AN EXPERIENCE WITH SIXTY CASES OF HAEMATOLOGICAL MALIGNANCIES; A CLINICO HAEMATOLOGICAL CORRELATION

Muhammad Idris, S.H. Shah*, Jamila Fareed, Nasreen Gul

Department of Pathology, Ayub Medical College, Abbottabad and *Gomal Medical College, Dera Ismail Khan

Background: Haematological malignancies are not uncommon in our area. Due to inadequate diagnostic facilities and lack of health education they are diagnosed at an advanced stage when treatment is either impossible or very difficult. In our study, sixty patients with haematological malignancies were studied from 1-1-1999 to 1-1-2001, at Ayub Teaching Hospital, Abbottabad. Methods: Patients were interviewed in detail, a thorough physical examination and blood tests including haemoglobin estimation, total and differential leukocyte count, platelets count, reticulocyte count and blood film examination was done on each patient. Bone marrow examination for routine giemsa staining and cytochemistry was also done in each case. Trephine biopsy was done in selected cases. Results: About 35.9% patients had acute myeloid leukemia, while 19.15% patients had acute lymphoblastic leukemia. Non Hodgkin’s lymphoma was seen in 15.39% cases. Among chronic leukemias, chronic lymphocytic leukemia outnumbered chronic myeloid leukemia (13.91% against 10.76%). Multiple myeloma was seen in 4.61% patients while a single patient had Hodgkin’s disease. Male to female ratio in haematological malignancies was 1.4:1 and majority of the patients (66.66) belonged to two districts (i.e. Mansehra and Abbottabad). Low grade fever, progressive pallor, weakness and body aches were the commonest symptoms (70% cases) while pallor was the frequently observed sign. Medium age for acute myeloid and acute lymphoblastic leukemia was 26 years and 7 years respectively. For chronic myeloid and chronic lymphocytic leukemia it was 22 years and 56 years respectively. In case of non Hodgkin’s lymphoma it was 22.5 years. Conclusion: In our study acute myeloid leukemia was the commonest type of haematological malignancy. Males were affected more than the females. Majority of the patients belonged to districts Mansehra and Abbottabad. Non specific symptoms like low grade fever, progressive pallor and bodyaches were the commonest symptoms while pallor was the most frequently observed sign.

Key Words: Haematological malignancy, Clinicohaematological correlation, Leukemia

INTRODUCTION

Cancer can arise from any tissue in the body. Tissues with rapidly multiplying cells are at more risk of having cancer. Haemopoietic system is one of them. Malignancies of this system are known as leukemia and lymphoma. Leukemia was recognized by Virchow¹ in 1945 as a clinical entity for the first time. Later researchers contributed a lot by classifying this clinical condition.¹ Lymphoma, strictly speaking a malignant disorder of the cells native to lymphoid tissue, was grouped along with leukemia because of the common origin of both.

As for the other types of malignancies, there is no single known etiological agent for haematological malignancies. Some of the etiological factors include genetic predisposition, viruses, chemicals and radiations.² Tobacco smoking could be one of them. A lot of high tech research is going on in this field throughout the world, specially developed countries both from diagnostic and therapeutic point of view.^3-5 Acute lymphoblastic leukemia (ALL) is four times more common in children as compared to adults. The reverse is true with increasing age.⁶ Peak incidence of childhood All is between 3 and 5 years in Western countries.⁷ Median age of patients with Acute Myeloid leukemia (AML) is about 55 years and there is no peak age incidence in childhood AML⁸. Chronic lymphocytic leukemia is a disease of adults with median age 60 years. This is the commonest type of leukemia in Western countries.⁹ Chronic myeloid leukemia has peak incidence between 30 years and 50 years of age. Multiple myeloma being a plasma cell malignancy is also an age dependent disease.¹⁰ Hodgkin’s lymphoma has bimodal age incidence, first about 25 years and second in advanced age.¹¹ Non Hodgkin’s lymphoma is not a single disease. It represents a diverse group of neoplasms ranging from some of the most indolent tumors to most aggressive ones.¹²

The present study aims at knowing the break up of haematological malignancies, their clinico-haematological correlation and providing study based suggestions for better diagnosis and treatment of them in this part of the country.

MATERIAL AND METHODS

Consecutive patients of all ages, ethnic groups and both the sexes were selected from Ayub Teaching Hospital. Every patient was interviewed. In case of a child mother was interviewed. General particulars like age, sex, address and detailed history was recorded for every patient. Detailed clinical examination was then performed on each patient with particular emphasis on haematological examination. A clinical diagnosis was made based on history and findings of physical examination. Blood tests were performed on every patient. Haemoglobin estimation was done by Cyenmethaemoglobin method. Total leukocyte count and platelets count was done by visual method. Differential leukocyte count was also done by visual method after staining blood film with Giemsa stain (Sigma kit).

Blood film examination for cell morphology was performed after staining with Giemsa stain. Bone marrow was examined after aspiration from posterior iliac spine in adults and tibia in children under two years of age. In addition to routine examination after staining with Giemsa stain, bone marrow was also subjected to iron stain and cytochemistry (Pox, SB, PAS). Trephine biopsy was also performed where bone marrow aspirate was inadequate. Leukocyte alkaline phosphatase score was done where clinical diagnosis was consistent with chronic myeloid leukemia (all chemicals from sigma diagnostics). A total of 73 cases were included in the study in the beginning. However, three patient died during study, five patients left the hospital and complete data was not available in another five patients. So sixty patients were left in the end.

RESULTS

Results of the study are as shown in tables 1-6. In our study, haematological malignancies were found to be more common in males (male to female ratio being 1.41:1). Majority of the cases belonged to two districts i.e. district Mansehra and Abbottabad (about 36.66% and 30% respectively. 15.39% patients belonged to district Haripur, while about 7.69% patients were from district Kohistan and Batagram. About 7.68% patients belonged to neither of these districts.

AML was found to be the commonest type of haematological malignancy (35.39%). Acute lymphoblastic leukemia was the next most common (19.15%). Non Hodgkin lymphoma was seen in about 15.39% patients.

Among chronic leukemias, CLL was more common than CML (13.91 & 10.76% respectively). Only one patient was found to have Hodgkin’s disease (1.61%), while multiple myeloma was seen in 4.61% cases.

Table-1: Frequency distribution of haematological malignancies.

Type of Malignancy	No. of Cases	Percentage
AML	18	35.39 %
ALL	12	19.15%
NHL	10	15.39%
CLL	09	13.91%
CML	07	10.76%
MM	03	4.61%
HL	01	1.61%
	60	100%

Table-2: Gender distribution of haematological malignancies.

Sex	No. of Cases	Percentage
Male	34	56.66%
Female	26	43.33%
Total	60	100%

Table-3: Area distribution of haematological malignancies.

Area	No. of Cases	Percentage
Mansehra	22	36.66%
Abbottabad	18	30.00%
Haripur	10	16.66%
Kohistan	5	8.33%
Afghani	3	5.00%
Others	2	3.33%
Total	60	100%

Table-4: Clinical features

Clinical features	AML	ALL	NHL	CLL	CML	MM	HL
Low grade fever	95%	85%	72%	80%	87%	73%	100%
Progressive Pallor	100%	60%	65%	68%	82%	20%	Nil
Generalized weakness	93%	90%	87%	87%	45%	95%	100%
Bodyaches	97%	70%	90%	66%	63%	100%	100%
Weight Loss	54%	63%	47%	55%	38%	25%	100%
Bleeding	48%	52%	Nil	Nil	10%	Nil	Nil
Lymphadenopathy	42%	74%	68%	78%	Nil	Nil	100%
Pallor	100%	84%	42%	62%	65%	35%	100%
Hepatomegaly	74%	64%	22%	53%	10%	Nil	Nil
Splenomegaly	73%	67%	18%	43%	89%	Nil	Nil
Bone Tenderness	93%	86%	14%	16%	Nil	100%	Nil
Jaundice	17%	27%	Nil	Nil	Nil	Nil	Nil
Purpura	20%	12%	Nil	Nil	Nil	Nil	Nil
Retinal haemorrhages	15%	Nil	Nil	Nil	Nil	Nil	Nil

Table-5: Age distribution of haematological malignancies.

Age group in years	NO OF CASES							Total
	AML	ALL	CML	CLL	NHL	MM	HL
>5	2	4	00	00	1	00	00	07
6-10	1	5	1	00	1	00	00	08
11-15	1	3	1	00	3	00	00	08
16-20	2	00	00	00	1	00	1	04
21-25	2	00	2	00	1	00	00	05
26-30	1	00	00	00	00	00	00	01
31-35	3	00