Hematology - 15 Intro to Hematologic Maligancies

HEMATOLOGY INTRODUCTION TO HEMATOLOGIC MALIGANCIES • OUTLINE • • • Introduction To the Hematologic Malignancies o Introduction Characteristics of Leukemias, Lymphomas, & Myelomas o Forms of Leukemia o Lymphomas o Myelomas o Differentiation of Leukemias, Lymphomas, & Myelomas o Classification of Leukemias, Lymphomas, & Myelomas and their Laboratory Profile The Hematologic Malignancies o Acute Leukemias o Acute Myeloid Leukemia o Acute Lymphoid Leukemia o Cytochemical Staining • • INTRODUCTION TO THE HEMATOLOGIC MALIGNANCIES blood smears In urine, Bence- Jones proteins, which are the light chains of immunoglobulins are demonstable. Lymphomas represent a group of malignant tumors of the lymphoid tissue (lymph nodes and spleen) that vary greatly in degree of malignancy and response to therapy. The two main types are Hodgkin's and Non-Hodgkin's Lymphoma. In Hodgkin Lymphoma, Reed Stern-Berg cells are hallmark or characteristic. Malignant cells are initially confined to the organs containing mononuclear phagocytes such as the lymph nodes, spleen, liver and bone marrow. Lymphomas can spill over into blood and present a leukemic picture on the peripheral blood smear. The World Health Organization (WHO) classification stratifies neoplasms primarily according to cell lineage; myeloid, lymphoid, and histiocytic/dendritic cells. The WHO Classification in addition to cell morphology, cytochemical reaction, and clinical criteria includes immunophenotyping and genetic studies of peripheral blood, bone marrow and lymph nodes samples. INTRODUCTION • • • • • • Leukemia had been reported since the time of Hippocrates. The term leukemia was coined from the words, leuk( white blood cells/ lwhite blood cell) and emia ( blood). The condition then, means that there is predominance of white blood cell is the blood. Virchow was the first to recognize leukemia as a distinct clinical disorder between 1839 and 1845. He named this disorder "leukemia" because of the white appearance of the blood for patients with fever, weakness and lymphadenopathy. Leukemias are neoplastic proliferative disease, characterized by overproduction of immature or mature cells of various leukocyte types in the bone marrow and/or blood. Lymphomas are similar to leukemias, but lymphomas are solid tumors localized in the lymph nodes and associated tissues or bone marrow. The clinical symptoms, the maturity of the affected cell line and the total leukocyte count determine whether a leukemia will be classified as acute or chronic. After Virchow divided leukemias into 2 groups based on the presence of lymphadenopathy, different forms of leukemia were later classified according to the affected predominant blood cell type, morphological and cytochemical result and clinical criteria. These mentioned 3 criteria are the bases of the French-American-British Classification (FAB). Under this classification there are 3 types, myelogenous, monocytic and lymphocytic. With this information, they can be further classified as acute or chronic. In acute leukemias, 20% or more of cells in the bone marrow are young or immature stages while the chronic leukemias have more mature stages. The factors related to the occurrence of leukemia are genetic and immunological factors, occupational exposure, environmental exposure, chemical and drug exposure, genetic abnormalities and associations, viral agents and secondary causes. Myeloma or Multiple Myeloma is a malignant proliferation of atypical and immature forms of plasma cells, primarily occurring in the bone marrow. The exact cause of multiple myeloma is unknown, and heredity is not a factor. Patient's plasma is turbid because of increased level of myeloma proteins which cause rouleaux formation in their CHARACTERISTICS OF LEUKEMIAS, LYPMHOMAS & MYELOMAS • • • • Leukemia - is a disease, usually of leukocytes, in the blood and bone marrow. o Shift to the left o Cause: leukemoid 2 Forms of Leukemia: o Acute Leukemia o Chronic Leukemia It takes 18-21 days for BFU-E to become mature RBCs o <18 days, cause leukemia Laboratory Test o Bone marrow test ▪ Leukemia - abnormal ▪ Leukemoid - normal o Lymph nodes ▪ Leukemoid - normal ▪ Leukemia - abnormal o Cytochemical ▪ NAP/LAP • Leukemoid - normal • Leukemia - abnormal (low score) FORMS OF LEUKEMIA • • Acute Leukemia o Symptoms of short duration o Many immature cell forms in the bone marrow and/or peripheral blood o Elevated total leukocyte count o Life expectancy: +/- 3 months Chronic Leukemia o Symptoms of long duration o Mostly mature cell forms in the bone marrow and/or peripheral blood o Total leukocyte counts that range from extremely elevated to lower than normal o Life expectancy: >1 year LYMPHOMAS • • • • Lymphomas - is a general term for malignancy that starts in the lymph system, mainly in the lymph nodes. o Cancer of lymphocytes o Lymphadenitis - reactive o Lymphadenopathy - more reactive 2 Types: o Hodgkin Lymphoma o Non-Hodgkin Lymphoma Hodgkin Lymphoma o Proliferation of malignant lymphocytes which have a basophilic vacuolated cytoplasm with starry sky pattern due to numerous tangible body macrophage that are arrested at certain stages of maturation o Hallmark: presence of Reed-Sternberg cell (large binucleated or multinucleated cell resembles owl's eye appearance with each nucleus bearing a very large nucleolus. o More curable, 87% survive Non-Hodgkin Lymphoma o Diffuse large B-cell lymphoma o Reed-Sternberg is absent but mixed population of lymphocytes, histiocytes, eosinophils and some plasma cells are present. MYELOMAS • Myelomas - is a form of cancer of the plasma cells. o In myeloma, cells overgrows, forming a mass or tumor that is located in the bone marrow DIFFERENTIATION OF LEUKEMIAS, LYMPHOMAS, MYELOMAS Leukemias Lymphomas Basic Overproduction Solid malignant characteristic of tumors of various types of the lymph nodes immature or mature leukocytes in the bone marrow and/or peripheral blood, in most types of leukemias Cell type Usually involves Lymphocyte is leukocytes of the the distinctive myelogenous or cell type. Reedlymphocytic cell Sternberg types cells are diagnostic of Hodgkin-type lymphoma. Site of Malignant cells Malignant cells malignant freely are cells trespass the initially confined blood brain to the barrier organs (prominent in containing ALL) mononuclear phagocyte cells such as the lymph nodes, spleen, liver, and bone marrow • Myelomas Overproduction of plasma cells in the bone marrow with concurrent production of abnormal proteins Plasma cells Plasma cells form a mass or tumor that is located in the bone marrow Lymphomas can spill over into the circulating blood and present a leukemic appearing picture on a peripheral blood smear. CLASSIFICATION OF LEUKEMIAS, LYMPHOMAS AND MYELOMAS AND THEIR LABORATORY PROFILE FRENCH-AMERICAN-BRITISH (FAB) CLASSIFICATION • Separated into three broad leukocytes groups: o Myelogenous o Monocytic o Lymphocytic • • Major types of leukocytic leukemias can be classified as acute or chronic according to the leukocyte groups: o Examples: ▪ Acute or Chronic Myelogenous ▪ Acute or Chronic Monocytic ▪ Acute or Chronic Myelomonocytic ▪ Acute or chronic Lymphocytic Leukemia (CLL) o Acute - >20% blasts; more immature forms o Chronic - <20%; more mature forms Based on: o Morphology o Clinical manifestation o Cytochemistry WORLD HEALTH ORGANIZATION (WHO) CLASSIFICATION • GENERAL CHARACTERISTICS OF ACUTE MYELOID LEUKEMIA • Acute Myeloid Leukemia o most common leukemia subtype o recognized as a heterogenous clonal disorder, o characterized by: ▪ Maturation block and the accumulation of acquired somatic genetic alterations in hematopoietic progenitor cells that alter normal mechanisms of self- renewal, proliferation, and differentiation. ACUTE MYELOID LEUKEMIA (FAB CLASSIFICATION) • M0 (myeloid) o Undifferentiated blasts, AML— not otherwise categorized o WHO classification of AML not otherwise categorized • M1 (myeloid) o Blasts and promyelocytes predominate without further maturation of myeloid cells o WHO synonym for this condition is acute myeloblastic leukemia without maturation. Based on morphology but combine this information with: o Immunophenotyping and genetic studies of peripheral blood, bone marrow, and lymph node samples ▪ Genetic studies • Cytogenic - chromosomal • Molecular technology - DNA analysos ▪ Immunophenotyping - study cell wall to differentiate components THE HEMATOLOGIC MALIGNANCIES ACUTE LEUKEMIAS • • • • • • Acute myeloid leukemia (AML) must be distinguished from acute lymphoblastic leukemia (ALL), myelodysplastic syndrome (MDS), or AML arising in the presence of MDS, because therapeutic strategies and the prognosis vary considerably for these diseases. Acute leukemias are characterized by the presence of blasts and immature leukocytes in the peripheral blood and bone marrow Anemia is present. o Can be caused by bleeding and the replacement of normal marrow elements by leukemic blasts. Total leukocyte count is usually elevated, some patients may demonstrate normal or decreased leukocyte count. AML (also called acute myelogenous leukemia, acute nonlymphocytic leukemia, or ANLL) remains a lethal disorder, which kills the majority of afflicted adults. 2 Major Divisions: o Acute Myeloid Leukemia (AMLs) ▪ Divided into subtypes: (M0-M7) o Acute Lymphoid Leukemia (ALLs) ▪ Divided into three categories: (L1-L3) ACUTE MYELOID LEUKEMIA (AML) FAB & WHO CATEGORIES OF AML • WHO Classification o Classification is based on: ▪ Morphology ▪ Cytochemistry ▪ Immunophenotype ▪ Genetics ▪ Clinical features ▪ *To define clinically significant disease entities. • M2 (myeloid) o Myeloid cells demonstrate maturation beyond the blast and promyelocyte stage o WHO synonym for this disease is acute myeloblastic leukemia with maturation. • M3 (promyelocytic) o Promyelocytes predominate in the bone marrow o Prone to Disseminated Intravascular coagulation (DIC) • M4 (myelomonocytic) o Both myeloid and monocytic cells are present to the extent of at least 20% of the total leukocytes o Referred to as Naegeli type monocytic leukemia. o WHO synonym is acute myelomonocytic leukemia. • M5 (monocytic) o Most cells are monocytic; two subtypes (a and b) are recognized, o FAB M5a - characterized by large blasts in bone marrow and peripheral blood ▪ common in young adults o FAB M5b - differentiated type by monoblasts, promonocytes, and monocytes ▪ common during middle age o o Refered to as SCHILLING'S TYPE WHO synonyms are acute monoblastic leukemia (FAB M5a) and acute monocytic leukemia (FAB M5b). • M6 (erythroleukemia) o Refered to as Erythemic Myelosis or Di Guglielmo syndrome o Abnormal proliferation of both erythroid and granulocytic precursors; may include abnormal megakaryocytic and monocytic proliferations o WHO synonym for FAB M6a and M6b is acute erythroid leukemia ACUTE LYMPHOBLASTIC LEUKEMIA (ALL) • • • • • M7 (megakaryocytic) o Large and small megakaryoblasts with a high nuclear cytoplasmic ratio; pale, agranular cytoplasm o WHO synonym is acute megakaryoblastic leukemia ALL is the most common cancer in children, representing 23% of cancer diagnoses among children younger than 15 years of age. Divided into three subtypes: o L1 (children) o L2 (older children and adults) o L3 (patients w/ leukemia secondary to Burkitt lymphoma) Morphological Classification & Characteristics FAB Type L1 L2 L3 Size of Small Large, Large Blasts heterogeneous Nuclear Indistinct Indented, Regular oval Shape prominent to round Nucleoli Scant Large, Prominent, abundant basophilic Cytoplasm Invisible Moderately Prominent, clefted vacuoles General Characteristics of Acute Lymphoblastic Leukemia o The WHO classification that is synonymous with the FAB L1 and L2 classification is: o Precursor B lymphoblastic leukemia/ lymphoblastic lymphoma (precursor B-cell ALL) → neoplasm of lymphoblasts committed to the B-cell lineage. o Precursor T lymphoblastic leukemia/ lymphoblastic lymphoma (precursor T-cell ALL) → neoplasm of lymphoblasts committed to the T-cell lineage. ACUTE LEUKEMIA (FAB CLASSIFICATION) • L1 (homogeneous) o One population of cells within the case; small cells predominant; nuclear shape is regular with an occasional cleft; chromatin pattern is homogeneous and nucleoli are rarely visible; cytoplasm is moderately basophilic • L2 (heterogeneous) o Large cells with an irregular nuclear shape; clefts in the nucleus are common; one or more large nucleoli are visible; cytoplasm varies in color ACUTE MYELOID LEUKEMIA (WHO CLASSIFICATION) • • • Acute Myeloid Leukemia with Certain Genetic Abnormalities o AML with t(8;21) o AML with inv(16)or t(16;16) o AML with t(9;11) o APL with t(15;17) Acute Myeloid Leukemia, Not Otherwise Specified o AML with minimal differentiation o AML without maturation o AML with maturation o Acute myelomonocytic leukemia o Acute monoblastic/monocytic leukemia o Acute erythroid leukemia o Acute megakaryoblastic leukemia o Acute basophilic leukemia Acute Leukemias of Ambiguous Lineage o Acute undifferentiated leukemia o Mixed phenotype acute leukemia with t(9;22) o Mixed phenotype acute leukemia with t(v;11q23) o Mixed phenotype acute leukemia, B lymphocytesmyeloid cells o Mixed phenotype acute leukemia, T-myeloid • L3 (Burkitt lymphoma type) o Cells are large and homogeneous in size; nuclear shape is round or oval; one to three prominent nucleoli; cytoplasm is deeply basophilic with vacuoles often prominent • • ALL: CLINICAL SIGNS & SYMPTOMS • • • • • Symptoms can vary from few days to few weeks. Pain in the extremities, particularly the legs, is produced by an infiltration of leukemic cells into the tissues. Lymphadenopathy and hepatomegaly are present in 75% of patients. Leukemic meningitis and cranial nerve palsies caused by nerve infiltration by leukemic blasts are quite common. Leukemic cells can infiltrate many areas of the body Chloroacetate Esterase (Napthol ASD) (SE) o Stains granulocytic lineage o Also known as specific esterase o To differentiate granulocytic leukemia from monocytic leukemia that produces red granules if positive Non-Specific Esterase (NSE) o Stains monocytic lineage including megakaryocytes and macrophage o To differentiate monocytic leukemia from granulocytic leukemia o α-naphthyl acetate esterase - Monocyte, Plasma Cell & Megakaryocyte ▪ (+) red brown o Sodium Fluoride - added to inhibit monocytic series o α-naphthyl butyrate esterase - monocytic series ▪ (+) dark red precipitate ALL: LABORATORY DATA • • • • Total leukocyte count → elevated in 60% to 70% of patients; ranging from 50 to 100 × 109/L. < 15% of patients exhibits extreme leukocytosis → TL > 100 × 109/L Approx. 25% of patients exhibits leukocytopenia Peripheral Blood Smear: o predominance of blast cells o close to 100% lymphoblasts, lymphocytes & smudge cells • Periodic Acid Schiff (PAS) o Stains most carbohydrates in all red cells except PRONORMOBLAST o Useful for AML M6 or Erythroleukemia o (+) Color - magenta or purple o Basophils, Lymphocytic Series, plasma cells and erythrocytic cell series • Acid Phosphatase Stain o Stains ACP found in lysosomes in myelocytic lineage and lymphocytic lineage o Tartaric acid may be used to identify Hairy Cell Leukemia which is resistant to L-tartrate (TRAP) ▪ Presence of Isoenzyme 5 o Heparin must be used (+) → purple to red granules Terminal Deoxyribonucleotidyl Transferase (TdT) o Can stain ALL due to polymerase immunoperoxidase o To differentiate ALL to AML Toluidine Blue / Metachromatic Stain o Stains acid mucopolysaccharide of mast cells and basophils CYTOCHEMICAL STAINS • • Myeloperoxidase (MPO) o To differentiate AML (+) to ALL (-) o Must be fresh because enzymes are unstable o Marker for Auer Rods due to primary granules o (+) color → black precipitate or reddish brown termed as phi bodies o (+) Philadelphia - CML** Sudan Black B (SBB) o To differentiate AML (+) to ALL (-) o Stains lipids & phospholipids o Air dry and Fresh can be both used o (+) color → black color o Done simultaneously with myeloperoxidase o More stable & accurate than myeloperoxidase • • AML: CYTOCHEMICAL STAINING •