Leukemias Flashcards
causes of leukocyte neoplasms or leukemia
damage to HSC ( red marrow)
- radiation
- chemotherapy
- chemical and rug exposure
- viral infections (HTLV, EBV)
- oncogene mutations
- secondary to other conditions
general characteristics of acute leukemia
- sudden onset
- rapid progression, esp. with no treatment
- immature cells involved; blasts
- all age groups
- 6 mos life expectancy if not treated
general characteristics of chronic leukemia
- slow, insidious onset
- asymptomatic
- slow progression
- mature cells involved
- common in adults, rare in children
myeloblasts vs lymphoblasts
- myelo: larger, numerous nucleoli, auer rods
- lympho: smaller, scant cytoplasm, indistinct nucleoli
precipitated peroxidase proteins
auer rods
type I vs type II myeloblasts
type I = no granules
type II = few to many azurophilic granules
promyelocytic leukemia
- very heavy granulation in promyelocytes
- may be some blasts present but promyelocytes are predom
microgranular variant PL
butterfly nuclei
may see very fine stippling or very fine ground glass granule appearanceo
myeloperoxidase
found in primary granules
stains granulocytes and monocytes
sudan black
cellular lipids in 1ry and 2ry granules; similar reactivity to MPO/MPX
stains granulocytes and monocytes
alpha-naphthyl acetate esterase stain (NSE)
non-specific esterase
high activty in monocytes/macs/histocytes
PAS
stains glycogen in cytoplasm
primarily stains lymphs, erythroblasts, megakaryocytes
these will differentiate between myeloid and lymphoid lineage
MPO/MPX, Sudan Black
pos for granulocytes and moncytes
this stains monocytes reddish/brown
NSE
dark staining in cells that are monoblastic in lineage
this shows block positivity
PAS
very strnog pos in lympphoblasts and diffuse pos rxn in erythroblasts and megs (staining is scattered around cell, not as intense)
lymphoid lineages CD
2,3,4,5,7,819,20,22
B cell CD
19,20,22
T cell CD
2,3,4,5,7,8
TdT
terminal deoxynucleotidyl transferase
- DNA polymerase in stem cells, early lymph cells
- seen in ALL (pos in both B and T cell)
- can be detected via monoclonal Abs through flow
karyotyping helps to…
diagnose
sub-classify
monitor residual disease
prognosis
molecular genetics to differentiate blasts
karyotyping at molecular level
helps to show disease progression, accurate prognosis, predict response to therapy
detection of mutations, gene arrangements using PCR
what is the difference between lymphomas and leukemias
leukemia = PB and BM involvement
lymphoma = PB, BM, and lymph node (tumor)
how do we classify B cell and T cell leukemias
B cell = recurrent genetic abnormalities or NOS (no specific gene abnormalities)
T cell = no further classification
B-cell lymphoblastic leukemia/lymphoma
- small blasts: scant blue cytoplasm with condensed chromatin
- large blasts: moderate light blue to grey cytoplasm, may have vacuolation with dispersed chromatin
- typical = anemia, infections, fever, organomegaly, bone pain
- WBC count variable with neutropenia
T- cell lymphoblastic leukemia/lymphoma
- cytogenetic abnormalities common
- blasts indistinguishable from B cell blasts
- typical acute anemia symptoms
- WBC count increased
how to know if ALL is B cell or T cell
cytochemical staining will only tell us it is ALL… so need flow cytometry
types of acute myeloid leukemia
- APL with recurrent genetic abnormalities (APL w PML-RARA)
- AML with myelodysplasia
- therapy-related myeloid neoplasms
- AMS, NOS
- myeloid sarcoma
- myeloid proliferation related to down syndrome
CBC of chronic leukemia
- mature cells in BM; increased M:E
- WBC increased
- N/N anemia
PBS = mature cell morphologies with left shift
chronic leukemia
describe CLL
- mature b-cell neoplasm
- immunologically incompetent lymphs
> altered humoral immunity
> hypogammaglobulinemia
> increased infections = complications, death
> may lead to autoimmune disorders (hemolytic anemia, thrombocytopenia (ITP))
> malignant b cells do not progress to normal plasma cells
> bystander b cells produce autoantibodies (not leukemic clones)
WBCs in CLL
high (20-250)
lymphocytosis
neutropenia
RBCs in CLL
decreased
N/N anemia (unless AIHA = retics and spherocytosis)
PLTs in CLL
normal until advanced = decrease
CLL PBS
mature lymphs
pro-lymphs
smudge cells
CLL BM
hypercellular
increase in small lymphoid cells
Flow for CLL
CD19+, 20+. 22+
CD5+ (usually only T cells nut seen in 90% of CLL)
this is TRAP stain pos
hairy cell leukemia
- lymphs pos for acid phosphatase and resistant tartrate (other cells neg after adding tartrate)
hairy cel leukemia immunophenotype
CD123+ (b cell markers)
hairy cell leukemia diagnosis
- TRAP pos
- CD123+
- trephine biopsy to show increase marrow fibrosis + hairy cells
- Annexin A1 positive
plasma cell neoplasms
- either increase in complete or incomplete immunoglobulins
- can lead to hypergammaglobulinemia
> monoclonal = single clone, increase in single type of immunoglobulin
> polyclonal = different immunoglobulin, broad increase in gamma
monoclonal gammopathies
increased abnormal Igs (para-protein or M-protein)
complete one of IgA,IgG,IgE,IgD,IgM and excess free light chains
MGUS can turn into…
Multiple myeloma if class switch to IgG, IgA
Waldenstrom’s macroglobulinemia if switched to IgM
properties of the M-protein
cryo-protein
pyroglobulin (precipitates when heated; Bence-Jones)
cold-agg due to cryoglobulin
hyper-viscosity (increased protein in blood)
interference in coag = fibrin formation interference, coat PLT and coag factors (can’t participate in coag)
amyloidosis (excess proteins precipitate out into tissue)
attract basic dyes so blue background staining on PBS
MGUS
- M-protein in blood but <30 g/L
- BM plasma cells <10%
- no CRAB
- may not progress to malignancy, monoclonal spike
- no pt symptoms
plasma cell myeloma
- abnormal proliferation of plasma cells and b cells in BM
- osteolytic destruction of bone
> bone pain, osteoporosis, fractures
> lesions on X-ray
> decrease height
> release of calcium due to bone destruction = hypercalcemia - tubular damage form light chain proteinuria
- anemia (EPO loss, HSC replacement
(CRAB)
PBS and CBC of plasma cell myeloma
- N/N anemia
- decreased retics
- plts/wbcs normal to decreased
- occasional plasma cell
- rouleaux
- neutropenia
BM of plasma cel myeloma
plasma cells (flame)
hypercellularity
ESR and flow of plasma cell myeloma
- ESR increased
- flow = CD8,56,79,138 pos
CD19 neg
chemistry of plasma cell myeloma
increased protein in serum and urine
increased calcium
protein electrophoresis of plasma cell myeloma
- increased monoclonal
- IFE = bence-jones (light chains)
T or F. heavy chains cannot be cleared by the kidney
T! only light chains are found in urine
how to differentiate PCM vs plasmacytosis
plasmacytosis = no CRAB, no gamma peak
Waldenstrom’smacroglobulinemia
- type of non-Hodgkin lymphoma (lymphoplasmacytic lymphoma)
- monoclonal peak, IgM
- b cells start to mimic plasma cells
- cells infiltrate BM, spleen, liver
- anemia, thrombocytopenia, neutropenia
- decreased normal IgG
- no CRAB
CBC/PBS of WM
N/N anemia
rouleaux
neutropenia
BM of WM
plasmacytoid lymph
no CRAB
ESR and flow of WM
increased ESR
CD19, 20, 24 pos
light chain restriction (only kappa or only lambda)
myeloproliferative neoplasms
- can progress to acute leukemia
- unregulated proliferation of myeloid HSCs
- affect middle-aged to older adults
- CML, PV, ET, PMF
features of MPNs
- hypercellular BM (increased grans and megs with abnormal morph)
- increased gran in PBS, normal morph
- initial increase of RBC, PLT (dysfunctional) followed by marrow fibrosis
- splenomegaly and hepatomegaly common
- low onset
- tyrosine kinase genes abnormalities
abnormal activation of tyrosine kinases
leads to uncontrolled and unregulated cell proliferation (i.e. cells won’t know when to die)
CML
- Philadelphia chromosome pos (BCR/ABL gene fusion)
- increased + uncontrolled proliferation of granulocytes
- ACQUIRED
Philadelphia chromosome
- translocation between long arms of chr 9 and 22 (reciprocal)
- chr 9 longer, chr 22 shorter
- only found in leukemia cells
- leads to formation of the BCR/ABL gene -> increased tyrosine activity
T or F. The Philadelphia chromosome is only resent in HS tissues such as RBCs, neuts, PLTs, basophils, monocytes…
T! not present in lymphs or non-hem stem cells
CBC/PBS of CML
- N/N anemia
- retics normal or decreased
- PLT dysfunction
- WBC increased >25
- left shift (increase in myeloids)
- blasts <2%
- nRBC
- basophilia, neutrophilia, etc.
BM of CML
- hypercelular (increased M:E)
- normoblasts decreased
- blasts <5%
- megakaryocytes normal to increased; clusters
- fibrosis with disease progression
LAP stain CML
normal or decrease
how to see BCR/ABL translocation
southern blot
PCR
phases of CML
- chronic: stable and responsive to therapy
- accelerated: 3-5 yrs after onset; symptoms worsen; blasts 10-19%; less responsive to therapy
- blast: >20% in PBS or BM => AML
drug for CML
Gleevec
polycythemia vera
panmyelosis (primarily erythroid precursors)
JAK2 V617F mutation
> AA substitution => continuous activation of JAK2 kinase
> continuous EPO activation even though EPO absent
JAK2 V617F mutation
bypasses EPO
EPO independent proliferation of RBC
EPO levels decreased or absent
causes of JAK2 V617F mutation
radiation or toxin exposure
PV patient symptoms
- hyperviscosity -> thrombosis
- increased PLT -> bleeding
- headaches, nosebleeds, stroke, angina, MI, visual disturbances, itching (increased basos and histamine)
- patients can transform into spent phase - anemia and marrow fibrosis and splenomegaly bc BM so overworked &exhausted
- can transform into blast phase (acute leukemia; 15%)
CBC/PBS of PV
- Hb >165 g/L
- increased Ht and RBC
- N/ to M/H anemia
- retic N
- WBC/PLT increased; may see left shift (but normal morph)
BM of PV
hypercellular (M:E normal)
cell morph = normal
iron stores decrease/absent
megs increase and atypical
disease progression => fibrosis
this demonstrates PV’s EP-indepdent erythropoiesis
endogenous erythroid culture
- harvest malignant HSC tissue and give them everyting needed to grow but dont give EPO; pts with PV will still make HSCs and will still differentiate
major diagnosing criteria for PV
- increased Hb (>165F; >185M)
- JAK2 mutation
PV treatment
phleb (may make pts more iron def)
myelosuppressive agents (can increase risks of transforming to leukemia)
secondary PV
- caused by tissue hypoxia (high altitudes, cardiac diseases, pulmonary disorders, obesity, increased methem in smokers, Hb barts (abnormal Hb and O2 affinity)
- inappropriate EPO increases (kidney lesions/tumors, androgen or EPO abuse, chemical exposure (cobalt))
CBC of secondary PV
Hb/Hct increase
WBC/PLT normal
T or F. The LAP of secondary PV is decreased
F! it is normal
BM of secondary PV
erythroid hyperplasia
tissue hypoxia causes EPO to
increase
relative PV
- caused by dehydration (decrease inplasma vol) or smoking
- CBCD = Hb and Ht increased; WBC/PLT normal
- BM = normal; EPO normal
- plasma layer decreased by a lot so looks like lot of RBCs but this is false
essential thrombocytopenia
- megs and PLTs affected
- can convert to AML
- lots of genetic mutations associated
ET patient symptoms
mild bleeding probs (nosebleeds, easy bruising)
thrombosis
headaches
dizziness
blurred vision
abnormal functioning PLT
asymptomatic often
CBC/PBS of ET
increase in PLTs (600 to 1000)
giant plts, clumps, agranular
megakaryocytic fragments
N/N to M/H anemia
BM of ET
increase in megs and larger, clusters, and hyperlobulated
normal to hypercellular
PLT testing for ET
adhesion and agglutination is abnormal
primary myelofibrosis
overproduction of HSC and fibroblasts
> increased grans and megs in BM
reactive fibrosis and collagen increase 2ry to increased release of fibroblastic growth factors secreted by malignant or neoplastic megs
lots of genetic muations associated
PM phases
initial or pre-fibrotic: hypercell BM and minimal reticulin buildup
fibrotic: increased retic and collagen deposit in BM, organomegaly (spleen and liver), extramed hematopoiesis (teardrops)
can transform to AML
PM lab tests for initial phase
increase in WBCs and PLTs, N/N anemia
hypercell Bm and lots of megs and grans
PM lab tests for fibrotic phase
CBCD/PBS = poikilocytosis (tears, elliptos, nRBCs), myeloid precursors and blasts (leukoerythroblastic)
BM = decrease WBCs and PLTs (abnormal & large)
diagnosing PM stain
reticulin stain after trephine biopsy
micromegakaryocytes look like
lymphs
clonal disorders with progressive cytopenia in PB
myelodysplastic syndromes
MDS
- dysplastic and ineffective production of blood components
- early = cytopenia and increased apoptosis
- late = apoptosis decreased, increased malignant and neoplastic cell survival, progression towards leukemia
- abnormal cell function
how does MDs develop
- exposure to chemicals (benzene)
- smoking
- Hx of hematopoietic neoplasms in family
- environmental toxin exposure
- may develop secondary to therapy
dyserythropoiesis
- refractory anemia from treatment
- low retics
- PBS = N/N anemia, macro, M/H, oval macro, tears, schistos, acanthos, spheros, BS, nRBC, HJ bodies
- BM = meg changes, large multi-nuclear normoblasts, nuclear fragments, karyorrhexis, ringed sideroblasts
dysmyelopoiesis
PBS = neutropenia, moncytosis, blasts <20%, agranular, pseudo-PH
BM = abnormal grans, N:C asynchrony, megaloblastic changes, abnormal staining of cells
dysmegakaryopoiesis
PBS = decreased PLTs, giant PLTs, agranular
BM = abnormal megs, large cells with meg changes, nuclei detached from one another, agranular PLTs, multi-lobed megs, abnormal cells in sheets or clusters
