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\title{Clinico Haematological Study of Acute Lymphoblasticleukemia}
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             \author[1]{Dr. Preethi C  R}

             \affil[1]{  JJM MEDICAL COLLEGE DAVANGERE}

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\date{\small \em Received: 12 December 2013 Accepted: 31 December 2013 Published: 15 January 2014}

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\begin{abstract}
        


Context: Acute Lymphoblastic leukemia encom-passes a group of neoplasms composed of immature, precursor B (pre- B) or T (pre-T) lymphocytes referred to as lymphoblast. Aims: 1. To know the relative incidence of Acute Lymphoblastic leukemia among the patients referred for complete haemogram at the department of pathology, JJMMC, Davangere. 2. To study the clinical manifestations and their correlation with various types of acute Lymphoblastic leukemia. 3. To study the haematological profiles in acute Lymphoblastic leukemia. Settings and design: The study was a hospital based study conducted at haematology unit, Department of Pathology, JJM Medical college, Davangere. Methods and material: The present study was done during the period of June 2006 to May 2008 at haematology unit department of Pathology, JJM Medical college, Davangere. Cases from chigateri general hospital, Bapuji hospital and other private hospitals situated in and around Davangere were included for the study. The case selection was based on clinical features and supported by laboratory evidence. Bone marrow aspiration was subsequently carried out after obtaining written consent from the patient or the guardian. Statistics: The results were expressed in percentage. Results and conclusion: A total of 1039 patients who were referred to the department of haematology out of which 13 patients were diagnosed as Acute Lymphoblastic Leukemia. The present study is to highlight that light microscopic features of peripheral smear and bone marrow will still remain mainstay in the diagnosis of acute Lymphoblastic leukemias. Aims:1. To know the relative incidence of Acute Lymphoblastic leukemia among the patients referred for complete haemogram at the department of pathology, JJMMC, Davangere. 2. To study the clinical manifestations and their correlation with various types of acute Lymphoblastic leukemia. 3. To study the haematological profiles in acute Lymphoblastic leukemia.Settings and design: The study was a hospital based study conducted at haematology unit,

\end{abstract}


\keywords{leukemias, all, hospital-based study.}

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\let\tabcellsep& 	 	 		 
\section[{Clinico Haematological Study of Acute Lymphoblasticleukemia}]{Clinico Haematological Study of Acute Lymphoblasticleukemia}\par
Dr. Preethi C R Abstract-Context: Acute Lymphoblastic leukemia encompasses a group of neoplasms composed of immature, precursor B (pre-B) or T (pre-T) lymphocytes referred to as lymphoblast.\par
Aims:\par
1. To know the relative incidence of Acute Lymphoblastic leukemia among the patients referred for complete haemogram at the department of pathology, JJMMC, Davangere. 2. To study the clinical manifestations and their correlation with various types of acute Lymphoblastic leukemia. 3. To study the haematological profiles in acute Lymphoblastic leukemia.\par
Settings and design: The study was a hospital based study conducted at haematology unit, Department of Pathology, JJM Medical college, Davangere.\par
Methods and material: The present study was done during the period of June 2006 to May 2008 at haematology unit department of Pathology, JJM Medical college, Davangere.\par
Cases from chigateri general hospital, Bapuji hospital and other private hospitals situated in and around Davangere were included for the study. The case selection was based on clinical features and supported by laboratory evidence. Bone marrow aspiration was subsequently carried out after obtaining written consent from the patient or the guardian. 
\section[{I. Introduction}]{I. Introduction}\par
cute lymphoblastic leukemia encompasses a group of neoplasms composed of immature, precursor(B-pre-B) or T (pre-T) lymphocytes referred to as lymphoblast \hyperref[b0]{1} .\par
Although ALL affects all age groups, ALL has its highest incidence in children between ages, 1-5 years with a peak at 3-4 years 2 . In 1976, Bennet JM et al classified ALL into three sub types (L1, L2 and L3). According to a) the occurance of individual cytological features b) The degree of heterogeneity in the distribution among the leukemic population of some or all of these features. The features considered are cell size, nuclear chromatin, nuclear shape, nucleoli, amount and basophilia of the cytoplasm  {\ref 3.} In the year 1985, the first MIC (morphologic, immunologic, cytogenetic cooperative study group) proposed a classification of ALL \hyperref[b3]{4} . The children cancer study group (CCSG) has presented their own classification of ALL which borrows from FAB nomenclature \hyperref[b4]{5} . The latest WHO classification of the acute leukemias differs from the FAB classification in that greater than or equal to 20\% blasts are used for the diagnosis of acute leukemias 6 . 
\section[{II. Objectives}]{II. Objectives}\par
1. To know the relative incidence of Acute lymphoblastic leukemia among the patients referred for complete haemogram at the department of pathology, JJMMC, Davangere. 2. To study the clinical manifestations and their correlation with various types of acute lymphoblastic leukemia. 3. To study the haematological profiles in acute lymphoblastic leukemia. 
\section[{III. Materials and Methods}]{III. Materials and Methods}\par
The present study on "Clinico-Haematological study of Acute LymphoblasticLeukemias" was undertaken during the period of June 2006 to may 2008 at haematology unit, Department of Pathology, J J M Medical College, Davangere.\par
The cases from chigateri hospital, Bapuji hospital and other private hospitals situated in and around Davangere formed the material of the study. Case selection was based on clinical features and supported by laboratory evidences. Bone marrow aspiration was subsequently carried out after obtaining written consent from the patient or the guardian. 
\section[{Inclusion criteria -New cases of ALL Exclusion criteria -Treated cases of ALL}]{Inclusion criteria -New cases of ALL Exclusion criteria -Treated cases of ALL}\par
The following investigations were done: 1. Complete haemogram was performed and peripheral smear was stained by Leishman stain for all cases and examined in detail.\par
2. Bone marrow aspiration and study was done in all cases and leishman stained smears were examined. In all cases, the following cytochemical stains were employed for diagnosisand subtyping of leukemias.\par
? MPO -Myelo-peroxidase stain ? SBB -Sudan Black B ? PAS-Periodic Acid Schiff stain ? NSE-Non specific esterase stain Acute lymphoblasticleukemias were classified based on FAB Criteria. 
\section[{IV. Results}]{IV. Results}\par
13 patients in this study were diagnosed as ALL. ALL patients were seen in the age range of 5months to 16 years with a mean age of 8.3 years. The mean ages for males and females were 9.2 years and 6.0 years respectively. Out of the 13 patients, 9 were males and 4 were females, with a male to female ratio of 2.2:1.\par
The main presenting symptoms were fever in 6 patients (46.1\%), generalized weakness in 4 patients (30.8\%) and backache in 3 patients (23\%).\par
Physical examination showed pallor of varying degrees in all patients. Lymphadenopathy was present in 8 out of 13 patients constituting (61.5\%). All the patients had localized lymphadenopathy among which cervical lymphadenopathy was common.\par
Mild to moderate Hepatomegaly was seen in 7 patients (53.8\%).\par
Mild to moderate Splenomegaly was seen in 10 patients (76.9\%).\par
Anemia of variable degree was seen an all patients of ALL. The Hb level ranged from 5.9-7.2gm/dl. The mean Hb level being 6.7gm/dl. TLC ranged from 16.9× 10 9 /l to 210× 10 9 /l. the mean TLC being 75.8× 10 9 /l. 5 patients (38.4\%) had count between 11-49× 10 9 /l, 4 patients (30.7\%) had counts between 50-100× 10 9 /l, 4 (30.7\%) patients had counts >100× 10 9 /l.\par
All the 13 patients had thromobocytopenia at the time of diagnosis, 5 patients had counts from 11-49× 10 9 /l, 4 patients had counts from 50-100× 10 9 /l, 4 patients had counts >100× 10 9 /l, with a mean platelet count of 82.3× 10 9 /l. 10 out of 13 patients had an ESR of >50mm at the end of 1 st hour and 3 patients between 20-50mm at the end of 1 st hour.\par
Bone marrow aspiration was performed in all 13 patients. Lymphoblast was the predominant cell with an average of 85\% blasts on differential count. All the patients had decreased megakaryocytes. All were subtyped on morphological basis using FAB criteria into 3 subtypes-L1, L2, and L3. The identification of lymphoblasts was mainly on morphological grounds as stated in the FAB proposals. MPO/SBB and PAS stains were performed. Most of the ALL patients were MPO/SBB negative, but characteristic block positivity on PAS was seen in 38.5\% of the patients. All the 13 patients who were diagnosed as ALL were ALL-L2 in this study. The age range was 5 months to 16 years with a mean age of 8.3 years. The mean ages for males and females were 9.2 years and 6 years respectively. Out of the 13 patients, 9 were males and 4 were females, with a male to female ratio of 2.2:1.\par
The main presenting symptoms were fever in 6 patients (46.1\%), generalized weakness in 4 patients (30.8\%) and backache in 3patient (23\%).\par
Physical examination showed pallor of varying degrees in all patients. Lymphadenopathy was present in 8 of the 13 patients constituting (61.5\%). All the 8 patients had localized lymphadenopathy among which cervical lymphadenopathy was common.\par
Mild to moderate hepatomegaly was seen in 7 patients (53.8\%).\par
Mild to moderate Splenomegaly was seen in 10 patients (76.9\%).\par
Anemia of variable degree was seen an all patients of ALL. The Hb level ranged from 5.9-7.2gm/dl. The mean Hb level being 6.7gm/dl. TLC ranged from 16.9× 10 9 /l to 210× 10 9 /l. the mean TLC being 75.8× 10 9 /l. 5 patients (38.4\%) had count between 11-49× 10 9 /l, 4 patients (30.7\%) had counts between 50-100× 10 9 /l, 4 (30.7\%) patients had counts >100× 10 9 /l.\par
All the 13 patients had thromobocytopenia at the time of diagnosis, 5 patients had counts from 11-49× 10 9 /l, 4 patients had counts from 50-100× 109/l, 4 patients had counts >100× 10 9 /l, with a mean platelet count of 82.3× 10 9 /l. 10 out of 13 patients had an ESR of >50mm at the end of 1st hour and 3 patients between 20-50mm.\par
Bone marrow aspiration was done in all 13 patients. Marrow was hypercellular. Aspiration showed reduced erythropoiesis and megakaryopoiesis. Leucopoiesis showed a predominance of lymphoblasts which comprised of heterogenous population of both large and small lymphoblasts. The average blast count was 85\%.\par
Cytochemical staining for MPO/SBB was negative and PAS positivity was seen in 38.5\% of the patients. 
\section[{c) Acute Lymphoblastic Leukemia (L3)}]{c) Acute Lymphoblastic Leukemia (L3)}\par
No case of L3 was encountered in this study. 
\section[{V. Discussion}]{V. Discussion}\par
The mean age incidence in the present study was 8.3\%. In studies conducted by Shome et al (1985)7 and Mathur (1993)8 et al, the mean age incidence was 15.6 and 29.7 respectively. This was more when compared to the present study.\par
The male female ratio in our study was 2.2:1. In studies done by Shome et al (1985) and Mathur (1993)  et al, the male to female ratio was 3.4:1 and 2.4:1 respectively. This is more when compared to the present study.\par
The average figures for age incidences in the present study are less than the figures quoted in other Indian studies.\par
The main presenting symptoms were fever and generalized weakness in our study. The same was noted by Shome et al (1985) and Mathur (1993) et al. Bleeding manifestation as a presenting symptom was not noted in this study. Higher incidences of bleeding manifestations were noted by Shome et al (55\%) and Mathur et al (47\%). A high incidence of lymphadenopathy was seen consistently in this study and also in other studies. Hepatosplenomegaly was also a presenting symptom in this study. Similar observation was noted by Shome et al (1985) and Mathur (1993) et al, but with a more frequency among patients. Backache was seen in 23\% of the patients in this study. Backache was not seen in study done by Shome et al (1985) and Mathur (1993) et al.\par
Pallor was present in our study and it correlates well with a study done by Mathur (1993)  Anemia was seen in all the cases of ALL in the present study. Similar finding was observed in study conducted by Mathur  Thrombocytopenia was present in all the patients in the present study. The mean platelet count was 82.3×10 \hyperref[b8]{9} /l in the present study. This was high when compared to the study conducted by Mathur et al, where it was 55.2×10 9 /l. Bone marrow examination was performed in all 13 cases.\par
The mean blast percentage was 85\%. This was more when compared to Mathur et al where it was 57\%. In the present study, all the patients, that were diagnosed as ALL were ALL-L2 (100\%). In the study done by Mahendrakumar (1998)9 L2 was a predominant subtype. Shome et al (1985) reported an almost equal incidence of L1 and L2 (45.8\% and 42.4\%).\par
The mean age for L2 was 8.3 years in the present study. Shome et al (1985) reported a mean age of 17.7, whereas Mahendrakumar (1998) reported a mean age 13.6 for L2. In this study, the sex ratio showed a male predominance in L2 subtype (2.2:1). The Shome  et al (1985) showed a sex ratio of 2.6:1 in L2 type, whereas the study of Mahendrakumar (1998) showed a sex ratio of 1.8:1 in L2 type.\par
The general pattern of clinical features varies with the findings of Shome et al (1985). Fever and generalized weakness were a common initial clinical presentation in the present study whereas in study done by Shome et al (1985) a higher percentage of fever and generalized weakness were noted. Lymphadenopathy was common in ALL-L2 in the present study (61.5\%) and is less when compared to Shome et al (73\%). Splenomegaly correlates well with study by Shome et al  (1985). Hepatomegaly was seen in less frequency when compared to Shome et al (1985). Backache was seen in 23\% of the patients in this study and was not seen in study conducted by byShome et al (1985).\par
The mean Hb levels in ALL-L2 subtype correlates with Shome et al study (1985). TLC also correlates with Shome et al series.\par
Thrombocytopenia was seen in all patients in this study. The mean platelet count was little less when compared to study done by Shome et al (1985).  
\section[{VI. Conclusion}]{VI. Conclusion}\par
ALL was diagnosed in 13 patients (20.63\%). All the patients that were diagnosed with ALL were ALL-L2. Lymphadenopathy was the most consistent feature with fever, generalised weakness, backache and hepatomegaly. Anemia and thrombocytopenia were pre -sent in all the patients. TLC count ranged from 16.9 to 210×10 9 /l with a mean of 75.8×10 9 /. The mean blast percentage was 85\%.\par
The present study is to highlight that light microscopic features of peripheral smear and bone marrow still remain mainstay in the diagnosis of acute leukemias, whereas immunotyping and cytogenetics are complimentary procedures at specialized centres.\par
However, with newer modalities of therapy and rewarding curative results in haematological malignancies, the use of cytochemistry, immunotyping and cytogenetics have become gold standards for arriving at a specific diagnosis.\begin{figure}[htbp]
\noindent\textbf{}\includegraphics[]{image-2.png}
\caption{\label{fig_0}}\end{figure}
  \begin{figure}[htbp]
\noindent\textbf{1} \par 
\begin{longtable}{P{0.4759052924791086\textwidth}P{0.1775766016713092\textwidth}P{0.059192200557103065\textwidth}P{0.11128133704735375\textwidth}P{0.026044568245125348\textwidth}}
Haematological\tabcellsep ALL (n=13)\tabcellsep L1\tabcellsep L2\tabcellsep L3\\
parameters\tabcellsep \tabcellsep \tabcellsep \tabcellsep \\
Hb (gm/dl)\tabcellsep \tabcellsep \tabcellsep \tabcellsep \\
Range\tabcellsep 5.9-7.2\tabcellsep -\tabcellsep 5.9-7.2\tabcellsep -\\
Mean\tabcellsep 6.7\tabcellsep -\tabcellsep 6.7\tabcellsep -\\
\tabcellsep \tabcellsep TLC (×10 9 /L)\tabcellsep \tabcellsep \\
Range\tabcellsep 16.8-210\tabcellsep -\tabcellsep 16.8-210\tabcellsep -\\
Mean\tabcellsep 75.8\tabcellsep -\tabcellsep 75.8\tabcellsep -\\
\tabcellsep \multicolumn{2}{l}{Platelets (×10 9 /L)}\tabcellsep \tabcellsep \\
Range\tabcellsep 0.46-145\tabcellsep -\tabcellsep 0.46-145\tabcellsep -\\
Mean\tabcellsep 82.3\tabcellsep -\tabcellsep 82.3\tabcellsep -\\
Blast range (\%)\tabcellsep 60-90\tabcellsep -\tabcellsep 60-90\tabcellsep -\\
Bone marrow\tabcellsep 13\tabcellsep -\tabcellsep 13\tabcellsep -\\
decreased\tabcellsep \tabcellsep \tabcellsep \tabcellsep \\
megakaryocytes\tabcellsep \tabcellsep \tabcellsep \tabcellsep \\
Blast mean\tabcellsep 85\%\tabcellsep -\tabcellsep 85\%\tabcellsep -\\
\multicolumn{2}{l}{a) Acute Lymphoblastic Leukemia (L1)}\tabcellsep \tabcellsep \tabcellsep \\
\multicolumn{2}{l}{No case of L1 was encountered in this study.}\tabcellsep \tabcellsep \tabcellsep \end{longtable} \par
  {\small\itshape [Note: b) Acute Lymphoblastic Leukemia (L2)]} 
\caption{\label{tab_0}Table 1 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{2} \par 
\begin{longtable}{P{0.85\textwidth}}
et al.\end{longtable} \par
 
\caption{\label{tab_1}Table 2 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{3} \par 
\begin{longtable}{P{0.5741228070175438\textwidth}P{0.12302631578947369\textwidth}P{0.15285087719298246\textwidth}}
\multicolumn{3}{l}{Haematological parameters Mathur et al (1993) Present study (2008)}\\
Hbgm/dl\tabcellsep 2-9.5\tabcellsep 5.9-7.2\\
Range\tabcellsep 5.2\tabcellsep 6.7\\
Mean\tabcellsep \tabcellsep \\
TLC (×10 9 /l)\tabcellsep 8-90\tabcellsep 16.8-210\\
Range\tabcellsep 35.8\tabcellsep 75.8\\
Mean\tabcellsep \tabcellsep \\
Platelets (×10 9 /l)\tabcellsep 20-150\tabcellsep 0.46-145\\
Range\tabcellsep 55.2\tabcellsep 82.3\\
Mean\tabcellsep \tabcellsep \\
Blasts (\%)\tabcellsep 20-90\tabcellsep 60-90\\
Range\tabcellsep 57\tabcellsep 85\\
Mean\tabcellsep \tabcellsep \end{longtable} \par
 
\caption{\label{tab_2}Table 3 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{4} \par 
\begin{longtable}{P{0.5199029126213591\textwidth}P{0.07014563106796116\textwidth}P{0.04951456310679612\textwidth}P{0.07427184466019418\textwidth}P{0.04126213592233009\textwidth}P{0.07014563106796116\textwidth}P{0.02475728155339806\textwidth}}
Haematological parameters\tabcellsep L1\tabcellsep \tabcellsep L2\tabcellsep \tabcellsep L3\tabcellsep \\
\tabcellsep PGI\tabcellsep \multicolumn{3}{l}{PS PGI PS}\tabcellsep PGI\tabcellsep PS\\
Hbgm/dl)\tabcellsep 6.6\tabcellsep -\tabcellsep 6.8\tabcellsep 6.7\tabcellsep 8.4\tabcellsep -\\
Mean\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \\
TLC (×10 9 /l)\tabcellsep \multicolumn{2}{l}{39.10 -}\tabcellsep \multicolumn{2}{l}{77.6 75.8}\tabcellsep 29\tabcellsep -\\
Mean\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \\
Platelets (×10 9 /l)\tabcellsep 81\tabcellsep -\tabcellsep 85\tabcellsep 69.3\tabcellsep 49.3\tabcellsep -\\
Mean\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \\
\multicolumn{2}{l}{Bone marrow decreased megakaryocytes (in \%) 96}\tabcellsep -\tabcellsep 90\tabcellsep 100\tabcellsep 100\tabcellsep -\end{longtable} \par
 
\caption{\label{tab_3}Table 4 :}\end{figure}
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\end{document}
