CH6 - White Blood Cell Disorders Flashcards
1
Q
What does hematopoetic CD34+ stem cells produce?
A
Myeloid stem cells and lymphoid stem cells
2
Q
What does myeloid stem cells produce?
A
Erythroblast, Myeloblast, Monoblast, Megakaryoblast
3
Q
What does erythroblast produce?
A
RBCs
4
Q
What does myeloblast produce?
A
Neutrophils, basophils, Eosinophils
5
Q
What does monoblast produce?
A
Monocytes
6
Q
What does megakaryoblast produce?
A
megakaryocytes
7
Q
What does lymphoid stem cells produce?
A
B lymphoblast and T Lymphoblast
8
Q
What does B lymphoblast produce?
A
Naïve Bcells
9
Q
What does Naïve B cells produce?
A
Plasma cells
10
Q
What does T lymphoblast produce?
A
Naïve Tcells
11
Q
What does Naïve T cells produce?
A
CD8+ and CD4+ T cells
12
Q
How does hematopoiesis occur?
A
via a stepwise maturation of CD34+ hematopoietic stem cells
13
Q
What happens to hematopoetic stem cells?
A
Cells mature and are released from the bone marrow into the blood.
14
Q
What is the normal white blood cell (WBC) count?
A
it is approximately 5-10 K/pL
15
Q
What is a low WBC count? What is it called?
A
(< 5 K) is called leukopenia.
16
Q
What is a high WBC count? What is it called?
A
(> 10 K) is called leukocytosis.
17
Q
What is a low or high WBC count usually due to?
A
a decrease or increase in one particular cell lineage.
18
Q
What is neutropenia?
A
refers to a decreased number of circulating neutrophils
19
Q
What are some of the causes of neutropenia?
A
1) Drug toxicity 2) severe infection
20
Q
How can drug toxicity lead to neutropenia?
A
e.g., chemotherapy with alkylating agents, cause damage to stem cells resulting in decreased production of WBCs, especially neutrophils.
21
Q
How does severe infection lead to neutropenia?
A
e.g., gram-negative sepsis leads to increased movement of neutrophils into tissues resulting in decreased circulating neutrophils.
22
Q
What is GM-CSF or G-CSF?
A
granulocyte monocyte stimulating factor or granulocyte stimulating factor, it can be used to boost the neutrophil count decreasing the risk of infection
23
Q
What is lymphopenia?
A
it refers to a decreased number of circulating lymphocytes
24
Q
What are the some of the causes of lymphopenia?
A
1) immunodeficiency 2) high cortisol state 3) autoimmune destruction 4) whole body radiation
25
What are some examples of immunodeficiency that lead to lymphopenia?
e.g., DiGeorge syndrome or HIV
26
How does a High Cortisol state lead to lymphopenia?
exogenous corticosteroids or Cushing syndrome, induces apoptosis of lymphocytes
27
What is an example of autoimmune destruction leading to lymphopenia?
e.g., systemic lupus erythematosus
28
How can whole body radiation lead to lymphopenia?
Lymphocytes are highly sensitive to radiation; lymphopenia is the earliest change to emerge after whole body radiation
29
What are the different types of leukocytosis?
1) neutrophilic leukocytosis 2) monocytosis 3) Eosinophilia 4) Basophilia 5) Lymphocytic leukocytosis
30
What does neutrophilic leukocytosis refer to?
increased circulating neutrophils
31
What are the causes of neutrophilic leukocytosis?
1) Bacterial infection 2) tissue necrosis 3) High cortisol state
32
How does Bacterial infection or tissue necrosis lead to neutrophilic leukocytosis?
It induces release of marginated pool and bone marrow neutrophils, including immature forms (left shift)
33
When immature cells are released into the blood, how are they characterized?
by decreased Fc receptors
34
What is the marker for the decreased Fc receptor?
CD16
35
Why are Fc receptors important?
They help the neutrophil to recognize immunoglobulin which is going to act as an opsonin for phagocytosis
36
How does high cortisol state lead to neutrophilic leukocytosis?
impairs leukocyte adhesion, leading to release of marginated pool of neutrophils
37
What does monocytosis refer to?
increased circulating monocytes
38
What are the causes of monocytosis?
inflammatory states (e.g., autoimmune and infections) and malignancy.
39
What does eosinophilia refer to?
increased circulating eosinophils
40
What are the causes of eosinophilia?
include allergic reactions (type I hypersensitivity), parasitic infections, and Hodgkin lymphoma,
41
What is eosinophilia driven by?
increased eosinophil chemotactic factor
42
What does basophilia refer to?
increased circulating basophils
43
What is basophilia classically seen in?
chronic myeloid leukemia
44
What does lymphocytic leukocytosis refer to?
increased circulating lymphocytes
45
What are the causes of lymphocytic leukocytosis?
1) viral infection 2) Bordetella pertussis infection
46
How does viral infections lead to lymphocytic leukocytosis?
T lymphocytes undergo hyperplasia in response to virally infected cells
47
How does Bordetella pertussis infection lead to lymphocytic leukocytosis?
Bacteria produce lymphocytosis-promoting factor, which blocks circulating lymphocytes from leaving the blood to enter the lymph node.
48
What is infectious mononucleosis?
EBV infection that results in a lymphocytic leukocytosis comprised of reactive CD8+ T cells; CMV is a less common cause
49
How is EBV transmitted?
by saliva (kissing disease); classically affects teenagers
50
What does EBV primarily infect?
1. Oropharynx, resulting in pharyngitis 2. Liver, resulting in hepatitis with hepatomegaly and elevated liver enzymes 3. B cells
51
CD8+ T-cell response leads to what?
1) LAD 2) Splenomegaly 3) High WBC count with atypical lymphocytes (reactive CD8+ T cells) in the blood
52
How does the CD8+ T cell response lead to generalized lymphadenopathy (LAD)?
It is due to T-cell hyperplasia in the lymph node paracortex
53
How does CD8+ T cell response lead to splenomegaly?
It is due to T-cell hyperplasia in the periarterial lymphatic sheath (PALS)
54
What is used for screening of IM?
The monospot test
55
What does the monospot test do?
Detects IgM antibodies that cross-react with horse sheep red blood cells (heterophile antibodies)
56
When would the monospot test turn positive?
Usually turns positive within 1 week after infection
57
What would a negative monospot test suggest?
CMV as a possible cause of IM
58
How is a definitive diagnosis for IM made?
by serologic testing for the EBV viral capsid antigen.
59
What are the complications of EBV?
1) increased risk for splenic rupture 2) Rash 3) Recurrence and B cell lymphoma
60
What are patients told who have an increased risk for splenic rupture?
patients are generally advised to avoid contact sports for one year.
61
When might a rash develop as a complication of EBV?
if exposed to ampicillin
62
With EBV complications, why is there a risk of recurrence and B cell lymphoma?
Dormancy of virus in B cells leads to increased risk for both recurrence and B-cell lymphoma, especially if immunodeficiency (e.g., HIV) develops.
63
What is acute leukemia?
Neoplastic proliferation of blasts; defined as the accumulation of >20% blasts in the bone marrow.
64
What is the acute presentation for acute leukemia?
Anemia (fatigue), thrombocytopenia (bleeding), or neutropenia (infection)
65
What is the reason for the acute presentation of acute leukemia?
Increased blasts crowd-out normal hematopoiesis,
66
In acute leukemia, why is there a high WBC count?
Blasts usually enter the blood stream, resulting in a high WBC count
67
Describe blasts.
they are large, immature cells, often with punched out nucleoli
68
What is acute leukemia subdivided into?
acute lymphoblastic leukemia (ALL) or acute myelogenous leukemia (AML)
69
The subdivision of acute leukemia is based on what?
the phenotype of the blasts.
70
What is acute lymphoblastic leukemia?
Neoplastic accumulation of lymphoblasts (> 20%) in the bone marrow
71
Why is TdT useful in characterizing lymphoblasts?
It is absent in myeloid blasts and mature lymphocytes.
72
Acute lymphoblastic leukemia most commonly arises in whom?
children
73
What is acute lymphoblastic leukemia associated with and when does it usually arise?
Down syndrome (usually arises after the age of 5 years)
74
Acute lymphoblastic leukemia is subclassified into? What is it based on?
B-ALL and T-ALL based on surface markers
75
What is the most common type of ALL?
B-ALL
76
What is B-ALL usually characterized by?
lymphoblasts (TdT+) that express CD10, CD19, and CD20.
77
What is the treatment for B-ALL?
Excellent response to chemotherapy; requires prophylaxis to scrotum and CSf
78
What is the prognosis B-ALL based on?
It is based on cytogenetic abnormalities,
79
Which B-ALL has a good prognosis and is more commonly seen in children?
t(12;21)
80
Which B-ALL has a poor prognosis and in what population is it seen?
t(9;22) has a poor prognosis; more commonly seen in adults (Philadelphia+ALL)
81
What is T-ALL characterized by?
lymphoblasts (TdT+) that express markers ranging from CD2 to CDH (e.g., CD3, CD4, CD7). The blasts do not express CD10.
82
How does T-ALL usually present?
Usually presents in teenagers as a mediastinal (thymic) mass (called acute lymphoblastic lymphoma because the malignant cells form a mass)
83
What is acute myeloid leukemia?
Neoplastic accumulation of myeloblasts (> 20%) in the bone marrow
84
How are myeloblasts usually characterized?
by positive cytoplasmic staining for myeloperoxidase (MPO)
85
What may be seen in the characterization of myeloblasts?
Crystal aggregates of MPO may be seen as Auer rods
86
In whom does acute myeloid leukemia most commonly arise?
older adults (average age is 50-60 years)
87
What is the subclassification of AML based on?
cytogenetic abnormalities, lineage of myeloblasts, and surface markers.
88
What are the high-yield subtypes?
Acute promyelocytic leukemia, Acute monocytic leukemia and acute megakaryoblastic leukemia
89
What is acute promyelocytic leukemia characterized by?
t(15;17), which involves translocation of the retinoic acid receptor (RAR) on chromosome 17 to chromosome 15
90
What is the effect of RAR disruption?
It blocks maturation and promyelocytes (blasts) accumulate
91
How does acute promyelocytic leukemia lead to increased risk for DIC?
Abnormal promyelocytes contain numerous primary granules that increase the risk for DIC
92
What is the treatment for acute promyelocytic leukemia?
with all-trans retinoic acid (ATRA, a vitamin A derivative)
93
How does ATRA work?
It binds the altered receptor and causes the blasts to mature (and eventually die)
94
What is acute monocytic leukemia?
Proliferation of monoblasts; usually lack MPO
95
In acute monocytic leukemia what do blasts characteristically do?
infiltrate gums
96
What is acute megakaryoblastic leukemia?
Proliferation of megakaryoblasts; lack MPO
97
What is acute monocytic leukemia associated with?
Down syndrome (usually arises before the age of 5)
98
What is myelodysplastic syndrome?
acute myeloid leukemia may also arise from pre-existing dysplasia = myelodysplastic syndromes, especially with prior exposure to alkylating agents or radiotherapy
99
What do myelodysplastic syndromes usually present with?
cytopenias, hypercellular bone marrow, abnormal maturation of cells, and increased blasts < 20%
100
With myelodysplastic syndromes resulting in acute myeloid dysplastic syndrome what do most patients die from?
Most patients die from infection or bleeding, though some progress to acute leukemia.
101
What is chronic leukemia?
Neoplastic proliferation of mature circulating lymphocytes
102
What is chronic leukemia characterized by?
a high WBC count
103
Describe the onset of chronic leukemia?
Usually insidious in onset and seen in older adults
104
What is chronic lymphocytic leukemia?
Neoplastic proliferation of naive B cells that co-express CD5 and CD20;
105
What is the most common leukemia overall?
Chronic lymphocytic leukemia (CLL)
106
In CLL what is seen on the blood smear?
Increased lymphocytes and smudge cells are seen on blood smear
107
small lymphocytic lymphoma
In CLL, with involvement of lymph nodes leads to generalized lymphadenopathy
108
What are the complications of CLL?
1) Hypogammaglobulinemia, 2) autoimmune hemolytic anemia, 3) Richter transformation
109
What is the most common of death in CLL?
infection
110
What is Richter transformation?
transformation to diffuse large B-cell lymphoma
111
What is Richter transformation marked clinically by?
an enlarging lymph node or spleen
112
What is Hairy cell leukemia?
Neoplastic proliferation of mature B cells
113
What characterizes hairy cell leukemia?
hairy cytoplasmic processes
114
What are hairy cell leukemia cells positive for?
tartrate-resistant acid phosphatase (TRAP).
115
What are the clinical features for hairy cell leukemia?
Splenomegaly, dry tap on bone marrow aspiration
116
Why is there splenomegaly in hairy cell leukemia?
Due to accumulation of hairy cells in red pulp
117
Why is there a dry tap on bone marrow aspiration in hairy cell leukemia?
due to marrow fibrosis
118
How is lymphadenopathy related to hair cell leukemia?
Lymphadenopathy is usually absent
119
What drug is used in the treatment of hairy cell leukemia?
2-CDA (cladribine)
120
How does hair cell leukemia respond to cladribine?
excellent response
121
How does cladribine work?
Its an adenosine deaminase inhibitor, adenosine accumulates to toxic levels in neoplastic B cells.
122
What is adult T cell leukemia?
Neoplastic proliferation of mature CD4+ T cells (ATLL)
123
What is adult T cell leukemia associated with?
Associated with HTLV-I (human T cell lymphotrophic virus -1)
124
Where is ATLL associated with HTLV-1 most commonly seen in?
Japan and the Caribbean
125
What are the clinical features for ATLL?
include rash (skin infiltration), generalized lymphadenopathy with hepatosplenomegaly, and lytic (punched-out) bone lesions with hypercalcemia
126
What is mycosis fungoides?
Neoplastic proliferation of mature CD44 T cells that infiltrate the skin, producing localized skin rash, plaques, and nodules
127
What are Patitrier microabscesses?
Aggregates of neoplastic cells in the epidermis
128
Sezary syndrome
cells can spread to involve the blood, producing Sezary syndrome.
129
What are Sezary cells?
Characteristic lymphocytes with cerebri form nuclei
130
What would you see on blood smear in mycosis fungoides?
Sezary cells
131
What are myeloproliferative disorders?
Neoplastic proliferation of mature cells of myeloid lineage; disease of late adulthood (average age is 50-60 years)
132
What does myeloproliferative disorders result in?
high WBC count with hypercellular bone marrow
133
How are myeloproliferative disorders characterized?
Cells of all myeloid lineages are increased; classified based on the dominant myeloid cell produced
134
What are the complications for myeloproliferative disorders?
1) Increased risk for hyperuricemia and gout due to high turnover of cells 2) Progression to marrow fibrosis or transformation to acute leukemia
135
What is chronic myeloid leukemia?
Neoplastic proliferation of mature myeloid cells, especially granulocytes and their precursors;
136
In chronic myeloid leukemia what are characteristically increased?
basophils
137
What is chronic myeloid leukemia driven by?
driven by t(9:22) - Philadelphia chromosome - which generates a BCR-ABL fusion protein with increased tyrosine kinase activity
138
What is the first line treatment for chronic myeloid leukemia?
imatinib,
139
What does imatinib do?
It blocks tyrosine kinase activity
140
How is splenomegaly related to chronic myeloid leukemia?
Splenomegaly is common, enlarging spleen suggests accelerated phase of disease;
141
In chronic myeloid leukemia what usually follows after splenomegaly?
transformation to acute leukemia
142
What can chronic myeloid leukemia transform to?
AML in 2/3 of cases or ALL in 1/3 of cases since mutation is in a pluripotent stem cell,
143
What is a leukemoid reaction?
Reactive neutrophilic leukocytosis
144
How is CML distinguished from a leukemoid reaction (reactive neutrophilic leukocytosis)?
Negative LAP stain, inc basophils, t(9;22)
145
What is a LAP stain?
leukocyte alkaline phosphatase (LAP) stain
146
How is a LAP stain related to a leukemoid reaction?
granulocytes in a leukemoid reaction are LAP positive
147
Why are basophils useful in determining the difference between a leukemoid reaction and CML?
Basophils are increased in CML and are absent with a leukemoid reaction
148
How is t(9;22) useful in determining the difference between a leukemoid reaction and CML?
It is present in CML and absent in leukemoid reaction
149
What is polycythemia vera?
Neoplastic proliferation of mature myeloid cells, especially RBCs
150
In polycythemia vera, in addition to the RBC increase what are also increased?
Granulocytes and platelets are also increased
151
What mutation is associated with polycythemia vera?
JAK2 kinase mutation
152
What are the clinical symptoms for polycythemia vera due to?
they are mostly due to hyperviscosity of blood
153
What are the clinical symptoms for polycythemia vera?
1. Blurry vision and headache 2. Increased risk of venous thrombosis (e.g., hepatic vein, portal vein, and dural sinus) 3. Flushed face due to congestion (plethora) 4. Itching, especially after bathing (due to histamine release from increased mast cells)
154
What is plethora in relation to PV?
One of the clinical symptoms; flushed face due to congestion
155
Why is there itching in PV?
Itching, especially after bathing due to histamine release from increased mast cells
156
What is the treatment for PV?
phlebotomy;
157
What is the second-line therapy for PV?
hydroxyurea.
158
What happens to a patient with PV who goes intreated?
Without treatment, death usually occurs within one year.
159
How can PV be distinguished from reactive polycythemia?
1. In PV, erythropoietin (EPO) levels are decreased, and Sao, is normal. 2. In reactive polycythemia due to high altitude or lung disease, SaO2 is low, and EPO is increased. 3. In reactive polycythemia due to ectopic EPO production from renal cell carcinoma, EPO is high, and Sao2 is normal.
160
What are the EPO and SaO2 levels in PV?
EPO is decreased and SaO2 is normal
161
What are the EPO and SaO2 levels in reactive polycythemia due to high altitude or lung disease?
EPO is increased and SaO2 is low
162
What are the EPO and SaO2 levels in reactive polycythemia due to renal cell carcinoma?
EPO is high, SaO2 is normal
163
What is essential thrombocythemia?
Neoplastic proliferation of mature myeloid cells, especially platelets
164
In ET, in addition to the platelets what else is increased?
RBCs and granulocytes are also increased.
165
What is mutation is ET associated with?
JAK2 kinase mutation
166
What do the symptoms of ET result from?
they are related to an increased risk of bleeding and/or thrombosis.
167
What do the symptoms of ET rarely progresses to?
marrow fibrosis or acute leukemia
168
In ET what is there no significant risk for?
hyperuricemia or gout
169
What is myelofibrosis?
It is neoplastic proliferation of mature myeloid cells, especially megakaryocytes
170
What mutation is associated with myelofibrosis?
JAK2 kinase mutation in 50% of cases
171
In myelofibrosis, what causes marrow fibrosis?
Megakaryocytes produce excess platelet-derived growth factor (PDGF) causing marrow fibrosis
172
What are the clinical features for myelofibrosis?
1) splenomegaly 2) leukoerythroblastic smear 3) Increased risk of infection, thrombosis, and bleeding
173
In myelofibrosis what is splenomegaly due to?
extramedullary hematopoiesis
174
In myelofibrosis what is the leukoerythroblastic smear?
It’s tear-drop RBCs, nucleated RBCs, and immature granulocytes
175
What is lymphadenopathy (LAD)?
it refers to enlarged lymph nodes
176
Painful LAD is usually seen in what?
lymph nodes that are draining a region of acute infection (acute lymphadenitis)
177
Painless LAD can be seen with what?
chronic inflammation (chronic lymphadenitis), metastatic carcinoma, or lymphoma.
178
In inflammation, lymph node enlargement is due to what?
hyperplasia of particular regions of the lymph node
179
What is follicular hyperplasia seen with?
(B-cell region) rheumatoid arthritis and early stages of HIV infection, for example.
180
What is paracortex hyperplasia seen with?
(T-cell region) viral infections (e.g., infectious mononucleosis).
181
What is involved with hyperplasia of sinus histiocytes?
It is seen in lymph nodes that are draining a tissue with cancer.
182
What is lymphoma?
Neoplastic proliferation of lymphoid cells that forms a mass; may arise in a lymph node or in extranodal tissue
183
What is lymphoma divided into?
non-Hodgkin lymphoma (NHL 60%) and Hodgkin lymphoma (HL 40%)
184
NHL further classified based on what?
cell type (e.g., B versus T), cell size, pattern of cell growth, expression of surface markers, and cytogenetic translocations, - small, intermediate and large B cells
185
What are some examples of small B cells?
follicular lymphoma, mantle cell lymphoma, marginal zone lymphoma, and small lymphocytic lymphoma (i.e.. CLL cells that involve tissue)
186
What are some examples of intermediate-sized B cells
Burkitt lymphoma
187
What are some examples of large B cells
diffuse large B-cell lymphoma
188
What is the overall frequency for NHL?
60%
189
What is the overall frequency for HL?
40%
190
What are the malignant cells of NHL?
Lymphoid cells
191
What are the malignant cells of HL?
Reed-Sternberg cells
192
What is the composition of mass for NHL?
lymphoid cells
193
What is the composition of mass of HL?
Predominantly reactive cells (inflammatory cells and fibrosis)
194
How does NHL present clinically?
Painless lymphadenopathy, usually arises in late adulthood
195
How does HL present clinically?
Painless lymphadenopathy occasionally with 'B' symptoms, usually arises in young adults
196
What is the spread of NHL?
Diffuse: often extranodal
197
What is the spread of HL?
Contiguous; rarely extra nodal
198
Do you use staging in NHL?
Limited importance
199
Do you use staging in HL?
Guides therapy; radiation is the mainstay of treatment.
200
Is there a Leukemic phase in lymphoma?
Occurs in NHL but not in HL
201
What is follicular lymphoma?
Neoplastic proliferation of small B cells (CD20+) that form follicle-like nodules
202
How does follicular lymphoma present clinically?
in late adulthood with painless lymph adenopathy
203
What is follicular lymphoma driven by?
t(14;18)
204
How does t(14:18) result in follicular lymphoma?
BCL2 on chromosome 18 translocates to the Ig heavy chain locus on chromosome 14 this results in overexpression of Bcl2, which inhibits apoptosis
205
What is the treatment for follicular lymphoma?
is reserved for patients who are symptomatic and involves low-dose chemotherapy or rituximab (anti-CD20 antibody).
206
What does follicular lymphoma progress to and how does it present?
diffuse large B-cell lymphoma which is an important complication and presents as an enlarging lymph node
207
How is follicular lymphoma distinguished from reactive follicular hyperplasia?
1) disruption of normal lymph node architecture (maintained in follicular hyperplasia) 2) Lack of tangible body macrophages in germinal centers (tangible body macrophages are present in follicular hyperplasia) 3) Bcl2 expression in follicles (not expressed in follicular hyperplasia) 4) Monoclonality (follicular hyperplasia is polyclonal)
208
What is mantle cell lymphoma?
Neoplastic proliferation of small B cells (CD20+) that expands the mantle zone
209
How does mantle cell lymphoma present clinically?
presents in late adulthood with painless lymph adenopathy
210
What is mantle cell lymphoma driven by?
t(ll;14)
211
How does t(11;14) result in mantle cell lymphoma?
1) Cydin D1 gene on chromosome 11 translocates to Ig heavy chain locus on chromosome 14. 2) Overexpression of cydin Dl promotes Gl/S transition in the cell cycle, facilitating neoplastic proliferation
212
What is marginal zone lymphoma?
Neoplastic proliferation of small B cells (CD 20+) that expands the marginal zone
213
What is marginal zone lymphoma associated with?
chronic inflammatory states such as Hashimoto thyroiditis, Sjogren syndrome, and H pylori gastritis
214
What is the marginal zone formed by?
post-germinal center B cells.
215
What is MALToma?
it is marginal zone lymphoma in mucosal sites.
216
How might Gastric MALToma regress
with treatment of H Pylori,
217
What is burkitt lymphoma?
Neoplastic proliferation of intermediate-sized B cells (CD20+);
218
What is butkitt lymphoma associated with?
EBV
219
How does burkitt lymphoma classically present?
as an extranodal mass in a child or young adult
220
What is specific about the african form of burkitts lymphoma?
usually involves the jaw
221
What does the sporadic form of Burkitts lymphoma usually involve?
the abdomen
222
What is Burkitt lymphoma driven by?
Driven by translocations of c-myc (chromosome 8)
223
What is the most common translocation for Burkitts lymphoma?
t(8;14) is most common,
224
In Burkitts lymphoma what does t(8:14) result in?
translocation of c-myc to the Ig heavy chain locus on chromosome 14.
225
What does overexpression of c-myc oncogene do?
promotes cell growth
226
How is Burkitts lymphoma characterized?
by high mitotic index and 'starry-sky' appearance on microscopy
227
What is diffuse large B-cell lymphoma?
Neoplastic proliferation of large B cells (CD20+) that grow diffusely in sheets
228
What is the most common form of non-hodgkins lymphoma?
Diffuse large B-cell lymphoma
229
Describe diffuse large B-Cell lymphoma clinically?
Clinically aggressive (high-grade)
230
How does diffuse large B-cell lymphoma arise?
either sporadically or from transformation of a low-grade lymphoma (e.g., follicular lymphoma)
231
How does diffuse large B-cell lymphoma present?
Presents in late adulthood as an enlarging lymph node or an extranodal mass
232
What is Hodgkins Lymphoma?
Neoplastic proliferation of Reed-Slernberg (RS) cells,
233
What are Reed-Slernberg cells?
large B cells with multilobed nuclei and prominent nucleoli ('owl-eyed nuclei');
234
Hodgkins lymphoma is classically positive for what?
CD15 and CD30
235
What do RS cells secrete?
cytokines.
236
What are the symptoms for HL
Occasionally results in 'B' symptoms (fever, chills, and night sweats)
237
In HL what do the RS cells attract?
reactive lymphocytes, plasma cells, macrophages, and eosinophils
238
What may the RS cells in HL lead to?
fibrosis
239
What makes up a bulk of the tumor and form the basis for classification of HL?
Reactive inflammatory cells
240
What are the subtypes of reactive inflammatory cells in HL?
Include 1. Nodular sclerosis 2. Lymphocyte-rich 3. Mixed cellularity 4. Lymphocyte-depleted
241
What is the most common subtype of HL?
Nodular sclerosis (70% of all cases),
242
What is the classic presentation for nodular sclerosis?
it is an enlarging cervical or mediastinal lymph node in a young adult, usually female
243
Dsecribe the lymph node in nodular sclerosis?
It is divided by bands of sclerosis; RS cells are present in lake-like spaces (lacunar cells),
244
What are lacunar cells?
Lake like spaces in the lymph node where the RS cells are present
245
What type of HL has the best prognosis of all types?
Lymphocyte-rich
246
In HL mixed cellularity is often associated with what?
abundant eosinophils (RS cells produce IL-5).
247
What is the most aggressive HL type and in whom is it usually seen?
Lymphocyte-depleted is the most aggressive of all types; usually seen in the elderly and HIV-positive individuals
248
What are the plasma cell disorders?
Dyscrasias: 1) multiple myeloma 2) MGUS 3) Waldenstrom Macroglobulinemia
249
What is multiple myeloma?
Malignant proliferation of plasma cells in the bone marrow
250
Whis the most common primary malignancy of bone?
metastatic cancer,
251
What is the most common malignant lesion of bone overall?
Multiple myeloma
252
In multiple myeloma what is usually present?
High serum IL-6 is sometimes present; stimulates plasma cell growth and immunoglobulin production
253
What are the clinical features for multiple myeloma?
1) Bone pain with hypercalcemia 2) Elevated serum protein 3) increased risk of infection 4) Rouleaux formation of RBC’s on blood smears 5) Primary AL amyloidosis 6) Proteinuria
254
Why is there bone pain with hypercalcemia in multiple myeloma?
Neoplastic plasma cells activate the RANK receptor on osteoclasts, leading to bone destruction.
255
With multiple myeloma what might you see on x-ray?
Lytic, 'punched-out' skeletal lesions are seen on x-ray, especially in the vertebrae and skull; increased risk for fracture
256
Why is there elevated serum protein in multiple myeloma?
Neoplastic plasma cells produce immunoglobulin;
257
In multiple myeloma, what is seen on electrophoresis?
M spike is present on serum protein electrophoresis (SPEP), most commonly due to monoclonal IgG or IgA
258
In multiple myeloma why is there increased risk of infection?
Monoclonal antibody lacks antigenic diversity
259
What is the most common cause of death in multiple myeloma?
infection
260
Why is there rouleaux formation of RBCs on blood smear?
increased serum protein decreases charge between RBCs
261
Why is there primary AL amyloidosis in multiple myeloma?
Free light chains circulate in serum and deposit in tissues.
262
Why is there proteinuria in multiple myeloma? What does this increase the risk for?
Free light chain is excreted in the urine as Bence Jones protein; deposition in kidney tubules leads to risk for renal failure (myeloma kidney).
263
What is monoclonalgammopathy of undetermined significance?
Increased serum protein with M spike on SPEP; other features of multiple myeloma are absent (no lytic bone lesions, hypercalcemia, AL amyloid, or Bence Jones proteinuria)
264
MGUS is common in what group of people?
elderly (seen in 5% of 70-year-old individuals);
265
What are the odds of a patient with MGUS developing multiple myeloma?
1% of patients with MGUS develop multiple myeloma each year.
266
What is Waldenstrom macroglobulinemia?
B-cell lymphoma with monoclonal IgM production
267
What are the clinical features for waldenstrom macroglobulinemia?
1) Generalized lymphadenopathy, lytic bone lesions are absent 2) Increased serum protein with M spike (comprised of IgM) 3) Visual and neurologic deficits (e.g., retinal hemorrhage or stroke) IgM (large pentamer) causes serum hyperviscosity. 4) Bleeding
268
Why is there bleeding in waldenstrom macroglobulinemia?
Viscous serum results in defective platelet aggregation
269
What are the complications for waldenstrom macroglobulinemia treated with?
plasmapheresis, which removes IgM from the serum
270
What are langerhans cells?
specialized dendritic cells found predominantly in the skin.
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What are langerhans cells derived from?
bone marrow monocytes
272
What do langerhans cells present?
Present antigen to naive T cells
273
What is langerhans cell histiocytosis?
it is a neoplastic proliferation of Langerhans cells
274
What is seen on electron microscopy in langerhan cell histiocytosis?
Characteristic Birbeck (tennis racket) granules are seen on electron microscopy;
275
What is langerhan cell histiocytosis immunochemistry?
cells are CDla+ and S100+
276
What is Letterer-Siwe disease?
Malignant proliferation of Langerhans cells
277
What is the classic presentation of Letterer-Siwe?
it is a skin rash and cystic skeletal defects in an infant (< 2 years old).
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Can Letterer-Siwe be fatal?
Multiple organs may be involved; rapidly fatal
279
What is eosinophilic granuloma?
Benign proliferation of Langerhans cells in bone
280
What is the classic presentation for eosinophilic granuloma?
it is a pathologic fracture in an adolescent; skin is not involved
281
What does biopsy of eosinophilic granuloma show?
Langerhans cells with mixed inflammatory cells, including numerous eosinophils
282
What is Hand-Schuller-Christian disease?
Malignant proliferation of Langerhans cells
283
What is the classic presentation of Hand-Schuller-Christian disease?
it is scalp rash, lytic skull defects, diabetes insipidus, and exophthalmos in a child.
