mlab 1415- hematology keri brophy-martinez introduction to hematopoietic neoplasms
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MLAB 1415- HematologyKeri Brophy-Martinez
Introduction to Hematopoietic Neoplasms
Terms Neoplasm or tumor: “New growth”
Results from a dysregular prolieferation of a single transformed cell Can be malignant or benign
Malignant “Deadly” Clone of abnormal, proliferating cells, without function or
differentiation Have the potential to metastasize or get bigger “Cancer”
Benign Premalignant Originate from highly organized, differentiated cells Do not spread or invade surrounding tissues
Classification of Neoplasms in Bone Marrow
Lymphoid Only lymphocytic cells affected
Myeloid Granulocytes, monocytes, megakaryocytes,
erythrocytes affected Both Lymphoid and Myeloid lines can
include benign and malignant neoplasms
More Terms Leukemia
A malignant disease of hematopoietic tissue characterized by replacement of normal bone marrow elements with abnormal (neoplastic) blood cells. Abnormal cells are also seen in peripheral blood
Lymphoma Abnormal proliferation of lymphoid cells within the
lymphatic tissue or lymph nodes, results in a solid tumor
Leukemias
General ClassificationAcute Chronic
Age All ages Adults
Clinical onset Sudden Gradual
Course of disease Weeks to months Months to years
Predominant cell BlastsSome mature forms
Mature forms
Anemia Mild-severe Mild
Thrombocytopenia Mild-severe Mild
WBC Variable Increased
Organomegaly Mild Prominent
Blood Picture
Acute Chronic
How Do Leukemias Arise? Somatic mutation of a single
hematopoietic stem or progenitor cell
Unlimited self-renewal of the cancer-initiating cell
As the mutant cell line predominates, normal hematopoiesis is inhibited causing leukemic cells to spill into peripheral blood
Proto-oncogenes and Oncogenes Proto-Oncogene—normal unaltered gene that has the
potential to become an oncogene Oncogene–Altered cell genes that cause tumors Located at breakpoints of chromosomal aberrations, such as
translocations
Oncogene Activation Factors
Genetic susceptibility Fanconi’s anemia Down’s syndrome (18-20 fold increased incidence)
Somatic mutation Ionizing radiation, nuclear weapons Chemicals and drugs Benzene,Chloramphenicol, phenylbutazone Certain chemotherapy drugs that are cytotoxic, especially when used in conjuction with
therapeutic radiation Viral infection
Retrovirus-HIV-1, HTLVI, II EBV
Immunologic dysfunction Ataxia-telangiectasia - lymphoid leukemia or lymphoma Sex-linked agammaglobulinemia
Epidemiology Most new cases found in older adults ( > 67 yrs old) 50% of leukemias are acute More common in whites More common in males Age groups
ALL: children 2-5 years old: lymphoid CLL: Adults> 50: lymphoid AML: adults: myeloid CML: adults: myeloid
Evaluation of Leukemia Note onset of symptoms Analyzing CBC
Thrombocytopenia? RBC level/ anemia?
Observe cell lineage Lymphoid or Myeloid?
Assess maturity of predominating cells
Lab Features and Patient Symptoms Normochromic,normocytic anemia
Due to erythropenia
Thrombocytopenia Results in bleeding episodes Platelet morphology and function can be abnormal
Leukocyte count can be increased, decreased or normal If count decreased- results in infections
Immature leukocyte precursors seen Bone marrow hypercellular
Bone pain due to marrow expansion
Maturation abnormalities in all cell lines Uric acid increased
Due to cellular breakdown
Official Hematopoietic Neoplasm Classification
Two systems French-American British(FAB)
Historical World Health Organization (WHO)**
Widely accepted Important because..
Allows clinicians a way to compare therapeutic regimens System for ID and comparison of clinical features & lab findings Permit associations of cytogenetic abnormalities with disease
FAB classification
Consists of three groups Myeloproliferative Disorders(MPD) Myelodysplastic Syndromes(MDS) Acute leukemia (AL)
Based on morphological characteristic of Wright-stained cells in peripheral blood or bone marrow with supplementary cytochemical stains
WHO Classification Classification system uses morphology, cytochemistry and
immunophenotyping to determine cell lineage and degree of maturation(similar to FAB)
Additionally uses genetic and clinical features prior to therapy and history of MDS to define subgroups
Consists of three groups Myeloid
Further classified as MPD, MDS/MPD, MDS, AML
Lymphoid Further classified as B/T cell, T/NK cell, Hodgkin’s Disease, CLL
Histiocytic
Lab Techniques for Diagnosis and classification of neoplasms
Cytochemical analysis In vitro staining of cells to look at cells’ chemical
composition Evaluation of positivity in these stains must be
determined on the leukemic blast stage of the cell Usually performed on bone marrow slides Helpful in differentiating lymphoid or myeloid lineage of
blasts in AL Reactions are either enzymatic or nonenzymatic
Cytochemical stains Types
Myeloperoxidase (MPO) Activity is present in the primary granules and Auer rods of
myeloid cells Separates myeloid and lymphoid blasts Stains late myeloblasts, granulocytes, monocytes less intensely Differentiates AML from ALL Granules stain black to reddish-brown
Cytochemical stains: con’t Sudan Black B
Activity is present in phospholipids in the membrane of 1J (nonspecific) and 2J granules (specific)
Differentiates AML from ALL Granules stain black
Periodic Acid Schiff (PAS) Activity is in glycogen and related substances Stains lymphocytes, granulocytes, megakaryocytes Helpful in diagnosing erythroleukemia where there is strong reactivity
in normoblasts Stains red-purple in blocks in cytoplasm
Cytochemical stains: con’t Esterases
Specific Esterase (Naphthol AS-D Chloroacetate) Activity is in cytoplasm Stains neutrophilic granulocytes, differentiates monoblasts and
myeloblasts Granules of myeloblasts stain blue-black
Nonspecific Esterase (Alpha-Naphthyl Acetate) Activity is in cytoplasm Stains monocytes and also megakaryocytes Differentiates myeloblasts from monoblasts Granules stain orange red
Cytochemical stains: con’t
Leukocyte Alkaline Phosphatase (LAP) Enzyme within the 2O or specific granules of maturing
granulocytes Distinguishes leukemoid reactions ( ) from chronic
myelogenous leukemia ( ) Acid Phosphatase (Tartrate Resistant)
Present in lysosomes in normal leukocytes Helpful in diagnosing hairy cell leukemia because they
are NOT inhibited by TRAP
Cytochemical stains: con’t
Terminal Deoxynucleotidy transferase (TdT) Primitive cell marker found in cell nuclei Distinguishes ALL from malignant lymphoma
Toluidine Blue Positive marker for basophils and mast cells
Lab Techniques for Diagnosis and classification of neoplasms
Immunologic marker studies Cell surface markers
Monoclonal or polyclonal antisera is added to cell suspensions of fresh peripheral blood or bone marrow and an immunofluorescent method is used in a flow cytometry instrument to analyze the markers which are expressed as cluster designations (CD).
CD’s identify antibodies that are specific for certain cells and allow for a positive identification.
Lab Techniques for Diagnosis and classification of neoplasms
Molecular Genetics This newer method of diagnosing leukemia consists of DNA probes and
polymerase chain reaction (PCR)-based studies. They are rapid and precise and are used to confirm chromosomal abnormalities that are not detected by conventional studies. They are also used to monitor residual disease
following therapy. FISH (Fluorescence in situ hybridization) Cytogenetics (Chromosome studies)
Identifies chromosome translocations which are specific for certain leukemias
Philadelphia chromosome (t[9:22]) is associated with CML t[15:17] is associated with acute promyelocytic leukemia
Treatment Cures are not common except in childhood
leukemia. The best hope for a cure in adults lies in bone marrow transplantation. Cytoreductive chemotherapy
Reduces the leukemic cell mass Block DNA synthesis Block RNA synthesis Complications arise from marrow hypoplasia and
resulting cytopenia
Treatment Radiotherapy (radiation)
Kills focalized leukemic cells Usually used in addition to chemotherapy and for CNS
prophylaxis
Bone marrow transplantation Bone marrow is eradicated with chemo and radiation. Compatible donor cells are transfused and they travel to the
empty marrow where they engraft and repopulate the marrow with healthy cells.
Complications include graft vs host (GVH) disease which can be fatal.
References McKenzie, Shirlyn B., and J. Lynne. Williams. "Chapter 21."
Introduction. Clinical Laboratory Hematology. Boston: Pearson, 2010. Print.
http://www.lls.org/content/nationalcontent/resourcecenter/freeeducationmaterials/generalcancer/pdf/facts.pdf