L38 and L16 Approach to hematological malignancies and investigations

Question 1

Hematological overview:

Acute + Lymphoid malignancy?

Answer 1

Acute Lymphoblastic leukemia (ALL)

Question 2

Hematological overview:

Chronic + Lymphoid malignancy?

Answer 2

Chronic Lymphoid leukemia (CLL)
(Lymphoproliferative neoplasm)
- Plasma cell neoplasm

Question 3

Hematological overview:

Acute + Myeloid malignancy?

Answer 3

Acute myeloid leukemia

Question 4

Hematological overview:

Chronic + Myeloid malignancy?

Answer 4

Chronic myeloid leukemia

Myeloproliferative neoplasm

Question 5

In AML, there are excessive _________ in the bone marrow, pancytopenia in PB and also increase in WBC.

Answer 5

blast cells

Question 6

In Myelodysplasitc syndrome, proliferation of cells are normal or excess but _____________.
Blast cells in bone marrow is <20% but hypercellular.
Pancytopenia in PB.

Answer 6

ineffective

differentiation of cells impaired

Question 7

When is a bone marrow study required? What possibilities are evaulated?

Answer 7

• unexplained pancytopenia (due to BM failure)
  1. Acute leukemia
  2. Aplastic anemia
  3. Infiltration: TB, carcinoma

Question 8

What is the main difference between BM aspiration and biopsy?

Answer 8

Aspiration:
- cytological abnormalities

Biopsy:
- histological abnormalities: architecture, infiltration, cellularity

Question 9

Immunophenotyping: Flow cytometry is used to? (2)

Answer 9

1. Determine lineage

2. Detect minimal residual diseases (MRD)

Question 10

What is Forward scatter and Side scatter detecting?

Answer 10

Forward scattering: Cell size

Side scattering: Granularity

Question 11

Granulocytes / Neutrophils FS and SS?

Answer 11

Large and more granular, therefore with high SS and FS

Question 12

Monocytes FS and SS?

Answer 12

Large cells but not so granular, therefore high FS but low SS.

Question 13

Lymphocytes FS and SS?

Answer 13

SMall cells, not granular, therefore low FS and low SS.

Question 14

Gating means to isolate a single population of interest from a heterogeneous sample by its specific ____________ and SS/FS properties.

Answer 14

specific antigen

e.g. CD45

Question 15

Which types of cells have bright and dim CD45 antigen expression respectively?

Answer 15

Bright: Mature leukocytes
Dim: Blast
Negative: erythroid and non-hematological cells

Question 16

What is CD in CD45.

Answer 16

Cluster differentiation, antigens found on leukocytes

Question 17

Which of the following is not a B-lymphoid marker? 
A. CD19
B. CD20 
C. CD22
D. CD33
E. CD79a 
F. CD10

Answer 17

D

Myeloid marker!

Question 18

Which of the following is not a T-lymphoid marker?
A. CD2
B. CD3
C. CD5
D. CD7
E. CD13

Answer 18

E

Myeloid marker!

Question 19

Which of the following is not a myeloid marker?
A. CD33
B. CD13
C. CD117
D. CD34
E. Myeloperoxidase (MPO)

Answer 19

D

in hematopoietic progenitor cells

Question 20

Which of the following are hematopoietic progenitor markers?
A. CD34
B. TdT
C. HLA-DR

Answer 20

All of the above

Question 21

In patient with paroxysmal nocturnal hemoglobinuria (PNH), what markers are used to monitor the RBCs and neutrophil levels respectively? Levels of them increases/decreases.

Answer 21

RBC: CD59
Neutrophils: FLAER;

decreases

Question 22

In HS (hereditary spherocytosis), marker ____________is reduced.

Answer 22

EMA

= eosin-5′-maleimide

Question 23

To assess cytogenetics, what techniques can be used? (2) Briefly describe each of them.

Answer 23

1. G-banding: Identify extra or missing chromosome and structural aberrations in KARYOTYPE, e.g. PML-RARA in APL
2. FISH: Target specific aberrant DNA sequence, e.g. PML-RARA

Question 24

To do molecular study, PCR, RT-PCR, RQ-PCR, NGS etc. can be done to detect?

Answer 24

Point mutations, insertions or deletions that are not detectable in cytogenetics
e.g. FLT3-ITD in AML
+
MRD

Question 25

What is MRD (minimal residual disease)?

Small number of __________ that remain in the patient during/after treatment

Answer 25

leukemic cells

Question 26

In traditional assessment of treatment response monitoring by morphology, e.g. PB count, BM cellularity, BM blast count for remission…, what are the 2 main issues?

Answer 26

1. Not sensitive: patients in morphological complete remission may still have a large number of residual leukemia cells
2. Haematogones: normal B cell progenitors highly resemble residual leukemic cells; higher haematogones in BM after temporary stop in chemotherapy, end of treatment/ HSCT transplantation

Question 27

RQ-PCR is one of the ways of MRD detection. In patients with B-ALL and T-ALL, what exactly is measured?

Answer 27

B-ALL: Clonal rearrangement of Ig gene

T-ALL: TCR

Question 28

RQ-PCR can also measure expression of gene fusion and leukemia specific markers.
What is detected in the following disease?
1. CML
2. APL
3. AML

Answer 28

1. CML: BCR-ABL
2. APL: PML-RARA
3. AML: NPM1 mutation

Question 29

Compared to flow cytometry, RQ-PCR is more/less sensitive and more/less time-consuming.

Answer 29

More sensitive;

More time consuming

Question 30

Flow cytometry is used to distinguish ___________ from ___________ in leukemia-associated immunophenotype.

Answer 30

Leukemic cells from hematogones (normal prongenitor cells)

Question 31

Example: Some B lymphoid cells aberrantly expressed CD-5, a __________ marker. This is a feature of _________.

Answer 31

T-linieage marker;

CLL

Question 32

Example: CLL: CD20+ but CD10-. CD10 is usually +ve in ?

Answer 32

follicular lymphoma (B cell proliferative neoplasm)

Question 33

PNH cells showed _________ reduction. Lost of it from red cells allows uncontrolled ___________activation and intravascular hemolysis.

Answer 33

CD59;

complement