Title: Leukemia/Lymphoma
1Leukemia/Lymphoma
2Components and General Properties of Blood
- Seven kinds of formed elements
- Erythrocytes red blood cells (RBCs)
- Platelets (thrombocytes) (clotting cells)
- Cell fragments from special cell in bone marrow
- Leukocytes white blood cells (WBCs)-5 kinds
3Components and General Properties of Blood
- Five leukocyte types divided into two categories
- Granulocytes (with granules)
- 3)Neutrophils
- 4)Eosinophils
- 5)Basophils
- Agranulocytes (without granules)
- 6)Lymphocytes
- 7)Monocytes
4Components and General Properties of Blood
Monocyyte
Small lymphocyte
Neutrophil
Platelets
Eosinophil
Small lymphocyte
Erythrocyte
Young (band) neutrophil
Neutrophil
Monocyte
Large lymphocyte
Neutrophil
Basophil
5Leukocytes
- Least abundant formed element
- 5,000 to 10,000 WBCs/?L
- Protect against infectious microorganisms and
other pathogens - Conspicuous nucleus
- Spend only a few hours in the bloodstream before
migrating to connective tissue - Retain their organelles for protein synthesis
- Granules
- All WBCs have lysosomes called nonspecific
(azurophilic) granules inconspicuous so
cytoplasm looks clear - Granulocytes have specific granules that contain
enzymes and other chemicals employed in defense
against pathogens
6Types of Leukocytes
- Granulocytes
- Neutrophils (60 to 70) polymorphonuclear
leukocytes - Barely visible granules in cytoplasm three- to
five-lobed nucleus - Eosinophils (2 to 4)
- Large red-orange granules
- Basophils (less than 1)
- Large, abundant, violet granules
7- Agranulocytes
- Lymphocytes (25 to 33)
- Variable amounts of bluish cytoplasm (scanty to
abundant) ovoid/round, uniform dark violet
nucleus - Monocytes (3 to 8)
- Largest WBC generally ovoid, kidney-, or
horseshoe-shaped nucleus
8Granulocytes
- Neutrophilsincreased numbers in bacterial
infections - Phagocytosis of bacteria
- Release antimicrobial chemicals
- Eosinophilsincreased numbers in parasitic
infections, collagen diseases, allergies,
diseases of spleen and CNS - Phagocytosis of antigenantibody complexes,
allergens, and inflammatory chemicals - Release enzymes to destroy large parasites
9- Basophilsincreased numbers in chickenpox,
sinusitis, diabetes - Secrete histamine (vasodilator) speeds flow of
blood to an injured area - Secrete heparin (anticoagulant) promotes the
mobility of other WBCs in the area
10Agranulocytes
- Lymphocytesincreased numbers in diverse
infections and immune responses - Destroy cells (cancer, foreign, and virally
infected cells) - Present antigens to activate other immune cells
- Coordinate actions of other immune cells
- Secrete antibodies and provide immune memory
11Agranulocytes
- Monocytesincreased numbers in viral infections
and inflammation - Leave bloodstream and transform into macrophages
- Phagocytize pathogens and debris
- Present antigens to activate other immune
cellsantigen-presenting cells (APCs)
12The Leukocyte Life Cycle
- Leukopoiesisproduction of white blood cells
- Pluripotent stem cells (PPSCs)
- Myeloblastsform neutrophils, eosinophils,
basophils - Monoblastsform monocytes
- Lymphoblasts give rise to all forms of
lymphocytes
13Leukopoiesis
Pluripotent stem cell
Colony-forming units (CFUs)
Precursor cells
Mature cells
leaves
Eosinophilic myelocyte
Eosinophilic promyelocyte
Eosinophilic myeloblast
Eosinophilic CFU
Eosinophil
Basophilic CFU
Basophilic myeloblast
Basophilic promyelocyte
Basophilic myelocyte
Basophil
Neutrophilic CFU
Neutrophilic myeloblast
Neutrophilic promyelocyte
Neutrophilic myelocyte
Neutrophil
Monoblast
Promonocyte
Monocyte
Monocytic CFU
B lymphocyte
B prolymphocyte
T lymphocyte
T prolymphocyte
Lymphoblast
Lymphocytic CFU
NK cell
NK prolymphocyte
14What Is Leukemia?
- Cancer of the white blood cells
- Acute or Chronic
- Affects ability to produce normal blood cells
- Bone marrow makes abnormally large number of
immature white blood cells called blasts
15History
- Means white blood in Greek
- Discovered by Dr. Alfred Velpeau in France, 1827
- Named by pathologist Rudolf Virchow in Germany,
1845
16Leukocyte Disorders
- Leukemiacancer of hemopoietic tissue that
usually produces an extraordinary high number of
circulating leukocytes and their precursors - Myeloid leukemia uncontrolled granulocyte
production - Lymphoid leukemia uncontrolled lymphocyte or
monocyte production
17Acute vs Chronic Leukemia
- Acute leukemia appears suddenly, progresses
rapidly, death within months blasts found in
peripheral blood - Chronic leukemia undetected for months, survival
time average of 3 years - Effects normal cell percentages disrupted
impaired clotting opportunistic infections
18Main Types
- Acute Lymphocytic Leukemia (ALL)
- Acute Myelogenous Leukemia (AML)
- Chronic Lymphocytic Leukemia (CLL)
- Chronic Myelogenous Leukemia (CML)
19Demographics of Leukemia Patients (2001 Data)
CLLChronic Lymphocytic ALLAcute
Lymphocytic CMLChronic Mylogenous AMLAcute
Mylogenous
Total Reported Cases 31,500
20Pictures Of Blood
21Development of Leukemia in the Bloodstream
Legend
White Cell
Red Cell
Platelet
Blast
Germ
22Causes
- High level radiation/toxin exposure
- Viruses
- Genes
- Chemicals
- Mostly unknown
23Signs and Symptoms of AML
- Insidious nonspecific onset
- Pallor due to anemia
- Febrile (fever) due to ineffective WBC
- Petechiae (skin bruising) due to thrombocytopenia
- Bone pain
- Petechiae
24Typical Labs of AML
- Leukocytosis
- Blastemia
- Leukemic hiatus
- Auer rods only found in myelocytic blasts
- Thrombocytopenia
- Anemia
- gt20 blasts in Bone Marrow
25Auer Rods
Auer Rod
26CD Markers
- The cluster of differentiation (cluster of
designation) (often abbreviated as CD) is a
protocol used for the identification and
investigation of cell surface molecules providing
targets for immunophenotyping of cells. - The CD markers can be used to identify the type
of cell.
27Other Findings
- CD 13 and CD 33 in flowcytometry
- Cytochemistries-stains that can be used to
differentiate leukemias - Myeloperoxidase
- Sudan black B
- Choloroacetate esterase (specific)
- Nonspecific esterase
28Flow Cytometry
Large clustering of CD 33s shows presence of
blasts
29FAB (1976) Classification
- M0 -- Undifferentiated AML
- M1 -- AML without maturation
- M2 -- AML with maturation
- M3 -- Acute Promyelocytic Leukemia
- M4 -- Acute Myelomonocytic Leukemia
- M5 -- Acute Monocytic Leukemia
- M6 -- Erythroleukemia (DiGuglielmos)
- M7 -- Megakaryoblastic Leukemia
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31Myeloperoxidase (MPO)
p-Phenylene diamine Catecol H2O2
MPO gt Brown black deposits Brown deposits
considered to be a positive test-differentiates
AML from other leukemias
32M1 and M2
33M3
M4
M5
34Chloracetate (Specific) Esterase Myeloid Cell
Line
Naphthol-ASD-chloracetate CAE gt Free
naphthol compounds Stable diazonium salt (eg,
Fast Corinth) gt Red deposit
35Non-Specific Esterase Monocytic Line
? Naphthyl acetate ANAE gt Free naphthyl
compounds Stable diazonium salt (eg,
Fast blue RR) gt Brown deposits
36FAB vs WHO Classifications of Hematologic
Neoplasm
- FAB criteria
- Morphology
- Cytochemistry
- WHO criteria
- Morphology
- Immunophenotyping
- Genetic features
- Karyotyping
- Molecular testing
- Clinical features
37WHO Classification of AML
- AML with recurrent cytogenic translocations
- AML with multi-lineage dysplasia
- AML and myelodysplasia, therapy related
- AML, not otherwise categorized
38AML with Recurrent Cytogenetic Translocations
(WHO 1995)
- t(821) -- some maturation of neutrophilic line
rare in older patients AML1/ETO fusion protein
gt90 FAB M2 - t(1517) -- APL (granular and microgranular
variants) retinoic acid receptor (RAR)
leukemias middle aged adults DIC - inv(16) or t(1616) -- monocytic and
granulocytic abnormal eosinophilic component - 11q23 -- monocytic children most common is
t(911)
39Lymphocytic Leukemias
- Can involve T or B lymphocytes
- B lymphs mature in bone marrow
- Responsible for making antibodies
- T lymphs go to thymus to mature
- Are cytotoxic cells of immune system
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43FAB Classification of ALL
- L1 Small homogeneous blasts mostly in children
- L2 Large heterogeneous blasts mostly in adults
- L3 Burkitt large basophilic B-cell blasts with
vacuoles
44L3
L2
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46Periodic Acid Schiff
Periodic acid Glycogen oxidation gt Aldehyde
Schiff reagent (para-rosaniline, Na
metabisulfite) gt Red deposit
47ALL Cytochemistries
- Oil Red O stains L3 vacuoles
- Terminal deoxynucleotidyl transferase (Tdt) DNA
polymerase in early lymphoblasts - Cell surface markers (CDs)
- Cytoplasmic and surface immunoglobulins B-cell
line - T-cell receptor (TCR)
48WHO Classification of Lymphoproliferative
Syndromes
- Precursor B Lymphoblastic Leukemia/Lymphoma
(ALL/LBL) -- ALL in children (80-85 of childhood
ALL) LBL in young adults and rare FAB L1 or L2
blast morphology - Precursor T ALL/LBL -- 15 of childhood ALL and
25 of adult ALL - Burkitt Leukemia/Lymphoma (FAB L3)
49Prognosis
Indicators Favorable Poor
WBC lt 50,000/?L ? 50,000/?L
Age 1 - 10 lt 1 or ?10
Gender Female Male
Blast B-cell T-cell and mixed
Karyotype Hyperploidy Trisomy 4, 10, 17 t(1221) (TEL/AML1) Hypoploidy Trisomy 5 t(119 (E2A/PBX1) Mixed lineage leukemia T(922) (Ph)
BM blast count during induction Mkd reduction at day 7 Mild reduction at day 7
50Burkitts Lymphoma
51CML
52Typical Labs in CML
- Leukocytosis with blastemia
- Thrombocytosis
- Basophilia
- Micro-megakaryocytes
- Low LAP score (intermediate if infected)
- About 10 blasts in BM
- Philadelphia chromosome
53Bone marrow aspirate and biopsy
54- Conventionally, a leukocytosis exceeding 50,000
WBC/mm3 with a significant increase in early
neutrophil precursors is referred to as a
leukemoid reaction.
55- Serum leukocyte alkaline phosphatase is normal or
elevated in leukemoid reaction, but is depressed
in chronic myelogenous leukemia.
56- Leukemoid reactions are generally benign and are
not dangerous in and of themselves, although they
are often a response to a significant disease
state
57- Historically, various clues including the
leukocyte alkaline phosphatase score and the
presence of basophilia were used to distinguish
CML from a leukemoid reaction. However, at
present the test of choice in adults to
distinguish CML is an assay for the presence of
the Philadelphia chromosome, either via
cytogenetics and FISH, or via PCR for the BCR/ABL
fusion gene.
58Leukocyte Alkaline Phosphatase (LAP)
Naphthol AS-MX phosphate LAP at
pH8.6 gt Naphthol AS-MX Diazonium
salt (eg, Fast blue RR) gt
Insoluble pigment
59LAP Score
- Count 100 consecutive segmented neutrophils and
bands - Score
- 0 no granules
- 1 occasional diffuse granules
- 2 moderate number of granules
- 3 many strongly positive granules
- 4 confluent strongly positive granules
600
1
2
3
4
61LAP Score
Example 0 x 35 cells 0 1 x 30 cells
30 2 x 20 cells 40 3 x 10 cells 30 4 x 5
cells 20 120 LAP Score
62Philadelphia Chromosome
- 9 22 translocation almost specific to CML
- Karyotype to visualize Ph chromosome
- Produces BCR/c-abl fusion oncogene
- Gene product p190 is a hyperactive tyrosine
kinase - Ph chromosome seen in ALL produces p210 and
chronic neutrophilic leukemia produces p230
63Karyotype 46,XX,t(922)(q34q11.2) -- Ph
chromosome
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65FISH showing the BCR (green), ABL (orange), and
BCR-ABL fusion signals (arrow) Apositive
(contains a residual ABL signal), Bnormal
66Chronic Lymphocytic Leukemia
- Exclusive in elderly
- Lymphocytosis unrelated to viral infection
- Hyper-mature lymphocytes with highly condensed
nuclei - Smudge cells
67CLL PB and BM
Smudge cell
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70Bone Marrow