1.

Development of Leukocyte

Gambar 1. Proses Haematopoiesis. Source : Harrison’s Hematology and Oncology

Granulocytes and monocytes are formed in the bone marrow from a common precursor cell. In the
granulopoietic series progenitor cells, myeloblasts, promyelocytes and myelocytes form a proliferative or
mitotic pool of cells while the metamyelocytes, band and segmented granulocytes make up a post‐mitotic
maturation compartment. The granulocyte series arises from bone marrow progenitor cells which are
increasingly specialized.

Many growth factors are involved in this maturation process including IL‐1, IL‐3, IL‐5 (for
eosinophils), IL‐6, IL‐11, granulocyte–macrophage colony‐stimulating factor (GM‐CSF), granulocyte
CSF (G‐CSF) and monocyte CSF (M‐CSF). The growth factors stimulate proliferation and differentiation
and also affect the function of the mature cells on which they act (e.g. Phagocytosis, superoxide
generation and cytotoxicity in the case of neutrophils). They also inhibit apoptosis. Increased granulocyte
and monocyte production in response to an infection is induced by increased production of growth factors
from stromal cells and T lymphocytes, stimulated by endotoxin, and cytokines such as IL‐1 or tumor
necrosis factor (TNF)
 2. Leukemia

Acute and chronic forms differ in cell maturity and onset:

• Acute forms: Onset is often abrupt, within weeks. Proliferation of abnormal cells leaves little room for
normal cell production. Early myeloid or lymphoid progenitors (blasts) accumulate in the bone marrow
and to varying degrees spill into the peripheral blood and infiltrate other tissues. They are believed to
arise from early myeloid or lymphoid progenitors. Cells may proliferate in the liver and spleen as well, and
they may infiltrate other organs, such as the meninges, gums, lymph nodes, and skin.

Leukemic blasts are so primitive as to be nonfunctional and tend to displace or suppress the production
of normal hematopoietic elements in the marrow.

• Chronic forms: Onset is much slower, often over months or years. Arise in the bone marrow and most
commonly lead to the increased production of one or more types of mature myeloid cells. They may arise
from early myeloid progenitors or hematopoietic stem cells. Normal cell production may occur as well for
a long period of time, but in late stages of chronic disease, the abnormal cells interfere with normal cell
production. The majority of leukocytes are mature. Most symptoms initially stem from the
hyperproliferation of bone marrow progenitors and increased numbers of red cells, granulocytes, and/or
platelets in the peripheral blood and the spleen. Chronic forms are rare in children.
 1. Acute Lymphocytic Leukemia (ALL)

Acute myelogenous leukemia (AML) is a clonal, malignant disease of hematopoietic tissues that is
characterized by :

 Accumulation of abnormal (leukemic) blast cells, principally in the marrow

 Impaired production of normal blood cells.

Thus, the leukemic cell infiltration in marrow is accompanied, nearly invariably, by anemia and
thrombocytopenia. The absolute neutrophil count may be low or normal, depending on the total white
cell count.

This is the most common type of childhood leukemia (85%), peaking between ages 2 to 5 and rare after
age 15 with incidence in males higher than females. Down syndrome increases risk.

Etiology

Initiation and progression of ALL are driven by successive mutations that alter cellular functions, including
an enhanced ability of self-renewal, a subversion of control of normal proliferation, a block in
differentiation, and an increased resistance to death signals (apoptosis). Familial disorders of DNA repair
may play a role. Environmental agents, such as ionizing radiation and chemical mutagens, have been
implicated in the induction of ALL in some patients. However, in most cases, no etiologic factors are
discernible. In the favored theory, leukemogenesis reflects the interaction between host
pharmacogenetics (susceptibility) and environmental factors, a model that requires confirmation in well-
designed population and molecular epidemiologic studies.

Sign and Symptoms

ALL results in impaired immune system, anemia, and increased bleeding tendencies. About 10% of
patients initially present with disseminated intravascular coagulation (DIC) because of thrombocytopenia.
Typical symptoms include:
• Fever (common). • Anorexia, weight loss. • Dyspnea.
• Weakness, lethargy. • Palpatations. • Pallor.
• Increased bruising, petechiae. • Anemia.
• Abnormal bleeding, nosebleeds. • Increased infection.

Infiltration of leukemic cells to other organs if more common with ALL than with other forms of leukemia:
• Bone infiltration with bone pain. • Splenomegaly (30-54%) with left upper
• Mediastinal mass (associated with T lymphocyte abdominal fullness.
ALL). • CNS infiltration with headaches, nausea, and
• Painless lesions (lymphadenopathy) in neck, vomiting.
axillae, abdomen, and groin. • Rash from infiltration into skin.
• Hepatomegaly (10-20%) with pain and fullness • Hyperuricemia with renal failure.
inferior to ribs.
Laboratory Finding

Anemia, neutropenia, and thrombocytopenia are common in newly diagnosed ALL. The severity reflects
the degree of marrow replacement by leukemic lymphoblast.

 Hyper-leukocytosis  Thrombocytosis
 Neutropenia  Increased LDH, uric acid
 Hypereosinophilia  Leukemic blast >20% in CSF
 Decreased platelet
Subtypes

 FAB

 WHO

Subtype Description
B-cell  Early precursor-B ALL (also called pro-B ALL)
 Common ALL
 Precursor-B ALL
 Mature B-cell ALL (Burkitt leukemia)
T-cell  Precursor-T ALL
 Mature T-cell ALL
Prognosis is usually better for T-cell ALL than B-cell. Mature B cell has the worst prognosis. Other B-cell
subtypes fall in the middle. Younger patients have a better prognosis than older. People with a lower
white blood count (< 30,000 for B-cell ALL and <100,000 for T-cell ALL) at the time of diagnosis tend to
have a better prognosis.
About 25 to 30% of those with ALL have a translocation between chromosomes 9 and 22, which predicts
a poor prognosis. About 5% have a translocation between chromosomes 4 and 11, also predicting a poor
prognosis. Those who go into remission within 4 to 5 weeks have a better prognosis than those who take
longer.

Treatment

The standard adult treatment protocol comprises 4 phases:

• Induction: A 4-drug regimen of vincristine, prednisone, anthracycline, and cyclophosphamide or

L -asparaginase or a 5 drug regimen of vincristine, prednisone, anthracycline, cyclophosphamide,
and L -asparaginase is given over the course of 4-6 weeks.

• Consolidation: Studies show varying results from consolidation treatment, but most studies show
benefit. Regimens using a standard 4- to 5-drug induction usually include Ara-C in combination
with an anthracycline or epipodophyllotoxin.

• Maintenance: While studies show that adults on maintenance have longer periods of remission,
the definitive protocol has not been developed, so various treatment protocols are used including
a 4-drug regimen for 12 months.

• CNS prophylaxis: Meningeal infiltration is common with relapse, so intrathecal chemotherapy is

necessary.

The pediatric treatment protocol comprises 5 phases:

 Induction: rapidly kill tumors, consists of 3-4 drugs, which may include a glucocorticoid,
vincristine, asparaginase, and possibly an anthracycline. Last for 4-6 weeks.

 Consolidation: drugs are given at doses higher than those used during induction or the patient is
given different drugs (ie, highdose MTX and 6-mercaptopurine [6-MP]), epipodophyllotoxins with
Cytarabine (Ara-C), or multiagent combination therapy Interim maintenance: oral medications are
administered to maintain remission and allow the bone marrow to recover for 4 weeks.

 Delayed intensification: Intensified treatment for any remaining leukemic cells that were resistant
to previous phases.

 Maintenance: Intrathecal MTX every 3 months, monthly vincristine, daily 6-MP and weekly MTX.

The duration of pediatric treatment varies depending on the type of ALL. B-cell acute lymphoblastic
leukemia is usually treated with two months to 8 months of intensive therapy. However, those with B-
precursor and T-cell acute lymphoblastic leukemia require approximately 2 to 2.5 years of continuation
therapy to prevent high relapse rates. In current acute lymphoblastic leukemia clinical trials, the total
duration of therapy for girls is 2 years from the start of interim maintenance and for boys is 3 years from
the start of interim maintenance.
 2. Chronic Lymphocytic Leukemia (CLL)

CLL is a malignant lymphoid neoplasmthat is characterized by the accumulation of a population of small

mature B cells. The diagnosis of CLL requires the presence of at least 5000 circulating B cells/μl with
clonality demonstrated by flow cytometry according to International Workshop on Chronic Lymphocytic
Leukemia (IWCLL) criteria.

CLL develops primarily from a malignant clone of B-lymphocytes. T-lymphocyte CLL is rare. About 1% of
CLL cases express T-cell markers (CD4 and CD7) and have clonal rearrangements of their T-cell receptor
genes. These patients have median survival of 13 months with minimal responses to chemotherapy. A
number of different chromosomal abnormalities have been noted in CLL, including 13q deletion (in 50%)
and trisomy 12 (in 15%).

Symptoms

Patients are often asymptomatic at the time of diagnosis, especially in the early stages of the disease,
but they are progressively more at risk for infection because of defects

Patients with advanced disease can uncommonly present with drenching night sweats, fevers, and
weight loss (B symptoms), and signs and symptoms related to anemia, thrombocytopenia, and
lymphadenopathy. Lymph nodes typically are enlarged and painful as lymphocytes become trapped in
the nodes. Hepatomegaly and splenomegaly also develop. Patients may complain of abdominal fullness
and discomfort and early satiety because of splenomegaly. Skin lesions may occur with T-cell CLL.

Staging and Lab Finding

CLL cells appear as small blue lymphocytes
with scant cytoplasm on the Wright-Giemsa
staining commonly used for evaluating blood
films. Smudge cells are also commonly
observed on the blood film and this results
from the mechanical disruption of the cells
during the slide preparation process

Typical chronic
lymphocytic
leukemia blood
film

Typical chronic
lymphocytic
leukemia blood
film with smudge
cells
Treatment

Because some types of CLL have a long period with slow progression, some older adults may fare better
with monitoring than with aggressive treatment. CLL is usually not curable, so patients may be treated
symptomatically for complications, such as hemolytic anemia, infections, or ITP.

Typically, patients with low risk or Binet A classification are simply monitored because early
chemotherapy has not been associated with increased survival. Corticosteroids are commonly used to
treat autoimmune hemolytic anemia and thrombocytopenia.

The first line agent is fludarabine, which is either given alone or in combination with cyclophosphamide
and/or rituximab (a monoclonal antibody). Alemtuzumab (a monoclonal antibody directed at CD52) is
approved for use in CLL as both a first-line agent and for salvage in patients with fludarabine-refractory
disease.

3. Acute Myeloid Leukemia (AML)

Rapidly progressive malignancy characterized by failure of myeloid cells to differentiate beyond blast

Stage. Incidence increases with age; median age of onset is 65 years old; 80% of acute adult leukemia, 10-
15% of childhood leukemia.

Risk Factors

• Myelodysplastic syndromes (MDS), benzene, radiation, Down Syndrome, alkylating agents as

treatment for previous malignancy

Pathophysiology

Etiology subdivided into

 Primary: de novo

 Secondary: hematologic malignancies (e.g. Myeloproliferative disorders and MDS) or previous

chemotherapeutic agents (e.g. Alkylating agents)

Uncontrolled growth of blasts in marrow leads to

 Suppression of normal hematopoietic cells

 Appearance of blasts in peripheral blood – risk of leukostasis

 Accumulation of blasts in other sites (e.g. Skin, gums)

 Metabolic consequences; tumour lysis syndrome

Clinical Features

• Anemia, thrombocytopenia (associated • Accumulation of blast cells in marrow

with DIC in promyelocytic leukemia),
• Skeletal pain, bony tenderness (especially
neutropenia (even with normal WBC), leads
sternum)
to infections, fever
 • Anorexia, weight loss.
• Mouth sores.
• Increased bruising, petechiae, abnormal
bleeding, nosebleeds.
• Leukostasis/hyperleukocytosis syndrome
(medical emergency)
 Large numbers of blasts interfere with
circulation and lead to hypoxia and
hemorrhage – can cause diffuse pulmonary
infiltrates, CNS bleeding, respiratory
distress, altered mental status, priapism
 Increased uric acid → nephropathy, gout
 Release of phosphate → decreased Ca2+,
decreased Mg2+
 Release of procoagulants → DIC (higher risk
in acute promyelocytic leukemia)
 Decreased or normal K+ before treatment,
increased K+ after treatment (from lysed
cells)

Investigations

 Blood work

 CBC: anemia, thrombocytopenia, variable WBC

3. INR, aptt, fibrin degradation products (FDP), fibrinogen (in case of DIC)

4. Increased LDH, increased uric acid, increased PO43- (released by leukemic blasts), decreased
Ca2+, decreased K+

 Baseline renal and liver function tests

 Peripheral blood film – circulating blasts with Auer rods (azurophilic granules) are pathognomonic
for AML

 Bone marrow aspirate for definitive diagnosis

 Blast count: AML >20% (normal is <5%) morphologic, cytochemical, and/or immunotypic features
are used to establish lineage and maturation (see sidebar for WHO classification of AML, H37)

 CXR to rule out pneumonia, ECG, MUGA scan prior to chemotherapy (cardiotoxic)

Treatment

• Mainstay of treatment is chemotherapy (rapidly fatal without treatment)

• All AML subtypes are treated similarly, except acute promyelocytic leukemia (APL) with t(15:17)
translocation

• All-trans-retinoic acid (ATRA) added to induce differentiation; arsenic trioxide + ATRA combination
therapy for APL is non-inferior to traditional chemotherapy
Treatment strategy

1. Induction: chemotherapy to induce complete remission of AML

 Several possible regimens (e.g. Cytarabine with tetracycline)

 Patients with poor response to initial induction therapy – worse prognosis

 Must ensure reversal of DIC, platelet transfusions if <10

2. Consolidation: to prevent recurrence

 Intensive consolidation chemotherapy

 Stem cell transplantation – autologous or allogeneic (younger patients with better performance
status)

 Consider acceleration with hematopoietic growth factors (e.g. G-CSF) if severe infection develops

4. Chronic Myeloid Leukemia (CML)

Myeloproliferative disorder characterized by increased proliferation of the granulocytic cell line without
the loss of their capacity to differentiate. Occurs in any age group (mostly middle age to elderly) with a
median age of 65 years old.

Pathophysiology

 Philadelphia chromosome (Ph)

 Translocation between chromosomes 9 and 22

 The c-abl proto-oncogene is translocated from chromosome 9 to “breakpoint cluster region”

(bcr) of chromosome 22 to produce bcr-abl fusion gene, an active tyrosine kinase

Clinical Features

 3 clinical phases

1. Chronic phase: 85% diagnosed here

 Few blasts (<10%) in peripheral film

 ± slightly elevated eosinophils and basophils

 No significant symptoms

2. Accelerated phase: impaired neutrophil differentiation

 Circulating blasts (10-19%) with increasing peripheral basophils (pruritus)

 CBC: thrombocytopenia <100 x 109/L

 Cytogenetic evidence of clonal evolution

  Worsening constitutional symptoms and splenomegaly (extramedullary hematopoiesis)

3. Blast crisis: more aggressive course, blasts fail to differentiate

 Blasts (>20%) in peripheral blood or bone marrow; reflective of acute leukemia (1/3 ALL, 2/3
AML)

 Clinical presentation

1. 20-50% of patients are asymptomatic when diagnosed (incidental lab finding)

2. Nonspecific symptoms

 Fatigue, weight loss, malaise, excessive sweating, fever

3. Secondary to splenic involvement

 Early satiety, LUQ pain/fullness, shoulder tip pain (referred)

 Splenomegaly (most common physical finding)

4. Anemia

5. Bleeding: secondary to platelet dysfunction

6. Pruritus, PUD: secondary to increased blood histamine

7. Leukostasis, priapism, encephalopathy (rare): secondary to very elevated WBC (rare)

Investigations

 Elevated WBC, decreased/normal RBC, increased/decreased platelets, increased basophils

 WBC differential shows a bimodal distribution, with predominance of myelocytes and
neutrophils
 Peripheral blood film
 Leukoerythroblastic picture (immature red cells and granulocytes present, e.g. Myelocytes and
normoblasts)
 Presence of different mid-stage progenitor cells differentiates it from AML
 Bone marrow
 Myeloid hyperplasia with left shift, increased megakaryocytes, mild fibrosis
 Molecular and cytogenetic studies of bone marrow or peripheral blood for Philadelphia
chromosome
 Abdominal imaging for spleen size

Treatment

 Imatinib mesylate inhibits proliferation and induces apoptosis by inhibiting tyrosine kinase
activity in cells positive for bcr-abl

 If loss of response or intolerance (~40%), trial of 2nd generation TKIs: dasatinib or nilotinib
  Dasatinib and nilotinib may also be considered for first line management

 Interferon-α: may improve response to tyrosine kinase inhibitors; typically now only used for
pregnant patients

 Fludarabine for young, strong patients, Chlorambucil for old, weak patients.

Treatment success is monitored based on therapeutic milestones

■ Hematologic: improved WBC and platelet counts, reduced basophils

■ Cytogenetic: undetectable Philadelphia-chromosome in the bone marrow

■ Molecular: reduction/absence of bcr-abl transcripts in periphery and marrow

5. Hodgkin’s Lymphoma

Malignant proliferation of lymphoid cells with Reed-Sternberg cells (thought to arise from germinal
centre B-cells). Bimodal distribution with peaks at 20 yr and >50 yr, associated with Epstein-Barr virus in
up to 50% of cases, causal role not determined.

Clinical Features

 Asymptomatic lymphadenopathy (70%)

 Non-tender, rubbery consistency

 Cervical/supraclavicular (60-80%), axillary (10-20%), inguinal (6-12%)

 Splenomegaly (50%) ± hepatomegaly

 Mediastinal mass

 Found on routine CXR, may be symptomatic (cough)

 Rarely may present with SVC syndrome, pleural effusion

 Systemic symptoms

 B symptoms (especially in widespread disease; fever in 30%), pruritus

 Non-specific/paraneoplastic

 Alcohol-induced pain in nodes, nephrotic syndrome

 Starts at a single site in lymphatic system (node), spreads first to adjacent nodes

 Disease progresses in contiguity with lymphatic system

Investigations

 CBC

 Anemia (chronic disease, rarely hemolytic), eosinophilia, lymphopenia, platelets normal or

increased early, decreased in advanced disease

 Biochemistry

 HIV serology

 Liver enzymes and/or lfts (liver involvement)

 Renal function tests (prior to initiating chemotherapy)

 ALP, Ca2+ (bone involvement)

 ESR, LDH (monitor disease progression)

 Imaging

 CXR, CT chest (lymph nodes, mediastinal mass), CT abdomen/pelvis (liver or spleen

involvement), PET scans have replaced gallium scans

 Cardiac function assessment (MUGA scan or echocardiography): for patients at high risk of
pretreatment cardiac disease (age >60, history of HTN, CHF, PUD, CAD, MI, CVA, malnourished),
treatment can be cardiotoxic

 Pulmonary Function Testings: if history of lung disease (COPD, smoking, previous radiation to
lung)

 Excisional lymph node or core biopsy confirms diagnosis

 Bone marrow biopsy to assess marrow infiltration (only necessary if B-symptoms, stage III or IV,
bulky disease or cytopenia)

Treatment

• stage I-II: chemotherapy (ABVD) followed by involved field or involved site radiotherapy (XRT)

• stage III-IV: chemotherapy (ABVD) with XRT for bulky disease

• relapse, resistant to therapy: high dose chemotherapy, autologous stem cell transplant

 PET scan results essential in clarifying disease response

Complications of Treatment

• cardiac disease: secondary to XRT, adriamycin is also cardiotoxic

• pulmonary disease: secondary to bleomycin (interstitial pneumonitis)

• infertility: recommend sperm banking

• secondary malignancy in irradiated field

  <2% risk of MDS, AML (secondary to treatment, usually within 8 yr)

 Solid tumours of lung, breast; >8 yr after treatment

 Non-Hodgkin lymphoma

• hypothyroidism: post XRT

6. Non Hodgkin Lymphoma

Malignant proliferation of lymphoid cells of progenitor or mature B- or T-cells

Classification

• multiple classification systems exist at present and may be used at different centres

• can originate from both B- (85%) and T- or NK- (15%) cells

 B-cell NHL: e.g. Diffuse large B-cell lymphoma, follicular lymphoma, Burkitt’s lymphoma, mantle
cell lymphoma

 T-cell NHL: e.g. Mycosis fungoides (skin), TCL-NOS, anaplastic large cell lymphoma

• WHO/REAL classification system: 3 categories of nhls based on natural history

 Indolent (35-40% of NHL): e.g. Follicular lymphoma, small lymphocytic lymphoma/CLL, mantle
cell lymphoma

 Aggressive (~50% of NHL): e.g. Diffuse large B-cell lymphoma

 Highly aggressive (~5% of NHL): e.g. Burkitt’s lymphoma

• Staging

 Stage I: Involvement of one lymph node group

 Stage II: Involvement of two or more lymph node groups on the same side of the diaphragm (a
thin muscle below the lungs)

 Stage III: Involvement of lymph node groups on both sides of the diaphragm

 Stage IV: Involvement of one or more organs other than the lymph nodes and possible
involvement of the lymph nodes
Categories A, B, X and E. The four stages of NHL can be divided into categories.

 The A category indicates that patients have not experienced fever, exaggerated sweating and
weight loss.

 The B category indicates that patients have fever, excessive sweating and weight loss.

 The X category indicates bulky disease (large masses of lymphocytes).

 The E category indicates areas or an organ involved other than the lymph nodes or has spread to
tissues beyond, but near, the major lymphatic areas.

Clinical Features

• painless superficial lymphadenopathy, usually >1 lymph node region

• usually presents as widespread disease (exception is aggressive lymphoma)

• constitutional symptoms not as common as in Hodgkin lymphoma

• cytopenia: anemia ± neutropenia ± thrombocytopenia can occur when bone marrow is involved

• abdominal signs

 Hepatosplenomegaly

 Retroperitoneal and mesenteric involvement (second most common site of involvement)

• oropharyngeal involvement in 5-10% with sore throat and obstructive apnea

• extranodal involvement: most commonly GI tract; also testes, bone, kidney

• CNS involvement in 1% (often with HIV)

Investigations

• CBC

 Normocytic normochromic anemia

 Autoimmune hemolytic anemia rare

 Advanced disease: thrombocytopenia, neutropenia, and leukoerythroblastic anemia

• peripheral blood film may show lymphoma cells

• flow cytometry of peripheral blood lymphocytosis is valuable for low-grade NHL

• biochemistry

 Increase in uric acid

 Abnormal lfts in liver metastases

 Increased LDH (rapidly progressing disease, poor prognostic factor)

• staging: CT neck, chest, abdomen, pelvis and bone marrow biopsy

• PET is useful for monitoring response to treatment and evaluation of residual tumour following
therapy

In aggressive histological disease

• diagnosed by

 Lymph node biopsy: excisional biopsy preferred, FNA unreliable

 Bone marrow biopsy: not optimal for diagnosis as BM involved in only 30% of high grade
lymphomas

Treatment

• localized disease (e.g. GI, brain, bone, head and neck)

 Radiotherapy to primary site and adjacent nodal areas

 Adjuvant chemotherapy

 Surgery: splenic marginal zone lymphoma

• indolent lymphoma: goal of treatment is symptom management

 Watchful waiting

 Radiation therapy for localized disease

 Bendamustine plus rituximab, an anti-CD20 antibody, is superior to CHOP + rituximab (CHOP-R)

for advanced stage disease (stil trial)

• aggressive lymphoma: goal of treatment is curative

 Combination chemotherapy: CHOP is mainstay, plus rituximab if B-cell lymphoma

 Radiation for localized/bulky disease

 CNS prophylaxis with high-dose methotrexate if certain sites involved (testicular)

 Relapse, resistant to therapy: high dose chemotherapy, autologous SCT

• highly aggressive lymphoma

 Burkitt lymphoma: short bursts of intensive chemotherapy “CODOX-M” chemotherapy regimen

also often used ± IVAC with Rituximab

 CNS prophylaxis and tumour lysis syndrome prophylaxis

• hypersplenism

• infection

• autoimmune hemolytic anemia and thrombocytopenia

• vascular obstruction (from enlarged nodes)

• bowel perforation

• tumor lysis syndrome (particularly in very aggressive lymphoma) see Tumour Lysis Syndrome, H52