Hematology 3

• RENE JESUS ALFREDO D. DINGLASAN RMT
• HEMATOLOGY PART 3
• Dohle bodies


  Smaller, round, PAS positive, contain ribosomal RNA
• MHA inclusions


  Larger, spindle-shaped, PAS negative, contain messenger RNA
• Leukemia


  • Malignant neoplasm of the blood-forming tissues of the bone marrow, spleen, and lymph system
  • More blasts: shorter, more fatal course of disease
  • Increased WBC count with shift to the left
  • M:E ratio of 10:1
• Type of anemia usually present in cases of acute leukemia is normocytic, normochromic
• Acute leukemias


  Described by symptom of short duration, numerous immature cell forms in the bone marrow and/or peripheral blood, increased total WBC count
• Chronic leukemias


  Described by symptoms of long duration, mostly mature cell forms in the bone marrow and/or peripheral blood, total WBC count ranges from extremely elevated to lower than normal
• FAB (French, American, British) Classification of Anemia is based on morphology of cells in Romanowsky-stained smear and cytologic and histochemical characteristics of cells involved
• Lymphocytic Leukemias


  • Myeloperoxidase negative
  • Sudan Black B negative
• Acute Lymphocytic Leukemia (ALL)


  • Most common form of childhood leukemia
  • Classification by FAB into 3 subtypes (L1, L2, L3)
  • Differentiating factors include cell size, nucleus, nucleolus, chromatin, cytoplasm, and cytochemistry
• Immunologic markers for ALL subtypes

  • E-rosette
  • Surface Ig
  • Serum Anti-ALL
• Chronic Lymphocytic Leukemia (CLL) is the most common type in the elderly
• CLL


  Characterized by persistent lymphocytosis and presence of increased number of smudge cells and Rieder cells in the peripheral blood smear

  
• Clinical variations of CLL

  • Hairy-cell leukemia
  • Lymphosarcoma cell leukemia
  • Prolymphocytic leukemia
• Solid tumor counterparts of leukemia types

  • Acute Lymphoblastic Leukemia (ALL) - Lymphoma, poorly differentiated; lymphocytic
  • Chronic Lymphocytic Leukemia (CLL) - Lymphoma, well-differentiated; lymphocytic
  • Monocytic Leukemia - Reticulum cell sarcoma
  • Acute Myelogenous Granulocytic Leukemia - Chloroma
  • Plasma Cell Leukemia - Myeloma / Plasma Cell Myeloma / Multiple Myeloma (excess Bence-Jones proteins)
  • Stem Cell Leukemia - Lymphoma, undifferentiated
• Non-lymphocytic leukemia / myelogenous leukemias are generally myeloperoxidase positive and Sudan Black B positive
• Acute Myelogenous Leukemia (AML) subtypes

  • M0 - AML, minimally differentiated
  • M1 - AML, without maturation
  • M2 - AML, with maturation
  • M3 - Acute Promyelocytic Leukemia (APL)
  • M4 - Acute Myelomonocytic Leukemia (AMML)
  • M5 - Acute Monocytic Leukemia (AMoL)
  • M6 - Acute Erythroleukemia
  • M7 - Acute Megakaryocytic Leukemia
  • M8 - Acute Basophilic Leukemia
• Auer rods


  • Linear projections of primary granules which aggregate to form rod-like materials, associated findings in some AML subtypes
• M3V (Acute Promyelocytic Leukemia, microgranular variant) cells have characteristic "butterfly", "bowtie", "coin-on-coin", or "apple core" nuclei
• Cytochemical stains for leukemia identification

  • Myeloperoxidase (MPO)
  • Sudan Black B (SBB)
  • Naphthol-D Chloroacetate (SE stain)
  • α-Naphthol Butyrate Esterase (NSE stain)
  • α-Naphthol Acetate Esterase (NSE stain)
  • Factor VIII stain
• Cytochemical stain reactions based on cell of origin

  • Myelocytic - positive for MPO, SBB, SE stain
  • Monocytic - positive for NSE stains
  • M7 - positive for Factor VIII stain only

  
• WHO Classification of AML

  • AML with certain genetic abnormalities
  • AML with myelodysplasia-related changes
  • AML related to previous chemotherapy or radiation
  • AML, NOS (not otherwise specified)
  • Myeloid sarcoma
  • Myeloid proliferations related to Down syndrome
  • Undifferentiated and biphenotypic acute leukemias
• Chronic Myelogenous Leukemia (CML)

  Also known as Chronic Granulocytic Leukemia, characterized by the presence of Philadelphia Chromosome (Ph1), has 3 clinical phases: chronic, accelerated, and blast crisis
• Coma


  Also known as Granulocytic Sarcoma or Chloroma
• Undifferentiated and biphenotypic acute leukemias

  • Are NOT strictly AML
  • Leukemias that have both lymphocytic and myeloid features
  • They are sometimes called MPALS (mixed phenotype acute leukemias)
• French, American, British Cooperative Group (FAB) is an old system devised during the 1970's
• World Health Organization (WHO) is a new system currently followed
• AML, NOS (Not Otherwise Specified) Group is where the majority of FAB leukemias are grouped under, which means the FAB classification is not completely eradicated but regrouped under WHO
• Chronic Myelogenous Leukemia (CML)


  • Also known as Chronic Granulocytic Leukemia (CGL)
  • Characterized by the presence of Philadelphia Chromosome (Ph1)
  • Has three clinical phases: Chronic phase, Accelerated phase, Blast crisis
  • Majority (90%) of patients with CML have the Philadelphia chromosome
• Philadelphia Chromosome indicates GOOD PROGNOSIS (meaning that the patient might get well)
• Philadelphia Chromosome


  • Symbol: (Ph1) read as Ph superscript 1
  • Due to the reciprocal transmutation of the part of the long arm of chromosome 9 (ABL gene) and the long arm of chromosome 22 (BCR gene)
  • The BCR and ABL gene are fused together. The fused gene is found at the long arm of the aberrant of chromosome 22
  • Abnormal chromosome 22 = Philadelphia chromosome

  
• BCR-ABL fusion gene


  • Also known as BCR-ABL1 fusion gene
  • Responsible for the characteristics sign and symptoms exhibited by patients with CML
• Leukemoid Reaction (LR)


  • Clinical syndrome resembling leukemia (CML)
  • LR is not a disease, it is only a description
  • The suffix "-oid" in medicine means "similar to"
  • Excessive leukocytic response in the peripheral blood
  • WBC ct.: greater than 50 X 109/L (with neutrophilia and a marked left shift [presence of immature neutrophilic forms])
  • LR most frequently refers to neutrophils, but the increased count may be due to an increase in other types of WBC
• Leukocyte (Neutrophil) Alkaline Phosphatase (LAP/NAP) Test

  • Generally used to distinguish LR from CML
  • Among all the leukocytes, only neutrophils contain the alkaline phosphatase enzyme
  • Principle: ↑ LAP activity can be observed in neutrophils that have undergone normal growth
  • NORMAL GROWTH: ↑ LAP activity
  • ABNORMAL GROWTH (ex. leukemia): There are plentiful amounts of neutrophils in the peripheral blood, but they contain little to no amount of alkaline phosphatase

  
• The LAP/NAP testing may be different from one laboratory to another. According to our sources, different reagents and stains are used in different clinical laboratories which means they have different reference ranges (sobrang magkakalayo).
• Kaplow's Method


  • Principle: Hydrolysis of sodium alpha naphthyl phosphate by alkaline phosphatase produces a colored precipitate with a diazotised amine
  • One of the methods or technique for lap determination
  • Reagents: Fixative (Methanol and formalin), Buffer (Propanediole), Substrate (Sodium alpha naphthyl phosphate), Initial stain (Brentamine-fast garnet salt), Counterstain (Aqueous Mayer's hematoxylin)
• Normal Lap scores are not the same because of different reagents used by laboratories.
• If there is interpretation of LAP score in the board examination, they would give the normal value they will use because normal values has different ranges.
• Kaplow's (LAP) Score


  • Normal Kaplow's (LAP) Score = 15 to 100
  • LAP score normal value is specific to kaplow's method