Hematologic Pathology p48-64

7/30/2019 Hematologic Pathology p48-64

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Thalassemia syndromes:

Erythroid cell death, decreased ox transport, splenomegaly,crew-cut skull. Anemia anoxia skeletal deformities.

HbH inclusions. Peripheral blood stained w/supravital stain brilliantcresyl blue. The RBC near the top central area (red arrow) demonstrates

numerous inclusions in an evenly diffuse distribution, creating a golf ballpattern. This cell is an HbH inclusion body seen in thalassemia. Thedifference between the HbH bodies that appear like dimpled golf ballsw/diffuse even involvement can be seen from reticulocytes w/unevenreticulin deposits (black arrows). The HbH inclusions are precipitated globin tetramers. Reticulocytes, Heinz bodies, and Howell-Jolly bodiesstain positive w/brilliant cresyl blue. Reticulocytes are darker, morereticular, clumped, and uneven in distribution. Heinz bodies are largerand not so numerous. Howell-Jolly bodies are usually single inclusions.Rare HbH inclusion bodies may be seen in one or two -gene deletions in-thalassemia trait, but there the absence of identifying these inclusionbodies does not exclude the disorder, which may require molecularstudies for definitive diagnosis. In HbH disease (three -gene deletion),HbH bodies are frequent and easily identifiable.

- Anemia: severity of anemia is dependent onthe degree of residual chain synthesis

- Splenomegaly (extramedullary hematopoiesis,RBC destruction)

- Secondary hemochromatosis (iron overload)- Skeletal deformities- Definitive confirmation:hemoglobin

electrophoresis

Above: Basophilic stippling in thalassemia. Peripheral bloodfilm demonstrating microcytic hypochromic RBCs and

basophilic stippling (arrows). Basophilic stippling occurs inthalassemia as well as in other hematologic disorders.

Above: High performance liquid chromatography (HPLC)sample demonstrating increased hemoglobin A2 (arrow) in a

case of thalassemia trait. HPLC is an automated way ofseparating and identifying variant hemoglobins and is moreaccurate at quantifying hemoglobin A2 than is Hbelectrophoresis. It can separate HbA2 from certainhemoglobins, which is not possible using hemoglobinelectrophoresis alone.


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Macrocytosis pattern Macrocyte: >8 mm MCV >95-100 fL

Normal in neonates (MCV 110-130 fL) Secondary to increased reticulocytes (severe hemolyticanemia with marked increase in erythropoiesis) True macrocytosis:

Alterations in lipid content of RBC membrane (liverdisease, post-splenectomy)

Alteration in DNA synthesis (B12/folate deficiency) Malignant primary bone marrow disorder

(myelodysplastic syndrome, MDS/MPD)

Liver disease/Post-splenectomy Biliary obstruction leads to increase in cholesterol andphospholipids in plasma, with increase in the RBC membrane

B12/folate deficiency: Impaired DNA synthesis Bone marrow:

Megaloblastic erythropoiesis Megaloblastic changes in granulocytic series (giant bands diagnostic??)

Peripheral blood: Macrocytosis (>100 fL) Macroovalocytes Hypersegmented neutrophils

Neurologic changes seen only in B12 deficiency (demyelinization, paraparesis, paresthesias)

Above: Hydrops fetalis at autopsy in hemoglobinBart disease. Hepatosplenomegaly in a newbornwith hemoglobin Bart disease. The loss of all four

-globin genes results in severe anemia, high-output heart failure, splenomegaly, edema, andintrauterine or immediately postpartum death forthe affected fetus. Dystocia, eclampsia, andhemorrhage can occur in the mother carrying theaffected fetus.

Above: skeletal deformity and splenomegaly resulting from -thalassemia.


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B12/folate deficiency: Bone marrow aspirate smear Hypercellular bone marrow Erythroid hyperplasia Megaloblastic erythropoiesis Megaloblastic changes in granulocytic series (giant bands) giant

granulocytic precursors Open chromatin Nuclear-cytoplasmic asynchrony

Peripheral blood smear Macrocytosis (>100 fL) Macroovalocytes Hypersegmented neutrophils

Test q:A 45F has experienced fatigue and tingling in her extremit ies for the past year, more pronounced in the last month. On phys exam, she has pale

conjunctivae. Her liver and spleen are of normal size. The following lab data are obtained: Hgb 7.5 g/dL, MCV 125m3, WBC 3000/mm

3, Seg 25%,

Lymph 73, Mono 1, Eos 1; Plt 77,000/mm3. A peripheral smear contained granulocytes w/4, 5, and 6 nuclear lobes. Which of the following lab tests

would be most helpful in establishing a diagnosis? Serum B12 and folate levels.

Role of B12/folate in DNA synthesis:

Megaloblastic anemias: VITAMIN B12 DEFICIENCY Decreased Intake

Inadequate diet, vegetarianism Impaired Absorption

Intrinsic factor deficiency Pernicious anemia /Gastrectomy

Malabsorption states Diffuse intestinal disease (e.g., lymphoma,

systemic sclerosis) Ileal resection, ileitis

Competitive parasitic uptake, Fish tapeworminfestation

Bacterial overgrowth in blind loops and

diverticula of bowel

Megaloblastic anemias: FOLIC ACID DEFICIENCY Decreased Intake

Inadequate diet, alcoholism, infancy Impaired Absorption

Malabsorption states, Intrinsic intestinal disease Anticonvulsants, oral contraceptives

Increased Loss -Hemodialysis Increased Requirement

Pregnancy, infancy, disseminated cancer, markedly increased hematopoiesis Impaired Utilization

Folic acid antagonists

Test q:A 39F sees her physician because she has experienced abdominalpain and intermittent low-volume diarrhea for the past 3 months. On physexam, she is afebrile. A stool sample is positive for occult blood. A

colonoscopy is performed, and biopsy specimens from the terminal ileumand colon show microscopic findings consistent w/Crohn disease. Becauseshe has failed to respond to medical therapy, surgery is warranted, and part

of the colon and terminal ileum are removed. She is transfused w/2 units ofpacked RBCs during surgery. Several weeks later, she appears healthy butcomplains of easy fatigability. On investigation, CBC findings show Hgb

10.6 g/dL, hematocrit 31.6%, RBC count 2.69 million/L, MCV118m3,

platelet count 378,000/mm3, and WBC count 9800/mm

3. The reticulocyte

count is 0.3%. Which of the following is most likely to produce these

findings? Vitamin B12 deficiency.Test q:A 40F vegetarian experienced fatigue. On phys exam, she is paleand has poor balance. What might you expect to see on a peripheral blood

smear? Macrocytosis and hypersegmented neutrophils.


4/17

B12/folate deficiency:Pernicious anemia Autoimmune destruction of gastric mucosa Antibodies blocking B12 binding to IF Antibodies blocking interaction of B12-IF complex with ileal mucosa

Test q:A 67F complains of gradually increasing fatigue. On phys exam, she is found to be anemic andhas a peripheral neuropathy characterized by loss of position and vibratory sense. Lab studies document

a macrocytic anemia and decreased WBC and platelet counts. What pathological mechanism accountsfor these findings? Autoantibodies against intrinsic factor.

Confirmation of B12/folate deficiency:

Decreased serum B12 Increased methylmalonic acid and total homocysteine (early indicators) Parietal cell antibodies Serum gastrin levels (elevated in PA)

Decreased folate

Demyelination and Subacute combined degeneration:

Myelodysplastic syndromes (MDS): Clonal stem cell disorder characterized by maturation defect and ineffective hematopoiesis Patient presents with pancytopenia, howeverbone marrow is hypercellular. Morphology is heterogeneous with all lineages present and showing dysplastic features

Test q:A 70M undergoes bone marrow biopsy. The biopsy shows dysplasia, 1% myeloblasts, and numerous ringed sideroblasts. All lineages aredysplastic. Deletion of 5q 32-33.3 is identified. Diagnosis? Myelodysplastic syndrome.

Normocytic normochromic pattern: Anemia of chronic disease

Most common anemia in hospitalized patient Reduced erythroid proliferation Reduced iron utilization

Anemia in renal failure Impaired EPO secretion Reduced erythroid production Shortened survival of RBCs

Paroxysmal nocturnal hemoglobinuria

Paroxysmal Nocturnal Hemoglobinuria: Acquired clonal disorder of hematopoiesis resulting from

the mutation in PIG-A gene encoding GPI anchor Mutation in PIG-A gene Located on Chr. X Encodes for 60kDa protein glucosyl transferase (first

step in synthesis of GPI anchor) More than 100 different mutations (deletions,

insertions) described producing abnormal ortruncated protein (non-functional) leading to lack ordiminished expression of GPI anchored proteins

Complement pathway: CD59. Lack of proteins hypersensitivity to complement-mediated lysis of RBCs.Thrombocytopenia. No anchor dysfunctional protein.

Test q:A 42M has been hospitalized in the burn unit for three months. He tireseasily during daily walks. CBC shows a normocytic anemia. Serum iron is low.A bone marrow biopsy shows increased iron stores. You suspect: Anemia ofchronic disease.

Test q:A 50M has experienced chronic fatigue and weight loss for the past 3months. There are no remarkable findings on phys exam. Lab studies shows

Hgb 11.2 g/dL, hematocrit 33.3%, MCV 91 m3, platelet count 240,000/mm

3,

WBC count 7550/mm3, serum iron 80 g/dL, total iron binding capacity 145

g/dL, and serum ferritin 565 ng/mL. The ANA test result is positive. Which of

the following is the most likely diagnosis? Anemia of chronic disease.


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PNH: Clinical Features Cytopenias: all lineages can be involved Often diagnosis delayed due to complex clinical presentation 25% patients survive longer than 25 years Spontaneous remissions reported Treatment: symptomatic, prednisone, immunosuppression (targeted at abnormal clone), EPO, BMT Cause of death:

Venous thromboses Complications of cytopenias Studies showed higher incidence of AML

CD55 Expression in PNH: CD59 Expression in PNH:

Test q:A 17M reports passage of dark ur ine, especially at night, to his physician. He has a history of multiple bacter ial infections and venousthromboses for the past 10 years, including portal vein thrombosis in the previous year. On phys exam, his right leg is swollen and tender. CBC showsHgb of 9.8 g/dL, hematocrit 29.9%, MCV 92m

3, platelet count 150,000/mm

3, and WBC count 3800/mm

3with 24% segmented neutrophils, 1% bands,

64% lymphocytes, 10% monocytes, and 1% eosinophils. He has a reticulocytosis, and his serum haptoglobin level is very low. A mutation affectingwhich of the following gene products is most likely to give rise to his clinical condition? Phosphatidylinositol glycan A (PIGA). (Other choices:Spectrin, G6P dehydrogenase, -globin chain, and Factor V mutation)

Classification of Immunohemolytic Anemias:WARM ANTIBODY TYPE (IgG ANTIBODIES ACTIVE AT 37C)

Primary (idiopathic)Secondary

Autoimmune disorders (particularly systemic lupus erythematosus)DrugsLymphoid neoplasms

COLD AGGLUTININ TYPE (IgM ANTIBODIES ACTIVE BELOW 37C)Acute (mycoplasmal infection, infectious mononucleosis)Chronic

IdiopathicLymphoid neoplasms

COLD HEMOLYSIN TYPE (IgG ANTIBODIES ACTIVE BELOW 37C)Rare; occurs mainly in children following viral infections

Aplastic Anemia:ACQUIRED

IdiopathicAcquired stem cell defectsImmune mediated

Chemical AgentsDose related- Alkylating agents, AntimetabolitesBenzene, Chloramphenicol,Inorganic arsenicals

Idiosyncratic- Chloramphenicol, Phenylbutazone, Organic arsenicals, Methylphenylethylhydantoin, Carbamazapine,Penicillamine, Gold salts

Physical Agents- Whole-body irradiationViral Infections

INHERITEDFanconi anemia, telomerase defect


6/17

Pathophysiology of aplastic anemia: Morphology:

Parvovirus B19 Pathology:

Giant Pronormoblast Infected PronormoblastIntranuclear Inclusion IHC for Viral Capsid Ag

Cause for the figures above can be infection of the stem cells by parvovirus B19.

No hematopoieticelement in BM.

Have some stromalcells

Test q:A 29F has had malaise and a low-gradefever for the past week. On phys exam, she

appears very pale. She has a history of chronicanemia, and spherocytes are observed on aperipheral blood smear. Her hematocrit, which

normally ranges from 35% to 38%, is now 28%,and the reticulocyte count is very low. The serumbilirubin level is 0.9 mg/dL. Which of the following

events is most likely to have occurred in thispatient? Reduced erythropoiesis fromparvovirus infection. (Other choices:

Development of anti-RBC antibodies, DIC,accelerated extravascular hemolysis in the spleen,and superimposed iron deficiency.)


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Malignant Lymphomas Fri. 10/22/10

WHO Classification of Tumors of Hematopoietic and Lymphoid Tissues: First classification in 2001 2008 classification, October 2008

Lymphomas: Malignant proliferations of lymphoid cells: Mirror stages of B or T cell differentiation

Morphology, phenotype, and genetics Are clonal proliferations: one bad cell that keeps producing.

Immunoglobulin heavy chain rearrangement Light chain restriction T cell receptor gene rearrangement If these (above) are all rearranged the same way, it is a clonal proliferation.

Present as discrete tissue mass Hodgkin Lymphoma vs. non-Hodgkin

Test q: Which of the following lymph node architectures suggests lymphoma: Follicles w/a single cell morphology.

Lymph Node Structure:

Lymph node has several parts capsule, subcapsular sinus, etc. Follicles = B cell areas. Follicles have two separatesections mantle zone and germinal center. Surrounding the follicles is the paracortex. Normal lymph nodes: light areasof B cells, darker surrounding areas of T cells.

Immunophenotype:

B cell marker: CD20 T cell marker: CD3(follicularpattern) (surrounding follicles)

WHO classification: Identify specific entities using a multiparametric approach: morphology immunophenotype (CD20 vs CD3) cytogenetics molecular analysis clinical features/presentation (age group is especially important)

First requirement: Morphology Low power evaluation (2-4x microscopic):

Is the lymph node architecture preserved? Or is it effaced? If it is effaced, what is the pattern of the proliferation? Nodular, diffuse, both

Test q: Paracortical hyperplasia is:histologic changes in lymph node Tcells.

Test q: In a normal lymph node, the B

cell and T cell areas should stain with __and __ respectively: CD20 and CD3.


8/17

Diffuse: Nodular:

Diffuse = no nodules. Nodular look like B cell follicles,but this is actually very highly atypical.

Cellular Morphology: High power evaluation (20 or 40x):

Do all the cells look similar? Are there multiple types of cell types? Size: Small, Intermediate, Large Nucleus: Irregular, regular and round Chromatin: Clumped, vesicular, open? Cytoplasm: abundant/scant, color

B cells and T cells are hard to distinguish based on morphology.Immunophenotype is important for distinguishing mature B cells fromimmature B cells. Immature B cells are involved in acute lymphoblasticleukemias. Mature B cells are involved in lymphomas. CD34 and TdTare immature B cell markers. CD20 typically found in mature B cell

lymphomas. Big distinguishing factor immunoglobulin on surface. Welook at part of the immunoglobulin receptor, known as the light chain,which is seen in lymphomas. Immature cells have not developed surfaceIg expression. CD34 and TdT are also markers for immature T cells.

TdT+ = immature T OR B cell.

Test q: Mature T-cells are characterized by expressions of: CD4 or CD8.

Above: Can see larger cells w/white in

nucleus = vesicular open chromatinpattern. See red objects eosinophils.

Above: Pretty much every cell looks

the same. More grayish/purplish nuclei= more coarsely clumped chromatin.

Above: Different sizes of cells

predominant cell type is dark purple(represents coarse chromatin pattern). Cansee much larger cells w/white areas vesicular open chromatin pattern.


9/17

Evidence of Clonality:B-cell lymphoma:

PCR: Immunoglobulin Heavy chain gene rearrangement is the same. IHC: Only one type of immunoglobulin light chain produced: light chain restriction

T-cell lymphoma: PCR: T cell receptor gene rearrangement Loss of specific CD antigen

Lymphomas: Hodgkin lymphoma B-cell lymphomas T-cell lymphomas

CASE: 18 yo male, broke his clavicle during football practice, presents to the ER. X-Ray showed a largemediastinal mass. Chest CT showed a large anterior mediastinal mass. Patient then said he was short of breathmore often then usual.

Hodgkin Lymphoma:Classical Hodgkin lymphoma (more common) subclassified based on morphology:

Nodular sclerosis classical Hodgkin lymphoma Mixed cellularity classical Hodgkin lymphoma Lymphocyte-rich classical Hodgkin lymphoma Lymphocyte-depleted classical Hodgkin lymphoma

Nodular lymphocyte predominant Hodgkin lymphoma

18 yo male:

Classical Hodgkin Lymphoma:

Clinical features:- Bimodal age of presentation:

- 15-35yo and later adult life- 75% of cases involve cervical region

- Mediastinal, axillary and paraaortic region- Primarily a nodal based disease: peripheral adenopathy, B symptoms

(night sweats) 40%

Modified Ann Arbor Staging:Stage Definition

I Single nodal region (spleen, thymus, Waldeyer ring)II 2 or >regions, same side diaphragm. # of anatomic sites should be indicated by suffix (II3)III LN on both sides of diaphragm

III1 W/ or w/o splenic, hilar, celiac or portal nodesIII2 W/ paraaortic, iliac or mesenteric nodes.IV Extranodal sites: BM, liver and > 1 single extranodal site

Test q: A 22M has been diagnosed w/classical Hodgkin Disease. Workup reveals involvement of several lymph nodes on both sides of the diaphragm.There is no history of fever or weight loss. Bone marrow and liver are not involved. The stage is? III-A.

Test q: A 33F reports having generalized fatigue and night sweats for 3 months. Phys exam shows nontender right cervical lymphadenopathy. Biopsyofone lymph node shows a microscopic pattern of thick bands of fibrous connective tissue w/intervening lymphocytes, plasma cells, eosinophils,

macrophages, and occasional Reed-Sternberg cells. An abdominal CT scan and bone marrow biopsy specimen show no abnormalities. Which of thefollowing is the most likely subtype and stage of this patients disease? Nodular sclerosis, stage IB.

Mass was taken out: can see pink dense areas offibrosis/sclerosis. The lymph nose has a thickenedcapsule. The sclerosis is separating the lymph nodeinto nodules. Higher power very distinctive cell: 2nuclei, VERY prominent nucleolus (almost same sizeas small lymphocytes in the background). Smalllymphocytes are also accompanied by small reddishcells (eosinophils).

Test q:An 18M who broke his clavicle duringfootball practice presents to the ER. Chest CT

showed a large anterior mediastinal mass. Biopsyof the mass shows lymphoid tissue w/large nodularareas separated by fibrosis. Large cells

w/prominent nucleoli are present. Numerouseosinophils and plasma cells are present.Diagnosis? Classic Hodgkin disease.


10/17

Nodular sclerosis classical Hodgkin lymphoma (NS HL) ~70% of classical HL in Europe and USA Higher risk in high socioeconomic status Peak age is 15-34yo Clinical features:

Mediastinal involvement in 80% Most present with stage II disease

Histology: Nodular growth pattern surrounded by collagen bands

Immunophenotype:

Reed-Sternberg/Hodgkins cells. CD15 CD30

HRS cells:Positive: CD15, CD30, focal/weak: CD20Negative: CD3

CD30, CD15 stains membrane, sometimes Golgi apparatus.All Hodgkin, Reed-Sternberg cells are + for CD30 not all for 15, but amajority of them are.

Test q:A 45M has experienced recurrent fevers and a 6kg weight loss over the past 5 months. On phys exam, his temp is 37.5C, and he has cervical

lymphadenopathy. A lymph node biopsy specimen shows effacement of the nodal architecture by fibrosis and a population of small lymphocytes,plasma cells, eosinophils, and macrophages. Which of the following additional cell types, which stain positively for CD15, is most likely to be found inthis disease? Reed-Sternberg cell. (Other choices: immunoblast, epithelioid cell, neutrophils, and mast cell)

CASE: 65 yo male presents to his PCP with weakness and generalized lymphadenopathy. Exam: Hepatosplenomegaly.CBC: Lymphocytosis composed of small-intermediate sized mature lymphocytes

Test q: An enlarged lymph node is removed from

the right neck of a 24y/o male w/fever and nightsweats. H&E stained sections show a nodularappearance. Cellular areas alternate w/thick

fibrous bands. The cellular areas contain plasmacells, eosinophils, small lymphocytes, and largecells w/prominent nucleoli which stain positive for

CD30. Lacunar cells are identified. Diagnosis:Classical Hodgkins Disease (Other choices:Follicular lymphoma, Small lymphocytic lymphoma,

Non-classical Hodgkins Disease, Benign reactivelymph node.)

HRS (Hodgkin, Reed-Sternberg)cells: Large, pleomorphic, owls eyelook, inucleation.

Characteristic milieu: eosinophils,plasma cells, small lymphocytes andhistiocytes

Modified cells: lacunar/mummifiedvariant cells


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B-cell lymphomas: Comprise over 90% of lymphoid neoplasms worldwide. Incidence rate per 100,000 is 26.13 and is increasing. Lymphomas involving mature B cells:

Negative for CD34 and TdT Recapitulate stages of B cell development

Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL): Is a CHRONIC leukemia mature leukemia cell type. (Acute leukemias have immature cells.) Most common leukemia of adults in western countries, incidence rate is 12.8/100,000 at age 65yo. Increasing incidence in younger pts. Clinical features:

Peripheral blood and bone marrow usually involved Lymph nodes, liver and spleen Many are asymptomatic, fatigue, anemia

Diffuse infiltrate but vaguely nodular

CLL/SLL immunophenotype:

Positive: CD20, CD5 *, CD23*Negative: CD3, cyclin D1

Test q: Small lymphocytic lymphoma is associated with: Clonal proliferation of mature CD5+ B-cells.

Three main stages of B cell maturation: earlier stageinvolves cells that have not yet reached the follicle, onestage involves the follicle, late stage involves cells thathave found their antigen and are makingantibodies/becoming memory cells.

Much different than Hodgkinlymphoma monotonouspopulation of small lymphocytesw/dark nuclei (coarsely clumpedchromatin pattern)

Test q:A 65M has lymphadenopathyand a biopsy shows small lymphocytes

w/rare mitoses and dense, regular nuclei.There are no follicles present.Diagnosis? Small Lymphocytic

Lymphoma.

Flow cytometryUse flow cytometry tolook at antigenicexpression of lymphoid

cells look w/graphanalysis. Can tellthere is an aberrant Bcell proliferationexpressing CD5,negative for T cellmarker CD3. CD20 ishere dimly positive.22 is another B cellmarker. CD23 ispositive.


12/17

More CLL/SLL Flow Cytometry:

Follicular lymphoma: Lymphoma composed of follicle center (germinal center) cells: centroblasts

and centrocytes (B cells) Pattern recapitulates lymphoid follicles. 20% of all lymphomas, highest incidence in USA and western Europe Median age in 6

thdecade (same as CLL)

Clinical: Widespread disease at diagnosis: Peripheral and central lymphadenopathy Splenomegaly BM 40-70% Only 1/3 are Stage I or II at dx.

Figure: Low power distinctly nodular infiltrate based on color differences.

Grading depends on morphology: High power view is important determines grading. Lowgrade/indolent will have more centrocyte (raisin) cells crinkly, cleaved. Grade 3 more aggressive mostlycentroblasts (large, prominent nucleoli). Greater than 15

centroblasts in view = Grade 3.

Follicular Lymphoma: Immunophenotype:

Positive: CD20, CD10, bcl-2 bcl-2 seen here because there is a specific

genetic aberration translocation between 14;18(involves BCL2 anti-apoptotic gene). Get increasein bcl-2 protein that normally would not be there cells do not die.

Negative: CD5, CD3 Genetics: t(14;18): BCL2, IGH (immunoglobulin heavy

chain locus)

Grade 1,2: Indolent, usually not curable Grade 3: More aggressive but curable by high-dose chemotherapy agents.

Test q: A 40F presents w/generalized lymphadenopathy. A cervical lymph node is biopsied and shows a follicular architecture. Germinal centersw/macrophages are not present. The lymph node is positive for CD20, CD10, and bcl-2. The expected translocation is: t(14;18).

Test q: A t(14;18) translocation in lymphoid malignancies causes the activation of which gene? BCL-2.

Test q: A 40y/o man notices an increasing number of lumps in his groin and armpits. On physical exam, he has generalized nontender lymph nodeenlargement and hepatosplenomegaly. An inguinal node biopsy shows a malignant tumor of lymphoid cells. Immunoperoxidase staining of the tumor

cells w/antibody to BCL2 is positive in the lymphocytic cell nuclei. Which of the following mechanisms has most likely produced the lymphoma?Inhibition of apoptosis. REPEATED x2 (once, was lack of apoptosis)

Test q: Follicular lymphoma is often associated with: presence of t(14;18) chromosome translocation.

Test q: Characteristics of B cell Follicular Lymphoma include: BCL-6 overexpression. (Other choices: t(8;14), dysregulated c-MYC expression,increased MYC/MAX, and T(11;18)). 2007, #99 Should the answer be BCL-2overexpression?

CLL/SLL involve mature B cells, so they should express surface lightchain Ig on these cells. Looking at lambda vs kappa light chain, all of

these cells are kappa light chain positive (which is atypical). Should seea mixture of both.

CLL/SLL: Prognosis:

Genetics, IGH (immunoglobulin heavy chainrearrangement), Immunophenotype

2-8% Diffuse large B-cell lymphoma (Richterssyndrome/transformation very aggressive) Median survival is < 1 year


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CASE: 12 yo female w/ h/o non-specific abdominal pain and distention for ~1 week presents to ER. Abdominal imaginglarge ileo-cecal mass.

Burkitt Lymphoma: another germinal center-type lymphoma EndemicBL:

Equitorial Africa, most common childhood malignancy 4-7 yo, EBV+ in majority

SporadicBL: Throughout the world, children/young adults 30-50% of all childhood lymphomas. Median age of adult 30yo

ImmunodeficiencyBL: HIV infection, often is initial manifestation of AIDS.

Clinical presentation: All at risk for CNS involvement

Endemic BL: 50%: Jaws, facial bones Ovaries, kidneys and breast: frequently Sporadic BL: Majority: Abdominal masses, ileo-cecal region. Ovaries, kidneys and breast: frequent Rarely Jaw Immunodeficiency-associated BL: Nodal localization and BM is frequent

Figure: Atypical lymphoid cells, intermediate size. See white, punched-outareas = TINGIBLE BODY MACROPHAGES. Looks like starry sky. Punched-out areas are macrophages engulfing lymphoid cell debris because this ishighly proliferative.

Test q: A 12F presents w/an abdominal mass. CT imaging shows a large mass at the ileo-cecal junction. The mass is excised and is positive forCD20, CD10, and bcl-6. Bcl2 is negative. On histology, you would expect to see: Tingible body macrophages surrounded by atypical

lymphocytes.

Burkitt Lymphoma: Immunophenotype: Positive: CD20, CD10, bcl-6, 100% proliferation rate (every cell is proliferative).

CD10, bcl-6 are germinal center markers.

Negative: bcl-2 (follicular lymphoma marker BIG distinguishing factor) Genetics:

t(8;14) MYC, IGH t(8;22) MYC , lambda lc t(8;2) MYC, kappa lc

Prognosis: 90% cure low stage, 60-80% - high stage

Burkitts will ALWAYS and ONLY have the MYC gene (oncogene). Can be translocated on B cell receptor either theheavy chain on 8;14 or one of the light chain genes (8;22 or 8;2).

Test q: Characteristics of Burkitt Lymphoma include: t(8;14).

Test q:A 12M is taken to the physician because he has had increasing abdominal distention and pain for the past 3 days. An abdominal CT scan

shows a 7cm mass involving the region of the ileocecal valve. Histologic exam of the mass shows sheets of intermediate-sized lymphoid cells, w/nucleihaving coarse chromatin, several nucleoli, and many mitoses. Cytogen analysis of the cells from the mass shows a t(8;14) karyotype. Which of thefollowing is the most likely diagnosis? Burkitt lymphoma.

Test q: Burkitt lymphoma is: bcl-2-; bcl-6+.

Test q: Which of the following tumors is involved in the overexpression of c-myc due to chromosomal translocation (Chromosome 8 to 14)? BurkittsLymphoma.

Test q: Prognosis in Hodgkin Disease is best predicted by: Stage.

Test q: Prognosis in Hodgkin Disease can be described as: Stage is important but grade is not.


14/17

Diffuse Large B cell Lymphoma: Most common lymphoma, 25-30% of adult non-Hodgkin lymphoma in

western countries. Heterogenous group of lymphomas (can look different) which are nodal

and extranodal based Morphology: Large pleomorphic cells which have a diffuse infiltrative

pattern Immunophenotype: + CD20, +/- CD10, +/-bcl-2, +/- bcl-6

Test q: In the US, the majority of non-Hodgkin lymphomas in adults are derived from: Blymphocytes.

Test q:A 60M has experienced vague abdominal discomfort accompanied by bloating and

diarrhea for the past 6 months. On phys exam, there is a midabdominal firm mass. The stool ispositive for occult blood. An abdominal CT scan shows a 5x12cm mass involving the wall of thedistal ileum and adjacent mesentery. A laparotomy is performed, and the mass is removed.

Microscopically, the mass is composed of sheets of large lymphoid cells w/large nuclei, prominentnucleoli, and frequent mitoses. The neoplastic cells mark w/CD19+ and CD20+ and have theBCL6 gene rearrangement. Which of the following prognostic features is most applicable to this

case? Aggressive disease that can be cured by aggressive chemotherapy. (Other choices:Indolent disease w/survival of 7-9yr w/o treatment; Aggressive disease that does not respond tochemotherapy and transforms to acute leukemia; Indolent disease that can be cured by

chemotherapy; Indolent disease that often undergoes spontaneous remission.) Robbinsexplanation: This patient has the clinical and morphologic features of diffuse large-cell lymphomaof B cells. These tumors often involve extranodal sites, show large anaplastic lymphoid cells that

involve the tissues diffusely, and contain BCL6 gene arrangements. These clinical course is

aggressive, and they become rapidly fatal if untreated.

Test q:A 37M known to have been infected w/HIV for the past 10yr is admitted to the hospitalw/abdominal pain of 3 days duration. Phys exam shows abdominal distention and absent bowel

sounds. An abdominal CT scan shows a mass lesion involving the ileum. He undergoes surgeryto remove an area of bowel obstruction in the ileum. Gross exam of the specimen shows a firm,white mass 10cm long and 3cm at its greatest depth. The mass has infiltrated through the wall of

the ileum. Histologic studies show a mitotically active population of CD19+ lymphoid cellsw/prominent nuclei and nucleoli. Molecular analysis is most likely to show which of the followingviral genomes in the lymphoid cells? Epstein-Barr virus. (Other choices: HIV, HHV-8, HTLV-1,

Cytomegalovirus) Robbins: This HIV-positive patient has an extranodal infiltrative mass,composed of B cells (CD19+) in the ileum. This is a diffuse large cell lymphoma of B cells.These tumors contain the Epstein-Barr virus (EBV) genome, and it is thought that immunosuppression

allows unregulated proliferation and neoplastic transformation of EBV-infected B cells.

T cell lymphoma: Mature T cell (so no CD34 or TdT) which loses normal antigen

expression and shows a positive T-cell receptor gene rearrangement. Peripheral T cell lymphoma, NOS

~30% of T cell lymphomas in western countries. Adults, LAN and B symptoms

Anaplastic large cell lymphoma, ALK-positive: D/Dx of Hodgkin lymphoma 10-20% of childhood lymphomas. Involves LN and extranodal sites, mediastinal disease is less frequent

then HL. 70% present with stage III-IV disease, B symptoms

Morphology: Variable, Hallmark cells (comma-shaped but hard tofind) Immuno: ALK+, CD30+, EMA+; CD2, CD5, CD4 are positive 70% CD3 is negative in 75% Genetics: also involves translocation t(2;5)ALK, nucleophosmin

84% Overall 5 yr survival rate ~80% (in kids, lower in adults)

All cells are 30+, as opposed to Hodgkins, where scattered largecells will be 30+ and the background reactive cells will be negative.CD2, 5 = T cell markers, but it loses CD3 in most cases.

Both figures above: Look like diffuse large B cannot differentiate based on morphology.Have large cells, prominent nucleoli,intermediate-size cells, mitotic figures, openchromatin.

See very blue-staining cells can evensee on low power. Pink area at top =necrosis.

Large cells, nucleoli, lighter-stainingchromatin pattern, some of them are verylarge and pleomorphic (but not Reed-Sternberg cells). Very atypical cells.


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Adult T-cell leukemia/lymphoma: MATURE T cell neoplasm. Is caused by the Human T-cell Leukemia virus type 1 (HTLV-1) human retrovirus Long latency, Japan incidence is 2.5% of HTLV-1 carriers. Occurs only in adults. Central Africa, Caribbean, Southwestern Japan.

Test q:A 25F immigrant from Japan develops lymphadenopathy.Lymph node biopsy shows features consistent with T cell lymphoma.It is likely she is infect with: HTLV-1.

Figure: HTLV-1. Nuclei are lobulated flower cells

Test q:A 51M visits his physician because the skin of his face, neck, and trunk has become scaly red. He also complains of intense itching and a 3kgweight loss over the past 2 months. On phys exam, his temp is 37.6C and he has a generalized exfoliative erythroderma. There is generalizednontender lymphadenopathy. Lab studies shows Hgb 12.9 g/dL, hematocrit 42.0%, platelet count 23,000/mm


3with 57%

segmented neutrophils, 3% bands, 26% lymphocytes, 5% monocytes, and 9% eosinophils. A skin biopsy specimen shows the presence of lymphoidcells in the upper dermis and epidermis. These cells have cerebriform nuclei w/marked infolding of nuclear membranes. Similar cells are seen on theperipheral blood smear. Which combo of the following phenotypic markers is most likely to be expressed on his abnormal lymphocytes? CD3+, CD4+.

REPEATED x2

From Robbins:Cutaneous T cell lymphomas: The involvement of skin and the presence of lymphocytes w/complex cerebriform nuclei in the skin andthe color are features of cutaneous T-cell lymphomas. These are malignancies of CD4+ and CD3+ T cells that may produce a tumor-like infiltration of

the skin (mycosis fungoides) or a leukemic picture w/o tumefaction in the skin (Sezary syndrome). Cutaneous T-cell lymphomas are indolent tumors,and patients have a median survival of 8-9 years.

Test q:A 53F has experienced nausea w/vomiting and early satiety for the past 7 months. On phys exam, she is afebrile and has no lymphadenopathyor hepatospelnomegaly. CBC shows Hgb 12.9 g/dL, hematocrit 41.9%, platelet count 263,000/mm


3. An upper GI

endoscopy shows loss of the rugal folds of the stomach over a 4x8 cm area of the fundus. Gastric biopsy specimens reveal the presence of

Helicobacter pyloriorganisms in the mucus overlying superficial epithelial cells. There are mucosal and submucosal monomorphous infiltrates of smalllymphocytes, which are CD19+ and CD20+ but CD3-. After treatment of the H. pyloriinfection, her condition improves. What is the most likelydiagnosis? MALT (marginal zone) lymphoma. Robbins: These lymphomas arise in middle-aged adults at sites of autoimmune or infectious

stimulation. If the lesion is associated w/lymphoid tissue, it is sometimes called a mucosa-associated lymphoid tissue tumor (MALT lymphoma, orMALToma). The most common sites are the thyroid (in Hashimoto thyroiditis), the salivary glands (in Sjogren syndrome), or the stomach (in H. pyloriinfection). Although monoclonal (similar to a neoplasm), these MALT lesions can regress w/antibiotic therapy for H. pylori. A MALT lesion can transform

to diffuse large B-cell lymphoma. The cells correspond to the marginal B-cells found at the periphery of stimulated lymphoid follicles.

Post-Transplant Lymphoproliferative D/O: Lymphoid or plasmacytic proliferations that develop as a consequence of immunosuppression in a post transplant

setting: solid organ, bone marrow or stem cell allograft Incidence:

Kidney 1% Liver 2% Heart 1.8-9.8%

Lung 4.6-9.4% BMT 0.6-24%

Early lesions: in early development of lymphoproliferation, not in early time after transplant. Infectious Mononucleosis (IM)-like Plasmacytic hyperplasia lots of plasma cells, but are polyclonal.

Polymorphic PTLD Effaced architecture Lots of different cell types: Immunoblasts, plasma cells and lymphocytes IGH clonal rearrangement, +/- EBV

Monomorphic PTLD (= lymphoma) B or T cell lymphoma +/- EBV (If a patient has a transplant and develops PTLD within 3 years, is probably EBV+. If 5+ years, will

probably be EBV-.

Test q: Post-transplant lymphoproliferative disease is most commonly associated with infection by: EBV.Test q: Polymorphic post-transplant lymphoproliferative disorders are frequently:EBV positive.

Leukemia Fri. 10/22/10

Leukemias: Clonal expansion of hematopoietic cells Originate in bone marrow and involve blood Test q:All acute leukemias originate in the: bone marrow Depending on clinical presentation leukemias are divided into:

o Chronic and acute Depending on the lineage of origin, leukemias are divided into:

o Lymphoid and myeloid Leukemias are further classified according to cell of origin, morphology, immunophenotype, molecular features,

clinical behavior and prognosis


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Leukemias:Myeloid leukemias: Acute Chronic myeloid neoplasms

Lymphoid leukemias: Acute Chronic

Myeloid neoplasms: Involve bone marrow and secondary hematopoietic organs (spleen, liver) Broadly subdivided into:

o Acute (acute myeloid leukemias)o Chronic:

myelodysplastic syndromes (manifesting as cytopenias) chronic myeloproliferative disorders (manifesting as increased numbers of cells in blood)

Both acute and chronic myeloid leukemias arise as a result of transforming events at the level of hematopoieticstem/progenitor cells, which affect hematopoietic differentiation and proliferation in a manner specific for eachindividual entity

Acute myeloid leukemias (AML): Most common form of acute leukemia in adults displacement/suppression of normal hematopoiesis Symptoms are related to the accumulation of immature myeloid cells due to aberrant differentiation Presentation:

Within weeks to months of onset (acute onset) Fatigue, fever and mucocutaneous bleeding related to anemia, neutropenia and thrombocytopenia These symptoms are related to the replacement of normal bone marrow cells by leukemic blasts

Test q:A 35F presents w/fatigue, fever , anemia, thrombocytopenia, and mucocutaneous bleeding. You suspect: Acute leukemia.

Classification of acute myeloid leukemias: Past and presentPast: French-American-British (FAB) classificationo Classification according to morphologically defined

stage of differentiation and hematopoietic lineageo Based on morphology and aided by enzyme

cytochemistry

Present: 2008 WHO classificationo Classification according to the stage of

differentiation, hematopoietic lineage and geneticso Based on morphology, flow cytometry, cytogenetics

and molecular studies

Acute myeloid leukemia and cytochemical stainso Myeloperoxidase and non-specific esterase are the most commonly used cytochemical

stainso Myeloperoxidase is seen in granulocytic lineage and leukemias with myeloid blasts and

granulocytic differentiation (red staining) o Nonspecific esterases are seen in monocytic cells (acute myelomonocytic and

monocytic leukemia)

Test q: The cytochemical stain non-specific esterase may be positive in: Acute myeloid leukemia.

WHO retains AML subtypes from original FAB classification:(20% blasts required for the diagnosis)

Type of leukemia Normal marrow counterpart

M0 Minimally differentiated AML Myeloblast

M1 AML without maturation Myeloblast

M2 AML with maturation Myeloblast

M3 Acute promyelocytic leukemia PromyelocyteAML with (15;17) [RARa/PML fusion gene]

M4 Acute myelomonocytic leukemia Myeloblast and monocytic precursors

M5 Acute monocytic leukemia Monocyte and its precursors

M6 Acute erythroleukemia Erythroid precursors

M7 Acute megakaryocytic leukemia Megakaryocytic precursors

Myeloperoxidase


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Select AML categories added in WHO classification:Do not memorize, for reference purposes (Note: this material has appeared in test qs some of it was mentioned inthe heme preview lecture.)

Subtype Comment

AML with t(8;21) favorable prognosis with intensified treatment regimen

AML with inversion of chromosome 16 favorable prognosis with intensified regimens

AML with t(15;17) Acute Promyelocytic Leuk. formerly AML M3,treated with retinoic acid, good prognosis

AML with involvement of chromosome 11q23 includes some therapy related leukemias, intermediate prognosis

AML with deletions of chromosome 7 and 5 therapy related, preceded by myelodysplastic syndromeadverse outcome

Test q:A diagnosis of leukemia has been made on a 23M. A bone marrow aspiration specimenwas sent to the cytogenetics lab. Culture cells showeda karyotype w/t(15;17) (q21;21). This is most consistent with: Acute promyelocytic leukemia (FAB, M3).Test q:A 35F presents w/acute leukemia. She exhibits microangiopathic hemolytic anemia and a translocation. She is successfully treated w/retinoic

acid. Diagnosis? AML (M3).Test q:A 45M presents w/many blasts in the peripheral blood. The patient develops DIC rapidly but was successfully treated w/retinoic acid. The FABclassification for this AML is: M3.

Acute myeloid leukemias (2008 WHO classification)Do not memorize, for reference purposes Red box = FAB classification

Diagnostic work-up of patient with suspected acute leukemia:

1. Review of clinical history, CBC, differential count 2. Bone marrow exam (biopsy)and peripheral blood smear:

o 47 year-old maleo

No prior medical historyo Routine CBC:

WBC 3.3 K/ul hemoglobin 8.4 g/dL platelet count 49 K/ul Thrombocytopenia differential count: 7% blasts

o No organomegaly

Normal bone marrow Acute myeloid leukemia

Documents

Hematologic Pathology p48-64