Subject: Pathology Topic: WBC disorder 01 and 02 Lecturer: Dr.

Ignacio De Guzman Date of Lecture: Transcriptionist: ALBINO CARABAO Pages: 30

RECALL 1.1. HEMATOPOEISIS AND REFERENCE VALUES 1.2. LYMPHOID TISSUES 1.3. LYMPH NODES 2. LESSON PROPER 2.1. MAJOR CATEGORIES OF WBC AND LYMPH NODES 2.1.1. LEUKOPENIA/DEFICIENCIES 2.1.1.1. NEUTROPENIA AND AGRANULOCYTOSIS 2.1.1.2. LYMPHOPENIA 2.1.2. PROLIFERATION 2.1.2.1. REACTIVE (INFLAMMATORY) PROLIFERATIONS 2.1.2.1.1. LEUKOCYTOSIS 2.1.2.1.1.1. NEUTROPHILIC 2.1.2.1.1.2. EOSINOPHILIC 2.1.2.1.1.3. BASOPHILIC 2.1.2.1.1.4. LYMPHOCYTOSIS 2.1.2.1.1.5. MONOCYTOSIS 2.1.2.1.2. ACUTE NON-SPECIFIC LYMPHADENITIS 2.1.2.1.3. CHRONIC NON-SPECIFIC LYMPHADENITIS 2.1.2.1.3.1. FOLLICULAR HYPERPLASIA 2.1.2.1.3.2. PARACORTICAL LYMPHOID HYPERPLASIA 2.1.2.1.3.3. SINUS HISTIOCYTOSIS 2.1.2.2. NEOPLASTIC 2.1.2.2.1. LYMPHOID NEOPLASM WHO CLASSIFICATION: 2.1.2.2.1.1. PRECURSOR B CELL NEOPLASM 2.1.2.2.1.1.1. ACUTE LYMPHOBLASTIC LEUKEMIA/LYMPHOMA 2.1.2.2.1.2. PRECURSOR T CELL NEOPLASMS 2.1.2.2.1.2.1. ACUTE LYMPHOBLASTIC LEUKEMIA/LYMPHOMA 2.1.2.2.1.3. PERIPHERAL B CELL NEOPLASM 2.1.2.2.1.3.1. CHRONIC LYMPHOCYTIC LEUKEMIA/SMALL LYMPHOPCYTC LYMPHOMA 2.1.2.2.1.3.2. FOLLICULAR LYMPHOMA 2.1.2.2.1.3.3. DIFFUSE LARGE B CELL LYMPHOMA 2.1.2.2.1.3.4. BURKITTS LYMPHOMA 2.1.2.2.1.3.5. PLASMA CELL NEOPLASM 2.1.2.2.1.3.5.1. MULTIPLE MYELOMA 2.1.2.2.1.3.5.2. PLASMACYTOMA 2.1.2.2.1.4. PERIPHERAL T CELL AND NK CELL NEOPLASM 2.1.2.2.1.5. HODGKIN LYMPHOMA 2.1.2.2.1.5.1. CLASSIC HODGKIN LYMPHOMA 2.1.2.2.1.5.1.1. NODULAR SCLEROSIS 2.1.2.2.1.5.1.2. MIXED CELLULARITY 2.1.2.2.1.5.1.3. LYMPHOCYTE RICH 2.1.2.2.1.5.1.4. LYMPHOCYTE DEPLETION 2.1.2.2.1.5.2. LYMPHOCYTE PREDOMINANCE 2.1.2.2.2. MYELOID NEOPLASM 2.1.2.2.2.1. ACUTE MYELOGENOUS LEUKEMIA FAB CLASSIFICATION 2.1.2.2.2.1.1. M0: MINIMALLY DIFFERENTIATED AML 2.1.2.2.2.1.2. M1: AML W/O MATURATION 2.1.2.2.2.1.3. M2: AML W/ MATURATION 2.1.2.2.2.1.4. M3: PROMYELOCYTIC LEUKEMIA 2.1.2.2.2.1.5. M4 : ACUTE MYELOMONOCYTIC LEUKEMIA 2.1.2.2.2.1.6. M5: MONOCYTIC LEUKEMIA 2.1.2.2.2.1.7. M6: ERYTHROLEUKEMIA (AKA DI GUGLIEMOS DISEASE) 2.1.2.2.2.1.8. M7: MEGAKARYOCYTIC LEUKEMIA 2.1.2.2.2.2. MYELODYSPLASTIC SYNDROME (MDS) 2.1.2.2.2.2.1. IDIOPATHIC OR PRIMARY MDS 2.1.2.2.2.2.2. THERAPY RELATED MDS 2.1.2.2.2.3. CHRONIC MYELOPROLIFERATIVE DISORDERS 2.1.2.2.2.3.1. CHRONIC MYELOGENOS LEUKEMIA 2.1.2.2.2.3.2. POLYCYTHEMIA VERA(PV) 2.1.2.2.2.3.3. ESSENTIAL THROMBOCYTOSIS 2.1.2.2.2.3.4. PRIMARY MYELOFIBROSIS 2.1.2.2.3. HISTIOCYTOSIS 2.2. SPLEEN 2.3. THYMUS 1.

SY 2011-2012

Recall: Hematopoiesis

this is pretty much self-explanatory. This is a good to know and will help you in understanding the WBC disorders. Note that from the common pluripotent stem cell it will give rise to two types of progenitor cells, one for the lymphoid series and the other one is for the myeloid series. Under the myeloid series, take note that it will give rise to granulocytes, platelets and monocytes.

NORMAL VALUES/REFERENCE VALUES (lifted from Henrys Clinical Diagnosis and Management by Laboratory Methods) CBC Normal Values/ Reference Values (SI units) Hematocrit Male: 0.4150.504 Female: 0.3590.446 Hemoglobin Male: 140175 g/L Female: 123153 g/L 12 Red Cell Count Male: 4.55.9 10 /L 12 Female: 4.15.1 10 /L Erythrocyte indices: Mean Corpuscular Volume(MCV) 80-96 fl Mean Corpuscular Hemoglobin (MCH) 27.533.2 pg Mean Corpuscular Hemoglobin Concentration (MCHC) 0.3340.355 9 White Cell Count 4.411.3 10 /L WBC Differential Segmented Neutrophils 0.56 Bands 0.03 Eosinophils 0.027 Basophils 0.003 Lymphocytes 0.34 Forms of Lymphoid Tissues 1. Diffuse Lymphoid (not shown) a. Loose Lymphoid Tissue o few and far apart b. Dense Lymphoid Tissue o numerous and close 2. Lymph Nodule/ Follicle Discrete ovoid masses, clustered and mainly B cells Types: a. Primary Nodule o no germinal layer, lymphocytes are at rest b. Secondary Nodule i. germinal/ reaction center composed of activated B cells lighter staining composed of Centrocytes and Centroblasts which are from stimulated nave B cells Germinal centers are normally polarized into 2 distinct regions: Dark zone: Centroblast o Centroblast- blastlike B cells; larger and more actively dividing, larger, vesicular or open chromatin and prominent nucleoli Light zone: Centrocytes o Centrocytes- B cell with irregular or cleaved nuclear contours, smaller cell o Inconspicuous nucleoli o Also capable of producing antibodies Interspersed between germinal B cells are tingiblebody macrophage which are Ag presenting cells(dendrites and macrophage) containing nuclear debris of B cells o Increased in tingible-body macrophage is attributed to the increase proliferation of B cells that undergo apoptosis due to failure to produce antibody/immunoglobulin with high affinity for Ag ii. mantle/ corona zone unstimulated small nave B cells Antigen will stimulate this nave B cells which will then occupy the germinal area dark peripheral area

Mantle zone

Tingible body macrophage

centroblast

Centrocyte please note that the second picture is HPO of follicular hyperplasia. Although it is from an reactive proliferation of lymphoid tissue, the structures pointed are still normal.

nave B cells has two pathways 1. immunoblast- B cell developed outside the germinal center and will differentiate into plasma cells which produces Ig. 2. Centroblast- B cell developed inside the germinal center which will become a centrocyte

note that B cell lymphoma can be from the marginal zone, mantle zone, centrocytes or centroblast

LYMPH NODE Filters lymph Most accessible and most commonly examined in the diagnosis of the lymph node neoplasms Regions 1. Cortex o Outer has Lymphoid Nodule[aka Lymphoid Follicles] embedded in dense Lymphoid tissue when stimulated forms germinal center that is B cell rich o Inner no lymphoid nodule T cell rich 2. Medulla o In between the sinuses is the medullary cords that contains B cells but mostly, plasma cells o Plasma cell- the ultimate outcome of antigenic stimulation o Sinuses- has histiocytes and phagocytic cells Also contains capsule and underneath that is the subcapsular sinus Trabeculae composed of reticular fibers Dendritic cells are found in between follicle and within the germinal center; recall that dendritic cells are important in antigen presentation It is important to remember the parts of the lymph node and the cell that composes it because it will give a clue to the origin of the lymphoid neoplasm. For example, in follicular lymphoma, theres follicular hyperplasia and hence, the cell of origin is B cells. Lymphoid neoplasms in paracortical area will indicate T cell neoplasm.

-------------------------------------------------------------------------------------------------------------------------------------------------------------------Lesson proper: 2 major categories of diseases of WBC and Lymph Nodes: 1. Deficiencies Termed as leukopenia Deficiency of leukocytes peripherally Note: peripherally means WBC found in blood or your circulating WBC; remember that the bone marrow is another location where these cells can be located in great amount and that a decrease in peripheral WBC does NOT necessarily mean that there is a decrease in WBC in your BM. Nevertheless, a constant WBC count or increase demand in WBC such as in inflammation is maintained and provided by your BM, respectively. 2. Proliferative Termed as leukocytosis Expansion of leukocytes a. Reactive o More common; usually host response to primary disease, such as bacterial infection o Recall that in inflammation, theres an increase in WBC b. Neoplastic o Less frequent and more important clinically

LEUKOPENIA/ WBC DEFICIENCIES NEUTROPENIA/ GRANULOCYTOPENIA Commonly drug induced Reduced neutrophils(aka PMN) 9 In severe cases, decrease in PMN [<1.0 x 10 /L] is known as AGRANULOCYTOSIS Remember that neutrophils play a major role in inflammation against infectious agents; in fact it is the first WBC that will try to contain the inflammation/infection. Naturally, a decrease in your primary defence in infection would mean greater susceptibility in infection. Pathogenesis of Neutropenia 1. Reduced or ineffective production of neutrophils a. Suppression of myeloid stem cells i. Ex. Aplastic Anemia b. Suppression of committed granulocytic precursors i. Drug Exposure c. Ineffective granulopoiesis i. Megaloblastic Anemia d. Impaired granulocytic differentiation as a rare genetic defect 2. Accelerated removal or destruction of neutrophils a. Immunologically mediated injury to neutrophils i. SLE, drugs b. Splenic sequestration (hypersplenism) c. Increased peripheral utilization Morphology Bone Marrow o either hypercellular ot hypocellular Infections o necrotizing lesions in oral cavity and GIT Clinical S/Sx o due to infection, patient present with malaise, fever, and weakness treatment: o antibiotics, granulopoeitin factor, WBC(transfusion) LYMPHOPENIA Reduced lymphocytes Less common than neutropenia Usually associated with use of steroids, infection and immunodeficient diseases, such as HIV

REACTIVE INFLAMMATORY PROLIFERATION I. REACTIVE LEUKOCYTOSIS Increase in peripheral WBC count Most commonly seen in inflammatory condition but also seen in neoplasms Note that leucocytosis does not always indicate infection, this is also seen in patients with MI, infectious toxic state and bleeding patients Types of leucocytosis according to cell type WBC involved Indication NEUTROPHILIA Neutrophils Most common type of leucocytosis Usually indicative of acute pyogenic BACTERIAL infection Also caused by sterile inflammation caused by tissue necrosis (MI and Burns)
The pictures on the left show a shift to the left, which means theres increase immature neutrophils(in this case the bands). Both neutrophilia and shift to the left is usual in acute pyogenic bacterial infection. Also notice that theres toxic vacoulation and granulation in this picture. These are also indicative of acute bacterial infection.

EOSINOPHILIA

Eosinophils

Associated with PARASITIC infestation and ALLERGIC reaction Also seen in drug reaction and some malignancies(HL and NHL), collagen vascular disorder and some vasculitides; artheroemnolic disease(transient) Recall: what Immunoglobulin is increased when theres parasitic infestation or allergic reaction? IgE

BASOPHILIA

Basophils

Rare; indicative of myeloproliferative diseases (chronic myeloid leukemia)

LYMPHOCYTOSIS

Lymphocytes

Usually seen in VIRAL infection Note that it is usually accompanied by monocytosis

Note that the picture on the left also shows reactive lymphocytes, theres greater cytoplasm than normal, and the nucleus is slightly indented. Please be aware that this is not true in all lymphocytosis, some may have lymphocytosis with normal lymphocytes. Also take note of the nuclei and chromatin and compare it to the monocytes below.

MONOCYTOSIS

Monocytes

Chronic Infection such as TB, endocarditis, malaria, chronic vascular disease(SLE), inflammatory bowel diseases (ulcerative colitis)

II. REACTIVE LYMPHADENITIS Reaction of lymph nodes Types: 1. ACUTE REACTIVE LYMPHADENITIS/ACUTE NONSPECIFIC LYMPHADENITIS Most commonly seen in bacterial infection Direct microbiologic drainage of infected area Seen with cardinal signs of inflammation (pallor, tumor, dolor, calor, and function laesa) Morphology o GROSS: Swollen, gray-red and engorged o MICRO: Prominent follicles with germinal centers a. LOCALIZED o Infection of arm may have reactive lymphadenitis on axillary lymph node o Infection of toe/foot may have acute reactive lymphadenitis on inguinal lymph nodes o Cervical Lymph nodes draining teeth or tonsils b. GENERALIZED o Viral infection and bacteremia 2. CHRONIC REACTIVE LYMPHADENITIS/CHRONIC NONSPECIFIC LYMPHADENITIS Generally enlarged and nontender More difficult to differentiate from neoplastic enlargement because of its presentation(enlarged, painless and non-tender) Without cardinal signs of inflammation Types: A. FOLLICULAR HYPERPLASIA o Prominent germinal centers due to B cell activation[humoral response] o Morphologically similar to follicular lymphoma Features favouring follicular(non-neoplastic) hyperplasia Preservation of the lymph node architecture, including interfollicular T cell zones and follicle Marked variation in shape and size of follicles Presence of frequent mitotic figures, phagocytic macrophages and recognizable dark and light zone (note: this is all absent in neoplastic follicles) o Ex. Early stages of HIV infection, Rheumatoid Arthritis, and toxoplasmosis B. PARACORTICAL LYMPHOID HYPERPLASIA o Hyperplasia of T cell origin Immunoblasts Activated T cells 3-4x larger than resting T cells Round nuclei, open chromatin, prominent nucleoli, moderate amount of pale cytoplasms o In exuberant reaction, T cell expands and efface B cell follicles o Theres hypertrophy of sinusoidal and vascular endothelial cells, accompanied by infiltrating macrophages and eosinophils o Acute viral infection(infectious mononucleosis), drug reaction C. SINUS HISTIOCYTOSIS (AKA RETICULAR HYPERPLASIA) o Distention of lymphatic sinusoids and engorged with histiocytes o Hypertrophy and hyperplasia of sinusoidal endothelial cells o Seen in axillary L.N. draining cancers particularly breast

Upper left: normal lymph node Upper right: follicular hyperplasia: Of the three Chronic Reactive Lymphadenitis, this is probably the easiest to identify, note how theres an increase in lymphoid follicle of variable sizes. (Remember that in follicular lymphoma, there will be an increase in lymphoid follicle but with almost the same size) Lower left: Paracortical lymphoid hyperplasia: note how it is enlarged but with scanty lymphoid follicles and how the paracortical tissues seems to invade the medulla. Lower right: sinus histiocytosis: note how the sinuses are distended

NEOPLASTIC PROLIFERATION CLASSIFICATION: 1. LYMPHOID NEOPLASM Diverse group of entities Resembles a particular stage of lymphocyte differentiation 2. MYELOID NEOPLASM Arises from hematopoietic stem cells that give rise to the cells of the myeloid Erythroid, granulocytic, or thrombocytic linkage 3. HISTIOCYTOSIS Proliferative lesions of histiocytes including Langerhan cells that behave as benign and malignant lesions LYMPHOID NEOPLASM Definition A. Leukemia Lymphoid and Myeloid neoplasms that present with widespread involvement of BM usually accompanied by tumor cells in the peripheral blood BM is mainly involved Diffuse replacement of BM of neoplastic cells Sometimes not seen in the peripheral blood and hence BM smear must be done to show the presence of neoplastic cells To be diagnosed as leukemia there must be neoplastic cells in the BM Two types o Acute Leukemia fatal, death within 6 months if not treated seen in both children and adults orgnanomegaly is NOT prominent To be diagnosed as acute leukemia there must be at least 20% blasts in the BM variable WBC count, either decreased, normal or increased in Peripheral blood leukemic leukemia- very high WBC count with increased leukemic cells subleukemic leukemia- slightly above normal with few blasts aleukemic leukemia- normal to decreased count o Chronic Leukemia usually seen in adults, indolent, incurable can be asymptomatic; no symptoms of BM failure(such as bleeding, anemia) because the process is gradual and the body can adapt to it

recently, there are new drugs that may cure this type of leukemia organomegaly is prominent in this type of leukemia- splenomegaly, hepatomegaly and enlarged lymph nodes few blasts in the peripheral blood, mostly are in the BM major types of leukemia o Acute Lymphoblastic leukemia- mainly in children o Acute Myelogenous Leukemia- seen in adults o Chronic Lymphocytic Leukemia- seen in adults o Chronic Myelogenous Leukemia-seen in adults Diagnosis is done by BM examination(BM biopsy and BM aspirate) B. Lymphoma Proliferations arising as discrete tissue masses(lymph nodes and extranodal tissues) Lymph node is mainly involved IMPORTANT PRINICIPLES relevant to LYMPHOID NEOPLASM Biopsy of lymph node for definitive diagnosis o lymph nodes are very accessible among lymphoid tissues and hence usually biopsied o convergence of lymphatics where lymph node enlargement are seen when patient has lymphomas inguinal lymph node axillary lymph node cervical lymph node mediastinal lymph node pelvic lymph node Histologic examination of the lymph node or involved tissue is required for diagnosis Lymphoid neoplasm vary from indolent to rapidly fatal proliferations o Indolent neoplasms are relatively inactive but are unresponsive to therapy; tumor persists o Aggressive neoplasms are active but are responsive to therapy; fatal if not treated right away hence, early diagnosis is critical INDOLENT AGGRESSIVE CHRONIC LYMPHOCYTIC LEUKEMIA/SMALL MULTIPLE MYELOMA LYMPHOCYTIC LYMPHOMA FOLLICULAR LYMPHOMA DIFFUSE LARGE B CELL LYMPHOMA BURKITT LYMPHOMA ACUTE LYMPHOBLASTIC LEUKEMIA/LYMPHOMA BURKITT LYMPHOMA

Vast majority (80-85%)are B cell origin, remaining being of T cell origin, only rarely are NK origin o The structure of B cell is very unstable as compared to T cell; hence, this makes it susceptible to mutation, mainly translocation. Tumors of T and B cells represent cells arrested at any stage along their differentiation pathways, a feature used in their classification. o From primitive to mature lymphocytes, cells from germinal center, marginal zone, or mantle zone(as in lahat!) is capable of developing into lymphomas o Since they are morphologically the same, specific stage of B or T cell involved is determined by immunohistochemistry and flow cytometry. It is important to remember their immunophenotype: B cell is CD20 (+) T cell is CD 3 (+) RS cell is CD 15 (+) and CD 30 (+) As tumors of immune system, lymphoid neoplasms frequently lead to immune abnormalities o susceptible to infection and autoimmunity o Lymphoma are prone to secondary malignancy All LYMPHOID NEOPLASM are MONOCLONAL, in contrast to reactive lymphoid proliferation which are polyclonal. Neoplastic B and T cells tend to home and grow in areas where their normal counterparts reside. o Ex. Follicular lymphoma means proliferation of B cells o Ex. Paracortical neoplasms means proliferation of T cells Most lymphoid neoplasms are widely disseminated at the time of diagnosis, therefore cure is possible in most lymphoid neoplasms only with systemic therapy EXCEPT Hodgkins Lymphoma o Hodgkins Lymphoma is localized to a region and hence, local therapy like radiation can be done. o NHL in cervical area is presumed to be widely disseminated and systemic therapy is needed.

Hodgkins Lymphoma spreads in an ORDERLY FASHION(hence, predictable manner of spread) and as a result, staging is important in determining therapy (not so for Non- Hodgkin Lymphoma) o Orderly fashion- means that it moves from one lymph node to the succeeding lymph node or it does NOT jump. Ex .an affected submandibular lymph node will most likely affect the cervical lymph nodes rather than jumping from submandibular and then to axillary lymph node. o This is also the basis why NHL is treated with systemic therapy, the lymphoma can spread from one area to another and hence, therapy on local area may not cure the neoplasm. Most commonly seen ADULT lymphoid neoplasm 1. FOLLICULAR LYMPHOMA 2. DIFFUSE LARGE B CELL LYMPHOMA 3. CHRONIC LYMPHOCYTIC LEUKEMIA/SMALL LYMPHOCYTIC LYMPHOMA 4. MULTIPLE MYELOMA 5. HODGKIN LYMPHOMA (with characteristic age group: young adults) Most commonly seen CHILDHOOD and ADOLESCENCE lymphoid neoplasm 1. ACUTE LYMPHOBLASTIC LEUKEMIA/LYMPHOMA 2. BURKITT LYMPHOMA WHO CLASSIFICATION OF LYMPHOID NEOPLASM: 1. PRECURSOR B CELL NEOPLASM Neoplasm of IMMATURE B cell A. B CELL ACUTE LYMPHOBLASTIC LEUKEMIA/LYMPHOMA o It is both Lymphoma and leukemia because the proliferative cells that are identical morphologically, genotypically and phenotypically o >35% blasts in BM- Acute Lymphoblastic LEUKEMIA o <25% blasts in BM- Acute Lymphoblastic LYMPHOMA o 85% of ALL are PRE-B CELL and present typically as acute LEUKEMIA o 15% of ALL are PRE-T CELL and present in adolescent males as LYMPHOMAS, often with thymic involvement(appears as mediastinal mass) o Most cases occur before age 15, peak incidence 4 y/o; o Prevalence: Male> Female o Must differentiate from AML since they are similar in signs and symptoms but different response to chemotherapy o (+) TDT in 95% of cases o 95% with numerical and structural changes in chromosomes o >75% hyperploidy 3 o >4000/mm in Peripheral Blood; proliferation of cell in peripheral blood- Leukemia 3 o <4000/mm in peripheral blood; discrete masses- Lymphoma o Clinically: Signs and symptoms related to BM depression Fatigue and pallor due to cytokines released by neoplastic cells leading to anemia Fever due to susceptibility to infection Bleeding due to thrombocytopenia Bone pain and tenderness due to BM expansion and infiltration of subperiosteum Neurologic symptoms such as head and vomiting, attributed to meningeal spread Hepatomegaly/splenomegaly due to leukemic infiltrates Poor prognostic factor (requires BM transplant) Less than 2 y/o Presentation in adolescence or adulthood 3 Peripheral blasts greater than 100,000/mm Presence of Philadelphia chromosome t(9;22) 2. PRECURSOR T CELL NEOPLASM o Neoplasm of IMMATURE T cell A. T CELL ACUTE LYMPHOBLASTIC LEUKEMIA/LYMPHOMA O Please see description above O PAS (+) stain lymphoblast granules to differentiate it with myeloblast[PAS (-) and peroxidase (+)]

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PERIPHERAL B CELL NEOPLASM o Neoplasm of MATURE B cell A. CHRONIC LYMPHOCYTIC LEUKEMIA/SMALL LYMPHOPCYTC LYMPHOMA o CLL/SLL are morphologically, phenotypically and genotypically indistinguishable 3 CLL[leukemia]: >4,000/mm blood lymphocytosis o More common in Western countries o INDOLENT type of leukemia o Tumor composed of lymphocytes that express CD19, CD20, and CD5 o Lymph node effaced by diffuse proliferation of small lymphocytes with proliferation centers o BM involved in 100% of cases of CLL and in most cases of SLL o Clinically: Median age, 60 y/o; male>female Patients are often asymptomatic or with non-specific symptoms Generalized lymphadenopathy in 50-60% of cases 3 WBC count slightly increased or exceed 200,000/mm Hypogammaglobulinemia and AIHA in some patients Most INDOLENT type leukemia, median survival: 4-6 years CLL and SLL may progress to prolymphocytic transformation or diffuse large B cell lymphoma Chromosomal translocations rare, unlike most lymphoid malignancies B. FOLLICULAR LYMPHOMA o most common form of lymphoma in the US; 45% of adult lymphomas o tumor cels resemble normal germinal center B cells o 2 types: Centrocytes Centroblasts o Express Bcl2 in 90% cases o Hallmark: T(14;18) o BM involvement in 85% of cases o Clinically: Tend to present with generalized painless lymphadenopathy Extranodal involvement UNCOMMON, peripheral blood involvement in 10% of cases INCURABLE; with INDOLENT, waxing, waning course Median survival years: 7-9 years, unaffected by treatment Treatment is palliative May progress to a higher grade type usually diffuse large B cell lymphoma C. DIFFUSE LARGE B CELL LYMPHOMA o 20% of NHL, 60-70% of AGGRESSIVE lymphoid neoplasms o Median age: 60 y/o; but wide age range o 5% of childhood lymphoma o Composed of a diffuse proliferation of large cells 4-5x small lymphocytes with vesicular nuclei, prominent nucleoli o Types: centroblastic immunoblastic o Special subtypes: Immunodeficiency associated large B cell lymphoma Seen in severe T cell immunodeficienciese.g. end stage HIV infection, neoplastic B cells are often latently infeted with EBV Body cavity large B cell lymphoma Arise in malignant pleural or ascitic effusions, mostly in advanced HIV infection Tumor cells are infected with HERPES VIRUS 8 D. BURKITTS LYMPHOMA o 30% of childhood NHL o 3 types: African (endemic) Burkitt Lymphoma Sporadic (non-endemic) Burkitt lymphoma occurring in HIV patients (immunodeficiency associated) o Diffuse infiltrate of intermediate size lymphocytes o High mitotic index

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numerous macrophages create a starry-sky pattern Not an exclusive in burkitts lymphoma and can be seen in actively dividing tumors, they have tangible body histiocytes o Clinically: Most tumors arise from extranodal sites Found largely in children and young adults AGGRESSIVE but RESPOND to HIGH DOSE chemotherapy with cure Endemic Burkitt Mandible, abdominal viscera(kidneys, ovaries, adrenals) Non-endemic Burkitt Abdominal mass involving ileocecum and peritoneum E. PLASMA CELL NEOPLASM o A group of lymphoid neoplasms of terminally differentiated B cells, characterized by expansion of a single clone of Ig secreting plasma cells; increased level of complete or incomplete on the plasma or urine o 15% of deaths from malignant white cell disease I. MULTIPLE MYELOMA (PLASMA CELL MYELOMA) Most important and most common disorder Multiple tumorous masses of plasma cells on the skeletal system, lymph nodes and extranodal sites(ex. Skin) Proliferation and lytic lesions depend on cytokines notably IL-6 Morphology Multiple destructive bone lesions: o vertebral column (66%) o ribs (44%) o pelvis (28%) o femur (24%) punched out soap bubbles lesions on xray or osteoporosis BM: plasmacytosis >30%, mature or immature Clinically Main presentation: BONE PAIN Peak incidence: 50-60 y/o Pain and pathologic features-- bone infiltrates (vertebrates, ribs, skull osteolytic lesions) Hypercalcemiabone resorption Recurrent infectionsdecreased production of normal Ig Renal insufficiencydue to toxic Ig light chains (Bence Jones Protein) Amyloidosisdue to excess production of Ig light chains Hyperviscosityaggregates of myeloma proteins especially with IgM or IgG3 myeloma Serum electrophoresis o theres a peak in the gamma globulin area due to increase production of immunoglobulin brought about by plasmacytosis o the different type of multiple myeloma, IgM type, IgA type, IgG type, Kappa type, etc can also be distinguished by this method immunoeletrophoresis- diagnostic Prognosis Generally poor, median survival, 3 years, 50-70% remission Most common cause of death: RENAL FAILURE/INFECTION II. PLASMACYTOMA 3-5% of plasma cell neoplasm Present as solitary lesion of either bone or soft tissue Bone (same as MM), soft tissue, lungs, oronasopharynx, nasal sinuses May progress to classic MM PERIPHERAL T CELL AND NK CELL NEOPLASM o Neoplasm of MATURE T cells and NK cells o More common in asia than in Western countries o 15% NHL in the US

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PRECURSOR B CELL NEOPLASM B CELL ACUTE LYMPHOBLASTIC LEUKEMIA/LYMPHOMA

Lymphoblast with condensed, dekicate and finely stippled nuclear chromatin, small nucleoli(absent or inconspicuous), and scant agranular basophilic cytoplasm. Nuclei somewhat larger than small lymphocyte. Nuclear membrane deeply subdivided, imparting a convoluted appearance.

Convoluted nucleus

PRECURSOR T CELL NEOPLASMS T CELL ACUTE LYMPHOBLASTIC LEUKEMIA/LYMPHOMA

Same description above. They only differ in origin. They can be differentiated by history and immunephenotyping.

PERIPHERAL B CELL NEOPLASM CHRONIC LYMPHOCYTIC LEUKEMIA/SMALL LYMPHOCYTIC LYMPHOMA

Upper left: lymphocyte invading liver; periportal lymphocytic infiltrate. Upper right: LPO view showing diffuse effacement of nodal architecture Lower: PBS flooded with small mature- looking lymphocytes with condensed chromatin and scant cytoplasm. Smudge cells (disrupted lymphocytes) are characteristic findings of CLL.(encircled) They sometimes aggregate and large lymphocyte is sometimes seen which is actually the prolymphocyte(not seen)aggregates of prolymphocyte distinguishes it from reactive lymphocyte

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proliferation in lymph nodes

FOLLICULAR LYMPHOMA
Upper: Mixed type of follicular lymphoma, both centrocytes and centroblasts are present (see continuation on next page) Lower: Increased amount of nodules Hard to distinguish with follicular hyperplasia BCL2 is used to distinguish it from reactive proliferation: Lymphomas germinal center positive for BCL2 while reactives germinal center is negative for BCL2 NO tingible body macrophage seen theres no apoptosis due to increased BCL2 in follicular lymphoma. Recall: BCL2- Antiapoptotic gene

DIFFUSE LARGE B CELL LYMPHOMA

Have large nuclei, open chromatin, prominent nucleoli Large cell type- 4-5x larger than small lymphocyte and a diffuse pattern of growth. Also notice nucleoli are located adjacent to nuclear membrane, or single and centrally placed

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BURKITTS LYMPHOMA
starry sky appearance due to pale tingible body macrophage. Tumor cells have multiple small nucleoli and high mitotic index Theres lack in variation in nuclear shape and size monotonous appearance

Tingible body macrophage

PLASMA CELL NEOPLASM: MULTIPLE MYELOMA

Note the distinct feature of the plasma cell eccentric nucleus with perinuclear clearing called hof which represents negative Golgi apparatus. The nucleus has a cartwheel or clockface appearance(not so apparent in the sample picture) xray is showing the characteristic punched out lesions of MM

PERIPHERAL T CELL LYMPHOMA

Small, intermediate, and large lymphoid cels, many with irregular nuclear contours

Well, most of them look the same and thats why its important to take note of their immunophenotype(CD20, CD15, etc) and special stain reactions. Some will have distinct features that will give you a clue in identifying them. For the most part the history and patients age should help you in determining the patients diagnosis.

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HODGKIN LYMPHOMA o Distinct from other lymphoid neoplasm o Neoplasm of Reed Sternberg cells and variants o Originate almost always from a single node or chain of nodes and spreads to contiguous nodes o Features that separate if from NHL o Presence of RS cells admixed with a variable inflammatory infiltrate o Associated with systemic manifestations o Neoplastic RS cells are derived from germinal center or post germinal center B cells, rarely (1-2%). From transformed T cells Classic Hodgkin Lymphoma has similar immunotype: CD15+, CD30+, CD20o RS cell marker- CD15 and CD30 o B cell marker- CD20 o The reason for this reaction is unknown, although they are negative for CD20 they are still considered as B cell in origin. Hypothesis of this change in reaction is probably due to several mutations these cells went through, causing them to be negative in CD20 Lymphocyte Predominance type is derived from germinal center B cells and has an immunotype distinct from classic subtypes: CD20+, CD15-, CD30 Note that the higher the reactive lymphocyte the better the prognosis The neoplastic cell in this lymphoma is the RS cell and not these lymphocytes Theres usually an inverse relationship in the number of RS cells and lymphocytes RS cell produce cytokines that will stimulate the production of the reactive cells o Eosinophils seen in HL is due to IL-5 produced by RS cells not by the lymphocytes o Eosinophilia in suspected lymphoma is most likely indicative of HL Remember that diagnosis of HL requires the presence of RS cell Present with B symptoms which is not seen in NHL fever, weight loss of more than 10% due to cytokines produced by the RS cells; this indicates poorer prognosis

HODGKIN LYMPHOMA

NODULAR SCLEROSIS (NS) GRADE 1 AND 2

INCIDENCE, SEX SALIENT PREDILECTION MORPHOLOGY CLASSIC HODGKIN LYMPHOMA 65-75% Bands of collagen M=F enclosing nodules Lacunar variant of RS cell (encircled)
Notice how the nuclei are foded or multilobed within an open space,, which is an artefact created by disruption of the cytoplasm during tissue sectioning. Formalin unable to penetrate the interior of the tissue due to sclerosis and this area around the cell appears clear because formalin is unable to fixed it.

CLINICAL FEATURES/MORPHOLOGY Stage 1 or 2 most common; Mediastinal involvement frequent; EXCELLENT PROGNOSIS; Rarely associated with EBV Nodules are surrounded by fibrosis(not seen) and can be mixed cell type: Grade 1- lymphocyte predominance Grade 2-Lymphocyte depleted; Poorer prognosis

MIXED CELLULARITY

20-25% M>F

Lymphocytes, Eosinophils, Plasma Cells, Histiocytes Numerous Classic RS Cell (encircled)

Biphasic Incidence (young adults and after 55 y/o); Stage 3 and 4; B symptoms; STRONGLY associated with EBV (70%); GOOD PROGNOSIS

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LYMPHOCYTE RICH

Uncommon M>F

Frequent mononuclear (encircled) and Classic RS cells Background rich with T lymphocytes Note how theres an increase amount of lymphocytes(Arrow)

Seen in older adults; GOOD to EXCELLENT PROGNOSIS; Associated with EBV (40%)

LYMPHOCYTE DEPLETION

5%; rarest M>F

Few lymphocytes Abundant RS cells, fibrosis or anaplastic histiocytes Pleomorphic variants of RS cells Notice that theres few lymphocyte present in this type of HL

Older males; HIV (+) individuals; Advanced disease; Least favorable diagnosis; WORST PROGNOSIS; Often associated with EBV

LYMPHOCYTE PREDOMINANCE

Other Type of Hodgkin Lymphoma 5% Abundant M>F lymphocytes Few RS cells L and H (POPCORN) variant of RS cell Aka Lymphohistiocytic variant (encircled)
Note how the cell nuclei has multiple infolded nuclear membranes, small nucleoli, fine chromatin, and abundant pale cytoplasm (inset) Also note the mature looking lymphocytes and few RS cells.

Young males with cervical or axillary lymphadenopathy; EXCELLENT PROGNOSIS; NOT associated with EBV Definite B cell origin, other types are only presumed B cell origin but without any concrete evidence

Reed Sternberg cell Common denominator of all types of Hodgkin Lympoma NEOPLASTIC ELEMENT of Hodgkin Lymphoma This must be present to DIAGNOSE Hodgkin Lymphoma Variants: o Lacunar RS Cell of NS HL o Mononuclear RS cell of Lymphocyte rich HL o Pleomorphic RS cell of Lymphocyte depleted HL o Popcorn RS cell or L and H RS cell of Lymphocyte predominance HL

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Classic RS cell Approximately 45um in diameter binucleate/bilobed and has mirror image with prominent owl-eye nucleoli surrounded by a clear halo abundant, amphophilic cytoplasm Note: Amphophilic means staining with acid and basic dye

ANN ARBOR STAGING Used for staging lymphomas Stage I Involvement of a single lymph node region(I) Or a single extra lymphatic organ or site(IE) Stage II Involvement of two or more lymph node regions on the same side of the diaphragm alone (II) or localized involvement of an extra-lymphatic organ or site(IIE) Stage III Stage IV Involvement of lymph node regions on both sides of diaphragm without (III) or with (IIIE) localized involvement of an extra-lymphatic organ or site Diffuse involvement of one or more extra-lymphatic organs or sites with or without lymphatic involvement

All stages are further divided on the basis of the absence(A) or presence(B) of the following symptoms: Unexplained fever, drenching night sweats, and /or unexplained weight loss of greater than 10% of normal body weight Clinical Differences Between Non-Hodgkin and Hodgkin Lymphoma Non Hodgkin Lymphoma Age Extremes of life: young and old Systemic S/S (-) LN involvement Multiple, symmetrical, peripheral; Waldeyers ring and mesenteric nodes are commonly involved Incidence in Philippines (9:1::NHL:HL) Spread Extranodal involvement More common Unpredictable; non-contiguous Common GIT- most common site; involves ileum, stomach, and/or large intestine Other sites: Skin Brain- seen in HIV patients (primary brain lymphoma) Variable(indolent to rapidly fatal) Treatment is usually systemic

Hodgkin Lymphoma Young adults: Average- 32 y/o (+) Localized to a single axial group; often unilateral; Waldeyers ring and mesenteric nodes are rarely involved Less common Localized with predictable, contiguous spread UNCOMMON Very characteristic of this type of lymphoma

Prognosis

Curable in most cases Stage I and IIA: 90%, 5 year survival rate Stage IVA and B: 60-70%; 5 year survival rate

Application: Lymph node enlargement, age of patient and distribution will give you a clue of the type of lymphoid proliferation Pain and tenderness- more likely acute lymphadenitis Painless enlargement in cervical lymph node, 60 y/o is possibly a lymphoma or leukemia; this can be confirmed by biopsy. Initially, some physicians may do FNAB but all it will show you is cytology (showing abnormal cell to normal cells), hence it is better to do either an excisional(best type of biopsy, able to see everything) or incisional biopsy of a lymph node to confirm diagnosis. Painless, multiple lymph node involvement- ex. Cervical and axillary lymph node involvement is indicative of lymphoma because this two are too far apart to be suspected as lymphadenitis. Extranodal lymphoma is most likely to be NHL; to specify the type of NHL, immunotyping must be done.

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MYELOID NEOPLASM Please be aware and dont get confused: o MYELOID series is comprised of RBC,PMN, eosinophil, basophil, monocytes and platelet series o The only exception and probably the source of confusion is the so called Myeloid:Erythroid ratio(M:E ratio) done when reading BM smears, in which the myeloid only refers to granulocytes. Increase in uric acid is seen in patient with myeloid neoplasm due to high turnover rate Heterogenous group of neoplasms that arise from a progenitor cell that normally give rise to terminally differentiated cells of the myeloid series [RBC, PMN, eosinophils, basophils, monocytes and platelets] 3 categories of MYELOID NEOPLASM: ACUTE MYELOGENOUS LEUKEMIA (AML) Accumulation of IMMATURE MYELOID CELLS in the bone marrow Failure in maturation of the stem cells Affects primarily adults, age 15-39 y/o Constitute 20% of childhood leukemias Presence of AUER RODS is indicative of AML FAB classification (Please memorize!!!!) o Based on degree of maturation (M0- M3) and lineage of differentiation of leukemic blasts (M4-M7) o Most common: M1, M2, M4 o Myeloperoxidase (+) for M1, M2 and M3 o Nonspecific esterase (+) and myeloperoxidase (+) for M4 o Nonspecific esterase (+) for M5 o PAS (+) and myeloperoxidase (+) for M6
Recall: to differentiate the cell series remember that it is classified according to the following: size, N:C ratio, presence or absence of nucleoli, number of nucleoli, the presence or absence of the granules, the color of the granules, cytoplasm and nucleus, and the characteristic of chromatin. If youre still having a hard time identifying these cells, read our histology book and make sure you have a good picture while reading its description. Pay attention to details! This will help you in our upcoming practical and written examination. If youre a visual type of person like me, imagining these cells while taking the exam will make it easier to remember and answer the questions. I only discussed the important features of each cells, pls take note of its size relative to the RBC seen in the picture.

1.

Normal Neutrophilic Series

1. Myeloblasts
no granules, with prominent nucleoli 4. Metamyelocyte with primary and 2ndary granules nucleus with indentation but less than 1/3 of cell chromatin clumping

2. Promyelocytes with prominent primary granules, with prominent nucleoli

5.

Stab

Prominent indentation of nuclei but without segmentation

3. Myelocytes smaller nucleus, with primary and secondary granules, without nucleoli, condensation of chromatin(nucleus more basophilic)

6.

Segmenters

With segmentation

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FAB CLASSIFICATION of AML M0 Minimally differentiated AML 2-3% of cases

Recall: Blasts has nucleoli that are seen as round to ovoid clearing in the nucleus. This requires immunotyping for diagnosis because it closely resembles ALL

M1

AML without maturation 20% of cases

Notice that there are few red granules in the cytoplasm; these are actually the azurophilic granules or primary ganules. Myeloblasts have delicate nuclear chromatin, prominent nucleoli, and fine azurophilic granules in the cytoplasm. Auer rods can be seen in this type of AML

M2

AML with maturation 30-40% of cases

Note: seen in the slide are matured cell(pointed with arrow) along with the blasts(encircled) Matured cells showing primary and secondary granulation.

M3

Acute Promyelocytic leukemia 5-10% of cases Uncommon, due to translocation of

chromosome 15 and 17
Notice how the encircled cell contains a lot of Auer rod, this is called Faggot cell Auer rods- eosinophilic rod-like cytoplasmic inclusions derived from myeloperoxidase-positive primary granule; note that this is only found in AML patients. (remember auer rods, he likes asking this in practical exams) Myeloblast are Myeloperpxidase positive, and will help you differentiate it from other blast if Auer rods are not present.

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M4

Acute Myelomonocytic Leukemia 15-20% of cases Two lines of differentiation: Myeloblast and monoblast are present

M5

Acute Monocytic Leukemia 10% of cases Purely monocytic

Note the ribbon-like, folded or lobulated nuclei of the blasts with prominent nucleoli, hence this is M5a(acute Monoblastic leukemia) M5a- with immature monoblasts M5b- with mature monocytes Nonspecific esterase (Ex. Alpha naphthyl acetate) specifically stain cytoplasmic granules of monocytes and monoblast.

M6

Acute Erythroleukemia Aka Di Gugliemos Disease Rare; 5% of cases Two lines of differentiation: erythroid(arrow) and myeloid series(arrow head). Notice and look at the myeloblast well, it actually has an auer rod(encircled).

M7

Acute Megakaryocytic Leukemia 1% of cases Megakaryoblast(encircled)

Well, most of them look the same and thats why its important to take note of their immunostain and special stain reactions. Some will have distinct features that will give you a clue in identifying them. For the most part the history and patients age should help you in determining the patients diagnosis.

Remember that in AML, it is possible to have a WBC count that is normal or decreased, this is where the history of the patient such as bleeding and anemia comes into play, this should give you a clue of the status of the BM; in other words, an abnormality in the BM may be present despite the normal CBC results (treat the patient not the lab result). BM examination is consists of BM aspiration and BM biopsy should be requested to confirm the diagnosis, the aspiration will show you the cytology while the biopsy will show you the architecture of the BM. o Remember to take into consideration the cell to fat ratio of the BM; it varies with age. Generally, adults have 50% cell and 50% fat. Younger patients have higher cellular component, while older patients have more fat component in their BM(this is relative to the decrease in cellular component as we go older)

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Proposed WHO Classification of AML (based on cytogenetic and molecular factor. I AML with genetic aberrations II AML with MDS-like features III AML, therapy related IV AML, not otherwise specified Difference between ALL and AML(these two have similar clinical manifestations-bleeding, anemia, signs of infection) Acute Lymphoblastic Leukemia (ALL) Acute Myelogenous Leukemia (AML) Age Incidence Children and young adult <15 y/o Adults 15-39 y/o 80% of childhood leukemias 20% of childhood leukemias Extramedullary Lymph nodes, liver, CNS; Spleen more commonly involved; disease Testicular involvement more common; Chloromas in AML (M1 and M2); Mediastinal mass in T cell ALL Gingival and skin infiltrates (M4 and M5) DIC in M3 Blasts Clumped chromatin Delicate chromatin 1-2 nucleoli 3-5 nucleoli NO Auer Rods AUER RODS(M1-M3) NO Azurophilic Granules WITH AZUROPHILIC GRANULES Cytochemistry PAS (+) Myeloperoxidase (+) M1, M2, M3 Non-specific esterase (+) - (M4-M5) Immunostaining TDT (+) 95% of cases TDT (+) 5% of cases Response to 90% complete remission with chemotherapy; 60% complete remission with chemotherapy; treatment 2/3 cured 15-30% cured with treatment but RELAPSES are common
TDT- terminal deoxyribonucleotidyl transferases; PAS-periodic acid Schiff

Laboratory Findings in AML or ALL Anemia, thrombocytopenia 3 WBC count <10,000 mm [50%] 3 WBC count >10,000 mm [20%] Greater than 20% blasts in the bone marrow 2. MYELODYSPLASTIC SYNDROME (MDS) Associated with INEFFECTIVE HEMATOPOIESIS and associated cytopenias Able to mature but abnormal mutated products is produced; because of this abnormality they often undergo apoptosis in the BM leading to decreased myeloid series in the peripheral blood, termed as PANCYTOPENIA o Pancytopenia- refers to decreased of all cells in peripheral blood o Note that some of this abnormal cells can be seen in the peripheral blood but in small quantities Definition: a clonal stem cell disorder characterized by maturation defects resulting in ineffective and disordered haematopoiesis and increased transformation to AML 2 types a. IDIOPATHIC OR PRIMARY MDS Affects patient over 60 y/o and develops insidiously MS(Major Survival): 9-29 months b. THERAPY RELATED MDS (TMDS) a complication of previous myelosuppressive drug or radiation, about 2-8 years after exposure poorer prognosis; MS: 4-8 months Morphology: o Peripheral blood: PANCYTOPENIA Note that this is usually seen in APLASTIC ANEMIA(always think of this first when this symptoms is present)and must be part of the differential diagnosis of MDS Another differential diagnosis is Hypersplenism, this will be further discussed later on. o Bone Marrow: hypercellular, normocellular, or hypocellular with disordered (dysplastic) differentiation of 3 lineages (eythroid, myeloid, and megakaryocytic) o <20% blasts in Bone Marrow Clinically: o Primary MDS affects elderly patients older than 60 y/o o Weakness, infection, haemorrhage (acute-leukemia like) due to pancytopenia Remember that this is also S/S of acute leukemia and hence, part of the differential diagnosis of MDS. Recall: whats the other differential diagnosis of MDS? Aplastic Anemia On what basis? Pancytopenia

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3.

o 50% are asymptomatic and discovered after accidental blood tests o 10-40% of patients progress to AML, particularly with TMDS CHRONIC MYELOPROLIFERATIVE DISORDERS (MPD) Associated with increased production of terminally differentiated myeloid cells Able to mature and differentiate which leads to flooding of the BM and peripheral blood of myeloid series This increased in myeloid series in the peripheral blood is termed as PANMYELOSIS o CML- predominantly myeloid series o PV- predominantly erythroid series o Essential thrombocytosis- predominantly megakaryocytes o Primary myelofibrosis- predominantly fibrosis Clonal neoplastic proliferation of multipotent progenitor cell capable of giving rise to mature RBC, platelets, granulocytes, and monocytes except CML in which the pluripotent stem cell that give rise to lymphoid and myeloid cells is affected Common pathogenetic factors: mutated and activated TYROSINASE KINASE o BCR-ABL fusion gene abnormality- CML o JAK2- PV, Essential thrombocytosis, primary myelofibrosis Common features of MPD o Neoplastic stem cells have the capacity to circulate and home to secondary hematopoietic, the most notable is the spleen theres varying degree of splenomegaly in MPD; Primary Myelofibrosis result to greatest degree of splenomegaly Remember that this is one of the most significant symptoms of MPD o Frequent occurrence of MYELOFIBROSIS AND PANCYTOPENIA on later stage of disease o Similar clinical and pathologic manifestation at some stage (overlaps and transitional forms between types) o All can progress to acute leukemia, most frequent with CML o Diagnosis is based on correlation between morphologic findings clinical and laboratory findings and cytogenetic studies MPD includes the following: a. CHRONIC MYELOGENOUS LEUKEMIA(CML) o Both a leukemia and myeloproliferative disease Leukemic leukemia differentiates it to other MPD o Most important type of MPD o Disease of adults: 25-60 y/o o 90% of cases, karyotype reveals the Philadelphia chromosome T(9;22) More specific examination(karyotyping) for diagnosis detects this chromosome The specific tyrosine kinase mutation is the BCR-ABL gene FISH(fluorescent in situ hybridization) test- use when the findings are equivocal and Ph chromosome is not seen in karyotyping. More sensitive in detecting this chromosome. o Morphology: Peripheral blood: 3 (Generally,) WBC count > 100,000/mm Shows entire spectrum of myeloid series Increase includes eosinophils, basophils, and platelets; with predominance of neutrophils, metamyelocytes, and myelocytes Bone Marrow 100% cellular, mostly maturing granulocytes o LAP 0 or markedly decreased [<10] Note: normal is 13-130 Simple laboratory test to differentiate it to other MPD LAP-leukocyte alkaline phosphatase Differential diagnosis: leukomoid reaction in severe infection such pneumoniaLAP is increased and blasts are rarely seen in leukomoid reaction o Clinically: Insidious onset, anemia, weakness, fatigue Massive splenomegaly (may be the initial finding) Poor response to treatment; MS 3 years; 50% go into the accelerated phase terminating in blastic crisis (acute leukemia like) 50% go directly to blastic crisis (70% AML; 30% ALL)

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b.

c.

d.

Treatment: Targeted therapy TYROSINE KINASE INHIBITOR: IMATINIB and newer kinase inhibitors Bone marrow transplantation INTERFERON ALPHA POYCYTHEMIA VERA o A neoplasm arising in a multipotent myeloid stem cell characterized by proliferation of erythroid, granulocyte and megakaryocytic elements. Proliferation is predominantly erythroid series. o Median age at onset 60 y/o o Most of the S/S related to increased red cells mass, plethora, cyanosis, headache, dyspnea, hypertension, bleeding, thrombosis o Other S/S: peptic ulcer, gout o LABORATORY: Hgb: 14-28 g/dL Hct: > or = 60% Leucocytosis Thrombocytosis To differentiate with CML Philadelphia (-) Elevated LAP o Prognosis: MS with treatment 10 years 15-30% go to myelofibrosis 2-15% develop AML ESSENTIAL THROMBOCYTOSIS o Extremely rare disease o Proliferation confined to megakaryocyte 3 o Platelet count : >600,000/mm o Diagnosed by exclusion of other MPDs PRIMARY MYELOFIBROSIS o a neoplastic transformation of a multipotent stem cell characterized by early progression to marrow fibrosis; proliferation in the BM is predominantly fibrosis o fibrosis due to fibrogenic factors secreted by neoplastic megakaryocytes; theres cluster of megakaryocytes along the fibrosis seen in the BM. o Recently, this is being questioned as a type of MPD because theres no increase in the cellular component, instead fibrosis is predominantly seen in the BM. It may just be a common pathway for all other types of MPD rather than a separate entity. o Morphology: Peripheral Blood Anemia Leukoerythroblastic reaction o Immature leukocyte and erythrocyte in the Peripheral blood Teardrop erythrocytes aka Dacrocyte Bone Marrow EARLY: tri-lineage hypercellularity; minimal fibrosis LATE: hypocellular with diffuse fibrosis and clusters of atypical megakaryocytes Spleen Extramedullary hematopoeisis (SPLENOMEGALY) MASSIVE SPLENOMEGALY o Clinically: Patient > or = 60 y/o Present with anemia and massive splenomegaly MS: 1-5 years 5-20% transform to AML

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MYELODYSPLASTIC DISORDER Upper left: ringed sideroblast Upper right: multilobed nRBC Lower left: Pseudopelger huet with hypogranulation Lower right: Multinucleated Megakaryocyte Recall: sideroblasts are normoblasts that contain one or more particles of stainable iron. Increased or normal production of iron is seen in neoplasms Nucleated RBC normally has NO LOBES. Pelger-huet anomaly has a characteristic bilobed and rounded, with spectacle or pince-nez shaped neutrophils; it is autosomal dominant; in the case of MDS, it is called pseudopelger huet because it has the same characteristic but not due to the AD inheritance, instead it is caused by some other stimuli that triggered this dysplastic change. Also remember that normally, neutrophils has 3-6 lobes. Megakaryocyte is normally multilobed and not multinucleated

Chronic Myeloproliferative Disorders CHRONIC LEUKEMIA MYELOGENOUS

blast

The slide shows cells ranging from blasts to mature granulocytes Decreased LAP and with Philadelphia chromosome and BCR-ABL abnormality

segmenter

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POYCYTHEMIA VERA
Note: normoblastic(arrow) erythroid hyperplasia in panmyelosis Recall: normoblast- RBC with pyknotic nuclei and pinkish cytoplasm

ESSENTIAL THROMBOCYTOSIS
Lt: Bone marrow showing increase megakaryocyte Rt: PBS; aside from increased number of platelets in this HPF, a giant platelet is also seen.

PRIMARY MYELOFIBROSIS
Lt: bone marrow showing fibrosis Rt: dacrocyte(tear drop) seen in PBS due to hypersplenism

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DIAGNOSTIC PROCEDURES in LYMPHOID and MYELOID NEOPLASMS 1. Chromosomal translocation and oncogenes 2. Inherited genetic factors Ex. Blooms syndrome, Fanconis anemia, Downs Syndrome, Neurofibromatosis Type I 3. Virus a. T cell leukemia virus: T cell leukemia/lymphoma b. EBV(most significant): Burkitt Lymphoma, Hodgkin Lymphoma, B cell Lymphoma in T cell immunodeficiency c. KSHV/HHV 8: unusual B cell lymphoma presenting as MALIGNANT EFFUSION 4. Environmental agents Ex. H. pylori infection gastric B cell lymphoma 5. Iatrogenic factors Radiotherapy and chemotherapy increase the risk of myeloid and lymphoid neoplasm SPLEEN
Normal spleen. C-capsule, WP-white pulp, RP-red pulp, T-trabeculae Regions: 1. White pulp contains the follicles(B cells and T cells are found, hence have role in immunity) 2. Red pulp has the cords of Billroth and sinusoids; important in phagocytosis and storage Theory of Blood flow in spleen: 1. Open theory-bloods from arterioles capillarie enter the red pulp venules blood stays a longer time in open theory 2. Close theoryfrom arterioles capillariesstraight into the sinusoids Damaged and old RBC are phagocytosed in the sinusoids NORMAL: 150 mg Funtion: o Filtration of unwanted elements from the blood o Secondary organ of immune system o Source of lymphoreticular cells and sometimes hematopoietic cells o Constitutes a reserve pool and storage site

A. CAUSES OF SPLENOMEGALY: In splenomegaly, blood goes into the open circulation resulting to sequestration of blood elementshypersplenism pancytopenia Differential diagnosis: aplastic anemia and MDS Degree of splenomegaly can give a clue to the etiologic agent Massive splenomegaly is seen in chronic leukemia(CML), primary myelofibrosis(and other MPD), liver cirrhosis and schistosomiasis I. Infections Nonspecific splenitis of various blood borne infections Tuberculosis Typhoid fever malaria II. Congestive State Related to Portal Hypertension Liver cirrhosis Schistosomiasis Right sided heart failure o Mild to moderate Portal or splenic vein thrombosis III. Lymphohematogenous Disorders Lymphoma (Hodgkin and Non-Hodgkin) Acute Leukemia Chronic Leukemia Myeloproliferative disease

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IV.

V.

VI.

B.

C.

D.

E.

F. G.

Hemolytic anemias ITP Immunologic- Inflammatory disease SLE Rheumatoid arthritis Storage disease Gauchers disease Niemann Pick disease Mucopolysaccharidosis Miscellaneous Amyloidosis Secondary neoplasms, very rare o Indication: tumors in the spleen is most likely a primary tumor Hypersplenism Splenomegaly Reduction of one or more cellular elements of the blood with BM hyperplasia of the deficient element Correction of cytopenia by splenectomy All three must be present to diagnose as hypersplenism Remember this he said he will give this in our examination Non- Specific Splenitis Occurs in any blood borne infection Gross: splenomegaly, soft with obscured white pulp and mushy cut surface Micro: o Reticuloendothelial hyperplasia o Neutrophils, plasma cells, and eosinophils may be present in red and white pulp Congestive Splenomegaly Due to persistent systemic or central venous congestion o CHF, chronic co pulmonale o Cirrhosis o Schistosomiasis o Portal vein thrombosis Gross: marked splenomegaly, thick and fibrous capsule, GAMMA-GANDY NODULES Micro: sinusoids congested with RBC, may have fibrotic, dilated sinusoids, fibrotic trabeculae, and gamma-gandy nodules (foci of recent and old hemorrhages with hemosiderin deposition in histiocytes) Splenic Infarcts Due to emboli arising from heart Anemic type, wedge-shaped Septic infarcts (in infective endocarditis) Neoplasms Rare except tumor of lymphohematopoetic system Rupture Crushing and severe blow Spontaneous rupture in IM, malaria, LEU, and acute splenitis

Picture above shows splenomegaly

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THYMUS

1.

2.

3.

4.

Normal: a. at birth: 0-15 grams b. at puberty: 20-50 grams c. elderly: 5-15 grams Developmental disorders a. Thymic hypoplasia and aplasia i. Seen in DiGeorges syndrome characterized by absence or loss of cell mediated immunity often with hypoparathyroidism (tetany) Thymic hyperplasia a. Characterized by the appearance of lymphoid follicles in the thymus(thymic follicular hyperplasia) b. Most frequently encountered in Myasthenia gravis (65-75%) i. Recall: myasthenia gravis- Ab against Ach receptors Thymomas a. Tumors of thymic epithelial cells together with non-neoplastic immature T cells (thymocytes) b. Thymomas are tumor of adults > 40 years c. Most arise in the antero-superior mediastinum (20-30% of tumors in that compartment) d. Morphology: i. Lobulated mass showing a mixture of epithelial cells and non- neoplastic thymocytes (T lymphocytes b. Clinically: i. 40% present as thymic mass on imaging studies or because of local pressure symptoms ii. 35-45% association with myasthenia gravis a. types: 2. Benign or encapsulate thymoma i. Cytologically and biologically benign (50% of thymoma) 3. Malignant Thymoma a. Type I i. Invasive thymoma ii. Cytologically benign but biologically aggressive (locally invasive and metastasize; 20-25% of thymomas) b. Type II i. Thymic carcinoma ii. Cytologically and biologically malignant (5% of thymomas) majority are squamous cell carcinoma

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Benign Thymoma Neoplastic epithelial cells are arranged in a swirling pattern and have bland, oval to elongated nuclei with inconspicuous nucleoli Few reactive lymphocyte(deeply basophilic cells seen in the picture) are interspersed

Malignant Thymoma Neoplastic epithelial cels are polyglonal and have round to oval, bland nuclei with inconspicuous nucleoli. Numerous small reactive lymphoid cells are interspersed

End of transcription Sources: Dr De Guzman s handout and voice recording, Henrys, Robbins, internet and my brain..haha! I tried to identify some of the cells and describe it the best way I can, I have not asked any of our professors to double check how I identified it so when in doubt, consult them about this transcription. Good luck! I hope you will enjoy the hema module as much as I enjoy it! Hahaha! Study hard and party harder! God bless!!

Let your hearts not be troubled. Believe in God, believe also in Me. In my Fathers house are many rooms. If it were not so, would I have told you that I go to prepare a place for you. I will come again and will take you to myself, that where I am you may be also. John 14:1-3

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