IM Hematology 6 With Oncology

IM HEMATOLOGY 6 WITH ONCOLOGY 1

HEMATOLOGY 6Dr. Tuy012309

ACQUIRED HEMOLYTIC ANEMIA

IMMUNE HEMOLYTIC ANEMIA (AIHA)- Erythrocytes destroyed prematurely by

immune mediated mechanism- Hemolysis resultd from ab or completements or

both, attached to RBC membrane – comfirmed by a positive direct antigloublin test (Coombs test)

Pathophysiology- Cause intravascular hemolysis/extravascular

hemolysis- Intra: a able to actvate complement sys

prodn of membrane attack complex (can directly attack the cell)

o IgM – can readily activate complento IgG – can sometimes activate

complement sys- Extra: reticuloendothelial system, ab in spleen

express the MPC phagocytosiso Fragmentation of membrane

spherocytes

Coombs test- Direct coombs test – binds to complement or

ab and makes the agglutination visible to the naked eye

o Detects the presence of ab that is attached to the cell

- Indirect coombs test – detects the presence of ab that is present in the serum

- Positive – presence of agglutinins- Mark of AIHA – positive coombs test

Classification1. Alloimmune HA

a. Ab are alloab / made in response to presence of foreign ag

i. Ex: ABOii. Major cross-matched reaction

2. Autoimmune HAa. Derangement in self toleranceb. Ab directed to the whole RBC age sp

RH antigeni. Ex. With AIHA – there is major

cross matching reaction3. Drug-induced HA

a. Secondary to ab initially directed to the bld which cross-react to the patients RBC

TYPE OF AIHAcharacteristics Warm

reactiveCold agglutinin dse

Paroxysmal cold hemoglobinuria

Ab isotype igG, rare IgA, IgM

Igm Igg

DAT Igg, rare C3 C3 C3Ag specificity Multiple esp

Rhi/I, Pr P

Hemolysis Extravas Extra Intra

Common dse associations

b-cell neoplasia, collagen-vascular

Viral, neoplasia

Syphilis, viral

*Warm reactive – active type of AIHA*Primary/Idiophatic – most cases*some are associated with common diseases

*positive Coombs test and presence of spherocytes*Tx: 1st line: use of steroids

WHITE BLOOD CELL DISORDERS- Granulocytes- Lymphocytes- Monocytes

The Normal Leukocyte CountCell type Percent Absolute count

Leukocytes 5-11x109/LNeutrophils 45-75% 4-6Stabs 0-5Monocytes 5-10 0.5-1Eosinophils 0-5 <.45Basophils 0-1 <0.05Lymphocytes 10-45 2-5

Absolute Neutrophil Count Segmental + Stab x Total WBC count

Ex. TWBC = 10,000, ___= 90%

*AN COUNT = >5000

Normal Myeloppoiesis- DO of granulocytes and monocytes

Myeloid Differentiation- Granulocytes and monocytes have a common

progenitor cell- Derived from more primitive myeloid stem cell

line- From pluripotent stem cells in bone marrow- G-CSF: necessary to activate neutrophil to be

able to perform its action like phagocytosis- IL-3: colony-stimulating factor

Myeloid Function- Able to move from bone marrow, to circulation

to tissues (one way), follows the interleukins to determine the site of location

o From circulation to tissue diapedesis - Mobilized during time of inflammation- Can phagocytose microorganism- Can exocytose- N stays in the circ from 6-7hrs

Sequence of Neutrophil Maturation- Can determine through the presence of

granules- Myeloblast- Promyelocytes – primary granules

(myeloperoxidase)- Myelocytes - eccentric nucleus- Metamyelocytes (band) – segmented nucleus- Polymorphonuclear neutrophils – mature


Histochemical stains for myeloid cellsCell type MPO Specific

esteraseNonspecific esterase

Periodic acid Schiff

Neutrophils

4+ 3+ 1+ 4+

Monocytes

2+ 1+ 3+ 2+

Lymphocyte

- - +/- +/-

CD34 – marker for pluripotent stem cellsLymphocytes – no specific immunologic markers

3 compartments:1. BM comp – 90%2. Peripheral bld – 2-3%

a. Circulating poolb. Marginated pool – attached to

endotheliumi. Decrease - leukocytosis

3. Extravascular space – remaining %*Quantitative DO – due to defect in the storage compartments*infection – BM inc granulocyte prodn, more granulocte enter circ leukopenia

NeutropeniaAbsolute Neutrophil Count

Clinical Significance

>1500/mm3 Normal1000-1500 No significant risk for

infxn500-1000 Some risk for infxn<500 Significant risk for infxn<200 Absence of inflammatory

response

Acute neutropenia – more dangerous than chronic type

- Leukemoid rxn – 15-30K, mostly mature cells, any infxn can trigger (cancer), no blast cells

- Shift to the left – presence of immature cells- Eosinophilia - >500- Basophilia – rare- Abnormalities in lymphoid cells

IINTRODUCTION TO LEUKEMIASLeukemia – presence of totally derived leukemic cells (abnormal cells), displacing normal hematopoiesis

- Presence of immature cells in the peripheral blood

Leukemic cells are frequently present in:- Periph bld- Invade reticuloendothelial tissue

o Spleen, liver, LN- May invade other tissues- Untreated eventually causes death

*Acute form: rapidly progressive

ClassificationClassified accdg to cell type – with regards to both:

- Cell maturity – used to distinguish bet acute and chronic leukemia

o If malignant cells are immature – acute Rapidly progressive

o If predominantly mature – chronic Slow and indolent

- Cell lineageo Myeloido Lymphoid

Classification:- Acute Lymphoid Leukemia- Acute Myeloid Leukemia or Acute Non-myeloid

Leukemia- Chronic Lymphocytic Leukemia- Acute Lymphocytic Leukemia

Etiology/Risk Factors- Heredity

o Congenital chromosomal abnormalitieso Hereditary immunodeficiency states

- Chronic marrow dysfunctiono Aplastic – 20%o PNH

- Drugs – anticancer drugs- Ionizing radiation- Chemicals - benzene- Viruses

o HTLV-1 causative agent of adult T-cell leukemia/lymphoma

Seen in Japan

Comparison of Acute and Chronic LeukemiaAcute Chronic

Age All ages AdultsClinical onset Sudden InsidiousCourse (untreated)

<6mo 2-6yrs

Leukemic cells Immature MatureAnemia Mild to severe MildThrombocytopenia

Mild to severe Mild

White cell count Variable IncreasedOrganomegaly Mild Prominent

*cardinal feature: presence of blasts – acute

Pathogenesis Clin maniBM failureAnemia Fatigue, malaise, pallorThrombocytopenia Bruising, bleedingGranulocytopenia Fever, infectionsOrgan InfiltrationMarrow expansion Bone or joint painSpleen SplenomegalyLiver HepatomegalyLN LympadenopathyCNS Neurologic symptomsGums, mouth Gingival hypertrophy, oral

lesions


*adults - sternum*<4y/o – difficulty in walking*testes, brain, anterior chamber of eye – privilege sites, absence of lymphnodes

Laboratory Evaluation of Acute Leukemia- Purpose: confirm the dx and distinguish AML

from ALL- Preliminary evaluation:

o CBC and peripheral bld examno BM studies

Morphologic examination – subjective exam

Cytochemical staining Immunologic markers Cytogenetic studies Molecular genetic studies Electron microscopy

Morphologic Approach to Classification (book)Feature AML ALLBlast size Larger, usually

uniformVariable, small to medium size

Nucleoli 1-4, often prominent

Absent or 1-2, often indistinct

Auer rods Present in 60-70% of cases

Not present

Nuclear chromatin

Usually finely dispersed

Coarse to fine

Cytoplasm Moderate, abundant, fine granules present

Scant, coarse granules, sometimes present ~7%

Others Often dysplastic changes in maturing myeloid cells

Myeloid cells not dysplastic

*pathognomonic findings that distinguish AML/ALL: (+) Auer rods

Cytochemical reactions useful in the dx of acute leukemiaSpecial Stain Site of

ActionCells Stained Comment

Myeloperoxidase

Mainly primary granules; Auer rods

Late myeloblasts, granulocytes; monocytes less intensely

Separates AML (+) from ALL (-)

Sudan black B Phospholipids; sterols, neutral fats

Late myeloblast, granulocytes; monocytes less intensely

Parallels peroxidase, but smears do not need to fresh

Specific esterase (Naphthol AS-D chloroacetate

Cytoplasm Neutrophilic granulocytes; mast cells

Parallels peroxidase, but less sensitive;

Non-specific esterase

Cytoplasm Monocytes; focal staining

Useful for determining

(alpha-napththyl acetate and butyrate)

in T cells degree of monocytic differentiation; separates mono (+) from myelo (-) blasts

Periodic acid-Schiff

Glycogen and related substances

Lymphocytes, granulocytes, megakaryocytes

Helpful in supporting diagnosis of erythroleukemia

Immunologic Markers

Lineage Antigen

B cell CD19, CD20, CD21, CD22, CD23, D24

T cell CD1, CD2, CD3, CD4, CD5, CD7, CD8

Lymphoid TdT

Myeloid (granulocytic)

CD13, CD33, CD11b, CD15

Monocytic CD14, CD11b

Erythroid Glycophorin A

Megakaryocytic CD41, CD42b, CD61

Lineage Independent Antigens

HLA-DR HLA class II

CD45 Leukocyte common antigen

CD34 Stem cell antigen

CD10 Common ALL antigen (CALLA)

ACUTE MYELOID LEUKEMIA / ACUTE NONLYMPHOID LEUKEMIA

Definition - AML are clonal malignancies that are

characterized by the appearance of increased numbers of immature myeloid cells in the marrow and blood.

- AML is a clonal, malignant disease of the hematopoietic tissue that is characterized by

accumulation of abnormal (leukemic) blast cells, principally in the marrow

impaired production of normal blood cells.

Etiopathogenesis- Risk factors

Environmentalo radiationo benzeneso alkylating agents and other

cytotoxic drugs – therapy-related AML

Evolution from a chronic clonal hemopathy

Inherited syndromes

Epidemiology


- AML is the predominant form of leukemia during the neonatal period and

- accounts for 15 to 20 percent of acute leukemia in children and

- 80 percent of acute leukemia in adults.

Revised Criteria for the Classification of AML (FAB)

M0 with minimal differentiation

Large, agranular blasts (resemble ALL L2, rarely L1). Myeloperoxidase negative or<3 percent positive; B-, T lineage markers negative; CD13 and/or CD33 positive; myeloperoxidase positive by immunochemistry or electron microscopy; TdT may be positive.

M1 with minimal maturation

1. Blast cells, agranular and granular types (type I and type II) >90 percent of non erythroid cells. At least 3 percent of these are myeloperoxidase or Sudan black positive.

2. Remaining 10 percent (or less) of cells are maturing granulocytes or monocytes

M2 with maturation

1. Sum of agranular and granular blasts (types I and II) is from 30 to 89 percent of non-erythroid cells.

2. Monocytic cells, <20 percent.3. Granulocytes from promyelocytes to mature

polymorphs, > 10 percent.

M3 Promyelocytic

1. Majority of cells are abnormal promyelocytes with heavy granulation.

2. Characteristic cells containing bundles of Auer rods (“faggots”) invariably present.

Note: Microgranular variant (M3v) also occurs. Promyelocytes have marked nuclear irregularity that includes reniform, lobulated and monocyte-like indented nuclei. The cytoplasm contains fine or indistinct granules in contrast to the coarse azurophilic granules in typical M3.

M4 Myelomonocytic

1. In the marrow, blasts >30 percent of non-erythroid cells.

2. Sum of myeloblasts, promyelocytes, myelocytes and later granulocytes is between 30 and 80 percent of non-erythroid cells.

3. > 20 percent of non-erythroid cells are monocyte lineage.

4. If monocytic cells exceed 80 percent, diagnosis is M5

Note: (a) If marrow findings as above and peripheral blood monocytes (all types) are > 5.0 x 109/L, diagnosis is M4 (b) If monocyte count < 5 x 109/L, M4 can be confirmed on basis of serum lysozyme, combined esterase, etc. (c) Diagnosis of M4 confirmed if > 20 percent of marrow precursors are monocytes (confirmed by special stains).

M4 with eosinophilia

1. Eosinophils > 5 percent of non-erythroid cells in marrow.

2. Eosinophils are abnormal.3. Eosinophilis are chloroacetate and PAS

positive.

M5 Monocytic

1. 80 percent of marrow non-erythroid cells are monoblasts, promonocytes or monocytes.

2. M5a, 80 percent of monocytic cells are monoblasts.

3. M5b, < 80 percent of monocytic cells are monoblasts, remainder are predominantly promonocytes and monocytes.

M6 Erythroleukemia

1. The erythroid component of the marrow exceeds 50 percent of all nucleated cells.

2. 30 of the remaining non-erythroid cells are agranular or granular blasts ( types I and II).

Note: If > 50 percent erythroid cells but < 30 percent blasts, diagnosis becomes myelodysplastic syndromes. A rare form of erythoird neoplasia, erythremic myelosis, involves only the red blood cell precursors. The erythroblasts, primarily pronormoblasts and basophilic normoblasts, constitute 90% or more of the marrow cells.

M7 Megakaryocytic

1. 30 percent at least of nucleated cells are blasts.

2. Blasts identified by platelet peroxidase on electron microscopy, or by monoclonal antibodies.

3. Increased reticulin is common.

M0 – all cells primitiveM1 – Maturing granulocytesM2 – Pro-mature segmentersM3 – Unique disease, most abundant #of auer rods, best prognosis (50% cure), spontaneous remission, associated with DIC (usual complication), treatment is differentM4 – confused type; with eso: good prognostic signM5 – infiltrates the gums and cnsM6 – confused with megaloblastic anemiaM7 – with fibroblastic tissue, difficult to aspirate during BM studies


All trans retinoic acid (ATRA) – M3Same treatment for all except M3

Common Cytogenetic Abnormalities Associated with AML

ChromosomeAbnormality

Associated Disorder

t(8;21) AML (M2)

t(15;17) Unique to APL (M3)

16q abnormalities:inv (16) and del (16)

AML with abnormal eosinophilia (M4E)

t9;22)

t(9;11)

CML – Philadelphia chromosome

Treatment- Remission-induction therapy- Post-remission maintenance therapy- Stem cell transplant

ACUTE LYMPHOID LEUKEMIA(Acute Lymphoblastic leukemia, Acute Lymphocytic Leukemia)

Definition- ALL is a neoplastic disease that results from

multistep somatic mutations in a single lymphoid progenitor at one of several discrete stages of development.

- The immunophenotype of leukemic cells at diagnosis reflects the level of differentiation achieved by the dominant clones.

Etiopathogenesis- Risk Factors

Genetic syndromes Environmental factors Host pharmocogenetics In utero development of ALL

FAB Classification of ALLMorphologicFeatures

L1 L2 L3

Cell size Small Large Large

Nuclear chromatin

Fine or clumped

Fine Fine

Nuclear shape

Regular, may have cleft of indentation

Irregular, may have cleft or indentation

Regular, oval to round

Nucleoli Indistinct or not visible

1 or more per cell;

1 or more per cell;

large prominent

large prominent

Amount of cytoplasm

Scanty Moderately abundant

Moderately abundand

Cytoplasmic basophilia

Slight Slight Prominent

Cytoplasmic vacuoles

Variable Variable variable

L1: best prognosis, commonly seen in childrenL2: Poor prognosis, same appearance as myeloid leukemiaL3: Worst prognosis, mature B-cell type, cytoplasmic vacuolation, basophilia, heavy tumor burden, large adenopathy, organomegaly

Acute Leukemia A heterogeneous group of neoplasms affecting

uncommitted or partially committed hematopoietic stem cells.

The retained capacity of some differentiation is the basis for the phenotypic classification.

Broadly divided into (based on cell origin) Non-lymphoid (Myeloid) leukemia Lymphoid leukemia

Classification of Leukemia Acute Myeloid (FAB classification)

Acute myeloblastic leukemia without differentiation (M0) without maturation (M1) with maturation (M2)

Acute promyelocytic leukemia (M3) – APL

Acute myelomonocytic leukemia (M4) – AMML

Acute monocytic leukemia (M5) – AMoL Erythroleukemia (M6) – Di Guglielmo’s

syndrome Acute megakaryoblastic leukemia (M7)

Acute Lymphoblastic Precursor B-cell ALL

Early-Pre-B-cell ALL Pre-B-cell ALL

B-cell ALL T-cell ALL

Chronic Myeloid Chronic myelogenous leukemia (CML) Chronic eosinophilic leukemia (CEL) Chronic basophilic leukemia (CBL)

Chronic Lymphoid Chronic lymphocytic leukemia (CLL)

B-cell CLL T-cell CLL

Prolymphocytic leukemia Hairy cell leukemia Plasma cell leukemia


Sézary syndrome

Etiology and Risk Factors Host Factors

Heredity Congenital chromosomal abnormalities Immunodeficiency Chronic marrow dysfunction

Environmental Factors Ionizing radiation Chemicals and drugs Viruses

CHRONIC MYELOPROLIFERATIVE DISORDERS (CMPDs)Definition

- Clonal dos in multipotent hematopoietic progenitor cell characterized by:

Overprodn of one or more of the formed elements if the bld withut significant dysplasia

BM hypercellular Predilection to extramedullary

hematopoiesis Splenomegaly Myelofibrosis

WHO classification of CMPDs- CML – behaves as a malignant neoplasm (Ph

chromosome)- Chronic neutrophilic- Chronic esosinophilic- Polycythemia vera- Chronic idiopathic myelofibrosis- Essential thrombocythemia

Common clinical features of CMPDs- Affects middle-aged and o.der grps- Insidious, sometimes silent, asymp onset- Panhyperplasia of BM- Freq transitions between DO- Large numner of megakaryocytes- Elevation of plt ct- Hemorrhagic and thrombotic complications- Cytogenetic abnormalities (Ph chromosome)

CHRONIC MYELOID LEUKEMIA- Clonal do of a pluripotent stem cell- May occur at any age- Characterized by presence of Philadelphia

chromosome (t9:22)With tyrosine kinase activity – necessary for signal transduction

Clinical course- 3 separate phases

Chronic phase 2-5years Accelerated phase intractable anemia

and splenomegaly Blastic (acute) leukemia phase 3-

4months ¾ AML ¼ acute lymphoid leukemia

Clinical features- Sx of hypermetabolism – wt loss anorexia or

night sweats- Splenomegaly- Features of anemia- Signs of bleeding inspite of elevated platelet ct- Rare sx: visual disturbance, priapism- Asymptomatic

Laboratory findings- Leukocytosis >50000- Inc circling basophils- Nomocytic normochromic- Neutrophil alkaline phosphatase low

Treatment – chronic phase- Tyrosine kinase inhibitors

Imatinib mesylate- Stem cell transplantation – only curative tx

Age <70 1st degree relative

- Chemotherapy Hydroxyurea Busulfan

- a-interferon

CHRONIC LYMPHOPROLIFERATIVE DISORDERSDefinition

- accumulation in the blood of mature lymphocytes of either b or t cell type

- features may overlap lymphoma distinction bet CLL and lymphoma may

be difficult- generally incurable but may have a chronic and

fluctuating course

Classification of Chronic Lymphoproliferative DisordersB-cell T-cell Chronic lymphoid leukemia Chronic lymphoctyic leukemia (CLL)

Large granular lymphocytic leukemia

Prolymphocytic leukemia (PLL)

T-cell prolymphocytic leukemia (T-PLL)


Hairy cell leukemia (HCL) Plasma cell leukemia Leukemia/lymphoma syndromes Splenic lymphoma with villous lymphocytes

Sezary syndrome

Follicular lymphoma Adult T-cell leukemia/ Lymphoma

Mantle cell lymphoma Large cell lymphoma

Lymphoplasmacytic lymphoma Large cell lymphoma

Diagnosis- chronic persistent lymphocytosis- subtypes:

morphology immunophenotype cytogenetics DNA analysis showing a monoclonal

rearrangement of either Ig or T-cell receptor genes

Chronic Lymphocytic LeukemiaB-cell

- MC leukemia in the western worldsDefinition

- Clonal do of b cell lymphocyte characterized by:

Peripheral blood and BM lymphocytosis Morphologically the lympghocytes have

a relatively mature, well-differentiated appearance

- Presence of basket cells/smudge cells

Clinical features- Older adults- MF 2:1- Discovered incidentally- Some may have enlarged lymph nodes; signs

and symptoms of anemia; bleeding secondary to thrombocytopenia

- Spleen palpable in half of cases- Immunosuppression from

hypogammaglobulinemia and cellular immune dysfunction may occur

Laboratory findings- Absolute lymphocytosis > 5 x 109/L- Normocytic normochromic anemia- Lymphocytic replacement of normal marrow

elements- Hypogammaglobulinemia - Autoimmune phenomena- Immune hemolytic anemia- Immune thrombocytopenia or neutropenia

*Coombs positive

Immunophenotype- CD markers include : 19, 20. HLA-DR(Ia)- Express weakly Ig M or D- CD5 and CD23 positive

Staging of CLL-RAI Classification- Determine the survival of the patient

Stage Clinical features Survival (year)0 Ab

lymphocytosis>12.5

I Stage 0 + enlarged LN

8.5

II Stage 0 + enlarged liver /spleen + lymphadenopathy

6

III 0 + anemia 1.5IV 0 +

thrombocytopenia

1.5

Stages 0 and 1 = observation

Staging Binet (Europeans)Stage Organ

enlargement

Hemoglobin Platelets

A 012 areas - -B 345 areas >10 >100C Not

considered<10 And/or

<100

Stages A and B = watchful waitingStage C = needs treatment

Treatment- Chrlorambucil – DOC Phils- Purine analogs

fludarabine- Monoclonal antibodies

Campath-1H (anti-CD52)- Corticosteroids

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IM Hematology 6 With Oncology