Beruflich Dokumente
Kultur Dokumente
Title:
Date & Time:
Date & Time:
II)
Lecturer:
CD3, CD4, CD8, TcR, TcR, TcR, TCR, others: the more
mature T-cells (various kinds)
CD1a (T6): some T-cells, all Langerhans macrophages
CD5: mantle cell lymphoma, many CLL
* CD10 (CALLA): most B-cells (mantle cell lymphoma is negative)
CD15: Most Reed-Sternberg cells; some others
* CD19: B-cells, but not plasma cells
* CD20: all but the most primitive B-cells, but not plasma cells
* CD22: most B-cells (EBV receptor)
* CD34 : primitive blood cells -- great for counting "blasts" in
leukemia / preleukemia
CD45 ("common leukocyte antigen" / LCA): all white cells
(* exception: Reed Sternberg cells and some leukemias)
* CD65: Most consistent marker for the natural-killer lymphocytes,
non-B, non-T cells making up maybe 10% percent of your
circulating white cells. (They tend to be big and have granules.
Update on their neoplasms: Cancer 112: 1425, 2008).
CD68: common macrophages
* CD79a: The mantle lights up best
BCL-2 (apoptosis-preventer): turned OFF during hypermutation
(i.e., germinal centers); turned ON in most nodular lymphomas
surface Ig(M, etc): B-cells
kappa, lambda: mature B-cells, plasma cells -- especially useful
for showing clonality (i.e., neoplasia)
* Future pathologists only: To look for clonality, you can also
have the lab check to see if the rearrangements that
produce the specificity of a lymphocyte for a specific antigen
Monocyte
WebPath Photo
WebPath Photo
Basophil
WebPath Photo
WebPath Photo
Lots of neutrophils
WebPath Photo
WebPath Photo
Neutrophilia
Text and photomicrographs. Nice.
Human Pathology Digital Image Gallery
clozapine
dapsone
dipyrone
methimazole
procainamide
propylthiouracil
rituximab
sulfasalazine
ticlopidine
PERSONAL-TRIVIAL
Some people of African descent people just have
slightly low neutrophil counts
Some women get a mild neutropenia around their
periods
AGRANULOCYTOSIS is a time-honored misnomer for
neutropenia sufficiently severe to put a person at risk for serious
454, 2007. Today we know that the band count is very low in
health, around one white cell in 500.
Hypersegmented poly
WebPath Photo
Hypersegmented poly
Pernicious anemia
KU Collection
LOTS OF EOSINOPHILS (big review Mayo Clin. Proc. 80: 75, 2005):
The "Loeffler" family of eosinophil-mediated diseases -- now being
sorted out; while most remain idiopathic, a few have known mutations
CHRONIC EOSINOPHILIC LEUKEMIA, an entity removed from the
Loeffler's wastebasket by the discovery of FIP1L1-PDGFRalpha
(Haematol 95: 696, 2010) -- treat with imatinib.
type I immune injury
food allergy, hay fever, eczema, extrinsic asthma (supposedly -you won't be impressed)
bronchocentric granulomatosis (aspergillus superinfection in
asthma; this one's important)
* hyper-IgE ("Job's") immunodeficiency
Tissue parasites
ascariasis
filariasis (includes "tropical eosinophilia" of the Far East -- future
pathologists: filaria worms will be pushed to the "feather edge" of
the smear)
onchocerciasis
strongyloidiasis
trichinosis
echinococcus
LOTS OF MONOCYTES:
typhoid fever
bad granulomatous problems
TB
brucellosis
Crohn's disease
leprosy
deep fungi
sarcoidosis
others
* chronic autoimmune disease
rheumatoid arthritis is worth remembering
* rickettsial disease (often; red flag)
* disseminated cancer (occasionally)
LOTS OF LYMPHOCYTES:
"infectious mononucleosis" (see below)
whooping cough ("pertussis"; little cleaved lymphocytes; the toxin keeps
the T-cells from homing to lymphoid tissue; Am. J. Clin. Path. 114: 35,
2000)
infectious lymphocytosis (mild kids' disease, with T-cells, caused by
various non-herpes viruses notably coxsackie B2 ; a "chronic form" also
exists without marrow abnormalities; leave this to the pediatric
hematologists; Acta. Paed. 74: 633, 2008.)
Infectious Mononucleosis
Text and photomicrographs. Nice.
Human Pathology Digital Image Gallery
LOTS OF BASOPHILS:
chronic myelogenous leukemia
other "chronic myeloproliferative disorders"
polycythemia vera
* primary hemorrhagic ("essential") thrombocythemia
* supposedly in lots of other things; this will not be important
clinically.
NOTE: None of these "classic findings" is either particularly sensitive, or
particularly specific, for any particular disease. Use this information in
the setting of the "whole person".
ODD NEUTROPHILS:
Pseudo-Pelger Huet
AFIP
Wikimedia Commons
CDC photo
Within the medullary cords, expect to see a mix of B- and T-cells and
plasma cells. The sinusoids are lined by fixed phagocytes.
Despite the elegant pictures in histology books, lymph nodes are
seldom "normal", especially in adults.
LYMPHADENITIS: Inflammation of the lymph nodes
ACUTE LYMPHADENITIS described in "Big Robbins" is not much more
than the hyperplasia in a reactive node.
Localized lymphadenitis is most often due to a bacterial infection
in the area drained by the lymph node.
Really bad cases have polys and even abscess formation
within the nodes. The end result will be a scarred-up lymph
node. You have one or more.
Generalized lymphadenitis suggests a systemic viral infection.
"Mesenteric adenitis", often indistinguishable from acute
appendicitis, is caused by Yersinia enterocolitica.
Acute lymphadenitis, since it comes up suddenly and stretches
the capsule, is likely to make the node tender.
CHRONIC NON-SPECIFIC LYMPHADENITIS falls in one of three
distinctive patterns.
FOLLICULAR HYPERPLASIA (i.e., lots and lots of big follicles)
results from longstanding contact with organisms or "other things"
that stimulate the B-cells. If perplexed, think of:
toxoplasmosis (* look for mini-granulomas touching the
germinal centers at their edges, this is supposedly
pathognomonic; some of these are groups of macrophages;
some are big "monocytoid B-cells" especially in the
medulla)
rheumatoid arthritis (often lots of plasma cells)
Toxoplasma
lymphadenitis
Yutaka Tsutsumi MD
Follicular hyperplasia
Follicular hyperplasia
WebPath Photo
WebPath Photo
Follicular hyperplasia
HIV lymphadenopathy
WebPath Photo
Yutaka Tsutsumi MD
Rosai-Dorfman
S100 for dendritic macrophages
Wikimedia Commons
Bartonellosis
Cat scratch fever
Yutaka Tsutsumi MD
CD Markers
"Pathology Outlines"
Nat Pernick MD
Lymphomas
Bryan Lee
Lung lymphoma
Lung pathology series
FCC lymphoma
Pittsburgh Pathology Cases
B-cell lymphoma
Pittsburgh Pathology Cases
B-cell lymphoma
Large cell
Pittsburgh Pathology Cases
891, 1998, Occup. Environ. Med. 60: E11, 2003; Acta Haem. 116:
153, 2006; "only chlordane" Canc. Ep. 15: 251, 2006 from the
NIH; Env. Health Perspect. 111: 179, 2003 -- any link to persistent
organochlorides must be weak; others) and hair-coloring agents
(U.S.; review Cancer Inv. 18: 467, 2000 & Cancer Causes &
Control 10: 617, 1999 from the FDA; relationship if any is clearly
weak; Am. J. Pub. Health 88: 1767, 1998 no animal model), as
well as the African poinsettia (Burkitt's).
RULE: At surgery or autopsy, lymphoma tissue feels like "fish flesh" (i.e.,
there is very little fibrosis) or "firm rubber" (i.e., there is some fibrosis but
not much).
RULE: Fatigue, malaise, night-sweats, fever, and weight loss are the
usual symptoms (if any) of these diseases. These are called the
"B symptoms" used in staging. The cause, which must involve
cytokines, has proved remarkably elusive.
A significant number (in some series, as many as half) of patients
with "fever of unknown origin" prove to have non-Hodgkin's or
Hodgkin's lymphoma.
RULE: A majority of lymphomas arise in the lymph nodes (one or more
groups). Several groups of nodes may pop up at once. Nodular
lymphomas almost always arise in lymph nodes.
RULE: A large minority arise in extra-nodal lymphoid tissue, i.e.,
Waldeyer's ring, stomach, terminal ileum, skin, marrow.
RULE: When lymphomas arise in lymph nodes, they present as nontender enlargement.
RULE: Lymphomas metastasize to other lymphoid tissues (nodes,
spleen, etc.), and eventually to the marrow, blood ("leukosarcoma", less
often "lymphemia") and other organs. Low-grade lymphomas
metastasize as small nodules, while high-grade lymphomas metastasize
as bulky masses.
RULE: Mitotic figure counts tell the growth rate of a lymphoma, but
unless the mitotic figures are bizarre, they do not help distinguish it from
a benign lymph node. (Have you ever "counted mitoses" in a normal
germinal center? Try it!)
RULE: The lower the grade of the lymphoma, the MORE likely the bone
marrow is to be involved at the time of diagnosis. Paradoxical, no?
RULE: Lymphomas tend to spread to sites according to their B-cell or Tcell origin. B-cell tumors go to the germinal centers, their mantles, and
the outsides of the splenic white pulp. T-cell tumors to the anterior
mediastinum, paracortical regions of nodes, insides of splenic white
pulp, etc. Skin lymphomas are usually of T-cell origin.
RULE: The malignant cells of lymphomas are MORE uniform than the
mix of cells normally seen in lymphoid tissue, and they recapitulate
some phase in the life history of either normal B-cells or T-cells. Don't
expect to see much "cytologic atypia" in a lymphoma. Remember that
the genome is usually not destabilized in lymphomas. (Especially,
immunoblastic lymphomas can look pretty wild.)
RULE: Lymphomas that grow as nodules within a lymph node ("trying to
be germinal centers") are called NODULAR or FOLLICULAR
(synonyms). They are always of B-cell origin, and the lymphoma cells
will closely resemble one of the forms in the sequence from resting Blymphocyte to plasma cell.
{23581} nodular lymphoma
Nodular lymphoma
Nodular lymphoma
WebPath Photo
KU Collection
Diffuse lymphoma
WebPath Photo
* Don't worry about the details for pathologists. There are extraaggressive "blastoid" and "pleomorphic" subtypes, etc., etc.,
MALT LYMPHOMA ("maltoma", named for its occurrence on on mucosal
surfaces, of course) is now defined by its a trademark translocation
t(11;18) and fusion protein (API2/MALT1; AM. J. Path. 162: 1113, 2003),
or one of the related translocations.
Remember that helicobacter infection is the one known cause of
lymphomas (?) in the stomach (Blood 102: 1012, 2003). It's been
known for over a decade that eradicating helicobacter "often cures
the lymphoma". If the t(11;18) translocation is present, a cure is
less likely (Lancet 357: 39, 2001). Update on eradicating
"lymphoma" by eradicating helicobacter: Cancer 104: 532, 2005.
Many (but by no means all) Hashimoto and Sjogren-associated
lymphomas are MALT type.
* Since the MALT lymphoma cells have the markers of B-cells that
are just learning to fight a specific antigen, it makes sense that the
presence of the antigen keeps the lymphoma going. Someone
else can explain the molecular biology.
* Some pathologists consider these a subcategory of marginal
zone lymphoma, as in the alternate names for the tumor in the
new classification.
MARGINAL ZONE LYMPHOMA ("marginal cell lymphoma"; Am. J. Clin.
Path. 117: 698, 2002)
An indolent, nodular or diffuse, B-cell lymphoma that often arises
extranodally, famously in the spleen (a defined subtype:
Hematology 13: 27, 2008; Am. J. Surg. Path. 31: 438, 2007), or
orbit (Arch. Path. Lab. Med. 132: 1405, 2008).
Like mantle lymphomas, it tends to grow around benign germinal
centers.
Dermatopathologists are especially familiar with these, as they
tend to arise in the skin at sites of ongoing immune activation -infamously Lyme disease acting as a promoter
(Histopathology 37: 501, 2000).
WebPath Photo
WebPath Photo
{23590} diffuse small cleaved lymphoma (all you can tell is that it is small
cleaved)
{23593} diffuse small cleaved lymphoma (all you can tell is that it is diffuse)
{46344} diffuse small cleaved lymphoma, marrow
{23581} nodular lymphoma
Small cleaved lymphocyte in blood
Ed Lulo's Pathology Gallery
Post-Transplant Neoplasia
Great site
Transplant Pathology
Internet Services
Post-transplant lymphoproliferation
Pittsburgh Pathology Cases
Burkitt's lymphoma
Patient and photomicrograph
KU Collection
Burkitt's lymphoma
Starry sky
KU Collection
Burkitt's
Bryan Lee
Burkitt's
NCI
Wikimedia Commons
Burkitt's
Section
Wikimedia Commons
Burkitt's
Smear
Wikimedia Commons
o
across
o
multilobed
nucleus (often appears
"binucleate"), with
lobes appearing as
mirror images of one
another
pink-tolavender cytoplasm
CD15 positive
(except nodular
lymphocyte
predominant subtype)
Hodgkin's disease
Nice Reed-Sternberg cell
KU Collection
Hodgkin's, node
Hodgkin's, liver
WebPath Photo
WebPath Photo
Reed-Sternberg cells
Reed-Sternberg cell
WebPath Photo
WebPath Photo
Hodgkin's
H&E
Wikimedia Commons
Lacunar cells
WebPath Photo
WebPath Photo
Leukemia
Packed marrow
WebPath Photo
Leukemia / myelodysplasia
"Pathology Outlines"
Nat Pernick MD
M3
AFIP
Wikimedia Commons
Auer rods
WebPath Photo
ALL
Pittsburgh Pathology Cases
This is the familiar "childhood leukemia", with peak age in four year old
kids. Adult ALL is less common.
* Authoritative mega-review for pathologists considering a
diagnosis of leukemia in a child: Am. J. Clin. Path. 109(4S1):9S,
1998.
{12410} ALL (all you can tell from the smear is "blasts")
Burkitt's leukemia
Bone marrow
KU Collection
L3 is a distinct entity, but L1 and L2 aren't especially useful. Here's a moremodern immunophenotypic classification:
B-cell... 80%... * CD19+...* several subclasses exist
"pre-B"/"null", with surface Ig and TdT, carries a good prognosis;
Burkitt's / "mature B" / L3 is ominous
T-cell... 15%... * "intra-thymic markers, like T-lymphoblastic lymphoma";
chances of a cure are much less than with B-cell disease
Nothing... uncommon today...* markers are negative; there is only HLADR.
Apart from the fact that all L3's (Burkitt's) are B-cell tumors, there is little
correlation between the two systems.
In 2002, the World Health Organization proposed the following system, which
seems to be generally accepted now:
1. Acute lymphoblastic leukemia / lymphoma (all the old L1's and L2's go
here)
t(12;21) TEL/AML-1
t(1:19) PBX/E2A
T(V,11) V/MLL
Adults with ALL are often "Philadelphia-positive", and kids can be, too
(* the latter confers a bad prognosis: NEJM 342: 998, 2000). Several other
bad-prognosis translocations, including the Burkitt t(8:14), and the AML
variant of the Philadelphia chromosome, are known.
t(12;21) and del(9p) give a relatively favorable prognosis.
Almost all children with ALL get a complete remission on current therapy. Around
90% get apparent cures on today's regimens (NEJM 366: 1445, 2012).
The prognosis for adults is still guarded. Cure rates for teens are now
about as good as for young children (J. Clin. Onc. 29: 386, 2011).
Pccasionally the disease appears in older adults with less chance of cure.
* Precursor T-cell ALL and MLL gene-rearranged leukemias are
exceptions that are more refractory to cure.
{23857} ALL in the liver
{32027} ALL in the liver
{34513} ALL in the brain
{49316} ALL in the kidney
{49343} ALL in the testis
* In 1987, Coby Howard,who had ALL and a relapse, and belonged to a family
that did not work and received Medicaid as part of welfare, didn't get his
$100,000 bone marrow transplant that had maybe 25% chance of working (J.
Clin. Onc. 5: 1348, 1987 is from that era) because of Oregon's health-care
rationing, which was intended to spend the Medicaid money where it was most
likely to do the most overall public good. Pressure groups (liberal, conservative),
of course, had a field-day with Coby's death. During the activity at the legislature
that followed, it was pointed out that many working people who did not have
health insurance were dying because they lacked access both to transplants and
to far more basic services. Taxpayers understandably resent being forced to pay
for health benefits for others that they cannot get for their own children.
Remember poor Coby's name, and the principle.
ACUTE MYELOID LEUKEMIA ("AML", "acute myelogenous leukemia", "poorly
differentiated granulocytic leukemia", "acute non-lymphocytic leukemia", "ANLL", etc.)
This is the common acute leukemia of adults (the incidence increases with age,
but young adults are often affected, and occasionally children are affected).
Although most cases are idiopathic, many things are known to increase risk.
These include:
o Down's syndrome (trisomy 21 -- especially AML-M7)
o ionizing radiation exposure ("we estimate one case per 10000 childhood
CT scans" -- Lancet 380: 499, 2012).
primary myelofibrosis
The cancer arises out of a background of mutated marrow cells that typically
include granulocytic and other (erythroid and/or monocyte precursors). All are
likely to show some abnormalities (* good tipoff: megakaryocytes with nonlobulated nuclei).
The FAB classification (Ann. Int. Med. 103: 614 & 620, 1985) is worth knowing at
the recognition level (though it is of little interest to practicing oncologists, who
are today much more concerned about the molecular lesions):
M2
Pittsburgh Pathology Cases
M4-Eo
With eosinophils
Wikimedia Commons
M3
AFIP
Wikimedia Commons
M2
AFIP
Wikimedia Commons
M2
AFIP
Wikimedia Commons
M7 marrow
Tiny megakaryocytes
Wikimedia Commons
M1
AFIP
Wikimedia Commons
M6
AFIP
Wikimedia Commons
M0
AFIP
Wikimedia Commons
M6
Weird normoblasts in circulation
Wikimedia Commons
M5b
AFIP
Wikimedia Commons
M5a
AFIP
Wikimedia Commons
M4
AFIP
Wikimedia Commons
M5 -- electron micrograph
Dented nucleus
Wikimedia Commons
Untreated AML is fatal in a few weeks. Today, many AML patients have prolonged
survival and probably cures.
The prognosis depends primarily on the cytogenetics. The major papers
came from the early 2000's (Blood 96: 4075, 2000; Blood 100: 4325,
2002).
"Favorable prognosis" features t(8:21), t(15:17), del(9q) and/or
inv(16)/t(16;16).
"Adverse prognosis" features -5 / del(5q), -7 / del(7q), -17, -18,
inv(3)/t(3;3), t(6;9), t(9;22) and/or complicated cytogenetics (i.e.,
three or more unrelated abnormalities).
The others, including those with no chromosomal abnormalities, are
"intermediate prognosis."
Acute promyelocytic leukemia has the best response to treatment, with
98% adjusted six-year survival (Blood 110: 59, 2007).
A solid growth of myeloblasts is a CHLOROMA or GRANULOCYTIC SARCOMA
or NONLEUKEMIC MYELOID SARCOMA. This most malignant of solid tumors
turns green (Greek "chloros", as "chlorine" or "chlorophyll") on exposure to air
(why?) It's not common, but is treated as, and responds similarly to, AML, with a
somewhat better chance of cure (Cancer113: 1370, 2008).
<="" a="">
Myelodysplastic syndrome
Odd megakaryocyte / giant platelet
AFIP
CHRONIC MYELOID LEUKEMIA ("chronic myelogenous leukemia", "welldifferentiated granulocytic leukemia"): all about it Lancet 370: 1127, 2007
This is cancer of the myeloid stem cells in which there is overgrowth of normallymaturing myeloid cells
Radiation and exposure to chemicals (notably benzene) are known risk
factors. Most of the time, the disease seems to strike at random.
Patients typically have high counts of neutrophils and their precursors
(and almost always basophils). These are normal (functionally and
morphologically) for all intents and purposes, except that for some reason
they lack cytoplasmic alkaline phosphatase.
CLL
Pittsburgh Pathology Cases
CLL
CLL in liver
Great labels
Romanian Pathology Atlas
This indolent cancer is a clone of B-cells that multiply slowly and do nothing
useful. The diagnosis is made by finding a count of 5000 or more lymphocytes of
appropriate phenotype circulating in the blood.
If the cells have nucleoli, it's more likely to be called B-cell prolymphocytic
leukemia and to behave more aggressively.
Often you can find growth centers (where the cells are slightly larger and
perhaps show nucleoli) in solid-phase well-differentiated lymphocytic
lymphoma; these have the same molecular markers as classic CLL.
"T-cell CLL", with a peripheral smear looking like CLL, is now renamed "Tcell prolymphocytic leukemia", an uncommon and aggressive disease.
There are of course T-cell receptor rearrangements, and most often
inv 14(q11;q32).
tumors) has just been found in each of 48 hairy-cell patients (NEJM 364: 2305,
2011; assays Blood 119: 3151, 2012; Am. J. Clin. Path. 138: 153, 2012).
During the 20th century, the only treatment for this disease was splenectomy,
which helped. Today, most patients get a lasting remission after taking a course
of cladribine (2-chlorodeoxyadenosine, 2-CdA) or pentostatin (deoxycoformycin,
a purine analogue that's a naturally-occurring antibiotic). Update Cancer 104:
2442, 2005; Blood 109: 3672, 2007. These can be repeated is required if the
disease recurs (which it often doesn't), and there are additional treatments that
give results if the disease becomes resistant.
* There is a variant that features mutated p53 instead of BRAF V600# and is
much more common in men and is harder to treat. There's also a Japanese
variant that responds very well to cladribine.
{23872} hairy cell leukemia
{10766} hairy cell leukemia, spleen (top; normal at bottom)
{16543} hairy cell leukemia, TRAP stain (red)
{23875} hairy cell leukemia, TRAP stain (red)
{13925} hairy cell leukemia, TRAP stain (red)
{16541} hairy cell leukemia, TRAP stain (red)
{23881} hairy cell leukemia, bone marrow biopsy (trust me)
{42117} big spleen in hairy cell leukemia, foot ruler
Hairy cell leukemia
Peripheral smear
KU Collection
POLYCYTHEMIA VERA ("Osler's polycythemia", "P. V. rubra", etc.; Mayo Clin. Proc. 78:
174, 2003; Arch. Path. Lab. Med. 130: 1126, 2006)
By convention, POLYCYTHEMIA (a better synonym is ERYTHROCYTOSIS)
describes an abnormally high hemoglobin. Classification:
ABSOLUTE POLYCYTHEMIA (i.e., increased circulating red cell mass):
PRIMARY POLYCYTHEMIA (i.e., the main problem is with the red
cells)
Polycythemia vera rubra
NOTE: Cancer of the normoblasts (i.e., AML-M6) isn't
considered a polycythemia
* Erythropoietin-dependent polycythemias (altitude, posttransplant) can be ameliorated using ACE inhibitors, which is
puzzling: Lancet 359: 663, 2002.
RELATIVE POLYCYTHEMIA (i.e., dehydration)
Polycythemia vera is a proliferation of stem cells (again, the common precursors
of red cells, granulocytes, and megakaryocytes). This time, they are very
erythropoietin-sensitive and mostly mature into red cells.
The cells are the common ancestors of red cells, neutrophils, and
megakaryocytes. Over the course of years, these stem cells replace the
normal stem cells of the marrow. Their progeny, however, are fully
functional. (Neutrophils even have normal alkaline phosphatase levels.)
In addition to a high red cell count, white cells and platelets are likely to be
high.
On biopsy, expect to see a very hypercellular marrow, with all cell lineages
increased. In the late stages, there is often marrow fibrosis ("burned out
PVR", "postpolycythemic phase", * PDGF effect?) or replacement by
blasts (transformation to acute myelogenous leukemia -- still no good
treatment Cancer 104: 1032, 2005).
The trademark mutation in JAK2 (NEJM 356: 444, 2007) that is usually
present (* JAK2V617F) is now famous. Mouse with the mutation -Blood 120: 166, 2012.
JAK2 is central to polycythemia vera, essential thrombocytosis, and
primary myelofibrosis, as it is the tyrosine kinase for the cytokine
receptors that stimulate production of red cells (polycythemia vera),
megakaryocytes (essential thrombocytosis), and neutrophils
(primary myelofibrosis), explaining the overlap and transformations.
There are always additional mutations in other genes. Some
germline alleles are much more likely than others to mutate into the
really bad allele (Nat. Genet. 41: 385 & 450 & 455 & 446, 2009).
The new JAK2 inhibitors are now (2011) widely used.
This is a disease of older middle-age. Until the last stages, patients are troubled
primarily by the increased volume of hyperviscous blood.
This causes congestion of most organs ("the plethoric face", etc.)
More troubling, the stasis of gooey blood in the veins promotes clotting.
functionally active JAK2 mutation. Minor criteria are one of these -characteristic bone marrow morphology, too-low serum erythropoietin, and
the ability of red cell colonies to grow in tissue culture without
erythropoietin.
* Thrombosis, the most troublesome aspect of this disease, seems to be much
less of a problem if patients are simply given low-dose aspirin (NEJM 350: 114,
2004).
Polycythemia
Text and photomicrographs. Nice.
Human Pathology Digital Image Gallery
IgG spike >3.5 gm/dL or IgA spike >2.0 gm/dL or kappa or lambda light chain
excretion >1 gm/day
B. Minor criteria
PLASMA CELL MYELOMA: Two majors, OR one major and one minor OR three minors
including the first two.
INDOLENT MYELOMA: More than 30% bone marrow plasma cells, IgG spike <7 gm/dL
or IgA spike <s;5 gm/dL; fewer than three lytic lesions; no anemia, hypercalcemia, or
renal involvement
SMOLDERING MYELOMA: 10-30% plasma cells in the marrow, major criterion spike
present, no lytic lesions; no anemia, hypercalcemia, or renal involvement
MONOCLONAL GAMMOPATHY OF UNCERTAIN SIGNIFICANCE: <10% plasma cells in
the marrow (but who wants to check?); spike present but too small for major criterion; no
lytic bone lesions no anemia, hypercalcemia, or renal involvement
Myeloma skull
Myeloma skull
WebPath Photo
WebPath Photo
Myeloma marrow
WebPath Photo
WebPath Photo
WebPath Photo
WebPath Photo
o pathologic fractures
o hypercalcemia (several mechanisms)
o infections (myeloma cells suppress normal plasma cells)
o anemia and neutropenia (crowding out of normal cells)
o kidney failure (precipitate and/or amyloid)
o * myeloma neuropathy (infiltration, compression, vincristine)
o amyloidosis B (10% of myeloma patients; cardiac problems)
o plasma cell leukemia (a terminal stage)
{17273} myeloma kidney, Bence-Jones casts with foreign body reaction
{17274} myeloma kidney, Bence-Jones casts with foreign body reaction
The tumor generally excites no fibrous or osteoblastic response. At autopsy, the
tumor masses (if distinguishable) look and feel like reddish-gray jelly.
Prognosis is much better, nowadays due both to chemotherapy and to
bisphosphonate management of bone disease. The ongoing "total therapy"
studies is reporting prolonged remissions (cures?) in many patients (updates
Blood 112: 3115, 2008; Cancer 133: 355, 2008; Cancer 112: 2720, 2008). The
monoclonal bortezomib (proteasome inhibitor) is very promising (updates
Cancer 110: 1042, 2007; Cancer 112: 1529, 2008). Thalidomide for refractory
myeloma NEJM 341: 1565, 1999. This is now mainstream.
The disease often simply smolders, and if there are no symptoms,
perhaps it's best just to give bisphosphonates prophylactically
(Cancer 113: 1588, 2008).
OTHER PLASMA-CELL PROBLEMS ("plasma cell dyscrasias", an archaic term)
There are a variety of other MONOCLONAL PLASMA CELL PROLIFERATIONS.
We already looked at WALDENSTROM'S MACROGLOBULINEMIA and
the HEAVY-CHAIN DISEASES under "non-Hodgkin's lymphomas". These
are cancers of small lymphocytes with "plasmacytoid" features.
SOLITARY PLASMACYTOMAS may appear benign grossly and
microscopically, and they may or may not produce immunoglobulins.
Those in bone almost always recur as plasma cell myeloma.
In tissue, you will probably see a range of cells from "blasts" to welldifferentiated Langerhans cells.
The former claim that histiocytosis X is "polyclonal" probably
resulted from confusion of the tumor cells with non-neoplastic
inflammatory cells that had entered the tumor. By the mid-1990's
we knew the disease was clonal, hence a real neoplasm
(NEJM 331: 154, 1994; Br. Med. J. 310: 74, 1995; Lancet 344:
1717, 1994).
Future pathologists: Histiocytosis X and the dendritic macrophages from
which it derives stain for CD1/T6. They also stain with S-100.
The old names are passing out of use, but you might perhaps see the
syndromes:
LETTERER-SIWE DISEASE ("acute disseminated histiocytosis",
"multifocal multisystem LCH") affects small children and involves most of
the body's organs. These children are now often cured with elaborate
chemotherapy.
{23392} Letterer-Siwe disease. Weird histiocytes ("coffee-bean nuclei, even"). Trust me.
EOSINOPHILIC GRANULOMA ("unifocall LCH"; "granuloma" is an
unfortunate misnomer) causes solitary bone lesions in young people. The
Big spleen
Briish
ITP case
The healthy spleen weighs 50-250 gm or less. You remember that the cells right
around the arteries in the white pulp are T-cells, that there are likely to be B-cell
nodules, and that the Littoral cells lining the sinuses express both macrophage
and endothelial markers.
The spleen almost never gets biopsied, as it is so likely to rupture.
Hereditary spherocytosis
Hemoglobinopathies and bad thalassemia
Immune hemolytic anemia
Immune thrombocytopenic purpura
IMMUNOREACTIVE HYPERPLASIA
Lupus
Rheumatoid arthritis
Graft rejection
STORAGE DISEASES (huge spleen)
Gaucher's (very big, wadded-kleenex macrophages)
Niemann-Pick's (very big, foamy macrophages)
Hunter's
Hurler's
SARCOIDOSIS
AMYLOIDOSIS (sago, lard)
HYPERSPLENISM is said to be present when an enlarged spleen destroys
normal formed elements of blood too readily. The three causes you'll probably
see are: (1) cirrhosis; (2) rheumatoid arthritis (the serious "Felty's syndrome"),
and (3) Gaucher's disease. It's also one cause of thrombocytopenia in some
leukemia and lymphoma patients.
{00239} Gaucher's disease, spleen
{09864} Gaucher's disease, spleen
{16216} Gaucher's disease, watered-silk ("wadded kleenex") cell from spleen
The only proof that hypersplenism was the problem is that the blood
counts get better when the spleen is removed.
Big spleen
From a cirrhotic
WebPath Photo
Big spleen
Some myeloproliferative disorder
WebPath Photo
Splenomegaly
Urbana Atlas of Pathology
INFARCTS are common in the spleen, and may result from atheroembolization
(the twisty splenic artery is the most severely affected in the body), left-sided
endocarditis, or infiltrative disease.
Infarcts
WebPath Photo
Pri