ALL Secrets

By

Salah Mabruok Khalaf

Assistant Lecturer of Medical Oncology South Egypt Cancer Institute 2010

1. Historical view 2. Epidemiology 3. Etiology 4. Pathogenesis 5. Classification 6. Diagnosis 7. Differential diagnosis 8. Prognostic factors 9. Management 10.Special conditions

I. Historical view
A. Discovery of Leukemia 1845: Craigie and Bennett described a case of suppuration of the blood, and referred to the disease as leukocythemia Also in 1845, Rudolph Virchow described a similar case and suggested the term leukemia. 1855, Ernst Neumann : the bone marrow is the origin of the blood abnormalities 1900: cytochemistry confirms 4 main cell types - acute and chronic myeloid; acute and chronic lymphoid 1976: FAB classification 1984: The DNA profiling technique was first reported by Alec Jeffreys at the University of Leicester in England, and hence molecular classifications of leukemia e.g. using PCR

I. Historical view
B. Treatment of Leukemia 1865: Lissauer reported response to Fowlers solution (arsenious oxide) 1943: Nitrogen mustard 1949: ACTH, cortisone and prednisone 1953: triple therapy consisting of 6-MP, antifolate and steroid 1959: Cyclophosphamide 1962: Vincristine 1962: St Jude initiated the concept of treatment phases 1967: Used increased dose of cranial radiation, 24cG, with IT MTX 1970: Formation of Berlin-Frankfurt-Munster group based on aggressive 8-drug therapy 1973: Janet Rowley discovered the Ph chromosome 1970s: T and B lymphocytes discovered, immunophenotyping of lymphoid neoplasms 1980s: bone marrow transplantation

II. Epidemiology
A. Frequency Estimated New Cancer Cases by Sex, US, 2009
Both sexes: 5,760 Male: 3,350 Female: 2,410

Estimated Deaths by Sex, US, 2009

Both sexes: 1,400 Male: 740 Female: 660

2009 Estimated US Cancer Cases*

Men 766,130
Prostate Lung & bronchus Colon & rectum Urinary bladder Melanoma of skin Non-Hodgkin lymphoma Kidney Oral cavity 25% 15% 10% 7% 5% 5% 5% 3%

Women 713,220 27% Breast 14% Lung & bronchus 10% Colon & rectum 6% Uterine corpus 4% Non-Hodgkin lymphoma 4% Melanoma of skin 4% Thyroid 3% Kidney & renal pelvis 3% Ovary 3% Pancreas 22% All Other Sites

Leukemia
Pancreas All Other Sites

3%
3% 18%

Source: American Cancer Society, 2009.

2009 Estimated US Cancer Deaths*

Lung & bronchus Colon & rectum Prostate Pancreas 30% 9% 9% 6%

Men 291,270

Women 273,560 26% Lung & bronchus

15% 9% 6% 5% 4% Breast Colon & rectum Pancreas Ovary Non-Hodgkin lymphoma

Leukemia
Liver & intrahepatic bile duct Esophagus Non-Hodgkin lymphoma Urinary bladder Kidney All other sites

4%
4% 4% 3% 3% 3% 23%

3% Leukemia 3% Uterine corpus 2% Liver & intrahepatic bile duct 2% Brain/ONS 23% All other sites

ONS=Other nervous system. Source: American Cancer Society, 2009.

II. Epidemiology
B. Age:

Etiology

III. Etiology
He Smoke, He Radiate Chemical + virus

1. 2. 3. 4. 5. 6.

Hereditary Smoking Hematological diseases Radiation Chemicals Viruses

III. Etiology 1. Hereditary

A. Hereditary syndromes i. Bloom syndrome Short stature Delicate features Telangiectatic lesions over the malar eminences of the face, Photosensitivity A variety of other cutaneous abnormalities (acanthosis nigricans, hypertrichosis, ichthyosis, and caf-au-lait spots). AML, ALL, lymphoma, or other malignancies occur in approximately 25% of affected individuals

III. Etiology 1.Hereditary

A. Hereditary syndromes ii. Fanconis aplasia Skeletal abnormalities Squinting Microcephaly Short stature Hypogonadism. Approximately 50% of patients develop AML or myelodysplasia by the age of 40 Neurofibromatosis Juvenile CML, ALL, lymphomas, and a disproportionately high rate of myelodysplastic syndrome evolving into AML in young patients skin carcinoma

III. Etiology 1.Hereditary

A.Hereditary syndromes iii. Downs syndrome (mongolism, trisomy 21) Mental retardation Marked hypotonia and floppiness. Joint hyperextension or hyperflexibility. Tendency to keep mouth open with his tongue protruding, high arched palate, and furrowed tongue. Eyes slant upwards and outward with internal epicanthal folds. Flattened nasal bridge and flat facial profile. Small ears, often incompletely developed, low set. Single transverse palmar crease (simian crease). A 10- to 18-fold increased risk for leukemia. Before 3 years old, the leukemia is most frequently AML, of the FAB M7 subtype; After age 3, the development of ALL is more common.

III. Etiology 1. Hereditary

A. Hereditary syndromes

iv. WiskottAldrich syndrome

It is X-linked recessive immunodeficiency disorder characterized by the triad of
1. 2. 3. Recurrent bacterial sinopulmonary infections Eczema (atopic like dermatitis) Bleeding diathesis caused by thrombocytopenia and platelet dysfunction.

Associated with the occasional development of lymphomas, AML, and ALL

III. Etiology 1. Hereditary

B. Familial leukemias not associated with any defined syndrome
Siblings of younger patients with acute leukemia have a fivefold increased risk of developing leukemia. If one member of a monozygotic twinship develops acute leukemia, the risk that the other twin will also be affected is fourfold, especially if the patient is <8 years of age and it is within 1 year of the first diagnosis of leukemia.

III. Etiology
2. Smoking
A. Childhood leukemia
It is unclear whether maternal or paternal cigarette smoking before or during pregnancy is a risk factor for developing childhood leukemia1 Some reported elevated risks associated with smoking were observed for acute nonlymphocytic leukemia (odds ratio (OR) = 1.5; 95% confidence interval (Cl) 1.12.0) and acute lymphocytic leukemia (OR = 1 .5; 95% Cl 1.12.1)2. Other reported that Cigarette smoking has been found to be weakly and inconsistently associated with ALL3.

B. Adult leukemia

1.Brondum et al. 1999; Shu et al. 1996 2.Ross et al (Am. J. Epidemiol 1991. 134, 9: 938-941) 3.Belson et al, Environ Health Perspect. 2007 Jan;115(1):138

III. Etiology
3. Hematological disease
CML in lymphoblastic crisis 20-30% of blast crisis of CML Majority of these are of B-cell origin Bone marrow involvement in half of the cases Extramedullary involvement very common (lymph node being the commonest)

III. Etiology 4. Radiation

It is a well-documented leukemogenic factor in humans. i- Atomic bombs
Increased incidence of leukemia proportional to the cumulative radiation dose has been demonstrated in populations exposed to atomic bombs in Hiroshima and Nagasaki

ii-Therapeutic:
In patients irradiated for ankylosing spondylitis Ionizing radiation used in the treatment of malignancies such as Hodgkin lymphoma has also been linked to the development of acute leukemia

iii- Diagnostic:
In radiologists (before current protective precautions). Intrauterine foetal exposure to low dose radiation (for X-ray pelvimetry)

III. Etiology
5. Chemicals
It is related to their ability to mutate or ablate the bone marrow stem cells. The best known are benzene, toluene, mustard gas and arsenic Acute leukemia develops 1 to 5 years after exposure It is often preceded by bone marrow hypoplasia, dysplasia, and pancytopenia The incidence is lower than that of AML

III. Etiology
5. Viruses
Human T-cell leukemia virus type I (HTLV-1) adult T-cell leukemia/lymphoma There is an association between Epstein-Barr virus and ALL-L3 (Burkitt leukemia).

Alberts et al, Molecular Biology of the Cell, 4th ed. 2002.

Pathophysiology
Leukemogenesis

IV- Leukemogenesis
1. Activation of proto-oncogene to an oncogene 2. Formation of chimeric transcription factor 3. Formation of a fusion protein with enhanced tyrosine kinase activity 4. Inactivation of tumor suppressor gene 5. Numeric Chromosomal Changes

Block of differentiation

Increased proliferation

Arrest of apoptosis

IV- Leukemogenesis
1. Activation of proto-oncogene to an oncogene A-Translocation or chromosomal rearrangement
i. Abl v. LMO1 ii. c-myc vi. LMO2 iii. TAL1 vii. LYL1 iv. TAL2

B- Point mutation
RAS Gene Mutations

C. Amplification
i. c-myc ii. MYB Duplication

D. Inversion
HOX 11

IV- Leukemogenesis
1. Activation of proto-oncogene to an oncogene ABL oncogene
ABL= Abelson Location: 9q34.1 Function of its protein : Nuclear c-ABL plays a major role in the regulation of cell death after DNA damage. Cytoplasmic c-ABL : Possible function in adhesion signaling as an efflux of c-ABL from nucleus to the cytoplasm. Autoregulatory mechanism: by amino-acid N terminal "cap" of the protein with its ability and sufficiency of its tyrosine kinase activity and the loss of this cap portion activates the oncogenic potential of cabl.

IV- Leukemogenesis
1. Activation of proto-oncogene to an oncogene

ABL oncogene
Activation: t(9;22)(q34;q11)/ALL --> BCR/ABL= Philadelphia chr Disease: Most often CD 10+ B-ALL; frequent CNS involvement Prognosis: Poor Oncogenesis Several signaling pathways are simultaneously activated 1- Activation of RAS pathway leading to a proliferative behavior. 2- Activation of PI-3K/Akt as well as JAK/STAT pathways is most likely responsible for the anti-apoptotic potential. 3- Provocation of cell adhesive abnormalities (via CRK-L, FAK) as well as abnormalities of cell migration (via CXCR-4).

Leukemic patient

9; 22 Translocation The Philadelphia chromosome

Chr. 9
ABL

Chr. 22
BCR

IV- Leukemogenesis
1. Activation of proto-oncogene to an oncogene
ABL oncogene

Activation: t (9;12)(q34;p12) --> ETV6-ABL Disease: Common ALL Oncogenesis:

Abnormal Protein NH2-term Helix Loop Helix from ETV6 (TEL) fused to Tyr Kinase from ABL COOHterm Forms HLH-dependent oligomers, which may be critical for Tyr kinase activation; oncogenesis may be comparable to that induced by BCR/ABL

IV- Leukemogenesis
1.

Activation of proto-oncogene to an oncogene c-MYC

c-MYC = myelocytomatosis viral oncogene Location: 8q24 Function of its protein:
The encoded myc oncoproteins are apparently transcription factors known as basic region-helixloop-helix-leucine zipper (bHLH-Zip) proteins; like other b-HLH-Zip proteins, they modulate the expression of target genes by binding to specific DNA sequences. The binding requires dimerization to another b-HLH-Zip protein, namely Max and Myc/Max complexes activate transcription and promote cell proliferation and transformation. Expression of c-myc is required for proliferation; it can over-ride p53-induced Gl-arrest by inducing an inhibitor of the cyclin kinase inhibitor WAFI (p2l).

IV- Leukemogenesis
1. Activation of proto-oncogene to an oncogene c-MYC
Activation t(8;14)(q24;q32) t(2;8)(p12;q24) t(8;22)(q24;q11) Disease: L3-ALL and Burkitt lymphoma (mature B malignant cell) Incidence: t(8;14) is described in 75-85% of the cases, t(2;8) in 5% t(8 ;22) in the remaining 10%; Oncogenesis:
In all these three translocations, the oncogene C-MYC is juxtaposed either with 1. The immunoglobulin heavy chain locus IGH (14q32), 2. The kappa light-chain locus IGK (2p12), or 3. The lambda light-chain locus IGL (22q11).

IV- Leukemogenesis
1. Activation of proto-oncogene to an oncogene
LMO 2 oncogene

LMO2 = LIM domain only 2 Location: 11p13 Function of its protein: Hematopoiesis They form a transcriptional complex: LMO2 has no direct evidence in DNA binding capacity but could act as a bridging molecule bringing together different DNA binding factors (TAL1, LDB1, E12/E47, GATA1) that are essential for hematopoiesis (e.g. in the erythroid complex).

IV- Leukemogenesis
1. Activation of proto-oncogene to an oncogene
LMO 2 oncogene Activation t(11;14)(p13;q11) Disease: Found in about 5% of T-cell ALL

Oncogenesis: Juxtaposition to the TCRD enhancer (14q11), is the main determinant for LMO2 activation in the majority of t (11; 14) (p13; q11) translocations.

IV- Leukemogenesis
1. Activation of proto-oncogene to an oncogene
NRAS point mutation

NRAS= neuroblastoma Rat Sarcoma (RAS) viral oncogene Location: 1p13 Function of its protein: It is GTP-binding proteins involved in signal transduction pathway from growth factor receptor to nucleus Disease: CML, ALL Incidence: 0-10%

IV- Leukemogenesis
1. Activation of proto-oncogene to an oncogene

Ras Pathway
Growth factor binds receptor Receptor exchanges GTP for GDP on Ras
Ras activated

RasRafMekMap Kinasetranscription factors genes turned on

IV- Leukemogenesis
1. Activation of proto-oncogene to an oncogene
NRAS point mutation

Activation
Normal Ras gene (Proto-oncogene) DNA CCG GGC Mutated Ras gene (Oncogene) CAG GTC

RNA

GGC

GUC

Gly

Val

IV- Leukemogenesis
2- Activation of proto-oncogene by by Amplification MYB Duplication

MYB = Myeloblastosis viral oncogene Location: 6q23.3 Function of its protein:

MYB mostly operates as a transcriptional activator. MYB is involved in maintaining the proliferation of progenitor cells. Activation: Amplification

Disease: T- ALL Incidence:

about 10% T-ALL in children and adults

Oncogenesis
Overexpressed or activated MYB suppresses normal differentiation and promotes leukemic transformation and proliferation.

IV- Leukemogenesis
1. Activation of proto-oncogene by inversion

HOX 11

HOX 11 = HOMEOBOX 11 Location: 7p15 Function of its protein:

Expression of HOXA11 is detected at all differentiation stages of normal T cells in the thymus, suggesting a role in normal T cell development.

Activation: Inversion: inv(7)(p15q34) Disease: T- ALL Incidence:

3.5 % of T-ALL

Oncogenesis inv (7)(p15q34) places HOX11 cluster genes (7p15) under the influence of strong enhancers within the TCRB locus (7q34) resulting in its activation and promotes proliferation

IV- Leukemogenesis
2. Formation of chimeric transcription factor
Fusion gene

TF Bind to Regulatory element Transcription RNA Target gene DNA

Target gene Translation Increased proliferation Differentiation arrest

Fusion protein

IV- Leukemogenesis
2. Formation of chimeric transcription factor E2A
E2APBX1 Fusion Genes in Pre-B ALL E2AHLF Fusion Genes in Early Pre-B ALL MLLAF4 MLLENL MLLELL MLLCBP Fusion Gene in T-Cell Acute Lymphoblastic Leukemia Fusion Gene in Early Pre-B Acute Lymphoblastic Leukemia

MLL Fusion Genes

CALMAF10

TELAML1 (ETV6RUNX1)

IV- Leukemogenesis
2. Formation of chimeric transcription factor

E2APBX1 Fusion

Formation: t(l;19)(q23;pl3) Disease: ALL, L1/L2 type; exceptionally found in L3-like ALL, T-ALL. Incidence: 5% of ALL, or 20% of pre B ALL Genes
E2A = TCF3 (transcription factor 3)
Location: 19p13 Protein: contains a homeodomain to binds to DNA; nuclear localisation; transcription regulation

PBX1 (pre-B-cell leukemia homeobox 1)

Location: 1q23 Protein: contains a homeodomain to binds to DNA; nuclear localisation; transcription regulation

Oncogenesis: potent transcriptional activator

IV- Leukemogenesis
2. Formation of chimeric transcription factor: MLL fusion gene
MLLAF4 fusion gene

Formation: t(4;11)(q21;q23) Disease: B-ALL (L1 or L2), biphenotypic AL, at times ANLL (M4/M5 types
maily) .

Incidence: 2 to 5% of ALL Genes

AF4
Location: 4q21 Function of its protein: transcription activator

MLL (mixed lineage leukemia)= ALL 1

- Location: 11q23 Protein: transcriptional regulatory factor

Oncogenesis: transcription activation

IV- Leukemogenesis
3. Formation of a fusion protein with enhanced tyrosine kinase activity
NUP214ABL1

Disease: T-ALL

Incidence: 5-6% of childhood and adult T-ALL

Oncogenesis: episomal amplification of the NUP214 - ABL1 fusion gene

IV- Leukemogenesis
4. Inactivation of tumor suppressor gene The p53 Tumor Suppressor

P53 (Protein 53 kDa) = TP53 (Tumor protein p53) Location: 17p13

Incidence: 2% of ALL (but with high variations according to the ALL type, reaching
50% of L3 ALL (and Burkitt lymphomas).

Function: Tumor suppressor gene:

P53 is a transcription factor present at minute level in any normal cells. Upon various types of stress (DNA damage, hypoxia, nucleotide pool depletion, viral infection, oncogene activation), postranslational modification lead to p53 stabilization and activation.

The cell growth arrest activity of p53 allows the activation of the DNA repair
system of the cell.

IV- Leukemogenesis
4. Numeric Chromosomal Changes in Childhood ALL

Hyperdiploidy:
Increase of total number of chromosome(>46)Bad prognosis Good prognosis Hypodiploidy: Decrease of total number of chromosome(<46)

Unfavorable prognosis

Classification

V- Classification
1. FAB classification(1976)

V- Classification
1. FAB classification The problem in that classification was differentiation between L1 and L2, so the FAB group, in 1981, introduced a scoring system to differentiate L1 from L2 as follow: Features used to classify: (1) Nuclear to cytoplasmic ratio (2) Presence, prominence and frequency of nucleoli (3) Regularity of the nuclear membrane outline (4) Cell size Scoring system: Score of 0 to +2 indicates L1 Score of -1 to -4 indicates L2

V- Classification
1. WHO classification (2001): PRECURSOR LYMPHOID NEOPLASMS B lymphoblastic leukemia/lymphoma
B lymphoblastic leukemia/lymphoma, NOS B lymphoblastic leukemia/lymphoma with recurrent genetic abnormalities
B lymphoblastic ABL1 B lymphoblastic B lymphoblastic B lymphoblastic B lymphoblastic B lymphoblastic B lymphoblastic leukemia/lymphoma with t(9;22)(q34;q11.2); BCR-

leukemia/lymphoma leukemia/lymphoma leukemia/lymphoma leukemia/lymphoma leukemia/lymphoma leukemia/lymphoma

with t(v;11q23); MLL rearranged with t(12;21)(p13;q22); TEL-AML1 with hyperdiploidy with hypodiploidy with t(5;14)(q31;q32); IL3-IGH with t(1;19)(q23;p13.3); E2A-PBX1

T lymphoblastic leukemia/lymphoma

Swerdlow et al, Lyon, France: IARC; 2008.

Diagnosis

VI- Diagnosis
1. Clinical pictures A. Bone Marrow failure:
Anemia Bleeding tendency Repeated infection CNS involvement

B. Due to organ infiltration

Lymphadenopathy, , when is it significant? Hepatosplenomegaly. Testicular involvement (painless and mostly Unilateral) Eye involvement. Renal involvement
Hyperleucocytosis

C.Others

VI- Diagnosis
2. Laboratory studies i. Morphological examination ii. Cytochemistry iii. Immunophenotyping iv. Cytogenetic analysis v. Molecular genetic analysis vi. Other investigations

VI- Diagnosis
2. Laboratory studies i. Morphological examination: Peripheral blood Smear
At least 200 cells should be counted in PB WBCs:
(60%), (25%) or N (15%) Blasts > 20 % of nucleated cell (NC) count Subleukemic leukemia Aleukemic leukemia

RBCs:
Anemia, 90% Reticulocytes are nearly always decreased

Platelets:
Thrombocytopenia in 90% of cases

VI- Diagnosis
2. Laboratory studies i.Morphological examination: Bone marrow Ex
At least 500 cells should be counted in BM Hypercellular marrow in most of the cases Rarely hypocellular marrow Normal haematopoietic cells are reduced Blasts in excess of 20% establish the diagnosis of acute leukemia DD between myeloblast and lymphoblast

VI- Diagnosis
2. Laboratory studies ii. Cytochemistry
NO CYTOCHEMICAL STAIN IS SPECIFIC FOR LYMPHOBLAST Myeloperoxidase (MPO): NEVER seen in lymphoblast -ve Non-specific esterase -ve Sudan black B +ve Periodic acid Schiff's (PAS) reaction: BALL=block-like positivity in L1 and L2 ONLY . +ve Acid phosphatase: in T-ALL and Hairy Cell Leukaemia

VI- Diagnosis
2. Laboratory studies iii. Immunophenotyping (Flow cytometry): B-ALL

Stem cell

Pro-B

Common B

Pre-B

Mature B

VI- Diagnosis
2. Laboratory studies iii. Immunophenotyping (Flow cytometry): T-ALL Pro T-ALL: +VE
CD7 Cyt CD3

Cortical T-ALL: +VE

CD7 Cyt CD3 CD5 CD1a

Pre T-ALL: +VE

CD7 Cyt CD3 CD5 and/or CD2

Mature T-ALL: +VE

CD7 Cyt CD3 CD1a Membrane CD3

VI- Diagnosis
2. Laboratory studies iv. Cytogenetic analysis

Confirmation of diagnosis. Assessment of prognosis. Assessment of response to therapy. Detection of minimal residual disease

v. Molecular genetic analysis

PCR= Polymerase Chain reaction Reverse transcriptase polymerase chain reaction (RT-PCR) Southern blot analysis FISH= Fluorescence in situ hybridization

VI- Diagnosis
2. Laboratory studies iv. Other lab investigation: a-Biochemical tests b-Cerebrospinal fluid (CSF) examination c.Surveillance bacterial cultures

VI- Diagnosis
2. Radiological studies Chest radiograph to look for mediastinal broadening specially in T-ALL

Differential Diagnosis

VII- Differential Diagnosis

1. 2. 3. 4. Different types of leukemias Reactive lymphocytosis Hematogones Juvenile rheumatoid arthritis versus childhood leukemia

VII- Differential Diagnosis

1-Different types of leukemias
Peak age of incidence WBC count ALL Childhood High in 50% Normal or low in 50% Many lymphoblasts
Smaller size Scanty cytoplasm Absent Auer rods Coarse Nuclear chromatin Indistinct Nucleoli

AML Any age High in 60% Normal or low in 40%

CLL Middle and old age High in 98% Normal or low in 2%

CML Young adult High in 100%

Differential WBC count

Many myeloblasts Small lymphocytes

Larger Moderate May be present Fine Prominent, 1-4In

Entire myeloid series

Anemia

In > 90%, severe

> 90%, severe

In about 50%, mild Low in 20 to 30%

In 80%, mild

Platelet Lymphadenopathy Splenomegaly Other features

Low in > 80% Common In 60% Without prophylaxis, CNS commonly involved

Low in > 90%

High in 60% Low in 10%

Occasional
In 50%

Common
Infrequent Usual and moderate

Occasionally, CNS rarely involved hemolytic anemia and Hypogammaglobulinemia

Usual and severe Leukocyte ALP low; Ph+ve > 90%

VII- Differential Diagnosis

2. Reactive lymphocytosis
Age
ALL Mainly children Reactive lymphocytosis Any

History of the secondary Absent causes

Present

Cells Cytoplasm Nuclear chromatin Scalloping of borders Immunophenotyping Chromosomal study

Lymphoblast Scanty Coarse and dense Absent Monoclonal Usually +ve for malignancy

Reactive lymphocyte More amount Coarse and Fine Present Multiclonal -ve for malignancy

VII- Differential Diagnosis

3. Hematogones Definition It is physiologic B-cell precursors Mystery Cells Causes Proliferate in a variety of reactive states, most notably in children:
Autoimmune cytopenias (ITP, etc) Recovery from chemotherapy (including A.L.L. therapy) Post-bone marrow transplantation for AML or MDS De novo non-Hodgkin lymphoma

VII- Differential Diagnosis

3. Hematogones Resembling acute leukemia Hematogone hyperplasia usually <10% of nucleated cells in marrow, but occasionally much higher, raising differential diagnosis with acute leukemia Differential diagnosis: By a characteristic pattern of maturation, both morphologically and immunophenotypically

Prognosis

VII-Prognosis
Favorable prognostic factors in adult ALL:
Younger age (1-10) Female sex WBC count (50,000/L) Absence of blasts in CSF Common ALL Tel-AML1 translocation AND Hyperdiploidy ( >50) Absence of the Philadelphia chromosome (Ph1) Early achievement of remission

VIII-Prognosis

Adverse prognostic factors in ALL

Clinical characteristics
Age : > 10 years or < 1 year WBC count >500,000/L Late achievement of CR (occurring after >3 to 4 weeks)

Immunophenotype
B-cell : PreB-cell ALL T-cell : pre, Pro, and mature T-cell ALL

Cytogenetics and molecular genetics

Ph +ve PBX/E2A MLL gene rearrangement MLL-AF4 Hypodiploidy Expression of multidrug resistance (rarely assayed)

Management