3.25 STROM Hematologic Malignancies I Flashcards Preview

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Flashcards in 3.25 STROM Hematologic Malignancies I Deck (40):


(RBC/Bld Vol)x(RBC vol/RBC)=RBCxMCV


Blast Criteria

a. Big Cell

b. Increased nuclear/cytoplasm ratio

c. Immature Chromatin

d. Big nucleolus or two

e. A bunch of cell that look a like***

--Does not have to meet all the standards to be considered a blast



What hematologic malignancies look like

-Stuff that should be in the BM is in the peripheral blood



-Differnent cell types express different antigens

-use mAbs to detect

-hint most markers for T-cells will be <10

-Malignancies can change surface expression so not as helpful as ppl thought it would be

-Access via flow cytometry (remember lyse RBC so will not detect poss RBC precursors)

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B-cell and T-cell Antigens

B-cell: CD-20, IgG kappa/lambda, CD45(both)

T-cell: CD3, CD7, CD4 or CD8


CD45, CD33, CD34

Usually start with CD45: on almost all marrow cells and can help to ID a blast population (left ball of graft)

-Most blast tend to express CD34

-Maturing granulocytes tend to express CD33

-COMBO of CD33 & CD34 indicate AML if in large population (premature myeloid cell in peripheral)



-Works better for larger cells than flow cytometry

-use enzyme conjugated abs to desired cell surface protein and then use CHROMOGENIC substrate


Gilman's Hypothesis

Need to mutations for the AML to hurt the patients

Class I: increases proliferation

Class 2: decreases differentiation -together these will make the leukemia much more aggressive and dangerous


Summary of Malignancies Arising in the BM

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Rapidly proliferating clones: Blasts in marrow and often in blood stream

Can arise from 3 cell lineages:

(1) Megs

(2) Erythroid Lineage

(3) Myeloid lineage


Acute Lymphocytic Leukemias (ALL)

Arise from the lymphocyte lineage

-Rapidly proliferating clones: blasts in marrow and often blood stream



Typical Presentation of Acute Leukemias

-Clones can take over a variety of locations, usually blood stream and BM

-They can take over BM w/o raising the WBC count in peripheral

-Can sometimes present as cytopenias (decreased cellularity of the blood), would not expect a rapidly proliferating population to present as cytopenia

Blasts outside of Marrow (rare): Myeloid: Myeloid Sarcoma and Lymphoid: Lymphoblastic lymphoma


Acute Leukemia Diagnosis

-Use to simply be >20% blast in marrow, not very predictive of how the leukemia will progress

Other methods:Morphology (useless by itself), Immunophenotyping (blasts can change surface expression) and genotyping

-Use an many as possible, genotyping can predict AML even if blast count is low


Genotyping Acute Leukemias, Specific Mutations

t(15:17) PML-RARA (AML Subtype)

t(8;21) RUNX1-RUNXT1 (AML Subtype)

t(12;21) FLT3 mutation(+) (AML Subtype)

-These and others give increased prognostic value, predicts response to therapy, IDs molecular targets for therapy development


Gililand Hyposthesis AGAIN!!

Class I (proliferation/survival advantage):

-FLT3-ITD, FLT3-TKD, Kit, Ras, PTPN11 Jak2 (usually dectected via sequencing)

Class II (impaired differentiation/apoptosis):

-t(15;17) PML-RARA, t(8;21) Runx-Runx1T1, (inv(16) or t(16;16)))CBFB-Myh11, MLL fusions (usually detected via cytogenetics)

BOLDED= AML diagnosed with presence even w/o blast count



t(8;21) Runx-1-Run1T1 Mutation

Clinical Presentation: younger patients/kids

Auer rods: crystalization of granule contents (excess myeloperoxidase production)

Immunophenotype: CD34+, CD13+, CD33weak

Prognosis: good response to chemo

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t(15;17) fusion of PML (trans factor) with RARA (retinoic acid receptor)

-Class II mutation: Inhibits granulocyte differentiation

-TREATMENT: All Trans Retinoic Acid (ATRA), induces cell differentiation of the blasts to granulocytes (CLINICAL REMISSION)


-Morphology: AUER RODS in stacks (faggot cells)*** sometimes see Bi-nuclear appearance

Immunophenotype: Weak/absent: CD34, HLA-DR, CD13+, CD33+

Prognosis: good if diagnosis is made

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inv(16) or t(16;16)

-Class II mutant, clinical presentation: younger patients/kids

-Morphology: Myelomonocytic* (mixed granulocyte-monocyte feats), Increased Eosinophils in blood and marrow (not known why)

-Immunophenotype: CD34+, CD117+ (blasts); CD13+, CD33+ (granulocytes); CD14+, CD11b+ (monocytes)

Prognosis: GOOD; optimal with high dose CYTARABINE

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AML w/ Normal Cytogenetics 

40-50% of AML cases

-Any age group

Morphology: undifferentiated or variable granulocytic or monocytic/monoblastic

-Immunophenotype: blast markers (CD34, CD117)+, can show any lineage markers

-Prognosis: have to look at molecular genetics, pairing of mutation will determine 

-For some BM transplant doesnt help (NPMN! or CEBPA+, FLT3-ITD-, 60% 4-yr survival)

-for other it will (FLT3-ITD+ or NPM1-, CEBPA-, FLT3-ITD-, ~29% 4-yr survival)

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ALL (Acute Lymphoblastic Leukemias)

TdT: important for VDJ recombination and marker of B and T cells

-CD19,CD10 and uCD20 are markers of B cells, can also express myeloid markers (CD13, CD33)

-Can also express CD34 (GENERAL BLAST MARKER*****)



-t(9;22), proliferation activator (class I), diff from the mutation found in CML which is a class II mutation and prevents maturation of the cell, and have similar cytogenetics

-Clinical Presentation: Older adults (25% of all cases)

Morphology: Big agranular blasts, hard to tell ir myeloid or lymphoid

Immunophenotype CD10+, CD19+, TdT+

Prognosis: Poor



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ALL: MLL rearranged

t(v;11q23), or t(11;19) Class II mutation, also found in AML

Clinical Presentation: most common leukemia in kids

Morphology: big agranular blasts

Immunophenotype: CD10-, CD19+, TdT+

Prognosis: Poor

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ALL, Mutations that made St. Jude Famous

-t(12;21); TEL-AML1 (ETV6-RUNX1), class II (inhibits differentition)

-Clinical Presentation: Kids, 25% of pediatric B-ALL

Morphology: big agranular blasts

Immunophenotype: TdT+, CD34+, CD20-

Prognosis: 90% cure rate

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-Common motif for lymphoid malignancies: oncogene>>>>Ig or TCR promoter

-Clinical Presentation: Kids 25% of pediatric T-ALL, often wih thymic mass**

Morphology: Big agranular blasts

Immunophenotype: TdT+, CD3+, CD5+, can express myeloid or B-cell antigens as well

Prognosis: High Risk: more intense chemotherapy regime, pretty good survival rate

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Myeloproliferative Disease

Definition: Chronically proliferating clones which differentiate to circulating blood cells

Chronic Myelogenous Leukemia (CML): shows blast profile

CMML (myelodysplastic/myelomonocytic): hybrid b/t myelocytes and granulocytes

-Can also see Chronic: eosinophilic, neutrophilic or mastocytosis leukemia. Need to differentiate from a Reactive condition

--Best indicator if prominence of mature to immature cells is out of order, "Myeloid Bulge" (more blasts than more mature cells)


Myeloproliferative Diseases of Erythroid and Megs Lineages

Polycythemia Vera, elevated RBC count (erythroid lineage)

-Essential thromboythaemia/Primary myelofibrosis: elevated platelet count (meg lineage)

-Can progress to AML


CML that is Undectable

Cryptic Translocation, Cannot see with Routine Cytogenetics

-Will progress to AML (can be myeloid or lymphoid)

PHASES: chronic, accelerated, acute

-Can also confuse with sepsis, get a BM



--Usually presents as benign cutaneous lesions in kids (itchy) that goes away by itself

-Release of histamine can cause systemic symptoms that confuse clinician

Morphology: Aggregates of blank looking cells, round or spindle shapes, s/t with eosinophils

Immunophenotype: Tryptase+, CD117+, CD25+

Treatment: Imatinib

Prognosis: highly variable

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Polycythemia Vera

-Jak2 mutation in >95% of cases-detectable in PB leukocytes

-Clinical presentation: Thromboisis?hypertension/stroke or MI. increased RBC # 

Morphology: hypercellular marrow, erythroid hyperplasia, increased Megs

-Immunophenotype: no known features

Prognosis: >10yr survival is common, can progress to myelofibrosis MDS, acute leukemia

Epo will usually be low, one way to differ between neoplastic and reactive

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Essential Thrombocythemia

Jak2 mutation in ~50% of cases-detectable in PB

-Clinical Presentation: Thrombosis, increased platelets, can also be due to Fe deficiancy, infecion or chronic inflammation, can also have bleeding and splenomegaly

Morphology: Increased Megs (very abnormal and tend to cluster)

Immunopheno: not known, can not put Meg through flow cytometry (too fragile)

-Prognosis: >10yr survival is common, can progress to myelofibrosis MDS, acute leukema

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Primary Myelofibrosis

Jak2 mutation ~50%, disputed diagnostic criteria

-Morphology: increased Megs, bizarre shapes, clusting and fibrosis (TEAR DROPS?)

No known immunopheno

Prognosis: usually shorter survival than ET, can progress to marrow failure, acute leukemia

-Cells of bone marrow will relocate to spleen and liver: Extra-medullary hematopoiesis

Treatment: supportive care, blood transfusions, splenectomy are dangerous (pts too old, will bleed) and HSCT is curative but high mortality rate b/c pts are old as hell

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-Usually present as unexplained cytopenia, bicytopenia or pancytopenia

-see poorly functioning clones, mostly in elderly (>70)

5 major adult forms (best to worst prognosis): (1) Refractory cytopenia with unilineage dysplasia (2) refractory anemia with ring sideroblasts (3) myelodysplastic syndrome with isolated del(5q) (4) refractory cytopenia with multilineage dysplasia (5) refractory anemia with excess blasts

-Accumulation of several mutations over time in different mutations


Refractory Cytopenia with Unilineage Dysplasia

Clinical pres: unexplanined cytopenai

Morphology: weird looking precursors: binucleation or irregular nuclei, can show fibrosism high or low cellularity, megaloblastoid features

Prognosis: surival unclear, rarely progresses to AML

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Refractory Anemia with Ring Sideroblasts

-Nonspecific cytogenetic abnormalities (trisomes, monosomes) may be present

-Morphology: ring sideroblasts usually with dyspoietic feats (in red cell series only)

--Iron granules form ring around nucleus 

-Prognosis: rarely progresses to AML

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MDS with Isolated del(5q)

-All the Megakaryocytes are MONOCUCLEAR

-Clinical pres: Anemia often severe, usually elderly

-Morph: megs are mononuclear

-Prognosis: good median survival; treatable with LENALIDOMIDE, 10% progress to AML

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Refractory Cytopenia with multilineage dysplasia

-Two or more lineages show dysplastic changes

-Clinical pres: Anemia often severe: usually elderly

-Morph: Granulocytes dont granulate normally (if affected), nuclei dont lobulate normally

Prognosis: Median survival 30 months, 10% progress to AML in 2 years


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Myelodysplastic Case Study

77y.o. man with newly diagnosed pulmonary adenocarcinoma

-anemia was not worked up completely, has had for past 2 years (b/f diagnosis): Fe studies, folate, B12 levels are all normal

-Gave chemo for initial diagnosis

-Really had Refractory Anemia with trilineage dysplasia

BM biopsy: Myeloid hyperplasia

Poor prognosis, gave chemo that made him sick and was not going to help

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-Common motif for lymphoid malignancies: oncogene>>>>Ig or TCR promoter

-Clinical Presentation: Kids 25% of pediatric T-ALL, often wih thymic mass**

Morphology: Big agranular blasts

Immunophenotype: TdT+, CD3+, CD5+, can express myeloid or B-cell antigens as well

Prognosis: High Risk: more intense chemotherapy regime, pretty good survival rate

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