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HEMATOLOGY 2 MIDTERMS LECTURE 6, 7, 8, 9: NEOPLASTIC ALTERATION OF

LEUKOCYTES

*ACUTE VS CHRONIC BLOOD LOSS (Additional Source: Turgeon)


Acute Chronic

Age All Ages Adults

Clinical Onset Sudden Insidious

Coarse (Untreated) <6 Months 2-6 Years

Leukemia Cells Immature Mature

Anemia Mild to Severe Mild

Thrombocytopenia Mild to Severe Mild

White Blood Cells Variable Increased

Organomegaly Mild Prominent

NEOPLASTIC ALTERATION OF LEUKOCYTES

MAJOR TYPES
I. LEUKEMIAS
- Type of Abnormality when the is Uncontrolled Proliferation of one or more of the Hematopoietic
Cells
GENERAL SIGNS AND SYMPTOMS: Fever, Weight Loss, Increase Sweating
1. Acute Leukemia (Bone/ Joint Pain due to Large Leukemic Cell Mass present on the BM)
a. Acute Myeloid Leukemia
b. Acute Lymphoblastic Leukemia
2. Chronic Leukemia (Enlarged Spleen, Enlarged Liver, Enlarged Lymph Nodes)
a. Chronic Myeloid Leukemia
b. Chronic Lymphoblastic Leukemia
II. LYMPHOMAS
1. Hodgkin’s Disease
2. Non-Hodgkin’s Lymphoma
III. PLASMA CELL DISORDERS (ex. Multiple Myeloma)
IV. HISTIOCYTES DISORDERS (ex. Sea Blue Histiocytosis)
LABORATORY TESTS
I. MORPHOLOGY
1. Wright-Giemsa Stain
2. Blood Smear
3. Bone Marrow Biopsy
*If in the CBC, Atypical Cells are present it is suggestive for PBS and BMB
II. ELECTRON MICROSCOPY
- Not routinely used
- Can be very helpful in Rare Occasions
III. CYTOCHEMISTRY (Helpful in the identification of the present Malignancies)
IIIA. ENZYMATIC TECHNIQUES
IIIA1. MYELOPEROXIDASE (MPX/ MPO)
*Also known as the Acute Leukemia Enzyme
- Stains Neutrophilic/ Eosinophilic Cells
- Monocytes (Weak Reaction); Lymphocytes (Negative Reaction)
- Marker for Primary Granules and Auer Rods (Used Primary Granules; If Bundles of
Auer Rods are present it is termed as Faggot Cells) which will show Dark Brown
Granules (Packed: If Granulocytic Series; Scattered Activity: Monocytes)
*Fresh Sample as an Ideal Specimen:
- Neutrophils and Monocytes: Diaminobenzedine Method
- Eosinophil: Cyanide-Resistance Peroxidase Stain (Special because even with the
presence of Cyanide it will still give the positive reaction)
*AML (+); ALL (-)
IIIA2. ESTERASES (Hydrolyze the Aliphatic and Aromatic Esters in Acid or Neutral pH)
*Specific and Non-Specific Esterases are different because of the Isoenzyme Present
- Specific Esterase (SE) stains Myeloid Cells (Isoenzyme 1, 2, 7, 8, 9 = Using the Substrate
Chloroacetate)
- Non-Specific Esterase (NSE) stains Monocytes (Isoenzyme 3, 4, 5, 6 = Using the Substrate
Acetate/ Butyrate)
IIIA2a. NAPTHOL AS-D CHLOROACETATE ESTERASE (Specific)
- Marker for mature and immature Neutrophils and Mast Cells
- Bright Red Granules in Cytoplasm of Neutrophils, Neutrophil Precursors, and Mast
Cells
*Not Present in Primitive Myeloblast so it is Less Sensitive than MPO
*Can use Samples in Paraffin-Embedded Sections (ex. Granulocytic Sarcomma)
IIIA2b. α-NAPHTHYL ACETATE ESTERASE (Non-Specific)
- Marker for Monocytes, Histiocytes, Megakaryocytes, and Plasma Cells
- Monocytes stain Red Brown
*Can also stain Lymphocytes but needs Longer Incubation but still has a Weak Reaction (Focal
Dot-Like Reaction)
*Useful in diagnosing Chronic Lymphocytic Leukemia with T-Helper Phenotype
*Sodium Fluoride (Inhibits Esterase Activity) will cause a Negative Reaction
IIIA2c. α-NAPHTHOL BUTYRATE ESTERASE (Non-Specific)
*Even though Non-Specific, it will still stain Isoenzyme 2, 4
- Identifies Monocytes, Promonocytes, and Monoblasts
- Dark Red Precipitates in Cytoplasm
IIIA2d. α-NAPHTHYL BUTYRATE-CHLOROACETATE ESTERASE
- Gives a Definite Ratio between Monocytic and Neutrophilic Components
*Distinguishes M4, M5a, M5b from any other Acute Non-Lymphocytic Leukemia
Positive Reactions: Monocytes = Red; Neutrophils = Blue
IIIA3. PHOSPHATASES (Hydrolyze Monophosphate and Phosphate Esters in an Acidic or
Alkaline pH RESPECTIVELY)
IIIA3a. ACID PHOSPHATASE
- Present in all Hematopoietic Cells and found in Lysosomes
- Activity indicated by Purple to Red Granules
*Use along with Tartaric Acid/ Tartrate (Remember that ACP Isoenzyme that is resistant to the Tartaric
Acid is the Band 5)
*TRAP = Detected in Hairy Cell Leukemia
*T-Cell Leukemia = ACP is Strongly Positive; ACP cannot be stored
*ISOENZYME OF ACID PHOSPHATASE
ISOENZYME POSITIVE CELLS

0 Gaucher Cells

1 and 4 Neutrophils and Monocytes

3a Lymphocytes and Platelets

3b Primitive Cells and Blasts

5 Hairy Cells
IIIA3b. TARTRATE-RESISTANT ACID PHOSPHATASE
- Marker for Hairy Cell Leukemia
- Activity indicate by Purple to Red Granules in the Cytoplasm
IIIA3c. LEUKOCYTE-ALKALINE PHOSPHATASE (LAP/ NAP - Neutrophilic-ALP)
*Kaplow Count - If termed as a test
*Distinguishes Chronic Myelocytic Leukemia (Decreased LAP) and Leukemoid Reaction
(Increased LAP)
- Neutrophils are the Leukocytes to contain various amount of Alkaline Phosphatase
- 100 Cell Count Neutrophilic Origin is counted; Scored from 0 (No Activity) to 4+ (With
Large Amount of Activity)
*Get the Percentage (%): How: Number of 1+, 2+, 3+, or 4+ Cells Counted x Respective Cell Rating
ex. 40 4+ Cells x 4 = 160%, 20 3+ Cells x 3 = 60%, 20 2+ Cells x 2 = 40%; TOTAL: 260%
*Normal Values depends on the Azodye Used: Fast Blue RR: 32-182%; Fast Violet B: 12-180%

IIIA4. IMMUNOCYTOCHEMICAL TECHNIQUES


IIIA5. TERMINAL DEOXYNUCLEOTIDYL TRANSFERASE
- Stains DNA Polymerase
- Present in 90% cases of ALL
- Marker for Immature Lymphocytes

Positive Negative

MPO AML ALL

TdT ALL AML

*MPO and TdT can distinguish AML from ALL


IIIB. NON-ENZYMATIC TECHNIQUES
IIIB1. PERIODIC ACID-SCHIFF (PAS)
- Marker for Glycogen, Glycoproteins, Mucoproteins, and High Molecular Weight
Carbohydrates
- Activity result in Bright Fuschia-Pink
- Pattern of Staining varies each Cell Type
 Lymphoblastic Leukemia: Blocky or Chunky Pattern
 L1 and L2: Block Pattern
 L3: Negative
*All cells are positive except for Erythroblast except for:
 Erythroblast in M6 Leukemia (Erythroleukemia): Positive instead of Negative because it is an
abnormality

IIIB2. SUDAN BLACK B (SBB)


- Same pattern as MPO; More sensitive to Younger Cells
- Marker for Phospholipid and Lipid
- Neutrophil Precursors: Purple-Black Granules
- Lymphoblast: Negative

Positive Negative

MPO and SBB AML ALL

TdT ALL AML

*Difference of MPO and SBB is that SBB can be used in Stored Samples, while MPO needs Fresh
Samples

IIIB3. TOLUIDINE BLUE


- Metachromatic Stain (Strongly Metachromatic) because its color reaction is different to its
original color
- Binds with Acid Mucopolysaccharide in Blood Cells
*Recognizes Mast Cell Diseases and Acute or Chronic Basophilic Leukemia
- Recognition of Mast Cells and Tissue Basophils = Reddish Violet
Precursor B-ALL T-ALL AML

Myeloperoxidase - - +

Sudan Black B - - +

Non-Specific Esterase - - + (M4, M5)


(ex. TdT)
Periodic Acid-Schiff + (Coarse) - + (Fine except M6)

Acid Phosphatase - + -

IIIB4. IMMUNOPHENOTYPING
*Used in the principle of Flow Cytochemistry
- 95% of AML and ALL are diagnosed using Immunophenotyping
- Look for Antigens or Markers on Cell Surface
*SOME USEFUL MARKERS
 CD5 - Expressed on All T-Cells
 CD10 - Expressed on Developing B-Cells
 CD19/ CD20 - Expressed on Mature B-Cells
 CD33 - Expressed on Myeloid Precursors and Monocytes
*Most helpful in Lymphoid Leukemias
IMMUNOPHENOTYPING OF ACUTE LEUKEMIAS
5 Major Groups identified in ALL and 3 Subgroups based of FAB Classification
 Precursor B-ALL
 Burkitt B-ALL
 Precursor T-ALL
*Acute Leukemias of Ambiguous Lineage under WHO Classification
*IMPORTANT MONOCLONAL ANTIBODIES USED IN THE DIAGNOSIS OF ACUTE LEUKEMIA
A. BLASTS
A1. Anti-TdT
- T and B Lymphoblasts
- Less in Myeloid Blasts
A2. HLA-DR
- Myeloid Blasts and B-Lymphoblasts
A3. CD34
B. MYELOID
B1. CD13, CD33
B2. Anti-Myeloperoxidase
C. MONOCYTIC
C1. CD11b, CD14
D. MEGAKARYOCYTE
D1. CD41, CD61
E. ERYTHROID
E1. Anti-Glycophorin
F. B-LYMPHOID
F1. CD10, CD19, CD20, CD22
F2. Surface Immunoglobulins
G. T-LYMPHOID
G1. CD3, CD5, CD7
IV. CYTOGENETICS
*Limited; Can only detect abnormalities that will cause big chunks of Chromosomes to move around
- Examination of Chromosomes under a Microscope
- Gives a rough overall look at all the Patient’s Chromosomes
- Sometimes confirms Diagnosis; Often more useful for Prognosis
V. MOLECULAR STUDIES
- Knowing the DNA Sequence of the Abnormality Involved using PCR and Southern Blotting
- Very Sensitive for Specific Chromosomal Abnormalities
- Can often detect Abnormalities that don’t show up on Cytogenetics

LEUKEMIA
- Generalized Neoplastic Proliferation or Accumulation of Leukopoietic Cells
- A condition in which there is a growth of Tissue that serves No Physiological Function but may
contribute to the Bone Pain in Acute Types of Leukemia
- With or Without the involvement of the Peripheral Blood
- Infiltration of Non-Infiltration of the Hematopoietic Cells
- Problem: Abnormal Proliferation of Stem Cells
- Etiology: Incompletely Understood
LEUKEMIA ACCORDING TO ONSET
A. ACUTE LEUKEMIA
- If no remission, it is fatal within 3 Months; BM is packed with Primitive Cells
B SUBACUTE LEUKEMIA
- Involves a longer Natural History of 3-12 Months; Cells have Intermediate Differentiation; Also
there is a mixture of Blasts Cells and Mature Cells
C. CHRONIC LEUKEMIA
- Survival is for more than 1 Year; Cell Types are more Differentiated

DIFFERENTIATION ACCORDING TO CYTOLOGICAL CHARACTERISTICS (MYELOID)


Acute Chronic

Cells Myeloblast More Differentiated Cells

Age Frequently in Adults Almost Exclusively in Adults

Onset Sudden (Associated with Slow (Associate with


Fatigue, Bleeding, and Infection) Organomegaly particularly
Splenomegaly)

Blood Smear Appearance Blasts Heterogenous Mixture of


Mature Cells

Survival Months to Years Years

DIFFERENTIATION ACCORDING TO CYTOLOGICAL CHARACTERISTICS (LYMPHOID)


Acute Chronic

Cells Lymphoblast Mature Lymphocytes

Age Children Adults

Onset Sudden Slow

Blood Smear Appearance Blasts Homogenous Mixture of


Mature Cells

Survival Years Years


DIFFERENTIATION OF AML VS ALL CLINICAL FEATURES
Factor AML ALL

Age Common in Adults; Rare in Common in Children; Rare in


Children Adults

Extramedullary and Focal Common in Spleen and Liver; Common in Lymph Nodes,
Diseases Less Common in Lymph Nodes Spleen, Liver, Central Nervous
and Central Nervous System System and Gonads

AML VS ALL BLASTS


AML Myeloblast ALL Lymphoblast

Blast Size Large Small

Cytoplasm Moderate Scant

Chromatin Fine, Lacy Dense

Nucleoli Prominent (Usually >2) Indistinct (Usually <2)

Auer Rods Present in 50-60% Never Present

MYELOID DISORDERS
- Comprise a group of closely related syndromes characterized by Self-Perpetuating Proliferation
of BM Cells (Not limited to the WBC but including Erythrocytes and Megakaryocytes)
- Proliferation is Abnormal; Etiologic Cause is Unknown
- All Cell Line or a single Cell Line Predominates (Erythroid Precursors, Granulocytes, Monocytes,
Megakaryocytes)
I. ACUTE MYELOID LEUKEMIA
CLINICAL FEATURES
- Most common during the first Few Months of Life (Second Peak: Middle and Late Ages)
- Childhood and Adolescent: Rare
- Middle and Later Years: Frequent
- Onset resembles an Acute Infection or a Septic Condition (Recall: Fatigue, Bleeding, Infection is
seen during onset of the condition)
- Granulocytic Insufficiency with Ulceration of Mucous Membranes (Particularly Mouth and Throat)
- Fever, Marked Prostration (Severe Loss of Strength), General Malaise (Feeling of being
Unhealthy or Unhappy)
DIAGNOSIS
-Initial Assessment: 500 Cell Count for AML
- ≥20% of the Nucleated Cells are Blast and/or Leukemic Cells
- Calculate the Percentage of Erythroid Precursor Cells
*Erythroleukemia = >50% of BM Cells are Erythroid Precursors
- Should be differentiated from NEC: Among all the Non-Erythroid Cells Erythroleukemia is having
>20% of Myeloblast Present (Most Common)
*ANC = All Nucleated Cells; NEC = Non-Erythroid Cells
*Asides from the Auer Rods, there are also presence of Phi Bodies - Strings of Eosinophilic Granules
seen in the Peroxisome of the Cell (Seen in AML)

ACUTE MYELOID LEUKEMIA CLASSIFICATION


I. FRENCH-AMERICAN-BRITISH (FAB) COOPERATIVE GROUP (1976)
- Morphology of cell in Romanosky-Stained Blood and Marrow Films
- Supplemented by Cytochemical Reactions or Serum Lysozyme Levels
II. WORLD HEALTH ORGANIZATION (WHO) (2001)
- Multilayered approach (Morphology and use of Cytogenetics, Immunophenotyping, and
Molecular Studies)
WHO CLASSIFICATION (Most Commonly used by Physicians)
 Recurrent Acquired Cytogenic Abnormalities (If there is Translocation, Inversion, and what
Chromosomes are involved)
 History of Predisposing Factors/ Multilineage AML
- Prior to Cytotoxic Therapy (Having Chemotherapy which can have side effects causing
Malignancies)
- Prior MDS (Precursor of AML)
 Morphologic Stratification (FAB) - AML not otherwise categorized
A. AML WITH RECURRENT GENETIC ABNORMALITIES
- Affects Children and Young Adults
*Due to the Formation of Fusion Gene (One Chromosome binds with Another Chromosome) resulting
to Chimeric Protein (Abnormal Protein) but still has Good Prognosis
- Involvement of a Committed Precursor
- High Rate of Complete Remission with Chemotherapy
 AML with t(8:21) - (t = Translocation); Seen in 1/3 of M2 Type ANLL Cases; Having favorable
remission EXCEPT if Monosomy 7 is present
 AML with inv(16) - (inv = Inversion); Corresponds to M4; Higher Rate of Extramedullary
Hematopoiesis
 Acute Promyelocytic Leukemia with t(15: 17) - Overlapping of FAB and WHO Classifications;
Differentiation block at the Promyelocytic Stage; Procoagulant Activity of Cells (esp.
Promyelocytes) = Coagulation may occur which is associated with DIC
 AML with 11q23 Abnormalities - t(9:11); Diverse group of Abnormalities associated with Gingival
and Skin Involvement; Indicates Poor Prognosis
B. AML WITH MULTILINEAGE DYSPLASIA
- Indicates Poor Prognosis
- Arise from Myelodysplastic Sydrome (MDS) or Arise from De Novo but with features of MDS
- Typically occur in older people and have poor prognosis
- ≥20% Blasts in Blood and/or Marrow
- Dysplasia in >50% of Cells of at least 2 Lineages
C. AML, THERAPY RELATED
- 10-20% of AML Cases
C1. Alkylating Agent - Related AML
- AML occurs following the treatment of: Chlorambucil, Cyclophosphamide, or Radiation
- Occur 5-10 Years after exposure
- Poor response to therapy
C2. Topoisomerae II Inhibitor - Related AML
- After 1-5 Years Exposure
D. AML NOT OTHERWISE CLASSIFIED (ANLL)/ ACUTE NON-LYMPHOCYTIC LEUKEMIA
*Not categorized because it does not fit in the criteria of the WHO Classification, use:
FAB CLASSIFICATION
- Based on Morphology and Cytochemical Reaction
- Requires presence of ≥20% Blasts in the Blood an/or Marrow
D1. M0 (ACUTE MYELOBLASTIC LEUKEMIA, MINIMALLY DIFFERENTIATED)
- ≥20% ANC are Blasts
- <3% of Blasts are Myeloperoxidase and SBB Positive (Minimally differentiated because
>3% only)
- ≥20% of Blast are Positive for Myeloid Associated Antigens (ex. CD13, CD33, CD117)
*>30% of cells present can’t be differentiated if using Staining Technique
D2. M1 (ACUTE MYELOBLASTIC LEUKEMIA, WITHOUT MATURATION)
- ≥20% ANC are Blasts
- ≥90% of Non-Erythroid Cells are Myeloblasts
*Often confused with the L2 of the Lymphoid Leukemia
- ≤10% of Leukocytes shown Maturation
*Steininger and Review Notes: >30% Blasts; <10% Granulocytes (Termed as No Maturation)
- ≥3% of Blasts are Positive for Peroxidase and SBB
*Weak Result for CAE = Less Sensitive
- t(14:17)
D3. M2 (ACUTE MYELOBLASTIC LEUKEMIA, WITH MATURATION)
- ≥20% ANC are Myeloblasts
- ≥10% NEC are Promyelocytes or More Mature Granulocytes
- <20% are of Monocytic Lineage (Because of the Maturation happening)
- Usually >85% of Leukemic Cells are Positive for Peroxidase, SBB, and CAE (Positive
because granules are already present)
- t(8:21)
D4. M3 (ACUTE PROMYELOCYTIC LEUKEMIA)
- ≥20% Blasts and Abnormal Granular Promyelocytes
- Auer Rods and Faggot Cells
- Usually >85% of Leukemic Cells are Positive for SBB/ PX/ CAE
*DIC present in Recurrent Genetic Abnormalities
- Promyelocytes have Procoagulant Activity which may initiate clotting causing DIC
- t(15:17) particularly in the RARA (Retinoic Acid Receptor Alpha) Gene
- >50% of Promyelocyte Present
*M3M (MICROGRANULAR PROMYELOCYTIC LEUKEMIA) = More specific to occur in Males than
Females
D5. M4 (ACUTE MYELOMONOCYTIC LEUKEMIA)
- ≥20% of ANC are Myeloblasts
*Also known as Naegeli’s Type of Anemia
- Granulocytic series represent 30-80% of NEC
- Sum of Monoblasts, Promonocytes, and Monocytes is: More than 20%; But if compared to
all NEC it is still Less than 80% (Myeloid Lineage % is still greater)
- ≥20% of Blasts are Positive for SBB/ PX/ CAE/ PAS
- Postive for Alpha-NAE and Alpha-NBE
- inv(16)
D6. M5a (ACUTE MONOBLASTIC LEUKEMIA, POORLY DIFFERENTIATED)
*Also known as Schilling’s Type of Leukemia which has the Highest Incidence of Organ
Involvement
- ≥80% of NEC are Monoblasts, Promonocytes, or Monocytes
- ≥80% of Monocytic Cells are Monoblasts (Predominating)
- Negative for SBB/ MPO and Specific Esterase
- Strongly Positive for Non-Specific Esterase (Used to Stain Monocytic Lineage)
- t(9:11)
D7. M5b (ACUTE MONOBLASTIC LEUKEMIA, DIFFERENTIATED)
- ≥80% of NEC are Monoblasts, Promonocytes, or Monocytes
- <80% of Monocytic Cells are Monoblasts (Because they are already mature)
*Presence of Erythematous Rash
- Negative for SBB/ MPO and Specific Esterase
- Strongly Positive for Non-Specific Esterase
D8. M6 (ERYTHROLEUKEMIA)
*Also known as the Di Gugliemo Syndrome or “Erythremic Myelosis” = Presence of Large
Granules in the Cytoplasm
- ≥50% of ANC are Erythroblasts
- Many Erythroid Precursors are PAS Positive (Should be Negative but having a Positive
Reaction to PAS because it is an abnormality)
D9. M7 (ACUTE MEGAKARYOBLASTIC LEUKEMIA)
- ≥20% of NEC are Megakaryoblasts or Leukemic Cells
- Platelet Peroxidase Positive on Electron Microscopy (Found in the Nuclear Envelope and
Endoplasmic Reticulum of developing Megakaryocytes)
- Positive for Glycoproteins Ib or IIIa
- Positive for ANAE but Negative with ANBE (ANBE is very specific for Monocytic Series so
Megakaryoblasts are Negative)
- Affects Chromosome 21
TREATMENT
*Treatment are same except for M3 because it is associated with DIC (Needs more Treatment)
A. CHEMOTHERAPY
Phases:
 Induction of Complete Remission
 Consolidation
 Maintenance Remission
REMISSION INDUCTION
- Goal: Get rid of all Visible Leukemia
DRUGS:
 Cytosine arabinoside (ara-C)
 Anthracycline (Daunorubicin)
*Remission Rate = 65% when use both Drugs
*Amsacrine - Single drug to treat Resistant AML
- Administered in a week
- Requires Hospitalization because Mode of Therapy is Intravenous
- Target: <5% Blasts in the Marrow after 1-2 Weeks (40-80% Success Rate)
CONSOLIDATION THERAPY
- Goal: Destroy any remaining Leukemia Cells and Prevent Relapse
- High dose of Cytarabine in 5 Days
- 15-40% Success Rate
MAINTENANCE REMISSION
- Support the first 2 Phases
- Goal: Complete Healing of Patient
B. STEM CELL TRANSPLANT
*Usually comes from the Umbilical Cord
- After Successful Induction
B1. Allogenic
B2. Autologous
FACTORS CONSIDERED:
 More Intensive Induction
 Availability of Tissue Match
 Presence of 1 or More Adverse Prognostic Factors (ex. Prior MDS)
 Young Patients
 Patient’s Wish
II. CHRONIC MYELOPROLIFERATIVE DISORDERS
- Are malignant clonal proliferation of a Pluripotent Stem Cell (Will affect different Cell Lineage)
- Leads to excessive proliferation of Myeloid Cells in the Blood and Bone Marrow
*May evolve into Acute Type of Leukemia because of the Tissues present which is fit in the description
of AML and not CML
- CML, RCV, MMM, ET
All Myeloproliferative Disorders have in common:
- High White Blood Cell Count with a Left Shift (Except for Chronic Neutrophilic Leukemia - Rarest
form of CMPD)
- A Hypercellular Bone Marrow
- Splenomegaly
A. POLYCYTHEMIA VERA
- Primary Polycythemia (Primary = True Increase)
- Chronic MPD characterized by Panmyelosis (Increase in all Cellular BM)
- True Increased RCM
*Main Cell Type Affected: Erythrocytes
- Mild Granulocytosis and Thrombocytosis
- Erythropoietin (Serum and Urine) = DECREASED
- Dacryocytes (Most common finding in the PB in Long Term PV) which indicates a Transition to
become Irreversible Myelofibrosis/ Myeloid Metaplasia
*Ruddy Cyanotic Appearance = Reddish-Purple Discoloration
A1. ABSOLUTE POLYCYTHEMIA
A1a. SECONDARY POLYCYTHEMIA WITH APPROPRIATELY INCREASED
ERYTHROPOIETIN PRODUCTION
 Decreased Oxygen Loading (Present in Hypoxia, Pulmonary Diseases, Higher Altitudes,
Carboxyhemoglobin, Methemoglobin, HbM)
 Decreased Oxygen Unloading (2,3-DPG Deficiency, Presence of HbBarts, HbF)
A1b. SECONDARY POLYCYTHEMIA WITH INAPPROPRIATELY INCREASED
ERYTHROPOIETIN PRODUCTION
 Neoplasms (ex. Wild’s Tumor, Renal Carcinoma, Cerebral Hemangioma)
 Localized Tissue Hypoxia (Presence of Polycystic Kidney, Renal Artery Stenosis)
 Post Renal Transplant
 Acute Hepatitis
A1c. GENETIC POLYCYTHEMIA
 Primary Familial Congenital Polycythemia (Mutated ABO Receptors)
 Chuvash Polycythemia (Von-Hippel-Lindau Gene)
A1d. PRIMARY MARROW DISORDERS
 Polycythemia Vera (Janus Kinase 2 Gene)
B. CHRONIC MYELOGENOUS LEUKEMIA
*LAP can differentiate CML and Leukemoid Reaction
- Common in >30 years old
- Increased of Mature and Immature Cells of the Granulocytic Series
- Splenomegaly (Due to Extramedullary Hematopoiesis)
- Weight Loss, Fever, and Night Sweats (Will occur due to Increased Metabolism = Increased
Granulocyte Turnover)
- Philadelphia Chromosome (Ph1) - t(9:22) Indicates Favorable Prognosis
COMPLETE BLOOD COUNT
- Anemia, Leukocytosis, and usually Thrombocytosis
- Neutrophil and Basophil Count and usually Eosinophil Count is Increased
- Monocyte Count is usually Increased but Relatively Less Than the Neutrophil Count
- Dominant Cell Types in the Blood are Neutrophils and Myelocytes
- 90-95% of the cases have One Arm of Chromosome 22 to be Translocated to Chromosome 9
- Treatment = Busulfan
*WBC Count = >50x10^9/L
*Philadelphia Chromosomes also indicate the presence of Fusion Gene: BCR-ABL Fusion Gene

CML VS LEUKEMOID REACTION


Leukemoid Reaction CML

Granulocytosis  

Toxic Changes  ×

Basophilia × 

Philadelphia Chromosome × 

LAP Score Increased Decreased

JUVENILE CHRONIC MYELOGENOUS LEUKEMIA


- Seen in Children who have CML Variant with Negative Philadelphia Chromosome Cells
*Occurs in Young Children (1-2 Years Old)
- Increased: Serum and Urine Muramidase Level, HbF
*Increase Leukocyte Destruction = Increase Muramidase Levels
- Decreased: Leukocyte Count, Thrombocytopenia (Moderate to Marked), Decreased Marrow
Megakaryocyte
*CML = Thrombocytosis; JCML = Thrombocytopenia (May cause Hemorrhagic Episodes to occur)
- Poor Prognosis
C. MYELOFIBROSIS WITH MYELOID METAPLASIA (AGNOGENIC MYELOID METAPLASIA)
- Characterized by Fibrosis and Granulocytic Hyperplasia of the Bone Marrow
*Primary Cells affected are Fibroblasts
- Granulocytic and Megakaryocytic Proliferation in the Liver and Spleen
- Middle Aged to Older People
- Dysplastic Megakaryocytosis (Abnormal Platelets are seen in the Circulation, if they die it will
release Granules also releasing Platelet Derived Growth Factor (PDGF) which will cause
Fibroblastic Growth to occur)
*Fibroblast
*Characterized of having Fibrosis in Bone Marrow
D. ESSENTIAL THROMBOCYTHEMIA
*Should be differentiated from PCV
Main Cell Type Affected = Megakaryocytes and Platelets
- Thrombocytosis in Excess of 1000 x 10^9/L with Spontaneous Aggregation of Functionally
Abnormal Platelets
*Sponteneous Aggregation can be seen in Platelet Aggregate Studies
Normal = Secondary Thrombocytosis (Caused by Splenectomy or Chronic Infection
Abnormal = Essential Thrombocythemia (Unknown Cause)
- Increase in Platelet Mass without accompanying Significant Erythrocytosis

III. MYELODYSPLASTIC SYNDROME (MDS)


- Occurs in persons over age 50 median age 70
- Normal Spleen, Liver, Lymph Nodes
- Bone Marrow is Hypercellular
- Maturation of Cells are Abnormal
- “Pre-Leukemia” because it is a precursor of AML
*Progressive Cytopenia occuring in MDS

TYPES OF MYELODYSPLASTIC SYNDROME


A. REFRACTORY ANEMIA
B. REFRACTORY ANEMIA WITH RINGED SIDEROBLAST (RARS)
C. REFRACTORY ANEMIA WITH EXCESS BLAST (RAEB)
D. REFRACTORY ANEMIA WITH EXCESS BLAST IN TRANSFORMATION (RAEB-t)
E. CHRONIC MYELOMONOCYTIC LEUKEMIA (CMML)
*Refractory = Cannot be Treated and Irresponsive to Drugs
RA RARS RAEB RAEB-t CMML

% PB Blasts <1 <1 <5 ≥5 <5

% BM Blasts <5 <5 5-20 20-30 5-20

Other <15% RS; >15% RS; Cell <1x10^9/L; >1x10^9/L;


Significant Oval Dimorphic Dysfunction; Oval Oval
Findings Macrocytes; RBC Oval Macrocytes Macrocytes;
Cytopenias Population; Macrocytes;
Oval Cytopenias
Macrocytes;
Cytopenias
*%PB Blast of CMML is <5 due to Persistence of Monocytosis in the Blood
*CMML will always be Negative for Ringed Sideroblast
*RA, RAEB, RAEB-t, can be Positive or Negative for Ringed Sideroblast

LYMPHOID DISORDERS
- Disorders represent a group of Neoplastic Conditions originating from Cells of Lymphoreticular
System; Not only limited in the Peripheral Blood and Bone Marrow but also includes the Spleen and
Lymph Nodes
LEUKEMIA: Predominantly involves Blood and the Bone Marrow (Use Bone Marrow Biopsy)
LYMPHOMA: Predominantly limited to Lymph Nodes and/or organs (Use Lymph Node Biopsy)

ACUTE LYMPHOBLASTIC LEUKEMIA (ALL)


CLINICAL FEATURES
- Peak of Occurrence: 2 to 5 Years Old
- Symptom of Fatigue (Caused by Anemia which is present), Fever (Due to Neutropenia and
Infection) and Bleeding (Due to the Present Thrombocytopenia)
- Lymphadenopathy, Splenomegaly, and Hepatomegaly
*Important to take what Subtype of ALL is present because it is a Prognostic Factor/ Indicator
*ALL SUBTYPES: T-Cell Leukemia, Early Pre-B Cell Leukemia, Pre B-Cell Leukemia, B-Cell
Leukemia
- Periosteal and Meningeal Infiltration
- Subarachnoid Hemorrhages
FAB CLASSIFICATION OF ALL (Morphology as Basis)
 L1 (Childhood ALL) - (Small and Homogenous Cell); Small Cells, High Nuclear:Cytoplasmic
Ratio; Best Prognosis among the ALL
 L2 (Adult ALL - >15y/o)- (Large and Heterogenous Cell); Larger Cells, Lower Nuclear
Cytoplasmic Ratio
 L3 (Burkitt Type) - (Large and Homogenous Cell); Combination of L1 and L2- Vacuolated (Stain
with Oil Red O), Basophilic Blast Cells; Poor Prognosis
WHO CLASSIFICATION (GENERAL)
 Precursor B Lymphoblastic Leukemia
 Precursor T Lymphoblastic Leukemia
 Burkitt Leukemia

A. PRECURSOR B LYMPHOBLASTIC LEUKEMIA


*Fatigue, Bleeding, Fever; Cure Rate is 80%
- Most common type of ALL
- Most common Malignancy in Children and Adolescents
*Cure Rate: 80%
BLOOD
- Leukocytosis
- Lymphoblast
- Anemia
- Thrombocytopenia
MARROW: 50% Blasts
*5-10 y/o = Favorable Prognosis; <5 y/o = Poor Prognosis
POSITIVE FOR
 TdT, CD22, CD79A, CD19, CD10, HLA-DR
 Translocation: t(12:21), t(9:22), t(4:11)
*t(12:21) = Favorable Prognosis; t(9:22), t(4:11) = Poor Prognosis
 Hyperploidy (Excess of 1 or More Chromosomes)
NEGATIVE FOR: SBB, Peroxidase, Naphthol AS-D CAE
*FAVORABLE PROGNOSIS: 5-10 y/o, Presence of t(12:21) and Hyperploidy

B. PRECURSOR T LYMPHOBLASTIC LEUKEMIA


- 10-20% all the ALL
- Affects Boys more than Girls
*Precursor T ALL is characterized to be a Lymphoma than a Leukemia because it can be seen with
the presence of the condition Mediastinal Lymphoma
BLASTS: Similar to all B-ALL
POSITIVE FOR: TdT, CD7, CD3, CD1a, CD2, CD5, and MAY BE Postive for CD4, and CD8

C. BURKITT LYMPHOMA
- 1/3 Cases of Pediatric Non-Hodgkin’s Lymphoma
- Having “Starry Sky” Pattern = Diffused Lymphoid Proliferation
2 TYPES
C1. Endemic
- Common in Africa
- Associated with EBV Infection
C2. Sporadic
- Worldwide
- Not Associated with EBV
- May occur in Adults
BLAST
POSITIVE FOR: CD19, CD22, CD20, CD79, CD10
- Translocation of C-MYC on Chromosome 8q24
*C-MYC = Suppose to be a Regulator Gene; In BL it is an Oncogene (Can transform into Tumor Cell)
NEGATIVE FOR: TdT
*90% Cure if treated with Chemotherapy
*Rapid Disease Progression due to Very High Mitotic Rate

CHRONIC LYMPHOCYTIC LEUKEMIA (CLL)


*Also known as SMALL LYMPHOCYTIC LEUKEMIA under the WHO Classification but have different
activities:
*CLL = Observed in the PB and BM
*SLL = Observed in Lymph Node and Lymphoid Organs
- Abnormal Proliferation of Small Lymphocyte (Seen in PB, BM)
CLINICAL FEATURES
- Most common above Age of 60
- Twice as common in Men than in Women
- Insidious Onset: Discovered by chance
- Lymphadenopathy and Asymptomatic
- Weakness, Fatigue, Anorexia, Weight Loss
- Enarged Lymph Nodes, Spleen and Liver

Smudge Cells
- Associated with the Diagnosis of CLL
- Disintegrated Lymphocytes
- Uncommon Finding in Other Malignancies

A. HAIRY CELL LEUKEMIA


- Characterized by Proliferation of Abnormal Cells in the Reticuloendothelial Organs and Blood
- Subtypes of B-Cells Infiltrate
- 50 Years Old (Often in Males); *Median Age Affected = 55 y/o
- Insidious Onset
- Splenomegaly and Pancytopenia
- 5-6 Years Survival
*Strongly Positive for CD19, CD20, CD22 (19, 20 = For Mature B-Cells)

DIAGNOSTIC CHARACTERISTICS

- B-Cells with Numerous Hair-Like Projection in the Cytoplasm


- Cells contain Tartrate Resistant Acid Phosphatase (TRAP)
*Bone Marrow Biopsy described as “Dry Tap” because BM is
Fibrotic (Filled with Reticulin Fibers)

LYMPHOMA
- Neoplastic Proliferation of One Cell Type of the Lymphoreticular Tissue
- Involves the Spleen, Lymph Nodes, and GIT
CLASSIFICATION
A. NON-HODGKIN’S LYMPHOMA (Burkitt’s Lymphoma)
- 95% of Neoplastic Cells are B-Cells; 5% T-Cells
B. HODGKIN’S LYMPHOMA/ HODGKIN’S DISEASE (Hereditary Disease)
B1. NODULAR LYMPHOCYTE-PREDOMINANT HODGKIN LYMPHOMA

- Comes from the Germinal Center of Lymphoid Cells


- Have “Popcorn Cells” (Relatively Rare Neooplastic Cells)
- Large, Multilobed, Folded Nucleus; and Surrounded by Small
Lymphocytes

B2. CLASSICAL HODGKIN LYMPHOMA

- Presence of Reed-Sternberg Cell” = Owl’s Eye Appearance


(Binucleated Cells with Prominent Nucleolus)

C. MYCOSIS FUNGOIDES
*Most common Cutaneous Lymphoma
- Lymphoreticular Neoplasm primarily involving the skin
- More common in Men than in Women
- Having Pautrier’s Abscesses (Neoplastic Cells infiltrate the Epidermis and form clusters) which is
Limited only in the Skin, but termed as Sezary’s Syndrome if the Neoplastic Cells are found in the
Skin, Lymph Nodes and Visceral Organs; All the symptoms plus Lymphocytosis
*“Cerebriform Nuclei” - If seen in PB is an indication MF or SS

*PLASMA CELL CLASSIC FEATURES

- Oval Cytoplasm, Round Nucleus off to Side


- Cartwheel/ Clockface Chromatin
- Prominent Golgi or “Hof” = Light Staining area of Plasma Cells
*Responsible in Synthesizing the Immunoglobulins
PLASMA CELL DYSCRASIAS
- Involves the Immunoglobulin
A. MULTIPLE MYELOMA
* Spike in the Serum Protein Electrophoresis
- Rare; Affects 40 y/o
*Abnormal Clones will Synthesize L-Chain (Light Chains)
- Multiple Proliferation of Plasma Cells in the BM
- Mean age affected is 60 Years Old
- Bone Pain and Neurologic Symptoms
>50% IgG, 20% IgA, <1%IgD, Very Rarely IgE
RISK FOR INFECTION: Impaired Antibody Production
MOST COMMON SYMPTOM: Pathologic Fractures, Bone Pain (Due to Patchy Infiltrates in Skeletal
Structure) = Causes Osteolysis which may lead to Osteoporosis
BLOOD PICTURE:
 Normocytic, Normochromic Anemia
 Rouleaux Formation - Marked Increase in Serum Globulin (Due to Reduce Z-Potential)
*Abnormal Clones will Synthesize L-Chain
Plasma Cells = 1-3% of Marrow, >20% or Plasma Cells
*In the Blood Circulation, Plasma Cells are seen with having
B-Pleated Sheets
- >50% IgG, 20% igA, <1% IgD, Very rarely IgE
- Amyloidosis (Proteinaceous Deposits from all over the body)
*Proteinaceous Fragments are mostly L-Chain Fragment
(Stained with Congo Red)
*Primary Amyloidosis: If L-Chain Fragments are seen (Lambda
has more potential than Kappa to produce deposits)
*Secondary Amyloidosis: Due to Chronic Illness, no L-Chain
Fragments
- Secretion of Free Monoclonal Light Chains (Bence-Jones Protein) in the Urine (Indicates Renal
Failure)
B. PLASMA CELL LEUKEMIA
- Large amount of Plasma Cells are found in the Circulation
- >2x10^9/L
*Seen in Younger Age Group
- Less Bone Pain than MM; Presence of Hepatosplenomegaly and Lymphadenopathy
C. WALDENSTROM’S MACROGLOBULINEMIA
- Characterized by Greater Degree of Maturation of B-Cells to Plasma Cells
- Increased production of IgM (Increased IgM will form Glomerular Lesions)
- Common among 60-70 Years Old
*Rarely occurring Bone Pain
*Mast Cells are helpful in the diagnosis of WMG
*Flame Cells = (Pink to Red Cytoplasm); Lymphocyte with Alteration seen in Leukemia/ Lymphoma;
Indicates there is Increased IgA and can also be found in Multiple Myeloma
*Mott Cells with Russell Bodies/ Grape Cell/ Morula Cell/ Berry Cell = Plasma Cells With Vacuoles
(Accumulation of Immunoglobulins = Rusell Bodies)
*Dutcher Bodies - Immunoglobulins Filled in Cytoplasm; But Invagination happens in the Nucleus
creating an Appearance of Intranuclear Body/ Inclusion

HEAVY CHAIN DISEASES


 GAMMA HEAVY CHAIN DISEASE
- Resemble Malignant Lymphoma (With Fever and Erythema)
- Occuring in Older Men
 ALPHA HEAVY CHAIN DISEASE
*Most common among the 3 HCD
- Histiocytic Lymphoma of the Intestine of Respiratory Tract
- Infiltration of Plasma Cell in the Duodenum/ Jejunum (Malabsorption Syndrome occurs)
- Present in the Respiratory Tract due to the Secretory Site for IgA (causes Pulmonary Efficiency)
 MU HEAVY CHAIN DISEASE
*Rarest
- Associated with Chronic Lymphocytic Leukemia (CLL/SLL)
- Proliferation of Small Lymphocytes

SEA BLUE HISTIOCYTOSIS


- May also be described CLL
Sea-Blue Histiocytes - Lipid Rich Granules