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Slide 1 - Week 10: Leukemia AML ALL FAB classification WHO classification Cytochemistries MPO SBB PAS ORO CD markers Flowcytometry CML CLL Karyotype Ph chromosome LAP
Slide 2 - Signs and Symptoms of AML Insidious nonspecific onset Pallor due to anemia Febrile due to ineffective WBC Petechiae due to thrombocytopenia Mucus membrane and gum bleed in M4 and M5 Bone pain
Slide 3 - Typical Labs of AML Leukocytosis Blastemia Leukemic hiatus Auer rods in M2, M3, M4 Thrombocytopenia Anemia >20% blasts in BM
Slide 4 - Other Findings CD 13 and CD 33 in flowcytometry Cytochemistries Myeloperoxidase Sudan black B Choloroacetate esterase (specific) Nonspecific esterase
Slide 5 - FAB (1976) Classification M0 -- Undifferentiated AML M1 -- AML without maturation M2 -- AML with maturation M3 -- Acute Promyelocytic Leukemia M4 -- Acute Meylomonocytic Leukemia M5 -- Acute Monocytic Leukemia M6 -- Erythroleukemia (DiGuglielmo’s) M7 -- Megakaryoblastic Leukemia
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Slide 7 - M1 and M2
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Slide 10 - Myeloperoxidase (MPO) p-Phenylene diamine + Catecol + H2O2 MPO > Brown black deposits
Slide 11 - M3 M5 M4
Slide 12 - Chloracetate (Specific) Esterase Myeloid Cell Line Naphthol-ASD-chloracetate CAE > Free naphthol compounds + Stable diazonium salt (eg, Fast Corinth) > Red deposit
Slide 13 - Non-Specific Esterase Monocytic Line  Naphthyl acetate ANAE > Free naphthyl compounds +Stable diazonium salt (eg, Fast blue RR) > Brown deposits
Slide 14 - Double Esterase in M4 NSE with Fl inhibition Histiocyte
Slide 15 - FAB vs WHO Classifications of Hematologic Neoplasm FAB criteria Morphology Cytochemistry WHO criteria Morphology Immunophenotyping Genetic features Karyotyping Molecular testing Clinical features
Slide 16 - WHO Classification of AML AML with recurrent cytogenic translocations AML with multi-lineage dysplasia AML and myelodysplasia, therapy related AML, not otherwise categorized
Slide 17 - AML with Recurrent Cytogenetic Translocations (WHO 1995) t(8;21) -- some maturation of neutrophilic line; rare in older patients; AML1/ETO fusion protein; >90% FAB M2 t(15;17) -- APL (granular and microgranular variants); retinoic acid receptor (RAR) leukemias; middle aged adults; DIC inv(16) or t(16;16) -- monocytic and granulocytic; abnormal eosinophilic component 11q23 -- monocytic; children; most common is t(9;11)
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Slide 21 - FAB Classification of ALL L1: Small homogeneous blasts; mostly in children L2: Large heterogeneous blasts; mostly in adults L3: “Burkitt” large basophilic B-cell blasts with vacuoles
Slide 22 - L3 L2
Slide 23 - Periodic Acid Schiff Periodic acid + Glycogen oxidation > Aldehyde + Schiff reagent (para-rosaniline, Na metabisulfite) > Red deposit
Slide 24 - ALL Cytochemistries Oil Red O: stains L3 vacuoles Terminal deoxynucleotidyl transferase (Tdt): DNA polymerase in early lymphoblasts Cell surface markers (CD’s) Cytoplasmic and surface immunoglobulins: B-cell line T-cell receptor (TCR)
Slide 25 - WHO Classification of Lymphoproliferative Syndromes Precursor B Lymphoblastic Leukemia/Lymphoma (ALL/LBL) -- ALL in children (80-85% of childhood ALL); LBL in young adults and rare; FAB L1 or L2 blast morphology Precursor T ALL/LBL -- 15% of childhood ALL and 25% of adult ALL Burkitt Leukemia/Lymphoma (FAB L3)
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Slide 27 - Prognosis
Slide 28 - Typical Labs in CML Leukocytosis with blastemia Thrombocytosis Basophilia Micro-megakaryocytes Low LAP score (intermediate if infected) About 10% blasts in BM Philadelphia chromosome
Slide 29 - CML
Slide 30 - Bone marrow aspirate and biopsy
Slide 31 - Pseudo-Gaucher’s cells in BM
Slide 32 - Leukocyte Alkaline Phosphatase (LAP) Naphthol AS-MX phosphate LAP at pH8.6 > Naphthol AS-MX + Diazonium salt (eg, Fast blue RR) > Insoluble pigment
Slide 33 - LAP Score Count 100 consecutive segs and bands Score: 0 = no granules 1+ = occasional diffuse granules 2+ = moderate number of granules 3+ = many strongly positive granules 4+ = confluent strongly positive granules
Slide 34 - 0 1+ 2+ 3+ 4+
Slide 35 - LAP Score Example: 0 x 35 cells = 0 1+ x 30 cells = 30 2+ x 20 cells = 40 3+ x 10 cells = 30 4+ x 5 cells = 20 120 LAP Score
Slide 36 - Philadelphia Chromosome 9 and 22 translocation almost specific to CML Karyotype to visualize Ph chromosome Produces BCR/c-abl fusion oncogene Gene product p190 is a hyperactive tyrosine kinase Ph chromosome seen in ALL produces p210 and chronic neutrophilic leukemia produces p230
Slide 37 - Karyotype 46,XX,t(9;22)(q34;q11.2) -- Ph chromosome
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Slide 39 - FISH showing the BCR (green), ABL (orange), and BCR-ABL fusion signals (arrow): A=positive (contains a residual ABL signal), B=normal
Slide 40 - FAB (1982) Classification of Myeloproliferative Disease (MPD) Chronic Myelocytic Leukemia (CML) Polycythemia Vera (PV) Essential Thrombocythemia (ET) Agnogenic Myeloid Metaplasia with or without Myelofibrosis (AMM) Benign Leukemoid Reaction
Slide 41 - WHO Classification of MPS (1997) CML becomes CML, Ph + t(9;22) BCR/ABL Chronic Neutrophilic Leukemia (CNL) Chronic Eosinophilic Leukemia and Hyper-eosinophilic Syndrome (CEL/HES) PV remains PV ET remains ET AMM becomes Chronic Idiopathic Myelofibrosis
Slide 42 - Myelofibrosis
Slide 43 - Myelofibrosis
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Slide 45 - Chronic Lymphocytic Leukemia Exclusive in elderly Lyphocytosis unrelated to viral infection Hyper-mature lymphocytes with highly condensed nuclei Smudge cells: preventable with a drop of bovine albumin
Slide 46 - CLL PB and BM
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Slide 49 - Bone Marrow
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Slide 51 - WHO Lymphoid Neoplasms B cell neoplasms T/NK cell neoplasms Hodgkin lymphoma (disease)
Slide 52 - Mature B Cell Neoplasms B cell CLL/SLL B prolymphocytic leukemia Burkitt’s lymphoma / leukemia Splenic marginal zone B lymphoma Extranodal marginal B lymphoma Hairy cell leukemia Lymphoplasmocytic leukemia Mantle cell lymphoma Plasma cell myeloma / plasmacytoma Follicular lymphoma Diffuse large B lymphoma
Slide 53 - T/NK Cell Neoplasms T prolymphocytic leukemia T granular lymphocytic leukemia Aggressive NK cell leukemia Adult T lymphoma / leukemia Mycosis fungoides (Sezary syndrome) Anaplastic large cell lymphoma Hepatosplenic T lymphoma Peripheral T lymphoma Immunoblastic T lymphoma