Simplified summary of the FAB classification of acute myeloid leukaemia
Simplified summary of the FAB classification of acute myeloid leukaemia
| M0 | AML with minimal evidence of myeloid differentiation |
| M1 | Acute myeloblastic leukaemia without maturation |
| M2 | Acute myeloblastic leukaemia with maturation |
| M3 | Acute hypergranular promyelocytic leukaemia and its variants |
| M4 | Acute myelomonocytic leukaemia |
| M5 | Acute monocytic/monoblastic leukaemia |
| M6 | Acute erythroleukaemia |
| M7 | Acute megakaryoblastic leukaemia |
In addition there are some rare myeloid leukaemias which are not included in the FAB classification including mast cell leukaemia and Langherhans cell leukaemia.
Summary of cytochemical stains used in the diagnosis of acute leukaemia
| Stain | Significance of positive reaction |
| Myeloperoxidase | Myeloid; granulocytic lineage has stronger reactions than monocytic lineage |
| Sudan Black B | Myeloid; granulocytic lineage has stronger than reactions than monocytic lineage |
| Chloroacetate esterase | Myeloid; less sensitive than myeloperoxidase and Sudan black B in detecting myeloid differentiation |
| Non-specific esterases | Monocytic; weaker reactions in granulocytic series |
| Periodic acid-Schiff (PAS) | Block positivity in lymphoblasts but this pattern is not totally specific; diffuse cytoplasmic positivity is seen in M3 AML and in the erythroblasts of some cases of M6 AML; granular positivity is the most usual pattern in other acute myeloid leukaemias. |
| Acid phosphatase | Focal positivity in T lymphoblasts but pattern not totally specific |
| Perls’ reaction for iron | Useful in identifying abnormal erythroblasts in some myeloid leukaemias |
Esterase reactions used in the diagnosis and classification of acute leukaemia
| Specific esterase | |
| Naphthol AS-D chloroacetate esterase (CAE) | Granulocytic lineage |
| Non-specific esterases | |
| a-naphthyl acetate esterase (ANAE) | Positive in monocyte lineage, weak in granulocyte lineage; also positive in megakaryocytes and platelets |
| a-naphthyl butyrate esterase (ANBE) | Positive in monocyte lineage, weak in granulocyte lineage |
| Naphthol AS-D acetate esterase (NASDA) | Strong reactions which are inhibited by fluoride in monocyte and megakaryocyte lineages; weak fluoride-resistant reactions in granulocyte lineage |
| Naphthol AS acetate esterase (NASA) | Strong reactions which are inhibited by fluoride in monocyte and megakaryocyte lineage; weak fluoride-resistant reactions in granulocyte lineage |
Important monoclonal antibodies used in the diagnosis of acute leukaemia
| Antibody | Specificity |
| CD13 | Myeloid |
| CD33 | Myeloid |
| CD117 | Myeloid |
| CD65 | Myeloid |
| Anti-myeloperoxidase | Myeloid |
| CD41, CD42 | Megakaryocyte |
| CD61 | Megakaryocyte |
| Anti-glycophorin | Erythroid |
| CD19 | B-lymphocyte lineage |
| CD79a | B-lymphocyte lineage |
| CD10 | B-lymphocyte lineage (if strongly expressed) |
| CD3 | T-lymphocyte lineage |
| CD7 | T-lymphocyte and myeloid lineages |
| Anti-terminal deoxynucleotidyl transferase (anti-TdT) | B- and T-lineage lymphoblasts and a lower proportion of myeloid blasts |
Monoclonal (or polyclonal) antibodies useful in the diagnosis and classification of acute leukaemia
| Cluster of differentiation or other specificity | Specificity within haemopoietic lineage |
| Antibodies identifying antigens expressed mainly in haemopoietic precursors | |
| HLA-DR (major histocompatibility complex, class II antigens) |
B lymphocytes and B-lymphocyte progenitors, activated T lymphocytes, blasts of a small minority of cases of T-lineage acute lymphoblastic leukaemia (ALL), monocytes and their precursors, myeloid precursors, blast cells of most cases of acute myeloid leukaemia (AML) |
| Anti-TdT (terminal deoxynucleotidyl transferase) | Blasts in ALL (stronger in B lineage than T lineage), more weakly in blasts in 10–20% of AML |
| CD34 | B-lineage lymphoblasts, early T-cell precursors, myeloid progenitors, myeloblasts in most cases of AML and undifferentiated acute leukaemia |
| Antibodies identifying antigens expressed mainly in B cells | |
| CD19 | B lymphocytes and B-lymphocyte precursors, blast cells of B-lineage ALL |
| CD20 | B lymphocytes, some B-lymphocyte precursors, blast cells of some B-lineage ALL |
| CD22 | B lineage: as a surface antigen in B lymphocytes, as a cytoplasmic antigen in B-lymphocyte precursors, as a surface antigen in some B-lineage ALL and as a cytoplasmic antigen in c. 98% |
| CD24 | B lymphocytes and precursors, blast cells of B-lineage ALL, activated T lymphocytes, granulocytes (neutrophils and eosinophils) |
| CD10 (common ALL antigen (CALLA)) |
A subset of B-cell progenitors, about 90% of B-lineage ALL, more weakly expressed in some T-lineage ALL (c. 15–20%), some follicular lymphomas and multiple myeloma cells, neutrophils |
| CD79a (part of the B-cell receptor) |
B cells and their precursors, plasma cells |
| CD79b (part of the B-cell receptor) |
Most normal and abnormal B cells (but not chronic lymphocytic leukaemia cells), late B-cell precursors (from the pre-B cell onwards) |
| Anti-immunoglobulin and anti-g, a, m, d immunoglobulin heavy chains | Surface membrane expression in B cells (SmIg), cytoplasmic expression in pre-B cells (Cy m chain) and in late B lymphocytes and plasma cells (CyIg) |
| Anti-k, l (anti-immunoglobulin light chains) | Surface membrane expression in B lymphocytes and cytoplasmic expression in late B lymphocytes and plasma cells |
| Antibodies identifying antigens expressed mainly in T cells | |
| CD3 (part of T-cell receptor (TCR) complex) |
Membrane antigen in late thymocytes and mature T lymphocytes, blast cells in c. 25% of T-lineage ALL and leukaemias of mature T cells, cytoplasmic expression in the majority of thymocytes and blast cell of most T-lineage ALL |
| CD7 | Thymocytes, majority of mature T cells, natural killer (NK) cells, blast cells of T-lineage ALL, subset of immature myeloid cells, blast cells of 5–15% of AML, some leukaemias of mature T cells |
| CD5 | Cortical and late thymocytes, some early thymocytes, T lymphocytes, blast cells of some T-lineage ALL, small subset of B lymphocytes, some leukaemias and lymphomas of mature B cells and mature T cells |
| CD2 (receptor for sheep red cells) |
Cortical and late thymocytes, mature T lymphocytes, most NK cells, blast cells of c. 80% of T-lineage ALL, leukaemias of mature T cells |
| CD1 or CD1a | Cortical thymocytes, blast cells of about 20% of T-lineage ALL, subset of B cells, Langerhans’ cells |
| CD4 | Cortical thymocytes (co-expressed with CD8), late thymocytes, subset of mature T cells, some leukaemias of mature T cells, immature myeloid cells, monocytes, eosinophils |
| CD8 | Cortical thymocytes (co-expressed with CD4), late thymocytes, subset of mature T cells, some leukaemias of mature T cells |
| TCR ab | Subset of T lymphocytes and some T-lineage ALL |
| TCR gd | Subset of T lymphocytes and some T-lineage ALL |
| Antibodies identifying antigens expressed mainly in myeloid cells | |
| CD13 | Pan-myeloid: membrane expression in blast cells of c. 80% of cases of AML, cytoplasmic expression in a higher proportion |
| CD33 | Myeloid progenitors and some maturing myeloid cells (myeloblasts, promyelocytes, myelocytes, monocytes), blast cells of about 80% of AML |
| CD15 | Maturing myeloid cells (granulocytic more than monocytic) |
| CD11b (C3bi receptor) |
Mature monocytes, granulocytes to a lesser extent, blast cells of most monocytic and some granulocytic leukaemias, macrophages, NK cells |
| CD14 | Monocytes, macrophages, granulocytes to a lesser extent, blast cells of monocytic and some granulocytic leukaemias |
| CD64 | Monocytes, macrophages, activated granulocytes |
| CD65 | Cells of granulocytic and monocytic lineages (weaker expression on monocytes) |
| Anti-myeloperoxidase | Myeloid cells (granulocytic more than monocytic) |
| CD117 | c-kit, stem cell factor receptor: haemopoietic precursors, myeloblasts, primitive erythroid cells, some megakaryoblasts, mast cells, blasts of AML, myeloma cells in some cases |
| CD41 (platelet glycoprotein IIb/IIIa complex (CD41a) and platelet glycoprotein Iib (CD41b)) |
Megakaryoblasts, megakaryocytes, platelets |
| CD42a (platelet glycoprotein IX) |
Megakaryoblasts, megakaryocytes, platelets |
| CD42b (platelet glycoprotein Iba) |
Megakaryoblasts, megakaryocytes, platelets |
| CD61 (platelet glycoprotein IIIa) |
Megakaryoblasts, megakaryocytes, platelets |
| CD36 (platelet glycoprotein IV) |
Erythroblasts and progenitors, monocytes, macrophages, megakaryoblasts, megakaryocytes and platelets |
| Anti-glycophorin A or C | Erythroid cells |
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Blasts ³30% of bone marrow nucleated cells
-
Blasts ³30% of bone marrow non-erythroid cells*
-
<3% of blasts positive for Sudan black B or for myeloperoxidase by light microscopy
-
Blasts demonstrated to be myeloblasts by immunological markers or by ultrastructural cytochemistry
*Exclude also lymphocytes, plasma cells, macrophages and mast cells from the count.
-
Blasts ³30% of bone marrow cells
-
Blasts ³90% of bone marrow non-erythroid cells*
-
³3% of blasts positive for peroxidase or Sudan black B
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Bone marrow maturing monocytic component (promonocytes to monocytes) £10% of non-erythroid cells
-
Bone marrow maturing granulocytic component (promyelocytes to polymorphonuclear leucocytes) £10% of non-erythroid cells
*Exclude also lymphocytes, plasma cells, macrophages and mast cells from the count.
-
Blasts ³30% of bone marrow cells
-
Blasts 30–89% of bone marrow non-erythroid cells
-
Bone marrow maturing granulocytic component (promyelocytes to polymorphonuclear leucocytes) >10% of non-erythroid cells
-
Bone marrow monocytic component (monoblasts to monocytes) <20% of non-erythroid cells and other criteria for M4 not met
Criteria for the diagnosis of M3 and M3 variant AML
The diagnosis of M3 AML does not require any specific numbers of blasts. These are often less than 30% because the dominant leukaemic cell is an abnormal promyelocyte rather than a blast. The diagnostic criterion is that the bone marrow is largely replaced by abnormal promyelocytes which may be hypergranular, with or without multiple Auer rods, or hypogranular or apparently agranular but with characteristic bilobed nuclei.
Criteria for the diagnosis of acute myeloid leukaemia of M4 category
(acute myelomonocytic leukaemia)
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Blasts ³30% of bone marrow cells
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Blasts ³30% of bone marrow non-erythroid cells
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Bone marrow granulocytic component (myeloblasts to polymorphonuclear leucocytes) ³20% of non-erythroid cells
-
Significant monocytic component as shown by one of the following:
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Bone marrow monocytic component (monoblasts to monocytes) ³20% of non-erythroid cells and peripheral blood monocytic component ³5 x 109/l, or
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Bone marrow monocytic component (monoblasts to monocytes) ³20% of non-erythroid cells and confirmed by cytochemistry or increased serum or urinary lysozyme concentration, or
-
Bone marrow resembling M2 but peripheral blood monocyte component ³5 x 109/l and confirmed by cytochemistry or increased serum or urinary lysozyme concentration
-
-
Blasts ³30% of bone marrow cells
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Blasts ³30% of bone marrow non-erythroid cells
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Bone marrow monocytic component ³80% of non-erythroid cells
Acute monoblastic leukaemia (M5a)
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Monoblasts ³80% of bone marrow monocytic component
Acute monocytic leukaemia (M5b)
-
Monoblasts <80% bone marrow monocytic component
Criteria for the diagnosis of acute myeloid leukaemia of M6 category
(acute erythroleukaemia).
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Erythroblasts ³50% of bone marrow nucleated cells
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Blasts ³30% of bone marrow non-erythroid cells
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Blasts ³30% of bone marrow nucleated cells
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Blasts demonstrated to be megakaryoblasts by immunological markers, ultrastructural examination or ultrastructural cytochemistry
Morphological features of ALL subtypes
| FAB category | L1 ALL | L2 ALL | L3 ALL |
| Cell size | Mainly small | Large, heterogeneous | Large, homogeneous |
| Nuclear chromatin | Fairly homogeneous, may be condensed in some cells | Heterogeneous | Finely stippled, homogeneous |
| Nuclear shape | Mainly regular | Irregular; clefting and indentation common | Regular; oval or round |
| Nucleolus | Not visible or small and inconspicuous | Usually visible, often large | Usually prominent |
| Amount of cytoplasm | Scanty | Variable, often abundant | Moderately abundant |
| Cytoplasmic basophilia | Slight to moderate | Variable | Strong |
| Cytoplasmic vacuolation | Variable | Variable | Often prominent |
Simplified summary of FAB classification of ALL
| L1 ALL | typical morphology of childhood cases of ALL; there are small to medium sized blasts with a high nucleocytoplasmic ratio and a regular nuclear and cellular outline |
| L2 ALL | cells are larger and more pleomorphic than those of L1 ALL; the blasts and the nuclei may be irregular in shape and nucleoli may be large or prominent |
| L3 ALL | cells are regular in shape but have strongly basophilic cytoplasm and prominent cytoplasmic vacuolation |
Alternative criteria for the diagnosis of biphenotypic leukaemia
| Score | B lineage | T lineage | Myeloid |
| Royal Marsden Criteria | |||
| 2 | cCD22 CD79a |
cCD3 | Myeloperoxidase (MPO) (any method) |
| 1 | CD10 | CD2 | CD13 |
| CD19 | CD5 | CD33 | |
| 0.5 | TdT | TdT | CD11b/11c |
| CD7 | CD14 | ||
| CD15 | |||
| If > 2 points is scored for two or more lineages the case is classified as biphenotypic | |||
| EGIL criteria | |||
| 2 | CD79a | CD3 (Cy or Sm) | MPO |
| Cy IgM | Anti-TCR ab | ||
| Cy CD22 | Anti-TCR gd | ||
| 1 | CD19 | CD2 | CD13 |
| CD10 | CD5 | CD33 | |
| CD20 | CD8 | CDw65 | |
| CD10 | |||
| 0.5 | TdT | TdT | CD14 |
| CD24 | CD7 | CD15 | |
| CD1a | CD64 | ||
| CD117 | |||
| If > 2 points is scored for both myeloid and one of the lymphoid lineages the case is classified as biphenotypic | |||
Alternative classifications of T-lineage acute lymphoblastic leukaemia
| MIC classification (all cases are usually TdT and CD7 positive) | |
| Early precursor T | E-receptor or CD2- |
| T | E-receptor or CD2+ |
| Pediatric Oncology Study Group (cases generally positive for CD7, CD2 and CD5 and sometimes CD38 or CD71) | |
| Early thymocyte | CD1-, mCD3-, CD4-, CD8- |
| Intermediate or common thymocyte | CD1+, mCD3-, CD4 and CD8 + or - (usually CD4 and CD8 both positive) |
| Mature thymocyte | CD1-, mCD3+ (usually CD4 or CD8 positive) |
| EGIL classification (all cases are positive for Cy or Sm CD3; some cases are CD10 positive) | |
| T-I (pro-T) | CD7+, CD2-, CD5-, CD8-, CD1a- |
| T-II (pre-T) | CD2+ and/or CD5+ and/or CD8+, CD1a- |
| T-III (cortical T) | CD1a+, membrane CD3 + or - |
| T-IV (mature T) | Membrane CD3+, CD1a- |
| Group a | Anti-TCR ab+ |
| Group b | Anti-TCR gd+ |
| Cytogenetic abnormality | Molecular genetic abnormality | FAB category | Reference |
| t(1;11)(p32;q23) | MLL-AF1p fusion | M5 | [Drexler 1995] |
| t(1;11)(q21;q23) | MLL-AF1q fusion | M4 | [Rubnitz 1996] |
| inv(3)(q21q26) or t(3;3)(q21;q26) | EVI1 dysregulation | Various | |
| t(3;5)(q25.1;q34) | NPM-MLF1 fusion | Various | [Drexler 1995] |
| t(3;12)(q26;p13) | fusion of various genes at 3q26 with TEL at 12p13 | Various | [Raynaud 1996] |
| t(3;21)(q26;q22) | heterogeneous, mainly AML1-EAP, AML1-EVI1 and AML1-MDS1 | Variable | [Nucifora 1994] |
| t(4;11)(q21;q23) | MLL-AF4 fusion | M5 | [Drexler 1995] |
| t(5;17)(q32;q21 | NPM-RARa fusion | M3-like | [Redner 1996] |
| t(6;9)(p23;q34) | DEK-CAN fusion | M2Baso | [Drexler 1995] |
| t(6;11)(q27;q23) | MLL-AF6 fusion | M4 or M5 | [Drexler 1995] |
| t(7;11)(p15;p15) | NUP98-HOXA9 fusion | M2 | [Huang 1997] |
| inv(8)(p11q13) | MOZ-TIF2 fusion | M7* | [Liang 1998] |
| t(8;16)(p11;p13) | MOZ-CBPb fusion | M4 or M5 | [Borrow1996] |
| t(8;21)(q22;q22) | AML1-ETO fusion | M2 | [Andrieu 1996] |
| t(9;11)(p21-22:q23) | MLL-AF9 fusion | M5 | [Drexler 1995] |
| t(9;22)(q34;q11) | BCR-ABL fusion | M0, M1 or M2 | |
| t(10;11)(p12;q23) | MLL-AF10 fusion | M5 | [Chaplin 1996] |
| t(10;11)(p11.2;q23) | MLL-ABI1 fusion | AML | [Taki 1998] |
| t(10;11)(p13;q14) | CALM-AF10 fusion | M4 | [Dreyling 1996] |
| ins(11;9) (q23;p22p23) | MLL-AF9 fusion | M5 | |
| inv(11)(p15q22) | NUP98-DDX10 fusion | Various | [Arai 1997] |
| t(11;16)(q23;p13) | MLL-CBFb fusion | Variable | [Rowley 1997] |
| t(11;17)(q23;q21) | MLL-AF17 fusion | M5 | [Drexler 1995] |
| t(11;17)(q23;q21) | PLZF-RARa fusion | M3-like | [Licht 1995] |
| t(11;19)(q23;p13.1) | MLL-ELL fusion | M4 or M5 | [Drexler 1995] |
| t(11;19)(q23;p13.3) | MLL-ENL fusion | M4 or M5 | [Drexler 1995] |
| t(11;22)(q23;q13) | MLL-p300 fusion | AML | [Ida 1997] |
| +11, 11q+ or normal | partial tandem duplication of MLL | AML | [Kwong 1997] |
| t(12;22)(p13;q11) | MN1-TEL fusion | Variable | [Wlodarska 1996] |
| t(15;17)(q22;q21) | PML-RARa fusion | M3 | |
| inv(16)(p13q22) or t(16;16)(p13;q22) | CBFb-MYH11 fusion | M4Eo | |
| t(16;21)(p11;q22) | FUS-ERG fusion | Variable | [Ichikawa 1994] |
| t(X;11)(q13;q23) | MLL-AFX fusion | M4 or M5 | [Drexler 1995] |
MIC-M categories of B-lineage Acute Lymphoblastic Leukaemia
| Cytogenetics | Molecular Genetics | Immuno- phenotype | Clinical |
| t(1;19)(q23;p13) | E2A-PBX fusion | Pre-B | Children, average prognosis; L1, L2 or L3 |
| t(8;22)(q24;q11) | MYC dysregulation by proximity to k gene | Mature B | L3, poor prognosis with standard treatment |
| t(4:11)(q21;q23) | MLL-AF4 fusion | Early B | Infants, poor prognosis |
| t(5;14)(q31;q32) | IL3 dysregulation by proximity to IGH* | Common | Eosinophilia |
| t(6;11)(q27;q23) | MLL-AF6 fusion | Early B | Also AML, T-ALL |
| t(8;14)(q24;q32) | MYC dysregulation by proximity to IGH | Mature B | L3, poor prognosis with standard treatment |
| t(8;22)(q24;q11) | MYC dysregulation by proximity to l gene | Mature B | L3, poor prognosis with standard treatment |
| t(9;11)(p21;q23) | MLL-AF9 fusion | Early B | Also AML, biphenotypic acute leukaemia |
| t(9;22)(q34;q11) | BCR-ABL fusion | Common | Adults, poor prognosis |
| t(10;11)(p12-22;q23) | MLL-AF10 fusion | Early B | |
| t(11;19)(q23;p13.3) | MLL-ENL fusion | Early, common or pre-B | Also AML |
| t(12;21)(p12;q22) | TEL-AML1 fusion | Early precurs or common | 10-30% of cases of childhood B-lineage ALL,usually L1, good prognosis |
| t(17;19)(q21-22;p13) | E2A-HLF fusion | ||
| t(X;11)(q13;q23) | MLL-AFX fusion |
* mechanism of eosinophilia
MIC-M categories of T-lineage Acute Lymphoblastic Leukaemia
| Cytogenetics | Molecular genetics |
| TALd | Occult deletion 5’ to TAL gene on chromosome 1 leading to SIL-TAL fusion and TAL1 dysregulation |
| t(1;7)(p32;q35) | TAL1 is dysregulated by proximity to the TCRb gene |
| t(1;14) t(1;14)(p32;q11) | TAL1 is dysregulated by proximity to the TCRd gene |
| t(7;9)(q34;q34) | TAN1 gene disrupted and codes for a truncated protein |
| t(7;9)(q35;p13) | TAL2 is dysregulated by proximity to the TCRb gene |
| t(7;10)(q35;q24) | HOX11 is dysregulated by proximity to the TCRb gene |
| t(7;11)(q35;p13) | RBTN2 is dysregulated by proximity to the TCRb gene |
| t(7;19)(q35;p13) | LYL1 is dysregulated by proximity to the TCRb gene |
| t(8;14)(q24;q11) | MYC is dysregulated by proximity to the ad locus |
| t(10;14)(q24;q11) | HOX11 is dysregulated by proximity to the ad locus |
| t(11;14)(p15;q11) | RBTN1 is dysregulated by proximity to the d gene |
| t(11;14)(p13;q11) | RBTN2 is dysregulated by proximity to the d gene |
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