Laboratory diagnosis of acute leukemia – analyzes

A blood test for acute leukemia. Most patients with acute leukemia (OL) at the time of diagnosis of the disease have normochromic normocytic anemia, which is more pronounced in acute myeloblastic leukemia. With the development of hemorrhagic complications, hypochromia may occur due to iron deficiency. The number of peripheral blood leukocytes varies widely (from 1 • 109 / l to 200 • 109 / l), but more often it remains at the subleukemic level and does not exceed 20-30 • 109 / l.

The most pronounced leukocytosis is observed in patients with T-ALL and acute monoblastic leukemia. When calculating the leukocyte formula in 90% of patients with acute leukemia blast cells are detected, the number of which can vary from 1-2 to 100%. In typical cases, there are no intermediate forms of neutrophilic cells between the blasts and mature granulocytes (“leukemic failure”, or hiatus leukaemicus).

In 20% of patients, the number of blast cells exceeds 50 × 109 / l, and in 10% of the blasts in the peripheral blood are absent (pancytopenia and relative lymphocytosis are usually noted). At the level of leukocytes above 100 • 109 / l, the risk of the development of leukostatic complications (neurological disorders, acute respiratory distress syndrome, in men, in addition, priapism) sharply increases.

Thrombocytopenia is detected in the overwhelming number of patients with acute leukemia and is more pronounced in acute myeloblastic leukemia (AML) (in half of the patients the number of platelets is less than 50 • 109 / l). At the same time, in 1–2% of patients thrombocytosis is noted (more than 400 • 109 / l).

In some patients, an increase in prothrombin and partial thromboplastin time may be noted; in acute promyelocytic leukemia, a decrease in fibrinogen level and other signs of DIC are often observed. It should be noted that the development of the syndrome of DIC is possible with any variant of acute leukemia.

Myelogram with acute leukemia. The study of bone marrow aspirate is needed to diagnose and establish a variant of acute leukemia. The number of myelokaryocytes is usually increased, megakaryocytes are absent or their number is reduced. When calculating the myelogram, at least 20% of blasts are detected, constriction of normal hemopoiesis sprouts. To verify the variant of acute leukemia, it is necessary to conduct cytochemical, immunological and cytogenetic studies, the results of which have prognostic significance and allow planning medical tactics.

Infectious complications

Infectious complications (respiratory infections, bacterial sepsis) rarely develop in the onset of the disease, but have important practical and prognostic significance. Complications of various etiologies (bacterial, viral, fungal) usually occur during treatment, most often with the development of agranulocytosis and are one of the main causes of deaths.

Neuroleukemia in most cases manifests with a meningeal symptom complex or a picture of an intracerebral tumor (nausea, vomiting, headache), isolated lesion of cranial nerves is much less common (nn oculomotorius, facialis).

Clinical signs do not allow to reliably differentiate acute myeloblastic leukemia (AML) and acute lymphoblastic leukemia (ALL) without performing cytochemical and immunological studies of blast cells. However, some symptoms are more likely to occur in certain types of acute leukemia (OL).

Acute myeloid leukemias are characterized by more vivid symptoms: patients usually have intoxication, anemic, and hemorrhagic syndromes, often with severe infectious complications. 90% of patients with ALI develop syndrome of DIC. Acute monocytic, rarely myelomonocytic leukemia more often than other variants of AML are accompanied by hypertrophic gingivitis, lymphadenopathy, the appearance of leukemides on the skin and high leukocytosis.

In acute erythromyelosis, the anemic syndrome, macrocytosis and peripheral blood normocytosis are leading. Acute megakaryoblastic leukemia is usually characterized by pronounced myelofibrosis, which makes it difficult to obtain bone marrow aspirate and serves as a basis for performing bone marrow trephine biopsy to verify the diagnosis.

Acute lymphoblastic leukemias are characterized by more scarce clinical manifestations: intoxication, anemic and hemorrhagic syndromes are less pronounced, and infectious complications occur less frequently. At the same time, in patients with acute lymphoblastic leukemia (ALL), ossalgia, lymphadenopathy (including an increase in mediastinum), hepatosplenomegaly and neuroleukemia are significantly more common.

Debut of acute leukemia

The debut of acute leukemia has no characteristic clinical manifestations.
For children and young people, a more acute onset is more typical, in which patients are worried about progressive general weakness, malaise, headache, shortness of breath, myalgia, ossalgia, less often – abdominal pain, fever. In mature and advanced age, the disease usually develops more slowly and is characterized by a predominance of symptoms of anemia and intoxication.

More rarely, the first manifestation of acute leukemia (OL) are hemorrhages in the skin, nose bleeds, blood admixture during defecation, mucosal bleeding, hypertrophic gingivitis, and necrotic stomatitis. Finally, in 5% of patients, a diagnosis is made by examining peripheral blood for other diseases.

On examination, most patients determine the paleness of the skin and mucous membranes due to anemia, and manifestations of hemorrhagic syndrome (petechiae and / or ecchymosis on the mucous membranes of the oral cavity and on the skin, signs of internal bleeding are possible). Rarely marked increase in the liver and spleen, lymphadenopathy.

With the developed clinical picture of acute leukemia (OL), the following syndromes are expressed to varying degrees:

1) syndrome of tumor intoxication (weakness, fatigue, weight loss, increase in body temperature, not associated with infection);
2) anemic syndrome (shortness of breath during normal exercise, dizziness, pallor of the skin and mucous membranes);
3) hemorrhagic syndrome (hemorrhage, bleeding mucous membranes, in severe cases – profuse bleeding of various localization, bleeding in the brain);
4) syndrome of leukemic proliferation (ossalgia, swollen lymph nodes, liver, spleen, hypertrophic gingivitis, neuroleukemia);
5) syndrome of infectious complications (local or generalized infections).

Basic data of clinical, laboratory and instrumental studies

In most patients, the symptoms of acute leukemia are not specific, however, the diagnosis is usually not difficult to study the history of the disease, physical data, the study of peripheral blood and myelogram.

I. Symptoms of acute leukemia: Weakness, indisposition, shortness of breath; hemorrhagic manifestations from minimal effects and injuries; weight loss; ossalgia; abdominal pain (rare); neurological symptoms (rare).

Ii. Clinical signs of acute leukemia: Anemic syndrome (weakness, pallor, tachycardia); hemorrhagic syndrome (ecchymosis, petechiae, internal and external bleeding); fever and infections (pneumonia, sepsis, pararectal abscess); lymphadenopathy, hepatosplenomegaly, expansion of the mediastinum; infiltration of the gums and skin (rarely); increased kidney and development of renal failure (rare); damage to the meninges and cranial nerves (rare).

III. Important laboratory and diagnostic tests for acute leukemia. A blood test with leukocyte count; coagulogram with determination of fibrinogen level; biochemical parameters (transaminases, creatinine, uric acid, calcium, phosphorus, electrolytes); a study of aspirate and trepanobioptata (not in all cases) of the bone marrow; determination of the blast cell phenotype, cytogenetic (according to indications – molecular genetic) studies; analysis of cerebrospinal fluid; X-ray of the chest, ultrasound of the abdominal cavity, computed tomography of the chest and abdominal cavity (according to indications in acute lymphoblastic leukemia); HLA-typing (in young patients).

The most significant moments of pathogenesis

1. In most cases, acute leukemia (OL) develops from cells committed in the direction of myeloid or lymphopoiesis, fewer cell lines are involved. This explains the diversity of the clinical course and response to therapy for different types of blast cells that make up the tumor clone.

2. For acute leukemia, tumor progression is characteristic: as the disease progresses, clones of leukemic cells with new properties (morphological, cytochemical, immunological, etc.) appear, which explains the development of resistance to previously effective treatment.

3. The development of most clinical manifestations and laboratory data (anemia, hemorrhagic syndrome, fever) is due to the “crowding out” of normal hemopoietic tissue with a leukemic clone.

4. As the acute leukemia progresses (more rarely, from the onset of the disease), blast cells metastasize beyond the blood-forming organs. This leads to the development of specific (blast) infiltration of internal organs, lymphatic tissue, skin, mucous membranes, and may be accompanied by functional failure of various internal organs, organomegaly, lymphadenopathy, hyperplastic gingivitis, skin leukemides, etc. In some cases, acute leukemia (often – acute lymphoblastic leukemia (ALL)) blast cells metastasize to the central nervous system, which leads to the development of neuroleukemia.

5. The proliferation of blast cells and their death are accompanied by the development of intoxication syndrome and metabolic disorders that occur in most patients.

Mechanisms of development of acute leukemia – pathogenesis

Acute leukemias result from the clonal neoplastic proliferation of blast cells, which are characterized by blockade of differentiation into more mature blood cells and the ability for virtually unlimited division. In acute leukemia, the tumor is a clone – the offspring of a single malignant cell. Accumulating in the bone marrow, leukemic blasts displace normal hematopoiesis cells, which ultimately leads to symptoms of the disease.

In laboratory studies of acute leukemia, about 1011 blast cells are found in the patient’s body, with the development of clinical symptoms – 1012 blasts (approximately one kilogram).

Leukemia cells circulate in the blood and can cause damage to other organs and tissues (the frequency and nature of the lesion depends on the variant of acute leukemia). Unlike chronic leukemias, which have the phenotypic and biological characteristics of more mature cells, acute leukemia develops and is biologically similar to primitive hematopoietic progenitor cells. The phenotypic heterogeneity of leukemic cells suggests that acute leukemia (AL) can occur at various stages of differentiation.

Etiology of acute leukemia

In most cases, the etiology of the disease is impossible to establish. In connection with the frequent detection of various chromosomal changes in tumor blast cells, various carcinogens are assumed to be the causes of acute leukemia.

Ionizing radiation as a cause of acute leukemia. Persons who survived the atomic bombing of Hiroshima and Nagasaki had a 30–50-fold increase in the frequency of secondary acute leukemia (almost always AML), with the largest number of diseases occurring 4–8 years after exposure to ionizing radiation.

An increased risk of developing acute myeloblastic leukemia (AML) is promoted by radiation therapy and, especially, combined chemoradiotherapy. Leykozogenny effect of small doses of ionizing radiation (diagnostic x-ray or radionuclide studies) and electromagnetic fields has not been proven.

Cigarette smoke contains many different carcinogens and therefore is a risk factor for the development of acute leukemia (OL). In smoking patients over 60, specific chromosomal abnormalities that are typical for exposure to chemical mutagens are often detected. It is estimated that at least 20% of AML cases are associated with smoking.

Chemical compounds with strictly proven leukemic properties are benzene and cytotoxic drugs. Benzene contributes to the development of secondary acute leukemia with prolonged production contact.

Secondary leukemias are acute myeloblastic leukemias (AML) that occur at different times (more often 5-6 years) after the completion of chemotherapy and / or radiation therapy for tumor or non-tumor diseases. Among cytostatic drugs, alkylating agents and podophyllotoxins have the greatest leukemic potential. The likelihood of developing secondary AML is increased in patients with breast and ovarian cancer who received alkylating agents.

Among the alkylating agents, cyclophosphamide has the lowest leukemic potential. The use of podophyllotoxins (etoposide and teniposide) and alkylating agents in children with acute lymphoblastic leukemia increases the incidence of secondary acute myeloblastic leukemia (AML).

Treatment of podophyllotoxins in adults and children is accompanied by an increased frequency of secondary acute monoblastic leukemia with a chromosomal abnormality llq23. The use of etoposide, doxorubicin increases the risk of developing acute promyelocytic leukemia (APL) with t (15; 17).

Genetic diseases as a cause of acute leukemia. Some genetic defects (Down syndrome, Fanconi anemia, Blum syndrome, ataxia-telangiectasia) are accompanied by an increased risk of developing OL. In Down syndrome, there is a 20-fold increase in the frequency of OL (in children under 3 years of age – megakaryoblastic leukemia, older than 3 years – pre-B-ALL). In patients with Fanconi anemia, AML is significantly more likely to develop, with ataxia-telangiectasia, ALL and non-Hodgkin lymphomas.

Viruses as a cause of acute leukemia. Human T-lymphotropic retrovirus (HTLV-1) has been found to be relevant in the occurrence of adult T-cell leukemia / lymphoma. The role of oncogenic retroviruses in the development of human NL has not been proven. Epstein-Barr virus (EBV) is important in oncogenesis in B-ALL, endemic Burkitt lymphomas and lymphomas associated with the human immunodeficiency virus.

The immunological susceptibility to the development of acute leukemia has not been proven, however, analysis of various cytogenetic variants of acute myeloid leukemia (AML) revealed an association between certain HLA loci and karyotype disorders.

Acute leukemia – a history of study, causes

Oncohematological diseases (hemoblastosis) are malignant tumors originating from blood cells. The main groups of hemoblastosis include acute leukemia, myelodysplastic syndromes, chronic myeloproliferative diseases and lymphoproliferative diseases.

Acute leukemia (OL) is a life-threatening cancer, the tumor cells of which originate from blood cells. The first description of leukemia (leukemia, or “leukemia”) belongs to R. Virchow (1845). Soon NLs were described by German and Russian doctors E. Freidreich (1857), K. Slavyansky (1867) and V. Kussner (1876). The terms “acute” and “chronic” used to identify and classify leukemias are of historical origin: prior to the introduction of effective methods of treatment, the patients with NL died within a few weeks; the life expectancy of patients with chronic leukemia ranged from several months to several years.

Acute leukemias are a separate nosological form and never transform into chronic leukemias.

The incidence of acute leukemia averages 4–5 cases per 100,000 population per year and is about the same in different regions. The share of NL accounts for only 3% in the structure of cancer incidence, however, significantly reduces the overall survival in persons younger than 35 years.

There are two types of diseases that differ in their course, the nature of chemotherapy and the results of treatment: 1) acute lymphoblastic leukemia (ALL), accounting for 80-90% in the structure of leukemia in children; 2) acute myeloid leukemia (AML), which in 80% of cases develop in adults.

The average age of patients with ALL is 10 years, AML is 60-65 years old, but both forms of acute leukemia can occur at any age.

The incidence of acute myeloblastic leukemia is 2.5-3 cases per 100,000 population per year, acute lymphoblastic leukemia – 1.5-2 cases per 100,000 population per year.

The incidence of acute myeloid leukemia is slightly higher in men (1.5: 1.0). The disease is relatively rare before the age of 40 (1 case per 100,000 population), after which it begins to increase, reaching 15 per 100,000 in people 75 years and older. In ALL, the peak incidence occurs in the age group up to 10 years (this is the most common malignant tumor in children).

In general, about 80% of patients with OL are adults. In connection with the peculiarities of the course of the disease at different ages, there are two main groups: acute leukemia in children (up to 15 years) and acute leukemia in adults (older than 15 years). There is also a third group – OL elderly (over 60 years), the effectiveness of which is significantly lower because of the poor tolerance of intensive chemotherapy.

Treatment of acute lymphoblastic leukemia

Induction of remission of acute lymphoblastic leukemia. Before starting treatment for the disease, anemia is corrected by blood transfusion, the risk of bleeding is minimized in case of platelet transfusions. Conduct rehabilitation of chronic foci of infection.

Additional hydration and administration of allopurinol (or urotoxicity, when the number of leukocytes is high and the risk is increased) is prescribed in order to protect the kidney tissue from the toxins that occur during tumor lysis syndrome. Remission implies the absence of blasts and the restoration of normal bone marrow functions. A 4-week course of combined chemotherapy is carried out; current induction is achieved in 95% of cases.

Intensification of acute lymphoblastic leukemia. Chemotherapy intensification courses are prescribed to achieve consolidation of remission. They improve the effectiveness of treatment, but at the expense of increased toxicity.

Cytotoxic drugs do not penetrate the central nervous system. Since the leukemic cells in this place can survive an effective systemic treatment, they use an additional treatment using the administration of drugs under the meninges to prevent recurrences in the CNS. Previously, treatment included the irradiation of the head area or the administration of high-dose methotrexate, but this therapy leads to adverse neuropsychic effects, so both methods are now excluded from the first-line treatment.

Continuing maintenance therapy for acute lymphoblastic leukemia. Low-intensity chemotherapy is continued for a relatively long period of time — up to 3 years after diagnosis. Cotrimoxazole is prescribed to prevent pneumonia caused by Pneumocystis jiroveci (carinii). Treatment of recurrent acute lymphoblastic leukemia. High-dose chemotherapy, often with total body irradiation and bone marrow transplantation, is used as an alternative to conventional chemotherapy after relapse.

Classification of hematopoietic and lymphoid tissue tumors. WHO

Less than 7 years separates this edition from the first consensus classification of lymphomas, published in the journal Blood in 1994. The implementation of this project in one of the most difficult areas of onco-hematology can be an example of the coordinated work of pathologists from various countries and scientific schools aimed at achieving a common goal – systematization and generalization of extensive molecular biological, genetic, immunological and morphological knowledge of lymphomas in the form of a list of actually existing ones (consonance to the accustomed abbreviation REAL — from English. Revised Eur opean American Lymphoma classification) of nosological units.

To be fair, it should be noted that by far not all the publication of the REAL classification in 1994 was accepted without objection. The work was criticized by the editors of the journal Blood. Serious complaints related to the clinical significance of the classification, its reproducibility, and even the very principle of diagnosis, taking into account the T or B linearity of the tumor cells, has been questioned.

A special clinical committee of leading hematologists of the world was established, which confirmed the clinical significance of the classification.

The final classification takes into account the comments made, and it differs significantly from the first publication. Added new nosological forms, many of the previously proposed are excluded.

“Nowhere in pathology is the chaos of names obscured by clear concepts to the same extent as in the subject of lymphoid tumors.” I want to believe that these words of RA Willis are in the past, and the modern names of variants of lymphomas, giving an increasingly complete picture of the nature of tumor cells based on their degree of maturity and linear affiliation, will, on the contrary, clarify the essence of these diseases and contribute to their more effective treatment. .