B-lymphoblastic Leukemia/Lymphoma

doi:10.1017/9781009397797.021

Chapter 21 - B-lymphoblastic Leukemia/Lymphoma

from Section 3 - Acute Lymphoblastic Leukemia/Lymphoma

Published online by Cambridge University Press: 20 May 2026

Sa A. Wang

Edited by

Wei Wang and

Sa A. Wang

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Wei Wang: Affiliation:
The University of Texas MD Anderson Cancer Center
Sa A. Wang: Affiliation:
The University of Texas MD Anderson Cancer Center

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Summary

This chapter covers initial diagnosis of B-lymphoblastic leukemia (B-ALL), and measurable disease detection (MRD) post therapy by flow cytometry. The classic and variant immunophenotypic features of B-ALL are illustrated, correlated with molecular genetic characteristics, and summarized in a genotype-phenotype table. The key features are provided in the differential diagnosis of B-ALL with aberrant MPO versus mixed B/myeloid acute leukemia (MPAL), as well as B-ALL with a mature phenotype versus high grade B cell lymphoma. Under B-ALL MRD detection, the common immunophenotypic alterations are demonstrated by comparing them to normal immature B cells (hematogones). Strategies for MRD detection post targeted therapy are also discussed. The pros and cons of flow cytometry MRD are compared with molecular MRD, including NGS sequencing (Clonoseq) and BCR::ABL1 quantitative PCR. The challenges, including loss of lineage markers, lineage switch, and normal mimics, are discussed and illustrated under diagnostic pitfalls.

Keywords

B-lymphoblastic leukemia B-ALL genotype phenotype correlation MPO mixed phenotype acute leukemia immunophenotypic heterogeneity hematogones ETV6::RUNX1 TCF::PBX1 KMT2A lineage switch target therapy CD19-negative relapse CD24 Clonoseq BCR:ABL1 CRLF2 stage 0 hematogones

Information

Type: Chapter
Information: Flow Cytometry in Hematolymphoid Neoplasms
A Comprehensive and Practical Guide to Diagnosis
, pp. 185 - 204
DOI: https://doi.org/10.1017/9781009397797.021 [Opens in a new window]
Publisher: Cambridge University Press
Print publication year: 2026

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References

Khoury, JD, Solary, E, Abla, O, Akkari, Y, Alaggio, R, Apperley, JF, et al. The 5th edition of the World Health Organization, classification of haematolymphoid tumours: Myeloid and histiocytic/dendritic neoplasm. Leukemia 2022; 36(7): 1703–1719.10.1038/s41375-022-01613-1CrossRef Google Scholar

Arber, DA, Orazi, A, Hasserjian, RP, Borowitz, MJ, Calvo, KR, Kvasnicka, H-M, et al. International Consensus Classification of myeloid neoplasms and acute leukemias: Integrating morphologic, clinical, and genomic data. Blood 2022; 140(11): 1200–1228.10.1182/blood.2022015850CrossRef Google Scholar PubMed

Duffield, AS, Mullighan, CG, Borowitz, MJ. International Consensus Classification of acute lymphoblastic leukemia/lymphoma. Virchows Arch 2023; 482(1): 11–26.10.1007/s00428-022-03448-8CrossRef Google Scholar PubMed

Alduailej, H, Kanfar, S, Bakhit, K, Raslan, H, Alsaber, A, Bashawri, L, et al. Outcome of CD20-positive adult B-cell acute lymphoblastic leukemia and the impact of rituximab therapy. Clin Lymphoma Myeloma Leuk 2020; 20(9): e560–e568.10.1016/j.clml.2020.04.008CrossRef Google Scholar PubMed

Tsagarakis, NJ, Papadhimitriou, SI, Pavlidis, D, Marinakis, T, Kostopoulos, IV, Stiakaki, E, et al. Flow cytometric predictive scoring systems for common fusions ETV6/RUNX1, BCR/ABL1, TCF3/PBX1 and rearrangements of the KMT2A gene, proposed for the initial cytogenetic approach in cases of B-acute lymphoblastic leukemia. Int J Lab Hematol 2019; 41(3): 364–372.10.1111/ijlh.12983CrossRef Google Scholar PubMed

Lopez-Millan, B, Sanchez-Martinez, D, Roca-Ho, H, Gutierrez-Aguera, F, Molina, O, Diaz de la Guardia, R, et al. NG2 antigen is a therapeutic target for MLL-rearranged B-cell acute lymphoblastic leukemia. Leukemia 2019; 33(7): 1557–1569.10.1038/s41375-018-0353-0CrossRef Google Scholar PubMed

Blin, N, Mechinaud, F, Talmant, P, Garand, R, Boutard, P, Dastugue, N, et al. Mature B-cell lymphoblastic leukemia with MLL rearrangement: An uncommon and distinct subset of childhood acute leukemia. Leukemia 2008; 22(5): 1056–1059.10.1038/sj.leu.2404992CrossRef Google Scholar PubMed

Deucher, AM, Qi, Z, Yu, J, George, TI, Etzell, JE. BCL6 expression correlates with the t(1;19) translocation in B-lymphoblastic leukemia. Am J Clin Pathol 2015; 143(4): 547–557.10.1309/AJCPO4U4VYAAOTELCrossRef Google Scholar

Konoplev, S, Lu, X, Konopleva, M, Jain, N, Ouyang, J, Goswami, M, et al. CRLF2-positive B-cell acute lymphoblastic leukemia in adult patients: A single-institution experience. Am J Clin Pathol 2017; 147(4): 357–363.10.1093/ajcp/aqx005CrossRef Google Scholar PubMed

Tzankov, A, Reichard, KK, Hasserjian, RP, Arber, DA, Orazi, A, Wang, SA. Updates on eosinophilic disorders. Virchows Arch 2023; 482(1): 85–97.10.1007/s00428-022-03402-8CrossRef Google Scholar PubMed

Schinnerl, D, Mejstrikova, E, Schumich, A, Zaliova, M, Fortschegger, K, Nebral, K, et al. CD371 cell surface expression: A unique feature of DUX4-rearranged acute lymphoblastic leukemia. Haematologica 2019; 104(8): e352–e355.10.3324/haematol.2018.214353CrossRef Google Scholar PubMed

Fawzy, MM, Abd, El-hafez A, El-Ashwah, S, Abouzeid, TE, Waheeb, MF, Saif, M, et al. Isolated myeloperoxidase immunohistochemical expression in bone marrow biopsy depicts clinical outcomes in adults with typical B-acute lymphoblastic leukemia. Asian Pac J Cancer Prev 2021; 22(7): 2143–2152.10.31557/APJCP.2021.22.7.2143CrossRef Google Scholar PubMed

Oberley, MJ, Li, S, Orgel, E, Phei, Wee C, Hagiya, A, O’Gorman, MRG. Clinical significance of isolated myeloperoxidase expression in pediatric B-lymphoblastic leukemia. Am J Clin Pathol 2017; 147(4): 374–381.10.1093/ajcp/aqx021CrossRef Google Scholar PubMed

Qiu, L, Wang, SA, Tang, G, Wang, W, Lin, P, Xu, J, et al. Blastoid B-cell neoplasms: Diagnostic challenges and solutions. Cancers (Basel) 2023; 15(3): 848.10.3390/cancers15030848CrossRef Google Scholar PubMed

Wang, SA, Orazi, A, Gotlib, J, Reiter, A, Tzankov, A, Hasserjian, RP, et al. The International Consensus Classification of eosinophilic disorders and systemic mastocytosis. Am J Hematol 2023; 98(8): 1286–1306.10.1002/ajh.26966CrossRef Google Scholar PubMed

Kamoda, Y, Izumi, K, Iioka, F, Akasaka, T, Nakamura, F, Kishimori, C, et al. Philadelphia chromosome-positive acute lymphoblastic leukemia is separated into two subgroups associated with survival by BCR-ABL fluorescence in situ hybridization of segmented cell nuclei: Report from a single institution. Acta Haematol 2016; 136(3): 157–166.10.1159/000445972CrossRef Google Scholar PubMed

Nishiwaki, S, Kim, JH, Ito, M, Maeda, M, Okuno, Y, Koyama, D, et al. Multi-lineage BCR-ABL expression in Philadelphia chromosome-positive acute lymphoblastic leukemia is associated with improved prognosis but no specific molecular features. Front Oncol 2020; 10: 586567.10.3389/fonc.2020.586567CrossRef Google Scholar PubMed

Nagel, I, Bartels, M, Duell, J, Oberg, HH, Ussat, S, Bruckmueller, H, et al. Hematopoietic stem cell involvement in BCR-ABL1-positive ALL as a potential mechanism of resistance to blinatumomab therapy. Blood 2017; 130(18): 2027–2031.10.1182/blood-2017-05-782888CrossRef Google Scholar

Van Wering, ER, Beishuizen, A, Roeffen, ET, van der Linden-Schrever, BE, Verhoeven, MA, Hahlen, K, et al. Immunophenotypic changes between diagnosis and relapse in childhood acute lymphoblastic leukemia. Leukemia 1995; 9(9): 1523–1533.Google Scholar PubMed

Chatterjee, G, Sriram, H, Ghogale, S, Deshpande, N, Khanka, T, Panda, D, et al. Immunophenotypic shift in the B-cell precursors from regenerating bone marrow samples: A critical consideration for measurable residual disease assessment in B-lymphoblastic leukemia. Cytometry B Clin Cytom 2021; 100(4): 434–445.10.1002/cyto.b.21951CrossRef Google Scholar

Sedek, L, Theunissen, P, Sobral da Costa, E, van der Sluijs-Gelling, A, Mejstrikova, E, Gaipa, G, et al. Differential expression of CD73, CD86 and CD304 in normal vs. leukemic B-cell precursors and their utility as stable minimal residual disease markers in childhood B-cell precursor acute lymphoblastic leukemia. J Immunol Methods 2019; 475: 112429.10.1016/j.jim.2018.03.005CrossRef Google Scholar PubMed

Theunissen, P, Mejstrikova, E, Sedek, L, van der Sluijs-Gelling, AJ, Gaipa, G, Bartels, M, et al. Standardized flow cytometry for highly sensitive MRD measurements in B-cell acute lymphoblastic leukemia. Blood 2017; 129(3): 347–357.10.1182/blood-2016-07-726307CrossRef Google Scholar PubMed

Chen, X, Gao, Q, Roshal, M, Cherian, S. Flow cytometric assessment for minimal/measurable residual disease in B lymphoblastic leukemia/lymphoma in the era of immunotherapy. Cytometry B Clin Cytom 2023; 104(3): 205–223.10.1002/cyto.b.22113CrossRef Google Scholar

Kantarjian, HM, Stock, W, Cassaday, RD, DeAngelo, DJ, Jabbour, E, O’Brien, SM, et al. Inotuzumab ozogamicin for relapsed/refractory acute lymphoblastic leukemia in the INO-VATE trial: CD22 pharmacodynamics, efficacy, and safety by baseline CD22. Clin Cancer Res 2021; 27(10): 2742–2754.10.1158/1078-0432.CCR-20-2399CrossRef Google Scholar PubMed

Jabbour, E, Gokbuget, N, Advani, A, Stelljes, M, Stock, W, Liedtke, M, et al. Impact of minimal residual disease status in patients with relapsed/refractory acute lymphoblastic leukemia treated with inotuzumab ozogamicin in the phase III INO-VATE trial. Leuk Res 2020; 88: 106283.10.1016/j.leukres.2019.106283CrossRef Google Scholar PubMed

Xu, X, Sun, Q, Liang, X, Chen, Z, Zhang, X, Zhou, X, et al. Mechanisms of relapse after CD19 CAR T-cell therapy for acute lymphoblastic leukemia and its prevention and treatment strategies. Front Immunol 2019; 10: 2664.10.3389/fimmu.2019.02664CrossRef Google Scholar PubMed

Cherian, S, Miller, V, McCullouch, V, Dougherty, K, Fromm, JR, Wood, BL. A novel flow cytometric assay for detection of residual disease in patients with B-lymphoblastic leukemia/lymphoma post anti-CD19 therapy. Cytometry B Clin Cytom 2018; 94(1): 112–120.10.1002/cyto.b.21482CrossRef Google Scholar PubMed

Wood, B, Wu, D, Crossley, B, Dai, Y, Williamson, D, Gawad, C, et al. Measurable residual disease detection by high-throughput sequencing improves risk stratification for pediatric B-ALL. Blood 2018; 131(12): 1350–1359.10.1182/blood-2017-09-806521CrossRef Google Scholar PubMed

Short, NJ, Kantarjian, H, Ravandi, F, Konopleva, M, Jain, N, Kanagal-Shamanna, R, et al. High-sensitivity next-generation sequencing MRD assessment in ALL identifies patients at very low risk of relapse. Blood Adv 2022; 6(13): 4006–4014.10.1182/bloodadvances.2022007378CrossRef Google Scholar PubMed

Zaliova, M, Fronkova, E, Krejcikova, K, Muzikova, K, Mejstrikova, E, Stary, J, et al. Quantification of fusion transcript reveals a subgroup with distinct biological properties and predicts relapse in BCR/ABL-positive ALL: Implications for residual disease monitoring. Leukemia 2009; 23(5): 944–951.10.1038/leu.2008.386CrossRef Google Scholar PubMed

Nishiwaki, S, Imai, K, Mizuta, S, Kanamori, H, Ohashi, K, Fukuda, T, et al. Impact of MRD and TKI on allogeneic hematopoietic cell transplantation for Ph+ALL: A study from the adult ALL WG of the JSHCT. Bone Marrow Transplant 2016; 51(1): 43–50.10.1038/bmt.2015.217CrossRef Google Scholar PubMed

Kovach, AE, Wood, BL. Updates on lymphoblastic leukemia/lymphoma classification and minimal/measurable residual disease analysis. Semin Diagn Pathol 2023; 40(6): 457–471.10.1053/j.semdp.2023.10.001CrossRef Google Scholar PubMed

Novakova, M, Zaliova, M, Fiser, K, Vakrmanova, B, Slamova, L, Musilova, A, et al. DUX4 r, ZNF384 r and PAX5-P80 r mutated B-cell precursor acute lymphoblastic leukemia frequently undergo monocytic switch. Haematologica 2021; 106(8): 2066–2075.10.3324/haematol.2020.250423CrossRef Google Scholar

Ramalingam, TR, Vaidhyanathan, L, Muthu, A, Swaminathan, VV, Uppuluri, R, Raj, R. Deciphering stage 0 hematogones by flow cytometry in follow-up bone marrow samples of pediatric B-acute lymphoblastic leukemia cases: A potential mimicker of residual disease after anti CD19 therapy. Cytometry B Clin Cytom 2024; 106(2): 92–98.10.1002/cyto.b.22159CrossRef Google Scholar

Zhou, T, Karrs, J, Ho, T, Doverte, A, Kochenderfer, JN, Shah, NN, et al. Circulating CD22+/CD19−/CD24− progenitors and CD22+/CD19+/CD24− mature B cells: Diagnostic pitfalls for minimal residual disease detection in B-lymphoblastic leukemia. Cytometry B Clin Cytom 2023; 104(4): 294–303.10.1002/cyto.b.22104CrossRef Google Scholar PubMed

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