Mixed Phenotype Acute Leukemia, B/Myeloid with t(9;22): Diagnostic and Therapeutic Challenges

  • Namrata P. Awasthi
  • Poonam SinghEmail author
  • Narendra Agrawal

Dear Editor,

Mixed phenotype acute leukemia (MPAL) account for 4% of all cases of acute leukemia. Extensive immunophenotypic analysis is required for evaluation of these neoplasms, as morphologically distinct blast populations may not be evident [ 1]. The 2008/2016 WHO established strict criteria for diagnosis of MPAL, emphasizing assignment of myeloperoxidase for myeloid lineage, cytoplasmic CD3 for T lineage and CD19 and other B markers for B lineage (Table  1). WHO recognizes 2 distinct categories: MPAL with the t(9;22)(q34;q11)/ BCR- ABL1 and MPAL with t(v;11q23)/ MLL rearrangement. The remaining cases are designated as MPAL NOS (not otherwise specified).
Table 1

World Health Organization 2008/2016 criteria for mixed-phenotype blasts




MPO (flow cytometry, immunohistochemistry, or enzyme cytochemistry) –OR


Monocytic differentiation (at least 2 of the following: NSE cytochemistry, CD11c, CD14, CD64, lysozyme)

T lineage

Strong cytoplasmic CD3







Author Contributions

NPA: Definition of intellectual content, Literature search, Data acquisition, Data analysis, Manuscript editing, Manuscript review, Guarantor; PS: Design, Definition of intellectual content, Literature search, Data analysis, Statistical analysis, Manuscript preparation, Manuscript review, Guarantor; NA: Definition of intellectual content, Clinical studies, Data acquisition, Manuscript editing, Manuscript review, Guarantor.

Compliance with Ethical Standards

Conflicting interest

The authors declare that they have no conflicting interest.


  1. 1.
    Charles NJ, Boyer DF (2017) Mixed-phenotype acute leukemia diagnostic criteria and pitfalls. Arch Pathol Lab Med 141:1462–1468CrossRefGoogle Scholar
  2. 2.
    Borowitz MJ, Bene MC, Harris NL et al (2008) Acute leukemias of ambiguous lineage. In: Swerdlo SH, Campo E, Harris NL (eds) WHO classification of tumors of hematopoietic and lymphoid tissues, 4th edn. IARC, Lyon, pp 150–155Google Scholar
  3. 3.
    Arber DA, Orazi A, Hasserjian R et al (2016) The 2016 revision to the World Health Organization classification of myeloid neoplasms and acute leukemia. Blood 127(20):2391–2405CrossRefGoogle Scholar
  4. 4.
    Wolach O, Stone RM (2015) How I treat mixed-phenotype acute leukemia. Blood 125(16):2477–2485CrossRefGoogle Scholar
  5. 5.
    Porwit A, Béné MC (2015) Acute leukemias of ambiguous origin. Am J Clin Pathol 144(3):361–376CrossRefGoogle Scholar
  6. 6.
    Peters JM, Ansari MQ (2011) Multiparameter flow cytometry in the diagnosis and management of acute leukemia. Arch Pathol Lab Med 135:44–54Google Scholar
  7. 7.
    Matutes E, Pickl WF, Van’t Veer M, Morilla R, Swansbury J, Strobl H et al (2011) Mixed-phenotype acute leukemia: clinical and laboratory features and outcome in 100 patients defined according to the WHO 2008 classification. Blood 117(11):3163–3171CrossRefGoogle Scholar
  8. 8.
    Choi W, Kim M, Lim J et al (2014) Four cases of chronic myelogenous leukemia in mixed phenotype blast phase at initial presentation mimicking mixed phenotype acute leukemia with t(9;22). Ann Lab Med 34:60–63CrossRefGoogle Scholar
  9. 9.
    Weir EG, Ali Ansari-Lari M, Batista DA et al (2007) Acute bilineal leukemia: a rare disease with poor outcome. Leukemia 21(11):2264–2270CrossRefGoogle Scholar

Copyright information

© Indian Society of Hematology and Blood Transfusion 2018

Authors and Affiliations

  1. 1.Department of PathologyDr. Ram Manohar Lohia Institute of Medical SciencesLucknowIndia
  2. 2.Department of Lab MedicineSahara HospitalLucknowIndia
  3. 3.Rajiv Gandhi Cancer InstituteNew DelhiIndia

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