1. MLAB 1415- Hematology Keri Brophy-Martinez Introduction to Hematopoietic Neoplasms

2. Terms  Neoplasm or tumor: “New growth” Results from a dysregular prolieferation of a single transformed cell Can be malignant or benign  Malignant “Deadly” Clone of abnormal, proliferating cells, without function or differentiation Have the potential to metastasize or get bigger “Cancer”  Benign Premalignant Originate from highly organized, differentiated cells Do not spread or invade surrounding tissues

3. Classification of Neoplasms in Bone Marrow  Lymphoid Only lymphocytic cells affected  Myeloid Granulocytes, monocytes, megakaryocytes, erythrocytes affected  Both Lymphoid and Myeloid lines can include benign and malignant neoplasms

4. More Terms  Leukemia A malignant disease of hematopoietic tissue characterized by replacement of normal bone marrow elements with abnormal (neoplastic) blood cells. Abnormal cells are also seen in peripheral blood  Lymphoma Abnormal proliferation of lymphoid cells within the lymphatic tissue or lymph nodes, results in a solid tumor

5. Leukemias

6. General Classification AcuteChronic AgeAll agesAdults Clinical onsetSuddenGradual Course of diseaseWeeks to monthsMonths to years Predominant cellBlasts Some mature forms Mature forms AnemiaMild-severeMild ThrombocytopeniaMild-severeMild WBCVariableIncreased OrganomegalyMildProminent

7. Blood Picture Acute Chronic

8. How Do Leukemias Arise?  Somatic mutation of a single hematopoietic stem or progenitor cell  Unlimited self-renewal of the cancer-initiating cell  As the mutant cell line predominates, normal hematopoiesis is inhibited causing leukemic cells to spill into peripheral blood

9. Proto-oncogenes and Oncogenes  Proto-Oncogene—normal unaltered gene that has the potential to become an oncogene  Oncogene–Altered cell genes that cause tumors  Located at breakpoints of chromosomal aberrations, such as translocations

10. Oncogene Activation  Factors Genetic susceptibility  Fanconi’s anemia  Down’s syndrome (18-20 fold increased incidence) Somatic mutation  Ionizing radiation, nuclear weapons  Chemicals and drugs  Benzene,Chloramphenicol, phenylbutazone  Certain chemotherapy drugs that are cytotoxic, especially when used in conjuction with therapeutic radiation Viral infection  Retrovirus-HIV-1, HTLVI, II  EBV Immunologic dysfunction  Ataxia-telangiectasia - lymphoid leukemia or lymphoma  Sex-linked agammaglobulinemia

11. Epidemiology  Most new cases found in older adults ( > 67 yrs old)  50% of leukemias are acute  More common in whites  More common in males  Age groups ALL: children 2-5 years old: lymphoid CLL: Adults> 50: lymphoid AML: adults: myeloid CML: adults: myeloid

12. Evaluation of Leukemia  Note onset of symptoms  Analyzing CBC Thrombocytopenia? RBC level/ anemia?  Observe cell lineage Lymphoid or Myeloid?  Assess maturity of predominating cells

13. Lab Features and Patient Symptoms  Normochromic,normocytic anemia Due to erythropenia  Thrombocytopenia Results in bleeding episodes Platelet morphology and function can be abnormal  Leukocyte count can be increased, decreased or normal If count decreased- results in infections  Immature leukocyte precursors seen  Bone marrow hypercellular Bone pain due to marrow expansion  Maturation abnormalities in all cell lines  Uric acid increased Due to cellular breakdown

14. Official Hematopoietic Neoplasm Classification  Two systems French-American British(FAB)  Historical World Health Organization (WHO)**  Widely accepted  Important because.. Allows clinicians a way to compare therapeutic regimens System for ID and comparison of clinical features & lab findings Permit associations of cytogenetic abnormalities with disease

15. FAB classification  Consists of three groups Myeloproliferative Disorders(MPD) Myelodysplastic Syndromes(MDS) Acute leukemia (AL)  Based on morphological characteristic of Wright- stained cells in peripheral blood or bone marrow with supplementary cytochemical stains

16. WHO Classification  Classification system uses morphology, cytochemistry and immunophenotyping to determine cell lineage and degree of maturation(similar to FAB)  Additionally uses genetic and clinical features prior to therapy and history of MDS to define subgroups  Consists of three groups Myeloid  Further classified as MPD, MDS/MPD, MDS, AML Lymphoid  Further classified as B/T cell, T/NK cell, Hodgkin’s Disease, CLL Histiocytic

17. Lab Techniques for Diagnosis and classification of neoplasms  Cytochemical analysis In vitro staining of cells to look at cells’ chemical composition Evaluation of positivity in these stains must be determined on the leukemic blast stage of the cell Usually performed on bone marrow slides Helpful in differentiating lymphoid or myeloid lineage of blasts in AL Reactions are either enzymatic or nonenzymatic

18. Cytochemical stains  Types Myeloperoxidase (MPO)  Activity is present in the primary granules and Auer rods of myeloid cells  Separates myeloid and lymphoid blasts  Stains late myeloblasts, granulocytes, monocytes less intensely  Differentiates AML from ALL  Granules stain black to reddish-brown

19. Cytochemical stains: con’t Sudan Black B  Activity is present in phospholipids in the membrane of 1 ̊ (nonspecific) and 2 ̊ granules (specific)  Differentiates AML from ALL  Granules stain black Periodic Acid Schiff (PAS)  Activity is in glycogen and related substances  Stains lymphocytes, granulocytes, megakaryocytes  Helpful in diagnosing erythroleukemia where there is strong reactivity in normoblasts  Stains red-purple in blocks in cytoplasm

20. Cytochemical stains: con’t  Esterases Specific Esterase (Naphthol AS-D Chloroacetate)  Activity is in cytoplasm  Stains neutrophilic granulocytes, differentiates monoblasts and myeloblasts  Granules of myeloblasts stain blue-black Nonspecific Esterase (Alpha-Naphthyl Acetate)  Activity is in cytoplasm  Stains monocytes and also megakaryocytes  Differentiates myeloblasts from monoblasts  Granules stain orange red

21. Cytochemical stains: con’t  Leukocyte Alkaline Phosphatase (LAP) Enzyme within the 2 O or specific granules of maturing granulocytes Distinguishes leukemoid reactions ( ) from chronic myelogenous leukemia ( )  Acid Phosphatase (Tartrate Resistant) Present in lysosomes in normal leukocytes Helpful in diagnosing hairy cell leukemia because they are NOT inhibited by TRAP

22. Cytochemical stains: con’t  Terminal Deoxynucleotidy transferase (TdT) Primitive cell marker found in cell nuclei Distinguishes ALL from malignant lymphoma  Toluidine Blue Positive marker for basophils and mast cells

23. Lab Techniques for Diagnosis and classification of neoplasms  Immunologic marker studies Cell surface markers  Monoclonal or polyclonal antisera is added to cell suspensions of fresh peripheral blood or bone marrow and an immunofluorescent method is used in a flow cytometry instrument to analyze the markers which are expressed as cluster designations (CD).  CD’s identify antibodies that are specific for certain cells and allow for a positive identification.

24. Lab Techniques for Diagnosis and classification of neoplasms  Molecular Genetics This newer method of diagnosing leukemia consists of DNA probes and polymerase chain reaction (PCR)-based studies. They are rapid and precise and are used to confirm chromosomal abnormalities that are not detected by conventional studies. They are also used to monitor residual disease following therapy. FISH (Fluorescence in situ hybridization) Cytogenetics (Chromosome studies)  Identifies chromosome translocations which are specific for certain leukemias  Philadelphia chromosome (t[9:22]) is associated with CML  t[15:17] is associated with acute promyelocytic leukemia

25. Treatment  Cures are not common except in childhood leukemia. The best hope for a cure in adults lies in bone marrow transplantation. Cytoreductive chemotherapy  Reduces the leukemic cell mass  Block DNA synthesis  Block RNA synthesis  Complications arise from marrow hypoplasia and resulting cytopenia

26. Treatment Radiotherapy (radiation)  Kills focalized leukemic cells  Usually used in addition to chemotherapy and for CNS prophylaxis Bone marrow transplantation  Bone marrow is eradicated with chemo and radiation.  Compatible donor cells are transfused and they travel to the empty marrow where they engraft and repopulate the marrow with healthy cells.  Complications include graft vs host (GVH) disease which can be fatal.

27. References  McKenzie, Shirlyn B., and J. Lynne. Williams. "Chapter 21." Introduction. Clinical Laboratory Hematology. Boston: Pearson, 2010. Print.  http://www.lls.org/content/nationalcontent/resourcecenter/fre eeducationmaterials/generalcancer/pdf/facts.pdf