Leukemia is a malignant disease of the blood-forming tissues characterized by abnormal proliferation of white blood cells. It presents clinically with anemia, recurrent infections, bleeding tendencies, and organ enlargement, and it remains one of the most common hematological cancers worldwide. According to global cancer statistics, leukemia contributes a small proportion of overall cancer incidence but carries a significant impact on childhood cancer burden, representing nearly one-third of pediatric malignancies. The occurrence of various subtypes—acute lymphoblastic leukemia (ALL), acute myeloid leukemia (AML), chronic lymphocytic leukemia (CLL), and chronic myeloid leukemia (CML)—differs by age group and geographic region. While acute forms dominate in children, chronic leukemias are more often seen in adults. Such variation underlines the need for region-specific data to improve diagnostic accuracy and optimize health services.

In India, leukemias constitute a considerable share of both childhood and adult cancers, but their epidemiology is not uniform across the country. Reports from major urban centers suggest that acute leukemias, particularly in children and young adults, are common, while chronic leukemias also show an earlier age of onset compared with Western populations. For example, CML, which typically peaks in the fourth or fifth decade in Western countries, has been reported more frequently in the second and third decades in Indian series. These differences may arise from genetic background, environmental exposures, or referral patterns. Despite the large population of Eastern Uttar Pradesh and its neighboring regions, systematic data on leukemia distribution are limited. Understanding the local burden and subtype pattern is therefore essential to guide clinical decision-making and regional healthcare planning.

Accurate classification of leukemia is vital for treatment selection and prognosis. The World Health Organization recommends an integrated approach that includes morphology, cytochemistry, immunophenotyping, cytogenetics, and molecular studies. However, such facilities are not consistently available in resource-limited areas of India. Many hospitals rely mainly on peripheral smear examination, bone marrow morphology, and basic cytochemical stains. As a result, a significant proportion of patients are labeled as having “acute leukemia, unclassified,” which reflects limitations in diagnostic capacity rather than true biological distinctiveness. Highlighting this issue can help underline the importance of strengthening laboratory infrastructure and making advanced tests more accessible, so that patients receive timely and accurate diagnoses.

For primary care and family physicians, who are usually the first point of contact, awareness of the clinical and hematological spectrum of leukemia is critical. Symptoms such as pallor, fever, or unexplained bleeding are often attributed to nutritional anemia or infection in rural practice, which can delay referral and definitive management. Early suspicion, simple blood tests, and prompt referral can greatly improve outcomes, particularly in acute leukemias that progress rapidly. This study, undertaken at Banaras Hindu University in Varanasi, aims to describe the clinicopathological profile of leukemia cases diagnosed over three years. By analyzing age distribution, sex ratio, hematological findings, and subtype frequencies among 283 patients, the study addresses a key knowledge gap for Eastern Uttar Pradesh and provides evidence to strengthen both specialized hematology services and the capacity of frontline practitioners in early detection.

Study Design and Setting

This prospective observational study was conducted in the Department of Family Medicine and Primary Care, Banaras Hindu University, Varanasi, from January 2019 to March 2022.

Study Population

A total of 283 consecutive patients of all ages and both sexes, newly diagnosed with leukemia, were included. Cases of relapse and incomplete records were excluded.

Diagnostic Workup

All patients underwent detailed clinical examination, complete blood count (CBC), peripheral smear evaluation, and bone marrow aspiration/biopsy. Sudan Black B (SBB) staining was performed when indicated. Flow cytometry was performed in a subset of 10 cases to further classify undifferentiated acute leukemias. Diagnosis was established according to WHO classification.

Data Analysis

Demographic variables (age, sex), subtype distribution, and hematological parameters (hemoglobin, total leukocyte count, platelet count) were recorded. Data were analyzed using descriptive statistics (frequency, percentage, mean, and range).

Demographics

A total of 283 patients were included, of whom 192 were male and 91 female, giving a male-to-female ratio of 2.1:1. The mean age at presentation was 26.8 years, with a median of 20 years. The largest group was children aged 0–10 years, followed by young adults in the second and third decades.

Subtype Distribution

The most frequent subtype was acute leukemia, unclassified (92 cases, 32.5%), followed by CML (73 cases, 25.8%), ALL (52 cases, 18.4%), AML (52 cases, 18.4%), and CLL (10 cases, 3.5%). Rare entities included plasma cell leukemia, chronic eosinophilic leukemia, hairy cell leukemia, and chronic myelomonocytic leukemia (4 cases, 1.4%).

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Figure 1. Distribution of Leukemia Subtypes

Hematological Findings

Anemia was the most consistent finding across all groups. Thrombocytopenia was particularly common in acute leukemias, while CML cases often showed normal or raised platelet counts. Total leukocyte count (TLC) varied:

• ALL patients frequently presented with marked leukocytosis (>100,000/µL).
• AML showed variable TLC, with both leukopenic and leukocytotic presentations.
• CML patients were mostly in the chronic phase, with elevated TLC but preserved hemoglobin levels in some cases.

Figure 2. Hemoglobin Distribution Across Subtypes

Figure 3. Sex Distribution by Subtype

Figure 4. Platelet Count Patterns Across Subtypes

Flow Cytometry Sub-analysis

Among 10 cases initially categorized as acute leukemia, unclassified:

• 4 were reclassified as AML,
• 3 as ALL,
• 1 as T-ALL,
• while 2 remained unclassified.

This highlights the limitations of relying solely on morphology and cytochemistry, and the value of immunophenotyping in refining diagnosis.

Leukemia remains one of the most challenging hematological malignancies because of its wide clinical spectrum and the regional differences in its epidemiology. The present study from Eastern Uttar Pradesh, based on 283 cases, offers valuable data from a region where published information is sparse. Our findings demonstrate that acute leukemias constituted nearly two-thirds of cases, with acute leukemia, unclassified, being the single largest subgroup. The mean age at presentation was 26.8 years, which is considerably lower than that reported in Western literature. In addition, there was a strong male predominance, with a male-to-female ratio of 2.1:1. These results not only confirm earlier trends noted in parts of India but also highlight specific gaps in diagnostic facilities that need to be addressed.

When placed against global studies, several contrasts become evident. In Europe and North America, chronic lymphocytic leukemia (CLL) is the most common leukemia in adults, typically presenting in the elderly, whereas in our cohort CLL accounted for only 3.5% of cases. Similarly, the median age of leukemia patients in Western series often exceeds 60 years, while our median was 20 years. Chronic myeloid leukemia (CML), which accounts for around 10–15% of cases internationally, represented more than a quarter of cases here and was often seen in younger adults. Such differences underscore that Indian and Western populations have distinct epidemiological patterns, which may be influenced by environmental factors, genetic susceptibility, or differences in healthcare access.

Findings from other Indian centers provide both similarities and differences. Studies from Delhi and Mumbai have documented CML as the most frequent adult leukemia, often comprising 30–40% of cases, similar to the high proportion in our cohort. However, those reports noted a smaller overall burden of acute leukemias compared with the nearly 70% observed here. A study from Lucknow also documented a predominance of acute cases and younger ages at presentation, suggesting regional consistency in northern India. On the other hand, centers in southern India, such as Vellore, have described a higher proportion of AML among adults and fewer unclassified cases, likely reflecting wider use of immunophenotyping. These variations highlight how diagnostic facilities and referral practices can shape observed case distributions.

Hematological profiles in our patients were in keeping with classical descriptions, but the patterns also carried important clinical significance. Anemia was nearly universal, pointing to the need for transfusion support at the time of diagnosis. Thrombocytopenia was particularly pronounced in acute leukemias, increasing the risk of bleeding complications, while CML patients frequently had normal or even elevated platelet counts. Hyperleukocytosis, observed in many ALL cases, has been described in earlier Indian series and is associated with complications such as leukostasis and tumor lysis syndrome. Recognizing these laboratory features is crucial not only for hematologists but also for physicians in peripheral centers, as they can indicate life-threatening risks that demand urgent referral and intervention.

One of the more distinctive features of this study was the high proportion of “acute leukemia, unclassified.” While smaller numbers of unclassified cases have been reported from other Indian centers, our figure of 32.5% is considerably higher. The explanation lies largely in the limited access to flow cytometry, which is essential for distinguishing between myeloid and lymphoid lineages in poorly differentiated cases. In the small subset where immunophenotyping was performed, most cases could be reassigned to AML or ALL. This gap is not merely academic—precise classification is critical for determining treatment strategy, as ALL and AML protocols differ significantly, and some subtypes carry specific therapeutic targets. Expanding immunophenotyping facilities in regional centers would therefore directly improve patient care.

Gender distribution also deserves comment. Our male-to-female ratio of 2.1:1 is higher than most Western reports, which generally range around 1.3–1.5:1, but comparable to figures from several Indian series. While biological factors may contribute, healthcare-seeking behavior is an important consideration. In many parts of India, male patients are more likely to be brought for specialist care, while female patients may face delays or underreporting. This imbalance underlines the need for awareness campaigns to promote timely diagnosis in both sexes, as delayed presentation adversely affects outcomes.

Finally, the implications for family medicine and primary care must be emphasized. In our region, many patients first present to local practitioners with vague symptoms such as pallor, fever, or fatigue. Because nutritional anemia and infections are so common, leukemia may not be suspected until the disease is advanced. A simple complete blood count, however, can provide early clues such as anemia with thrombocytopenia or unexplained leukocytosis. For frontline physicians, maintaining vigilance and arranging timely referral can make the difference between survival and rapid decline, especially in acute leukemias. Our findings, when compared with other Indian and global studies, demonstrate that strengthening primary care recognition, coupled with improved diagnostic facilities in tertiary centers, is essential for reducing the burden of leukemia in this region.

Leukemia in Eastern Uttar Pradesh is characterized by a predominance of acute and pediatric cases, with a significant burden of unclassified acute leukemias due to diagnostic limitations. Strengthening diagnostic infrastructure and raising awareness among family physicians are essential to improve early detection and timely referral.

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