تقدیم به شما خوبان

1. Henry, john bernard
Clinical diagnosis and management by
laboratory methods, 20th ed 2001
Neoplastic abnormalities of leukocytes
1

2. Blood Cell Formation
2

3. Neoplastic abnormalities of leukocytes
3
Leukemia
Lymphoma
Leukemia / Lymphoma
Mycosis Fungoides & Sezary Syndrome
Plasma cell dyscrasia
Plasma cell leukemia

4. Acute and Chronic Leukemia
Acute Leukemia (AML and ALL)
 excess myeloblasts or lymphoblasts
 short clinical course (weeks to months)
Chronic Leukemia (CML and CLL)
 accumulation of mature granulocytes or lymphocytes
 longer clinical course (several to many years)
4

5. Acute Leukemia classification
Morphologic & Cytochemical studies
Immunologic markers & Flow cytometry
Cytogenetic & Molecular analysis
5

6. Cytochemical differentiation of acute leukemia
6
Cytochemistry AML ALL
Myeloperoxidase + -
Sudan black + -
Non-specific esterase + (M4,5) -
PAS + (M6) +
Acid phosphatase + (M6) +

7. Immunologic markers/Flow cytometry in AML & ALL
7
AML:
CD13, CD33, glycophorin (M6), platelet antigens (M7)
ALL:
 B lineage:
CD19, CD22, CD10, surface or cytoplasmic Ig, TdT
 T lineage:
CD7, CD3, TdT

8. Cytogenetic abnormalities in acute leukemia
8
AML-M2 :
t(8,21) (q22,q22) (ETO/AML1) AML2-ETO
AML- M3 :
t(15,17) (q21,q22) RAPA-PML
AML-M4 :
inv(16) (p13,q22) AML-M4EO
AML-M5 :
t(8,16)
ALL:
t(2,8), t(8,14), t(8,22)

9. Acute lymphoblastic leukemia (ALL)
ALL-L1
Small, uniform lymphoblast
Scant cytoplasm, clumped chromatin, nuclei without indentation,
indistinct nucleoli
Affects primarily children
9

10. ALL-L2
Large, heterogeneous lymphoblast
Abundant cytoplasm, nuclei with indentation, predominant
nucleoli
Affects adults
10

11. ALL-L3:
Large, uniform cells with deeply basophilic cytoplasm and
numerous vacuoles
Affects adults and children
11

12. Clinical manifestation in acute leukemia
12
Anemia, pallor,
Neutropenia, infection
Thrombocytopenia, abnormal bruising and bleeding
Gingival ulceration

13. Chronic Myeloid Leukemia (CML)
13
Genetic
Mutation

14. CML – Peripheral Blood and BM Findings
Peripheral smear can only give a presumptive
diagnosis of CML, you need to confirm the t(9;22) :
 1) leukocytosis with a ‘left shift
 2) normocytic anemia
 3) thrombocytosis in 50% of pts
 4) absolute eosinophilia with a normal % of Eos.
 5) absolute and relative increase in basophils
 6) LAP score is low (not frequently employed)
14

15. Bcr-Abl and CML
15
produces a new, abnormal gene called bcr-abl. This abnormal gene produces Bcr-
Abl tyrosine kinase, an abnormal protein that causes the excess WBCs typical of
CML.

16. Diagnostic Considerations in CML
16
Karyotyping
Fluorescence in-situ hybridization (FISH)
Quantitative RT-PCR for Bcr-Abl

17. Karyotyping in CML
Allows for the diagnosis of CML
2) Requires a bone marrow aspirate for
 optimal metaphases
3) Allows for evaluation of clonal evolution as
 well as additional chromosomal
abnormalities
 in the non-Ph+ clones
4) Occasional cryptic and complex karyotypes
 can result in the missed identification of the
t(9;22)
17

18. Fluorescence in-situ hybridization
(FISH) in CML
) Allows for the diagnosis of CML
2) Does not require a bone marrow aspirate for
 optimal results
3) Allows for the identification of potential
 duplications of the Ph chromosome
4) Allows for the identification of the loss of the
 der (9) chromsome
5) Allows for the identification of cryptic
translocations involving Bcr-Abl
18
Abl – Ch 9
Bcr- Ch 22
Bcr-Abl Fusion

19. FISH in CML
19
Ch 9 Ch 22
Green Bcr probe→
Red Abl Probe→
Yellow fusion of Bcr and Abl→
Bcr- Ch 22
Abl – Ch 9
Bcr-Abl Fusion

20. Quantitative RT-PCR for Bcr-Abl in CML
1) Allows for the diagnosis of CML
2) Does not require a bone marrow aspirate for
 optimal results
3) Can quantify the amount of disease
4) Allows for the identification of cryptic
 translocations involving Bcr-Abl
5) Many primers sets only detect the p190 and/or
 the p210 translocation and may miss the p230
 or alternative translocations
20
Bcr-Abl
BcrAbl
cDNA

21. Chronic Lymphocytic Leukemia (CLL)
21
I II III IV

22. B-CLL clinical symptoms
22
Cervical and axillary lymphadenopathy in 60-years
old patient with B-CLL

23. 23
Cervical and axillary lymphadenopathy
in 70-years old patient with B-CLL

24. 24
Cervical lymphadenopathy in patient
with B-CLL

25. 25
The CLL patient has splenomegaly, which is visible

26. Mycosis Fungoides & Sezary Syndrome
26
MF is a cutaneous lymphoma of mature CD4+ T cells
The commonest cutaneous T-cell lymphoma
It has unique clinical & histologic features
Not all cutaneous T-cell lymphomas are MF
MYCOSIS
FUNGOIDES
SÉZARY
SYNDROME
MF/SZ

27. clinical manifestations of MF
27
Patch Plaque Tumor

28. 28
Multiple discrete &
confluent plaques
of
cutaneous
T-cell lymphoma
“MF”
Multiple plaques
of cutaneous
T-cell lymphoma
with
tumor formation
“MF

29. 29
TUMOR STAGE
dense dermal infiltrate
involving the full breadth
of the dermis
Tumors could get infected  sepsis  death
PATCH STAGE
epidermal hyperplasia with
band-like infiltrate
of small- to medium-sized
PLAQUE STAGE
The density of the
neoplastic
cells within dermis