Veah Deborah CruzemJustine Chlarissa Del RosarioArianne Mirabueno

MT0831

• a form ofhematopoiesis inwhich white bloodcells (WBC,or leukocytes) areformed in bonemarrow located inbones in adults andhematopoieticorgans in the fetus.

LEUKOCYTES

∗ White blood cells∗ Defend the body against both infectious

disease and foreign materials∗ Five different types exist∗ All produced and derived from Hematopoietic Stem

cell∗ Two categories:

∗ Granulocytes & Agranulocytes

Leukocytes

∗ Presence of granules∗ Released from the bone marrow by the

regulatory complement proteins.∗ Includes:

∗ Neutrophils∗ Eosinophils∗ Basophils

Granulocytes

∗Absence of granules∗ Includes:

∗Monocytes∗Lymphocytes

Agranulocytes

Neutrophil Maturation

Myeloblast<1% in the normal bone marrow

15-20 µm in size

Nucleus: delicate with prominent nucleoli

Cytoplasm: contains rough endoplasmicreticulum, a developing Golgi apparatusinitial presence of primary or azurophilicgranules

Granules color positively formyeloperoxidase

Myeloblast

MYELOPEROXIDASE –an enzyme that occurs inprimary granules ofpromyelocytes,myelocytes, andneutrophils and exhibitsbactericidal, fungicidaland viricidal properties.

o The cell is incapable ofmotility, adhesion, andphagocytosis

Promyelocyte(Progranulocyte)

1%-5% in the bone marrow

Greater than or equal to 20 µm

Nuclear chromatin: shows slightclumping; nucleoli began to fade

Promyelocyte

This activates neutralproteinases cathepsin G,elastase, and proteinasesfor killing to take place.

Neutrophilic Myelocyte

<10% of total BM cell population

Last cell capable of mitosis

Nucleus: round to oval with flattened sidenear a well-developed Golgi apparatus

Nuclear chromatin: shows clumping;nucleoli is no longer visible

“DAWN OFNEUTROPHILIA” – faintblush of pink within thecytoplasm; caused bythe granules

Neutrophilic Myelocyte

Neutrophilic Myelocyte

Some important compounds within thesecondary granules:

Thrombospondin receptor

β2-microglobulin

Apolactoferrin

Lysozyme

Plasminogen activators

Neutrophilic Metamyelocyte

After cessation of all active DNA synthesis

Nucleus: indented

13%-22% of BM

Synthesis ofgelatinasegranule by theend of stagedevelopment

Contain lysozymeand acetyltransferase

Neutrophilic Metamyelocyte

Neutrophilic Band

Nonsegmented form

40% of WBCs in BM

Absence of nuclear segments composedof dense heterochromatin

Represents the almost mature cell

Possesses full motility,active adhesion properties,and some phagocytic ability

Membrane maturity:changes in cytoskeleton,changes in surface charge,and presence of receptorsfor complement (CRs),specifically for CR1 and CR3.

<6% of WBCs in peripheralblood

Neutrophilic Band

Neutrophilic Band

Presence of secretory vesicle, animportant store of surfacemembrane-bound receptors andmay be functional in antigenpresentation

Endocytosis

PolymorphonuclearNeutrophil

Many-shaped nucleus

Nucleus: easily deformable; visiblesegments; some appear grossly twistedand folded

Present in the bone marrow and in themarginating and circulating pools

50%-70% in the peripheral blood

Positive for the adhesion moleculesCD62, CD11a/CD18

Performs phagocytosisand pinocytosis

Neutrophils areattracted are attractedto particles by severalmechanisms:

Chemotaxis

Complement fixation

PolymorphonuclearNeutrophil

*First recognizable cell.

*Diameter between 14 and 18µm

*Occupied by a large oval nucleus

*Nucleus is composed of very fine nonaggregated chromatin and possesses 3 or more nucleoli.

* Cell size, 12 to 20 µm

* Contains a few, as yet undifferentiated, cytoplasmic granules

* Second largest stage in the granulocytic series

*Granules are peroxidase positive

*One to three nucleoli are also visible

* First of the maturation stages of the granulocytic leukocytes normallyfound in the bone marrow

*Granules are seen in the cytoplasm

* Cell is flat and contains increasing numbers of granules as maturationprogresses.

*Appearance of a bent nucleus, cytoplasmic granules

*Absence of visible nucleoli.

Myeloblast Promyelocyte Myelocyte Metamyelocyte MaturedEosinophils

Myeloblast Promyelocyte Myelocyte Metamyelocyte MaturedBasophils

*10-12 microns

*1-3% of circulating WBCs

*Responsible for combatingmulticellular parasites andcertain infections in vertebrates

*Control mechanisms associatedwith allergy and asthma.

*Acid-loving

*Nucleus with 2-3 lobes

*Stained heavily with eosindye used in conventionalRomanowsky stain

*Spends less than 1 week inperipheral blood

*Actively motile

*Acid phosphatase

*Arylsulfatase

*Β-Glucuronidase

*Cathepsin

*Peroxidase

*Phospholipase

EosinophilicGranules Contents

*Water-soluble

*Needle-shape

*Result of eosinophildisintegration

Charcot-LeydenCrystal

* Irregular, s-shaped, bilobednuclei

*8-10 microns

*0-1% of circulating WBCs

*Obscure the cell nucleus

*Large heavily staining granulesstain with basic dyes

*contains anticoagulant heparin

*contains the vasodilator histamine

*plays a role in both parasiticinfections and allergies

*regulates the behavior of T cells

*have protein receptors on theircell surface that bind IgE

*Mastocyte

*Rich in histamine and heparin

* Involved in wound healing anddefense against pathogens.

MAST CELLS

MONOCYTES

MONOCYTEdevelop from thesame precursor asneutrophils -the CFU-GM.cells that are madein the bone marrow,and they spreadthrough the body inone to three days.

MONOCYTEMATURATION

MONOBLAST

the earliestprecursor arisingfrom a committedstem cell in themonocytic series,which developsinto thepromonocyte.

PROMONOCYTE

• a cell in an intermediatestage of developmentbetween a monoblast anda monocyte

• Size: 12-20 microns indiameter.

• Nucleus: The nucleus isoval or indented and lightpurple.

• Cytoplasm: Thecytoplasm is gray-bluewith fine dust likeazurophilic

MATURED MONOCYTE

incapable of mitosis and enter the circulation.Size: 12-20 microns in diameter.Nucleus: The nucleus is round or kidney-shaped, but can be deeply indented or havetwo or more lobes.Cytoplasm: foamy blue grayFunction:take longer time to get to site of infection butarrive in larger numbersbecome wandering macrophages once theyleave the capillariesdestroy microbes and clean up dead tissuesfollowing an infection

LYMPHOCYTES

LymphocytesHuman blood leukocytes whose site of

development is not solely the bone marrow,but also tissues referred to as primary andsecondary lymphoid organs

Thymus and bone marrowSpleen, Peyer’s patches, Waldeyer ring of

the tonsils and adenoids, and lymph nodesand nodules scattered throughout the body

Hand mirror shape is a result of theircharacteristic form of locomotion

DEVELOPMENTThe thymus and bone marrow give rise

to lymphocytes, foster differentiationand are independent of antigenicstimulation.

T cells – cells that develop under theinfluence of the thymus; have a specific,unique set of receptors and responses

B cells – derived from BM ad have adifferent set of functions and capabilities

Plasma cell – end cell of B lymphocytematuration

B CELL

T CELL

PLASMA CELL

LymphocyteMaturation

Lymphoblast to ProlymphocyteLYMPHOBLAST

10-18 µm in size Nucleus: round to oval, with loose chromatin and

one or more active nucleoli. Cytoplasm: scanty and has basophilia

proportional to amount of RNA present

PROLYMPHOCYTE Slightly more clumped chromatin, lessened

nuclear prominence, change in thickness ofnuclear membrane

Lymphoblast Prolymphocyte Lymphocyte

Small lymphocyteMost commonapprox. 9 µm in sizeNucleus: round to oval; block type

chromatin patternNondiving or resting

LYMPHOCYTE

LYMPHOCYTEMedium Lymphocyte

11-14 μm in diameter Contains azurophilic granules that are more

clearly discerned nondiving

LYMPHOCYTELarge lymphocyte

Rarest in PB 15 μm Has a deeper shade of blue when stained May be part of natural killer cells

1. The first of the maturation stages of the granulocytic leukocytesnormally found in the bone marrow.

a.Myeloblast b. Promyelocyte c. Myelocyte d. Metamyelocyte

2. It is characterized by the appearance of abent nucleus, cytoplasmic granules, and the absence ofvisible nucleoli.

a.Myeloblast b. Promyelocyte c. Myelocyte d. Metamyelocyte

3. Cells that develop under the influence of the thymus, have aspecific, unique set of receptors and responses.

a. T cells b. B cells c. Plasma cells d. Mast cells

4. Tissue equivalent of circulating basophil. Involved in allergicinflammation and initiate localized and system anaphylaxis.

a. T cells b. B cells c. Plasma cells d. Mast cells

5. Size of matured basophil.

a. 10-12 microns b. 8-10microns c. 10-15 microns d. 6-9microns

Terminologies Quantitative

Change in number Terminology

Cytosis / philia Increase in number

Cytopenia Decrease in number

LEUCOCYTES BENIGN DISORDERS Quantitative changes (LEUKOCYTOSIS) Definition

Raised TWBC due to elevation of any of a singlelineage.

Note: elevation of the minor cell populations can occurwithout a rise in the total white cell count.

Normal reference range (adult 21 years) 4.5 -- 11.0 x 109/L

LEUCOCYTES BENIGN DISORDERS Quantitative changes (LEUKOPENIA)

DefinitionTWBC lower than the reference range for the age isdefined as leucopenia Leukopenia may affect one or more lineages and it is

possible to be severely neutropenic or lymphopenicwithout a reduction in total white cell count.

LEUCOCYTES BENIGN DISORDERS Quantitative changes (contd.)

GranulocytosisIncrease in the count of all or one of thegranulocytic component

Neutrophils Basophils Eosinophils

AgranulocytosisDecrease in the count of all or one granulocyticcomponent

Leukocytes Leukocytes

Phagocytes Granulocytes

Neutrophils Eosinophils Basophils

Mononuclearphagocytic cells Monocytes Macrophage and

denderetic cells Lymphocytes

B-cells T-cells

N

E

B

LM

Band

P

Neutrophils Count 2.5 - 7.5 x

109/l Granular cytoplasm Transient stay in

blood Major phagocytic

role Bacterial killing

3-5 lobes of nucleus

Disorders of Neutrophil Neutrophilia

Infection (Bacterial) Inflammatory conditions Neoplasia Metabolic conditions

Uraemia Haemorhage / haemolysis Corticosteroids Marrow infiltration

Haematologicalmalignancies

Chronic Myeloid Leukaemia Myeloproliferative disorder

CML

MM M

N

Baso

Myeloid malignancies

Acute Myeloid Leukaemia(AML M-3)

Chronic Myeloid Leukaemia

Disorders of Neutrophil

Neutropenia Count < 1.5 x 109/l Drugs Chemotherapy Viral infection Inherited disorders

Morphological abnormalities Pelger-Huet anomaly May-Hegglin anomaly Chediak-Higashi syndrome

Neutrophilia Transiently with stress and exercise by a shift of

neutrophils from the marginating pool to thecirculating pool. Infection Toxins: metabolic (uremia), drugs, chemicals Tissue destruction or necrosis: infarction, burns,

neoplasia, etc Hemorrhage, especially into a body cavity Rapid hemolysis

Neutropenia Aplastic anemia Toxins that damage marrow Infection Viral (Hep-B), Mycoplasma etc. marrow infiltration by infections or carcinomas,

Radiation therapy Chemotherapy Hematologic malignancies such as leukemias Myeloproliferative disorders Congenital disorders Increased neutrophil destruction as in

Splenomegaly, Immune destruction

Lymphocytes Count varies with

age1.5 – 3.5 x109/l The subset cells are

B-cells Antibody mediated

immunity

T-cells Cell mediated immunity

NK cells

Disorders of lymphocytesBenign disorders Lymphocytosis

Viral infections Bacterial infections Protozoal infections

Lymphopenia Marrow failure (drugs, irradiation) Infections (viral infections)

Immune-deficiency syndromes Antibody deficiency Cell mediated immune defieciency Combined cell and antibody immune deficiency

Disorders of Lymphocytes Infectious

mononucleosis Epstein-Barr virus

infection

Autoimmunelymphoproliferativesyndrome

Disorders of LymphocytesMalignant disorders Acute lymphoblastic

(ALL) leukemia Chronic lymphocytic

leukemia (CLL)

Lymphomas Non Hodgkin’s

lymphoma Hodgkin’s disease

ALL

CLL

LymphocytosisNormally be observed in infants and young

children.Acute infections, including pertussis,

typhoid, and paratyphoid Infectious mononucleosis, with "atypical"

lymphocytosisViral infections, including measles, mumps,

adenovirus, enterovirus, and Coxsackie virusToxoplasmosis

Lymphopenia Immunodeficiency syndromes, including

congenital (DiGeorge syndrome, etc)and acquired (AIDS) conditions

Corticosteroid therapyNeoplasia, including Hodgkin's disease,

non-Hodgkin's lymphomas, andadvanced carcinomas

Radiation therapyChemotherapy

Monocytes Count is 0.2-0.8 x

109/l Functions

Antigen presentation Cytokine production Phagocytosis

Disorders of Monocytes Monocytosis

Benign Chronic bacterial infection

Malignant Chronic Myelomonocytic Leukaemia CMML

Monocytosis Infections: such as brucellosis,

tuberculosis and rickettsiaMyeloproliferative disordersHodgkin's diseaseGastrointestinal disorders, including

inflammatory bowel diseases andsprue

Eosinophils

Count 0.2 – 0.8 x 109/l Bilobed nucleus Phagocytic activity is

low Modulation of

hypersensitivity andallergic reactions

Disorders of Eosinophil Eosinophilia

>0.8 x 109/l Allergic reactions Parasitic infections Malignancy Inflammatory conditions Myeloproliferative disorders Hypereosinophilic syndrome

Basophils

Count 0.1 – 0.2 x 109/l Bilobed nucleus Nucleus is hided

behind the granules Inflammatory

response Basophilia is seen in

Myeloproliferativedisorders (CML)

EosinophiliaAllergic drug reactionsParasitic infestations - with tissue invasionExtrinsic asthmaHay feverExtrinsic allergic alveolitis ("farmer's lung“)Chronic infectionsHematologic malignancies: CML,

Hodgkin's disease

Eosinopenia, Monocytopenia& Basopenia

Acute stress reactions with increasedglucocorticoid and epinephrinesecretion

Cushing's syndrome withcorticosteroid therapy

Steroid therapyAcute inflammation

Leukemoid Reaction:Definition A leukemoid reaction (LR) is a hematological disorder,

defined by a leukocyte count greater than 50,000cells/mcL with reactive causes outside the bone marrow

LR is characterized by a significant increase in matureneutrophils in the peripheral blood and a differentialcount showing marked left shift.

The diagnosis of LR is based on the exclusion of chronicmyelogenous leukemia (CML) and chronic neutrophilicleukemia (CNL).

NONMALIGNANT LEUKOCYTEDISORDERS

Many bands, metamyelocytes, and myelocytes areseen

Occasional promyelocytes and myeloblasts maybe seen.

This condition resembles a chronic myelocyticleukemia (CML), but can be differentiated fromCML based on the fact that in leukemoid reactions:

There is no Philadelphia chromosome The condition is transient There is an increased leukocyte alkaline

phosphatase score (more on this later) Leukemoid reactions may be seen in tuberculosis,

chronic infections, malignant tumors, etc.

Leukemoid Reaction MajorCauses: Infections Clostridium difficile colitis Severe shigellosis Disseminated tuberculosis Serious bacterial infections

Work up of LR should include cultures of blood,sputum, and bone marrow for common bacteria andmycobacteria. Stool cultures should not beoverlooked.

Leukemoid Reaction MajorCauses: Infections

C. difficile colitis with an LR appears to beassociated with a much higher mortality rate (approx50%).

Leukemoid Reaction MajorCauses: Drugs/Toxins

Corticosteroids Minocycline Recombinant hematopoietic growth factors Ethylene glycol

Leukemoid Reaction Major Causes:Malignancy

Carcinomas (lung, oropharyngeal, gastrointestinal,genitourinary)

Hodgkin's lymphoma Melanoma Sarcoma

Leukemoid Reaction Major Causes:Malignancy

Leukemoid reactions can present simultaneouslywith malignancy, late in the course of the disease, orprecede the diagnosis by as many as 4 years.

In a study of 227 patients with carcinoma of thelung, 33 patients (14.5%) were diagnosed withtumor-related leukocytosis and 6 patients (2.6%)with LR.

Leukemoid Reaction Major Causes:Malignancy

The mechanism of the generation of an LR inassociation with a neoplasm has not been fullyelucidated.

It is likely that various cytokines produced irregularly bythe tumor cells, including granulocyte colony-stimulatingfactor (G-CSF), granulocyte-macrophage colony-stimulating factor (GMCSF), and interleukin 6 (IL-6), mayunderlie the pathogenesis of LR in such conditions.

Leukemoid Reaction versus CNLversus CML

CML:

immature cells, basophilia or monocytosis decreased leukocyte alkaline phosphatase (LAP) score bcr/abl translocation.

The differential diagnosis between LR and CNL may bedifficult or even impossible because both conditionsshare:

identical morphological features increased LAP score absence of the bcr/abl translocation.

Leukemoid Reaction versus CNLversus CML: The Smear

In CML, there are more immature cells, basophils,and eosinophils.

In LR, consist mostly of mature neutrophils. Thedifferential count discloses a marked left shift,presence of myelocytes and metamyelocytes.

In CNL, there is marked neutrophilia with noimmature cells

Leukemoid Reaction versus CNLversus CML: The Bone Marrow

In CML, basophilia, eosinophilia, monocytosis, or even aminimum percentage of blasts are characteristic.

Increased cellularity with myeloid hyperplasia is seen inboth LR and CNL.

In LR there is marked proliferation and orderlymaturation of all normal myeloid elements with normalmorphology, without fibrosis.

Leukemoid Reaction versus CNLversus CML: The Bone Marrow

Similar morphological features are present in CNLand LR, but a packed bone marrow biopsy, togetherwith a slight increase in reticulin fibrosis, may helpdifferentiate it from a reactive process.

Leukemoid Reaction versus CNLversus CML: LAP score

LAP is an enzyme present in the cytoplasmicmicrosomes of neutrophils, bands,metamyelocytes, and myelocytes, but not inlymphocytes or monocytes.

Immature neutrophils, such as those observed inCML, have decreased LAP scores.

Stimulated neutrophils of an LR have high LAPscores.

Leukemoid Reaction versus CNLversus CML: LAP score

Leukocyte alkaline phosphatase (LAP) score is highin infection/inflammation, polycythemia vera andCNL.

LAP score is low in CML.

Leukemoid Reaction versus CNLversus CML: Cytokine Levels

Although G-CSF, GM-CSF, and IL-6 are notincluded in diagnostic criteria for CNL,measurement of enzyme-linked immunosorbentassay (ELISA) have been used to elucidatecytokine-producing tumor and the developmentof an LR.

Generally CML and CNL patients havesignificantly low G-CSF levels, suggesting thatneoplastic granulopoiesis can exert asuppressor effect on G-CSF synthesis.

Leukemoid reaction

Leukemoid reactions are characterized by blasts, promyelocytes,myelocytes, and metamyelocytes in the peripheral blood.

Leukemoid reactions may be secondary to benign or malignantconditions.

A leukoerythroblastic reaction is similar to a leukomoidreaction with the addition of nucleated red blood cells. Aleukoerythroblastic picture indicates severe disruption ofthe marrow and is common in myelofibrosis (primary orsecondary).

In infants a leukoerythroblastic reaction suggestssevere hemolytic anemia, such as erythroblastosis

END Prepared By:

•Savannah Lima

•Johnpaul Mojica

•Gurpreet Singh

Questions

1.) a hematological disorder, defined by a leukocyte count greaterthan 50,000 cells/mcL with reactive causes outside the bonemarrow.

A.neutrophilia B.eosiniophilia C.leukemoid reactionD.neutropenia

2.)term used for increase in neutrophils A.basophilia B.neutrophilia C.neutropenia D.eosinophilia 3.)an agranulocyte with horse shoe shaped nucleus. A.lymphocyte B.monocyte C.segmenters D.PMN 4.)normal value for TWBC A.4.5-11x10 9 B.2.5-11x10 9 C.6.5-11x10 9 D. 9.5-11x10 9

5.)these are drugs/toxins associated with leukemoid reaction,EXCEPT

A.corticosteroids B.rifampin C.ethylene glycolD.tylenol

#1 ADAO, Dyrelle#6 CASTILLO, Gileen Grace I.

#11 DELA CRUZ, Sharmila Mae R.MT0831

Dra. Asilo

Qualitative Non-Neoplastic WBC Disorder

∗ Recessive disorder∗ Azurophilic granules in one or all cell types∗ Inclusions: Lymphocyte w/ no neutrophil

abnormalities

Alder-Reilly Anomaly

∗ Dense, Large, dark lilac, azurophilic granules(neutrophil, eosinophil, basophil, occasionallylymphocytes and monocytes)

∗ Granules• Larger than normal azurophilic and basophilic

granules• Lilac with Wright-Giemsa Stain• Metachromatic with Toluidine Blue• Evenly distributed throughout cytoplasm

Morphology

∗ Resemble Toxic Granulation∗ Obscure the nucleus- function normally

∗ Inclusions:∗ more frequently seen in Bone marrow∗ Lymphocyte inclusion: less numerous∗ Basophilic inclusion: surrounded by clear halo & stain

metachromatically

Morphology

Normal Neutrophil

Neutrophil with Alder-ReillyAnomaly

Alder-Reilly Anomaly withAzurophilic Granules

Neutrophil Lymphocyte Monocyte

ToxicGranulation

∗ Mucopolysaccharide Degradation:∗ Hunter’s Syndrome (Mucopolysaccharidosis Type II /

MPS II)∗ Hurler’s Syndrome (Mucopolysaccharidosis Type I/

MPS I)∗ Maroteaux–Lamy syndrome (Mucopolysaccharidosis

Type VI/ MPS VI)

Associated Disease

Hurler’s Syndrome

Hurler’s Syndrome

∗ Aka Mucopolysaccharidosis Type II / MPS II∗ Named after physician Charles A. Hunter∗ X-linked recessive∗ Deficiency or absence of the lysosomal enzyme

iduronate-2-sulfatase (I2S)∗ Physical Appearance:

∗ Coarse facial features (gargoylism)∗ nose with a flattened bridge, and an enlarged tongue∗ Large head (macrocephaly)∗ Joints of fingers, arms, and legs held in partial flexion∗ Enlarged abdomen (due to enlarged liver and spleen)∗ No cloudy corneas

Hunter’s Syndrome

Hunter’s Syndrome

∗ Aka Mucopolysaccharidosis Type VI/ MPS VI∗ Name after Pierre Maroteaux and Maurice Lamy∗ Deficiency in arylsulfatase B (ARSB)∗ Onset before age 3∗ No current treatment for the syndrome∗ Physical Appearance:∗ clouded corneas∗ deafness∗ thickening of the dura

Maroteaux–Lamy syndrome

Maroteaux–Lamy syndrome

∗The following syndromes areassociated with Alder-ReillyAnomaly EXCEPT:a.Hunter syndromeb.Hurler syndromec.Myeloperoxidase deficiency syndromeMaroteaux-Lamy syndrome

Question #1

∗The appearance of Alder-ReillyAnomaly is difficult to distinguishfrom:a.Dohle bodiesb.May-Hegglin Anomalyc.Toxic granulationd.Chediak-Higashi syndrome

Question #2

∗Which of the following isassociated with Alder-Reillyinclusions?

a. membrane defect of lysosomesb. Dohle bodies and giant plateletsc. two-lobed neutrophilsd. mucopolysaccharidosis

Questions #3

∗The cytoplasmic abnormality of thewhite blood cell of Alder-Reillyanomaly is found in the:a. endoplasmic reticulumb. lysosomesc. mitochondriad. ribosomes

Question #4

∗Where can Alder-Reilly inclusionsbe frequently seen?a. Peripheral bloodb. Bone marrowc. Spleend. Kidney

Question #5

Chédiak-Higashi syndromeChédiak-Higashi syndrome

Azarcon, dyna mae j.Zipagan, valeriemt0831

Chédiak-Higashi syndromeChédiak-Higashi syndromeEponymEponym

Alexander Moisés Chédiak--- Cuban physician and serologistOtokata Higashi--- Japanese pediatrician

Chédiak-Higashi syndromeChédiak-Higashi syndromeBackgroundBackground

Beguez Cesar in 1943Steinbrinck in 1948Chédiak in 1952Higashi in 1954

rare childhood autosomalrecessive disorder

Chédiak-Higashi syndromeChédiak-Higashi syndromeBackgroundBackground

hypopigmentation of theskin, eyes, and hair; prolongedbleeding times; easy bruisability;recurrent infections; abnormalnatural killer cell function; andperipheral neuropathyMorbidity results from patientssuccumbing to frequent bacterialinfections or to an accelerated-phase lymphoproliferation intothe major organs of the body

Chédiak-Higashi syndromeChédiak-Higashi syndromeCauseCause

mutations in the LYST geneWhat is the official nameof the LYST gene?The official name of this gene is“lysosomal trafficking regulator.”LYST is the gene's official symbol.What is the normal functionof the LYST gene?provides instructions for making aprotein known as the lysosomaltrafficking regulatordetermine the size of lysosomesand regulate their movement within cells.

Chédiak-Higashi syndromeChédiak-Higashi syndromePathophysiologyPathophysiology

How are changes in the LYST generelated to health conditions?At least 30 mutationsin the LYST geneChildhood formabnormally short, nonfunctional versionof the lysosomal trafficking regulator proteinAdult versionusually change a single protein building block (amino acid) inthe protein

Chédiak-Higashi syndromeChédiak-Higashi syndromePathophysiologyPathophysiology

abnormally large lysosomes andrelated structures in cellsthroughout the body= interferewith normal cell functionscellular structures called melanosomes

(which are related to lysosomes) areabnormally large= melanin is trappedwithin the giant melanosomeslysosome-like structures inside blood cellscalled platelets= abnormal bruisingand bleeding

abnormal lysosomes in nerve cells= neurologicalproblems associated with this disease

Chédiak-Higashi syndromeChédiak-Higashi syndromePathophysiologyPathophysiology

Where is the LYST gene located?Cytogenetic Location: 1q42.1-q42.2Molecular Location on chromosome 1: base pairs235,824,342 to 236,030,219

The LYST gene is located on the long (q) armof chromosome 1 between positions 42.1 and 42.2.More precisely, the LYST gene is located from basepair 235,824,342 to base pair 236,030,219 onchromosome 1.

SYMPTOMS:SYMPTOMS:Children with this condition may have: Albinism Increased infections in the lungs, skin, and mucous

membranes Nystagmus Accelerated phase - (EBV)◦ fever, episodes of abnormal bleeding, overwhelming

infections, and organ failure.

Common: Infections – (mucous membranes, skin,respiratory

tract) Neuropathy

OTHER SYMPTOMS:OTHER SYMPTOMS: Decreased vision Mental retardation Muscle weakness Peripheral neuropathy Nosebleeds or easy bruising Numbness Tremor Uncontrolled bowel movements Seizures Photophobia ataxia

DIAGNOSIS/EXAM/TEST:DIAGNOSIS/EXAM/TEST: Physical exam Biopsy of skin, muscle, and nerves - granules Bone marrow smears - giant inclusion bodies white blood cells (leukocyte

precursor ). Prenatal testing EEG - seizures Brain MRI or CT scan – small brain (atrophy) EMG or nerve conduction velocity testing – delayed

nerve signaling Peripheral blood smear - neutropenia and

hypergammaglobulinemia. Fluorescence cytometric analysis - analysis of cellular

granularity and surfacemolecules

TREATMENT:TREATMENT: no specific treatment Bone marrow transplants Antibiotics- infections Antiviral drugs - terminal phase of the

disease◦ Acyclovir◦Cyclophosphamide◦ prednisone

Vitamin C therapy - improved immunefunction and clotting in some patients.

MORTALITY/MORBIDITY:MORTALITY/MORBIDITY: Death - first decade result of infection, bleeding,

or development of the accelerated lymphomalike phase

The second and third decades – survivalreported

RACE: Affects all races Al-Khenaizan - underreported in persons of darker-

skinned races.

AGE:Usually appear soon after birth or in children youngerthan 5 years.

PHOTOSPHOTOS

Questions:Questions: What do you call the phase where there is a lymphoma like

syndrome?a. slow phase c. latent phaseb. primary phase d. accelerated phase

What is the diagnostic hallmark of Chediak-Higashisyndrome?a. Small inclusion bodies c. Medium inclusion bodiesb. Giant inclusion bodies d. Darkly pigmentedinclusion

What is the medical term for jerky eye movement?a. Hyperhidrosis c. Nystagmusb. seizures d. Ataxia

What is the official name of the gene affected in patientswith Chediak-Higashi syndrome?

a. Lysosome transport regulatorb. Lysosomal trafficking regulatorc. Lysosyme transcriptase regulatord. Lysosomal transferase regulator

What disease form of the Chediak-Higashi syndrome isvery fatal?

a. childhood form c. pregnant formb. teenage form d. Late adulthood form

Prepared by: Valerie S. Zipagan

May Hegglin Anomaly

Chua, CristinaDela Pena, Andrew Vittorio

Guia, Alexa

May-Hegglin anomaly (MHA)

o Also known as Dohle leukocyteinclusions with giant platelets andmacrothrombocytopenia withleukocyte inclusions

o It is a rare genetic disorder of the bloodplatelets that causes them to beabnormally large.

o The anomaly also causes abnormalitiesin the  white blood cells knownas leukocytes.

Backgroundo In 1909, Richard May described the

presence of leukocyte inclusions andlarge platelets in an asymptomaticyoung woman.

o In 1945, Robert Hegglin described aman and his 2 sons who were healthybut had a triad consisting ofthrombocytopenia, giant platelets,and leukocyte inclusions (see pictureon next slide)

Background

Blood smear (originalmagnification X2000) in apatient with May-Hegglinanomaly (MHA)demonstrates acharacteristic giantplatelet with poorlydefined granulation. Anormal-sized platelet isalso present. The trilobedneutrophil contains alarge, well-defined,basophilic, peripherallyplaced cytoplasmicinclusion body (resemblinga Döhle body). Used withpermission from Little,Brown

Backgroundo His diagnostic triad was later given the

eponym May-Hegglin anomaly (MHA).

o May-Hegglin anomaly- is an autosomal dominant disorder

characterized by various degrees ofthrombocytopenia that may be associatedwith: purpura and bleeding giant platelets containing few granules and large (2-5 µm), well-defined, basophilic,

cytoplasmic inclusion bodies in granulocytesthat resemble Döhle bodies.

Backgroundo May-Hegglin anomaly

- is one of a family ofmacrothrombocytopeniascharacterized by mutations inthe MYH9 gene.

o The other members of this familyinclude:- Sebastian syndrome- Epstein syndrome- Fechtner syndrome

Pathophysiologyo Patients have a mutation of

the MYH9 gene present inchromosomal region 22q12-13.

o The mutation results in disorderedproduction of nonmuscle myosinheavy-chain type IIA, which leads toinvariable macrothrombocytopeniasecondary to defectivemegakaryocyte maturation

Pathophysiologyo Platelet function in patients with May-Hegglin

anomaly has been reported as normal.o However, in one study, epinephrine response

was described as abnormal in 8 of 15 patientso Leukocyte Döhle inclusion bodies are

visualized on standard Wright stain andappear bright blue and spindle shaped

o Ultrastructural studies reveal that thesebodies consist of clusters of ribosomesoriented along parallel myosin heavy-chainfilaments 7–10 nm in diameter

o Neutrophil function is considered to benormal, and patients have no increasedsusceptibility to infections.

Signs and Symptomso Asymptomatico Minor hemorrhageso Mild leukopeniao Mild reduction in level of blood plateletso Skin hemorrhageo Nosebleedo Excessive oral bleeding during dental

procedureso Headacheo Muscle weakness on one side of body

Signs and Symptomso Intracranial bleedingo Large blood plateletso Mild reduction of level of blood

plateletso Prolonged bleeding timeo Bleeding inside the braino Excessive menstrual bleedingo Easy bruisingo Gums that bleed easilyo Excessive bleeding after operations

o Active bleeding from the mucosalsurfaces may be observed.

o The most common sites of bleedinginclude the mouth and nose.

o Prolonged and excessive bleedingand oozing associated withlacerations and sutures may also beobserved.

Skin Hemorrhage

Nosebleed

Intracranial hemorrhage

Bleeding inside the brain

Causes

o Mutation of MYH9 geneo Malignant hypertensiono Thrombotic thrombocytopenic

purpurao Schulman-Upshaw syndrome

Lab Diagnosis

Platelet Count and Morphology

o Degree of thrombocytopenia varies

o Platelet count is usually 40-80 X 109/L (Normal Value 150-450 X 109/L)

o Characterized by macrothrombocyte - Platelets are enlarged 15-20 µm in diameter (Normal size 1-4 µm)

o Mean platelet volume 30 fL (Normal Value 6.8-10.2 fL)

Clinical Features of MYH9 -RelatedThrombocytopenias

Condition Macrothrombocytopenia

Granulocyteinclusions

Nephritis andDeafness Cataracts

MHA Yes Linear Döhle No No

Epsteinsyndrome

Yes Absent orfaint

Yes No

Fechtnersyndrome

Yes Sphericalgranules

Yes Yes

Sebastiansyndrome

Yes Sphericalgranules

No No

Wright Stain

Döhle bodies

1.Neutrophils (most commonly seen)2.monocytes3.eosinophils4.basophils

Döhle bodies and Macrothrombocyte

Döhle bodies and Macrothrombocyte

Döhle bodies (Eosinophil)

Electron Microscopyo Increased amount of disorganized

microtubule

Immunocytochemistry

o Detectection ofNMMHCIIA complexes within theleukocytes

- Confirmatory test

Treatment

o Specific treatment is not requiredo In rare patients with severe bleeding,

platelet transfusion may be required

Complication - bleeding risk is increased by taking

drugs that decrease plateletfunction

e.g. Aspirin and NSAIDs

Questions:1. Mutation of what gene will result to

MHA?a. MYJ9 b. MZH9c. MYH9 d. MXH9

2. Other name for MHA?a. Dohle leukocyte inclusions with small plateletsb. Dohle leukocyte inclusions with giant leukocytesc. Dohle leukocyte inclusions with giant rbcd. Dohle leukocyte bodies with giant platelets

3. What are the 2 most common site ofbleeding in MHA?

a. mouth and nose b. mouth and skinc. nose and skin d. skin and brain

4. What inclusion bodies is commonly seen inMHA?

a. Heinz bodies b. Döhle bodiesc. Cabot ring d. Siderotic granules

5. What platelet morphologycharacterized MHA?

a.Microthrombocytesb.Macrothrombocytesc.Microleukocytesd.Macroleukocytes

PELGER-HUETPELGER-HUETANOMALYANOMALY

Mangon, Kimberly Christine L.Santos, Czarinnah F.

Vergara, Verlyn C.

• PHA is a benign dominantly inheriteddefect of terminal neutrophil differentiationsecondary to mutations in the lamin Breceptor (LBR) gene.

• Pelger, a Dutch hematologist, describedleukocytes with dumbbell-shaped bilobednuclei, a reduced number of nuclearsegments, and coarse clumping of thenuclear chromatin.

• Huet, a pediatrician, identified it as aninherited disorder.

• Genome-wide analysis of individuals fromthe Gelenau region of Germany was usedto identify the affected gene in humansas LBR gene, located on subband 1q42.1

• Heterozygotes have neutrophils with apredominance of bilobed dumbbell-shaped nuclei, which are also describedas pince-nez (ie, looking like pinched-nose spectacles)

• LBR also interacts with HP-1heterochromatin proteins

• LBR abnormalities do not affectneutrophil function

• Distinguishing this autosomal dominantdisorder from acquired orpseudo–Pelger-Huët anomaly isimportant

• Homozygous individuals are rare• In Homozygous individuals:

– Neutrophils contain a single, round,eccentric nuclei with clumped chromatinand little or no nuclear segmentation

– Basophils, eosinophils, andmegakaryocytes also show densenuclear chromatin and rounded nuclearlobes

• Unique physical findings are notobserved in heterozygousindividuals with Pelger-Huëtanomaly

• Homozygous individualsinconsistently have skeletalanomalies such as postaxialpolydactyly, short metacarpals,short upper limbs, short stature,or hyperkyphosis.

MORTALITY/MORBIDITY

• Neutrophilic function is normal• HETEROZYGOUS:

– are in good health– natural resistance to infection is unimpaired

• HOMOZYGOUS:– Skeletal anomalies– Developmental delay– Seizures

• From Switzerland,Germany, or Holland

• In ALL ethnic groups- Whites, Blacks and Asians

• Male-to-female ratio is 1:1• May also be in individuals of all ages

• Distinguished from:Acquired or pseudo–Pelger-Huët

anomaly• observed in individuals with myeloid

leukemia, myelodysplasia, and bi-lineage acute lymphocytic leukemia

Acquired or pseudo–Pelger-Huëtanomaly

– in the course of acute or chronicmyelogenous leukemia and inmyelodysplastic syndromes

– cells tend to appear late in the disease– morphologic changes have been

described in myxedema

• MYXEDEMA– Panhypopituitarism– Vitamin B-12 and folate deficiency– Multiple myeloma– Enteroviral infections– Malaria– Muscular dystrophy– Drug sensitivity

In Acquired or pseudo–PHA:– Fewer bilobed cells– Higher percentage of normal trilobed

neutrophils– Presence of leukemic and immature cells

*predicative of the clinical onset of myelodysplastic disorders andmalignant conditions.

• Heterozygous PBS– neutrophils are bilobed, spectacle-shaped nuclei -

> pince-nez– Cells with twin, joined, and plump nuclei

resembling dumbbells are predominant– A thin bridge joins the two lobes– 69-93% of the neutrophils show nuclear

segmentation that is arrested at the bilobe level– neutrophils that possess a nonlobulated oblong

or peanut-shaped nucleus is often present– >10% of cells contain 3 lobes; 4 lobes are rare

• Homozygous PBS– neutrophils with a single, round, eccentric

nucleus (clumped chromatin and little or nonuclear segmentation)

– most neutrophils are round or oval– basophils, eosinophils, and megakaryocytes

show dense nuclear chromatin and roundednuclear lobes

– bone marrow: normal morphologic features inthe myeloid precursors to the myelocyte stage

• Electron microscopy: persistence ofnucleoli in the mature neutrophils with asingle oval nucleus -> altered andretarded nuclear maturation of themyeloid precursors

• No treatment is needed

• have good health• natural resistance to infection is

unimpaired

-END

Questions:• What is the treatment for Pelger-Huët anomaly?a. Corticosteroids b. Splenectomy c. Platelet transfusion

d. none

• Describe the nucleus of the neutrophil in heterozygous Pelger-Huëtanomaly.

a. spectacle-shape b. Single c. Eccentric d. bilobed, oval

• What is the gene affected in Pelger-Huët anomaly?a. DAF b. LBR c. MYH9 d. PIGA

• Heterozygotes have neutrophils with a predominance of bilobeddumbbell-shaped nuclei which are also described as what?

a. Pince-nez b. Rosette c. Oval d. Irregular

• The following are findings in homozygous Pelger-Huet EXCEPT:a. postaxial polydactyly b. short stature c.

Hyperkyphosis d. resistance to infection

ANSWERS

• D• A• B• A• D

Dohle Bodies• first described by H. Dohle in 1911 in

patients with scarlet fever

• remnants of free ribosomes or rough-

surfaced endoplasmic reticulum

Morphology

• small, oval inclusions in the peripheral

cytoplasm of polymorphonuclear

neutrophils

• stain pale blue with Wright stain

Dohle Bodies• are considered normal if they are

present only in small numbers

• If there are many neutrophils inthe bloodstream containing Döhlebodies, these can be referred toas toxic neutrophil.

Dohle Bodies• They are found in:

– Infective and inflammatory states

– severe burns

– Tuberculosis

– post chemotherapy

– pregnancy

Dohle Bodies

• More abundant in cats andhorses

Vacuoles• Vacuoles are vacuoles

• vacuoles appear as holes in thecytoplasm and are frequentlyfound in association with toxicgranulation.

• They are form by the ingestionand degradation of bacteria andare unevenly distributed.

•

Vacuoles• The occasional tiny single

"vacuole" present in thecytoplasm of one or twolymphocytes is always NOTsignificant.

• On the other hand, they areClinically significant whenassociated with toxicgranulation, degranulation orDohle bodies

Vacuoles• Found in

– Infection and Toxic effect of

ethanol.

– They are also found in Jordan's

anomaly

WHITE BLOODCELL

INCLUSIONBODIESBy: Elizes, Nicole Joy B.

Toxic granulationRefers to changes in granulocyte cells

seen on examination of theperipheral blood film of patients withinflammatory conditions.

Toxic granulations are abnormally large,dark coarse granules found ingranulocytes, particularly neutrophils.

Toxic Granulation• Morphology:

Increased granulation. Granulation ismore basophilic and larger thannormal.

• Found in:- Severe bacterial infection- Normal pregnancy- G-CSF and GM-CSF Therapy

- Patients with sepsis

Drumstick Represent the inactive X chromosome

of the female. The presence andfrequency of drumstick is related tothe number of X chromosome.

They do not occur in normal males, inindividuals with the testicularfeminization syndrome who arephenotypically female but genetically(XY) male, or in Turner’s syndrome(XO) females.

DrumstickMorphology:

Drumstick shaped nuclearappendage. ± 1.5 µm in diameter andattached to the nucleus by a filament.

Found in:- Neutrophils of females- Males with Klinefelter syndrome

Sessile Nodule• Morphology:

Inactive X chromosome found asnodule on neutrophils of females.

• Found in:- Neutrophils of females

Detached nuclearfragments

• Morphology:Detached nuclear material in cytoplasm.

• Found in: - Dysplastic granulopoiesis due to HIVinfection- Patients on anti cancer chemotherapy- Administraion of drug interfering withDNA synthesis, including chlorambucil,mycophenolate, mofetil and tacrolimus

Actin Inclusion• Found in: - Congenital abnormality associated

with anemia and grey skin

Large Granular Lymphocyte

• Morphology:Small eosinophilic granules in thecytoplasm of large lymphocytes

• Found in:Natural killer cellsLymphokine activated T cells

Mott Cells

• Morphology:Plasmacytoid lymphocyte with globularinclusions composed of immunoglobulin.

• Found in:Reactive changes in peripheral blood

Auer Rods• Morphology:

Small azurophil rods in the cytoplasm ofmyeloblasts and promyelocytes.

• Needle-shaped, pink-staining inclusion in thecytoplasm

• These inclusions contain enzymes such as acidphosphatase, peroxidase, and esterase and mayrepresent abnormal derivatives of cytoplasmicgranules.

Found in:Acute myeloblastic leukemiaMyelodysplastic syndromes

• The End..

Questions

• 1. These are plasmacytoid lymphocyte withglobular inclusions composed ofimmunoglobulin.

• A. large Granular lymphocyte• B. Auer Rod• C. Mott Cells• D. None• 2. What disease can be found in Large

granular lymphocyte?• A. Natural killer cells• B. Lymphokine activated T cells• C. Both• D. None

• 3. A needle-shaped, pink-staining inclusion inthe cytoplasm of myeloblasts andpromyelocytes containing azurophil rods.

• A. Auer Rods• B. Mott Cell• C. Large Granular Lymphocyte• D. None• 4. What disease can be found in mott cell?• A. chronic LGL lymphocytosis• B. Reactive changes in peripheral blood• C. aggressive LGL leukemia• D. None

• 5. These inclusions contain enzymes thatmay represent abnormal derivatives ofcytoplasmic granules.

• A. Acid Phosphatase• B. Peroxidase• C. Esterase• D. All the above

QUESTIONS

QUESTIONS:

1. In what condition/s can you find toxicgranulation?

A. Severe bacterial infectionB. Patients with sepsisC. HIVD. Both a and bE. Both b and c

QUESTIONS:

2. It refers to changes in granulocyte cellsseen on examination of theperipheral blood film of patients withinflammatory conditions?

A. InfectionB. SepsisC. Toxic granulationD. None of the above

QUESTIONS:

3. Which of the following findings inthe cytoplasm of granulocytes issuggestive of an inflammatory process ?

A. Toxic granulationB. Dohle bodiesC. Cytosolic vacuolationD. All of the above

QUESTIONS:

4. In what particular white blood cell canyou find toxic granulations?

A. EosinophilB. BasophilC. LymphocyteD. Neutrophil

QUESTIONS:

5. Which of the following inclusion bodiesare found in neutrophils of female?

A. DrumstickB. Detached nuclear fragmentsC. Sessile noduleD. Both a and bE. Both a and c

Questions• Give at least 3 condition where you

can find your Dohle bodies• This is a familial disorder in which

vacuoles are present in the cytoplasmof granulocytes, lymphocytes, andmonocytes.

• In relation to the formation ofvacuoles, this is often seen withprolonged exposure to drugs such asantimicrobial agents and alcohol orradiation.

CHRONIC MYELOCYTICCHRONIC MYELOCYTICLEUKEMIA(CML)LEUKEMIA(CML)

Maglanque, Carolina G.#18

CHRONIC MYELOCYTIC LEUKEMIA (CML)CHRONIC MYELOCYTIC LEUKEMIA (CML)•Chronic Granulocytic Leukemia (CGL).•Form of leukemia characterized by the increasedand unregulated growth of predominantly myeloidcells in the bone marrow and blood.•Resistance to apoptosis, abnormal signaling andadhesion.•9;22 chromosomal translocation(Philadelphiachromosome)•Peak age of 30-50.

EpidemiologyEpidemiology Exposure to ionizing radiation

Example:-People exposed to the atomic

bombings of Hiroshima• Philadelphia chromosome

Philadelphia chromosomePhiladelphia chromosome

Signs and SymptomsSigns and Symptoms Enlarged spleen Malaise, low-grade fever Gout Increase susceptibility to infection Anemia Thrombocytopenia with easy bruising Night sweats

DiagnosisDiagnosisComplete Blood CountPeripheral Blood Increase granulocytes of all types Normal or decrease erythrocytes Normal reticulocytes Presence of nucleated RBCs Normal or increase platelets LAP is decrease(<13)

DiagnosisDiagnosisB. Bone marrow aspiration and biopsy

Bone Marrow in CMLBone Marrow in CML

Bone Marrow in CMLBone Marrow in CML

DiagnosisDiagnosisC. Fluorescent In Situ

Hybridization(FISH) Philadelphia chromosome

- BCR/ABL fusion gene-TRITC (red) for BCR on ch 22, FITC (green) forABL on ch 9-If the BCR/ABL fusion gene is present, aYELLOWYELLOW fusion signal will appear

ClassificationClassificationChronic phase

- few blast in the blood and bonemarrow.- 3-4 years(without therapy)

ClassificationClassification Accelerated phase

- more blast in the blood and bonemarrow; fewer normal cells.-fatal within months

WHO criteria: 10–19% myeloblasts in the blood or bone marrow >20% basophils in the blood or bone marrow Platelets count <100,000, unrelated to therapy Platelet count >1,000,000, unresponsive to therapy Cytogenetic evolution with new abnormalities in addition to

the Philadelphia chromosome Increasing splenomegaly or white blood cell count,

unresponsive to therapy

ClassificationClassification Blast crisis

- terminal phase and clinically behaveslike an acute leukemia.- more than 30% of the cells in theblood or bone marrow are blast cells.- fatal within weeks.

Criteria: >20% myeloblasts or lymphoblasts in the blood or bone

marrow Large clusters of blasts in the bone marrow on biopsy Development of a chloroma (solid focus of leukemia outside

the bone marrow)

TreatmentTreatment Targeted therapy

- tyrosine kinase inhibitors Imatinib mesylate (Gleevac or Glivec)

- first line therapy Dasatinib ( Spyrcel)

-TK inhibitor that blocks several oncogenicproteins

Nilotinib ( Tasigna)-bind more tightly than imatinib to the Bcr-Ablabnormal fusion

Omacetaxine-administered subcutaneously .

Ponatinib-oral drug

TreatmentTreatmentChemotherapy

- stops the growth of the cell Hydroxyurea ( Hydrea)Stem cell transplant

- for patient who developed T315Imutation

TreatmentTreatmentSurgery Splenectomy

Biologic therapy/ Immunotherapy- uses the patient’s system to fightcancer.

PrognosisPrognosisDepends on the following: The patient’s age. The phase of CML. The amount of blasts in the blood or

bone marrow. The size of the spleen at diagnosis. The patient’s general health.Lowest risk group: 98 monthsMiddle group: 65 monthsHighest risk group: 42 months

Questions:

Questions:Questions: Philadelphia chromosome is characterized

by which translocation?A. 19;22 B. 9;22 C. 9;12

D.19;12 In CBC, what is the common findings for

granulocytes?A. Increase B. Decrease C.

Normal D. Absent Level of Leukocyte alkaline phosphatase in

CML.A. Increase B. Decrease C. Normal Classsified as terminal phase in CML. Chronic B. Accelerated C. Blastic D.

Refractory Stage of CML which is fatal within months.

A. Chronic B. Accelerated C. Blastic D.Refractory

Prepared by :Alejandro, Louie Carmela KimPutong, Ma. Fatima B.Mendoza, Maria Lady Lyn

ACUTE LEUKEMIAACUTE LEUKEMIA

Is a result of malignant transformation of a stem cell leading tounregulated proliferation and arrest in maturation at theprimitive blast stage.

Acute leukemia is a form of cancer that affects the white bloodcells. It can present in many forms such as Acute LymphocyticLeukemia (ALL), which is very common in children,especially 2-5 years of age; and Acute Myelogenic Leukemia(AML).

See video

ACUTE LEUKEMIA SUMMARY

Age : all ages (young and old)

Clinical onset : sudden

Course (untreated) : 6 months or less

Leukemic cells : immature >30% blasts

Anemia : prominent

Thrombocytopenia : prominent

WBC count : variable

Lymphadenopathy : mild

Splenomegaly : mild

Symptoms

low fever, anemia, pale skin, general ill feeling, easily bruised skin, and/or frequent nose bleedsor bleeding gums.

abdominal pain with an enlarged spleen, and infections with sores in the mouth.

Causes

unknown, but risk of contracting the disease increases with a family history, Down Syndrome,or other congenital disorders, identical twins, or exposure to toxic chemicals.

Diagnosis

The first indication of a problem is typically an observation of theaforementioned symptoms.

A physical exam with studies of the blood, bone marrow, or cerebral spinalfluid should follow to confirm the diagnosis.

In some cases certain x-rays or CT scans may also be used to confirm thediagnosis.

Treatment

blood or platelet transfusions, anticancer medication and radiation treatments. A bone marrow transplant may be necessary in some cases. A physician may

also prescribe cortisone drugs and pain relievers (except aspirin) to help apatient deal with symptoms.

Laboratory diagnosis:Laboratory diagnosis:

Increased number of immature cells in the bone marrow including blast,promeolocytes , promonocytes

The term used to described the coexistence of immature and mature cell formsis “hiatus leucaemicus”

Identification of the cell lineage of the leukemic cells.

Peripheral blood:Peripheral blood: Anemia- normocytic,normochromic Decreased platelets Variable WBC count

Classification of the degree of peripheralinvolvement: Leukemic- increased WBC due to blast Subleukemic- blast without increased WBC Aleukemic- decreased WBC with no blast.

Acute Lymphoblastic leukemiaAcute Lymphoblastic leukemia

Is primarily a disease of childhood (2 and 10years) and rare in adult

is a form of leukemia, or cancer of the whiteblood cells characterized by excess lymphoblast

Malignant, immature white blood cellscontinuously multiply and are overproduced inthe bone marrow

causes damage and death by crowding outnormal cells in the bone marrow, and byspreading to other organs

Signs and symphtomsSigns and symphtoms fatigue, pallor, fever, weight loss, irritability, anorexia, infection, bleeding, and bone pain

Types of ALL Most common cellL1 children • small with fine or

clumpedhomogenous nuclearchromatin

• absent or indistinctnucleoli

L2 adult • large andheterogenous withvariable nuclearchromatin andprominent nucleoli

• nucleus is irregularL3 is a very rare

form of ALL

• is large, with fine,homogenous nuclearchromatin containingprominent nucleoli

• nucleus is regularoval to round

Age , WBC count and cell type(mostimp.)

Chromosomal translocation- thestrongest predictor of adverse treatmentoutcome for children and adult

Philadelphia chromosome(t(9;22))-is anindicator of adverse effects

(t(9;21))-marker in childhood with ALLpatient

Early pre-B cell(most commonpresence of surface immunoglobulin)

Mature pre-B cell( presence ofcytoplasmic immunoglobulin)

B cell T cell

DiagnosisDiagnosis complete blood count blood smears bone marrow biopsy

TREATMENTTREATMENT Methotrexate Chemotherapy radiation therapy

QuestionsQuestions How can you differentiate the

immature pre-B cell from mature pre-B cell?

a)Presence of surface immunoglobulinb)Presence of cytoplasmic

immunoglobulinc)Bothd)Neither

How can you differentiate the maturepre-B cell from immature pre-B cell?

a)Presence of surface immunoglobulinb)Presence of cytoplasmic

immunoglobulinc)Bothd)Neither

What is the most common treatmentfor ALL?

a)Chemotherapyb)Radiotherapyc)Methotrexated)Aspirin

What is the strongest predictor ofadverse treatment outcome forchildren and adult?

a)Philadelphia chromosomeb)(t(9;21))c)Chromosomal translocationd)A and be)A and c

ACUTE MYELOIDACUTE MYELOIDLEUKEMIALEUKEMIA

(AML)(AML)

Prepared by : Putong, Ma Fatima B.Prepared by : Putong, Ma Fatima B.MT0831MT0831

Acute myeloid leukemia• Acute myeloid leukemia (AML) is one of four types of

leukemia.• The most common family of leukemia in children younger

than 1 year of age. It is rare in older children andadolescents, but a second incidence peak occurs at 40 yearsof age.

• AML is cancer of the blood-forming tissue (bone marrow).• Normal bone marrow produces red cells, white cells, and

platelets.• AML causes bone marrow to produce too many immature

white blood cells (blast cells).• See Video

Acute Myeloid LeukemiaSee Video

Acute myeloid leukemia• Suppresses normal blood cell production.

– Anemia, leucopenia, thrombocytopenia– Acute in which the onset is usually rapid, the

disease is very aggressive, and the cells involvedare usually poorly differentiated with many blasts.

• characterized by clonal proliferation ofmyeloid precursor cells with reduced capacityto differentiate into more mature cellularelements.

• results in accumulation of leukemic forms inbone marrow, peripheral blood, and othertissues.

ACUTE MYELOIDLEUKEMIA

--the myeloblast is alarge blast with amoderate amount ofcytoplasm, fine laceychromatin, andprominent nucleoli;10-40% ofmyeloblasts containAuer rods

Myeloblasts with Auer Rod

Classification of Acute Myeloid LeukemiasAML withRecurrentAbnormal

Karyotypes

AML withDysplasia

AML as a resultof previous

therapy-relatedMyelodysplasias

AML nototherwise

Categorized

Acute Leukemiaof Ambigiuos

Lineage

•AML witht(8;21)(q22;q22)

•AML with inv(16) 9p13q22)or t(16;16)(p13;q22)

•AML witht(15;17)(q22;q12) (APL)

•AML with11q23

•AML occurringafter a diagnosisof amyeloproliferativeormyelodysplasticdisease

•AML withhistory ofalkylatingagent exposure

•AML withtopoisomeraseexposure

•AML withotherexposuressuch asradiation

•AML with minimallydifferentiated

•AML withoutmaturation

•Acutemyelomonocyticleukemia

•Acutemonobalstic/monocytic leukemia

•Acute erythroidleukemia

•AcuteMegakaryocyticLeukemia

•Acute BasophilicLeukemia

•Acutebilineageleukemia

•Acutebiphenotypicleukemia

FAB Classification (Summary)M0: minimally differentiatedM1: without maturationM2: with maturation.M3: promyelocyticM4: myelomonocyticM5: monoblasticM6: erythroleukemiaM7: megakaryoblastic

ACUTE MYELOID LEUKEMIA(M0)

M0•Minimally differentiatedAuer Rods (absent)•No cell maturation•Negative in :

MyeloperoxidaseSudan Black B

ACUTE MYELOID LEUKEMIA(M1)

M1•“Myeloblastic without maturation”

•The bone marrow shows ≥ 90% blasts and < 10% promyelocytes•The disease occurs in older adults•Blasts same with M0•Auer rods (usually Positive) for MYELOPEROXIDASE orSUDAN BLACK B dye.•No specific recurrent chromosome abnormalities

MYELOBALSTIC WITH MATURATION

M2

•“Myeloblastic with maturation”

•The bone marrow shows 30-89% blasts and > 10%promyelocytes;•Auer rods and other aspects are present•Monocytic line –increased•It has a less favorable prognosis

ACUTE PROMYELOCUTIC LEUKEMIA (M3)

M3•“Hyper granular Promyelocytic”

•This form of AML has a bone marrow with >30% blasts•Is more virulent than other forms•Occurs with a medium age of 39•WBC count – decreased (low)•Treatment causes a release of the granules and may send the patient intodisseminated intravascular coagulation and subsequent bleeding

M3m – Hypogranular Promyelocytic

ACUTE MYELOMONOCYTIC LEUKEMIA (M4)

M4

•“Acute Myelomonoblastic Leukemia”

•Both myeloblasts and monoblasts are seen in the bonemarrow and peripheral blood•Infiltration of extramedullary sites is more commonthan with the pure granulocytic variants•WBC –elevated•Monocytic cells constitute atleast 20% of all marrowcells.

ACUTE MONOCYTIC LEUKEMIA (M5)

M5• “Acute Monoblastic Leukemia”

• >80% of the nonerythroid cells in the bone marrow aremonocytic•There is extensive infiltration of the gums, CNS, lymph nodesand extramedullary sites•This form is further divided into•M5A - Poorly differentiated (>80% monoblasts)•M5B - Well differentiated (<80% monoblasts)

ERYTHROLEUKEMIA (M6)

M6•“Erythroleukemia”

•Di Guglielmo’s Syndrome•This is rare and is characterized by a bone marrow having a predominance oferythroblasts•It has 3 sequentially morphologically defined phases;•Preponderance of abnormal erythroblasts•Erythroleukemia – there is an increase in both erythroblasts and myeloblasts•Myeloblastic leukemia – M1, M2, or M4•Anemia is common

ACUTE MEGAKARYOBASTIC LEUKEMIA (M7)

M7

Signs and Symptoms•• AnemiaAnemiaweakness and easy fatigue•• NeutropeniaNeutropeniainfections•• ThrombocytopeniaThrombocytopeniagingival bleeding, ecchymoses, epistaxis, menorrhagia

These three give rise to clinical findings :• Pallor• Fatigue• Shortness of breath on exertion• Easy bruising• Petechiae• Bleeding in the nose or from the gums• Prolonged bleeding from minor cuts• Recurrent minor infections or poor healing of minor cuts• Loss of appetite or weight loss• Mild fever

Treatments for AMLThere are four general types of therapy

ChemotherapyPhase One – Remission induction therapyPhase Two – Remission continuation therapy

Bone marrow transplant Radiotherapy Immunotherapy

Prognosis for AML• Survival rates greatly improved over past 25 years.• Remission rates inversely related to age.• Dependent upon several factors.

– Age– White blood cell count– Presence of translocations in bone marrow

QUESTIONS

1. What FAB classification where monocyticline increases?

a. M2b. M3c. M4d. M1

• 2. What FAB classification is associated w/t(16;16) or inv(16)(p13q22)?

a.M4b.M3c.M2d.M1

3.What do you call the large blast with amoderate amount of cytoplasm, fine laceychromatin, and prominent nucleoli whichcontains 10-40% Auer rods in AML?

a. Promyeloblastb.Myeloblastc. Promonoblastd.Prokaryoblast

4.What form of AML has a bone marrow with>30% blasts and it is more virulent than otherforms?

a. M3b. M4c. M5d. M2

5. What form of AML wherein infiltration ofextra medullary sites is more common than withthe pure granulocytic variants?

a.M4b.M3c.M5d.M2

Chronic LymphocyticLeukemia

CLL/ Chronic Lymphoid Leukemia

# 24Ong, TanyaYuinMT0831Dr. Asilo

Understanding CLL• Chronic lymphocytic leukemia (CLL) is one of the four

main types of leukemia.• Common in people 60 years and older.• Children do not get CLL.• CLL is the most common type of leukemia in North

America and Europe.• It is characterized by accumulation of small lymphoid

cells in the peripheral blood, bone marrow, & lymphoidorgans.

• They are derived from recirculating CD 5+, IgM+, IgD+B cells which are normally present in the peripheralblood

• CLL has a peripheral blood (lymphocytosis > 10 x 10⁹/ L)

• CLL starts with a change (mutation) to theDNA of a single cell called a lymphocyte.

• The change occurs in a B lymphocyte but othercells transforming from normal to leukemicmay have features of a T lymphocyte or a NKcell.

• Over time, the CLL cells multiply and replacenormal lymphocytes in the marrow and lymphnodes.

• Presence of “Smudge Cells” or bare nuclei canbe frequently found.

CommonTargetCell ofCLL

Othertarget cells

Healthy NormalLymphocytes

Chronic LymphocyticLeukemia Cells

Symptoms and Signs• CLL signs and symptoms usually develop

slowly.• No known cause of CLL.• Some people with CLL do not even have any

symptoms.• Many of the signs and symptoms of CLL are

more likely to be caused by other illnesses.• Specific blood tests and bone marrow tests

are needed to make a diagnosis.

Some signs and symptoms ofCLL include :

• Tiring more easily. People mayhave less energy due to fewerhealthy red cells and more CLLcells.

• Shortness of breath duringnormal activities. This is due tofewer healthy red cells andmore CLL cells.

• Swollen lymph nodes or spleen.High numbers of CLL cells cangather in the lymph nodes orspleen as the number of

CLL cells grows.

• Infections. People with a very high numberof CLL cells building up in the marrow mayhave repeated infections of the skin orother parts of the body.

• Weight Loss. Some people with CLL loseweight because they eat less and/orbecause they are using more energy.

*Some patients may also have othersymptoms, such as aches, fever

or night sweats.

Prognosis• Late stage patients usually have a more progressive

disease.• Significant subset of early stage eventually progress by --refractory to treatment --infectious Complications --autoimmune complications• Stage Definition 0 Absolute lymphocytosis >15 x 109/L. 1 Stage 0 + enlarged lymph nodes. 11 Stage 0 + liver or/and spleen ↑ ±

adenopathy. 111 Stage 0 + anemia ±organomegally or

adenopathy. 1V Stage 0 + thrombocytopenia ±

organomegally or adenopathy.

Notes to consider:• Average survival of the patient is 5 years but may

take an aggressive course with only 1-2 years ofsurvival.

• CLL is a Highly Variable disorder.• Not associated with radiation/ exposure to

occupational hazard.• Has the strongest tendency for familial incidence.• May results to altered humoral immunity resulting

from suppression of all classes ofimmunoglobulins, leading tohypogammaglobulinemia.

• May develop autoimmune disorders and produceautoantibodies to neutrophils, platelets, or RBCs(AIHA)

READY??READY????

Question # 1

1.) What do you call a “ Bare Nuclei” ?

A. Smudge Cells B. Vacuoles C. Pelger-Huet Cells D.Dohle Bodies

Question # 2

2.) What is the average survival of apatient with CLL?

A. 10 years B. 15 years C. 5 years D.2 years

Question # 3

3.) The most common target cell of theChronic Lymphocytic Leukemia.

A. T-Cell B. B-Cell C. NaturalKiller CellD. Lymphocyte Progenitor Cells

Question # 4

4.) Where is CLL most commonlyfound?

A. Africa B. Southeast Asia C. North AmericaD. India

Question # 5

5.) Which of the following is not a Sign& Symptoms of a CLL?

A. Anorexia B. NightSweatC. Swollen Lymph Nodes D. Fever

Hodgkin’s DiseaseBalasta, DarwinBasa, AaronnGiorla, Jake

∗ Hodgkin's lymphoma is a malignant disordercharacterized by painless, progressive enlargement oflymphoid tissue, usually first evident in cervical lymphnodes. Characterized by splenomegaly and thepresence of Reed-Sternberg cells in lymphoid tissue.

∗ The nomenclature of HL, formerly called Hodgkin'sdisease, is little changed from that of the Ryeconference.

∗ The hallmark of HL is the Hodgkin Reed–Sternberg(HRS vs. RS) cell.

∗ Accurate diagnosis and staging are critically importantfor successful treatment.

∗ Clinical staging provides strong predictor of prognosisand selection of a specific treatment regimen

Hodgkin's Lymphoma

∗ treatment of Hodgkin's disease is based on solidprinciples of radiobiology and chemotherapy thatserve as a model for all other treatment regimens(treatment has become very successful).

∗ untreated, 90% of patients with Hodgkin's disease diewithin 2-3 years. 80% or more are now curable withmodern therapy.

∗ one of the best examples of a malignancy that can becured if diagnosed and managed well

∗ Its cause remains unknown.

∗ Hodgkin's disease usually presents as anenlargement of the lymphoid organs,frequently accompanied by systemic symptomssuch as∗ fever∗ weight loss∗ Fatigue

∗ unique in several respects.∗ Unlike the non-Hodgkin's lymphomas, the

tumor masses∗ largely comprise normal reactive T cells∗ usually CD4 predominant, not a clone of

malignant lymphocytes.

DIAGNOSIS &CLASSIFICATION

∗ Reed-Sternberg cell - which is a largebinucleated, multinucleated or mononuclear(Hodgkin) cell with each nucleus bearing a verylarge inclusion-like nucleolus∗ closely resembles a macrophage-like cell than a

lymphocyte.∗ Immunophenotyping studies : monoclonal B cells

derived from germinal center cells∗ These neoplastic cells appear in an

immunoproliferative background containingvariable numbers of lymphocytes, histiocytes,eosinophils and plasma cells∗ Relative number may vary from very high to very

low, but always make up < 2% of the apparenttumor load.

∗ difficult to study because they are present in smallnumbers and are difficult to separate from thesurrounding infiltrate of reactive cells.

∗ mechanism and their precise role in the malignantprocess remain obscure

REED-STERNBERG CELLS &LYMPHOCYTIC/HISTIOCYTIC

CELLS

Reed-Sternberg cell in a marrow smear(Wright's stain), showing the mirror nucleiwith prominent nucleoli.

Lymph node section from a patient withHodgkin's disease, showing a classic Reed-Sternberg cell

- Lymphocyte-Predominant Hodgkin Lymphoma- Classical Hodgkin Lymphoma

Type of Hodgkin’s Disease

Lymphocyte-Predominant HodgkinLymphoma

Is the least common form of HD and accounts for fewerthan 1% of all HD cases. The disease affects moremen than women, and it tends to occur in individualswho are older, HIV-positive, or residents of non-industrialized nations. The disease usually arises in thelymph nodes of the abdomen and pelvis (hip region),while sparing the nodes of the neck and underarms.LDHD is an aggressive form of HD, and most patientsare diagnosed with advanced-stage disease.

Divided into two subtypes:- Nodular Lymphocyte-Predominant Hodgkin lymphoma- Diffuse lymphocyte-Predominant Hodgkin Lymphoma

Nodular Lymphocyte- Predominant Hodgkinlymphoma

∗ Nodular lymphocyte predominant Hodgkin's disease(nLPHD) accounts for about 5% of all HD cases. It is threetimes more common in men than in women, and it primarilyaffects young adults in their third through fifth decades of life.Most patients (75%) are diagnosed at an early stage (e.g.,Stage 1), and a majority (by some reports up to 90%) respond totherapy with a complete response. The peripheral lymph nodes(underarm, neck, ear, and groin nodes) are frequently involved,whereas the deep, intrathoracic (within the trunk) nodes arespared.

∗ Classic Reed-Sternberg cells are not seen or are veryuncommon in patients' tissue samples. Instead, large, circularmeshworks of cells take over the lymph nodes. These nodulescontain unusual lymphocytes and histiocytes known as "L & Hcells" or "popcorn cells," as well as B-cells and scattered T-cells.The T-cells may be distributed in a nodular (knot-like)arrangement within the tissues.

∗ L & H (Popcorn) cells

∗ In its early stages, LPHD is characterized bylymphocytes that are mostly B-cells; however,in LPHD's later stages, T-cells may surpass B-cells in number. LPDH has a slow clinicalcourse. Late relapses are common, but theyusually do not affect survival; survival isfavorable even among patients with recurrentdisease. Patients with this diagnosis are morelikely than other HD patients to develop non-Hodgkin's lymphomas (NHLs), typically largecell lymphoma of B-cell type.

Diffuse Lymphocyte-PredominantHodgkin Lymphoma

∗ is an extremely rare form of Hodgkin'sdisease. It not as well defined as nLPHD.In dLPHD, there are no circular meshworksof cells, and B-cells are missing. Instead,the lymphatic tissue is dominated byspread out arranged T-cells.

Classical Hodgkin Lymphoma

∗ Comprises a group of heterogenous germinal centercell disorders

∗ Reed-Sternberg cells, large lymphoid cell with abilobed nucleus or two nuclei with prominenteosinophilic nucleoli and abundant cytoplasm, arethe diagnostic neoplastic cells

∗ Can be divided into four subtypes depending on thearchitectural features, composition of the reactivebackground, and relative proportion of neoplasticcells:

- Nodular Sclerosis Hodgkin’s disease - Mixed Cellularity Hodgkin’s disease - Lymphocyte Rich Hodgkin’s disease - Lymphocyte Depleted Hodgkin’s disease

Classical HodgkinSubtype Diagnostic Feature

Nodular Sclerosis Broad collagen bands with thickeningof the nodal capsule and lacunar cells

Mixed Cellularity

Reed-Sternberg cells are scatteredamong the diffuse backgroundproliferation of small lymphocytes,histiocytes, eosinophils, neutrophilsand plasma cells

Lymphocyte Rich Background cellularity is lessheterogenous

Lymphocyte DepletedScarcity of cells of reactivebackground, and neoplastic Reed-Sternberg cells

Nodular Sclerosis Hodgkin Lymphoma

Mixed Cellularity Classical Hodgkin Lymphoma

Lymphocyte Rich Hodgkin Disease

Lymphocyte Depleted Hodgkin Lymphoma

∗ most common presentation of a Hodgkin's disease patientis the appearance superficial lymph node or group ofnodes in a young adult.

∗ first appearance in a single node group a healthyindividual make it difficult to distinguish from thelymphadenopathy associated with an infectious process.

∗ Hodgkin's nodes can on occasion wax and wane in thesame way as those associated with an infectious process.

∗ The diagnosis is obviously easier when the mass is large,presents in more than one area, and is associated withsystemic symptoms (B symptoms) such as:∗ night sweats, fever, weight loss, pruritus, or fatigue.

CLINICAL FEATURES

∗ most common areas of involvement in young patients :∗ cervical, axillary, and mediastinal nodes

∗ incidence of Hodgkin's disease has been linked toseveral factors, including∗ environment, social status, infectious agents, and genetic

propensity.∗ slightly more common in men, occurred as clustered

cases in families, communities, and schools.∗ Patients who have had infectious mononucleosis or

have a positive test for prior EBV infection have athreefold increased risk for developing the disease.

∗ Accurate staging is extremely important∗ natural history of the disease suggests that it arises in a single site

and then spreads∗ primary objective of staging is to determine the current location of all

the disease in the patient in order to plan a treatment that willaddress each of the involved areas and all contiguous sites ofpossible spread.

STAGING

Staging System for Hodgkin’s DiseaseStage Description Example

I Involvement of a single lymphoid region or a singlenonlymphoid site (IE)

Nodes on one side of the neck only

II Involvement of two or more regions on the sameside of the diaphragm

Nodes in the neck and chest

III Involvement of two or more regions on both sidesof the diaphragm

Nodes in the neck and retroperitoneum orthe spleen

IV Spread of disease from lymphoid sites tononlymphoid organs, involvement of more than onenonlymphoid organ

Nodes in the chest and infiltration of themarrow and lung

B Each stage is further modified as B by thepresence of fever, weight loss, or night sweats

Nodes in the retroperitoneum and groin withfever and night sweats (IIB)

History & Physical Examination∗The history should document the timingand characteristics of the onset of thedisease and the presence of systemic (B)symptoms∗physical examination, all portions of thelymphoid organs should be carefullyexamined∗Special attention should be paid

∗ the oral pharynx (Waldeyer's ring), thepopliteal and epitrochlear regions, thesubclavicular regions, common axillary,anterior and posterior cervical, andinguinal regions.

Biopsy∗biopsy of the principal tumor mass oraccessible enlarged node should be done,and the results reviewed with anexperienced hematopathologist.

Radiologic Studies∗routine chest x-ray will reveal patients with bulky mediastinal disease∗computed tomography (CT) scan accurately detect lymph node involvement ofthe mediastinum and abdominal nodes∗bipedal lymphangiography can be performed to evaluate retroperitoneal nodesof the lower abdomen.∗magnetic resonance image (MRI)Laboratory Studies∗laboratory evaluation of the Hodgkin's disease patient should include a

∗ complete blood count, tests of renal and liver function(ALP, LDH), serum calcium,and bilateral iliac crest marrow aspirates and biopsies.

∗studies of iron supply if anemia is present∗Abnormalities of the granulocyte and lymphocyte counts.∗guided needle biopsy of the lesion or laparoscopic liver biopsy if abnormalliver chemistries or a suspicious lesion on CTTherapy∗both radiotherapy and chemotherapy can cure Hodgkin's disease

THANKS!! ^_^

NAVAL, RICA NELL A.#23

DE LEON, LYSANDER LINUS D.# 9

MULTIPLEMYELOMA

MULTIPLE MYELOMA is….

*neoplastic proliferation of plasma cells, primarilyoccurring in the bone marrow

*plasma cell cancer characterized bymonoclonal gammopathy and multifocaldestructive bone lesions throughout the skeleton* also called plasma cell myeloma or Kahler'sdisease

INCIDENCE rare under age 40 50-75 yrs. (peak of incidence.) mean age at the time of diagnosis is 62 years equal sex distribution second most prevalent blood cancer (10%)

after non-Hodgkin's lymphoma. 1% of all cancers and 2% of all cancer deaths

PATHOGENESIS Chromosomal and gene damages loss of

control on antibody production Clonal proliferation of malignant plasma cells –

BONE MARROW May synthesize complete Ig or an L-chain subunit

-IgG --- 50% of patients-IgA --- 25%

Decreased ability to synthesize normal Ig againstspecific ags

Chromosome 13,14 abnormalities --- 50%patients

SYMPTOMS Bone pain -- most common symptom Infection – most common cause of death Neurologic symptoms Renal failure – 50% of cases Anemia (NC,NC) Bleeding

Conditions associated with Mproteins

Stable production Monoclonal gammopathy of undetermined significance Smouldering multiple myeloma

Progressive production Multiple myeloma (IgG, IgA, free light chains, IgD, IgE) Plasma cell leukaemia; Solitary plasmacytoma of bone Extramedullary plasmacytoma Waldenström's macroglobulinaemia (IgM) Chronic lymphocytic leukaemia; Malignant lymphoma Primary amyloidosis Heavy chain disease

Non neoplastic conditions: Cirrhosis,Sarcoid,CaColon/Breast

Multiple Myeloma

LABORATORY FINDINGSPeripheral Blood Smear-normochromic, normocytic anemia-normoblasts may be present-leukocyte count is slightly decreased, normal, or slightlyincreased-platelet count is usually normal, but may be decreased

Most striking feature: marked degree of rouleau formation

Peripheral Blood Smear

LABORATORY FINDINGS

Bone marrow-presence of plasma cells or myeloma cells (less than 1% to over 90%)

Serum protein electrophoresis-shows an M-spot (homogeneous band in the gamma- or beta-region)-hypogammaglobulinemia (when only light chains are produced by theneoplastic plasma cells)

Immunoelectrophoresis-shows that monoclonal protein is:

*IgG in over half the cases*IgA in about one-fifth*IgD in less than 1%*IgE very rarely

Bone Marrow Aspirate (Normal)

Bone Marrow Aspirate (MM)

Bone Marrow Aspirate (MM)

LABORATORY FINDINGS-5% of myeloma proteins are cryoglobulins

(proteins that precipitate from cooled serum andredissolve on warming)

-Bence Jones protein-Myeloma kidney—due to excretion of light chains-Amyloidosis (10-15% of cases) -- may be a factor

in the renal failure.

LABORATORY FINDINGS Other Findings:-serum monoclonal immunoglobulin-radiologic evidence of lytic bone lesions

(osteoclastic activity, hypercalcemia andneurologic changes)

-Serum globulin is usually increased-elevated ESR

Laboratory DiagnosisHelpful Mnemonics:

•[C] Calcium elevation in the blood S.Calcium >10.5 mg/l or upper limit ofnormal{8.6-10 mg/l}•[R] Renal insufficiency S. Creatinine > 2mg/dl{0.6-1.3 mg/dl}•[A] Anemia Hemoglobin < 10 g/dl or 2 g <normal{12-18g/dl}•[B] Lytic bone lesions or osteoporosis

Lytic lesions(Punched out lesions) on XRay.

Vertebral collapse secondary toosteoporosis/pathological fracture

1.Normal Plasma 2.Polyclonal Hyperglobulinemia3.Monoclonal Spike4.Bence Jones proteins in urine

Bence Jones Protein

MULTIPLE MYELOMA

DIAGNOSTIC CRITERIA: ALL 3 REQUIRED

1.Monoclonal plasma cells in the bone marrow > 10% and/or presence of a biopsy-proven plasmacytoma

2.Monoclonal protein present in the serum and/or urine*

3.Myeloma-related organ dysfunction (1 or more)• [C] Calcium elevation• [R] Renal insufficiency• [A] Anemia Hemoglobin• [B] Bone lesions or osteoporosis

*Non-secretory Multiple myeloma

Differential Diagnosis

MGUS AsymptomaticMultiple Myeloma

Symptomatic MultipleMyeloma

Serum M protein <30 g/L Serum M protein >30 g/L M protein in the serumor urine

Clonal † bone marrowplasmacytosis <10%

Clonal bone marrowplasmacytosis >10%

Clonal bone marrowplasmacytosis orplasmacytoma

No other B celllymphoproliferativedisorder

No related organ andtissue impairment

Related organ andtissue impairment

No related organ andtissue impairment

STAGING International Staging System Durie-Salmon staging system

STAGINGInternational Staging System

Stage I: β2-microglobulin (β2M) < 3.5 mg/L,albumin >= 3.5 g/dL

Stage II: β2M < 3.5 mg/L and albumin <3.5 mg/dL; or β2M 3.5 mg/L - 5.5 mg/Lirrespective of the serum albumin

Stage III: β2M >= 5.5 mg/L

STAGINGDurie-Salmon staging system

Stage I: all of Hb > 10g/dL normal calcium Skeletal survey: normal or single plasmacytoma or

osteoporosis Serum paraprotein level < 5 g/dL if IgG, < 3 g/dL if IgA Urinary light chain excretion < 4 g/24h

Stage II: fulfilling the criteria of neither I nor III Stage III: one or more of

Hb < 8.5g/dL high calcium > 12 mg/dL Skeletal survey: Three or more lytic bone lesions Serum paraprotein > 7g/dL if IgG, > 5 g/dL if IgA Urinary light chain excretion > 12g/24h

Stages I, II, and III of the Durie-Salmon stagingsystem can be divided into A or B depending onserum creatinine:

A: serum creatinine < 2 mg/dL (< 177 umol/L)B: serum creatinine > 2 mg/dL (> 177 umol/L)

PROGNOSIS 62 months for stage 1 disease 45 months for stage 2 disease 29 months for stage 3 disease.

Chromosome 13 abnormalities – POORPROGNOSIS

TREATMENT Initial therapy- depends on the patient’s age- high-dose chemotherapy with hematopoietic

stem-cell transplantation: patients under the age of65

- Autologous stem cell transplantation: thetransplantation of a patient’s own stem cells afterchemotherapy (most common type of stem celltransplantation for multiple myeloma)

- Allogeneic stem cell transplantation --transplantation of a healthy person’s stem cells intothe affected patient (available to a small percentageof patient)

- Patients over age 65 -- chemotherapy withmelphalan and prednisone

Thank you for listening

QUESTIONS

QUESTIONS1. All of the following are symptoms associated

with multiple myeloma EXCEPT…a. Weakness, Fatigueb. Spinal cord compressionc. Normocytic, hypochromic anemiad. Hypercalcemia

QUESTIONS2. Abnormalities with which chromosome is

associated with multiple myeloma with POORPROGNOSIS?a. Chormosome 15b. Chromosome 20c. Chromosome 13d. Chromosome 8

QUESTIONS3. Which of the following statements is TRUE

about multiple myeloma?a. MM is a neoplastic proliferation of plasmacells, primarily occurring in the bone marrowb. plasma cell cancer characterized by monoclonal gammopathy and multifocaldestructive bone lesions throughout the skeletonc. Eitherd. Neither

QUESTIONS4. Peak of incidence for multiple myeloma occurs

betweena. 0-10 years oldb. 20-30 years oldc. 50-75 years oldd. 35-40 years old

QUESTIONS

5. Another term for Multiple Myeloma is…a. plasma cell myelomab. Kahler’s diseasec. eitherd. neither

Questions1.) Cause of recurrent infection of a patient withmultiple myeloma

a.) neutropeniab.) Waldenström's macroglobulinaemiac.) renal impairmentd.) M protein

Questions2.) Which of the following is true in the diagnosisof Multiple Myeloma

a.) Serum M protein >30 g/Lb.) No related organ and tissue impairmentc.) Serum M protein <30 g/L

d.) Calcium elevation in the blood

Questions3.) What causes hypercalcemia in a patient withmultiple myeloma?

a.) neutropeniab.) renal impairmentc.) OFA secretion of Myeloma cellsd.) none of the above

Questions3.) Laboratory procedures done in the diagnosis ofmultiple myeloma:

a.) Blood chemistry: calcium determinationb.) Imaging testsc.) bothd.) neither

Questions4.) True or false: Multiple myeloma could be ruledout if there is an absence of M proteins in thepatients serum, even if the common symptoms arepresent.

Questions5.) What causes Lytic bone lesions in a patientwith multiple myeloma?

a.) Osteoblastsb.) Osteocytesc.) Bone Macrophagesd.) neither

NON- HODGKIN’S LYMPHOMA

Non-Hodgkin’s Lymphomas

non-Hodgkin's lymphomas (NHLs) are aheterogeneous group of disorders characterized bymalignant proliferation of B or T lymphocytes. Froma clinical standpoint, lymphomas generally presentas SOLID TUMORS of the lymphoid system

type of cancer that originates in a subset of whiteblood cells called lymphocytes. lymph nodes Spleen tonsils, thymus Lymphatic tissue

Hodgkin's vs. non-Hodgkin's lymphoma:What's the difference?

Hodgkin’sLymphoma

Non Hodgkin’slymphoma

-Less common -more common- Reed-Sternberg cell -no Reed-Sternberg

cell-Young people (20-30)Older people (55 andup)

-risk increases with age(60’s)

Reed-Sternberg cell

Simplified schema of Hematopoetic Cancers

Myeloid

Lymphoid

Acute and chronic

Myeloid‘Leukemias’

LymphomasHodgkins (30%)

Non Hodgkins(70%)

WBC

RBC

Platelets

B Cells

T cells

NHL: Epidemiology

85% are B cell type and 15% are T celltype

5th most frequently diagnosed canceroverall for both males and females

males > females incidence

NHL increasing over time Hodgkin lymphoma stable

Mechanisms of lymphomagenesis

Genetic alterations Infection Antigen stimulation Immunosuppression

NHL : Etiology

cause of NHL is unknown but substantialevidence suggests:

viral cause (human T-cell leukemia-lymphoma virus, Epstein-Barr virus,hepatitis C virus, HIV)

Helicobacter pylori infection mucosa-associated lymphoid tissue (MALTlymphoma)

immunosuppression, AIDS, primaryimmune disorders

Risk factors for NHL

immunosuppression orimmunodeficiency

connective tissue disease family history of lymphoma infectious agents ionizing radiation

NHL:Pathophysiology

Most (80 to 85%) NHLs arise from Bcells; the remainder arise from T cells ornatural killer cells

Classification

Rappaport classification Lukes-Collins classification International Working Formulation

based almost entirely on morphologic criteria Revised European American Classification

(REAL) WHO classification, 2000 (most recent)

NHL: WHO ClassificationB-cell neoplasms T- and NK-cell neoplasms

Precursor B-cell neoplasm Precursor T-cell neoplasmPrecursor B-lymphoblastic leukemia/lymphoma

(precursor B-cell acute lymphoblastic leukemia)

Precursor T-lymphoblastic lymphoma/leukemia

(precursor T- cell acute lymphoblastic leukemia)

Mature (peripheral) B-cell neoplasms Mature (peripheral) T-cell neoplasmsB-cell chronic lymphocytic leukemia/small

lymphocytic lymphoma

T-cell prolymphocytic leukemia

T-cell granular lymphocytic leukemia

B-cell prolymphocytic leukemia Aggressive NK-cell leukemia

Lymphoplasmacytic lymphoma Adult T-cell lymphoma/leukemia

Splenic marginal zone B-cell lymphoma (with

or w/o villous lymphocytes)

(human T-cell lymphotropic virus type I positive)

Extranodal NK/T-cell lymphoma, nasal type

Hairy cell leukemia Enteropathy type T-cell lymphoma

Plasma cell myeloma/plasmacytoma Hepatosplenic gammadelta T-cell lymphoma

Extranodal marginal zone B-cell lymphoma of

mucosa- associated lymphoid tissue type

Subcutaneous panniculitis-like T-cell lymphoma

Mycosis fungoides/Sezary syndrome

Nodal marginal zone B-cell lymphoma (with or

w/o monocytoid B cells)

Anaplastic large cell lymphoma, T/null-cell,

primary cutaneous type

Follicular lymphoma Peripheral T-cell lymphoma, not otherwise

Mantle cell lymphoma

Diffuse large B-cell lymphoma

characterized

Angioimmunoblastic T-cell lymphoma

Mediastinal large B-cell lymphoma

Primary effusion lymphoma

Anaplastic large cell lymphoma, T/null-cell,

primary systemic type

Burkitt's lymphoma/Burkitt's cell leukemia

WORKING FORMULATION Clinically very useful and practical Divides lymphomas into : 1. Low grade 2. Intermediate grade and 3. High grade NHL

based on aggressiveness Based on morphology (Architecture

and Cell size)

Low grade /Indolent NHL Are INCURABLE

Intermediate /High Grade Are more “Aggressive” but potentially

CURABLE!

NHL: Diagnosis

immunophenotyping (flow cytometry) andcytogenetics

Bone Marrow Biopsy CT scan of chest, abdomen and pelvis Lumbar Puncture if CNS symptoms or aggressive

lymphoma with bone marrowinvolvement

peripheral blood

Diagnosis of NHL

Biopsy of lymph node is preferred toshow nodal architecture (follicular regionvs. diffuse).

Flow cytometry: CD 19, CD20 for B cell lymphomas CD 3, CD 4, CD8 for T cell lymphomas

NHL:Clinical manifestations

Variable severity: asymptomatic to extremely ill time course: evolution over weeks, months, or

years

Systemic manifestations fever, night sweats, weight loss, anorexia,

pruritis

Local manifestations lymphadenopathy, splenomegaly most common

any tissue potentially can beinfiltrated

NHL: Staging Ann Arbor StagingSystem I :indicates that the cancer is located in a single

region, usually one lymph node and thesurrounding area

II :indicates that the cancer is located in twoseparate regions, an affected lymph node ororgan and a second affected area, and that bothaffected areas are confined to one side of thediaphragm - that is, both are above thediaphragm, or both are below the diaphragm.

III: Involvement above and below diaphragm IV: Diffuse or disseminated involvement of 1 or

more extralymphatic tissues or organs (A= Absence of systemic symptoms, B= Presence

of B symptoms)

Staging of lymphoma

Stage I Stage II Stage III Stage IV

NHL: Ann Arbor Staging System

Suffix ‘A’ means absence of B symptoms Suffix ‘B’ means presence of B symptoms Suffix ‘E’ means extra nodal (not in

the lymph nodes) disease Suffix ‘S’ means splenic involvement Suffix ‘X’ means bulky disease argest

deposit is >10 cm large For example: Stage IIIB-S means disease

above and below the diaphragm, with Bsymptoms and Splenic involvement

NHL: Two most commonsubtypes

Diffuse Large Cell Lymphoma 39%

Follicular Lymphoma21%

Follicular lymphoma

most common type of “indolent” lymphoma lymphoma of follicle center B-cells (centrocytes and

centroblasts), usually widespread at presentation often asymptomatic not curable cell of origin: germinal center B-cell Prefer treatment if asymptomatic (“watch-and-wait”) several chemotherapy options if symptomatic median survival: years although considered “indolent”, morbidity and mortality

can be considerable transformation to aggressive lymphoma can occur

NHL :Diffuse large cell Lymphoma Commonest subtype most common type of “aggressive”

lymphoma usually symptomatic extranodal involvement is common cell of origin: germinal center B-cell treatment should be offered curable in ~ 40%

Treatment: Diffuse large cellLymphoma Limited stage (I or II) Non bulky: Combination of abbreviated chemotherapy (3-

4 cycles of CHOP) and radiation

Advanced Stage (III or IV) or bulky disease: Full 6-8 cycles of chemoRx with additional

XRT to bulky areas

Rituximab

Chemotherapy regimen is CHOP:Cyclophosphamide, Hydroxydoxorubicin,Oncovin and Prednisone)

Other ImportantNon Hodgkins Lymphomas Mantle Cell Lymphoma: due to CD5 positive

antigen-naive pregerminal center B-cell within the mantlezone that surrounds normal germinal center follicles

comprising about 6% of NHL cases subtype of B-cell lymphoma essentially is an

abnormal break and subsequent translocation ina gene that causes the cells to divide too earlybefore becoming capable of helping to fightdiseases

do not die as they should therefore accumulate in the lymphoid system

Burkitt’s Lymphoma African variety: jaw tumor, strongly linked

to Epstein-Barr Virus infection. Most rapidly growing human tumor. associated with a chromosomal

translocation of thec-myc gene. Thisgene is found at 8q24.

Classification:Burkitt’s Lymphoma

endemic variant occurs in equatorialAfrica. It is the most common malignancyof children in this area

involves the jaw or other facial bone,distal ileum, cecum, ovaries, kidney orthe breast.

Sporadic type of Burkitt lymphoma -(alsoknown as "non-African") is another formof non-Hodgkin lymphoma found outsideof Africa.

jaw is less commonly involved

Immunodeficiency-associated Burkittlymphoma is usually associatedwith HIV infection or occurs in the settingof post-transplant patients who are takingimmunosuppressive drugs. Burkittlymphoma can be one of the diseasesassociated with the initial manifestationof AIDS.

Microscopic exam

tumor consists of population of mediumsize lymphoid cells with high proliferativeactivity and apoptotic activity. The "starrysky" appearance

Gastric MALT Lymphoma: formof lymphoma involving the mucosa-associated lymphoid tissue (MALT),frequently of the stomach, but virtuallyany mucosal site can be afflicte

associated with chronic inflammation as aresult of the presence of Helicobacter pylori

treatment with antibiotic eradication of H.pylori

Small Lymphocytic lymphoma andChronic Lymphocytic Leukemia: is atype of non-Hodgkin lymphomacharacterized by an excess of whiteblood cells in the lymph nodes.When cancer cells are found in the bloodand bone marrow the disease is calledchronic lymphocytic leukemia (CLL).

is very indolent but relentless, withmedian survivals of almost a decade.

predominantly in older individuals.

Mycosis Fungoides

Malignancy of helper T cells. Affinity for skin. Can be treated with electron beam

radiation, ultraviolet light, or topicalalkylating

SummaryNON HODGKINS LYMPHOMA Extremely heterogenous group of

disease WHO classification is probably going to

stay Indolent NHL : Slow growing but

incurable Aggressive NHL: Faster growing

but/therefore potentially curable Follicular NHL: Commonest indolent

type DLCL: Commonest aggressive type

THANKYOUU…

questions

Which type of lymphoma has noReed-Sternberg Cell uponmicroscopic examination?

a.Hodgkin’s lymphomab.Non- Hodgkin’s lymphoma

2.Which type of lymphoma occurs at ahigher percentage than the other?

a.Hodgkin’s lymphomab.Non- Hodgkin’s lymphoma

3. Which cell type comprises more than80 % in NHL?

a. B cellb. T cell

4. Most common type of “indolent”lymphoma

a. Diffuse large cell Lymphomab. Follicular lymphomac. Mantle Cell Lymphomad. None of the above

5. Most common type of “aggressive”lymphoma

a. Diffuse large cell Lymphomab. Follicular lymphomac. Mantle Cell Lymphomad. None of the above