymphocytes. The exact cause of CLL is
unknown, however, certain genetic and environmental factors may increase the risk of
developing CLL. These include a family history of CLL, exposure to certain chemicals such
as benzene, certain viral infections, and exposure to radiation.

Laboratory investigations of Chronic Lymphocytic

Leukemia Laboratory investigations of Chronic Lymphocytic Leukemia (CLL) may include a

complete blood count (CBC) with differential, peripheral blood smear, bone marrow
examination, and flow cytometry.

CBC with differential: A CBC with differential measures the levels of red and white blood
cells, platelets, and their relative proportions in the bloodstream. It is used to detect anemia,
infection, and other markers of CLL such as lymphocytosis (an increase in lymphocytes) and
monocytosis (an increase in monocytes).

Peripheral blood smear: A peripheral blood smear is a microscope slide of a sample of the
patient’s blood. It can be used to identify abnormal cells, such as lymphocytes with a
distinctive morphology that is typical of CLL.

Bone marrow examination: A bone marrow examination involves taking a sample of bone
marrow and examining it under a microscope. It is used to diagnose CLL, as well as to
assess the extent of the disease and identify any unusual features.

Flow cytometry: Flow cytometry is a technology used to measure the characteristics of

individual cells, such as their size, shape, and markers on their surface. It is used to
diagnose CLL, as well

Cytochemistry involved in diagnosis of various types of leukemia.

Cytochemistry is a laboratory technique used to identify and characterize cell components,

such as proteins and enzymes, by staining them with specific chemical dyes or fluorescent
molecules.

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This technique is often used in the diagnosis of various types of leukemia, including acute
myeloid leukemia (AML), acute lymphoblastic leukemia (ALL), chronic myeloid leukemia
(CML), and chronic lymphocytic leukemia (CLL).

The most commonly used cytochemical stains for leukemia diagnosis are:

• Myeloperoxidase (MPO) stain: This stain is used to differentiate myeloid cells from
lymphoid cells. It stains myeloid cells blue and lymphoid cells pink.

• Naphthol AS-D Chloroacetate Esterase (CAE) stain: This stain is used to differentiate
blasts from normal cells. It stains blasts purple and normal cells pink.

• Sudan Black B (SBB) stain: This stain is used to detect cell surface markers on blasts. It
stains certain cell surface markers brown.

• Peroxidase (PAS) stain: This stain is used to detect cell surface markers on blasts. It stains
certain cell surface markers purple

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