Eugene Heme Oncology Flashcards
Cell Cycle Cancer examples
Hereditary Melanoma, Retinoblastoma, Li-Fraumeni Syndrome Catergory
point mutation in cyclin-dependent kinase (cdk4) inhibitor on Chr9; insensitive to p16 inhibition
Hereditary Melanoma: Pathophysiology
Loss of RB (cell cycle control protein)
Retinoblastoma: Pathophysiology/Diagnosis
tumor suppresor: when NOT phosphorylated, binds E2F to block transcription and cell division (inactive in most human cancers)
Rb pathway: Rb
onco, TFs required for cell cycle progression, blocked by Rb binding
Rb pathway: E2F
onco, phosphorylate (inactivate) Rb
Rb pathway: Cdk4/Cyclin D
tumor suppressor, downregulate Cdk4/Cyclin D activity
Rb pathway: p16
Lots of cancers (breast, colon, etc.)
Li-Fraumeni Syndrome: Signs/Symptoms
Inherited p53 mutation
Li-Fraumeni Syndrome: Pathophysiology/Diagnosis
tumor suppressor, activates p53
p53 pathway: ATM (Li-Fraumeni)
oncoprotein, inhibits p53
p53 pathway: Mdm2 (Li-Fraumeni)
tumor suppressor, G1 cycle arrest allows for DNA repair in fibroblasts, some epithelial cells, apoptosis in thymocytes
p53 pathway: p53 (Li-Fraumeni)
tumor suppressor, downstream of p53
p53 pathway: p21 (Li-Fraumeni)
trisomy 21, Fanconi’s anemia, Li-Fraumeni
Acute Myloid Leukemia (AML): Inherited
Downs also ALL
Age (>60 yo = poor outcomes), rad exposure, MDS, myeloproliferative neoplasms (CML, PV, ET), prior chemo (alkylating agents for lymphoma, breast cancer; topoisomerase inhibitors for testicular cancer via 11q23 MLL gene deletion)
Acute Myeloid Leukemia (AML): Epi/Risk Factors
large, very granular cells with bilobed nuclei
Acute Myloid Leukemia: APL subtype
blasts w/lots of cytoplasm, prominent nucleoli, granules and some maturing cells
Acute Myloid Leukemia: M2 subtype Histology
Sx: Anemia, infections, bleeding. Hemorrhage, skin or gum infiltration, no mediastinal masses, LAD and hepatosplenomegaly less likely
Acute Myeloid Leukemia (AML): Signs/Symptoms
Generally poor (<60% @ 5yr); t(8;21)(15;17), inv(16) good, 5q, chemo or complex karyotype bad
Acute Myeloid Leukemia (AML): Prognosis
If good prognosis: 7+3: cytarabine x7d, doxorubicin x3d
Acute Myeloid Leukemia (AML): Treatment/Notes
AML by day 14 of cyta/doxo 7+3
hopefully shows aplastic marrow
if not salvage/clinical trial/palliation
Sx: Anemia, infections, high risk for hemorrhage; differentiation syndrome: fever, dyspnea, weight gain, pulmonary infiltrates, pleural and pericardial infusions
Acute Promyelocytic Leukemia (APL)(AML M3 Subtype)
Myeloblast/lymphoblast progenitor cell overgrowth; t(15;17) PML/RAR-alpha fusion transcript
Acute Promyelocytic Leukemia (APL)(AML M3 Subtype): Pathophysiology/Diagnosis
Acute Promyelocytic Leukemia (APL)(AML M3 Subtype): Prognosis
80-90% at five years
Sensitive to ATRA, may cause differentiation syndrome. Tx: dexamethasone, arsenic trioxide (ATO)
Acute Promyelocytic Leukemia (APL)(AML M3 Subtype): Treatment/Notes
myeloblast/lymphoblast progenitor cell overgrowth
Acute Leukemias (AML, APL, ALL): pathophysiology
iliac crest bone biopsy, blood tests
Acute Leukemias (AML, APL, ALL): diagnosis
leukostasis (AML>ALL, tx: leukaphoresis, hydroxyurea), DIC, tumor lysis syndrome
Acute Leukemias (AML, APL, ALL): complications
Rare. Extremes of age, radiation, downs
Acute Lymphoblastic Leukemia (ALL): Epi/Risk Factors
Sx: Anemia, infections, bleeding, ant. mediastinal mass, DIC, bone pain; rarely lymphadenopathy and hepatosplenomegaly
Acute Lymphoblastic Leukemia (ALL): Signs/Symptoms/Findings
Mediastinal mass, especially
T-ALL common presentation
way high lymphocytes, large cells, high N:C ratio, prominent nucleoli, no granules, open chromatin, lack of PMNs and platelets
Acute Lymphoblastic Leukemia histology
TdT+, Ig+, CD10+
B-cell ALL surface markers
TdT+, CD2+, CD3+
T-cell ALL surface markers
peds: 10; adults >60
ALL adverse prognostic factors: age
> 30k (B), or >100k (T)
ALL adverse prognostic factors: WBC
philedelphia: t(9;22), found in adults >60; t(4;11), found in peds <1
ALL adverse prognostic factors: cytogenetics
Acute Lymphoblastic Leukemia (ALL): Prognosis
> 90% five year survival. Philadelphia chromosome bad
Induction w/ CHOP; CNS prophylaxis, stem cell xplant, maintenance (prednisone, mercaptopurine, MTX)
Acute Lymphoblastic Leukemia (ALL): Treatment/Notes
myelodysplasia 5 ways
Mylodystplastic syndrome, 5q, Polycythemia Vera, Essential thrombocythemia, primary myelofibrosis
Risk of transformation to AML
Myelodysplastic Syndrome (MDS)
High blasts, proliferation, apoptosis; low WBC, RBC, plts. anemia
Myelodysplastic Syndrome (MDS): Signs/Symptoms/Findings
Stem cell disorder: bad hematopoesis leads to defects in all non lymphoid lined, cytopenia due to TNF-mediated apoptosis. De novo or exposure: chemo, radiation, benzenes
Myelodysplastic Syndrome MDS
Low risk: Lenalidomide if 5q del, growth factor therapy if not
High risk or EPOdecitabine if no Sx
stem cell transplant curative
Myelodysplastic Syndrome (MDS): Treatment/Notes
Deletion leads to Anemia with increased PLT (megakaryocytes slow-growing)
5q Syndrome, MDS subtype
Del(5q31) leads to del(RPS14) leads to death of rapidly dividing cells (erythroid). Low AML conversion
5q Syndrome
MPN: expansion of RBC lineage
Polycythemia Vera: Findings
itching, ruddy complexion, splenomegaly, early saiety, DVT or PE
Polycythemia Vera: Symptoms
JAK2V617F in 92% of cases leads to increase in all cell types (mainly RBC lineage)
Polycythemia Vera: Pathophysiology/Diagnosis
MPN w/Good prognosis. 3% yearly mortality
Polycythemia Vera: Prognosis
Platelet lineage expansion. increased PLT, normal Hgb
Essential Thrombocytosis (Primary Thrombocythemia): Findings
megokaryocytes in bone marrow, exclusion, JAK2 mut in 42%
Essential Thrombocytosis (Primary Thrombocythemia): Pathophysiology/Diagnosis
low risk: low dose aspirin; high risk (>60, past thrombosis, CV risk): low dose aspirin, hydroxyurea
Essential Thrombocytosis (Primary Thrombocythemia): Treatment/Notes
teardrop RBCs (dacrocytes), increased LDH
Primary Myelofibrosis (Idiopathic Myelofibrosis): Findings
bleeding, anemia, infxn, cachexia, fullness, splenomagaly
Primary Myelofibrosis (Idiopathic Myelofibrosis): Signs/Symptoms
Marrow fibrosis, extra-medullary hematopoiesis
Primary Myelofibrosis (Idiopathic Myelofibrosis): Pathophysiology/Diagnosis
5 year survival, CALR better than JAK2
Primary Myelofibrosis: Prognosis
epo/transfusion, hydroxyurea, thalidomide/steroids, SC transplant (cure!), JAK inhibitors
Primary Myelofibrosis (Idiopathic Myelofibrosis): Treatment/Notes
increased mature and immature myeloid cells, basophilia, decreased hgb/hct, increased platelets (thrombocytosis)
Chronic Myelogenous Leukemia (CML): Findings
fatigue, fullness, hepatosplenomagaly, weight loss, ecchymoses, anemia
Chronic Myelogenous Leukemia (CML): Signs/Symptoms
abl is oncogene, MR3 (major) = >3log bcr-abl reduction, MR4.5 (complete) = 4.5 log reduction
chronic myelogenous leukemia (CML): genetics
t(9;22) leads to Bcr/Abl fusion gene on Philadelphia chromosome (22q-) leads to increased tyrosine kinase activity
Chronic Myelogenous Leukemia (CML): Pathophysiology/Diagnosis
slow-growing Ca harder to kill. Chronic phase of high blood counts (4-6 years) leads to accelerated phase (`1y) leads to blast crisis, AML (3-6 mos to death)
Chronic Myelogenous Leukemia (CML): Prognosis
Tx: Imatinib (Gleevec) ± xplant
Progresses from chronic (splenomegaly or asymptomatic) leads to accelerated (anemia, decreased PLT) leads to blast crisis (~AML)
Chronic Myelogenous Leukemia (CML): Treatment
most common leukemia, >60 yo, not radiation!
Chronic Lymphocytic Leukemia (CLL): Epi/Risk Factors
Sx: Asymptomatic increased WBC, lymphadenopathy, splenomegaly, sino-pulmonary infxns, gradual onset fatigue, dyspnea, dizziness, weight loss
Chronic Lymphocytic Leukemia (CLL): Signs/Symptoms
lymphocytosis (small w/clumped chromatin), smudge cells
Chronic Lymphocytic Leukemia (CLL): findings
CD20+***, CD5+
Chronic Lymphocytic Leukemia (CLL): Diagnosis (flow cytometry)
Dx: CBC, peripheral blood smear/FACS, no marrow biopsy
Chronic Lymphocytic Leukemia (CLL): Pathophysiology/Diagnosis
Largely incurable except in rare cases with bone marrow xplant (slow-growing Ca harder to kill); Prognosis: 13q- good, 11q- & 17p- bad
Chronic Lymphocytic Leukemia (CLL): Prognosis
Tx: FCR (fludarabine, cyclo-phosphamide, rituximab), alemtuzumab, idelalisib, ibrutinib, allogenic xplant (only cure, but 20% fatal)
Chronic Lymphocytic Leukemia (CLL): Treatment
AIHA, ITP, pure red cell aplasia ( decreased RBCs, severe anemia), decreased Ig’s (chronic infxn)
Chronic Lymphocytic Leukemia (CLL): Complications
Aberrant lymphocytes in blood or marrow, <5000 lymphocytes, not considered malignancy but can be risk for one
Monoclonal B-Lymphocytosis
Most common lymphoma, 25K/yr
Diffuse Large B-Cell Lymphoma (DLBCL): Epi/Risk Factors
Large lymphocytes (4-5x normal), diffuse growth
Diffuse Large B-Cell Lymphoma (DLBCL): Findings
germinal center markers (CD19, 20, 10; BC16)
Diffuse Large B-Cell Lymphoma (DLBCL): IHC markers
lymphadenopathy, night sweats, fatigue
Diffuse Large B-Cell Lymphoma (DLBCL): Signs/Symptoms
BCL6 overexpression (GC type), NFkB addition (non-GC), or Type 3 (primary mediastinal) subtypes
Diffuse Large B-Cell Lymphoma (DLBCL): Pathophysiology/Diagnosis
Not great (50% 10 yr in germinal-center-like, less good in ABC, PMBL)
Diffuse Large B-Cell Lymphoma (DLBCL): Prognosis
Tx: R-CHOP (Rituximab, Cyclophosphamide, Hdoxorubin, Ovincristine, Prednisone
immunodeficiency-associated, primary effusion lymphoma
Diffuse Large B-Cell Lymphoma (DLBCL): Treatment/Notes
All respond better to infusional chemo and etoposide
Special situational and subtype DLBCL
burkitts or DLBCL of germinal center origin + HIV
HIV DLBCL (well controlled)
primary effusion lymphoma, post-germainal center immunoblastic lymphoma, plasmoblastic lymphoma, bad prognosis
HIV DLBCL (not controlled)
hodgkin’s-like, lymphoid or plasmacytic proliferations in immunosuppressed pt
post-transplant DLBCL
CD30 mutation (like Hodgkin’s), YA female; mass, thrombosis, SVC syndrome
Type 3 aka Primary Mediastinal BCL
Elderly, aggressive CNS disease, treat with intrathecal chemo
Double Hit Lymphoma (MYC +/- BCL2 or 6 mutations)
EBV infection (especially African)
Burkitt’s Lymphoma: Epi/Risk Factors
Starry-sky appearance (normal macrophages eat nuclear remnants)
Burkitt’s Lymphoma: Histo
IgM+, germinal center markers (CD19, 20, 10, Bc16); never express Bcl12
Burkitt’s Lymphoma: IHC
aggressive chemo, CODOX-M-IVAC (McGrath protocol); very curable
Burkitt’s Lymphoma: treatment
c-myc translocation from t(8;14), t(8;22), or t(2;8), EBV
Burkitt’s Lymphoma: Pathophysiology
3 types: HIV-associated, African endemic (mass in mandible), sporadic
Burkitt’s Lymphoma: Notes
Painless nodes, nodular pattern with small cells
Follicular BCL: Signs/Symptoms/Findings
CD10(+), t(14;18) common (Bcl2)
Follicular BCL: Pathophysiology/Diagnosis
Follicular BCL: Prognosis
7-9 yrs (BCL subtype)
Incurable but can treat with Rituximab, XRT for stage I
Follicular: Treatment/Notes
Nodular to diffuse, small lymphocytes
Mantle Zone: Signs/Symptoms/Findings
older males, CD5(+), Cyclin D1(+)
Mantle Zone BCL epi
translocation of cyclin D1 (11) and heavy-chain Ig(14)
Mantle Zone: Pathophysiology/Diagnosis
Based on Ki67 levels; high to low: blastic, aggressive, indolent, leukemic)
Mantle Zone: Prognosis
Bortezomib, aggressive chemo and auto-SC transplant v. watch & wait (depending on variant)
Mantle Zone: Treatment/Notes
Causes: Sjogren’s, Hashimoto’s (thyroiditis), H. pylori (gastritis), HCV (splenomegaly), c. psittaci (ocular adnexa), borrelia, c. jejuni
Extra-Nodal Marginal Zone (MALT): Epi/Risk Factors AND Signs/Symptoms/Findings AND Picture
CD20, 19 but no germinal center trademark CD10
Extra-Nodal Marginal Zone (MALT): Pathophysiology/Diagnosis
Treat antigenic stimulation to cure
Extra-Nodal Marginal Zone (MALT): Treatment/Notes
Polymorphous small lymphocytes
Marginal Zone: Signs/Symptoms/Findings AND Picture
increased NFkB via translocations
Marginal Zone: Pathophysiology/Diagnosis
Look like hybrid of plasma cells and lymphocytes
Lymphoplasmacytic Lymphoma: Signs/Symptoms/Findings
Igm(+), leads to increased viscosity, neuro/visual problems
Lymphoplasmacytic Lymphoma: Pathophysiology/Diagnosis
IgM causes Waldenstrom’s macroglobulinemia
Lymphoplasmacytic Lymphoma: Treatment/Notes
Rare, 5-10% of NHL in US, more in Asia (secondary to Ebv)
Peripheral T-Cell Lymphomas (PTCL): Epi/Risk Factors
General features: infiltration of plasma cells, B-cells, usually have T-cell markers, TCR rearrangements common
Peripheral T-Cell Lymphomas (PTCL): Signs/Symptoms/Findings AND Picture
Types: angioimmunoblastic, extranodal NK/T-cell (nasal type), hepatosplenic, subQ, enteropathy-associated
Peripheral T-Cell Lymphomas (PTCL): Pathophysiology/Diagnosis
Peripheral T-Cell Lymphomas (PTCL): Prognosis
Worse than B-cell; median survival is 1-3y, except ALK+ ALCL (5y surivial is 65-90%)
Horseshoe-shaped nuclei, CD30+, ugly anaplastic-cells
Anaplastic Large Cell: Signs/Symptoms/Findings
Brentuximab (anti CD30)
Anaplastic Large Cell: Treatment/Notes
younger, better prognosis, t(2;5) mutation
Anaplastic Large Cell T-Cell lymphoma, ALK+
Rash, poor prognosis, no standard Tx
Peripheral TCL NOS: Signs/Symptoms/Findings
AI syndromes, hemolytic anemia, TCP, rash
Angioblastic T-cell lymphoma (AILT) presentation
arborized vessels, polymorphous infiltrate, Bc16, CD10; lacking normal CD2, 3, 5, 7
Angioblastic T-cell lymphoma (AILT), smear and IHC
lymphoma treated with gemcitabine
Angioblastic T-cell lymphoma (AILT) treatment
Always EBV+, often Asian; large blue granules, CD56+ NK cells, (-) TCR rearrangment
Extranodal NK/T-cell lymphoma (nasal type): epi, findings and IHC
high dose radiation and chemo; dismal prognosis
Extranodal NK/T-cell lymphoma (nasal type): tx and prognosis
heptosplenomegaly, coombs (-) hemolytic anemia, purpura/rash, RBCs engulfed by phagocytes, smear is small to medium cells with (=) TCR rearrangment (usually gamma/delta)
hepatosplenic t-cell lymphoma
progressing skin lesions, history of eczema, plaque leads to tumor leads to LN involvement
Mycosis Fungoides: Signs/Symptoms/Findings
steroids, topical radiation, phototherapy, topical chemo (early), chemo and transplant (late)
Mycosis Fungoides: tx
subcutaneous infiltrate, hemaphagocytic syndrome
subcutaneous panniculitis-like lymphoma
(+) TCR rearrangment (alpha/beta), CD3&8+, no NK cells (CD56-)
subcutaneous panniculitis-like lymphoma
carribean
Adult T-Cell Leukemia/Lymphoma: Epi/Risk Factors
long latency (10-30y), rash, hypercalcemia, CNS sx (confusion)
Adult T-Cell Leukemia/Lymphoma: Signs/Symptoms/Findings
Flower cells
Adult T-Cell Leukemia/Lymphoma: Signs/Symptoms/Findings
Driven by HTLV-1 via breast milk, blood, sex; TAX(+), CD4(+), CD25(+)
Adult T-Cell Leukemia/Lymphoma: Pathophysiology/Diagnosis
Adult T-Cell Leukemia/Lymphoma: Prognosis
19 weeks!
:(
EPOCH or novel therapies
Adult T-Cell Leukemia/Lymphoma: Treatment/Notes
Young adults w/Slarge mediastinal mass, B-symptoms (pruritus, Pel Ebstein (periodic) fevers, painful nodes upon boozing)
Hodgkin’s Lymphoma: Epi/Risk Factors
Histo: Reed-Sternberg, owl’s eye nuclei, eosinophils and macs, fibrotic bands
Hodgkin’s Lymphoma: Histo
10k/year, bimodal (15-35, >50)
Hodgkin’s Lymphoma: Epi
B-cell origin, but no B- or T-cell markers; CD30(+), CD15(+), PAX(+)
Hodgkin’s Lymphoma: Pathophysiology/Diagnosis
Based on IPS score, generally good (1% fatal)
Hodgkin’s Lymphoma: Prognosis
90% cured with ABVD combo chemotherapy (pulmonary toxicity possible)
Hodgkin’s Lymphoma: Treatment/Notes
Salvage with xplant or Brentuximab
Hodgkin’s Lymphoma: Treatment/Notes
Rare, 5% of HL, young males, Nodular infiltrates, small lymphocytes, no Reed-Sternberg cells
Lymphocyte-Predominant Hodgkin’s Lymphoma: Epi/Risk Factors
CD20(+), CD30(=); cervical LAD
Lymphocyte-Predominant Hodgkin’s Lymphoma: Pathophysiology/Diagnosis
Tx: ABVD (A/Doxorubicin, Bleomycin, Vincristine, Dacarbazine); salvage after PET dx relapse
Lymphocyte-Predominant Hodgkin’s Lymphoma: Treatment/Notes
most common HL, thick fibrous bands on smear
nodular sclerosis HL
HIV associated HL
mixed cellularity HL
mass > 1/3 thoracic cavity, B symptoms or high ESR (inflammation), older (>40-50y)
poor prognosis for early HL
older than 45, male, albumin under 40, hgb under 105, stage IV, leukocytosis>15k/mm3, lymphs ,600 or <8% WBC count
poor prognosis in advanced HL (IPS score)
2nd most common heme malignancy; black>W>asian M>F (1.4:1)
Multiple Myeloma: Epi/Risk Factors
Sx: Calcium is high, renal insufficiency (Cr>2), Anemia (Hgb<10), Bone pain;XR: lucencies = lytic lesions
Multiple Myeloma: Signs/Symptoms/Findings
Histo: Mott cells, Dutcher bodies, CD38+ (kappa or gamma restricted)
Multiple Myeloma: Signs/Symptoms/Findings
Dx: monoclonal protein spike in SPEP or UPEP, >10% monoclonal plasma in BM, >1 CRAB
Multiple Myeloma: Pathophysiology/Diagnosis
MM prognosis
38.2% 5yr OS if treated, 6mo if not; Chromosome abnormality in 90% of pts
t(4;14)(p16;q32), t(14;16)(q32;q23) and -17p13 (aka p53)
bad prognosis in MM
deletion of 13q14
intermediate prognosis in MM
no cytogenic abnormalities in MM
good prognosis
chemo and biphosphonates
tx for MM bone disease complications
lenalidomide, bortezomib
Multiple Myeloma: Treatment/Notes
before day 100
acute GVHD timing
inflammatory attack by donor T-cells on host organs (gut, liver, skin)
acute GVHD pathogenesis
erythematous maculopaular rash, increased bilirubin, diarrhea
acute GVHD presentation
prevent with cyclosporine +/- MTX, treat with prednisone
acute GVHD tx
after day 100
chronic GVHD timing
defect in immune reconstitution leads to dysregulation, impaired organ function, decreased survival
chronic GVHD pathogenesis
AI symptoms in skin, eyes, gut, mouth, liver, MSK, lungs, GU; scleroderma, skin and deep sclerosis
chronic GVHD presentation
risk of rejection is proportional to
MHC/HLA mismatch