Hematology/Oncology (WBC,s)

Question 1

What is the diffrence between leukemia and lymphoma?

Answer 1

Leukemia- cancer of wbc in blood (abnormal wbc in blood)
lymphoma - cancer of wbc in the ymph nodes (abnormal wbc in lymphnodes)

Lymphoma is a solid tissue mass (lemon)
leukemia is liquid (in blood,lemonade)

lemon can be made into lemonade and lemonade seed in lemon

so lymphoma can give rise to leukemia and leukemia to lymphoma.

Question 2

Explain lymphocytes.

Answer 2

Lineage-lymphoid
agranulocytes

1) NK cells
2) T cells ( form in BM, mature in thymus)
3) B cells( form in BM, mature in MALT/ GALT (peyer patches)

circulation/bone marrow - leukemia
lymph nodes / maturing organs - lymphoma

Question 3

Can you diffrentiate between T and B cell under the microscope?

Answer 3

No, its impossible.
We diffrentiate by flow cytometry (Detection of cluster of diffrentiation) (CD - basically the ID of the cell)

NK cells- CD16, CD56

T cells- Helper- CD3, 4
killer- CD3, 8

B cells - MHC2 CD19 and 20

Question 4

What are some Benign Leucocyte reactions? (Reactions that are not diorders)

Answer 4

Eosinophilia
neutrophilic leucocytosis
basophilia
monocytosis
etc

Question 5

What is the diffrence between normal division and neoplastic division/

Answer 5

Neoplasia on its own doesn’t mean malignancy. Neoplasia can be benign or malignant
Neoplasia is monoclonal (a single cell decides to go bezerk)
it is irregular and not reversible

normal division is regular, reversible and include many cells (polyclonal)

Question 6

Name the Hematological Malignancies (all the malignancies related to the hematology) (high WBC)

Answer 6

Leukemia ( in the blood/BM)

1) Acute Lymphoblastic Leukemia (ALL) (newborn to 14 years)
2) Acute Myeloblastic Leukemia(AML) (14-60)
3) Chronic Lymphocytic leukemia (CLL) (>60)
4) Chronic myelocytic Leukemia (CML) (14-60)

Lymphomas (in the LN)
Hodgkins and Non-Hodgkins

Myeloma (multiple Myeloma)

Question 7

What are the main diffrences between Acute and Chronic leukemias?

Answer 7

Acute-
young patients
Cells are immature (blasts)
cell lose ability to diffrentiate byt retains ability to divide

chronic
older patients
mature cells (cytes)

for example

ALL- since its lymphoblastic (lymphoid lineage) we know that when maturing they will form lymphocytes (T and B cells)
but the immature cells will lose diffrentiating abilitya and we will have a lot of immature lymphoid lineage cells
These will be Medium sized
agranular (lymphoid lineage doesn’t form any granulocytes so obviously immature cells will also not have granules)
Scanty cytoplasms (because mature T and B cells also doesn’t have much cytoplasms)

AML- Myeloid lineage so they are the immature forms of the Granulocytes
They are larger. Granules present and more cytoplasm

now chronic-

CLL- Lymphocytes will be seem (Chronic=mature)
smudge cells

CML - Myelocytes,neutrophils and basophils high

Question 8

Explain Acute Leukemias :)

Answer 8

We will have BLASTS.

Reasons for development of leukemias- Both genetic and environmental
Antineoplastic agents
radiation
Hodgkin lymphoma
benzene 
multiple myeloma

Acute Leukemias asre MONOCLONAL disorders of early stem cells of either MYELOID or LYMPHOID origin

these Myeloblasts and Lymphoblasts Replicate and

1) Replace most of the bone marrow cells, crowding out normal haematopoesis
this will result in pancytopenia (BM wll have trouble doing normal haematopoesis as the abnormal one is crowding)
due to pancytopenia
RBC low-anaemia
WBC low-INfections
Patelets low-Bleeding

2) Then they Enters the peripheral blood
3) metastasize throughout the body (further lead to splenomegaly, Hepatomegaly, Lymphomas,bone pain)

platelets less than 100,000
WBC less than 10,000 or more than 100,000

Question 9

Explain the clinical features of the acute leukemias

Answer 9

1) painless LN enlargement
2) testicular enlagment in ALL
3) bone pain

Question 10

How can leukemias / lymphomas or other cancer leads to megaloblastic anaemias?

Answer 10

Due to high cell turnover (a lot of dividing and forminf cells) a lot of FOLATE is consumed by these cells leading to the high demand of folate and not enough for the RBC DNA synthesis.

Question 11

What are auer Rods?

Answer 11

Seen in the Blast cells Of AML (acute myeloid Leukemia) Myeloid are Granulocyte lineage

-in myeloblasts not monoblasts

Auer rods are clumps of azurophilic granular material that form elongated needles and can be seen in the cytoplasm of leukemic blasts under microscopic examination. They are composed of fused lysosomes and contain peroxidase, lysosomal enzymes, and large crystalline inclusions.

Immature Myeloid lineage cells will contain auer rods (myeloblasts not monoblasts)

Question 12

Explain Chronic Leukemias :)

Answer 12

MONOCLONAL disorders of the LATE cells
Mature and smaller
can be identified easily
in older persons
Blasts cells are not seen or less than 10%

Onset of signs and symptoms are usually slower
lypadenopathy still seen
hepato and aplenomegaly also seen

platelets less than 100,000
WBC less than 10,000 or more than 100,000
basophilia can be seen

Question 13

Explain Acute Lymphoblastic Leukemia :) (ALL)

Answer 13

F

Question 14

What do you mean by secondary AML?

Answer 14

CML can cause AML that means chronic myelocytic leukemia (meloid lineage ) (mature) can give rise to Acute one (immature)

in this case it is called secondary AML.

Question 15

What are the risk factors for the Acute Myelocyitic anaemia?

Answer 15

Acute ML means immature myeloid lineage cells
high cytoplasm and granular
Myeloid lineage —-1) Myeloblasts (have Auer rods that are peroxidase posiitive)
2) monoblasts

primary AML occurs due to Radiation, Bemzene, or antineoplastic agents

if nn of these agents then we call it the seconary AML that can be due to
Myelodysplastic Syndrome
Aplastic Anaemia
PNH
Myeloproliferative Disorders
Fanconi anaemia

AML will have gum Infilteration )M5 variant

all other symtoms are the same of the leukemia

Question 16

Classification of AML?

Answer 16

M0 to M7

most Important to learn
M2- Myeloblastic with Maturation t(8;22)
M3- Acute promyelocytic leukemia

M5 - monocytic gum infiltration

Question 17

What is good and Bad prognosis?

Answer 17

A bad prognosis means there is little chance for recovery. Someone with a good or excellent prognosis is probably going to get better.

Question 18

Explain Acute Promyelocytic leukemia. (aPML)

Answer 18

Specific subtype of AML
M3
The problem is not with the BLASTS cells (Myeloblasts)
but with promyeloblasts (one step further before division not Neuto mono baso)

auer rods present

t(15:17)

Complication- DIC syndrome

very good prognosis as it can be treated with Vitamin A (ATRA- All Trans Retinoic Acid) or Arsenic

vitamin A induces maturation of primitive promyelocytes- from neutrophils that will go apoptosis and will not continue to diffrentiate

however Vit A can cause Diffrentiaton syndrome]

Vitamin A also does not cause myelosuppresion (other cancer drugs do)

Question 19

Explain Some clinical used of Vitamin A.

Answer 19

• Treatment of Acne (but can cause abortion)
• treatment of measles and low risk of blindness
• Treatment of aPML (acute promyelocytic leukenmia)
• treatment of Hairy Leukoplakia
• retinitis pigmentosa

Question 20

What is Diffrentiation Syndrome?

Previously known as retinoic acid syndrome

Answer 20

Differentiation syndrome (DS; originally called “retinoic acid syndrome”) is a potentially fatal complication of treatment of acute promyelocytic leukemia (APL) with all-trans retinoic acid and/or arsenic trioxide

treatment- Give high dose of Dexamethasone (when doctors have no clue,they give corticosteroids)

stopping the ARTA

Question 21

What are the treatment for Acute lymphoblastic Leukemia? (ALL)

Answer 21

First we should stabilize the symptoms of the patient to make them ready for the chemotherapy
for example if patient have
thrombocytopenia- do a platelet tranfusion
fever and granulocytopenia- blood culture+antibiotics
leucostasis- do leucopharesis

1) remission induction- Prednisone + Vincristine
2) consolidation- (maintainence)

high dose methotrexate

bone marrow transplant is the last resort

If the patient have a philadelphia chromosome translocation in ALL t(9:22) then we will give
Tyrosine Kinase Inhibitor.

Question 22

What are the treatment for Acute myelogenous Leukemia? (AML)

Answer 22

1) remission induction - give chemotherapy to suppress all cell lines (patient can become prone to infections)

cytosine arabinoside for 7 days + daunorubicin for 3 days

2) consolidation= same drugs

stem cell transplan== only for person less than 60 years

if aPML give retinoic acid

Question 23

What is post remission therapy (consolidation therapy)?

Answer 23

Postremission therapy is used to kill any cancer cells that may be left in the body.
It may include radiation therapy, a stem cell transplant, or treatment with drugs that kill cancer cells.
Also called consolidation therapy and intensification therapy.

Question 24

What can be the complictions for treatment of ALL?

Answer 24

Chemotherapy given (drugs) can cause the Tumor lysis syndrome.
Direct testicular radiation can lower sperm count and cause infertility (so sperm sonation and preservation should be suggested)

Question 25

What can be the complictions for treatment of ALL?

Answer 25

``` Chemotherapy given (drugs) can cause the Tumor lysis syndrome. Direct testicular radiation can lower sperm count and cause infertility (so sperm donation and preservation should be suggested) Intrathecal methotrexate and cranial irradiation can lead to cognitive disfunction ```

Question 26

What is tumor Lysis syndrome? | A complication of anticancer therapyies

Answer 26

Tumor lysis syndrome is a group of metabolic abnormalities that can occur as a complication during the treatment of cancer, where large amounts of tumor cells are killed off (lysed) at the same time by the treatment, releasing their contents into the bloodstream A lot of cell killed at the same time--> high K+ and Phosphate and uric acid released in blood stream from the lysis cell---> bad for blood-----> kidney overworks to remove these substances-----> renal failiure

Question 27

Explain how Myelodysplatic syndrome can lead to AML?

Answer 27

MDS is the intermediate gateway between the normal state and the AML (almost 30% cases of MDS convert to AML) here hypercellular bone marrow is seen (not similar to aplastic anaemia in which pancytopenia is due to hypocellular BM) dysplasia means pre cancerous the whole reason for treatment is to prevent the MDS to convert to AML Myelodysplastic syndrome is not the same as myeloproliferative disorders Both are Myeloid lineage but in Myeloproliferative there is no cytopenia and there is adequate maturation in MDS there is cytopenia and inadequate maturation

Question 28

What is Myelodysplastic syndrome? | sad bone marrow

Answer 28

MDS is the stem cell disorder with ineffective haematopoesis, defect in maturation of cell of myeloid lineage (this include rbc. Granulocytes,wbc and platelets, this is why we will have pancytopenia MCV will be high because immature cells It is acquired clonal disorder affecting stem cells causes can be acquired or environmental

Question 29

Classify MDS.

Answer 29

1) Refractory Anaemia (Slowest subtype to progres to AML) refractory anaemia- anemia inresponsive to treatment 2) Refractory Anaemia with ringed Sideroblasts 3) Chronic myelomonocytic 4) refractory anaemia with Excess blasts in transformation (fastest subtype to get converted into AML) Unfavorable cases- high % of blasts (in acute leukemias >20% and in MDS<20% so if the number of blasts is increasing you are getting close to getting cancer/leukemia) high no. Of cytopenias high age cytogenetic anomalies (chr 7) Favourable cases- 5q (in females) or 20q deletion

Question 30

How can MDS be treated?

Answer 30

Supportive therapy human growth factors CHEMO stem cell transplant (last resort)

Question 31

Chronic Myelogenous Leukemia

Answer 31

``` Mature cells older patients non existent or very few blasts cell (less than 10% in BM) small cells onset is insidious ``` risk factor - ionising radiation in high doses usually 40-60 years age 15% of adult leukemias

Question 32

What is the cause of CML?

Answer 32

T(9:22) translocation of the proto-oncogen "ABL" ABL fuses with the Break cluster region (BCR) on ch 22 ABL(chr 9) + BCR (chr 22) ==> BCR-ABL fusion gene (on chr 22) this is called the Philadelphia Chromosome this philadelphia chromosome can lead to ALL or CML BCR-ABL fusion gene-----.translation-----> BCR-ABL protien 100% of patients with CML have philadelphia chromosome nut it is not specific because phil. Chr is also present in pattients with ALL this protien form is a tyrosine kinase (all enzymes are protiens) this tyrosine kinase will dirupt the cell function and will cause increased proliferation and decreased apoptosis this is why we treat this with tyrosine kinase inhibitor IMATINIB

Question 33

What are the three phases of CML

Answer 33

Chronic phase (most patiens are diagnosed here) asymtomatic or mild symptoms accelarated phase - splenomegaly , basophilia , more immature cells are seen Blast crisis - clinically it starts to behave like an acute leukemia transfers to AML(70%) or ALL(30%)

Question 34

What is LAP test? (Leukocye alkaline phosphatase test) specifically used for CML

Answer 34

A leukocyte alkaline phosphatase (LAP) test is a laboratory test that can be conducted on a sample of your blood. Your doctor can order it to measure the amount of alkaline phosphatase, a group of enzymes, in certain white blood cells. Leukocyte alkaline phosphatase (LAP) is the term for alkaline phosphatase that’s found in leukocytes. Another name for leukocytes is white blood cells. When your test results are available, your doctor will discuss them with you. They will help you understand what the results mean and discuss follow-up steps. Scores for the LAP test can range from zero to 400, with those between 20 and 100 being considered normal. A score that’s higher than normal may be caused by: leukemoid reaction essential thrombocytosis myelofibrosis polycythemia vera A score that’s lower than normal may indicate: CML (because leukemic cells are useless) aplastic anemia pernicious anemia If your doctor suspects you may have CML based on your test results, they will likely order a cytogenetic test. This will help them confirm their diagnosis.

Question 35

Explain Blast crisis.

Answer 35

A phase of chronic myelogenous leukemia in which tiredness, fever, and an enlarged spleen occur during the blastic phase, when more than 30% of the cells in the blood or bone marrow are blast cells (immature blood cells). CML coverts to AML and behave like it increased Basophilia is aldo seen

Question 36

What is Leukemoid reaction? (It is not leukemia)

Answer 36

It is a benign condition It is an exaggerated responseof leucocytes against a microbial pathogen or response to stress WBC> 50,000 could be wither Myeloid or Lymphoid origin

Question 37

How can we rule out CML id there is Leukemoid Reaction suring diagmosis?

Answer 37

Both wil have basophilia However the LAP score is low in CML (the leucocytes are useless but high) and high in leukemmoid recation (exaggerated response)

Question 38

What is Alkaline Phosphatase enzyeme?

Answer 38

Alkaline- Stable and works in Alkaline environment (basic) phosphatase- an enzyme that removes phosphate group from a molecule (Kinase adds a phosphate group :) do not confuse it with Acid phosphatase that works best in acidic environment

Question 39

How can we use acid phosphatase to diffrentiate in acute lymphoblastic leukemia subtypes?

Answer 39

In B-ALL it is negative | T-aLL positive

Question 40

Where can you find Alkaline phophatase enzyme in the body?

Answer 40

Hepatobilliary and musculoskeletal system. ALP is high in case of- ``` hepatobilliary diseases hepatic cirrgoiss leukemoid rxn (also LAP high) Paget disease osteomylasia hyperthyroidism/parathyroid pregnancy ``` ALP will be low in- wilson disease PNH CML hypothyroidism and menopause

Question 41

Leucocyte Alkaline Phosphatase?

Answer 41

Enxyme removing the Phosphate group in an basic environment in Mature Leucocytes

Question 42

Why leucocte ALP will be low in CML (even though the cells are mature?

Answer 42

Even though in CML the cells of the myeloid lineage is mature but it is cancer and in cancer we have a left shift. These cells would no be as mature as normal cells in leukemoid rxn the cells are fully mature and functional so high LAP LAP high in leukemoid rxn polycythemia vera low in- CML Apastic anaemia (because of pancytopenia) pernicious anaemia

Question 43

Explain Tyrosine kinase inhibitors. (TKI) (-tinib) (imatinib)

Answer 43

Tyrosine kinase adds phophate group (ON-OFF switch) It takes Phosphate group from ATP and gives it to a protien Now the Tki,s Blocks the ATP binding site on the tyrosine kinase enzyme so no phosphate tranfer to the protien now for Imatinib the target protiens are different like in CML -- BCR-ABL protien These are teratogenic in nature so not given in pregnancy.

Question 44

Treatment of CML.

Answer 44

We use TKI's 1) First Generation- Imatinib (all phases) 2) Second generation- Dasatinib (all phases), Nilotinib (cannot give in case of blast crisis), Bosutinib (never the first choice) 3) third- Ponatinib we can also give Omacetaxine that is a more selective on BCR-ABL (after 2 or more TKI's have failed)

Question 45

What is Leukostasis? To which type of leukemia is it related to?

Answer 45

Leukostasis happens because of high number of blasts in the blood high viscosity= low tisseue perfusion that can lead to stroke cerebral ischemia haemorrhage sludge in pulmonary vessels-pulmonary effusion DIC tumor lysis syndrome because its blasts cell it is realted to AML, ALL and CML(in case of blast crisis)

Question 46

how can we treat leukostasis?

Answer 46

Give hydroxyurea (in tumor lysis syndrome) leukopharesis (to remove the blast cells) Induction chemotherapy Prophylaxis for tumor lysis syndrome by giving hydrate the patient and give allupurinol, rasburicase. Brain radiation

Question 47

Explain chronic lymphocytic leukekmia. (CLL)

Answer 47

Lymphoproliferative disorder of high no of mature lookinf lymphocytes (that are of no use or incompetant0 If there is a solid lymph nodal mass (as lymphocyte goes to mature in lymph nodes) we will call it SLL CLL/SLL as leukemia can lead to lymphoma and vice versa Elderly caucasian male usually asymptomatic lymphocytosis (smudge cells seen) lymphadenopathy hepato splenomegaly anaemia and thrombocytopenia is seen (n severe cases)

Question 48

Explain classification or prognosis of CLL (very important) | The Rai system

Answer 48

Stage 0 lymphocytosis with smudge cell risk low Stage 1 lymphocytosis+adenopathy medium Stage 2 lymphocytosis + hepatosplenomegaly mid Stage 3 Anaemia high Stage 4 thrombocytopenia high

Question 49

Can CLL lead to lymphoma?

Answer 49

Yes | 10% of the people with CLL will have diffuse large cell lymphoma (aggressive form)

Question 50

What is Hairy cell leukemia?

Answer 50

Rare Indolent (not aggressive,mild) some say it is a subtype of CLL Hairy cells ----> Mature B lymphocytes Leukemic cell accumulate in the spleen Leukemic cell will overcrowd other cell lines causing anaemia, leukopenia and thrombocytopenia high risk for people who do farming and gardening good prognosis tretament- supportive therapy purine analogs (metabolites that mimic sttructure of purines) - Cladribine and pentostatin BRAF inhibitors

Question 51

Why can leukemias cause anaemias and other pennias?

Answer 51

Leukemia itself can also cause anemia. As leukemia blood cells multiply rapidly, little room is left for normal red blood cells to develop. If your red blood cell counts drop too low, anemia can occur

Question 52

What happen when lymphoma occurs in mediastinum?

Answer 52

Airway Obstruction | Superior vena cava syndrome

Question 53

How can lymphomas lead to hypervisosity syndrome?

Answer 53

Some lymphomas can create IgM antibodies that can cause hv syndrome