CHAPTER 14

LESSON TOPIC: CHRONIC LEUKEMIA

1. RATIONALE
Chronic myeloid leukemia (CML) makes about 20% of all leukemia cases in
adults, is observed in patients of all age groups, more than a half of patients get the
disease at the age of 40-50. Early diagnosis of CML allows to timely administer
pathogenetic therapy to achieve the survival of CML patients similar to that of the
general population.
Chronic lymphoid leukemia is the most frequent type of leukemia in adults.
Timely verification of the diagnosis allows to administer the personalized therapy,
to improve the prognosis and the quality of life of CLL patients.
2. LESSON GOAL
By independently studying the theoretical material, the student will learn:
pathogenesis, diagnostic criteria, clinical manifestations, diagnostic principles and
treatment protocols for chronic leukemia.
3. LESSON PLAN
3.1 CML definition and pathogenesis.
3.2 CML clinical manifestations and diagnostic criteria.
3.3 CML diagnostic and treatment protocols.
3.4 CLL definition and stages.
3.5 CLL clinical pattern and follow-up.
3.6 CLL treatment principles.
4. SUMMARY
CHRONIC MYELOID LEUKEMIA
Chronic myeloid leukemia (CML) is a clonal myeloproliferative disease
developing as a result of malignant transformation of early hematopoietic
progenitor cells. The unique CML characteristic is translocation t (9; 22) (q34,
q11), the Philadelphian chromosome and BCR-ABL fusion gene in tumor cells.
The CML morphological substrate is primarily growing and mature
granulocytes, generally neutrophils which are characterized by reciprocal
chromosomal translocation t (9;22) (q34; q11.2) which leads to formation of the
Philadelphian chromosome (Ph) and BCR-ABL fusion gene.
The incidence is about 1 (0,7-0,8) case per 100,000 of adults per year.
Median age in adult patients is 50 years (18 to 82), the peak incidence is in 50-59s,
33% are patients under 40 years of age. The disease occures in males a little more
frequently than in females (1.4 : 1).

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 Possible etiological factors: ionizing radiation, small doses of radiation,
weak electromagnetic radiations, herbicides, insecticides, etc., chemical agents
(benzene), infections, smoking, etc.
CML pathogenesis
CML is a clonal disease, the cellular damage is associated with a pluripotent
stem cell.
Translocation t (9:22), (q34; q11) of the so-called Philadelphian
chromosome (Ph-chromosome) and BCR-ABL fusion gene is the basis of CML
pathogenesis. The product of the BCR-ABL fusion gene is an abnormally
hyperactive tyrosinekinase (tyrosinekinases are enzymes catalyzing the transfer of
phosphate from ATP to tyrosine on specific cellular proteins participating in the
transfer of regulating signals to the cell nucleus) which regulating signals
responsible for the cellular growth, activation, differentiation, adhesion and
apoptosis. Depending on the breakpoint, over 16 different variants of the BCR-
ABL transcript with various molecular weight can be detected. The most
widespread (up to 95%) is transcript p210. Increased tyrosinekinase activity of the
abnormal BCR-ABL protein causes not only increased reproduction of cells, but
also their advantages in the signal-independent growth, inhibition of apoptosis as
the mechanism of cellular self-destruction; so that neoplastic hematopoiesis
prevails over the normal one and gradually displaces it.
CML may be considered on the basis of the following clinical and
hematological findings: hepato- and splenomegaly; anemia, leukocytosis,
thrombocytosis or thrombocytopenia, myelocytic shift, eosinophilic-basophilic
association.
Clinical manifestations of CML have no pathognomonic symptoms and
include several syndromes:
- tumor intoxication syndrome: weakness, loss of appetite, loss of body weight,
sweating, subfebrile temperature;
- tumor proliferation syndrome: pain and feeling of heaviness in the left side
associated with splenomegaly;
- anemic syndrome: general weakness, dyspnea, decreased exercise tolerance,
pallor of skin and mucous membranes, pronounced tachycardia;
- thrombotic complications: thromboses and thromboembolisms of vessels of
various organs and tissues can occur in hyperthrombocytosis and be the cause of
examination and diagnosis following thrombophlebitis of peripheral vessels,
myocardial infarction, and cerebrovascular accidents;

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- hemorrhagic syndrome: bleeding after slight injuries, either spontaneous
petechiae or ecchymoses, most often in the acceleration and blast crisis phases,
caused by thrombocytopenia.
CML has three phases:
1. Chronic
2. Acceleration (transitional), and
3. End-stage or blast transformation (blast crisis) phase.
 Chronic phase is diagnosed in the absence of signs of acceleration phase or
blast crisis.
 Signs of disease progression (acceleration phase):
- blast cells up to 15% - 29% in peripheral blood and bone marrow;
- total blast cells and promyelocytes ≥30% in peripheral blood and/or bone
marrow (with blasts cells <30%);
- blood basophiles ≥20%;
- persistent thrombocytopenia <100x109/l, not related to therapy;
- clonal cytogenetic anomalies in Ph-positive cells during therapy (trisomy on
chromosome 8, 19, doubling of Ph-chromosome (der (22) t (9; 22) (q34,
q11), etc.).
 Blast crisis is diagnosed if blast cells are ≥30% in peripheral blood or in bone
marrow or if there are extramedullary hematopoiesis sites (with the exception
of liver and spleen), big blast accumulation sites in the marrow trepanobiopsy
sample.
CML diagnostic algorithm
1. Complaints, history, clinician-observed parameters (liver and spleen sizes
in centimeters from the edge of the costal arch).
2. Peripheral blood cell morphology (Common blood test): leukocytosis,
thrombocytosis, basophilic-eosinophilic association, shift of differential WBC
count to the low-differentiated forms of neutrophils.
3. Bone aspirate morphology (myelogram): hypercellular marrow, increased
leuko: erythro ratio, expanded granulocytic lineage, increased neutrophil
maturation index by more than 1,0.
4. Standard cytogenetic testing of marrow for Philadelphia chromosome and
fluorescent in situ hybridization (FISH).
5. Molecular genetic testing of peripheral blood for BCR-ABL p210 fusion
gene transcript expression by qualitative and quantitative polymerase chain
reaction (PCR).
If indicated (lack of treatment efficacy, disease progression): testing for
BCR-ABL gene mutations (rare transcripts p190, p230, etc.).

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 Differential diagnosis
Primary myelofibrosis (PM) develops due to the transformation of
myelopoiesis precursor cell followed by the development of marrow fibrosis,
extramedullary hematogenesis sites, particularly trilineage myeloid spleen
metaplasia, with severe splenomegaly and leukoerythroblastic pattern of peripheral
blood, teardrop shape of red blood cells in peripheral blood, symptoms of
cytopenia or cytosis. Mean age is over 50 years with the median of about 65 years.
The primary clinical manifestation of PM is splenomegaly which is reported in 100
% of patients. Trepanobiopsy data are crucial: presence of myelofibrosis.
Acute leukemia. Major characteristics of differential diagnosis of AL and
CML chronic phase: WBC differential has "intermediate forms" in CML while
hiatus leukemicus is characteristic of AL; besides, the blast cells are single in CML
chronic phase; eosinophilic-basophilic association is observed in CML patients,
and eosinophilic-basophilic dissociation is noted in AL; platelet levels in CML are
either normal or increased, while thrombocytopenia is reported at the very
beginning of AL. The blast cells in the bone marrow in AL is 20 % with
megakaryocytes decreased or absent.
Leukemoid reactions of myeloid type (changes in blood similar to leukemia,
but which are not transformed to the tumor they are similar to), are mostly due to
infectious and toxic causes. Slighter "left" shift in the differential WBC count,
toxic granularity in neutrophils are characteristic. After the main process which
caused leukemoid reactions is arrested, all manifestations resolve.
Treatment
The objective of current CML treatment is maximum suppression of Ph-
positive tumoral clone, decreased risk of disease progression, and the survival
comparable to that of the general population, high quality of life during treatment.
During the examination and prior to obtaining the cytogenetic results which
confirm the existence of the Ph-chromosome in the bone marrow cells,
symptomatic treatment for correction of leukocytosis and thrombocytosis can be
adminstered (hydroxurea [Hydrea, Hydroxycarbamide Medac, Hydroxyurea]) to
the patient. In patient intolerant to hydroxurea or with inadequately controlled
hyperthrombocytosis, anagrelide (Agrilin, Thromboreductal) can be administered.
After the diagnosis of CML is confirmed, therapy with 1st generation
tyrosine kinase inhibitors (TKI1) (imatinib (Gleevec, Philachromine, Neopax)) or
2nd generation TKIs (Dasatinib (Sprycel) or Nilotinib (Tasigna)) should be
initiated. Bosutinib (Bosulif) may be used as the second and subsequent lines of
therapy. Treatment can be provided in the out-patient settings, administration of
imatinib can be started with WBC levels.

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 Indications to hematopoietic stem cell transplantation (HSCT) in
patients with chronic phase HML: resistance or intolerance to TKI treatment,
identification of T315I mutation.
Interferon-α (Intron, Roferon-A, etc.) administration is reasonable in
patients intolerant of TKI; with inadequate response to TKI and when allo-HSCT
is impossible; in case of identification of T315I mutation and when allo-HSCT is
impossible; in some cases, when the administration of TKI is impossible (i.e.,
during pregnancy).
Cytoreductive and cytostatic therapy (during examination, in patients
intolerant and/or resistant to TKI): hydroxurea, mercaptopurine, cytarabine.
Polychemotherapy with TKI can be provided to patients in the acceleration
phase and blast crisis in accordance with the treatment schedule for acute
leukemia, depending on the blast cell phenotype.
Treatment response criteria in CML are provided in table 1.

Table 1
Treatment response criteria in CML
Hematological
WBC count Splenomegaly Platelets
response

<10×109/l, recovery,
Complete No <450×109/l
basophils <5 %

≤ 20×109/l, single
Partial Persisting <450×109/l
myelocytes

20×109/l, myelocytic
Absent Splenomegaly ≥ 450×109/l
shift >3%
Cytogenetic response % of Ph+ cells in bone marrow
Complete Ph: 0% of metaphases
Partial Ph 1: 35% of metaphases
Slight Ph 36: 65% of metaphases
Minimum Ph 66: 95% of metaphases
Absent Ph >96% of metaphases
Complete molecular response: BCR-ABL transcript cannot be detected (by
PCR). The major molecular response is the BCR-ABL/ABL IS ratio <0,1% and
≥0,01%.
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 CHRONIC LYMPHOID LEUKEMIA
Chronic lymphoid leukemia is a B-cell tumor from small lymphoid cells.
Chronic lymphoid leukemia (CLL) is the tumor which is characterized by the
accumulation of mature lymphocytes with the expression of CD19, CD23, CD20,
CD5.
The main cytogenetic marker which directly affects the choice of treatment
is deletion 17p.
Epidemiology
CLL is the most frequent type of leukemia in adults (25 % - 30 % of all
leukemias). In the USA and Europe, 95 to 98 % of CLL patients have B-cell
tumors while the T-phenotype prevails in Asian countries.
The median age in the European countries at the time of the diagnosis is 69
years, and 62 years in the Russian Federation, the mean age is below 50 years in 10
to 15 % of patients.
The incidence of CLL is 4:100,000 per year, and >30 per 100,000 in people
over 80 years of age. The morbidity among men is greater than among women
(5.8:3.0).
Etiology. The cause of CLL remains so far unknown.
Potential etiological factors include genetics (CLL prevails in first-degree
relatives (risk factor), develops in the next generation at a younger age and
increases in severity with each next generation), the role of retroviruses is also
discussed.
Pathogenesis of chronic lymphoid leukemia is related to proliferation of a
clone of transformed lymphocytes which leads to the enlargement of lymph nodes
and other lymphoid organs, progressive lymphoid infiltration of the bone marrow
with replacement of normal hematopoiesis.
Staging systems for chronic lymphocytic leukemia
There are 2 different systems for staging CLL:
 Rai system: This is used more often in the United States.
 Binet system: This is used more widely in Europe.
In the Binet staging system, CLL is classified by the number of affected
lymphoid tissue groups (neck lymph nodes, groin lymph nodes, underarm lymph
nodes, spleen, and liver) and by whether or not the patient has anemia (too few red
blood cells) or thrombocytopenia (too few blood platelets).
Binet staging system
Stage A (Low-stage disease): Hb >100 g/l, platelets >100x109/l, more than 3
involved node areas (survival >120 months).

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 Stage B (Intermediate-stage disease): Hb >100 g/l, platelets >100x109/l,
more than 3 involved node areas (median survival = 61 months).
Stage C (High stage disease): Hb <100 g/l or platelets <100x109/l (median
survival = 32 months).
Note. Node areas: cervical, axillary, inguinal lymph nodes (uni- or bilateral);
liver, spleen.
Clinical pattern
CLL most commonly begins gradually. Compensated patients are usually
detected accidentally. Eventually they have complaints about increased fatigue,
weakness, sweating, decreased work productivity, weight loss. The sizes of lymph
nodes in CLL patients vary in a wide range from 1, 5-2 cm to 10-15 cm in diameter
(fig. 1). Nodes are soft, mobile, dough-like in consistency, not adhering among
themselves and surrounding tissues (most often cervical, supra- and subclavicular,
axillary lymph nodes).
When the disease progresses, generalized lymphadenopathy is observed; at
the same time, they are not adherant among themselves, dense, mobile, painless.
In most patients, the spleen and then liver are enlarged later, after
lymphadenopathy starts (fig. 2).

Fig. 1. Lymph node enlargement in Fig. 2. Enlarged spleen, liver

CLL patients. and lymph nodes in a CLL patient

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 In end-stage CLL, severe anemic, hemorrhagic, intoxication syndromes,
infectious complications are prevalent. Increased lymph nodes get stony (fig. 3),
infiltrate and squeeze the adjacent tissues, causing swelling and pain (sarcomatous
growth).

Fig. 3. Enlarged lymph nodes in a CLL patient.

Neuroleukemia may develop. Blast cells may appear in peripheral blood,
blast crisis or sarcomatization of lymph nodes may occur.
CLL complications. Autoimmune hemolytic anemia withoout significantly
increased reticulocyte levels or decreased platelet levels; immune
thrombocytopenia; infectious complications; development of secondary tumors
(skin, throat and lung, stomach, bladder cancer, etc.).
Diagnosic criteria
The diagnosis of CLL requires blood testing and immunophenotyping.
The diagnosis is established when more than 5000/mcl B-lymphocytes are detected
in peripheral blood which have to be morphologically mature forms. CLL cells
express B-cellular markers CD19, CD20 and CD23 and CD5 antigen with no other
pan-T-cell markers. The clonality of lymphocytes has to be confirmed by flow
cytometry.
Auxiliary diagnostic characteristic of the lymphatic tumor proliferation is
Botkin-Gumprecht cells in the blood smear (cells of leukolysis are an artifact: they
are not present in liquid blood, they are formed in the course of the smear
preparation).
Bone marrow aspiration: the myelogram should show not less than 30% of
lymphocytes.

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 Indications for treatment initiation
The therapy starts when the patient has at least one of the 6 signs listed
below:
1. One or more symptoms of intoxication:
- loss of more than 10 % of weight within 6 months if the patient did not undertake
any special measures to lose weight and has no other reason to explain the weight
loss;
- weakness, disability;
- subfebrile body temperature with no symptoms of any active infection;
- night sweats with no symptoms of any infection.
2. Increasing anemia and/or thrombocytopenia caused by bone marrow
infiltration.
3. Prednisolone-resistant autoimmune anemia and/or thrombocytopenia.
4. Large spleen size:
- massive splenomegaly (6 cm and more from under the costal arch);
- evident spleen enlargement.
5. The massive and progressive lymphadenopathy.
6. Lymphocytosis:
- lymphocytes increased by more than 50% within 2 months;
- lymphocyte doubling time less than 6 months.
Note: lymphocyte doubling time = (initial absolute number of lymphocytes x
number of months between measurements) / the difference between the second and
first measurements of the absolute number of lymphocytes.
CLL treatment protocols
Treatment of young patients:
 FCR: fludarabine + cyclophosphamide + rituximab.
 CHOP: (cyclophosphane + prednisolone + vincristine +
hydroxyadriamycin or adriablastin).
 BR: bendamustine + rituximab.
 Treatment goal: long-term remission.
Treatment of elderly patients
Standard first-line therapy in this patient group is chlorambucil and FCR;
BR protocols; bendamustine.
Ribomustine (bendamustine) is a double-action agent (alkylating agent +
antimetabolite).
Treatment goal: disease control, low toxicity.

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 Indications to splenectomy in CLL:
- hypersplenism with severe anemia and/or thrombocytopenia, especially if the
tumor is resistant to chemotherapy (CT) and/or CT is impossible because of
severe cytopenia;
- severe autoimmune anemia and/or thrombocytopenia, resistant to drug
treatment;
- massive splenomegaly resistant to CT.
New drugs for treatment of chronic lymphoid leukemia:
- monoclonal antibodies (Ofatumumab, Obinutuzumab).
- BCR signal inhibitors (ibrutinib, idelalisib, etc.).
Treatment efficacy determination
Complete remission- tumor volume parameters:
1. lymphadenopathy (absent >1,5 cm),
2. absent hepato- or splenomegaly,
3. lymphocytes in blood <4x109/l,
4. bone marrow is normocellular,
5. <30% of lymphocytes,
6. absent lymph node involvement.
Partial remission: reduction in tumor volume parameters by ≥50%.
Bone marrow functional capacity parameters: platelets >100x109/l,
Hb >110 g/l, neutrophils >105x109/l.
5. SELF-CHECK QUESTIONS
5.1 Definition of CML, CLL.
5.2 Pathogenesis of CML.
5.3 Clinical manifestations of CML, CLL.
5.4 Blood pattern in CML, CLL.
5.5 Diagnostic criteria of CML, CLL.
5.6 Follow-up plan for patients with chronic leukemia.
5.7 Treatment protocols for CML, CLL.
5.8 Treatment efficacy evaluation.
6. REVISION ASSIGNMENTS
6.1 Name peripheral blood and marrow aspirate findings in patients with CML,
CLL.
6.2 Specify the diagnostic criteria of CML, CLL.
6.3 List the molecular and biological test methods used in CML.
6.4 Make the provisional diagnosis and the follow-up plan.

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