SDL 13 – ALL

1. Introduction
a. Lymphoid Neoplasms
i. B-cell, T-cell, & NK-cell neoplasms
ii. Resembles a particular stage of neoplasm
iii. Leukemia, Lymphoma, or Both
1. Lymphoma is either Hodgkin or Non-Hodgkin
b. Myeloid Neoplasms
i. Arise from early hematopoietic progenitors in the bone marrow
ii. Erythroctyres, Granulocytes, Monocytes, Megakaryocytes
iii. Three Categories = AML, MDS, & Chronic Myeloproliferative Disorders (CMDs)
1. AML
a. Clonal prolif, contains >20% blasts in the bone marrow or peripheral blood
2. MDS
a. Abnormal cellular maturation in the bone marrow  ineffective hematopoiesis
b. Hypercellular bone marrow, peripheral cytopenias  progress to refractory AML
3. CMDs
a. Polycythemia Vera
b. Essential Thrombocythemia
c. Primary Myelofibrosis
d. CML
e. All feature effective clonal proliferation without dysplasia of  1 lineages in the
blood, <20% marrow hypercellularity?, and a tendency to develop marrow
fibrosis & increasing splenomegaly
c. Histiocytoses
i. Uncommon disorders of cell accumulation
ii. Derived from connective tissue histiocytes (Mφ's) & professional APCs (Dendritic cells)
iii. Special DC is the Langerhans cell  Langerhans Histiocytosis (LH cells contain Birbeck granules)
1. Wide spectrum of disease
2. Lymphoid Neoplasms
a. Definitions
i. Leukemia
1. Malignant disease of the bone marrow characterized by altered proliferation &
development of leukocytes & precursors in the bone marrow and most often the blood
2. WBCs don’t die off in natural cycle but rather rapidly multiply and leave less room for
other cell lineages
3. Most Common Symptoms  fever & recurrent infection due to WBCs with  function
a. May also have weakness & pallor due to anemia
b. Possibly easy bleeding, bruising, & epistaxis due to thrombocytopenia
ii. Lymphoma
1. Malignant proliferations that arise as discrete tissue masses, often in thymus or nodes
a. Tonsils, appendix, Peyer’s patches are also involved as well as any other organ
2. Invovlement of the spleen or bone marrow = systemic dissemination
3. Most Common Symptoms  enlarged painless nodes, fever, drenching sweats,
a. unintentional weight loss, itching, tiredness
4. If tumor cells are seen in the blood the lymphoma has become “leukemic”
5. Same neoplasm may clinically manifest with leukemia or lymphoma
b. Classification
3.
i. CD3 is present on Thymocytes & Mature T cells
ii. CD4 is present on Helper T cells
iii. CD5 is present on T cells & a small subset of B cells
iv. CD8 is present on Cytotoxic T cells, a subset of thymocytes
v.
vi. Histology is required for diagnosis
vii. Immunohistochemistry & Flow Cytometry
1. T Cells = CD1, 3, 4, 5, 8
2. B Cells = CD10, 19, 20, 21, 23, 38, 79a, 138
3. Monocytes = CD11c, 13, 14, 15, 33, 64
4. NK-Cell = CD16, 56
5. Activation = CD30 (activated B cells, T cells, & Monocytes; Reed-Sternberg cells
6. All Leukocytes = CD45
viii. 85-90% of all lymphoid neoplasms are B-cell
ix. Lymphoid neoplasms are commonly associated with immune abnormalities
1. Loss of protective immunity = susceptibility to infection
2. Breakdown of tolerance = autoimmunity
3. Lymphoid neoplasms d/t oncogenic virus in immunocompromised (inherited/acquired)
x. Retain Some Normal Behavior
1. Leading to typical patterns of involvement
 2. Follicular lymphomas home to germinal centers in nodes
3. Cutaneous T-cell lymphomas home to the skin
4. Most are widely disseminated
a. EXCEPTIONS include Hodgkin’s & Marginal Zone B-cell lymphoma
i. Hodgkin  neck, cervical/supraclavicular
1. Also spreads in an orderly fashion – good for staging
ii. MZ  chronic inflammation located in the…
1. Stomach (H. pylori), Salivary glands (Sjögren), Skin (Borrelia),
Ocular adnexa (Chlamydia psittachi), Small Bowel (Campy)
b. Lymphocyte Development
i. B-cells
1. Hematogones – bone marrow precursor B cells
a. Express CD10, CD19, & Tdt (terminal deoxynucleotidyl transferase)
b. Lack CD20 (seen on more mature B cells) & lack Ig light chains
2. Some progentiros go to the germinal centers of lymph nodes
a. Further development & maturity occurs here, develop Ig Heavy chains & will
synthesize IgM
b. In precursor (progenitor) B-cells, IgM is expressed in the cytoplasm
c. In mature B cells, IgM is expressed on the surface
3. Activation & clonal expansion occurs and the B-cells move to the B-cell dependent
meduallary cords where they become mature plasma cells or move to periphery
4. Plasma cells = eccentric nuclei, clumped chromatin marginated at the nuclear
membrane – “clock face chromatin”
a. Plasma cells also don’t express CD20 or surface Ig
ii. T-cells
1. Migrate from bone marrow to the thymus for maturation
2. CD2, 3, 5, & 7 and then finally CD4 & CD8
3. Recombination of TCRs gives diverse population of T cells
4. T cells move to nodes, spleen, & peripheral blood to become post-thymic T cells
5. MHC-II  CD4  IL1, IL2
c. Bone Marrow Biopsy & Aspirate
i. Cellularity = ratio of hematopoietic cells to fat – decreases with age
ii. Mostly maturing granulocyte precursors, erythroid precursors, & megakaryocytes (trilineage)
iii. Myeloid:Erthryoid ratio is normally between 2:1 & 5:1
iv. Normally 2-5 megakaryocytes per HPF
v. Normally less than 3% plasma cells
vi. Up to 20% lymphocytes
vii. Only rare Mφ's & mast cells
viii. Blasts are usually <3% of marrow cells
d. Precursor B-cell & T-cell Neoplasms Classification
i. Includes ALL & LBLs of either T or B-cell lineage
ii. ALL is more B-cell
iii. LBL is more T-cell
iv. Leukemia vs Lymphoma is by convention is 25% bone marrow involvement = ALL
v. Patients with bulky tumors from lymph nodes or thymus or with no or minimal evidence of
peripheral blood or bone marrow involvement = lymphomas
4. B-Cell ALL & LBL
a. Definition
 i. Clonal proliferation of immature blasts with minimal morphologic evidence of differentiation
b. Epidemiology
i. ALL
1. Most common malignancy of children in the US
2. 80% of childhood leukemia vs 20% of adult
3. B-cell ALL > T-cell ALL
4. B-cell 4 years old & T-cell 10 years old
ii. LBL
1. Relatively rare in the US
2. T-cell lineage in 90% - median of 20 years old
c. Etiology
i. ALL is unknown
1. Multifactorial with a 2 hit model
2. First hit in uterus with the formation of chromosomal translocation & hyperdiploidy
creates a covert, pre-leukemic clone
3. Second hit is post-natal viral infection causing proliferative clonal expansion with
translocations
d. Clinical Features
i. B-cell ALL & LBL are overlapping clinical manifestations of the same disease
ii. Sudden onset fevers & fatigue  anemia, neutropenia, thrombocytopenia 2° to blasts invading
the bone marrow & replacing normal marrow
iii. White count can be normal, high, or low but has LYMPHOCTYIC PREDOMINANCE
iv. Weakness, pallor, anemia, gingival bleeding, epistaxis, petichiae, bruising 2° thrombocytopenia
v. B symptoms are often present but mild
vi. HSM or lymphadenopathy are seen in 50% at diagnosis ± organ problems - leukemic infiltration
vii. CNS – HA, vomiting, nerve palsy
viii. Bone or joint pain
ix. Testicular involvement
x. B-cell LBL very RARELY INVOLVES THE MEDIASTINUM unlike T-cell LBL
e. Morphology
i. Blast Cell Morphology – 25% of bone marrow cells be blasts (normally never more than 5%)
ii. Hypercellular bone marrow with diffuse infiltrate of densely packed lymphoblasts
1. Scant basophilic cytoplasm, high N:C ratio, round/indented nucleus, homogenously
condensed chromatin, absent or inconspicuous nucleolus & high mitotic rate
2. 1.5 to 2x normal lymphocyte
iii. To differentiate ALL & LBL, use extramedullary tissue involvement
1. B-cell ALL
a. Can have significant organ involvement with peripheral nodes, liver, spleen,
kidneys, gonads, & CNS being common sites
b. >50% of cases have enlarged nodes in the cervical, axillary, & inguinal areas
c. Nontender, firm, rubbery nodes
d. Hepatic involvement = infiltration of the sinusoids
e. Splenic involvement = infiltration of the red pulp
2. B-cell LBL
a. Tumor of lymphoblasts, most commonly skin or bone
b. Lymph nodes are less commonly involved
c. Cutaneous manifestations = red colored nodules or papules on the head & neck
d. Skin biopsies reveal dermis infiltration by blast cells
e. Most patients have no B symptoms
 f. If nodes are involved, show diffuse monotonous cells with blast morphology
g. If bone marrow is involved, fraction of malignant lymphoblasts is <25%
f. Cytochemistry
i. Lack of MPO & NSE staining
ii. MPO is exclusively in the azurophilic graules of PMN leukocytes
iii. Used to distinguish AML from ALL
iv. NSE is found in monocytes & macrophages
v. NSE is positive in Acute Monoblastic Leukemia but NEGATIVE in ALL & AML
g. Immunophenotype
i. Flow cytometry (fresh cell suspensions) or IHC (fixed tissue)
ii. Lymphoblasts of B-cell ALL/LBL are almost always positive for the B-cell markers CD19
1. CD19 is a transmembrane glycoprotein
iii. Other important B-cell markers are CD10, CD20, CD22, CD24, CD34, CD45
iv. Terminal deoxynucleotidyl Transferase (TdT) is a nuclear enzyme marker for lymphoid BLASTS,
seen in 98% of B-ALL
v. Expression of surface Ig is typically absent in neoplastic cells of early precursor B-cell ALL/LBL
h. Genetics
i. Hyperdiploidy
1. 25-30% of all cases
2. Non random multiple trisomies & tetrasomies of X, 4, 6, 8, 10, 14, 17, 18, 21
3. High hyperploidy & low WBC = good prognosis
ii. t(12;21) = ETV6 & RUNX1 (CBFα)
1. 25% of childhood, 3% of adulthood
iii. t(9;22) = BCR & ABL = Philadelphia chromosome
1. 25% of adult, 5% kids
2. Enhanced TyrK activity – disturbs downstream signaling pathways
3. Imatinib & Dasatinib treatment
iv. t(1;19) = TCF3 & PBX1
1. Generates a potent oncogenic fusion protein – PBX family
v. Hypoploidy
1. Poor outcome
i. Prognosis
i. ALL is one of the better ones – 95% of children get CR & 75-85% are cured
ii. Only 20-40% of adults are cured
5. T-cell LBL/ALL
a. Definition
i. Bulky tumor of the thymus or mediastinum = lymphoma
ii. >25% blasts on bone marrow aspiriate = leukemia
b. Epidemiology
i. Less common than B-cell ALL but T-cell LBL = 85-90% of all LBLs
ii. Teens & early twenties
c. Clinical Features
i. T-cell ALL  leukocytosis >50,000, peripheral lymphadenopathy, & organomegaly
ii. T-cell LBL  mediastinal mass in >80% of cases (can cause SVC syndrome, dysphagia, airway)
1. Pulmonary & Cardiac function can be altered too
2. Lymphadenopathy of the cervical, supraclavicular, & axillary regions is seen in 50%
3. Extramedullary involvement can be seen but less commonly
d. Morphology
i. T-cell LBL is an infiltrative process that diffusely replaces lymph node follicular architecture
 1. Frequently etends through the capsule infiltrating the perinodal fat
2. T-cell LBL tends to be proliferative process with multiple mitotic figures
e. Immunophenotype
i. CD2, CD3, CD4, CD5, CD7, and/or CD8
ii. >90% express TdT as well
f. Genetics & Molecular Findings
i. Chromosomal Translocations
1. T-cell ALL is thought to result from precursor T cells that arise from bone marrow
derived HSCs that then migrate to the thymus where they develop into thymocytes
2. TCR gene translocations have been found in 35% of all T-cell ALLs – Chromosome 7 & 14
3. 95% of T-cells have TCR of α & β chain from TRA (14q)
4. 5% of T-cells have TCR of γ & δ chains from (7p) & (14q) respectively
5. These translocations involve putting a strong promoter & enhancer elements from TCR
α or β chain with various transcription factors
6. TAL1 (T-cell ALL protein 1)
a. Seen in 60% of T-cell ALLs
b. Overexpression gives rise to T-cells that show abnormal cell cycle control,
proliferation, & differentiation
c. t(1;14) & t(1;7) placing TAL1 beside α chain locus on 14 & β chain locus on 7
ii. Single Gene Mutations
1. CDKN2A & CDKN2B
a. LoF mutation on 9p21 found in 60-80% of T-cell ALL
b. CDKN2A encodes p16INK4a & p14ARF
c. CDKN2B encodes p15INK4b
d. All act to negatively regulate G1  S phase
e. P15 & p16 inhibit CDK4 & CDK6 therby inactivating Rb
f. When cyclin D binds CDK4/6 this complex is able to phosphorylate Rb1 inducing
the release of E2F transcription factor which actiavates G1  S phase
2. NOTCH1
a. Binds signal sending cells & the two proteolytic cleavages occur
b. First by ADAM10 at S2
c. Second cleavage by γ-secretase at S3
d. Together these release the Notch Intracellular Domain (NICD) which translocates
to the nucleus inducing downstream target genes
e. MAM mastermind complex is used
g. Clinical Course
i. Males in their teens to early twenties with lymphadenopathy or mediastinal mass
ii. Extranodal disease is less common
iii. B symptoms are often present
iv. More aggressive & poorer outcomes than B-cell