HEMATOLOGY 2  Hypertension
PRELIMS I FIRST SEMESTER  Hepatomegaly (extramedullay hematopoiesis)
INSTRUCTOR: DR. MARILYN D. CASTRO RMT MD
LABORATORY FINDINGS
CHRONIC MYELOPROLIFERATIVE DISORDERS PERIPHERAL BLOOD
GENERAL CONSIDERATIONS
 Chronic MPDs are usually found in patients in
their 5th and 6th decades
 Clonal abnormalities (single abnormal cell)
 Cells involved include mature and immature
granulocytes, erythrocytes, and platelets
 All have strong inter-relations - frequent
transformation between them - commonly
terminate as AML or ALL (small percentage)
 Common manifestations
o Splenomegaly
o Cellular cytosis
o Degrees of marrow fibrosis
POLYCYTHEMIA VERA
 "Vera" - L. true
 Characterized by PANMYELOSIS specifically
red cells
 Also known as primary polycythemia
 RBC count are usually > 5.9 * 10 ^ 12 / L
(women) and 6.6 X 10 ^ 12 / L (males)
associated with an increase in plasma volume
 Most causes of absolute and relative
polycythemia should be ruled out.
LABORATORY FINDINGS
BONE MARROW
CLINICAL PRESENTATION
 50-60 years old but can be seen in all age
groups
 Combination of headaches, vertigo, ringing of
the ears, blurred vision, upper Gl pain (peptic
ulcers), feeling of fullness (splenomegaly),
and pruritus
 Mucous membranes have a ruddy cyanotic
(reddish purple) color
 Gout
 High erythrocyte count (may reach to levels
of 10 * 10 ^ 12 / L )
 High hemoglobin
 High hematocrit
 MCV and MCHC are low normal to low
because of decreased or absent iron stores as
a result of chronic bleeding and phlebotomy
 Occasional nRBC
 Reticulocyte count is not characteristically
increased
 LAP score is increased
 Red cell mass (RCM) increased
 WBC and platelet count are increased
(characteristic!)
 Slight WBC shift to the left
 Basophils are frequently elevated
 Abnormal platelet forms may be present
 Decreased PF-3
 No signs of marrow fibrosis
 Smears are prepared with much difficulty
because of blood viscosity
o Dilute with equal amount of saline before
smearing
 Hypercellular marrow with fat spaces filled
with red blood cells
 Increased megakaryocytes and normoblast
numbers
 Abnormal and large megakaryocytes
 Increased d basophils=Increased I histamine
(itching)
 Minimal to absent fibrosis but tends to
G.S TOLEDO
 worsen with disease progression  Decreased serum iron
Due to Megakaryocytic alpha granules releasing  Decreased ferritin
platelet derived growth factors
 Decreased to normal serum erythropoietin
Decreased to absent iron

DIAGNOSIS
POLYCYTHEMIA VERA STUDY GROUP CRITERIA FOR
DIAGNOSIS OF PV
CATEGORY A CATEGORY B
Increased red cell mass Thrombocytosis
 Male >36mL / kg  Platelets > 400 *
10 ^ 9 / L
 Female >32mL/kg
Leukocytosis
Normal arterial 02
saturation  WBC > 12 * 10 ^ 9
/L
 >92%
 +/- fever or
Splenomegaly infection
Increased LAP (> 100 )
with no fever or infection
Increased serum B12
 > 900ng / m * L
Increased unbound B12
binding capacity
 > 2200ng / m * L

DIFFERENTIAL DIAGNOSIS
 SECONDARY POLYCYTHEMIAS - increased
erythropoietin
 COMPENSATORY ERYTHROCYTOSES -
associated with tissue hypoxia
o INCREASED ERYTROPOIETIN - High
altitudes, CVD or pulmonary diseases,
abnormal hemoglobins with increased
oxygen affinity, and heavy smoking
o INAPPROPRIATE ERYTHROPOIESIS -
kidney diseases and tumors, liver CA,
ovarian tumors, uterine fibroids,
cerebellar hemangioblastomas

LABORATORY FINDINGS  RELATIVE POLYCYTHEMIA - not associated

with true increases in RCM and is measured
CHEMISTRY by the microhematocrit
o Elevation is due to decrease in plasma
volume
 Normal to elevated values of serum B12
o Dehydration and burns
 Increased B12 binding capacity
G.S TOLEDO
EFFECTS OF TREATMENT ON LABORATORY FINDINGS CLINICAL PRESENTATION
May be treated with:  Fatigue
 Phlebotomy  Shortness of breath after mild exertion
o Tends to worsen iron deficiency  Malaise
o Aggrevate thrombocytosis  Fullness (hepatosplenomegaly) - worst in
children
 Radioactive Phosphorus (^32P)
 Anorexia and weight loss
o Reduce platelets and RBCs
 Priapism (due to increased platelet and WBC
 Myelosuppresive drugs (Busulfan and count)
Chlorambucil)
 Platelet abnormalities (retinal hemorrhage,
o Increase malignancy hematuria, epistaxis)
o HYDROXYUREA (drug of choice)  Sternal tenderness
 May correct RBC and WBC  Warm and moist skin
 High normal platelet count  (+) lymphadenopathy
 Hypogranular granulocytes  Adult - low grade fever
 Platelet hypofunction and giant
morophology
LABORATORY FINDINGS
CYTOGENETICS
CHRONIC MYELOGENOUS LEUKEMIA
 PHILADELPHIA CHROMOSOME - found - in
 Malignant disorder characterized by cells of the
leukocytosis with increased mature and malignant
immature granulocytes proliferating
clone in 70%
 Thrombocytosis is common to 90% of
patients with
 Splenomegaly (extramedullary CML
hematopoiesis)
 Results from
 (+) Philadelphia chromosome (Ph¹) that is the t (9q^ +
found in granulocytes, RBC, platelets and B ;22q^ - )
cells
 Primarily a disease of adults
LABORATORY FINDINGS
 JUVENILE CML - reserved for P H^ 1- cases of
- infants and children <2 years old PERIPHERAL BLOOD

 Marked WBC elevation (50 - 600 * 10 ^ 9 / L)

 Anemia if present is N / N
 Platelets may be increased or decreased
o RULE: Platelets are inversely proportional
to WBC count in CML
o Attributable to "squeezing out" of marrow
megakaryocytes by the abundance of
WBC
 Dysplastic granulocytes and platelets ARE
NOT CHARACTERISTIC of CML except in:
G.S TOLEDO
 o Myeloid blast formation o Granulocyte hyperplasia in the marrow
o Ph1 CML o Proliferation of granulocytes in the spleen
and the liver
o Initial patients seen with CML in blast
transformation  Middle age and older people
 Consistent findings : defective platelets
secondary to dysplastic
LABORATORY FINDINGS megakaryocytopoiesis
BONE MARROW  Alpha granular release → PDGF → Fibrosis
 Markedly cellular with minimal fat with
predominance of the granulocytic series
CLINICAL PRESENTATION
 Shift to the left
 Anemia
 Increased megakaryocytes
 Abdominal pain
 (+) fibrosis
 Indigestion and fullness
 Fever and night sweats
DIFFERENTIAL DIAGNOSIS
 Patients appear ashen
 Must be differentiated with "Leukemoid
reaction"  Liver enlargement
 Epistaxis
JUVENILE CML  Petechiae
 Not chronic MPD
 Seen in children with P * h ^ 1 cells LABORATORY FINDINGS
 Peak age = 2-12 years PERIPHERAL BLOOD
 Unfavorable prognosis  Leukocytes and platelets may be increased,
normal or decreased
 Dyserythropoiesis
 Anemia = N / N or Hypo/Micro especially if
 Markedly increased serum muraminidase bleeding is evident
levels secondary to increased WBC
destruction  DACROCYTOSIS
 Leukocyte count below 100 * 10 ^ 9 / L  Occasional nRBC
 Increased HbF  Giant or agranular platelets
 Marked thrombocytopenia and decreased  Rare megakaryocyte fragments
marrow megakaryocytes
 Occasional immature myeloid cell
 Rare myeloblast
AGNOGENIC MYELOID METAPLASIA
 Mild reticulocytosis

 AKA - IDIOPATHIC MYELOID METAPLASIA,

MYELOFIBROSIS WITH MYELOID ETAPLASIA, LABORATORY FINDINGS
or IDIOPATHIC MYELOFIBROSIS
BONE MARROW
 Describes a clonal chronic myeloproliferative
disorder characterized by :  Dry tap
o Fibrosis a secondary reaction  Reticular fibrosis or collagen deposition

G.S TOLEDO
  Hypocellularity
 Increased megakaryocyte
 Osteosclerosis (end stage)
abnormal platelets
 No apparent cause of thrombocytosis
 Closely related to PV but with no
accompanying erythrocytosis
 Second rarest after CNL

CLINICAL PRESENTATION
 Frequent episodes of epistaxis
 Hematemesis
 GI bleeding
 Hepatosplenomegaly = except in splenic
infarctions
 Arterial and venous thrombosis
 Pulmonary embolism
 Gangrenous toes

LABORATORY FINDINGS LABORATORY FINDINGS

OTHER LABORATORY VALUES  PERIPHERAL BLOOD

 LAP score is normal to increased  Marked thrombocytosis

 Increased uric acid  Platelet aggregates with giant and bizarre

forms
 Serum albumin and cholesterol is decreased
 Platelet anisocytosis
 LDH increased
 Occasional megakaryocyte fragments
 RBC count is slightly elevated
DIFFERENTIAL DIAGNOSIS
 Micro/hypo anemia secondary to IDA
CML AMM
 Howell Jolly bodies due to splenic infarction
nRBC +/- +
 Leukocytic shift to the left
DACROCYTOSIS - +
MEGAKARYOCYTIC rare Often present
FRAGMENTS LABORATORY FINDINGS

LAP SCORE low Normal to BONE MARROW

increased
 "dry tap"
Ph1 + -
CHROMOSOME  Hypercellular with megakaryocytic
hyperplasia
 Aggregated platelets
ESSENTIAL THROMBOCYTHEMIA
 "glued together" appearance
 A chronic MPD characterized by
thrombocytosis in excess of 1000 * 10 ^ 9 / L  Erythroid and granulocytic hyperplasia
with spontaneous aggregation of functionally
G.S TOLEDO
 CRITERIA FOR DIAGNOSIS
 Peripheral blood leukocytosis >= 25 x 10 ^ 9 /
L
 Segmented neutrophils and bands >80% of
leukocytes
 Immature granulocytes <10% of leukocytes
 Myeloblasts <1% of leukocytes
 Hypercellular bone marrow
 Increased number and percentage of
neutrophilic granulocytes

LABORATORY FINDINGS  Nucleated marrow cells, with < 5%

myeloblasts
COAGULATION STUDIES
 Normal neutrophilic maturation pattern
 Platelet function studies are abnormal
 Hepatosplenomegaly
 Platelet aggregation with ADP and
epinephrine is abnormal but returns to  No Philadelphia chromosome or bcr / abl
normal when platelet count is reduced fusion gene
 No other cause for neutrophilia
DIAGNOSIS  No infectious or inflammatory process
DIAGNOSTIC CRITERIA FOR ESSENTIAL  No evidence of another myeloproliferative
THROMBOCYTHEMIA disease
Platelet count > 600 x 10 ^ 9 / L  No evidence of a myelodysplastic or
myelodysplatic, myeloproliferative diseas
Hemoglobin < 13g / dL or normal RCM
 No evidence of a tumor or, if present, myeloid
Males < 36mL / kg cells must show clonality
Females < 32mL / kg
Stainable iron in marrow or failure of iron trial (< 1g / CLINICAL PRESENTATION
dL rise in Hb after one month of iron therapy)
 Hepatosplenomegaly
No P h ^ 1 chromosome
 Nausea
Collagen fibrosis of marrow absent OR Less than 1/3
of biopsy area without splenomegaly or  Abdominal pain
erythroblastic reaction
 Afebrile
No known cause for reactive thrombocytosis
 Mild to marked hemorrhage

CHRONIC NEUTROPHILIC LEUKEMIA

LABORATORY FINDINGS
 The rarest of the chronic MPDs with only 17
cases reported PERIPHERAL BLOOD

 Maybe confused with CML

 Cells from patient with CNL have reduced  Neutrophilic leukocytosis without a left shift
number of CFU-C when culture when culture (>100 X
is attempted
 109/L)
 No cytogenetic abnormality
G.S TOLEDO
  Toxic granulation and a few Dohle bodies are  Predominantly a disease of children
present
 Most common malignant disease in children
 Occasional nRBCs (2-10 years)
 Normal to slightly decreased platelets
 Neutrophils have the capacity to phagocytize CLINICAL MANIFESTATIONS
bacteria but 70% reduction in destruction is
seen  Does not differ from those of the other types
of acute leukemias but their onset are usually
 Reduction in both azurophilic and specific more SUDDEN
granulation
 Prodromal or preleukemic symptoms are
 LAP scores are extremely high ranging from often associated with this syndrome
340-400
 Pancytopenia
 The B12 and B12 binding capacities are
markedly elevated  Malaise, fatigue and pallor
 Bone and joint pains
 Cranial nerve paralysis
 Increased ICP
 Fundic (eye) hemorrhages
 Meningeal infiltration signs
 Lymphadenopathy and hepatosplenomegaly

SUMMARY CAUSES OF DEATH

CML PV AMM ET CNL  Infection

WBC( 10 ^ 9 / > 50 15-50 6-41 6-41 30-100 o Staphylococcus aureus
L)
o Pseudomonas aeruginosa
Hb (g / d * L) N to ↓ ↑↑↑ ↓ Variable ↓

Plt(* 10 ^ 9 / Up to >1000 Variable >1000 N to ↓ o Candida albicans

L) 800 or usu not
<50 >2000 o Haemophilus influenzae
Marrow N to ↑↑ N to ↑↑ ↑↑ to N to ↑↑ No info o Proteus mirabilis
fibroblasts ↑↑↑

LAP ↓↓ ↑ N to ↑ N to ↑ ↑↑↑ o Klebsiella sp

Ph ^ 1 +/- - - - -  Bleeding
Histamine ↑↑ ↑ N N N o Hepatic involvement
B12 ↑↑ N to ↑ N to ↑ N to ↑ ↑↑↑ o Salicylates and other drugs
B12 binding ↑↑ N to ↑ N to ↑ N to ↑ ↑↑↑
capacity
LABORATORY FINDINGS

INTRODUCTION  Total WBC count is elevated (>10 X 109/L) -

 ALL is a malignant disease of the
lymphopoietic system that is manifested by a
slow but an uncontrolled growth of lymphoid
cells in the bone marrow, spleen and lymph
nodes
60%; markedly elevated (>100) - 15%
leukepenic (<5) - 25%
 (+) leukemic lymphoblast in smears
 BM: hypercellular and infiltrated with
lymphoid cells

G.S TOLEDO
  Fibrosis: 10-15%  PAS - significant between L1 and L2; L1 is
strongly positive
 Thrombocytopenia
 ACID PHOSPHATASE - positive for all ALL
 Anemia
o Golgi region is (+) for T-cell type
 Should be differentiated with:
o Diffuse pattern in myeloid cells
 PERTUSSIS - lymphoid leukocytosis
 NSE - focal positivity in T-cells
 INFECTIOUS LYMPHOCYTOSIS
o Useful in M5 VS L2 (M5 cytoplasm is
 INFECTIOUS MONONUCLEOSIS autoimmune diffusely stained)
anemia and thrombocytosis; (+) heterophil
antibody  TERMINAL DEOXYNUCLEOTIDYL
TRANSFERASE (TdT) - an intranuclear enzyme
 OTHER VIRAL DISEASE that catalyzes the addition of
deoxynucleotides to the 3' hydroxy end of
oligonucleotides or polynucleotides without
the use of templates
CLASSIFICATION
o Activity (+)- thymocytes, primitive
FEATURES OF ACUTE LYMPHOBLASTIC LEUKEMIA lymphocytes, and a small type other cells
in the BM
FEATURE L1 L2 L3
o Strong activity in ALL
Cell size Small Large, Large,
heterogenou homogenou o Useful in CML's lymphoblastic
s s transformation
Chromatin Homogen Variable; Finely
ous heterogenou stippled;
s Homogenou IMMUNOLOGIC MARKERS
s
Nuclear shape Regular Irregular Regular  Demonstrates immunologic markers on the
with occ Clefting and Round to cell surface
clefting indentation oval
and common  SURFACE Ig (SIg) - identifies B cells
indentatio
n  SHEEP ERYTHROCYTE ROSETTES - identifies T
cells (non-specific)
Nucleoli Not One or more Prominent;
visible, present; one or more  Reveals that the majority of ALLs are NON-B
small or often large vesicular and NON-T types
inconspicu
ous
 CALLA (COMMON ACUTE LYMPHOBLASTIC
Amount of Scanty Variable, Moderately LEUKEMIA ANTIGEN)
cytoplasm often mod abundant
abundant o Monoclonal antibody

Basophilia of Slight or Variable, Very deep 6 ALL CLASSES BY IMMUNOLOGIC MARKERS

cytoplasm moderate; deep in
rarely some CLASS % CHILDREN % ADULTS
intense
UNCLASSIFIED 10% 40%
Cytoplasmic Variable Variable Often ALL (uALL)
vacuolization prominent
COMMON ALL 75% 40%
(CALL)

T-ALL 15% 15%

CYTOCHEMICAL CLASSIFICATION Pre-T ALL Has T antigen but lacks sheep

erythrocyte receptors
Pre-B ALL (+) Clg and absence of Slg
 MYELOPEROXIDASE or SUDAN BLACK - ALL
are negative B ALL (BURKITT'S (+) Sig and B cell antigen
LYMPHOMA/LEU
KEMIA)
G.S TOLEDO
CLASSIFICATION  Chronic: mature forms of WBC; onset is more
gradual
uA cALL PRE- T PRE- B
LL T ALL B AL o do not mature all the way, so they are not
L as capable of defending against infections
as normal lymphocyte
Sheep RBC - - - + - -
receptors  Nature of disease onset
Sig - - - - - +
Cig - - - - + +
TdT + + + + + -
HLA-DR + + - - + +
CALLA - + +/- - + -
to -
T antigen - - + + - -
Acute vs. Chronic Leukemia
B antigen - +/- - - + +
Acute leukemias
Focal Acid - - + + - -
phosphatas  Young, immature, blast cells in the bone
e marrow (and often blood)
Acid a-NAE - - - +/- - -  More fulminant presentation
Morphology L1/ L1/L L1/L L1/L L1/L L3  More aggressive course
L2 2 2 2 2
 Occurs more commonly in children and young
adults
LABORATORY Chronic leukemias
 Accumulation of mature, differentiated cells
Development of Leukemia in the Bloodstream  Often subclinical or incidental presentation
Stage 1. Normal  In general, more indolent (slow) course
Stage 2. Symptoms  Frequently splenomegaly
Stage 3. Diagnosis  Mature appearing cells in the B. marrow and
Stage 4. Worsening blood

Stage 5a. Anemia  Occurs in adults of middle age or older

Stage 5b. Infection

Classification of Acute Leukemia

Leukemia Classification  confused with the blasts of acute myeloid

leukemia Approximately 66% of these cases
of ALL in patients older than 15 years are of
type 2.
Acute versus Chronic
 ALL-L3:
 Cell maturity
o Burkitt's lymphoma type: Cells are large
o Acute: clonal proliferation of immature and homogenous in size, nuclear shape is
hematopoietic cells (the formation of round or oval. One to three prominent
blood or blood cells) cells begin to nucleoli and sometimes to 5 nuleoli are
replicate before any immune functions visible. Cytoplasm is deeply basophilic
have developed. with vacuoles often prominent. Intense
cytoplasmic basophilia is present in every
G.S TOLEDO
 cell, with prominent vacuolation in most.
A high mitotic index is characteristic with
presence of varying degrees of
macrophage activity. Mature B- lymphoid
markers are expressed by most cases.
Leukemia Classification
 Type of white blood cell (WBC)
o Acute lymphocytic leukemia (ALL)
o Acute myelogenous leukemia (AML)
o Also called acute non lymphoblastic
leukemia (ANLL)
o Chronic myelogenous leukemia (CML)
o Chronic lymphocytic leukemia (CLL)
FRENCH-AMERICAN-BRITISH (FAB) CLASSIFICATION
SYSTEMS
 series of classifications of hematologic
diseases.
 based on the presence of dysmyelopoiesis
and the quantification of myeloblasts and
erythroblasts
 based morphology to define specific
immunotypes
 It was first produced in 1976.
Types include:
 FAB classification of acute lymphoblastic
leukemias: L1-L3 (three subtypes)
 FAB classification of acute myeloid leukemias:
MO-M7 eight subtypes)
 FAB classification of myelodysplastic
syndromes
WORLD HEALTH ORGANIZATION (WHO)
CLASSIFICATION
 reviews chromosome translocations and
evidence of dysplasia
 developed through the collaborative efforts
of the Society for Hematopathology, the
European Association of Hematopathologists,
and more than 100 clinical hematologists
Myelogenous Leukemia
 start in immature forms of myeloid cells-
white blood cells (other than lymphocytes),
red blood cells, or platelet-making cells
(megakaryocytes). They are also known as
myelocytic, myelogenous, or non-lymphocytic
leukemias
Myeloblast, Myelocyte and Eosinophil
The myeloblast has a large nucleus with fine
chromatin and nucleoli, Features that differentiate
the lymphoblasts and proerythroblast on include
1. Lymphoblasts have a coarser chromatin,
fewer nucleoli and the chromatin shows
condensation along the nuclear membrane.
2. Proerythroblasts have a coarser chromatin, a
perinuclear halo.
It may be impossible to tell the lineage of very
immature blasts. The fine chromatin of the
myeloblast is a contrast from the clumped chromatin
of the myelocyte. The blast has azurophilic primary
granules. Secondary granules are seen in the
myelocyte (pink) and eosinophil brick red).
Acute Myelogenous Leukemia (AML)
 Leukemia characterized by proliferation of
myeloid tissue (as of the bone marrow and
spleen) and an abnormal increase in the
number of granulocytes, myelocytes, and
myeloblasts in the circulating blood
 One fourth of all leukemias
 85% of the acute leukemias in adults
 Abrupt, dramatic onset
 Serious infections, abnormal bleeding
 Uncontrolled proliferation of myeloblasts
 Hyperplasia of bone marrow and spleen
Acute myeloid leukemia
Clinical features
1.
 Infiltration of bone marrow by leukemic cells
G.S TOLEDO
2. Spleen 35 90

Bone & Joint 2 5

 Suppression of normal hematopoietic
progenitor cells growth Lungs 5 50

o Anemia Heart 2 35

o Granulocytopenia CUN 1 27

GI - 10
o Thrombocytopenia

3.
ACUTE MYELOID LEUKEMIA- DIAGNOSIS
 Consequences of cytopenias
 The diagnosis of AML primarily based on
o infection of skin, mucous membranes, morphological and cytochemical criteria
gums, respiratory. Gl and GU tracts
 >20% of blasts and suppression of other
o fatigue, weakness, bleeding in skin, lineages
mucous membranes, gums, Gl and
GUtracts  Immunophenotyping, cytogenetic analysis
and molecular examination employed to add
specific information for a more precise
diagnosis
 abdominal fullness (enlargement of the liver
and spleen)
 bone and joint pain and tenderness Cytological criteria for the diagnosis of acute
myeloid leukemia: French-American-British (FAB)
 gum hypertrophy (AML-M4 and M5) classification
 neurological symptoms: headache, nausea, Eight morphologic subtypes (M0-M7) are
vomiting, blurred vision, cranial nerve distinguished according to FAB classification system
dysfunction (AML-M4 and M5) based on the morphologic features of the blasts and
histochemical staining
 DIC (AML-M3)
M0 - Undifferentiated acute myeloblastic leukemia
M1 - Acute myeloblastic leukemia with minimal
Signs and Symptoms of AML maturation
 Insidious nonspecific onset M2 - Acute myeloblastic leukemia with maturation
 Pallor due to anemia M3 - Acute promyelocytic leukemia (APL)
 Febrile due to ineffective WBC M4 - Acute myelomonocytic leukemia
 Petechiae due to thrombocytopenia M4 eos - Acute myelomonocytic leukemia with
eosinophilia
 Mucus membrane and gum bleed in M4 and
M5 M5 - Acute monocytic leukemia
 Bone pain M6 - Acute erythroid leukemia
M7 - Acute megakaryoblastic leukemia
Acute myeloid leukemia
TYPICAL LABORATORIES OF AML
Approximate frequency of organ infiltration  Leukocytosis
Organ % on Initial Exam % at Autopsy  Blastemia
Lymph nodes 10 50
 Leukemic hiatus
Liver 40 90
 Auer rods in M2, M3, M4
G.S TOLEDO
  Thrombocytopenia
 Anemia Myeloperoxidase (MPO)
 >20% blasts in BM p-Phenylenediamine + Catechol H2O2
MPO -> Brown black deposits
Other Findings Chloracetate (Specific) Esterase Myeloid Cell Line
 CD 13 and CD 33 in flow cytometry Naphthol-ASD-chloracetate

 Cytochemistries CAE -> Free naphthol compounds + Stable diazonium

salt (eg, Fast Corinth) -> Red deposit
o Myeloperoxidase
o Sudan black B
Immunophenotype of AML subtypes
o Chloracetate esterase (specific)
o Nonspecific esterase

AML CYTOCHEMISTRY
Reaction M M M M M M M M
0 1 2 3 4 5 6 7
Peroxidase - + + + +/ - +/ -
- -
Sudan - + + + +/ - +/ -
Black B - -
Unspecific - - - - + + - -
esterases
PAS - - - - - - - +

AML M1
 90% Blasts, Granulocytic component <10%.
Monocytic component <10% SBB/MPO 13%
AML M2
 >30% Blasts Granulocytic component > 10%,
monocytic component < 20% MPO 13%, CAE >
10% NSE < 20%
AML M3
 Hypergranular Promyelocytes Multiple Auer
rods Strong positivity for MPO / S * BB and
CAE. NSE +/-
AML M3v
 Deeply notched nuclei. Fine dust granules.
(Multiple) Auer rods +/- Cytochemical
features like the hypergranular variant
 > 30% Blasts. Monocytic component > 20 * 6/a
G.S TOLEDO
 granulocytic component >20%
AML M4
 MPO 13%, CAE > 20 deg% NSE > 20%
 A distinctive subtype, M4Eos- a variable
increase of abnormal eosinophils with
basophilic granules
AML M5a
 >30% Blasts. Granulocytic component < 20%
Monocytic component 80
 %. Monoblasts 80% of monocytic component.
MPO may be < 3% NSE > 80% Inhibited by
fluoride. 30% Blasts. Granulocytic component
< 20% . Monocytic component 80%
AML M5b
 Monoblasts 80% of monocytic component.
MPO may be <3%, NSE>80% inhibited by
Fluoride
 30% blast (non-erythroid population)
AML M6
 50% Erythroid precursors (total marrow cells)
 MPO3% in blasts. PAS, Acid phosphatase and
NSE may be positive in erythroblasts
ACUTE MYELOID LEUKEMIA CYTOGENETIC
PROGNOSIS
FAVORABLE RISK
 Translocation between chromosomes 8 and
21 seen most often in patients with M2
 Inversion of chromosome 16 or a
translocation between chromosome 16 and
itself seen most often in patients with M4 eos
 Translocation between chromosomes 15 and
17 seen most often in patients with M3
UNFAVORABLE ABNORMALITIES:
 Deletion (loss) of part of chromosome 5 or 7
(no specific AML type)
 Translocation or inversion of chromosome 3
 Translocation between chromosomes 6 and 9
 Translocation between chromosomes 9 and
22
 Abnormalities of chromosome 11 (at the spot
q23)
 Complex changes - those involving several
chromosomes (no specific AML type)
GENE MUTATIONS
MUTATION IN THE FLT3 GENE.
 people tend to have a poorer outcome
CHANGES IN THE NPM1 GENE (and no other
abnormalities)
 have a better prognosis than people without
this change.
CHANGES IN THE CEBPA GENE
 are also linked to a better outcome.
MARKERS ON THE LEUKEMIA CELLS
 If the leukemia cells have the CD34 protein
and/or the P- glycoprotein (MDR1 gene
product) on their surface, it is linked to a
Torse outcome.
AGE
 Older patients (over 60).
WHITE BLOOD CELL COUNT
 white blood cell count (>100,000) at the time
of diagnosis
PRIOR BLOOD DISORDER LEADING TO AML
 myelodysplastic syndrome
TREATMENT-RELATED AML
 AML that develops after treatment for
another cancer tends to be linked to a worse
outcome.
INFECTION
 Having an active systemic (blood) infection at
the time of diagnosis makes a poor outcome
more likely.
LEUKEMIA CELLS IN THE CENTRAL NERVOUS
SYSTEM
 Leukemia that has spread to the area around
the brain and spinal cold can be hard to treat
G.S TOLEDO
ACUTE MYELOID LEUKEMIA CYTOGENETIC RISK
GROUPS
 Smoking
 Certain chemical exposures
 Certain chemotherapy drugs
o myelodysplastic syndrome
o alkylating agents and platinum agents
o topoisomerase II inhibitors
 Radiation
 Certain Blood Disorders
o myeloproliferative disorders
Genetic syndromes
 Fanconi anemia
 Bloom syndrome
 Ataxia-telangiectasia
 Diamond-Blackfan anemia
 Shwachman-Diamond syndrome
 Li-Fraumeni syndrome
 Neurofibromatosis type 1
 Severe congenital neutropenia (also called
Kostmann syndrome)
 Some chromosome problems present at birth
are also liked to higher risk of AML including:
 Down syndrome (being born with an extra
copy of chromosome 21)
 Trisomy 8 (being bom with an extra copy of
chromosome 8)
Acute Lymphocytic Leukemia (ALL)
 Most common type of leukemia in children
 15% of acute leukemia in adults
 Immature lymphocytes proliferate in the
bone marrow
 starts from the early version of white blood
cells called lymphocytes in the bone marrow
(the soft inner part of the bones, where new
blood cells are made).
 Common form of malignancy in childhood,
Peak incidence at 4 - 5 yrs of age.
 Acute onset with short history of duration.
 85% are B cell 15% are T cell
MECHANISM OF LEUKEMOGENESIS
 Activation of a proto-oncogene to an
oncogene when it is translocated to a
transcriptionally active site
 Formation of a chimeric transcription factor
 Formation of a fusion protein with enhanced
tyrosine kinase activity
 Activation of FTL3 receptor
 Inactivation of tumor suppressor gene
pathway
SYMPTOMS
 Most common Pediatric Cancer
 Bleeding
 Infection
 Lymphadenopathy
 Fever
 Masakit ang tul an
FAB 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
G.S TOLEDO
ALL L1
 Size-small
 Cytoplasm is scanty basophilic. N / C .Ratio-
high.
 Nuclear membrane-regular.
 Nucleoli-invisible or indistinct.

ALL L2
 Size of blast-large & heterogenous
 Cytoplasm - moderate
 N/C Ratio-lower
 Cytoplasmic vacuoles - variable
 Nuclear membrane - irregular with clefting)
 Nucleoli - prominent, 1-2

ALL L3
 Size of blast-large & homogenous
 Cytoplasm-moderate & intensely basophilic
 N/C Ratio-lower
 Cytoplasmic vacuoles - prominent
 Nuclear membrane - regular
 Nucleoli - prominent, 1-2

PROGNOSTIC FACTORS

ALL VS AML
G.S TOLEDO
Chronic Myelogenous Leukemia (CML)
 Excessive development of mature neoplastic
granulocytes in the bone marrow
 Move into the peripheral blood in massive
numbers
 Ultimately infiltrate the liver and spleen
 Chronic, stable phase followed by acute,
aggressive (blastic) phase
 CML results from a somatic mutation in a
pluripotential lymphohematopoietic cell
 CML is a MPD characterized by increased
granulocytic cell Tine, associated with
erythroid and platelet hyperplasia
 The disease usually evolves into an
accelerated phase that often terminates in
acute phase
Classification of Myeloid Neoplasms According to
the 2008 World Health Organization Classification
Scheme
1. Myeloproliferative neoplasms (MPN)
1.1. Chronic myelogenous leukemia, BCR-ABL 1-
positive (CML)
1.2. Polycythemia vera (PV)
1.3. Essential thrombocythemia (ET)
1.4. Primary myelofibrosis (PMF)
1.5. Chronic neutrophilic leukemia (CNL)
1.6. Chronic eosinophilic leukemia, not otherwise
specified (CEL-NOS)
1.7. Mast cell disease (MCD)
1.8. MPN, unclassifiable
2. Myeloid and lymphoid neoplasms with eosinophilia
ued abnormalities of PDGFRA, PDGFRB, and FGFR1
3. MDS/MPN
3.1. Chronic myelomonocytic leukemia (CMML)
3.2. Juvenile myelomonocytic leukemia (JMML)
3.3. Atypical chronic myeloid leukemia, BCR-ABL-
negative (aCML)
3.4. MDS/MPN, unclassifiable
4. Myelodysplastic syndromes (MDS)
5. Acute myeloid leukemia (AML)
The bcr/abl fusion protein
1. Uncontrolled kinase activity
2. Deregulated cellular proliferation
3. Decreased adherence of leukemia cells to the bone
marrow stroma
4. Leukemic cells are protected from normal
programmed cell death (apoptosis)
Chronic Lymphocytic Leukemia (CLL)
 Production and accumulation of functionally
inactive but long-lived, mature-appearing
lymphocytes
 B cell involvement
 Lymph node enlargement is noticeable
throughout the body
 ↑ incidence of infection
Pathogenesis
Hematopoietic abnormality
 Expansion of granulocytic progenitors and a
decreased sensitivity of the progenitors to
regulation increased white cell count
 Megakaryocytopoiesis is often expanded
 Erythropoiesis is usually deficient
 Function of the neutrophils and platelet is
nearly normal
LABORATORY FEATURES
 The hemoglobin concentration is decreased
 Nucleated red cells in blood film
 The leukocyte count above 25000 / mu * l
(often above 100000/µl), granulocytes at all
stages of development
 Hypersegmented neutrophils
 The basophils count is increased
 The platelet count is normal or increased
 Neutrophils alkaline phosphatase activity is
love or absent (90%)
G.S TOLEDO
  The marrow is hypercellular (granulocytic Chronic Lymphocytic Leukemia
hyperplasia)
 Complications from early-stage CLL is rare
 Reticulin fibrosisHyperuricemia and
hyperuricosuria  May develop as the disease advances
 Serum vitamin B12-binding protein and  Pain, paralysis from enlarged lymph nodes
serum vitamin B12 levels are increased causing pressure
 Pseudohyperkalemia, and spurious
hypoxemia an hypoglycemia
Hairy Cell Leukemia
 Cytogenetic test-presence of the Ph
chromosome  2% of all adult leukemias
 Molecular test-presence of the BCR-ABL  Usually in males > 40 years old
fusion gene
 Chronic disease of lymphoproliferation
 B lymphocytes that infiltrate the bone
Differential diagnosis marrow and liver
 Polycythemia vera
 Myelofibrosis Unclassified Leukemias
 Essential thrombocytenia  Subtype cannot be identified
 Extreme reactive leukocytosis  Malignant leukemic cells may have Lymphoid,
myeloid, or mixed characteristics
 Frequently these patients do not respond well
Leukocyte alkaline phosphatase (LAP) to treatment
stain  Poor prognosis
 The leukocyte alkaline phosphatase (LAP)
stain is helpful in determining whether a high
peripheral blood leukocytosis is a reactive
process or a leukemia (chronic myelogenous
leukemia, or CML).
 The cells on a smear can be assessed and an
"LAP score" can be generated. A high score
generally indicates a "leukemoid reaction" or
reactive condition (with an infection or other
inflammatory process) while a low score
suggests CML.

CML Stages

Accelerated phase
 10% to 19% of the cells in the blood and bone
marrow are blast cells.
Blastic phase
 20% or more of the cells in the blood or bone
marrow areblast cells.
 Blastic Crisis

G.S TOLEDO