This document summarizes various neoplastic abnormalities of leukocytes, including leukemia, lymphoma, myeloma, and mycosis fungoides. It describes the characteristics, diagnostic markers, classification, and clinical presentation of different types of leukemia such as acute myeloid leukemia, acute lymphoblastic leukemia, chronic myeloid leukemia, and chronic lymphocytic leukemia. Cytogenetic abnormalities, immunophenotyping, and molecular testing play an important role in the diagnosis and classification of leukemias. Chronic myeloid leukemia is characterized by the Philadelphia chromosome and BCR-ABL fusion gene. Mycosis fungoides is a cutaneous T-cell lymphoma that typically presents in patches, plaques and tumors on the skin

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
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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
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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
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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
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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
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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
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Bcr-Abl
BcrAbl
cDNA

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

22. B-CLL clinical symptoms
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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
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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