Know

the morphology and diagnostic importance of the Reed Sternberg cell and its variants in Hodgkin Lymphomas

Know the major subtypes of Hodgkin lymphomas along with morphology and patient demographics per Table 13-8 in Robbins pathology text with emphasis on the 2 most common types. Identify Auer rods in the cytoplasm of myleoblasts in AML and know that they are particularly prominent in acute promyelocytic leukemia with t(15;17) Know the pathogenesis, morphology, clinical features and prognosis of myelodysplasia

 Know

the major categories of myeloproliferative disorders and their common pathogenetic mechanism (tyrosine kinase mutations). Know the molecular pathogenesis (Philadephia chromosome t(9;22) with resultant BCR-ABL fusion gene), morphology, clinical features and prognosis of chronic myeloid leukemia. Know the pathogenesis, morphology, clinical features and prognosis of polycythemia vera (PCV), essential thrombocytosis(ET) and myelofibrosis Be familiar with major forms of Langerhans cell histiocytosis including Letterer-Siwe disease, eosinophilic granuloma and pulmonary forms along with their morphology.

T-cell lymphoma, unspecified worse prognosis than diffuse large B-cell lymphoma Anaplastic large-cell lymphoma (ALK positive) rearrangement of ALK gene on chromosomes 2p23 hallmark cells with horseshoe shaped nuclei with good prognosis Adult T-cell leukemia/lymphoma-CD4+ T cells with human T-cell leukemia retrovirus type I infection (HTLV-1) in Japan, West Africa, Caribbean Mycosis Fungoides/Sezary syndrome Large Granular Lymphocytic leukemia- rheum. assoc. Extranodal NK/T-cell lymphoma associated with EBV infections
Peripheral

 Mycosis

Fungoides/Sezary Syndrome

Limited to skin in early stages as plaques or patches. Misdiagnosed as psoriasis commonly. Epidermal collections of atypical lymphocytes are known as Pautriers Microabscesses. Advanced stage with nodal or organ involvement, and circulating clonal T cells in blood are called Sezary Cells. Chronic illness, typically older patients, incurable. Treatment with topical nitrogen mustard, electron beam XRT, PUVA (psoralen with UV-A light) Sezary Syndrome treated with chemotherapy.

Figure 3. Collection of atypical lymphocytes with convoluted (ceribriform) nuclei in epidermis

Kadin, M. ASH Image Bank 2005;2005:101309

Copyright 2005 American Society of Hematology. Copyright restrictions may apply.

Figure 2. Epidermotropism of atypical lymphocytes with cerebriform nuclei

Kadin, M. ASH Image Bank 2005;2005:101309

Copyright 2005 American Society of Hematology. Copyright restrictions may apply.

Figure 3. Higher magnification of Sezary cell with convoluted nulceus and small nucleoli

Kadin, M. ASH Image Bank 2004;2004:101260

Copyright 2004 American Society of Hematology. Copyright restrictions may apply.

First four types are classical forms of HL since Reed-Sternberg cells have similar immunophenotype (CD 15 and 30 positive) The non-classical lymphocyte predominance differs from the classical types in that the RS cells have markers typical of germinal center B cells, such as CD20 and BCL6 and are negative for CD15 and CD30.

 HL

arises in a single node or chain of nodes and spreads first to anatomically contiguous lymphoid tissues (NHL may occur in extranodal sites and spread unpredictably)

The order of spread is predictable: nodal disease first, then splenic, hepatic and finally involvement of marrow and other tissues

HL

has distinctive morphologic features characterized by neoplastic giant cells called Reed-Sternberg cells (RS cells)

RS cells are derived from germinal center or postgerminal center B cells RS cells release factors attracting reactive lymphocytes, macrophages, and granulocytes

 Hodgkin

Lymphoma

Non-Hodgkin

More often localized to a single axial group of nodes (cervical, mediastinal, paraaortic) Orderly spread by contiguity Mesenteric nodes and Waldeyer ring rarely involved Extra-nodal presentation rare

lymphoma

More frequent involvement of multiple peripheral nodes Noncontiguous spread Waldeyer ring and mesenteric nodes commonly involved Extra-nodal presentation common

 ~8000

new cases in USA each year. Average age at diagnosis is 32 years and is one of the most common cancers of young adults and adolescents (occurs in older people as well) First human cancer to be successfully treated with radiation therapy and chemotherapy and is curable in most cases

 RS

cells originate from a germinal center or post-germinal center B cell but fail to express most B cell-specific genes

Activation of the transcription factor NF-kappaB (possibly by EBV infection or other mechanism) and turns on genes that promote lymphocyte survival and proliferation (EBV infected B cells in mononucleosis have a resemblance to RS cells) RS cells secrete a wide variety of cytokines and chemokines inciting a florid accumulation of reactive cells in tissues involved by classical HL RS cells are aneuploid and have diverse clonal chromosomal aberrations

http://www.cytojournal.com/viewimage.asp?img=CytoJournal_2010_7_1_20 _70966_f7.jpg

Figure 8. Nodular sclerosis involving lymph node in Hodgkin lymphoma - low magnification

Kadin, M. ASH Image Bank 2002;2002:100484

Copyright 2002 American Society of Hematology. Copyright restrictions may apply.

 Acute

myeloid leukemias Myelodysplastic syndromes Myeloproliferative disorders

Neoplastic proliferation arising in hematopoietic precursor cells resulting in overgrowth of myeloblasts and other immature cells of myeloid lineage Diagnosis based on at least 20% myeloid blasts in the bone marrow Myeloblasts delicate nuclear chromatin, two to four nucleoli and more cytoplasm than lymphoblasts

Cytoplasm may contain azurophilic granules (peroxidase positive) and Auer rods(needle like azurophilic granules) Auer rods particularly prominent in acute promyelocytic leukemia with a t(15;17)

Sometime blasts are entirely absent from blood (aleukemic leukemia) therefore need a bone marrow in pancytopenic patients to rule out leukemia May differentiate along monocytic, erythroid and megakaryocytic lines

Acute lymphoblastic leukemia

Acute myeloid leukemia

A group of clonal stem cell disorders characterized by maturation defects associated with ineffective hematopoiesis High risk of transformation to acute myeloid leukemia Disease of the elderly (mean age of onset is 70 years) Frequently discovered incidentally while asymptomatic Symptoms are due to pancytopenia (pancytopenia occurs because the abnormal cells stay within the bone marrow)

Weakness, infections and hemorrhage

 Primary

(idiopathic) Secondary to previous genotoxic drug or radiation therapy (t-MDS)

Appears 2 to 8 years after exposure Transformation to AML occurs more rapidly and frequently

 Refractory

anemia Refractory anemia with ring sideroblasts Refractory anemia with excess blasts Refractory anemia with excess blasts in transformation Chronic myelomonocytic leukemia

 Poorly

understood since abnormal progenitor cells undergo apoptosis at an increased rate yet somehow gain a selective advantage over any remaining normal marrow progenitors Clonal chromosomal abnormalities include monosomies 5 and 7, deletions of 5q,7q and 20q and trisomy 8

 Bone

marrow usually hypercellular at DX but may be hypo- or normocellular Dysplastic or disordered differentiation affecting the erythroid, granulocytic, monocytic and megakaryocytic lineages Peripheral blood smear may show PseudoPelger-Huet cells (neutrophils with only 2 lobes and some lack any segmentation), giant platelets, macrocytes, and poikilocytes with a monocytosis Blasts may make up less than 10% of WBC in peripheral smear

Erythroid series
Ringed sideroblasts-erythroblasts with iron-laden mitochondria Megaloblastoid maturation (like B12 and folate def) Nuclear abnormalites of red cell precursors

Granulocytic
Decreased secondary granules, toxic granulation and/or Dohle bodies Pseudo-Pelger-Huet cells only two nuclear lobes

Megakaryoctyes

Single nuclear lobes or multiple separate nuclei (pawn ball megakaryocytes)

Myeloid blasts may be increased but less than 20% of marrow

 Median

survival varies from 9 to 29 months but some may live for 5 years or more Worse prognosis with

Increased blasts (increased progression to AML) Multiple clonal chromosomal abnormalities Severe cytopenia

patients bone marrow transplant Older patients treated supportively with antibiotics, blood transfusion
Younger

A subset of older patients have improvement with thalidomide-like drugs and DNA methylase inhibitors which improve hematopoiesis

 Common

denominator in the myeloproliferative disorders are tyrosine kinase mutations (normally growth factors bind to surface receptors of normal progenitor cells and activate tyrosine kinases which turn on pathways promoting growth and survival) Categories of myeloproliferative disorders

Chronic myeloid leukemia (CML) Polycythemia Vera Essential thrombocytosis Primary myelofibrosis

disease of adults occurring in the 5th to 6th decades Leukocytosis often exceeding 100,000 cells per cubic mm consisting of neutrophils, bands, metamyelocytes, myelocytes, eos and basophils with blasts less than 10% Platelets are increased Hypercellular marrow with increased numbers of maturing granulocytic precursors and increased megakaryocytes Sea-blue histiocytes scattered in bone marrow (macros with abundant wrinkled, green-blue cytoplasm)
Mostly

 Spleen

is greatly enlarged from extensive extramedullary hematopoiesis May also have mild hepatomegaly and lymphadenopathy from extramedullary hematopoiesis

Figure 1. High power view of peripheral smear of a patient with CML reveals neutrophils and some immature myeloid forms including blasts (arrow) (MacNeal Tetrachrome 1000x)

Maslak, P. ASH Image Bank 2002;2002:100363

Copyright 2002 American Society of Hematology. Copyright restrictions may apply.

Figure 3. CML

Maslak, P. ASH Image Bank 2001;2001:100202

Copyright 2001 American Society of Hematology. Copyright restrictions may apply.

Figure 5. CML

Maslak, P. ASH Image Bank 2001;2001:100202

Copyright 2001 American Society of Hematology. Copyright restrictions may apply.

Figure 10. CML

Maslak, P. ASH Image Bank 2001;2001:100202

Copyright 2001 American Society of Hematology. Copyright restrictions may apply.

chimeric BCR-ABL gene derived from portions of the BCR gene on chromosome 22 and the ABL gene on chromosome 9 In more than 90% of cases BCR-ABL is created by a reciprocal (9;22)(q34;q11) translocation called the Philadelphia chromosome BCR-ABL directs the synthesis of a constitutively active BCR-ABL tyrosine kinase

Drives growth factor independent proliferation and survival of bone marrow progenitors It does not interfere with differentiation resulting in mature cells Detection of the BCR-ABL fusion gene through PCR or chromosomal analysis

Chronic Myeloid Leukemia (CML)

 Insidious

onset with non-specific symptoms Splenomegaly may produce a dragging sensation in abdomen or may get acute splenic infarct Slow progression After ~ 3 years, accelerated phase in 50% with increasing anemia and thrombocytopenia with additional cytogenetic abnormalities After 6 to 12 months, accelerated phase terminates in a blast crisis (lymphoid or myeloid) Median survival 3 years

 Bone

marrow transplant in young patients which is curative in 75% of cases performed during the stable phase Imatinib, a BCR-ABL inhibitor, results in sustained hematologic remission in greater than 90% of patents; however, does not extinguish the CML stem cell

 Characterized

by increased marrow production of red cells, granulocytes and platelets with SXs from RBC increase. PCV associated with mutations in the tyrosine kinase JAK2 gene leading to proliferation of hematopoietic cells independent of growth factors (less proliferative drive than CML) Erythropoietin levels are low

 Relative

polycythemia is an increased RBC count due to a decrease in PV for example dehydration RBC mass is normal Absolute polycythemia is an increase in bone marrow production of RBCs with increase in count and mass

Appropriate absolute polycthemia is a response to hypoxemia in smokers or other chronic lung disease or at altitude or cyanotic CHD Inappropriate absolute polycythemia

PCV or POLYCYTHEMIA VERA is an INAPPROPRIATE ABSOLUTE POLYCYTHEMIA with a low erythropoietin. Ectopic EPO or erythropoietin production, i.e. RCC

 Hypercellular

marrow (trilineage) with only subtle increase in RBC progenitor Mild organomegaly from congestion Peripheral blood has increased basophils and large platelets Late in course of disease, extensive marrow fibrosis is present with extramedullary hematopoiesis in the spleen and liver leading to organomegaly

 Occurs

in adults of middle age with incidence of 1-3 per 100,000 per year SXs occur due to hyperviscosity from increased RBC count Patients are plethoric and cyanotic due to stagnation and deoxygenation of blood in peripheral vessels Headache, dizziness, hypertension, and gastrointestinal SXs Most ominous is thrombosis and hemorrhage

 Gout

Increased breakdown of nucleated cells with uric acid production from purines

Increased

histamine release from mast cells

Pruritus after bathing (mast cells degranulate after change in skin temperature Peptic ulcer disease Histamine stimulates gastric acid production

 Without

Rx, death from bleeding or thrombosis occurs in months With phlebotomy, ~10 year median survival PCV evolves into a spent phase with development of myelofibrosis in 15 to 20% after ~ 10 years Extramedullary hematopoeisis develops PCV transforms to AML in ~2%

 Associated

with JAK2 (50% of cases) or MPL (5-10% of cases) a receptor tyrosine kinase normally activated by thrombopoietin. Unknown why JAK 2 causes PCV in some and ET in others JAK2 or MPL signaling renders the progenitors thrombopoietin-independent leading to hyperproliferation

 Mild

increase in bone marrow cellularity Megakaryocytes are markedly increased in number and in abnormally large forms Delicate reticulin fibers in bone marrow Peripheral smears show abnormally large platelets with mild leukocytosis Modest extramedullary hematopoiesis with mild organomegaly in ~50% of patents

Figure 3. A clustering of megakaryocytes is often noted in essential thrombocythemia

Maslak, P. ASH Image Bank 2003;2003:100634

Copyright 2003 American Society of Hematology. Copyright restrictions may apply.

Figure 1. Giant megakaryocytes can be seen alongside unilobed megakaryocytes in this bone marrow aspirate from a patient with essential thrombocythemia

Maslak, P. ASH Image Bank 2003;2003:100634

Copyright 2003 American Society of Hematology. Copyright restrictions may apply.

 Incidence

1-3 per 100,000 per year Occurs past 60 years old but may be seen in younger people Dysfunction of platelets leads to thrombosis and hemorrhage Erythromelalgia, a throbbing and burning of hands and feet caused by occlusion of small arterioles by platelet aggregates (may be seen in PCV) Indolent disease with median survival of 12 to 15 years. Rx with gentle chemotherapy

 Hallmark

of disease is development of obliterative marrow fibrosis JAK2 mutations present in 50 to 60% of cases MPL mutations in 1 to 5% of cases Main pathologic feature is extensive deposition of collagen in the marrow by nonneoplastic fibroblasts which displaces hematopoietic elements Likely caused by inappropriate release of fibrogenic factors (PDGF and TGF-B) from neoplastic megakaryocytes. Extramedullary production is disordered resulting in severe cytopenias

 Initially,

hypercellular marrow of all lineages

Megakaryocytes are large, dysplastic and abnormally clustered Peripheral blood may show leukocytosis and thrombocytosis

With

progression, marrow is hypocellular and fibrotic with clusters of atypical megakaryocytes with hematopoietic elements in dilated sinusoids due to fibrosis Late, fibrotic marrow is converted into bone, which is called osteosclerosis

 Extramedullary

hematopoiesis causes severe splenomegaly (up to 4000 grams) with subcapsular splenic infarcts Moderate hepatomegaly Peripheral blood smear shows:

Teardrop cells(dacrocytes) Leukoerythroblastosis (premature release of nucleated erythroid progenitors and early granulocyte progenitors) Abnormally large platelets Basophilia

Figure 1. Bone marrow fibrosis (hematoxylin and eosin stain, low power)

Fukumoto, J. et al. ASH Image Bank 2007;2007:6-00064

Copyright 2007 American Society of Hematology. Copyright restrictions may apply.

Figure 3. Bone marrow fibrosis (Trichrome stain, low power)

Fukumoto, J. et al. ASH Image Bank 2007;2007:6-00064

Copyright 2007 American Society of Hematology. Copyright restrictions may apply.

Figure 5. Bone marrow trephine biopsy: showing thick coarse reticulin fibers (Grade 4 fibrosis)

Baden, H. S. ASH Image Bank 2009;2009:9-00033

Copyright 2009 American Society of Hematology. Copyright restrictions may apply.

 Less

common than PCV and ET Age > 60 years Progressive anemia and splenomegaly with leukoerythroblastosis Decreased white counts and platelets as disease progresses AML transformation occurs in 5 to 20% Bleeding, thrombosis, intercurrent infections are complications Median survival is 3 to 5 years

 Histocytosis-proliferative

disorders of dendritic cells or

macrophages Langerhans cell-immature dendritic cell Mutlifocal multisystem Langerhans cell histiocytosis (Letter-Siwe disease)

Usually occurs before age 2 Cutaneous lesions along with multiorgan infiltration With chemo, 5 year survival is 50%

Eosinophilic

granuloma-proliferation of Langerhans cells admixed with eosinophils, lymphocytes, plasma cells and neutrophils, typically arises in bones Pulmonary Langerhans cell histiocytosis may be reactive proliferation in smokers

 Langerhans

cells have abundant vacuolated cytoplasm and vesicular nuclei containing linear grooves or folds Birbeck granules in the cytoplasm are pentalaminar tubules, with a dilated terminal end producing a tennis racket appearance.

Pardanani, T L Lasho, C Finke, C A Hanson and A Teffer. Prevalence and clinicopathologic correlates of JAK2 exon 12 mutations in JAK2V617F-negative polycythemia veraJAK2 exon 12 mutations in polycythemia vera. Leukemia 21, 1960-1963 (September 2007) American Society of Hematology Image Bank Chronic Myeloid Leukemia Polycthemia Vera: eMedicine Hematology from http://emedicine.medscape.com

 John

L. Frater, MD, Martin S. Tallman, MD, Daina Variakojis, MD, Brian J. Druker, MD, Debra Resta, RN, Mary Beth Riley, RN, MSN, OCN, Mary Ann Hrisinko, MT(ASCP), LoAnn C. Peterson. Chronic Myeloid Leukemia Following Therapy With Imatinib Mesylate (Gleevec). American Journal of Clinical Pathology. 2003;119(6). Lyons J. Pathology of Leukemia I and II presentation. LMU/DCOM. Robbins and Cotran Pathologic Basis of Disease 8th edition