• Bone marrow aspiration……..

• Patient “X” 5 years male presented to paediatrics emergency with complains of fever off and on, progressive pallor, and small red colour spots over body.

There is history of pain in legs off and on during night.There is history of easy fatigue and dyspnea on exertion.

• On examination: severe pallor present,febrile and multiple petechial rash present

• Multiple significant cervical axillary and inguinal lymph node present.

• Splenomegaly 5 cm BCM.

• Hepatomegaly present

• Sternal tenderness present.

• Xray shows mediastinal widening

• What is the most likely diagnosis?

• Complete blood count…….

• Peripheral blood smear………

• Bone marrow aspiration……..

• Bone marrow biopsy…….

• Lumbar puncture?????

• Cytogenetics……..

2

Pediatric Leukemias

(Leuka = white, emia = blood)

Definition:

Unregulated clonal proliferation of cells

↓

 Proliferation rate

↓

Poor response to normal Poor capacity for differentiation regulatory signals

e

Marrow Failure

Disruption of normal marrow function

4

The History of Leukemia

1845- Craig and Bennett described a case as suppuration of the blood

–Virchow discovered this as well, named it “leukemia”

1855- Ernst Neumann discovered that the bone marrow was the likely origin of leukemia

–

The History of Leukemia

6

⚫ 1946- Sidney Farber used antifolate agents to treat leukemia in children

⚫ 1960s- Addition of vincristine and steroid to regimens,

– Survival rates increased to over 50%

⚫ 1970- Beginning of classification, discovery of cytogenetics and risk based treatment

Epidemiology

– –

⚫ Most common malignant neoplasms in childhood (~ 25% of all Pediatric

cancers)

⚫ Demographics:

– Males more commonly than females Whites more than blacks

More commonly in patients with Down’s

Age Incidence

8

Classification of leukemias

Acute or Chronic Types 

•ALL-77%

•AML-11%

•CML-2-3%

•JCML-1-2%

10

Acute

LymphoblasticLeukaemia

• Epidemiology of ALL

peak incidence in 2 to 6 years more in boys than girls.

median age in adults-35years

• Etiology

less studied

environmental and genetic

factors

Predisposing Factors

Genetic Conditions

Down’s syndrome Fanconi’s

Bloom

Klienfelter

Ataxia telangiectasia SCIDPNH

NF-ILi- Fraumeni Turner

Environmental factors

Ionizing radiation Drugs

Alkylating agents Nitrosourea

Epipodophyllotoxin Benzene

Advanced maternal age Ebstein Barr infection

In Identical twins  if 1^st (monochorionic) twin diagnosed during infancy, risk >70% in 2^nd twin.

If ALL develops at 5-7 yrs, risk for 2^nd twin at least double the general population (irrespective of zygosity) ¹²

Hematopoisis

14

Blast cell

• Blast cells are immature precursors of either lymphocytes (lymphoblasts), or granulocytes (myeloblasts).

• They do not normally appear in peripheral

blood. they can be recognized by their large size, and primitive nuclei (i.e. the nucleus

contain nucleoli).

• Presence of BS in blood, signify ACUTE LEUKEMIA.

• Presence of an Auer Rod, is pathognomonic for Acute Myeloid Leukemia.

Blast cell

Bone marrow changes

Normal marrow

16

Marrow showing blasts

18

Classifications of ALL

• FAB CLASSIFICATION

• WHO CLASSIFICATION

• Cyto-genetic CLASSIFICATION

Basis of Classification

Morphology

Immunophenotypic characteristics

Cytogenetic & molecular genetic features

FAB CLASSIFICATION OF ALL

CYTOLOGIC

FEATURES L1 L2 L3

Cell size Small cells

predominate,homo genous

Large,heterogenou

s in size Large homogenous

cytoplasm Scanty Variable,often

moderately abundant

Moderately abundant

nucleoli Small One or more,often

large One or

more,prominent Nuclear size Homogenous Variable,

heterogenous Stippled, homogenous Nuclear shape Regular Irregular clefts regular

Cyt.basophilia variable variable Intensely

basophilic Cyt.vacuolation

4/28/2014 variable variable prominent

1820

Immunophenotypic classification

B-lineage ALL

ALL T-lineage ALL.

80%  derived from B cell progenitors

lymphoblasts having cell-surface expression of ≥ B-lineage–assoc.

antigens i.e., CD19, CD20, CD24, CD22, CD21, or CD79. CD10 is commonly expressed CALLA+).

10-15%  from T cells

only 1-3%  from B cells

Classification of ALL(WHO)

4/

Immunopheno-

type % of

cases FAB

subtype Cytogenetic abnormalites

Pre B ALL 75 L1,L2 t(9;22),t(4;1 1)t(1;19)

T cell ALL 20 L1,L2 14q11

or 7q34 Mature B cell

ALL(burkitt 5 L3 t(8;14)

leukemia)

19 22

TranslocationsinALL Prognosis

t(12;21) Good

t(1;19) Poor

t(4;11)MLLfusion Poor

JAK-2Mutation Poor

Cytogenetic classification

ALL presentation

24

⚫

Anemia

⚫

Bleeding and bruising

⚫

Bone and joint pain

⚫

Fever

⚫

Weight loss

Etiology and Pathophysiology

– –

⚫ ALL results from mutations of genes

– Radiation Chemicals

Viruses & Other

⚫ Malignant immature white blood cells i.e.

Lymphoblasts crowd out the bone marrow

T^–his includes crowding out of platelets, RBCs, a^–nd mature WBCs

CLINICAL FEATURES

Due to infiltration of marrow

• SYMPTOMS

Due to decreased production of normal marrow elements

26

Symptoms

symptoms percentage

fatigue 92

Bone or joint pain 79

fever 71

Weight loss 66

Abnormal masses 62

purpura 51

hemorrhage 27

28

Physical Signs

Physical Signs percentage splenomegaly 86

lymphadenopathy 76 hepatomegaly 74 Sternal tenderness 69

purpura 50

Fundus changes 14

Clinical features

• Generalized weakness and fatigue

• Anemia

• Frequent or unexplained fever and infection

• Weight loss and/or loss of appetite

• Excessive and unexplained bruising

• Bone pain, joint pain (caused by the spread of

"blast" cells from the marrow cavity)

• Breathlessness

• Enlarged lymph nodes, liver and/or spleen

• Petechiae, which are tiny red spots or lines in the skin due to low platelet levels

30

Diagnosis

• Confirmative tests

• Supportive tests

Investigation (supportive)

• LDH,Serum uric acid

• Coagulation profile

• LFT,RFT

• Chest x-ray,

• CT scan of chest & brain

• Blood culture

• Baseline Echo,ECG

32

Investigation (confirmative)

• CBC

• Bone marrow aspiration/biopsy

• Cyto genetics.

Investigations(conf.)

CBC-Anemia,thrombocytopenia,leucopenia or leucocytosis.

Peripheral smear study-circulating blast

can be seen.

Confirmatory

Bone marrow aspiration/biopsy

34

Bone marrow biopsy

gross specimen Marrow showing blasts

36

Criteria for diagnosis

• Bone marrow or peripheral smear showing

Aleast 30% blast(FAB)

Atleast 20%blast (WHO)

Treatment

Pre Chemotherapy supportive care Chemotherapy

Preinduction

Remission induction-phase 1 & 2 Reinduction

CNS preventive therapy consolidation

Maintenance therapy

Allogenic stem cell transplantation Newer drugs

Supportive care

Treatment of relapse

38

Supportive care

Treat metabolic complications

hyperuricemia - hydration,rasburicase hyperphosphatemia - po4 binders

hypocalcemia - Ca supplements Hyperleuc k ocytosis - leu k opharesis Infection control-broad spectrum

antibiotics

Hematologic support

Preinduction

• Prednisolone 1mg/ k g p.ofor 5 days

• Rechec k blast after 5 days, if blast

count dropped-good response.

40

Treatment of ALL Induction 1

cycle chemotherap

y Dose and schedule

Induction Prednisolon or 1mg/kg p.o days 1-28 days vincristine 1.5mg/m2 i.v weekly once

x 4 weeks

doxorubicin 30mg/m2 i.v weekly once x 4 weeks

L-Asparginase 1,00,000 u/m2(total dose) in divided doses of 10,000 u daily for 10 days

CNS Proph. methotrexate 12mg IT days 1,8,15,22

Reassess

• After 4 wee k s of phase 1 induction assess marrow for remission.

• If there is remission taper prednisolone and after 1 week, start phase2

induction,

• If there is no remission give 2 more

wee k ly doses of vincristine and doxo and

then assess, if still no remission go for

alternate regimen.

42

Induction 2

Induction2 drugs Dose and

schedule Cyclophosphamide

Cytosine arabinoside

650mg/m2 i.v days 1 and 15

75mg/m2 i.v x 4 days a weeks for 4 week

methotrexate 12mg/m2 IT days 1,8,15,22

Cranial radiation 200 cGy x 9days

Reinduction

Re induction drug Dose and schedule

vincristine 1.5 mg/m2 i.v weekly one dose on day 1 and 8

doxorubicin 30mg/m2 i.v. weekly one dose on day 1 and 8

prednisolone 1mg/kg p.o daily for 14

CNS Prophylaxis

44

Pui CH, Howard SC. Lancet Oncol 9 (3): 257-68,2008

⚫

CNS involvement at diagnosis <5%

– Without prophylaxis, over 80% of patients in CR will relapse in the CNS

– With prophylaxis, less than 5% have CNS relapse

⚫

Intrathecal chemotherapy is now the mainstay

– Sample intermediate risk regimen: IT MTX alone or “triple therapy”: IT cytarabine Day 1 of CR

followed by MTX/hydrocortisone/cytarabine

44

CNS Prophylaxis

CSF Blasts

Consolidation(2weeks)

consol

dation drugs Dose and schedule cyclophosp

hamide 750/m2 .i.v on days 1 and 15

Cytosine

arabinoside 75mg/m2 doses days 1-4 and 15-18

4/28/2014 4146

Maintenance phase duration- upto 2 years

maintena

nce drug Dose and schedule

1^st

month methotrexate 12.5mg i.t on day 1 vincristine 1.4mg/m2 .v day 1

prednisolone 1mg/kg p.o daily day 1-7 6 mercaptopurine 60mg/m2 p.o. daily for

next 3 weeks

methotrexate 15mg/m2 p.o. once a week for 3 weeks.

2^nd 6 MCP and

48

Allogenic stem cell transpantation

• Usually done in second remission.

• Can be done in first remission in high ris k patients

WBC>25000,

philadelphia chromosome positive,

poor initial response to remission

induction.

Newer drugs

Monoclonal antibodies

rituximab(CD20),epratuzumab(CD22) alemtuzumab(CD52),gemtuzumab(CD33) Antimetabolites

clofarabine,nelarabine Tyrosine k inase inhibitor

imatinib, nilotinib, dasatinib,

Vornistat, sirolimus,everolimus,oblimersen.

50

Follow up

If the patient completes chemotherapy for 2 years without relapse-stop chemo and follow up.

No relapse within 5 years-can be declared

as cured.

Long-Term Monitoring

Frequent clinic visits: - to administer outpatient chemo.

- to monitor blood counts

- to evaluate new symptoms.

Prevention of infections ^

- Pneumocystis carinii pneumonia: Trimethoprim- sulfamethoxazole (TMP-SMZ) or monthly IV pentamidine.

- Risk of candidiasis. oral fluconazole prophylaxis in infant leukemia

Relapse

Occurs in 20% cases (when blasts reappear after complete remission (CR) is achieved).

Majority of relapses involve the bone marrow Other sites → CNS or testes.

Isolated CNS relapse (< 5% of total relapses) or isolated testicular relapse (1-2% of total relapses)

→ rare with current ALL therapy

B-lineage ALL with early relapse in bone marrow ^(which

may be combined with other sites, such as CNS) or all T-lineage ALL → high risk for further relapse and poor survival.

Types of Relapse

Early relapse  - within 36 months of initial diagnosis or - within 6 months of completion of primary therapy

The vast majority of patients with T-lineage ALL suffer ER

Outcomes poor (only 35-40% of patients achieve long-term remission).

Late relapse: ^ occurs outside this time frame

Outcomes better than for early relapse (>50% achieve

Prognosis

The 5-year event-free survival (EFS) depends on risk category ^

Varies from 95% (low risk) - 30-80% (very high risk) Infant leukemia → the worst outcomes (20% survival for babies younger than 90 days).

Important prognostic factors 

-

- Stage of disease - Age of patient

- Rate of response to initial therapy

Acute complications of disease/treatment

Tumor lysis syndrome: hyperkalemia, hyperuricemia, hyperphosphatemia, hypocalcemia

Renal failure Anemia

Bleeding

Coagulation Abnormalities Sepsis

Typhlitis

Acute neurological toxicity: Seizures, Neuropathy,

Late Effects of Treatment

CNS sequelae Growth failure Obesity

Bony Morbidity: ostopenia, fractures, osteonecrosis

Cardiac sequelae

Sexual development & fertility Cataract

Second malignancies

Prognostic factors in ALL

Determinants Favourable unfavourable

WBC Counts <10,000 >2,00,000

Age 2-10 years <1yr,>10yr

Gender female male

Ethnicity white black

Node,liver,splenomegaly absent massive

Testicular enlargement absent present

CNS involvement absent Csf blast and pleocytosis

FAB Type L1 L2

Cytogenetics T(12;21)(TEL-AML1) Trsomies 4,10,17

t(9;22)(bcr-abl) t(4;11)(MLL-AF4)

Acute myeloid leukemia (AML)

Clonal proliferation of hematopoeitic precursors of myeloid, erythroid, & megakaryocytic lineage.

> complex & resistant

Occurs at any age, > common in adolescence.

Congenital Leukemia → mostly AML Exact etiology unknown

Several Genetic & Environmental predisposing factors (esp. Down’s Synd. Most common genetic predisposing factor in under 3 children)

Classification

Subtypes based on marrow findings.

The FAB classification system: 

M0: Undifferentiated

M1: Ac Myeloblastic leukemia with minimal maturation M2: Ac Myeloblastic leukemia with maturation

M3: Ac. Promyelomonocytic leukemia M4: Ac. Myelomonocytic leukemia

M5: Ac. Monoblastic leukemia M6: Erythroblastic leukemia

M7: Ac. Megakaryoblastic leukemia

Clinical Features

More infections, higher leukocyte count at presentation

Pallor, fatigue, bleeding, fever Bone pain is less common

Lymphadenopathy & massive hepatosplenomegaly <

common

Infants & toddlers → > organomegaly, CNS dis. &

higher leukocyte count (M4, M5)Some subtypes have characteristic clinical pictures 

- Gingival hyperplasia, CNS infiltration often assoc. with M5

- DIC > common in M3

Higher counts: → leukostasis

→ pulm infitrates, resp difficulty, stroke

• CNS involvement  15%

• Chloromas → CNS, neck, orbit, bones, skin

• Leukemia cutis

• Preleukemic phase or

Myelodysplastic syndrome (MDS) (lasting wks-mths)

may precede AML

Treatment Outline

Intensive chemotherapy Supportive care

Radiation treatment to treat chloromas and other masses that are pressing on a vital

structure

Persistent CNS leukemia usually requires craniospinal irradiation.

HSCT in first remission

Treatment of Acute Promyelocytic (M3)Leukemia

All-trans retinoic acid (ATRA)

↓

An anthracycline to induce remission.

Arsenic trioxide → highly active in newly

diagnosed & relapsing APL

Prognosis

Overall survival rate  45-60%

Prognosis improved significantly since the late 20^th century.

Cytogenetic abnormalities and risk 

Greater risk of recurrent disease (monosomy 7

& monosomy 5)

Lower risk (eg, t[8;21] and inv[16]/t[16;16]).