A Hematology Case Study about Leukemia by Sarah Wycoff ALL in a Days Work… A Hematology Case Study about Leukemia by Sarah Wycoff

Questions to Consider: How do you accurately determine a leukemic blast cell from a lymphocyte? What cytochemical stains can be used to diagnose Acute Lymphoblastic Leukemia?

Patient History 50-year-old female No prior medical problems Admitted to ER with chest pain, fatigue and shortness of breath

CBC and Differential Results WBC: 20.5 bil/L (4.3-10.9) Neutaphils: 1.84 (7.0-7.2) Lymphocytes: 4.10 (1.1-4.5) Monocytes: 0.21 (0.0-0.8) Myelocytes: 0.21 (0.0) Blast: 14.14 (0.0) Reticylocytes: 17 bil/L (25-85) RBC: 3.16 tril/L (3.87-5.05) HgB: 10.4 (12.1-15.0) MCV: 91.8 fl (80-100) MCHC: 35.9% (33-35) RDW: 18.1% (11.5-15.0) Platelets: 31 Bil/L (155-442)

Peripheral Blood Smear Normal lymphocyte in the middle 4 blast cells in the corners

Bone Marrow Aspirate Cellularity is increased at 95-100% Normal hematopoietic marrow is replaced by an immature lymphoid infiltrate

Normal Bone Marrow

Cytochemial Stains- SBB (Sudan Black B) Positive control cell is the mature neutrophil (granulocytic cell line) Stain determines if blasts are granulocytic Patient’s blasts are negative

Cytochemial Stains- MPO (Myeloperoxidase) Positive control cell is the mature neutrophil (granulocytic cell line) Stain determines if blasts are granulocytic Patient’s blasts are negative

Cytochemical Stains- PAS (Periodic-Acid Shiff) Positive control cells are the lymphocytic cell line and neutrophils Stain will be positive in lymphocytic and erythrocytic blasts Patient’s blast are slightly positive

Diagnosis: Acute Lymphoblastic Leukemia (ALL) Regarded as a childhood disease (80% of cases occur between the ages of 2 to 10) ALL subtypes T-Cell - 20-25% Precursor B-cell (L1 and L2) – 70-75% Mature B-cell (Burkitt – L3) – 5%

Clinical Manifestations of ALL Malaise, fatigue and pallor –related to anemia (too few RBC’s) Bruising, petechiae and epitaxis – related to thrombocytopenia (too few PLT’s) Weight loss, bone pain and sternal tenderness (due to proliferation of leukemic cells in bone marrow)

Philadelphia Chromosome Commonly associated with CML (95% are Ph +) 15% to 30% of adults with ALL are Philadelphia chromosome positive, making it the most common ALL associated chromosomal abnormality

Treatment Chemotherapy with Cyclophosphamide, Mesnex, Viacritine, Doxorubican and Decadron Transferred to University of Michigan Medical Center to receive a bone marrow transplant

Summary 50 year-old female admitted to ER Laboratory findings suggestive of adult ALL Diagnosis confirmed though cytochemisty and flow cytometry Transferred to University of Michigan to receive bone marrow transplant

Answers to Questions to Consider Blasts have a higher nucleus to cytoplasm (N:C) ratio and finer chromatin pattern than normal lymphocytes Cytochemical stains used to diagnosis Acute Lymphocytic Leukemia: MPO negative SBB negative PAS positive

Credits This case study was prepared by Sarah Wycoff, MT(ASCP) while she was a Medical Technology student in the 2004 Medical Technology Class at William Beaumont Hospital in Royal Oak, MI.