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Acute Leukemias

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Practical Lymph Node and Bone Marrow Pathology

Part of the book series: Practical Anatomic Pathology ((PAP))

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Abstract

Acute leukemias are some of the most urgent cases in the field of hematopathology requiring quick diagnosis and classification for effective, life-saving treatment. While morphology and immunophenotype are crucial in the identification of acute leukemias, accurate classification and identification of the numerous molecular and genetic abnormalities have gained increasing prominence in treatment decision as new targeted therapies are rapidly introduced. In this chapter, we will discuss various acute leukemias in the updated 2017 WHO classification and present the typical morphologic features, along with other diagnostic criteria, based on flow cytometry, cytogenetic, and molecular genetic findings. We will also discuss the minimal and optimal workup, major mimics, and how to differentiate these mimics to avoid misdiagnosis and inappropriate treatment.

The acute leukemias are traditionally divided into two major categories: acute myeloid leukemia (AML) and acute lymphoblastic leukemia (ALL). With increasing treatment options, it is critical to differentiate acute leukemias of ambiguous lineage from these two traditional categories. AMLs are considered to be neoplastic clonal transformation of stem cells or immature cells of myeloid lineage. In the modern classification scheme of AML, the traditional morphological and immunophenotypic classification based on presence or absence of differentiation and the path of differentiation (e.g., promyelocytic, monocytic, erythroid, megakaryocytic, etc.) is applied after first categorizing AMLs based on history of prior therapy, presence of dysplastic morphologic features, and detection of recurrent genetic abnormalities. When none of these conditions apply, it is considered to be “AML not otherwise specified (AML, NOS)” and classified into categories which parallel the older French-American-British (FAB) classification. Special categories also include myeloid sarcoma and myeloid leukemia associated with Down syndrome.

Acute lymphoblastic leukemias consist of two major categories: B-acute lymphoblastic leukemia (B-ALL) and T-acute lymphoblastic leukemia (T-ALL). Of these, B-ALL is much more common and is classified into B-ALL with recurrent genetic abnormalities and B-ALL, NOS. While most acute leukemias can be confidently diagnosed based on morphology and flow cytometry studies, we also discuss the mimics which pose diagnostic dilemma.

Acute leukemias have to be carefully differentiated from aggressive B-cell lymphoma involving peripheral blood/bone marrow, B-prolymphocytic leukemia (B-PLL), T-prolymphocytic leukemia (T-PLL), and atypical chronic lymphocytic leukemia (atypical CLL) and even from reactive conditions such as growth factor effect, vitamin B12 and/or folate deficiency, and severe toxin effect. Transient abnormal myelopoiesis associated with Down syndrome might need no treatment, while acute leukemia associated with Down syndrome requires immediate aggressive chemotherapy.

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  1. Department of Pathology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA

    Yang Shi

  2. Division of Pathology & Laboratory Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA

    David D. Grier

  3. Department of Pathology, Duke University School of Medicine, Durham, NC, USA

    Jadee Neff

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  1. Yang Shi
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  2. David D. Grier
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  3. Jadee Neff
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Correspondence to Jadee Neff .

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Editors and Affiliations

  1. Department of Pathology, Duke University School of Medicine and Duke Health System, Durham, NC, USA

    Endi Wang

  2. Department of Pathology, Duke University School of Medicine and Duke Health System, Durham, NC, USA

    Anand Shreeram Lagoo

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Shi, Y., Grier, D.D., Neff, J. (2020). Acute Leukemias. In: Wang, E., Lagoo, A.S. (eds) Practical Lymph Node and Bone Marrow Pathology. Practical Anatomic Pathology. Springer, Cham. https://doi.org/10.1007/978-3-030-32189-5_21

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  • DOI: https://doi.org/10.1007/978-3-030-32189-5_21

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  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-030-32188-8

  • Online ISBN: 978-3-030-32189-5

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