White Cell Disorders Overview Flashcards
What are the three major clues you can bet from a bone marrow biopsy to determine a WBC disorder ?
- What the abnormal cells look like 2. The immunophenytype of the abnormal cells 3. The Genotype of the abnormal cells.
What are the normal contents of a core marrow biopsy ?
Erythroid, Myeloid, and Magakaryocytes.
Is there iron in the bone marrow ?
Yes, on a histiocytic biopsy there will be ferritin in the stain.
What are the 5 tumor markers for B cells
CD-45 CD-79 CD-20 IgG Kappa IgG Lambda
What are the 5 common tumor markers for T cells ?
CD-45 TcR (CD-3) CD-7 CD-4 CD-8 (For the most part below ten)
What is the process for immunophenotyping WBC’s ?
The same as with RBC’s except you have to lyse the RBC’s first.
If a patient presents with a low white count, anemia, and thrombocytopenia what is this commonly called ?
Pancytopenia
What do the different regions on this flow cytometry readout correspond to ?
What does this region on the flow cytometry chart correspond to ?
This region is blasts
How do you know what protein cells in the blood are expressing ?
Immunophenotyping
What do you think this stain means ?
What is the difference between normal staining and immunostaining ?
The immunostain has an antibody that will bind to a specific tumor marker displayed on the surface of the WBC
Philedelphia Chromosome
Chronic Mylogenous Leukemia from a 9:22 translocation which most commonly shows up on FISH or traditional cytogenic examination.
IF Cytogenetic and Fish turn up normal and you still suspect the patient has CML what test should you perform next ?
PCR based DNA and RNA sequencing can turn up a NPM-1 mutation
Complete genome sequencing from two different samples, one from the leukemia cells and one from the skin biopsy
How many point mutations can lead to AML ?
720: 12 in the coding regions and up to 52 in the noncoding regions. You must always ask yourself if this is relevant to the pathogenesis or an independent mutation
**This is inefficent because typically only 4 are found in clinically significant cases.
What are the 4 lineages that can cause malignancies in the marrow ?
- Niave Lymphocytes
- Megakaryocytes
- Erythroid Lineage
- Myleoid Lineage
What causes acute leukemia ?
Rapidly proliferating bone marrow stem cells which will be indicated by blasts in the peripheral blood and bone marrow
What caues myeloproliferative disease ?
Chronically proliferating clones which differentiate into terminally circulating blood cells
What causes myelodysplastic syndromes ?
Poorly functioning clones
If you have a mutation in the Myeloid lineage that causes Myeloid clones to proliferate indefinetly what is this called ?
Acute Myeloid Leukemia
What will rapidly proliferating lymphoblastic clones in the peripheral blood indicate ?
Acute Lymphoblastic Leukemia
What will rapidly proliferating hematopoietic stem cells in the marrow indicate ?
Acute Undifferentiated leukemia of mixed phenotypes
Should you ever see blasts outside the bone marrow ?
No, Never this will indicate Lymphoblastic Lymphoma or Myleoid Sarcoma
What should you think if you see proliferating blasts in the marrow and in the peripheral cells ?
Marrow blast number over 20 % in the marrow will indicate acute leukemia
What is the blast immunophenotype ?
CD 34 +
What is the myleoid blast phenotype ?
CD 34+ / CD 33+
What is the immunophenotype of lymphoid blasts ?
CD 19+ / CD 10+
Can leukemias be diagnosed with immunophenotypes alone ?
No because often the cancer will express mixed immunophenotypes but is a usefull tool.
Blasts in Marrow and Blood Stream
t(15;17) (q22;q12)
PML-RARA
AML Subtype
Blasts in Marrow and Blood Stream
t(8;21) (q22;q22)
RUN X1-RUNXT1
AML Subtype
Blasts in Marrow and Blood Stream
t( 12;21) (p13, q22)
TEL-AML-1
ALL
Blasts in Marrow and Blood Stream
Cytogenetic testing negative
FLT3 Mutation (+)
AML Subtype
When you see blasts in the marrow and blood steram what should you do ?
What is the blast count ?
What is the blast morphology ?
What is the immunophenotype of the blast ?
What is the genetic makeup of the blast ?
In AML what are the two classes of translocations and mutations ?
Class 1 provide a proliferative and Survival advantage
Class 2 provide impaired differentiation and apoptosis
What are the class 1 Mutation Translocations ?
FLT3-ITD
FLT3-TKD
KIT
RAS
PTPN-11
JAK-2
What are the class 2 mutation translocations ?
PML-RARA
Runx1-Run1x1t1
CBFB-Myh11
MLL Fusions
CEBPA
NPM-1
What is the Gilland Hypothesis for AML ?
It takes two classes of mutations or translocations to get AML
What is the arrow pointing to ?
An Aeur Rod, This is a classical smear for Acute Myleoid Leukemia with an t(8;21) (q22, a22) Run X1- Run1X1
The smear shows myelocytes with some maturation with crystalization of the granule contents forming Auer Rods
**Remember these require a class 1 and a class 2 mutation
Describe the morphology you see in this stain ?
This stain repersents Big Blasts, some of which can be cleaved to show bat wing blasts, with Many cytoplasmic granules and Auer rods in the sacs.
What does CD-34 Cd-17 indicate on a immunophenotype ?
Blasts
CD-13 CD-33 +
Granulocytes
CD14 CD11b ?
Monocytes
You hace blasts, monocytes, and Granulocytes in the peripheral smear, what kind of Leukemia is this ?
Notice the eosinophilia
Acute Myeloid Leukemia
What do you see on this peripheral smear ?
The morphology of these cells is Granulocytic, or Monocytic or Monoblastic
NPM-1+
CEBPA+
But The Cytogenetic Testing Comes Back Normal
Acute Myleoid Leukemia
t(15;17) q22,12
PML RARA
AML subtype
t(8;21) (q22,q22)
RUNx1-RUNTX1
AML subtype
t(12;21) (p13,q22)
TEL AML -1
ALL Subtype
What is the Gilliand Hypothesis
It requires two mutations for a neoplastic conversion into AML
AML AML AML
How would you detect PML-RARA
RunX1- RunX1T1
CBFP-MYH11
MLL Fusions ?
These all are detected by Cytogenetic analysis
t(8;21) with (q22, a22)
CD34+ HLA-Dr+ CD13+ CD 33 weak
There are auer rods, that combined with the cell markers CD34 CD 13 HLA-Dr indicate this is Acute Myleoid Leukemia
Auer Rods AML
What are the B stem cell markers ?
CD-34 and TdT
What are the lymphoid precursor markers in B cell development ?
CD-19 and CD-10
What are the Pre-B cell markers ?
Cyto u and CD-20
What transcription factors regulate progression from Stem Cells to Lymphoid Precursors ?
Patient is presenting with DIC, Thrombocytopenia
CD 33+ CD 13+
t(15;17)
In the blood we see big blasts with cytoplasmic granules in the neutrophils and auer rods.
The t(15;17) will indicate a PML-RARA (Retinoic Acid Receptor)
Prognosis Good
Acute Myleoid Leukemia
What transcription factor regulates transmission from PreB1 to PreB2
Can Lymphoid Markers ever express myleoid markers ?
Yes they can express CD 13 and CD33
t(9;22) (q34; q11.2)
BCR-ABL 1
t(v;11q23)
MLL rearranged
t(12;21) (p13, q22)
TEL AML-1 ETV6 RUNX1
t(5;14) (q31, q32)
IL-3 IgH
In leukemia what is the difference between Hyperdiploid and Hypodiploid
Hyperdiploid has over 5-0 chromosomes in the tumor and better prognosis
t(9;22) (q34, q11.2)
CD10+ CD19+ TdT+
The smear shows large agranular blasts
CD10, CD19, TdT show you that is its Lymphoid
This is Acute Lymphocytic Leukemia
BCR-ABL prognosis is very poor for Leukemia
What two cancers is the BCR-ABL mutation present in ?
ALL and CML
IFKZ mutation is mutated in 84 percent of what type of cancer ?
Acute Lymphocytic Leukemia
t(v;11q23)
What will this mutation do ?
This mutation will lead to ALL, MLL, and AML. it fuses a transcription regulator
What does the t(12;21) (p13, q22) transmutation do ?
TEL-AML-1 (ETV-6 RUNX-1)
Usually associated with ALL. This is the ALL that has a 90% cure rate.
t(14 q11; 10q24) with TdT+, CD3+, CD5+, Myleoid or B cell antigens
T-ALL most have a very poor prognosis
Most have a translocation of a oncogene to a TCR promoter. This is a common motif for Lymphoid oncogenesis
What are myeloproliferative diseases ?
A disease characterized by chronically proliferating clones which differentiate into circulating blood cells.
What disease is characterized by all stages of granulocyte maturation present in the blood smear ?
Chronic Mylogenous Leukemia
What disease is characterized by monocytes, promonocytes, and weird hybrids between monocytes and granulocytes ?
Chronic Myelomonocytic Leukemia
What diseases are characterized by elevated RBC counts ?
Elevated Platelet counts?
Polycytemia Vera
Essential Thrombocytopenia or primary myelofibrosis
How can you distinguish between Myeloproliferative disease and sepsis ?
Myeloproliferative diseases have the myleoid buldge and sepsis does not
There is more Metas than myelocytes so this is a case of Sepsis
What is this a case of ?
More Myelocytes than metas is Myeloproliferative disease
This is CML and the peripheral smear shows Granulocyte precursors
What is mastocytosis ?
Mast cells similiar to basophils but longer lived and non circulating
How do mast cell neoplasms normally present ?
What is the most common site of mast cell neoplasms ?
As cutaneous lesions in kids, Uticaria Pigmentosum
The bond marrow but often other organs can be involved
This immunophenotype is positive for Tryptase , CD 117, CD25
What kind of mutation will be likely with this presentation
Mastocytosis, notice the aggregates of band looking cells with round spindel shaped, and sometimes containing eosinophillia.
cKIT is common in this presentation
What type of mutation is present in Polycytemia Rubivera ?
What do these patients present with ?
Jak-2 Mutations are present in over 95 precent
Thrombosis, Hypertension Stroke and MI
Increased RBC’s ?
Increased Platelets ?
Increased Platelets ?
Polycytemia Vera
Essential Thrombocytemia
Primary Myelofibrosis
The patient is presenting with thrombosis, hypertension and stroke with a Jak-2 Mutation
Polycytemia Vera
What do you see in this smear ?
A greatly increased number of platelets and Megakaryocytes
This is essential thrombocytopenia
What can you see in this peripheral smear ?
Increased Megakaryocytes bizarre shapes and clustering Fibrosis.
This is Primary Myelofibrosis
What can myelodysplastic syndrome progress to ?
Acute Leukemia
When you see unexplained pancytopenia and this on the peripheral smear, what will you suspect ?
Refractory Cytopenia It can also present with ringed cyteroblasts
What kind of cell is this ?
With a 5q deletion what disease will this cause ?
Mononuclear Megakaryocyte
MDS
What is the abnormal spear associated with ?
Refractory Cytopenia
