Acute leukemias | Treatment

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 Biphenotypic acute leukaemia; in aminority of cases of both AML and all. these features may be on the same cells "biphenotypic" or on two separate populations "bilineal". This termed hybrid acute leukaemia and its treatment usually based on the dominant pattern.


  1. Acute Lymphoblastic leukemia.
  2.  Acute Lymphoid leukemia.
  3. Acute Lymphocytic leukemia.

Acute lymphoblastic leukemia (All), is a form of leukemia characterized by excess proliferation lympoblasts.

Incidence ;the predominant type of leukemia in childern "childhood leukemia". The peak of incidence is between 10 yers. After 10 yers of age the incidence decrease, on the other hand in 55 yers the incidence increased. 

FAB classification ; FAB classification ALL into 3 types according to the following morphological features :
  1. Size of the cell
  2. Nuclear shape. 
  3. Appearance of nucleoli
  4. Amount of cytoplasm. 

All in childhood:

  • L1 ALL
Blast cell : - 
-Size : small and uniformed 
-N/C ratio : high 
-Nucleoli : may or may not visible. 
-Cytoplasm : scnty with modrate basophilia. 

  • L2 ALL
Blast cell:
- Size :larger than L1
-N/C ratio: lower than in L1
-Nucleus :irregular 
-Nucleoli : often visible and large 
-Cytoplasm: moderately abundant with variable basophilia. 

  • L3 ALL
Blast cell:
-Size : larger than L1 
-N/C ratio : lower than in L1 
-Nucleus :often visible and large 
-Cytoplasm: moderately abundant with variable basophilia. 

  • L3 ALL
Blast cell:
-Size :large
-N/C ratio: lower than L1
-Nucleus :regular (round to oval) 
-Nucleoli: usually prominent 
-Cytoplasm: moderately abundant with strong basophilia and prominent vaculation. 

Clinical presentation;

Related to bone barrow faillure:

  • Symptoms of anaemia 
  • Infections
  • Bleeding
Related to organ infiltration :
  1. Moderate splenomegaly and hepatomegaly 
  2. Tender bones
  3. Meningeal syndrome (headache, nausea, vomiting). 
  4. Testicular swelling (less common). 

Lab diagnosis :

  • Normocytic normochromic anaemia 
  • Thrombocytopenia
  • T. WBCs:decrease, normal or increase. 
  • PBP: show variable numbers of blast cells
  • B. M: hypercellular with >20% leukemic.

  1. MPO and SBB :negative 
  2. PAS: characteristic :positive
  3. Acid phosphtase (ACP) :
  4. Positivity in T-lineage ALL
  5. Rare in B-lineage
  6. L3 is usually PAS negative
  7. Oil red O : Positive in L3

Immunophenotying confirm:
  • B-lingage ALL
  • T-lineage ALL
  • Positive B-lineage blasts : {CD19, CD22, CD79} 
  • Positive T-lineage :{CD2, CD3, CD4, CD7, CD8, and anti-TCRaB}. 

Immunological; precusor B-ALL :CD19+, CD22+, TdT+
Include 3 types:
  1. Common ALL:CD10+
  2. Null ALL : CD10 -
  3. Pre B-ALL :intracytoplasmic y+, CD10+ or CD 10 - 
  4. T-ALL :CD3+,CD7. B-ALL:smIg+, TdT -. 

Cytogenetic ;  
  • t(12;21)
  • t(1;19)(q23;p13)
  • t(9:22)(q34;q11) 
  • t(4:11)(q21:q23)
  • t(8:14)(p13:q11) 
  • All translocations in ALL are associated with  bad prognosis  expcept: hyperdiploidy, and t(12, 21).

ALL score & WHO classification of ALL

Useful for L1 and L3 It is depend on  the following criteria in B. M examination : 

  1. N/C ratio :high +1, low - 1
  2. Presence of aprominent nucleoli in >25% of the blasts : if  it is as this - 1 if not +1 membrane : regular +1, irregular - 1 if homogenous and small +1 
  3. L1 score : O to +2 
  4. L2 score : - 1 to - 3

Acute lymphoblastic leukemia /lymphoma (FABL1&L2P) 
  • i. Precursor N acute lymphoblastic. 
  • ii. Precursor T acut lymphoblastic leukemiam/lymphoma 
  • 2-Burkittls leukemia/lymphoma(FAB L3) 
  • 3-Biphenotypic acute leukemia. 

  1. 1-Supportive 
  2. 2-Specific

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