תואנדס םיחמתמ היגולופרומב תנשל · 2020. 5. 3. · •cd56 is expressed...

סדנאות

מתמחים

במורפולוגיה

2020לשנת

Acute Leukemias

Acute Leukemias

1. Acute myeloid leukemias (AML), NOS

2. Acute promyelocytic leukemia (APL, APL-variant)

3. AML with myelodysplasia

4. AML with minimal differentiation

5. AML without maturation

6. AML with maturation

7. Acute myelomonocytic leukemia

8. Acute monoblastic/monocytic leukemia

9. Pure erythroid leukemia

10. Acute megakaryoblastic leukemia

11. Acute basophilic leukemia

12. Acute panmyelosis with myelofibrosis

13. Mixed phenotype acute leukemia (MPAL) leukemia.

AML with recurrent genetic abnormalities (2016)

Acute Leukemias

B-lymphoblastic leukemia/lymphoma

1. 17. B-lymphoblastic leukemia/lymphoma, NOS

2. 18. B-lymphoblastic leukemia/lymphoma with recurrent genetic abnormalities

T-lymphoblastic leukemia/lymphoma

1. 19. Early T-cell precursor lymphoblastic leukemia

2. 20. Natural killer (NK) cell lymphoblastic leukemia/lymphoma

Acute leukemias of ambiguous lineage

Blastic plasmacytoid dendritic cell neoplasm

Wet purpura

Sweet synd.

Gingival hyperplasia in AML

Relative frequency of mutations in the indicated genes according to age group for pre-AML cases and controls.

Abelson S. Nature. 2018; 559: 400-404

Control Pre-AML

Proportion of pre-AML cases (red) and controls (blue) who had age related clonal hematopoiesis putative driver

mutations in recurrently mutated genes.

Abelson S. Nature. 2018; 559: 400-404

*p

Gene categories that participate in AML leukemogenesis

• AML genomes have an average of only 13 mutations found in genes.

Of these, an average of 5 are in genes that are recurrently mutated.

• Signaling molecules (59%), DNA methylation (44%), , chromatin

modification (30%), nucleophosmin (27%) , myeloid transcription

factors (22%) , transcription factor fusions (18%), tumor suppressors

(16%), spliceosome complex (14%), cohesin complex (13% ) .

Ley TJ. N Engl J Med. 2013; 368: 2059

Significantly mutated genes in AML

Ley TJ. N Engl J Med. 2013; 368: 2059

Gene categories that participate in AML leukemogenesis

• Activated signaling include point mutations in FLT3, KIT, other tyrosine

kinases, serine-threonine kinases, KRAS/NRAS, or protein-tyrosine

phosphatases.

• Mutations affecting DNA methylation — genes that encode enzymes

involved in both DNA methylation (eg. DNMTs) and DNA demethylation

with deregulation of the IDH/WT1/TET2 axis.

Ley TJ. N Engl J Med. 2013; 368: 2059

Grimwade Blood 2016

Prognostic value of European Leukemia Net classification in AML - Favorable

SubsetsGenetic group

t(8;21)(q22;q22); RUNX1-RUNX1T1

Favorable

inv(16)(p13.1q22) or t(16;16)(p13.1;q22); CBFB-MYH11

Mutated NPM1 without FLT3-ITD (normal karyotype)

Mutated CEBPA (normal karyotype)

Mrózek K. J Clin Oncol 2012; 30:4515.

Prognostic value of European Leukemia Net classification in AML - Intermediate


Mutated NPM1 and FLT3-ITD (normal karyotype)

Intermediate

Wild-type NPM1 and FLT3-ITD (normal karyotype)

Wild-type NPM1 without FLT3-ITD (normal karyotype)

t(9;11)(p22;q23); MLLT3-MLL

Cytogenetic abnormalities not classified as favorable or adverse


Prognostic value of European Leukemia Net classification in AML - Adverse


inv(3)(q21q26.2) or t(3;3)(q21;q26.2); RPN1-EVI1

Adverse

t(6;9)(p23;q34); DEK-NUP214

t(v;11)(v;q23); MLL rearranged

–5 or del(5q); –7; abnl(17p); complex karyotype*


*Three or more chromosome abnormalities in the absence of one of the WHO designated recurring translocations or inversions, that is, t(15;17), t(8;21), inv(16) or t(16;16), t(9;11), t(v;11)(v;q23), t(6;9), inv(3) or t(3;3).

Novel therapies in AML

• Azacytidine+Venetoclax (VEN), Decitabine-VEN, ARAC-VEN.

• IDH1 Inhibitor: Ivosidenib (Tibsovo)

• IDH2 Inhibitor: Enasidenib (Idhifa)

• FLT3 inhibitors: Midostaurine, Quizartinib, Gilteritinib

• Sonic hedgehog inhibitor: Glasdegib

Paetl SA. Clin Lymphoma Myeloma Leuk. 2020 Glasdegib

Ivosidenib

Enasidenib

MidostaurinGilteritinibQuizartinib

Venetoclax

DiNardo, NEJM 2018

Durable remissions with Ivosidenib in IDH1-mutated relapsed or refractory AML

FLT3 inhibitors

Neutrophils

Blasts

Monocytes

Immunophenotypic Markers

CD34, CD38, CD117, CD133, HLA-DRPrecursor stage

CD13, CD15, CD16, CD33, CD65, cytoplasmic MPOGranulocytic markers

CD11c, CD14, CD64, lysozyme, CD4, CD11b, CD36Monocytic markers

CD41, CD42, CD61Megakaryocytic markers

CD235a (glycophorin A)Erythroid marker

Immunophenotypic markers

AML

Cytoplasmic granularity

Semolinaסולת

Nucleolus

Auer rod

“Thumbprinting”

Thumbprinting in AML

Cup-like nuclear invagination in AML

Kroschinsky F.P. Haematologica 2008; 93: 283-286

FLT3 and NPM1 mutated AML

AML with Recurrent Genetic Abnormalities

IF BL >20% then AML

AML with recurrent genetic abnormalities

• t(8;21)(q22;q22), RUNX1-RUNX1T1

• inv(16)(p13.1;q22) CBFB-MYH11

• t(15;17)(q22;q12) PML-RARA

The diagnosis of AML is independent of blast count, if

cytogenetic is positive for: t(8;21), inv(16) or t(15;17).

Arber D.A. in WHO classification of tumours of hematopoietic and lymphoid tissues p.130, 2017

AML with recurrent genetic abnormalities

• AML with t(9;11)(p21.3;q23.3); KMT2A-MLLT3

• AML with t(6;9)(p23;q34.1); DEK-NUP214

• AML with inv(3)(q21.3q26.2) or t(3;3)(q21.3;q26.2); MECOM (EVI1)

• AML (megakaryoblastic) with t(1;22)(p13.3;q13.1); RBM15-MKL1


If either t(8;21); INV(16); or t(15;17) is positivethen:

•AML with t(8;21) RUNX1-RUNX1t1

•AML with INV(16) CBFB-MYH11

•APL with PML-RARA,

respectively.

AML with t(8;21)(q22;q22.1), RUNX1-RUNX1T1

Arber D.A. in WHO classification of tumours of hematopoietic and lymphoid tissues p.130-132, 2017

• AML with t(8;21)(q22;q22.1) resulting in RUNX1-RUNX1T1, showing predominant neutrophilic maturation.

• 1 to 5% of AML, usually in younger patients.

• Large myeloblasts with abundant basophilic cytoplasm with azurophilic granules.

• Few blasts show very large granules

(pseudo-Chediak-Higashi)


“Thumbprinting”



• Immunophenotype: CD34+, CD13+, HLA-DR+, MPO+

• Neutrophilic maturation: blasts with coexpressing of CD34 and CD15

• CD56 is expressed in fraction of cases with adverse prognosis.

• Frequent aberrant expression of CD19+ and PAX5+ and may CD79a+

• The gene RUNX1 encodes the core binding factor alpha (CBFA).

• Good response to chemotherapy and a relatively high CR rate and

long term DFS


Zhang Y. Le Beau MM. Cytogenetics in acute myeloid leukemia, UpToDate 2019

Auer rods are easily identified, and several may be present in a single cell.

AML with t(8;21)(q22;q22.1), RUNX1-RUNX1T1genetic profile


• The RUNX1-RUNX1T1 transcript is consistently detected in AML

t(8;21)(q22;q22.1).

• The core binding factor (CBF) is essential for normal hematopoiesis.

• The RUNX1-RUNX1T1 represses normal RUNX1 target by recruitment of nuclear

transcriptional co-repressor complexes.

• KIT mutations occur in 20-30%

• ASXL2 mutation in 20-25%, ASXL1 -10-20%, and KRAS or NRAS in 10-20%.

AML with inv(16)(p13.1;q22) ort(16;16)(p13.1;q22) CBFB-MYH11

AML with inv(16)(p13.1;q22) or t(16;16)(p13.1;q22)

• CBFB-MYH11 (MYH11 – smooth muscle myosin heavy chain)

• Usually shows monocytic and granulocytic differentiation and

characteristically abnormal eosinophilic component in the BM.

• Immature large eosinophilic granules at the promyelocyte and

myelocyte stages.

• 5-8% of younger patients with AML, lower frequency in old.


AML with inv (16)


• In some cases typical abnormal eosinophils are rare.

• Occasional cases with INV(16) show only granulocytic

maturation without monocytic component, or show only

monocytic differentiation.

• In some cases with INV(16) the blast percentage is lower

than 20%, but they should be diagnosed as AML.



Immunophenotype

• Characterized by complex immunophenotype with multiple

blast populations.

• Granulocytic: CD34+, CD33+, CD13+, CD15+, CD65, MPO+.

• Monocytic: CD14+, CD4+, CD11b+, CD11c, CD64+, CD36+.

• Coexpression of CD2 with myeloid markers has been

frequently documented.



Genetic profile

• Secondary cytogenetic abnormalities (40%): +22, +8, and del(7q) or +21.

• Trisomy 22 is fairly specific for INV(16).

• Mutations: NRAS 45%, Kit 30-40%, FLT3 - 14%, KRAS – 13%

• High rate CR and favorable OS when treated with intensive consolidation with HD cytarabine.

• Old age, high WBC, FLT3-TKD and trisomy 8 are associated with worse outcome.


Acute Promyelocytic Leukemia (APL) with PML-RARA


• Abnormal promyelocytes predominate.

• Both hypergranular (typical) and microgranular(hypogranular) variant exist.

• Associated with DIC

• In the microgranular variant the WBC is very high, with rapid doubling time.

• High early mortality.


Long-term outcome of APL treated with all-trans-retinoic acid (ATRA), arsenic trioxide (As2O3), and gemtuzumab (GO).

Abaza Y. Blood 2017;129:1275-1283


• Characteristic cells contain bundles of Auer rods(fagot

cells) and cytoplasmic hypergranularity.

• Microgranular variant have few or no granules and

bilobed nucleus.


• Characterized by low or absence of HLA-DR, CD34, CD11a, CD11b and CD18.

• CD33+, CD13+, CD117+, CD64+

• CD56+ expression (10% of cases), worse prognosis.

• ISH: t(15;17)(q24.1;q21.2)

• PCR: PML-RARA +



Dekking EH. Leukemia.2012; 26:1976

Structure of the PML and RARA genes with the break point regions and the corresponding fusion gene transcripts

The PML gene contains three well-defined small break point cluster regions (bcr’s): bcr1 in intron 6, bcr2 in the downstream part of exon 6 and bcr3 in intron 3. In addition two rare break points in intron 7 have been reported. In the RARA gene the break points cluster in intron 2.

PML gene

RARA gene

Dekking EH. Leukemia.2012; 26:1976

Structure of the PML and RARA genes with the break point regions and the corresponding fusion gene transcripts

The three well-defined bcr’s and the rare intron 7 breaks in the PML gene result in four different PML–RARA fusion transcripts. Percentages refer to the relative frequency of the various PML–RARA variants.

• Rare cases of PML-RARA negative may occur due to

complex variant translocations or with submicroscopic

insertion of RARA into PML [Cryptic or masked t(15;17)]

• Mutations of FLT3-ITD occur in 30-40%, and are associated

with microgranular variant , bcr3 breakpoint of PML and

CD2+.


APL with Cryptic PML-RARA

• A subset of cases with morphologic features resembling

APL, show variant translocations involving RARA:

• ZBTB16 at 11q23.2 – unresponsive to ATRA

• NUMA1 at 11q13.4 – responsive

• NPM1 at 5q35.1 - responsive

• STAT5B at 17q21.2 - unresponsive to ATRA

• These variant translocations should be diagnosed as:

APL with a variant RARA translocation

Arber D.A. in WHO classification of tumours of hematopoietic and lymphoid tissues p.134-136, 2017Adams J. Arch Pathol Lab Med. 2015; 139:1308–1313.

Translocations in APL and APL with variant RARA translocation

Adams J. Arch Pathol Lab Med. 2015;139:1308–1313

Combining gene mutation with gene expression analysis improves outcome prediction in APL

• An integrative score in APL (ISAPL) demonstrated relationship with

clinical outcomes of patients treated with all-trans retinoic acid

(ATRA) in combination with anthracycline-based chemotherapy.

• ISAPL score is based on fms-like tyrosine kinase-3–internal tandem

duplication mutational status; the ΔNp73/TAp73 expression ratio;

and ID1, BAALC, ERG, and KMT2E gene expression levels.

Lucena-Araujo AR. Blood 2019, 134: 951-959

The probability of overall survival in in patients with APL, according to ISAPL score.

Lucena-Araujo AR. Blood 2019, 134: 951-959

High-risk APL patients treated with oral arsenic and all-trans retinoic acid.

complete molecular remission

Zhu HH. Blood EPUB May 4, 2018

Zhu HH. Blood, EPUB, 2018

High-risk APL patients treated with oral arsenic and all-trans retinoic acid.

Acute Promyelocytic Leukemia (APL) with t(15;17)(q22;q12) - Hypergranular

Fagot cell

Fagot

Acute Promyelocytic Leukemia (APL) with PML-RARA - Hypergranular

Acute Promyelocytic Leukemia (APL) with t(15;17)(q22;q12) - Hypergranular

Acute Promyelocytic Leukemia (APL) with t(15;17)(q22;q12) - Hypogranular

APL – Microgranular variant

Mr. Rod (Auer) Faggot

• ATRA 45 mg/m2 in two divided doses (BSA - 1.73)

• Tab. Vesanoid 10mg, 4 tablets BID

#100

Rx

AML with inv(3)(q21;q26/2) or t(3;3)(q21;q26.2); RPN1-EV1


• Associated with thrombocytosis and increased atypicalmegakaryocytes.

• Activation of the MECOM (EVI1) gene, located at 3q26.2.

• MECOM encodes transcription factor that interacts withtranscriptional and epigenetic regulators (CREBBP, CTBP, HDACs, KAT2B [P/CAF], SMAD3, GATA1, GATA2, DNMT3A, and DNMT3B), and mediates chromatin modifications and DNA hypermethylation.

• MECOM can act as a transcriptional activator to promote the proliferation of hematopoietic stem cells.

Bitter MA. Blood. 1985;66:1362


Associated with thrombocytosis and atypical megakaryocytes.

AML with t(6;9)(p23;q34.1) DEK-NUP214

t(6;9) — AML (p23;q34.1), DEK-NUP214

• Often associated with basophilia, anemia and thrombocytopenia.

• Most cases show myeloid and erythroid dysplasia.

• Non-specific immunophenotype with MPO+, CD34+, CD9+, CD13+, CD15+,

CD33+, CD38+, CD117+, CD123+ and HLA-DR+.

• High incidence of FLT3 internal tandem duplications.

• The fusion of DEK with NUP214 results in nucleoporin fusion protein that acts as

an aberrant transcription factor which binds to soluble transport factors.


t(6;9) — AML (p23;q34.1), DEK-NUP214

Basophil

AML with myelodysplasia-related changes

AML with myelodysplasia-related changes (AML-MRC)

• Occurs mainly in elderly .

• Accounts for 24-35% of all cases of AML.

• Often presents with pancytopenia.

• Dysplasia must be present in >50% of the cells of at least

two hematopoietic cell lines.


AML with myelodysplasia-related changes (AML-MRC)

• Dysgranulopoiesis – hypogranular cytoplasm,

hyposegmented nuclei (pseudo-Pelger).

• Dyserythropoeisis - megaloblastosis, karyorrhexis,

multinucleation, ring sideroblasts.

• Dysmegakaryopoesis – micromegakaryocytes, non-

lobated or multiple nuclei.


AML with myelodysplasia-related changes (AML-MRC)Diagnostic criteria:

requires that the following 3 criteria are met

1. > 20% blood or marrow blasts.

2. Any of the following- History of MDS of MDS/MPN neoplasm

- MDS related cytogenetic abnormality: Complex karyotype (>3 abnormalities), Unbalanced karyotype: 5, 7, 11, 12, 13, 17, X, Balanced translocations: t(11;16), t(3;21), t(1;3), t(2;11), t(5;12), t(5;7), t(5;17), t(5;10), t(3;5).

- Multilineage dysplasia (but is insufficient for diagnosis of AML-MRC in de novo case of AML with mutated NPM1 or biallelic mutation of CEBPA).

3. Absence of both of the following- Prior cytotoxic or radiation therapy for an unrelated disease

- Recurrent cytogenetic abnormality as described in AML with recurrent cytogenetic abnormalities: t(8;21), inv16, t(15;17), t(9;11), t(6;9), inv3, t(3;3), t(1;22).



Hypersegmentedneutrophil

Hyposegmentedneutrophil

Auerrod


Basophils and basophilic precursors Dyserythropoiesis

Bahmanyar M. Blood,127, 2503, 2016


Dysmegakaryopoiesis – separated nuclei Dyserythropoiesis – multinuclei

Acute myeloid leukemia with minimal differentiation

AML with minimal differentiation

• The myeloid nature of the blasts is determined by immunophenotyping to distinguish from lymphoblastic leukemia.

• Accounts for

AML with minimal differentiationImmunophenotype

• CD34+, CD38+, HLA-DR+.

• Blast cells express at least 2 myeloid markers: CD13+ and CD117+, CD33+.

• MPO and TdT may be positive

• Lack of myeloid and monocytic maturation: CD11b-, CD15-, CD14-, CD36-, CD64-, CD65-.

• Blasts are negative for T and B markers: cCD3-, cCD22- and cCD79a-.


AML with minimal differentiation (M0)

AML with Maturation

AML with Maturation (M2)

• Characterized by >20% blasts in BM.

• Evidence for >10% maturing granulocytic lineage.

• Cells of monocyte lineage constitute 60%.).

• Patients present with: anemia, thrombocytopenia and

neutropenia.


AML with Maturation (M2)Immunophenotype

• One or more of myeloid-associated antigens: CD13+, CD33+,

CD11b+, CD15+, CD65+.

• CD34+, CD117+, HLA-DR+.

• Monocytic markers usually absent: CD14-, CD36-, CD64-.


Acute Myeloid Leukemia with Maturation

Acute Myelomonocytic Leukemia


• Proliferation of both neutrophil and monocytic precursors.

• 5-10% of AML cases. Median age 50.

• Myeloid: CD13+, CD15+, CD33+, CD65+.

• Monocytic: CD14+, CD64+, CD11b+, CD4+, CD36+, CD68+, CD163+ and lysozyme.

• Blasts may express CD34+, CD117+ and HLA-DR+.

• CD7+ in 30%.


Acute Monoblastic and Monocytic leukemia

Acute Monoblastic and Monocytic leukemia

• In acute Monoblastic leukemia >80% of cells are monoblasts.

• In acute Monocytic leukemia >80% of cells are promonocytes.

• Extramedullary: gingival infiltration, CNS and skin.

• Hemophagocytosis and coagulopathy is associated with t(8;16).

• Immunophenotyping: CD14+, CD4+, CD11b+, CD11c+, CD64+, CD68+,

CD36+ and lysozyme. Aberrant expression of CD7+ and or CD56+


Gingival hyperplasia in Acute Monocytic leukemia

Acute monoblastic leukemia

Acute monoblastic leukemia with erythrophagocytosis

Acute monocytic leukemia

Acute Monocytic Leukemia with Erythrphagocytosis,

Pure Erythroid Leukemia

Pure Erythroid leukemia

• >80% of marrow cells are erythroid, with >30% proerythroblasts.

• No significant evidence of myeloblastic component.

• Profound anemia with circulating erythroblasts are common.

• Proerythroblasts have deeply basophilic with agranular cytoplasm

and frequently contain vacuoles.



• Multinucleated proerythroblalsts may be present.

• CD71+(transeferrin-R), CD235A (glycophorin), CD36+, CD117+

• HLA-DR- and CD34- are usually negative

• Complex karyotype in almost all cases, with loss of chromosome 5 /

del5q and loss of chromosome 7 / del 7q.

• Rapid clinical course with median survival of 3 months.



CD71+CD235A+

Acute Megakaryoblastic leukemia

• >20 blasts of which >50% are of megakaryocyte lineage.

• Patients present with cytopenia, often thrombocytopenia

although some have thrombocytosis.

• Megakaryoblasts are medium to large blasts (12-18µm).

• Cytoplasm is basophilic often with blebs or pseudopods.



Acute Megakaryoblastic Leukemia

• Circulating micro-megakaryocytes, megakaryocyte fragments

and dysplastic large platelets.

• Some patients have extensive bone marrow fibrosis.

• Platelet glycoproteins: CD41+, CD42b+, CD61+.

• CD13+,CD33+ and CD36+.

• CD34- and HLA-DR- are often negative.




CD41+, CD42b+, CD61+


Greene ME. Blood Cells Mol Dis. 2003

CD41+, CD42b+, CD61+


Rashidi A. Blood. 2013;122:2537

CD41+, CD42b+, CD61+

https://www.ncbi.nlm.nih.gov/pubmed/?term=Rashidi+A.Fisher+S.+megakaryoblastic

Acute MegakaryoblasticLeukemia

Tina Motroni St. Jude

CD41+, CD42b+, CD61+

Acute Basophilic Leukemia

Differentiation of neoplastic basophils

1. Metachromatically granulated blast cells 2. Basophilic promyelocytes 3. Basophilic myelocytes

4. Immature basophils with bi-lobed nuclei 5. Fully mature basophils with segmented nuclei.

Valent P. Leukemia 31: 788–797, 2017

• Cutaneous involvement, organomegaly, lytic lesions, and

symptoms related to high histamine.

• Cytoplasm is moderately basophilic with COARSE BASOPHILIC

GRANULES.

• CD13+, CD33+, CD11b+, CD9+, CD123+, CD203c+

• CD117(-)


Arber D.A. in WHO classification of tumours of hematopoietic and lymphoid tissues p.164-165, 2017Luo XH. Oncol Lett. 2014; 8: 2513-2516

• t(3;6)(q21;p21) and abnormalities involving 12p.

• Differential diagnosis with other AML with basophilia:

• t(6;9)(p23;q34)

• Mast cell leukemia

• Subtype of ALL with coarse granules.



B-lymphoblastic leukemia/lymphoma (NOS)

B-cell differentiation

Pro B Immature BPre B

CD34

TDT

CD10

CD19

LMO2

CD79a

PAX5

CD20

Mature naïve B

CD23CD38

Plasma cell

CD38

BLIMP1

CD138

XPB1

CD38

Germinal center B

CD10

LMO2

BCL6

Jaffe ES. in WHO classification of tumours of hematopoietic and lymphoid tissues p.192, 2017

Memory B

B-lymphoblastic leukemia/lymphoma (NOS)(B-ALL/B-LBL)

• Precursor lymphoid cells committed to B-cell lineage.

• Small to medium blast cells involving the bone marrow & blood

(B-ALL) and occasionally present with primary involvement of

nodal or extra nodal sites (B-LBL).

• Extramedullary involvement is common: CNS, LN, spleen and

liver and testes.

Borowitz M.J. in WHO classification of tumours of hematopoietic and lymphoid tissues p.200-213, 2017

B-lymphoblastic leukemia/lymphoma (NOS)(B-ALL/LBL)

• Lymphoblasts may be small with scanty cytoplasm and

condensed nuclear chromatin, or larger with moderate

amounts of blue cytoplasm, with dispersed nuclear

chromatin and prominent nucleoli.

• Nuclei are round or show convolutions.

• Coarse azurophilic granules are present in 10%


B-ALL/B-LBL

Scanty cytoplasm in ALL

B-lymphoblastic leukemia/lymphoma (B-ALL-LBL)

Cuplike nuclei in B-ALLCD34+CD19+CD20-CD10-

Li W. Blood EPUB 2019


• CD10+, CD19+, CD22+, TdT+.

• PAX5+[most sensitive, but also positive in AML with t(8;21)]

• Aberrant: CD13+, CD33+

Borowitz M.J. in WHO classification of tumours of hematopoietic and lymphoid tissues p.202, 2017


Degree of Differentiation

• Earliest stage (Pro-B ALL): CD19+, cCD79a+, cCD22+, TdT+

• Intermediate stage (Common B-ALL): CD10+

• Most mature (Pre-B ALL): cytoplasmic µ chain+, and

occasional surface heavy chain.


B-lymphoblastic leukemia/lymphoma (NOS)Novel therapies - Blinatumomab

A bispecific monoclonal antibody that enables CD3-positive T cells to eliminate CD19-positive ALL blasts. Blinatumomab resulted in significantly longer overall survival than chemotherapy among adult patients with relapsed or refractory B-cell precursor ALL.

Kantarjian H. N Engl J Med 2017;376:836-47.

B-lymphoblastic leukemia/lymphoma (NOS)Novel therapies – Inotuzumab ozogamicin

An anti-CD22 antibody conjugated to calicheamicin.

Kantarjian H. N Engl J Med d 2016;375:740-53.

B-lymphoblastic leukemia/lymphoma (NOS)Novel therapies – CAR-T

An anti-CD22 antibody conjugated to calicheamicin.

Kantarjian H. N Engl J Med d 2016;375:740-53.

B-lymphoblastic leukemia/lymphoma (NOS)Novel therapies – CAR-T Tisagenlecleuce – event free survival

Maude SL. N Engl J Med d 2018;378:439-48.

B-lymphoblastic leukemia/lymphomawith Recurrent Genetic Abnormalities

• B-ALL with BCR-ABL1 accounts for 25% of adult ALL.

• Typical CD10+, CD19+, CD25+ and TdT+ without myeloid antigens.

• In children the BCR-ABL1 fusion protein is p190.

• In adults, about half produce p210 fusion protein (characteristic of CML), and the remainder produce p190.

• The worst prognosis of the major cytogenetic subtypes of ALL.

B-lymphoblastic leukemia/lymphomawith t(9;22)(q34/1;q11.2); BCR-ABL1


• B-ALL/B-LBL which lack the BCR-ABL1 translocation but show a pattern of gene expression very similar to that seen in ALL with BCR-ABL1.

• Translocations frequent involving other tyrosine kinases or IGH/CRLF2 or rearrangements leading to truncation and activation of EPOR.

• Up to 25% of ALL, especially in young adolescents and adults. High frequency of CRLF2 translocations in Down synd.

B-lymphoblastic leukemia/lymphomawith BCR-ABL1-like (provisional entity)


• Ph-like B-ALL blasts typically have CD19, CD10+

• CRLF2 surface expression detected by FACS.

• Poor prognosis, especially in CRLF2 translocations.

• Translocation PDGFRB with EBF1 show resistance to induction chemotherapy. However, they show dramaticresponse to tyrosine kinase inhibitors such as imatinib and nilotinib.

B-lymphoblastic leukemia/lymphomawith BCR-ABL1-like (provisional entity)


• B-ALL with Hyperdiploidy accounts for 8% of adult ALL.

• Blast contain >50 chromosomes (usually 90% of children.

B-lymphoblastic leukemia/lymphomawith Hyperdiploidy


B-lymphoblastic leukemia/lymphomaPrevalence of ALL subtypes across age groups

Hunger SP. Blood 2015;125:3977

DD: Burkitt's lymphoma

T cell differentiation

Prothy-mocyte

Peripheral T cell

Subcapsularthymocyte

CD34TDT

CD10

CD2/CD5

CD7

Cortical thymocyte

CD1a

CD3 cytoplasmic

CD4/CD8

CD38 CD38

Jaffe ES. in WHO classification of tumours of hematopoietic and lymphoid tissues p.193, 2017

CD3 surface

Medullary thymocyte

CD8

CD4

T-regulatory

FOXP3

CD25

T Helper 1

T Helper 2

T Helper 17

TNFα

IL-17

RORC

IL-4

IFNγ

IL 2

TBX21 GATA3

IL-5

FollicularT-helper

PD1

BCL6

CD57

ICOS

CXCL13


• T-ALL accounts for 25% of adult ALL with more males than females.

• T-LBL accounts for 90% of LBL with frequent mediastinal involvement.

• The skin, tonsils, liver and spleen, CNS and testes may be involved.

• High WBC associated with large mediastinal mass on presentation.

• Same morphologic features as B-ALL.


T-Lymphoblastic Leukemia/Lymphoma


• CD1a+, CD2+, CD3+, CD4+, CD5+, CD7+, CD8+. TdT+

• CD3 is considered lineage specific.

• CD4 and CD8 are frequently co-expressed.

• CD1a+CD34+CD99+, indicate precursor nature of T-lymphoblasts.

• Aberrant expression of CD13 and CD33.

• CD117+ is associated with FLT3 mutations.


• t(1;17)(p32;q35) and t(1;14)(p32;q11); TAL1 dysregulation

• t(11;14)(p15;q11) LMO2 deletion or dysregulation

• t(10;14)(q24;q11) and t(7;10)(q35;q24) TLX1 dysregulation

• t(5;14)(q35;q32) TLX3 dysregulation, poor prognosis

• t(10;11)(p13;q14), PICALM-MLLT10, poor outcome

T-lymphoblastic leukemia/lymphomaCommon rearrangements

Hunger SP. Blood 2015;125:3977

Early T-cell precursor lymphoblastic Leukemia

ETP-ALL

Early T-cell precursor lymphoblastic LeukemiaETP-ALL

• Accounts for up to 10% of adult ALL.

• CD3+, CD7+, CD2+

• Positive to one or more myeloid/stem cell markers: CD34+, CD117+, CD13+, CD33+, CD11b+ HLA+DR+, and CD65+

• Lacks by definition CD8- and C1a- and MPO.

• Mutation profile similar to AML: FLT3, RAS family, DNMT3A, IDH1, IDH2

• Mutations more typical to ALL: NOTCH1, CDKN1/2 are in low frequency.

Borowitz M.J. in WHO classification of tumours of hematopoietic and lymphoid tissues p. 212, 2017

Early T-cell precursor lymphoblastic LeukemiaETP-ALL

1. Acute Undifferentiated Leukemia (AUL)

2. Mixed Phenotype Acute Leukemias (MPAL)


183Borowitz M.J. in WHO classification of tumours of hematopoietic and lymphoid tissues p. 180-187, 2017

Exclusions: AML with recurrent genetic abnormalities: t(8;21), inv(16), PML-RARA. CML in blast crisisTherapy related AML and AML with MDS


184

1. Acute Undifferentiated Leukemia (AUL)

2. Mixed Phenotype Acute Leukemias (MPAL):

A. B/myeloid leukemia (B/MY)

B. T/myeloid leukemia (T/MY)

Borowitz M.J. in WHO classification of tumours of hematopoietic and lymphoid tissues p. 180-187, 2017

Requirements for assigning more than one lineage to a single blast population - MPAL

Myeloid lineage:

Myeloperoxidase (MPO)

or

Monocytic differentiation:

(at least 2: NSE, CD11c, CD14, CD36, CD64, lysozyme)


T Lineage: Cytoplasmic or surface CD3 (FACS)

B lineage (multiple Ag required):Strong CD19 with at least 1 strongly expressed(CD79a, cyt-CD22, CD10)orWeak CD19 with at least 2 strongly expressed (CD79a, cyt-CD22, CD10)


Requirements for assigning more than one lineage to a single blast population - MPAL

MPAL exclusions:

1. Recurrent AML-associated with t(8;21),

t(15;17) or inv(16)

2. AML associated with FGFR1 mutations

3. CML in blast crisis

4. MDS-related AML

5. Therapy-related AML


MPAL

t(v;11q23); KMT2A rearranged

Acute undifferentiated leukemia (AUL)

• No specific clinical features to distinguish from other leukemias.

• Very poor prognosis

• Immunophenotype: HLA-DR+, CD34+ and/or CD38+, TdT+/-, CD7+/-

• Negative: MPO-, cCD3-, CD19-, cCD22-, CD79a-.

• Expressions of BAALC, ERG, and MN1.


Acute undifferentiated leukemia (AUL)192

MPAL with t(9;22)(q34.1;q11.2); BCR-ABL1

• The most common recurrent genetic abnormality in MPAL.

• This leukemia is rare and should not be diagnosed in patients known to have had CML.

• Majority of cases have criteria for B/Myeloid.

• FISH and PCR are positive for BCR-ABL1. The p190 fusion transcript is more common than p210.

• Dimorphic blast population: lymphoblasts and myeloblasts

• TKIs may improve outcome.


MPAL with t(9;22)(q34.1;q11.2); BCR-ABL1

194The blasts vary from small lymphoid-appearing blasts to large blasts with dispersed chromatin and nucleoli

Acute leukemia of ambiguous lineage

195


196

MPAL

197

MPAL

198

MPAL, B/myeloid, NOS

• Dimorphic or monomorphic blast population: resembling ALL or

lymphoblasts with myeloblasts

• Immunophenotype: MPO+ including CD13+, CD33+, CD117+,

with B-cell (CD19+).

• Cytogenetics: del(6p), 12p11.2, del5q, near-tetraploidy and

complex karyotype.



• Gene expression profile between ALL and AML.

• Mutations frequently found: ASXL1, TET1/2, IDH1, IDH2,

DNMT3A, NOTCH1 and ETV6, and deletion of IKZF1.

• Poor prognosis


201Asia-Pacific Journal of Clinical Oncology 2013; 9: 146


202

• B lymphoblasts are blue• MPO+ blasts and normal

cells are green.

• Most of the B lymphoblastslack MPO

• Small population of blastscoexpress CD19 and MPO

FACS in MPAL, B/myeloid, NOS

Borowitz et al. WHO 2008 classification p. 150

MPAL T/myeloid NOS

• May resemble ALL or have dimorphic populations:

lymphoblasts and myeloblasts

• Immunophenotype: MPO+, (CD13+, CD33, CD117+) or

monoblasts (CD11c, CD14, CD64), with cytCD3+, CD2+,

CD7+, CD5+.


MPAL T/myeloid (NOS)

204

Single population of blasts(red) coexpressingboth cytCD3 and MPO

Normal T cell are in violet

Borowitz et al. WHO 2008 classification p. 155

cMPO

cytC

D3

205Asia-Pacific Journal of Clinical Oncology 2013; 9: 146

MPAL T/myeloid NOS


Heesch S. Ann Hematol 92:747, 2013

Pro

bab

ility

of

Surv

ival

206 Months

MPAL; n=23

AUL; n=13



Pro

bab

ility

of

Surv

ival

207 Months

ALL protocol; n=22

AML protocol; n=9



Pro

bab

ility

of

Surv

ival

208Months

Blastic Plasmacytoid Dendritic Cell Neoplasm(BPDCN)

Blastic Plasmacytoid Dendritic Cell Neoplasm (BPDCN)

• Aggressive tumor derived from precursors of plasmacytoiddendritic cells

• High frequency of cutaneous and bone marrow, peripheral blood and lymph nodes.

• Cutaneous purplish nodules, preferentially on the head and lower limbs, and can be >10 cm.

• Median age ~65 years, male to female ratio 3:1.

• May progress to CMML, MDS or AML.

Facchetti F. in WHO classification of tumours of hematopoietic and lymphoid tissues p. 174-177, 2017


• Characterized blast cells resembling either lymphoblasts ormyeloblasts.

• CD4+, CD56+, CD123+, CD303+, TCL1A+, CD7+, CD33+.

• Some cases show CD2+, CD5+, CD36+, CD38+, and CD79a+.

• MPO-, CD3-, CD13-, CD16-, CD19-, and lysozyme- are negative.

• BCL2+, BCL6+, IRF4+, S100+, TdT+.



• Complex karyotype is common.

• Recurrent chromosomal abnormalities: 5q21/5q34, 12p13, 13q21-13, 6q23-qter, 15q, and loss of chromosome 9.

• TET2 is most commonly mutated gene in BPDCN.

• Increased expression of genes involved in NOTCH signaling and BCL2, as well as aberrant activation of NF-kappaBpathway.

• Deletion of CDKN2A.



Angelot-Delettre F. Blood, 2012;120,2784

• CD4+, • CD56+, • CD123+, • CD303+,• CD304+, • TCL1+

Blastic Plasmacytoid Dendritic Cell Neoplasm (BPDCN) - BM

Peripheralblood

What looks alike, but is not

Acute leukemia ?

Normal B-cell precursors (Hematogones)

• Benign B-cell precursors mimic lymphoblasts with higher

nuclear/cytoplasmic ratio and no noticeable nucleloli.

• Hematogones can be found after termination of individual

phases of therapy in ALL as well as ASCT.

• They are found at leukemia remission with the highest incidence

in B-ALL, and they were less frequent at remission of AML or T-

ALL.


Hemtogones

Benign lymphoid precursors whose morphology and immunophenotype are similar to the blasts found in ALL.

They may be seen as part of an exaggerated B-cell recovery in response to chemotherapy or infiltration of the marrow from a non-hematologic tumor.

Hematogones

Intermesoli T. Am. J. Hematol. 82:934,2007

Hematogones

Hematogones Acute lymphoblastic leukemia

Rimza L.M. Am J Clin Pathol 2000;114:66-75

Hematogones Acute lymphoblastic leukemia

Rimza L.M. Am J Clin Pathol 2000;114:66-75

Hematogones show a large proportion of kappa-positive cells (blue) and lambda-positive cells (pink), as well as CD20+, SIg-negative cells (red).

Acute lymphoblastic leukemias blastsfailed to stain with CD20, kappa, or lambda (purple).

No clonality Clonal

Normal maturational sequence of stage 1, 2 and 3 Hematogones

Babusikova O. NEOPLASMA 55, 6, 2008

Antigen expression during B-lymphocytes precursors (Hematogones) maturation

Chantepie S.P. Leukemia Res. 37 (2013) 1404 – 1411

Megaloblastic anemia

תואנדס םיחמתמ היגולופרומב תנשל · 2020. 5. 3. · •cd56 is expressed...

Documents