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Heme II > Neoplasms of white cells > Flashcards

Neoplasms of white cells Flashcards

1
Q

inherited genetic risk factors for leukemia

A 
bloom syndrome
fanconi anemia
ataxia telangiectasia
down syndrome
Type I neurofibromatosis
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2
Q

Viruses and leukemias

A

HTLV-1
EBV
KSHV/HHV-8

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3
Q

HTLV-1

A

adult T cell lymphoma

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4
Q

EBV

A 
burkitt lymphoma
HL
B-cell lymphomas
rare NK cell lymphomas
(benign HLH)
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5
Q

chronic inflammation that can lead to CA

A

H. pylori
gluten sensitive enteropathy
breast implants
HIV

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6
Q

H. pylori

A

gastric B cell lymphomas

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7
Q

gluten

A

intestinal T cell lymphomas

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8
Q

breast implants

A

T cell lymphomas

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9
Q

HIV

A

B cell lymphomas

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10
Q

smoking

A

acute myeloid leukemia

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11
Q

Primary T cell associated Ags

A 
CD1
CD3
CD4
CD5
CD8
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12
Q

Primary pre-B cell associated Ags

A

CD10
CD19
CD20

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13
Q

primary mature B cell associated Ags

A

CD19
CD20
CD21
CD23 (activated B cells)

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14
Q

CD21

A

EBV R

and on DCs

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15
Q

CD23

A

only activated B cells

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16
Q

CD11c

A

hairy cell leukemia

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17
Q

CD15

A

RS cells and variants

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18
Q

CD30

A

RS cells and variants

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19
Q

precursor B cell neoplasms

A

B-ALL

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20
Q

precursor T cell neoplasms

A

T-ALL

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21
Q

B-ALL

A 
childhood acute leukemia (uncommon presents in bone or skin)
most common cancer in children
W:B 3:1
slightly more frequent in boys
hispanics highest incidence
peaks at age 3
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22
Q

T-ALL

A

less common
adolescent males as thymic lymphomas
evolve to leukemic picture

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23
Q

B-ALL mutations

A

loss of fnx in PAX5, E2A, EBF, ETV6, RUNX1

12;21

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24
Q

T-ALL mutations

A

gain of fnx in NOTCH1

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25
ALL mutations
90% have numerical or structural chromosome changes | most commonly hyperploidy
26
ALL morphology
marrow hypercellular mediastinal thymic masses lymphadenopathy macriphages have stary sky appearance
27
B-ALL immunophenotype
``` CD19 PAX5 CD10 +/- CD20 IgM heavy chain ```
28
T-ALL immunophenotype
CD1- 5 | CD7 and 8
29
clinical ALL
Abrupt stormy onset w/in days to weeks
30
symptoms of ALL due to bone marrow supression
anemia low grade fever infections bleeding
31
other symptoms of ALL
``` bone pain generalized lymphadenpathy splenomegaly hepatomegaly testicular involvement meningeal (B-ALL) ```
32
worse prognosis ALL
100,000 | (9;22)- Philadelphia chrom
33
favorable prognosis ALL
``` 2-10 yrs low white count hyperdiploidy trisomy of 4,7,10 presence of t(12;21) ```
34
CLL
``` chronic lymphocytic leukemia absolute lympohocytosis >5000 most common leukemia of adults in western world median age 60 less common in japan and asia ```
35
CLL mutations
``` deletion of: 13q14.3 11q 17p trisomy 12q gain of fnx NOTCH1R in 18% ```
36
CLL pathogenesis
growth limited to proliferation centers due to stromal cells TFs unmutated Ig segments mor aggressive
37
CLL morphology
proliferation centers- larger activated lymphocytes gathered in loose aggregates pathognomonic for CLL smudge cells infiltrates in splenic white and red pulp and portal triads
38
CLL immunophenotype
``` CD19 CD20 CD23 CD5 low level expression of surface Ig ```
39
CLL presentation
usually asymptomatic at Dx
40
CLL symptoms
``` fatigability weight loss anorexia lymphadenopathy hepatosplenomegaly small monoclonal Ig spike infections ```
41
CLL and immune fnx
hypogammoglobulinemia common increased susceptibility to bacterial infections hemolytic anemia thrombocytopenia
42
worse prognosis CLL
deletion of 11q and 17p lack of somatic hypermutations ZAP-70 NOTCH1 mutations
43
richter syndrome
occurs when CA transforms to more aggressive DLBCL rapidly enlarging mass w/in lymph nodes or spleen survival <1yr
44
follicular lymphoma
most common form of indolent NHL in US | less common in Europe, rare in asia
45
follicular lymphoma pathogenesis
hallmark is (14;18) -> overexpression of BCL2 BCL2 antagonizes apoptosis and promotes survival MML2 mutations -> epigenetics
46
follicular lymphoma morphology
predominately nodular or nodular and diffuse no clear germinal centers visible lymphocytosis in 10% bone marrow involvement in 85% -> paratrabecular lymphoid aggregates splenic white pulp and hepatic portal tirads frequently involved
47
Follicular lymphoma immunophenotype
``` CD19 CD20 CD10 Surface Ig BCL6 BCL2 unlike CLL CD5 negative ```
48
Follicular lymphoma clinical
``` generalized lymphadenopathy extranodal sites uncommon waxing and waning course incurable anti CD20 may help histologic transformation in 30-50% most commonly to DLBCL survival <1yr ```
49
DLBCL
diffuse large B cell lymphoma most common NHL in US slight male predominance median age 60
50
DLBCL pathogenesis
dysregulation of BCL6 may arise from follicular cell lymphomas 5% MYC epigenetics
51
DLBCL morphology
large cell size diffuse pattern, no follicular formations large mutlilobar or cleaved nuclei karyorexis
52
DLBCL immunophenotype
CD19 CD20 +/- CD10, BCL5
53
DLBCL subtypes
immunodeficiency associated | primary effusion lymphoma
54
immunodeficiency DLBCL
HIV | EBV
55
primary effusion lymphoma DLBCL
always infected w/KSHV/HHV-8 typically do not express B or T cell markers have clonal IgH
56
DLBCL clinical
rapidly enlarging mass at nodal or extranodal site waldyer ring liver and spleen large destructive masses bone marrow rarely involved aggressive and rapidly fatal w/o Tx MYC worse prognosis if circulating neoplastic B cells worse prognosis
57
Burkitt lymphoma types
african/endemic/mandibular sporadic/nonendemic aggressive lymphomas in HIV
58
Burkitt pathogenesis
``` MYC on chrom 8 Warburg effect fastest growing CA sporadic usually class switch regions essentially all endemic have EBV ```
59
Burkitt morphology
diffuse infiltration phagocytes have starry sky pattern royal blue cytoplasm w/clear cytoplasmic vacules
60
Burkitt immunophenotype
``` IgM CD19 CD20 CD10 BCL6 consistent w/germinal center B cell origin almost always neg for BCL2 ```
61
Burkitt clinical
children and young adults endemic- mandible sporadic- GI worse prognosis in older adults
62
solitary myeloma
MM infrequent variant presents as single mass in bone or soft tissue soft tissue can usually be cured w/excision
63
smoldering myeloma
MM uncommon variant defined by lack of symptoms and elvelated plasma M, but < 3
64
Waldenstom macroglobinemia
syndrome in which high IgM leads to hyperviscosity symptoms usually older adults associated w/lymphoplasmacytic lymphoma
65
MM
commonly associated w/lytic bone lesions, hypercalcemia, renal failure, and acquired immune abnormalities higher incidence in men and african descent peak 65-70
66
MM pathogenesis
``` cyclin D1 deletions of 17p (TP53gene) -> poor prognosis late state disease MYC rearrangments NFkB mutations High level of IL6 poor prognosis ```
67
definition of MM
>3 serum Ig (IgG most common) and/or >6 BJ proteins
68
plamacytomas
destructive plasma cell tumors of axial skeleton seen in MM
69
Bone lesions on radiograph
appear as punched out defects consisting of soft gelatinous red tumor masses
70
malignant plasma cells
like their benign counter parts, have perinuclear clearing can be relatively normal appearing blast cells or bizarre multinucleated cells
71
buzz words for MM
``` flame cells mott cells russel bodies sitcher bodies rouleaux formation plasma cell leukemia meyloma tumor ```
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flame cells
fiery red cytoplasm
73
Mott cells
multiple grape like cytoplasmic droplets
74
MM cell inclusions
fibrisl crystaline rods globules
75
russel bodies
globular inclusions in cytoplasm
76
Ditcher bodies
globular inclusions in nucleus
77
rouleaux formations
high levels of M proteins cause red cells to stick together
78
plasma cell leukemia
rare, when tumor cells enter peripheral circulation
79
MM immunophenotype
CD138 (aka syndecan-1) | often express CD56
80
Symptoms of MM stem from
effects of plasma cell growth in tissues (bones) production of excessive Igs suppression of normal humoral immunity
81
symptoms of MM
bone pain and fragility decreased normal Igs -> recurrent bacterial infections amyloodosis renal insufficiency (major COD)
82
better prognosis MM
translocations of cyclin C1
83
worse prognosis MM
deletions of 13q, 17p, (4;4)
84
MGUS
asymptomatic serum M protein <3 1% develop symptomatic MM per year same genetic markers as MM, therefore thought to be early stage
85
lymphoplasmacytic lymphoma
superficial resemblance to CLL/SLL (but tumor cells are plasma) secretes IgM causing hyperviscosity syndrome -> waldenstom macroglobulinemia unlike MM light chains are rare and no bone lesions
86
lymphoplasmacytic lymphoma pathogenesis
acquired mutations in MYD88
87
lymphoplasmacytic lymphoma morphology
russel bodies | dutcher bodies
88
lymphoplasmacytic lymphoma immunophenotype
CD20 | IgM
89
clinical lymphoplasmacytic lymphoma
``` hepatosplenomegaly anemia common 10% autoimmune hemolysis due to cold agglutinins hyper-viscosity syndrome incurable progressive disease plasmopheresis can help Anti CD20 ```
90
Mantle cell lymphoma
male predominance | resemble normal mantle zone B cells
91
Mantle cell pathogenesis
almost all have (11;14) -> overexpress cyclin D1
92
mantle cell morphology
lymphandenopathy lymphomatoid polyposis in GI (misdiagnosed as inflammatory bowel disease) large cells resembling centroblasts and proliferation centers are absent distinguishing from follicular lymphoma and CLL
93
mantle cell immunophenotype
CD19 CD20 surface Ig usually CD5+ and CD23- distinguishing from CLL IgH lacks somatic hypermutation, therefore naive B cell origin
94
mantle cell clinical
most common presentation is painless lymphadenopathy prognosis poor blastoid variant even worse prognosis
95
marginal zone lymphomas
aka MALTomas arise w/in GI lymph nodes, spleen, extranodal tissue memory B cell origin
96
marginal lymphomas inflammatory conditions
``` sjogren -> salivary gland hashimotos -> thyroid H. pylori -> stomach may regress if condition treated lie on continuum btwn reactive and malignant ```
97
mutations that make marginal lymphomoas Ag independent
(11;18) (14;18) (1:14) all of these upregulate BCL10 or MALT1 increasing TFkB
98
hairy cell leukemia
rare B cell neoplasm middle aged white males M:F 5:1
99
hairy cell leukemia pathogenesis
BRAF
100
hairy cell leukemia morphology
hair like projections marrow has diffuse interstitial infilatrate -> dry tap splenic red pulp usually heavily infiltrated beefy red gross appearacne hepatic portal triads frequently involoved
101
hairy cell immunophenotype
``` CD19 CD20 Ig (usually IgG) CD11c CD25 CD103 annexin A1 ```
102
hairy cell clinical
``` splenomegaly often massive lympadenopathy is rare pancytopenia infections (myco) BRAF inhibitors successful prognosis excellent ```
103
peripheral T cell lymphoma unspecified
``` far less common ten B cell, more common in Asia mixure of variably sized malignant cells prominent inflitrate of reactive cells brisk neoangiogeneis CD2, 3, 5 alpha, beta, gamma, or delta receptor some CD4,8 PRUITIS worse prognosis then B cell ```
104
anaplastic large cell lymphoma ALK postive
due to ALK fusion proteins -> RAS and JAK/STAT hallmark cells ALK in children usually presents in soft tissues better prognosis ALK negative adult variant worse prognosis both ALK + and - express CD30
105
Adult T cell leukemia/lymphoma
neoplasm of CD4 only in adults | ALL infected with HTLV-1
106
HTLV1 endemic in
soutern japan west africa caribbean basin
107
common presentation of Adult T cell leukemia/lymphoma
``` skin lesions general lymphadeneopathy hepatosplenomegaly peripheral blood lymphocytosis hypercalcemia clover leaf or flower cells sometimes progressive demylinating disease of CNS ```
108
HTVL1
encodes TAX -> NFkB
109
Mycosis fungoides
tumor of CD4 cells that home to skin | often have cerebriform appearance
110
sezary syndrome
variant of Mycosis fungoides skin involvement is manifested as exfoliative erythroderma still have cerebriform appearance
111
ceribriform appearance immunophenotype
CLA CCR4 CCR10 all of these home to skin
112
large granular lymphocytic leukemia
T cell and NK cell variants of this rare neoplasm occur in adults
113
T cell large granular lymphocytic leukemia
mild to moderate lymphocytosis and splenomegaly | lymphadenopathy and hepatomegaly usually abscent
114
large granular lymphocytic leukemia mutations
STAT3
115
large granular lymphocytic leukemia tumor cells
large lymphocytes w/abundant blue cytoplasm and few course azurophilic granules, best seen in peripheral blood smears
116
large granular lymphocytic leukemia immunophenotype
T cell- CD3 | NK cell- CD3- CD56+
117
large granular lymphocytic leukemia clinical
neutropenia and anemia rarely pure red cell aplasia seen felty syndrome triad
118
felty syndrome tirad
RA splenomegaly neutropenia underlying autoimmune condition suspected
119
extranodal NK/T cell lymphoma
rare in US and europe, more common in asia destructive nasopharyngeal mass, less common sites are testes and skin typically surround and invades small vessels -> extensive ischemic necrosis HIGHLY ASSOCIATED w/EBV
120
extranodal NK/T cell lymphoma immunophenotype
CD3- lack T cell Rs rearrangments and express NK cell markers
121
extranodal NK/T cell lymphoma clinical
highly aggressive, responds to radiation, but if late in course poor prognosis
122
hodgkin lymphoma
``` arises in single node or chain of nodes and spreads in predictable pattern RS cells 2 spikes 20s and 60s one of most common CAs of young adults curable in most casses ```
123
RS cells
release cytokines and chemokines and other factors that induce accumulation of reactive immune cells which make up 90% of tumor usually derived from germinal centers or post germinal center B cells
124
HL classifications
``` nodular sclerosis mixed cellularity lymphocyte rich lymphocyte depletion lymphocyte predominance ```
125
HL pathogeneis
Ig genes in RS cells due to epigenetics usually derived from germinal centers or post germinal center B cells fail to express most B cell markers including Ig activation of TF NFkB common in classical
126
RS cells mutations due to
EBV loss of fnx of IkB or A20 copy number gains in REL on chrom 2p
127
RS cell morphology
large multiple nuclei or single multilobar nucleus | w/large inclusion like nucleolus
128
mononuclear variant
single nucleus w/large inclusion like nucleolus
129
Lunar cell variant
seen in nodular sclerosis | more delicate, folded, or multilobate nuclear and pale cytoplasm
130
mummification
cell death of RS cells where cell shrinks and becomes pyknotic
131
classical immunophenotype
PAX5 CD15 CD30 neg for other B and T cell markers and CD45
132
NODULAR sclerosis type
``` most common lacunar variant deposition of collagen in bands that divide involved lymph nodes into nodules mediastinal uncommonly associated w/EBV excellent prognosis ```
133
mixed cellular type
``` diagnostic RS and mononuclear variants usually plentiful EBV in 70% M>F older age systemic sympotms overall prognosis good ```
134
lymphocyte rich type
uncommon reactive lymphocytes vast majority of cells frequent mononuclear variants and diagnostic RS cells vague nodularity due t residual B cell follicles EBV 40% excellent prognosisj
135
lymphocytes depletion type
``` least common HL immunophenotyping essential to differentiate from large cell NHLs EBV 90% older adults HIV of any age nonindustrialized countries prognosis less favorable then other HLs ```
136
lymphocyte predominance type
``` uncommon nonclassical infiltrate of small lymphocytes and macros RS hard to find contains L&H variants typically nodular pattern of growth ongoing somatic hypermuations EBV NOT associated ```
137
L&H variant
multilobar nucleus resembing popcorn kernel express typical B and T cell marker CD20, BCL6 neg for CD15 and CD30
138
lymphocyte predominance type clinical
M>F <35 present w/cervical or axillary lymphadenopathy mediastinal and bone marrow involvement rare may transform to DLBCL excellent prognosis, but more likely to recur
139
HL clinical
cutaneous immune unresponsiveness -> anergy suppressed TH1 response spread nodal -> splenic -> hepatic -> marrow and other tissues tumor stage anti CD30
140
AML
accumulation of immature meloid blasts produces marrow failure and complications related to anemia, thrombocytopenia, and neutropenia AML all ages, peaks at 60
141
WHO classifications of AML
genetic abberations Post MSD therapy related AML, not otherwise specified
142
M0
minimally differentiated | myeloperoxidase neg
143
M1
without maturation >3% myeloperoxidase pos few granules or auer rods
144
M2
myelocytic maturation 30-40% aurer rods (8;21)
145
M3
``` acute promyelocytic leukemia 5-10% may aurer rods patients younger DIC (15;17) ```
146
M4
myelomonocytic maturation myeloperoxidase pos monoblasts pos for non-specific esterases inv(16)
147
M5
``` monocytic maturation myeloperoxidase neg esterase pos mature monocytes inperipheral blood older patients high incidence of organomegaly, lymphadenopathy, and tissue inflitrations ```
148
AML pathogenesis
(8;21) (M2) and inv (16) (M4) -> disrupt RUNX1 and CBFB genes (15;17) (M3) -> PML-RARa fusion protein activating mutation FLT3 epigenetics
149
AML morphology
at least 20% blasts in marrow
150
types of blasts
myeloblasts | monoblasts
151
myeloblasts
aurer rods | fine peroxidase pos
152
monoblasts
lack aurer rods | nonspecific esterase pos
153
AML immunophenotype
CD33 | CD34
154
AML following MDS or Tx
often have deletions in chrom 5&7
155
AML clinical
present w/in a few weeks or months on onset of symptoms spontaneous bleeding (mucosal) or thrombotic events infections frequent (fungal, psudo) CNS less common then in ALL
156
meyloblastoma, granulocytic sarcoma, or cholroma
occasional presentation of soft tissue mass that w/o Tx will progress to AML
157
MDS
maturation defects that are associated w/ineffective hematopoiesis -> cytopenia blasts <20% in BM primary (idiopathic) or secondary to drugs or Tx (tMDS)
158
MDS pathogenesis
``` epigenetics loss of fnx in TP53 monosomies 5&7 deletions of 5q. 7q, and 20q trisomy 8 ```
159
MDS morphology
``` marrow usually hypercellualr at Dx ring sideroblasts megaloblastoid maturation nuclear budding abnormalities pseudo-pleger-huet cells meyloid blasts ```
160
ring sideroblasts
erythroblasts w/iron laden mito visible as perinuclear granules in prussian blue stain
161
megaloblastoid maturation
resembling that seen in B12 and folate deficiency
162
neutrophils contain
toxic granulations and/or Dohle bodies
163
pesudo-pleger-huet cells
nuetrophils w/only 2 nuclear lobes
164
myeloid blasts
less then 20% of BM
165
MDS peripheral blood
``` pesudo-pleger-huet cells giant platelets macrocytes poikilocytes relative or absolute monocytosis ```
166
MDS clinical
``` primary is predominately disease of older adults mean age 70 50% discovered incidently live 9-29 months progression to AML in 10-40% ```
167
MPD
common pathogenic feature is presence of mutated constitiutvely activated TK increases proliferative drive in bone marrow -> increased WBCs extramedullary hematopoiesis
168
spent phase MPD
marrow fibrosis and peripheral blood cytopenias
169
types of MPD
CML PCV ET primary meylofibrosis
170
CML
chronic myelogenius leukemia | chimeric BCR-ABL gene (Philadelphia chrom) -> good prognosis in CML
171
CML pathogenesis
active TK -> RAS and JAK/STAT
172
CML morphology
marrow hypercellular w/elevated eos and basophils megakaryocytes increased, small sea-blue histiocytes leukocytosis >100,000 platelets increased spleen enlarged due to extramedullary hematopoiesis, may infarct
173
sea-blue histocytes
scattered macros w/abundant wrinkles | green blue cyto
174
CML clinical
``` adults insidious onset mild-moderate anemia and hypermetabolism accelerated phase in 50% blast crisis in 50% ```
175
PCV
Polycythmia vera point mutation in TK JAK2 increased marrow production of red cells, granulocytes, and platelets
176
PCV pathogenesis
erythropoietin levels low increased blood viscosity prone to thrombosis and bleeding
177
PCV morphology
marrow hypercellular marked increase in reticulin mild organomegaly peripheral blood had increased basophils and large platelets often progresses to spent phase with extensive marrow fibrosis and prominent organomegaly
178
PCV clincial
``` veins distended plethroic and cyanotic HA pruitis hyperuricemia, gout -> phlebotomy MAJOR RISK OF BLEEDING/THROMBOSES -> COD w/in months w/o Tx Dx due to DVT, stroke, MI spent phase bad prognosis ```
179
ET
``` essential thrombocytosis point mutation is JAK2 or MPL elevated platelets w/o polycythemia and marrow fibrosis megakaryocytes often increases in size and number mild leukocytosis uncommonly transforms to AML >60 thrombosis and hemorrhage Erythromelalgia gentle chemo ```
180
Erythromelalgia
throbbing and burning of hands and feet do to occlusions of small vessels
181
Primary myelobribrosis
``` obliterative marrow fibrosis cytopenias and extensive extramedullary hematopoiesis identical to spent phase of PCV activating JAK2 and MPL mutations PDGF and TGFbeta implicated severe anemia ```
182
Primary myelobribrosis morphology
erythroid and granulocytic precursors appear normal, but megakaryocytes are large, dysplastic, and clustered fibrotic marrow may be converted to bone (osteosclerosis) splenomegaly leukoerythroblastosis -> release of immature cells tear drop shaped red cells
183
Primary myelobribrosis clinical
spelnomegaly moderate to seer normochromic normocytc anemia w/leukoerythroblastosis infections, thrombotic episodes, bleeding, transformation to AML
184
langerhans cell histocytosis mutations
activating BRAF TP53 RAS TK MET
185
langerhans cell histocytosis morphology
birbeck granules | tennis racket like appearance
186
langerhans cell histocytosis immunophenotype
HLA-DR S-100 CD1a
187
langerhans cell histocytosis types
mutlifactorial, multisystem (letterer-siwe disease) unifocal and multifocal unisystem (eosinophilic granuloma) pulmonary express CCR6 and CCR7 to home out of skin
188
mutlifactorial, multisystem (letterer-siwe disease)
``` <2 cutaneous lesions concurrent hepatosplenomegaly, lymphadenopathy, pulmonary lesions, destructive bone lesion infection (otitis media and mastoiditis) rapidly fatal if untreated ```
189
unifocal and multifocal unisystem (eosinophilic granuloma)
langerhans cells w/eos, lymphocytes, plasma cells, neutros | arises in medullary cavity of bones
190
unifocal
often in skeleton of older children adults | heal spontaneously or w/excision and radiation
191
multifocal
young children Hand-schuler christrian triad many spontaneous regress or chemo
192
Hand-schuler christrian triad
calvarial bone lesions post pituitary stalk -> DI exopthalmus
193
pulmonary
adult smokers regress spontaneously upon cessation of smoking BRAF

Heme II (7 decks)

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