RPA haem Flashcards
AML vs CML on blood film
AML - large blasts, similar morphology CML - leukocytes in various stages of development; smaller sized
AML vs CML and bone marrow failure
AML is always assoc w BM failure where as CML is rarely assoc w BM failure Hence, AML presents w signs and symptoms of failures of the various lineages
Sweet’s syndrome
pruritic rash of the skin due to neutrophilic infiltration in skin could be caused by AML but also other immunological or iatrogenic causes
what type of AML is assoc w severe DIC
APML
4 tests at diagnosis for AML
morphology immunophenotype - good for distinguishing bw ALL and M chromosome analysis mutation analysis
proportion of AML w positive chromosome analysis
45%
AML vs ALL blood film
AML - fine granules/Auer rods - Auer rods are fine granules stuck together in a linear fashion - much cytoplasm ALL - no granules - slightly smaller blasts - scant cytoplasm
immunophenotyping characteristics of myeloid vs lymphoid
myeloid is generally higher number (aside from CD 13) myeloid CD 13, 33, 34, 117 lymphoid CD 3, 10, 19, blahblah
turnaround for FISH vs chromosome
6-8hr (FISH) vs a few days (chromosome)
AML w inferior prognosis
FLT3
APML blood film
promyelocytes very heavy granulation occasionally vaccuolated sometimes loaded with auer roads in bundles due to heavy granules
APML and DIC pathogenesis
85% of APML willdevelop DIC
APML membrane has a transmembrane glycoprotein that initiates coagulation causing DIC
release of tissue factor -> excessive release of thrombin plasminogen -> plasmin -> fibrinolysis -> clot formation can present w pancytopenia without blasts, with bruising +++
APML and DIC pathogenesis
85% of APML willdevelop DIC APML membrane has a transmembrane glycoprotein that initiates coagulation causing DIC release of tissue factor -> excessive release of thrombin plasminogen -> plasmin -> fibrinolysis -> clot formation can present w pancytopenia without blasts, with bruising +++
is d-dimer due to fibrin degredation or formation
formation as d-dimer is produced by plasmin lysis of cross-linked fibrin in thrombus
the most reliable index of DIC
D-dimer
APML cytogenetic abnormality
t(15,17)
how to detect APML cytogenetic abnormality
on FISH
what fusion gene is found in APML
PML/RAR alpha fusion protein
what does ATRA (all trans retinoic acid) target in APML
PML/RAR alpha fusion protein promotes differentiation
treatment of APML
ATRA + ATO (arsenic trioxide) +/- chemotherapy
ATRA syndrome
cell differentiation induced by ATRA leads to rising WCC and cytokine release –> leaky capillaries –> resp distress –> fluid overload Mx: steroids + chemotherapy
what chemotherapy agent is contained in all AML regimens
cytarabine (except APML where sometimes chemotherapy is not required)
what causes acute obstructive nephropathy in TLS
precipitation of UA, xanthine and phosphate in renal tubules
CML peripheral film
similar to a bone marrow can see full range of cell development stages
CML prognosis scoring
sokal score - spleen size, % blasts, age, platelet count
treatment targets of CML with TKI
0.1% leukaemic cells by 12 months
CML reasons for treatment failure
non compliance development of mutation T351I most common
secondary polycythemia
JAK2 negative EPO normal or high
Essential thrombocythemia and JAK2
only 60% of cases other genetic abnormalities CALR or MPL
what myelopropliferative disorder has the highest JAK2+ rate
polycythemia vera
non-JAK2 mutations in myeloproliferative disorders
CALR, JAK2
what allele is a risk factor for thrombosis in myeloproliferative diosorders
V617F mutated status and allele burdern
which myeloproliferative disorder always gets aspirin
PV ET is case by case
management of PV
low dose aspirin to all patients
venesect to Hct <0.45
anticoagulation if Hx of thrombosis
Hydrea if thormbosis/high risk
indications for cytotoxic therapy in MPN
extreme thrombosis risk rapid spleen enlargement
anagrelide
see slides
typical blood film for myelofibrosis
teardrop cells
Myelofibrosis treatment
allogenic transplant if debilitating symptoms and not suitable for alloSCT ruxolitinib (PBS for High risk and intermediate-2 risk myelofibrosis)
JAK2 inihibitors can lead to improved QoL but no improved survival shown yet
MDS prognosis
IPSS-R scoring: marrow blasts karyotype Hb Neutrophils Platelets
MDS management early/low risk
observation/supportive transfusions
MDS management intermediate/high risk
azacitidine - 30-50% response and overall survival benefit and decreased transformation to acute leukaemia alloSCT for <60 or 60-70 and fit
MOA of azacitidine
hypomethylating agent
MDS w 5q- abnormality treatment
lenalidomide
second gen TKIs for CML (2)
Dasatinib, Nilotinib
what are the AE of 2nd gen TKIs (cf 1st gen)
vascular issues so older people might use 1st gen
nilotinib - PAH, inhibition of plt function
dasatanib - diabetes, prolonged QTc, increased risk of vascular events
3rd gen TKI for CML
ponatinib effective for T315I mutations
CD20 and ALL
not in acute lymphoblastic leukaemia as more mature B cells
CD38 marker for?
plasma cells
CLL which cell lineage more common
B cell >95%
CDs in CLL
CD5, CD19, CD23
Mantle cell lymphoma vs CLL CD expression
both have CD5 + mantle has no CD23
smudge cells what malignancy
CLL (in vitro artefact)
Poor prognostic markers in CLL
beta 2 microglobulin LDH unmutated LgH (unreliable) FISH –> 17p deletion
when to do FISH in CLL
timepoint when patient is starting treatment (symptomatic patients)
indicaiton for treatment in CLL
- Evidence of progressive marrow failure as manifested by the development of, or worsening of, anemia and/or thrombocytopenia.*
- Massive (ie, ≥6 cm below the left costal margin) or progressive or symptomatic splenomegaly.
- Massive nodes (ie, ≥10 cm in longest diameter) or progressive or symptomatic lymphadenopathy.
- Progressive lymphocytosis with an increase of >50% over a 2-month period or LDT of <6 months. LDT can be obtained by linear regression extrapolation of absolute lymphocyte counts obtained at intervals of 2 weeks over an observation period of 2 to 3 months. Patients with initial blood lymphocyte counts of <30,000/microL, may require a longer observation period to determine the LDT. In addition, factors contributing to lymphocytosis or lymphadenopathy other than CLL (eg, infection) should be excluded.
- Autoimmune anemia and/or thrombocytopenia that is poorly responsive to corticosteroids.
- Symptomatic or functional extranodal involvement (eg, skin, kidney, lung, spine).
- Constitutional symptoms, defined as any one or more of the following disease-related symptoms or signs:
CLL treatment
Ritux, fludarabine, cyclophosphamide frail + elderly: Obinutuzumab anti-CD20 with enhanced ADCC + chlorambucil Oral enzyme inhibitors - ibrutinib - bruton’s tyrosine kinase inhibitor - venetoclax - bcl2 inhibitor - Idelalisib - PI3 kinase inhibitor
irbutinib
bruton’s tyrosine kinase inhibitor - blocks BCR signalling/activation. Induces apoptosis, blocks migration.adherence PBS listed for pts unsuitable for purine analogue - suitability based on age/fragility and also 17p del disease by FISH
venetoclax
mimics action for BH3 proteins restores the cell’s ability to undergo apoptotic death GRADUATED ORAL DOSING TO AVOID LIFE-THREATENING TUMOUR LYSIS
follicular lymphoma treatment - what grades determine treatment
grade 1-3 indolent lymphoma treatment 3b+ - treat as DLBCL
treatment options for follicular lymphoma
Ritux/obintuzumab + 1) CVP 2) benamustine 3) CHOP therapy at relapse chemo +rituximab add anthracyline if not used before obinutumab + bena CAR-T coming
obinutuzumab vs rituximab
obinu has enhanced ADCC but reduced complement activiation
Where does MALT most frequently occur?
primary gastric lymphoma
what preceeding infection is assoc w MALT
H. Pylori (eradication can be used as treatment)
mantle cell lymphoma cytogenetic markers
cyclin D t (11:14)
mantle lymphoma treatment
rituximab and chemotherapy cytarabine for the young R_bendamustine in >60 allog SCT relapsed disease can have ibrutinib
lymphoplasmacytic lymphoma (waldenstrom’s) genetic feature
aa change (L265P) in MYD88 –> ibruntinib minority has CXCR4 mutation - inferior prognosis
what antibody class does lymphoplasmacytic lymphoma produce
IgM –> hyperviscosity +++
hairy cell leukaemia mutation
BRAF V600E which activates ME-ERK vemurafenib is not availbale in leukaemia however
DLBCL pathology
large B cells w prominent nucleoi loss of follicular architecture ki-67 - proliferation marker (higher in DLBCL vs follicular)
double hit DLBC
MYC and the gene for BCL2 on chromosomes 8 and 14 respectively
R - CHOP
rituxcyclo vincristine doxorubicin pred
which R-CHOP agent causes bad constipation
vincristine
what EF is required to receive full dose anthracycline
EF>50%
when does cardiotoxicity occur in anthracycline
6 months post
what CD does peripheral T cell lymphoma express
not TdT or CD1 CD3+ because they are derived from post-thymic T cells (cf lymphoblastic lymphoma)
CD30+
treatment for CD30+ Anaplastic large cell
bremtuximab anti CD 30 conjugated to tubulin toxim mono methyl auristatin E (MMAE) - causing cell arrest duration of response 13 months
SE bremtuximab
peripheral neuropathy
Burkitt’s lymphoma virus association
EBV HIV
genetic BUrkitt’s lymphoma
myc oncogene (chrom 8) translocation to Ig promotors 8:14 (or 2:8 or 8:22)
burkitt’s film
deep blue cytoplasma w vacuoles
B-ALL relapsed refractory disease
inotuzumab ozogamicin
Hodgkin lymphoma antigens
CD15, CD 30
Hodgkin chemotherapy treatment
ABVD escalated BEACOPP <45 - sterility, premature menopause, long term risk MDS/AML
Hodgkin treatment
PET adapted algorithms early stage favourable -> ABVD -> iPET escalation or deescalation and IFRT early stage unfavourable -> ABVD or escBEACOPP–>iPET escalation or deescalation advanced stage8 –> ABVD or escBEACOPP (see slides)
what mAB is approved for Hodgkin’s Lymphoma
bremtuximab (anti CD30) for refractory of note pembrolizumab is also used (see slides)
myeloma film appearance
basophilic cytoplasm with eccentric nucleus prominent golgi zones adjacent to the nucleus
most common Ab in myeloma
IgG 60%
MM criteria
plasma cell proliferating disorder + myeloma defining event CRAB or >60% plasma in BM >100 FLC ratio >1 focal lesion on MRI or skeletal surgery
poor genetic prognostic marker in MM
see slides
myeloma supportive therapies
bisphosphantes transfusion IVIG valtrex prophylaxis
thalidomide SE
tiredness, constipation, sens neuropathy, DVT
bortezomib SE
peripheral neuropathy a new proteasome inhibitor has recently been approved - carfilzomib has been approved recently w less peripheral neuropathy
daratumumab MOA and SE
anti-CD38 refractory MM probably should be used in combination
SE: transfusion reactions (as CD 38 is also expressed on RBC)
bortezomib MOA
proteasome inhibitor which inhibits NK-kappaB
flutarabine MOA
purine analogue
endotheliual function in haemostasis
release prostacyclin and nitric oxide –> prevents aggregation of platelets release t-PA - lyse fibrin above factors provide balance the following factors deal with things released by the platelets/clots ADPas from endothelial cell mops up ADP Thrombomudulin binds thrombin Heparan sulfate will activate antithrombin
what does VWF adhere to at high sheer rate in platelets
GP ib-V-IX - reversible binding this slows down the platelets
what factor does VWF carry
factor VIII
what does VWF irreversibly bind to
GP IIb/IIIa cause platelet shape change and activation –> aggregation of VWF, fibrinogen, red cells, leukocytes
platelet dense tubular system
calcium fux that trigger activation and PG synthesis
platelet alpha granula
coagulation factors and adhesion receptors
platelet shape change
microtubule system “pseudopodia” happens in activation
platelet adhesion receptors
all result in calcium influx that results in microvesicle relsease and negatively charged phosphatidylserine exposure collagen –> GP VI thrombin –> PARs vWF –> GP Ib-V-IX Fibrin –> GP IIb/IIIa
initiation of coagulation
tissue factor exposed on cell membrane/microparticle circulating factor VII binds TF and activates factor Xa trace thrombin is generated excress thrombin is cleared by antithrombin
amplification of coagulation
thrombin activates IX and XI, cleaves factor VIII from vWF and activates factor VIII and V factor VIII and IX together activates factor X X -> Xa Xa and Va works togehter and generally thrombin from prothombin this creates a large thrombin burst this is assembled on the negatively charged thrombin surface
propagation of coagulation
big thrombin burst changes fibrinogen into fibrin activates factor XIII which crosslinks fibrin
lysis in coagulation
plasmin is the main molecule in lysis breaks down polymer into fibrin degradation products (d-dimer is a particular fibrin degradation product - only produced in fully formed clot)
natural anticoagulants
antithrombin III switches off thrombin and X, IV, XI, XII protein C (cofactor is protein S) - switches off activates VIII and V tissue factor pathway inhibitor will switch off the initial tissue factor complex to localise the process
fibrinolytic pathway
tPA and uPA changes plasminogen to plasmin plasmin degrades fibrin plasminogen activator inhibitor stops tPA and uPA (PAI-1 and PAI-2) respectively
TAFI
TAFI when activated to TAFIa, functions to suppress fibrinolysis by the removal of lysine residues from the fibrin clot that are exposed as fibrin [in the fibrin clot] is degraded by plasmin. In this way tissue plasminogen activator binding is restricted and further activation of plasminogen to plasmin, prevented [remember - plasminogen binds to the lysine residues on the fibrin clot] and so the fibrin clot at the site of vascular injury is protected from fibrinolysis thrombin activatable fibrinolysis inhibitor cleaves off C-terminal lysine residue form fibrin and prevents binding to plasminogen. plasmin and tPA tranxemic acid competitively inhibits the same site also preventing fibrinolysis
functions of thrombin
see slides
PT testing
triggered by thromboplastin extrinsic pathway: TF, factor VIIa common pathway: Xa, Va, II, Thrombin, fibrin
APTT testing
triggered by contact activation intrinsic pathway VIIIa, IXa, XIa, XIIa common pathway: Xa, Va, II, Thrombin, fibrin
thrombin time testsing
add small amount of exogenous thrombin to convert fibrinogen to fibrin good assay for heparin (antithrombin III), dabigatran (direct thrombin inhibitor)
anti Xa assay
measuring activity of factor Xa using chromophore (optical density)
reptilase time
clots fibrinogen by a mechanism different from that of thrombin except it doesn’t respond to anti-thombin III like TT so can differentiate b/w heparin
time dependent inhibitor - most common
factor VIII inhibitor initial mixing may show inhibitor but later it doesn’t correct
severity of haemophilia
coag factor concentration % severe <1 - spontaneous bleeding moderate 1-5 - severe bleeding after minor trauma mild 5-25 - severe bleeding after surgery and slight bleeding after minor trauma
acquired TTP pathogenesis
severe deficiency <10% in the activity of ADAMTS-13 excess of ultra large vWF
TTP symptoms
Fever Anaemia Thrombocytopenia Renal failure Neurological dysfunction
TTP lab findings
D-DIMER NEGATIVE (due to no cross linked fibrin) no activation/depletion of clotting proteins - APTT/PT normal fibrinogen normal activation and depletion of platelets BLOOD FILM - microangiopathic haemolytic anaemia
TTP TREATMENT
plasma exchange, FFP, immunosuppression ritux avoid platelets
where does vWF gets released from
Wiebel-palade body
child pugh score for NOAC contraindication
contraindicated in B and C
what DOAC interacts w amiodarine and verapamil (potential p-gp inhibitors)
dabigatran
vitamin dependent factors
II, VII, IX, X, protein C and protein S
which cancers to avoid DOAC
GI/GU/Brain cancer
which DOAC will proong both APTT and TT
dabigatran the anti xas CAN also prolong APTT but not TT
what does DOAC do to LA testing
potential false positive with dabigatran and rivaroxaban potential false negative with apixaban
why might bone marrow SCT be collected instead of peripheral SCT (e.g. for genetic disease or aplastic anaemia)
t cell poor and stem cell rich decreased GVHD risk
what CD marker to look for when collecting peripheral SCT
CD 34 - early haematopoietic stem cells
most common non malignant cause for alloSCT
aplastic anaemia other indications are haemoglobinopathies and immunodeficiencies
most common indication for autologousSCT
myeloma
what tumours can get autoSCT
germ cell tumours
most common autoimmune condition for autoSCT
scleroderma
most common indication for alloSCT
AML all high risk get alloSCT when in remission
when does engraftment occur
day 15
what chemotherapy does haplo-related HSCT patients receive after HSCT?
day 3 cyclophosphamide because they have a preferential take up by self T cells and donor T cells are spared
HSCT conditioning duration
10 days
highest risk of CMV reactivation in HSCT
donor +ve receipient -ve
venous occlusive disease clinical features
hepatomegaly w weight gain, fevers, bilirubin rise resembles Budd-Chiari syndrome
histological findings of skin GVHD
lymphocyte infiltration of the dermis and basal vacuole changes
treatment of GVHD
steroids cyclosporin (aim 200-300 levels) Acute GVHD: - steroids + calcineurin inhibitor + ATG triple therapy - if refractory: retux, alemtuzumab, ATG - anti IL2 - extracorporal chemotherapy Chronic GVHD add on therapies: methotrexate, mycophenolate - note they both inhibit the BM; methotrexate can cause mucositis and mycophenolate liver toxicity rituximab extracorporeal photochemotherapy SEE SLIDES
GVHD prevention
donor selection ATG in unrelated donors
when do HSCT patients get viral infection
late - post engraftment
what is cytokine release syndrome driven by
IL-6 and TNF alpha
anti IL-6 used in CRS
tocilizumab
isolated APTT elevated incidental finding - correcting on mixing study; no prior bleeding hx
factor XII deficiency
what antiepileptic will interact w rivaroxaban
phenytoin combined CYP3A4 and P-glycoprotein inducer reduces level of rivaroxaban
what happens with solubte transferrin receptor in iron def anaemia
goes up
what is assoc w pure cell aplasia
parovirus thymoma recombinant EPO CLL autoimmunoe
what does cryoprecipitate contain
VIII, fibinogen, vWF, factor X, fibronectin
what chemo mandates the requirement of irrad PRBC
fludarabine - lymphocyte depleting to avoid transfusion related GVHD
what blood product is most assc w TRALI
FFP
first line for non bleeding ITP
plt >30 no treatment steroids IVIG 2nd line or severe romiplastim after splenectomy rituximab in relapsed ITP as 2nd line no platelet transfusions unless critical bleeding requiring surgery
emergency management of TTP in rural setting without PLEX
FFP
gestational thrombocytopenia
diagnosis of exclusion - Most common at delivery, but can occur at any time during pregnancy. - Mild thrombocytopenia. (In 99 percent of women, the platelet count is ≥100,000 /microL.) - No increased bleeding or bruising. - No associated abnormalities on complete blood count (CBC). - No fetal or neonatal thrombocytopenia.
paraprotein and clonal bone marrow cells cut off for MGUS vs smouldering/MM
paraprotei >30g/L bone marrow plasma >10% need both for smouldering/MM
what bone lesion qualifies someone for multiple myeloma
One or more osteolytic lesions ≥5 mm in size on skeletal radiography, MRI, CT, or PET/CT. In the absence of osteolytic lesions, the following are not sufficient markers of bone lesions: increased FDG uptake on PET, osteoporosis, or vertebral compression fracture.
burkitt’s lymphoma TLS prevention
RASBURICASE
blinatumumab
cd3 and cd19 brings together T cell and B cell used in B-ALL
alemtuzumab
CD52 mostly used in MS autoimmune side effects +++
Howell Jolly bodies
hyposplenonism
high risk thrombophillias
antithormbo III highest risk FVL/PTG homozygote/compount
MOA of tranexamic acid
tranexamic bind to plasminogen (the site where fibrin normally binds) and stops the conversion of plasminogen to plasmin
