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MT417 - CLINICAL HEMATOLOGY II Linda Sykora, MT(ASCP)SH

MT417 - CLINICAL HEMATOLOGY II Linda Sykora, MT(ASCP)SH. Rotation II Morphology Unit WBC Cases.

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MT417 - CLINICAL HEMATOLOGY II Linda Sykora, MT(ASCP)SH

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  1. MT417 - CLINICAL HEMATOLOGY II Linda Sykora, MT(ASCP)SH Rotation II Morphology Unit WBC Cases

  2. Morphology Unit – WBC CasesFor these cases, it is assumed that you have taken advantage of the Rotation I Quiz Reviews to recall the information you mastered during Rotation I. Remember to make use of the Rotation I WBC worksheet, quizzes and Exam.Before proceeding, you will need to have your Rotation II Morphology Unit objectives and handouts available.

  3. Morphology Unit – WBC CasesThe WBC cases will cover much (but not all) of the material you are responsible for. Use your objectives as a guide to identify material that is new for Rotation II. For new information, you will be referred to pages in the SL manual, handouts in the Rotation II Morphology unit (pink or lavender color) and/or your McKenzie text.Note: Throughout the case slides, click on if you would like to view the previous slide. P

  4. For the WBC disorders, your first steps should include evaluation of the WBC count and differential (% and absolute #s) to determine the predominant cell type. The presence or absence of anemia or thrombocyto-penia should also be noted. Patient age and morphologic changes (i.e., toxic neutrophils or reactive lymphs) can provide clues to a reactive versus a malignant cause. Most benign disorders can be distinguished from malignant disorders without doing a bone marrow; a marrow exam is generally required to establish a definitive diagnosis of malignancy. Refer to WBC classification sheet on SL pg 183. P

  5. Which of the following conditions indicate the need for a bone marrow evaluation? a. Immature/blast cells are seen on blood smear. b. Significant neutropenia is present. c. Unexplained pancytopenia exists. d. Cells that exhibit features of abnormal growth, i.e.,dyspoiesis, are seen. e. All of the above. Refer to Morph unit Bone Marrow Handout (pink) e. All of the above. The bone marrow handout reviews indications for a bone marrow examination and includes a normal bone marrow report. It allstarts with cell morphology…..the MT/CLS has to decide that cells look ‘funny’ and need to be evaluated. P

  6. A B C • The cells shown may be seen in normal bone marrow. • What are the cells (A) that make the bone and resemble • plasma cells but are much bigger? • What is the multi-lobed cell (B) that produces platelets? • What is the multi-nucleated cell (C) that removes bone and resembles cell (B)? • See normal BM cells on Morph unit Terms Handout (lavender). • Osteoblasts; often seen in a group; normal kids • Megakaryocyte • 3. Osteoclast; has a cookie cutter nucleus P

  7. A B C • The cell (A) is a normal macrophage/histiocyte that is • present in the bone marrow, spleen, liver and other tissues. • The cell (B) is an abnormal macrophage full of the unmetabolized lipid, glucocerebroside. It is a: • The cell (C) is an abnormal macrophage full of the unmetabolized lipid, sphingomyelin. It is a: • See Lipid Disorders on Morph unit Terms Handout (lavender). • Gaucher cell (B) seen in Gaucher’s disease; wrinkled, tissue-paper appearance of macrophage cytoplasm. • 2. Niemann-Pick cell (C) seen in Niemann-Pick disease; foamy/bubbly appearance of macrophage cytoplasm. P

  8. Case A • A 4 year old girl is brought to the ER • due to fever. Lab data: • WBC 15.2 K/uL; Hgb 12.0 g/dL; • PLT 200 K/uL; Differential results: • 58 segs-25 bands-10 lymphs-7 monos • The appearance of her WBCs are shown. • Which of the following best describes her results? • a. regenerative left shift • b. degenerative left shift • c. neutrophilic leukemoid reaction • d. leukoerythroblastic reaction • a. regenerative left shift; elevated WBC due to • neutrophilia and increased band neutrophils • (the marrow released immature neutrophils). P

  9. Case A • How did you rule out the other possibilities (b,c,d)? • Her results are indicative of: • a. viral infection • b. acute lymphocytic leukemia • c. bacterial infection • d. normal findings • b. degenerative left shift – low WBC with ↑bands. • c. leukemoid reaction – WBC over 50.0 K/uL. • d. leukoerythroblastic – immature neuts & NRBCs. • Her results are indicative of: • a. viral infection – lymphocytosis & reactive lymphs. • b. acute lymphocytic leukemia – neutropenia, anemia, • thrombocytopenia and likely blast cells. • c. bacterial infection – toxic neutrophils are present. • d. normal findings – a 4 yo often has 45-75% lymphs. P

  10. Case B This 2 year old male has had multiple infections since age of 1 year. Infections have included pneumonias, skin infections and abscesses of the lung due primarily to staphylococci. His blood smear shows white blood cells that are normal in appearance however his red cells are acanthocytes. 1. What is his most likely disorder? a. Pelger-Huet anomaly b. May-Hegglin anomaly c. Alder-Reilly anomaly d. Chediak-Higashi anomaly e. Chronic Granulomatous disease 1. e. Chronic Granulomatous disease; the WBCs appear normal but function abnormally. CGD WBCs can’t produce the superoxide anion needed to kill ingested organisms; die of staph infections. The X-linked form is associated with McLeod phenotype and acanthocytes. P

  11. LAP (4+) • The LAP stain detects the activity of the enzyme alkaline • phosphatase in the cytoplasm of neutrophils (2o granules). • The amount of red precipitate in seg & band neutrophils is • graded 0-4+ to obtain a score. A normal score is 13-130. • A high LAP score (185) was • obtained on the LAP stain shown. • This is consistent with all of • the following except: • a. Chronic myelocytic leukemia • b. Severe bacterial infection • c. Polycythemia vera • d. Myelofibrosis See LAP on SL pg 193 • a. CML; a score <13 is usual. The main use of the • LAP is to differ CML (low score) from a severe bacterial infection/NLR (high score). The LAP is also used to differ the chronic myeloproliferative disorders; a score >130 is typical of PV and MMM; ET usually has a normal score. P

  12. Case C • A 50 year old male with a ‘red nose’ and chest pain has the • following lab data: • WBC 20.0 K/uL; Hgb 22.0 g/dL; PLT 995 L/uL • Diff: 52 segs-15 bands-12 lymphs-7 monos-4 basos; 1 NRBC • LAP 144; Erythropoietin (EPO) level low • His results are most consistent with: • a. aplastic anemia • b. primary polycythemia vera • c. idiopathic/essential thrombocythemia • d. chronic myelocytic leukemia • e. polycythemia secondary to hypoxia • f. pseudo polycythemia • b. primary polycythemia; based on pancytosis (only disorder!!), low EPO (malignant RBC production) and • high LAP score. See CMPD chart SL pg 205 P

  13. Case C • How did you rule out the other possibilities (a,c,d,e,f)? • What RBC mass and plasma volume is typical for this type of patient? • What bone marrow M:E ratio do you expect? • 5. What is the usual treatment? • 2. a. aplastic anemia – pancytopenia • c. ET – normal/low HGB, normal LAP • d. CML – normal/low HGB, low LAP • e. polycythemia 2o to hypoxia – normal WBC & PLT, increased EPO, normal LAP • f. pseudo polycythemia – normal WBC, PLT and EPO • 3. Increased RBC mass with normal plasma volume. • Normal M:E ratio; all cell lines are increased. • Phlebotomy to reduce blood viscosity. P

  14. Case D • The following results were obtained on a 75 year old male • with severe abdominal pain: • WBC 5.0 K/uL; Hgb 8.0 g/dL; PLT 99 K/uL • Diff: 16 segs-22 bands-28 lymphs-16 monos-1 eos-1 baso- • 4 metas-8 myelos-4 promyelos; 30 NRBCs/diff • Several teardrop red cells were noted. A bone marrow aspirate • was a “dry tap”. LAP 142; Philadelphia chromosome negative. • These results are consistent with: • a. primary polycythemia rubra vera • b. idiopathic/primary thrombocythemia • c. chronic myelocytic leukemia • d. myelofibrosis with myeloid metaplasia • d. myelofibrosis with myeloid metaplasia; noted for a dry tap, leukoerythroblastic diff, teardrops on smear. • See CMPD chart SL pg 205 P

  15. Case D • How did you rule out the other possibilities (a,b,c)? • What is seen on a leukoerythroblastic differential? • What does myeloid metaplasia mean? What was the likely cause of this patient’s abdominal pain? • 2. a. primary polycythemia vera – high HGB & PLT • b. idiopathic/primary thrombocythemia – high PLT • c. chronic myelocytic leukemia – high WBC, normal or • high PLT, low LAP, 90% of cases are Philadelphia • chromosome positive • Presence of immature neutrophils (left shift) and • nucleated red cells; fibrotic bone marrow, release of cells is disturbed. • Myeloid metaplasia = extramedullary hematopoiesis. This patient’s pain was likely caused by an enlarged spleen…the spleen is often massive in MMM. P

  16. Case E • A 60 year old female whose history includes several episodes of GI bleeding has the following lab data: • WBC 8.0 K/uL; Hgb 8.0 g/dL; PLT 2,300,000/uL • Diff: 70 segs-10 bands-18 lymphs-2 monos • Her blood smear is shown. • Her results are consistent with: • a. primary polycythemia vera • b. myelofibrosis • c. essential thrombocythemia • d. reactive thrombocytosis • 2. What marrow cell is increased? • c. essential/primary thrombocythemia; based on PLT count over 1 million/uL (PLT is <1 million/uL in reactive), giant/bizarre platelets, often with abnormal function. • 2. Increased number of megakaryocytes in the marrow. P

  17. Case F • A 55 year old male comes to the ER with a temperature of • 1030 F.His lab findings: • WBC 74.8 K/uL; Hgb 11.5 g/dL; PLT 305 K/uL; LAP 210 • Diff: 44 segs-40 bands-1 lymph-3 monos-0 eos-0 basos- • 5 metas-7 myelos. His WBC abnormalities are shown. • What is his most likely • disorder and its cause? • 2. How did you rule out CML? • Neutrophilic leukemoid • reaction caused by a severe • bacterial infection; based on • WBC >50.0 K/uL, neutrophilia • with left shift, toxic neutrophils and LAP score >130. • 2. CML typically has ↑eos, ↑basos, a low LAP score and immature neutrophils are not ‘toxic’. P

  18. Case G • A 61 year old farmer complained of generalized bone pain • to his local medical doctor . He was noted to have • splenomegaly during his physical exam. Lab data: • WBC 145.8 K/uL; Hgb 10.1 g/dL; PLT 344 K/uL; LAP 1 • Diff: 56 segs-15 bands-4 lymphs-1 monos-2 eos-5 basos- • 4 metas-12 myelos-1 promyelo. An occasional blast was noted. • Chromosome analysis revealed the 9;22 translocation. • What is his most likely disorder? Support your answer. • Is the presence of the Philadelphia chromosome associated with a better prognosis? What cell lines are involved? • What would you expect in his bone marrow? • 1. CML; neutrophilic leukocytosis with left shift, ↑ basos, LAP score <13, splenomegaly, Ph1 chromosome (+). • Better prognosis; present in all cells except lymphs. • 3. Hypercellular, high M:E ratio due to ↑↑ granulocytes. P

  19. Case H • A 43 year year old female was diagnosed with CML two • years ago when a WBC of 121.1 K/uL was discovered • during a routine yearly physical. She now presents with • fever and the following lab data: • WBC 25.8 K/uL; Hgb 7.5 g/dL; PLT 34 K/uL • Her diff has 40% blasts and chromosome analysis revealed • multiple chromosome abnormalities. • What has occurred? What is the prognosis? • 2. Under what circumstances might the LAP score in a CML patient be greater than 13? 1. Blast crisis; note the severe anemia and thrombocyto-penia that is not typical of a chronic leukemia. The blasts are usually myeloid but can also be lymphoid; flow cytometry is required. Prognosis is generally poor. 2. A normal LAP is seen during remission or infection. P

  20. Bone Marrow • Case I • This 53 year year old male had noticed the onset of easy • fatigability and bruising. He saw his doctor when he • developed a boil in the perianal • area. His CBC and subsequent • bone marrow exam (shown) • were abnormal. Lab data: • WBC 78.0 K/uL; Hgb 7.3 g/dL • PLT 59 K/uL • What is the most likely diagnosis? • 2. What further testing would you suggest? • Acute myeloid leukemia; based on predominance of blast cells (over 30%), lack of normal precursors, blood values and the blast with an Auer rod that excludes ALL. • Cytochemical stains, immunophenotyping and • chromosome analysis (most often done on marrow). P

  21. 3. What peroxidase, SBB, and PAS stain results do you expect for the blast cells in Case I? How will Auer rods stain? 4. Which of the following marker panels do you expect will be positive in this case? a. CD13, CD33, CD34 b. CD2, CD3, CD4 c. CD10, CD19, CD20 5. Are the expected stain & marker results always obtained? • 3. Myeloid cells should stain positive for peroxidase & SBB • and negative for PAS, as do Auer rods (1o granules) . • a. Early/immature myeloid cells should be positive for CD13, CD33, CD34, and negative for lymphoid markers. • No, the “expected” is not always present. This is why • morphologic, cytochemical, cell marker, cytogenetic and • clinical information must be correlated. Diagnosis is • never based on a single diagnostic tool. P

  22. Case J • A 48 year female with a sudden onset of weakness and • fatigue went to her doctor. Her lab data revealed: • WBC 33.6 K/uL; Hgb 5.3 g/dL • PLT 24 K/uL • Diff: 1 seg-11 lymphs-88 blasts • The blasts (shown) were noted to • have some monocytic features • and an occasional Auer rod. The • bone marrow showed similar cells. • What is the most likely diagnosis? • 2. What further testing would you suggest that could determine the leukemia subtype? • Acute myeloid leukemia…….AML, AMML, or AMonoL. • Cytochemical stains and immunophenotyping are • needed to determine the FAB subtype. P

  23. The blasts in Case J were peroxidase and SBB positive and showed CD13, CD33, and CD34 cell markers. The cells were also positive for CD14, a monocytic marker. The blast cells showed positivity for both the specific and nonspecific esterase stains. See SL pg 192 and Morph unit Leukemia Handouts (pink) and/or McKenzie text chapter 26. 3. Based on these results, which type of acute leukemia does this lady most likely have? Support your answer. • AMML, FAB type M4 which is characterized by cells with • both granulocytic and monocytic features. The SBB, • peroxidase, and cell marker results are consistent with • this diagnosis. • The specific esterase is positive in granulocytes and • negative in monocytes. The nonspecific esterase is • negative in granulocytes and positive in monocytes. • Both esterases should be positive in cases of AMML. P

  24. Case K • A 24 year old woman was admitted due to weakness and a • severe nosebleed that she could not stop. Lab findings • revealed anemia and severe thrombocytopenia (PLT 18 K/uL). • Her WBC was normal but her diff had 2 segs-40 blasts and • 58 blast-like cells with intense granulation. Some cells had • bundles of ‘bodies’ in the cytoplasm. • STAT coag results showed prolonged PT/APTT tests, a low • fibrinogen level, and a positive Dimer test. • Which type of acute leukemia do you suspect? • What do you think the ‘bodies’ are? • What is the significance of her coagulation results? • Promyelocytic, M3; predominance of blasts & promyelos. • Multiple Auer rods. • 3. She has DIC which is a frequent presentation for AProL. P

  25. Bone Marrow • The bone marrow performed on the patient in Case K is • shown. Additional testing • included cytochemical stains, • flow cytometry and cytogenetics. • What results do you expect • for the peroxidase, SBB and • specific esterase stains? • What genetic abnormality • was likely detected? • All three stains would likely show brilliant positivity. • A nonspecific esterase would be negative and a PAS, if done, would be negative. Immunophenotyping would detect the presence of myeloid markers. • t(15;17), virtually diagnostic for AProL. Prognosis is fairly good if DIC can be controlled; patients with this translocation (RARA oncogene) respond well to retinoic acid….causes maturation of promyelocytes. P

  26. Case L • An 80 year old man with abnormal blood and bone marrow • findings is suspected to have acute erythroleukemia (EL), M6. • His bone marrow contains 40% myeloblasts and numerous • giant RBC precursors similar to those seen in megaloblastic • anemia, however his folate and B12 levels are normal. • What term is used to describe giant RBC precursors that mimic those seen in megaloblastic anemia? • See Morph unit Terms Handout (lavender). • 2. What cytochemical stain is used to differentiate malignant erythroid cells from normal red cell precursors? • See SL pg 192 and/or Morph unit Leukemia Handouts (pink). • Megaloblastoid red cells; resemble megaloblastic RBCs but are caused by abnormal growth and associated with malignancy such as EL and myelodysplastic syndromes. • The PAS stain; normal erythrocytes are negative and malignant red cells stain PAS positive. P

  27. The giant, multinucleated RBC precursors from the patient in Case L (shown on the right) stained PAS positive (on left). This is consistent with a diagnosis of EL, FAB type M6. Erythroleukemia behaves similar to CML cases that develop a ‘blast crisis’. The bone marrow in the terminal stage of EL shows mainly myeloblasts. P

  28. Case M • An 70 year old female with “possible leukemia” is transferred to • your hospital for evaluation. A CBC reveals the following: • WBC 2.4 K/uL; Hgb 9.0 g/dL; MCV 110 fL; RDW 22.4%; • PLT 80 K/uL; Diff: 68 segs-6 bands-18 lymphs-3 monos-5 blasts • Her folate and B12 levels are normal. A bone marrow exam • reveals 75% cellularity and 24% blasts, a few with Auer rods. • Erythrocytic, granulocytic and megakaryocytic precursors • exhibit features of abnormal growth. Monocytic cells are normal • in number. See Morph unit MDS Handout (lavender) • According to the FAB classification, this patient likely has: • a. AML, M2 • b. Refractory Anemia with Excess Blasts (RAEB) • c. RAEB in transformation (RAEB-T) • d. ALL, L2 1. c. RAEB in transformation P

  29. You suspect this diagnosis for Case M because………… • Does this patient exhibit one or more blood cytopenias? • Name at least five signs of abnormal growth that were most likely present in the bone marrow (or blood) of this patient. • 5. According to the WHO classification, this patient has: • 2. Her bone marrow is hypercellular with 24% blasts & Auer rods and 5% blasts in her blood. Criteria for RAEB-T is 20-30% blasts in BM and 5% or more blasts in the blood. She does not fit the FAB criteria for AML (>30% blasts). • 3. Multiple cytopenias; low WBC, low PLT and a macrocytic anemia not due to low folate or B12. Her high RDW may be caused by a dimorphic RBC population. • Multinucleated and/or megaloblastoid RBCs, ringed sideroblasts, hyposegmented (aka pelgeroid) and/or hypogranular neutrophils, micromegakaryocytes. • See next slide to view features of abnormal growth. • 5. AML; the change to 20% blasts has eliminated RAEB-T. P

  30. Megaloblastoid rubricytes Normal rubricytes Multinucleated RBCs Micromegakaryocyte Hypogranular neutrophil Case M P

  31. Case N • A 6 year old boy had a 2 to 3 week history of fever at night • and cervical adenopathy. Physical exam showed a • generalized lymphadenopathy. His lab data: • WBC 20.7 K/uL; Hgb 10.9 g/dL; PLT 123 K/uL • Diff results: 1 segs-17 lymphs-1 monos-81 blasts • What do you suspect? • What is his absolute neutrophil count? Are you concerned? • 3. What is the next step for this patient? • Acute leukemia, probably ALL; based on his age, the predominance of blasts but no Auer rods noted. • Critically low ANC of 207/uL; severe neutropenia. • 3. Bone marrow aspirate/biopsy & spinal tap; staining panel, cell markers and cytogenetics. P

  32. The bone marrow obtained on the patient in Case N was hypercellular with 80% blasts that were fairly small and homogeneous. Blasts were not detected in his CSF. His blasts were peroxidase/SBB negative and PAS positive. Immunophenotyping showed positivity for CD10, CD19/20, and CD34; cells were negative for CD2/3. See Morph unit Leukemia Handouts (pink) and/or McKenzie text. 4. These results are most consistent with: a. Precursor-B ALL, CALLA type b. T cell ALL 5. Does this patient have a good prognosis? • a. Precursor-B ALL (probably FAB L1 morphology). • ALL-L3 is always a B cell malignancy and is known as the Burkitt’s type. The FAB types L1 & L2 are far less important than the immunophenotype. • 5. A child with CALLA type has a good prognosis. P

  33. Case O • This 72 year old male was discovered to have an elevated • WBC count 4 years ago. He has never received therapy • for his disorder. Physical examination showed no palpable • lymphadenopathy. Lab data: • WBC 50.7 K/uL; Hgb 13.9 g/dL • PLT 223 K/uL • Diff:10 segs-89 lymphs-1 mono • His blood smear is shown. • What is his most likely diagnosis and why? • 2. Are these usually malignant T or B cells? • CLL, based on age, normal HGB/PLT, predominance of mature lymphs with hyperclumped nuclear chromatin & smudge cells. • 2. Almost all cases of CLL are B cell type. P

  34. TRAP • Case P • A 75 year old male presents with pancytopenia and • splenomegaly. Several ‘lymph-like’ cells with monocytic • cytoplasm are observed on his blood smear. A bone • marrow aspirate is a “dry tap”. A TRAP stain, done on • the ‘lymph-like’ cells, is shown. • This information is consistent • with a diagnosis of: • a. Hodgkin’s lymphoma • b. CMV infection • c. Hairy cell leukemia • d. Chronic lymphocytic leukemia in blast crisis • e. Waldenstrom’s macroglobulinemia • c. HCL; hairy cells stain acid phosphatase positive and are resistant to tartrate inhibition (stay positive). • The splenomegaly and dry tap BM are usual findings. P

  35. The non-Hodgkin’s lymphomas consist of a very large • group of disorders that are constantly being reclassified. • You are responsible for selected examples. Refer to SL • pg 207 and pg 7 of the Rotation II Morph unit objectives. • NHL comments: • a. Patients with NHL often have a normal CBC/diff initially. • A lymphoma and a leukemia with the same malignant cell type are the same disease, they just have a different presentation, i.e. marrow and blood vs lymphoid tissue. • Immunophenotyping is essential for determining cell maturity and cell type; most NHL’s are B cell type. See the next slides to view the malignant cell types in certain non-Hodgkin’s lymphomas. P

  36. Patient A Patient B Patient A has small lymphocytic lymphoma that has spread from the tissues to the bone marrow and blood. SLL is the tissue counterpart of: Patient B has peripheralized ‘mixed’ cell lymphocytic lymphoma. These clefted lymphoid cells are called: ▪SLL is tissue CLL; patient A has small, hyperclumped lymphs. ▪Patient B has clefted cells called Rieder cells. P

  37. Patient D Patient C Skin biopsy Sezary cells Patient C has peripheralized Burkitt’s lymphoma that is associated with EBV and t(8;14). The leukemic form is called: Patient D has mycosis fungoides, a T cell lymphoma that involves the: ▪Patient C has B cell-ALL, L3. Burkitt cells have fat vacuoles in the nucleus & cytoplasm. ▪Patient D has a T cell lymphoma of the skin (note red skin and ulcers); the leukemic form is called Sezary syndrome. P

  38. Identify the cell A MONKEY

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