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

2. 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?

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

4. CBC and Differential Results
WBC: 20.5 bil/L ( )
Neutaphils: 1.84 ( )
Lymphocytes: 4.10 ( )
Monocytes: 0.21 ( )
Myelocytes: 0.21 (0.0)
Blast: (0.0)
Reticylocytes: 17 bil/L (25-85)
RBC: 3.16 tril/L ( )
HgB: 10.4 ( )
MCV: 91.8 fl (80-100)
MCHC: 35.9% (33-35)
RDW: 18.1% ( )
Platelets: 31 Bil/L ( )

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

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

7. Normal Bone Marrow

8. 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

9. 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

10. 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

11. 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 %
Precursor B-cell (L1 and L2) – 70-75%
Mature B-cell (Burkitt – L3) – 5%

12. 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)

13. 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

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

15. 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

16. 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

17. 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.