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INVESTIGATION ON THE PREVALENCE OF LEUKAEMIA AT A TERTIARY CARE HOSPITAL, LAHORE.

Byline: NIGHAT NASIM, KALIMUDDIN MALIK, NAUMAN A. MALIK SHAISTA MOBEEN, SAUD AWAN AND NAGHMANA MAZHAR

ABSTRACT

Introduction: Cancer in all forms is causing about 12% deaths throughout the world. After recent advances and improvement in treatment and prevention in cardiovascular diseases, tumour is an important cause of morbidity and mortality.1 The incidence of leukaemia across the world is 1 per 100,000 annually. It contributes to 25% of childhood cancers.2 The study was designed to investigate the Prevalence of Leukemia subtypes at Lahore General Hospital / The Graduate Medical Institute, Lahore and was carried out in the Bone Marrow Clinic. The study was cross - sectional prospective. The period of the study was two year from 01 June, 2010 to 30 June, 2012.

Methodology: Complete blood counts, bone marrow aspiration and trephine biopsies were performed according to standard methods.

Results: In a total of 45 cases of leukaemia, acute leukemia was more prevalent than chronic leukaemia. The ratio of acute and chronic leukaemias was 4:1. Male to female ratio was 1.3: 1. Most of the patients (42%) were below the age of 15 years. ALL (49%) was more common than AML (31%). Among chronic leukaemias, CML (16%) was more common than CLL (2%) and CMML (2%). The study of acute leukaemia subtypes revealed that ALL - L2 was more common (77%) than L1 (24%). In AML subtypes, M3 (57%) was most prevalent while M2 (14%) and M4 (14%) and M1 (7%) and M6 (7%) were less prevalent of leukaemia subtypes.

Conclusion: Acute leukaemias were more prevalent than chronic leukaemias. Leukaemias of all types were slightly more prevalent in male patients. ALL was more common than AML and was found to be a childhood malignancy. In leukaemia subtypes, ALL - L2 and AML-M3 were most common and in chronic leukaemias CML was most common.

Key Words: Leukemia, ALL, AML, CML, CLL.

INTRODUCTION

Cancer in all forms is causing about 12% deaths throughout the world. After recent advances and improvement in treatment and prevention in cardiovascular diseases, tumours are an important cause of morbidity and mortality.1 The incidence of leukaemia across the world is 1 per 100,000 annually. It contributes to 25% of childhood cancers.2

The term leukaemia refers to white blood cell malignancies and a rare case arising from red blood cell precursors in erythroleukaemia.3 Leukaemia are of two types; acute and chronic. Acute leukaemias are; acute lymphoblastic leukaemia (ALL) and acute myeloid leukaemia (AML). AML and ALL are further categorised into subtypes based on French, American, British (FAB) classification4. AML is further divided into 7 subtypes and ALL into 3 subtypes by the FAB classification.5

Chronic leukaemias are; chronic myeloid leukaemia (CML) and chronic lypmphocytic leukaemia (CLL). However, other variants of chronic myeloid leukaemias also exist e.g. chronic myelomonocytic leukaemia (CMML).6

Acute leukaemias are malignant disorders which are rapidly fatal if left untreated but they are curable with appropriate treatment. A sudden uncontrolled growth of immature haemopoietic cells replacing the normal marrow function is a hallmark of acute leukaemias.7 Acute myeloid leukaemia is primarily a cancer of adults and acute lymphoblastic leukaemia is more prevalent in children under 15 years of age. The chronic leukaemias are distinguished from acute leukaemia by their slower progression. CML is a clonal disorder of a pluripotential stem cells. The male to female ratio is 1.4:1 and common age of presentation is between 40 - 60 years.CLL is the most common tumour among chronic lymphoid leukaemias with a peak incidence of 60 - 80 years of age.8

This study was conducted to investigate the prevalence of different types of leukaemia at Lahore General Hospital, a tertiary care center catering for a large population of Lahore and nearby areas including Kasur, Hasilpur and Dipalpur. Therefore this representation was collected from a part of Lahore and its nearby towns.

The analysis was based on the prevalence of different types of leukaemia. Gender distribution and age of the patients were studied as well.

MATERIALS AND METHODS

The present study was carried out in the Pathology Department of Post Graduate Medical Institute, Lahore / Lahore General Hospital over a period of 2 years starting from 01.06.2010 till 30.06.2012. A total of 45 patients were diagnosed to have leukaemia. All indoor patients and a few outdoor patients from LGH or INMOL Hospital were included in the study. Patients on cancer chemotherapy and radiotherapy were excluded.

Detailed relevant history was taken and clinical examination was carried out. All the haematological parameters were recorded. Blood counts were performed on automated haematology analyser. Bone marrow examination included bone marrow aspiration and trephine biopsy.

The peripheral blood smears and bone marrow smears were stained with May - Grunwald Geimsa and Sudan Black B. Trephine biopsies were stained with haematoxylin and eosin. Findings of bone marrow aspiration and trephine biopsies were interpreted in the light of history, clinical examination and peripheral blood findings. FAB classification of acute leukaemia was applied for sub-typing.

RESULTS

The present study revealed that 80% of patients had acute leukaemia while 20% had chronic leukaemia (Table 1). Of acute leukaemia, 49% patients had acute lymphoblastic leukaemia (ALL) and 31% had acute myeloid leukemia. Of chronic leukaemia, 16% patients had chronic myeloid leukaemia (CML), 2% had chronic lymphocytic leukaemia and 2% had chronic myelomonocytic leukaemia (CMML) (Table 2).

Table 1: Percentage of leukaemias.

Type of Leukaemia###Total No. of Cases###Percentage

Acute leukaemia###36###80

Chronic leukaemia###19###20

The leukemias overall revealed a male preponderance with a percentage of 58% males and 42% females. Gender distribution revealed; in AML 57% males and 43% females and in ALL; 59% males and 41% females. In CML, there were 7 patients in total; 43% males and 57% female patients. One male patient was diagnosed to have juvenile CML. In CLL and CMML, there was single male patient in each group (Table 3). Investigation of age revealed that ALL was more prevalent in children and AML in adults (Table 4). AML sub-typing revealed M3 as the most common (57%), followed by M2 (14%) and M4 (14%) and leastcommon M1 (7%) and M6 (7%). ALL sub-typing showed L2 as the most common (72%), followed by L1 (24%), (Table 5).

Table 2: Prevalence of different types of leukae- mias.

Type of Leukemia###Total Cases###Percentage

ALL###22###49

AML###14###31

CML###07###16

CLL###01###2

CMML###01###2

Total###45###100

Table 3: Gender distribution in leukemia sub-ty- pes.

###Male Female Total

AML###8###6###14

ALL###13###9###22

CML###3###4###07

CLL###1###-###01

CMML###1###-###01

Total###26###19###45

###58%###42%###100

Table 3: Gender distribution in leukemia sub-ty- pes.

###Male###Female###Total

AML###8###6###14

ALL###13###9###22

CML###3###4###07

CLL###1###-###01

CMML###1###-###01

Total###26###19###45

###58%###42%###100

DISCUSSION

The present study revealed that acute leukaemias are more prevalent than chronic leukaemias. The results are consistent with other studies; Humayun et al (2005)1 showed 90% of acute type. In leukaemia subtypes, ALL was the most prevalent in children (< 15 years). This finding is consistent with other studies (Ali et al 19999 and Yasmin et al 2009).10

Acute myeloid leukemia was more prevalent in adults, a finding consistent with other studies (Ali et al 1999).10 There was a slight male preponderance in the study. The male to female ratio in the study was 1.3:1. The same frequency of gender distribution has been reported in different international and local studies, e.g. 1.5:111 and 1.2:112 and 1.7: 1.13 AML subtyping revealed AML-M3 as the most common type and consistent with other studies (Zaki et al 2002)14 while the study by Humayun et al1 shows M1 as the most common type and the study by Fauzia et al (2008)15 shows M2as the most common type. In ALL, L2 was the most common subtype in this study while the study by Humayun et al1 showed L1 as the most common subtype of ALL. No case was reported as ALL - L3 designating it to be the rarest of all ALL subtypes as found earlier. In CML, only one patient was diagnosed with juvenile CML.

It is concluded that acute leukaemias are more prevalent than chronic leukaemias. ALL is a more common childhood malignancy. In leukaemia subtypes, AML - M3 and ALL - L2 were the most prevalent and in chronic leukaemias, CML was most common in adult age.

Table 4: Age wise distribution of leukaemia cases.

Type of###Adult###Child###Total

Leukaemia###Adult###Child Percentage Percentage Percentage

ALL###9###13###41###59###100

AML###9###5###64###36###100

CML###6###1###86###14###100

CLL###1###100

CMML###1###100

Total###26###19

Table 5: Prevalence of subtypes of acute leukemia.

###AML###ALL

###M1###M2###M3###M4###M5###M6###M7###Total###L1###L2###L3###Total

###1###2###8###2###-###1###-###14###5###17###-###22

Percentage###7.2###14.3###57###14.3###-###7.2###-###100###24.5###77.5###-###100

Table 6: Prevalence of subtypes of chronic leukaemia.

###CML###CLL###CMML

###Juvenile Adult Total###

###1###6###7###1###1

Percentage###14###86###100###100###100

ACKNOWLEDGEMENTS

The authors are grateful to the Principal of PGMI - Lahore Pakistan, for allowing us do this study, at the Institute.

REFERENCES

1. Humayun M. Khan, SA, Muhammad W. Investigation on the prevalence of leukemia in North West Frontier Province of Pakistan. TJC 2005; Vol 35. No. 3: p. 119- 122.

2. Cartwright, R.A., Epidemiology. In leukemia (ed. J.A. Whittaker). Blackwell Scientific Publications, Oxford, 1992: pp. 3-33.

3. Rudden RW. Cancer Biology. 2nd ed. Oxford University Press, 1987: 14-24.

4. Bennett, J. M., Catovsky D., Daniel M-T., Flandrin, G., Galton, D.A.G, Gralnik, H.R, and Sultan C. Proposed revised criteria for the classification of acute myeloid leukemia: A report of the French - American - British Co-operative group. Ann Int. Med., 1985; 103: 620- 629.

5. Bain BJ, Baits I. Approach to the diagnosis and classification of blood diseases. In: Lewis SM, Bain BJ, Baits I, editors. Dacie and Lewis Practical Haematology. 10th ed. Philadelphia; Churchill Livingstone: 206 p.619&621.

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11. Harani MS, Adil SN Shaikh MU, Kakepoto GN, Khurshid M. Frequency of FAB subtypes in acute myeloid leukemia patients at Aga Khan University Hospital Karachi. J Ayub Med Coll Abbottabad. 2005; 17 (1): 26-29.

12. Braham - Jmili N, Sendi - Senana H, Labiadh S and Ben Abdelali R. Hematological characteristics, FAB and WHO classification of 153 cases of myeloid acute leukemia in Tunisia. Ann BiolClin (Paris). 2006; 64 (5): 457-65.

13. Khalil Ullah, Ahmed P, Raza S, Satti TM, et al. Management of acute myeloid leukemia - 5 years' experience at Armed Forces Bone Marrow Transplant Centre. Rawalpindi J Pak Med Assoc 2007; 57 (9): L 434-439.

14. S. Zaki. I.A. Burney. M. Khurshid. Acute myeloid leukemia in children in Pakistan: an audit. JPMA 2002; 52: 247.

15. Fauzia A. Irfan Z.Q. Clinical and cytogenetic analysis in Pakistani leukemia patients. Pakistan J. Zool., vol. 2008; 40 (3): pp. 147-157.
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Publication:Biomedica
Date:Jun 30, 2013
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