HEMA-1-LEC-FINALS PDF

Granulopoiesis Ma. Christy V. Gonzales, RMT, MPH School of Medical Technology Emilio Aguinaldo College MCC4 31 (Hematology 1) Lecture Granulocyte Maturation & Development Early Cells Pluripotent stem cells myeloid stem cell CFU-GEMM...

Granulopoiesis Ma. Christy V. Gonzales, RMT, MPH School of Medical Technology Emilio Aguinaldo College MCC4 31 (Hematology 1) Lecture Granulocyte Maturation & Development Early Cells Pluripotent stem cells myeloid stem cell CFU-GEMM CFU-GM myeloblast myelocyte Granulopoiesis Granulocytic kinetics development, distribution, and destruction of NEB BM Granulopoiesis BM Granulopoiesis PC Circulating pool Marginating pool adhere to the endothelium of the blood vessels Circulation pool to peripheral tissues diapedesis Neutrophils act as phagocytes Segmented neutrophils- 7-10 hrs Eosinophil- few hrs Charcot-Leyden crystals Basophils- 8.5 hrs H E M A T O P O I E S I S Granulocyte Maturation & Development Granulocyte Maturation & Development 1. Myeloblast 10-18 um N:C ratio 4:1 Nucleus finely reticular chromatin 1-5 light-staining nucleoli Cytoplasm small rim of basophilic cytoplasm lacks granules Auer rods aggregates of fused lysosomes appear as red, needle-like crystalline cytoplasmic inclusions Granulocyte Maturation & Development 2. Promyelocyte presence of prominent granulation N:C ratio 3:1 Granules primarily azurophilic granules enzymes myeloperoxidase and chloroacetate esterase 14 to 20 um Nucleus more condensed nucleoli are present Cytoplasm pale grayish blue Granulocyte Maturation & Development 3. Myelocyte appearance of secondary or specific cytoplasmic granulation NEB became visibly recognizable N:C ratio 2:1 or 1:1 12 to 18 um Nucleus more oval in appearance nucleoli are no longer visible Chromatin more clumped Cytoplasm blue-pink Granulocyte Maturation & Development 3. Myelocyte Neutrophilic granules fine and stain a blue-pink color with Wright stain Eosinophilic granules larger than neutrophilic granules, round or oval-shaped orange and have a glassy or semiopaque texture Basophilic granules dark blue-black color and dense appearance Granulocyte Maturation & Development 4. Metamyelocyte nucleus begins to assume an indented or kidney bean shape Nucleus chromatin continue to condensed color of the specific granulation continues to become a major distinguishing feature Cytoplasm Pink Granulocyte Maturation & Development 5. Mature Granulocytes Band form elongated nucleus Segmented form Mast cells not observed in the blood of healthy persons. appearance similar to that of the blood basophil round or oval nucleus granules of the mast cell do not overlie the nucleus as they do in basophils Monocytes & Macrophages Maturation & Development CFU-GM CFU-M CFU-G 1. Monoblast 2. Promonocyte 2-3 mitotic divisions in 2-2.5 days Monocytes & Macrophages Maturation & Development 3. Monocytes No large reserve of cells in maturation-storage pool Circulating and marginating pool in PC (1:3.5) 8.5 hours Largest mature cells in in PC Irregular cytopalsmic outline Commonly observed vacuoles blue-gray cytoplasm, with fine granulation resembling Lymphocyte Maturation & Development 1. Lymphoblast 1st morphologically identifiable cell of the lymphocytic maturational series in BM 15 to 20 um N:C ratio of 4:1 Nucleus round or oval 1-2 nucleoli Cytoplasm chromatin pattern is delicate looking medium blue or darker-blue border no granules Lymphocyte Maturation & Development 2. Prolymphocyte BM, thymus & 2° lymphoid organs 15 to 20 um N:C ratio of 4:1 or 3:1 Nucleus round or slightly indented 0-1 nucleoli Cytoplasm chromatin pattern is slightly condensed medium blue with thin, darker-blue rim few azurophilic granules Lymphocyte Maturation & Development 3. Mature Lymphocyte BM, thymus & 2° lymphoid organs 17 to 20 to 6-9 um N:C ratio of 2:1 or 4:1 to 3:1 Nucleus round or oval or indented Nucleoli not visible Cytoplasm chromatin pattern is dense and appears clumped light sky blue and very scanty few azurophilic granules Lymphocyte Maturation & Development 4. Mature B cell 8 to 20 um Nucleus round or oval and may be eccentrically placed Cytoplasm fine pattern chromatin nongranular mottled blue color References: Lotspeich-Steininger e.t al; Clinical hematology principles, procedures, correlations, Lippincott Company, 1992 Turgeon, Clinical Hematology: Theory and Procedures 5ht ed., Lippincott Williams & Wilkins, 2012 Keohane et. al, Rodak’s Hematology: Clincal Principles 6th ed., Elsevier, 2020 DOH Dept Circ 2017-0173 Schedule of EQAS Application  White Blood Cells Disorders: Acute Leukemia Ma. Christy V. Gonzales, RMT, MPH School of Medical Technology Emilio Aguinaldo College MCC4 31 (Hematology 1) Lecture Learning Objectives At the end of the lecture, the student should be able to: differentiate the various types of leukemia apply the concepts of WBC abnormalities to the concept of leukemia explain the different methods in identifying and classifying leukemia Hematopoietic malignancies Malignancy Defined as growth and proliferation of one or more clones of abnormal cells Abnormal cells Do not respond to normal control feedback mechanism Coexist in the with normal cells in BM Fill available spaces in BM and eventually inhibit or crowd normal cells May or may not be found in peripheral circulation in PC: normal/increased WBC count In BM: decreased WBC count Hematopoietic malignancies Morphologic evidence of malignancy Nuclear Shape abnormalities Multinuclearity Megaloblastoid Hypo- or hypersegmentation Giant or prominent nucleoli Increased mitotic figures Cytoplasmic Overall Hematopoietic malignancies Morphologic evidence of malignancy Cytoplasmic Abnormal granules Mixed granulation Decreased granulation Increased fragility Overall Abnormal size Tendency to cluster or clump Clonal morphology Hematopoietic malignancies Terminologies “dys”: prefix indicating abnormal growth, development or proliferation dyserythropoiesis or dysmegakaryopoiesis Leukemia: abnormal cells in PC and BM Aleukemic leukemia: abnormal cells in BM & do not circulate Lymphoma: bioplastic growth of cells in lymphatic tissues “oma”: tumor Leukemic lymphoma: lymphoma spread in BM & PC Hematopoietic malignancies Classification of malignancies According to stem line involved Myeloid leukemia myeloproliferative disorders or nonlymphocytic leukemias Acute nonlymphocytic leukemia (ANLL) Acute myeloid leukemia (AML) Granulocytes, monocytes, erythrocytes, megakaryocytes Lymphoid malignancies B and T cells Either leukemia or lymphoma Hematopoietic malignancies Classification of malignancies According to number of primitive cells in PC and BM Acute leukemia > 30% blast in PC > 50% blast in BM According to morphologic classification (FAB) Acute Myeloid Leukemia (AML) or Acute Nonlymphocytic Leukemia (ANLL) Acute Lymphoblastic Leukemia Chronic leukemia 10-30% blast in PC Subacute, chronic or transforming to acute Hematopoietic malignancies Classification of malignancies According to number of primitive cells in PC and BM Chronic leukemia Chronic myeloproliferative disorders Chronic granulocytic (myelocytic) leukemia (CGL or CML) Polycythemia vera (PV) Agnogenic myeloid metaplasia with myelofibrosis (AMM) Primary (essential) thrombocytopenia (ET) Chronic lymphoproliferative leukemias Chronic lymphocytic leukemia (CLL) Prolymphocytic leukemia (PLL) Hairy cell leukemia (HCL) Acute Myeloproliferative Leukemia Acute Myeloid Leukemia (AML) or Acute Nonlymphocytic Leukemia (ANLL) applied to all leukemias involving all cells other than lymphocytes immature marrow cells blocked at an undifferentiated or partially differentiated stage of maturation normal myeloid cells rapidly fatal course death: pancytopenia (anemia, bleeding, susceptibility to inf.) incidence:  Acute Myeloproliferative Leukemia Etiology Chemical drugs & chemicals cause BM depression & aplasia ex. chloramphenicol, phenylbutazone, arsenic-containing cmpds, sulfonamides, insecticides cytotoxic agent used for treatment of neoplasms: phenylalanine mustard & cyclophosphamide alkylating agents for Hodgkins dse. immunosuppresants benzene Radiation  Acute Myeloproliferative Leukemia Etiology Genetics chromosomal aneuploidy Down syndrome (trisomy 21) D-trisomy chromosomal breakage Bloom syndrome congenital leukemia: nonlymphocytic familial leukemia: acute leukemia Viruses Type C RNA viruses retrovirus  Acute Myeloproliferative Leukemia AML: Classification abundant cytoplasm importance: Auer rods educated treatment decisions MPO granules extend patient survival delicate nuclear chromatin morphologic techniques based on: type of normal cells the malignant clone resembles stage of maturation of given cell line presence of abnormal cells present provide clue on cell line involved Ex. Pelger-Huët: indicate ___________ Auer rods: __________________  Acute Myeloproliferative Leukemia Classification cytochemical techniques ICSH (International Committee for Standardization of Haematology) enzymes: peroxidase alkaline phosphatase acid phosphatase nonspecific esterase chloroacetate esterase  Acute Myeloproliferative Leukemia Clinical features Anemia S/S pallor, lethargy, dyspnea, fatigue, weakness pathophysiology bm failure dyserythropoiesis decreased RBC survival supportive therapy RBC transfusion  Acute Myeloproliferative Leukemia Clinical features Neutropenia S/S fever, malaise, infection pathophysiology BM failure dysmyelopoiesis supportive therapy granulocyte transfusion antibiotics isolation techniques  Acute Myeloproliferative Leukemia Clinical features Thrombocytopenia S/S hemorrhage, bruising, purpura, epistaxis pathophysiology bm failure coagulation defects qualitative platelet abnormalities supportive therapy platelet transfusion  Acute Myeloproliferative Leukemia Clinical features Organ infiltration S/S bone tenderness, splenomegaly, hepatomegaly, lymphadenopathy, etc pathophysiology extramedullary hematopoiesis metastatic disease supportive therapy radiotherapy  Acute Myeloproliferative Leukemia French-American-British (FAB) System proposed by seven French, American, and British hematologists for nomenclature (1976) based on: morphological characteristics of Wright-stained cells in peripheral blood or bone marrow cytochemical staining of blasts divides acute leukemias into 2 major divisions AML (M0 through M7) ALL (L1 through L3)  Acute Myeloproliferative Leukemia WHO Classification Based on morphology, cytochemistry, immunophenotype, genetics, and clinical feature Accurate classification of leukemia---tx & prognosis Recurrent chromosome translocation t(5;17)(q22;q12); t(8;21) (q22;q2) inversion inv 16(p13q22) complex karyotypes, partial deletions or loss of chromosome unfavorable prognosis Acute Myeloproliferative Leukemia (FAB) Acute Myeloproliferative Leukemia (WHO)  Acute Myeloproliferative Leukemia M0 WHO classification: AML not otherwise categorized undifferentiated large, granular blasts >30% blasts  Acute Myeloproliferative Leukemia M1 WHO classification: Acute Myeloblastic Leukemia without maturation >30% myeloblast in the BM 30% myeloblast in the BM >10% granulocytic cells Incidence: middle age (48 years old) 40% ≥ 60 years old male: female ratio ____ median survival time: ____ months after diagnosis  Acute Myeloproliferative Leukemia M3 WHO classification: Acute Promyelocytic Leukemia >30% myeloblast in the BM >10% granulocytic cells >50% promyelocytes With Ch translocation (15 & 17) Presence of faggot cells Incidence: middle age (38 years old) male: female ratio ____ median survival time: ____ months after diagnosis  Acute Myeloproliferative Leukemia M4 WHO classification: Acute myelomonocytic leukemia 30% blasts 20-5%) Incidence: middle age (50 years of age) male: female ratio ____ median survival time: __ months after diagnosis  Acute Myeloproliferative Leukemia M5a WHO classification: Acute Monoblastic Leukemia without maturation 20->80% monocytic cells monoblasts: >80% Incidence: young adults(16 years) male: female ratio ____ median survival time: _______ months after diagnosis  Acute Myeloproliferative Leukemia M5b WHO classification: Acute Monoblastic Leukemia with maturation 20->80% monocytic cells monoblasts: 50% erythroblastic precursors Incidence: 54 years male: female ratio ____ median survival time: ____ months after diagnosis  Acute Myeloproliferative Leukemia M7 WHO classification: Acute megakaryoblastic leukemia 30% blasts >30% megakaryocytes Incidence: children and adults  Acute Myeloproliferative Leukemia Cytogenetic Subgroup Clinical Features Laboratory Findings abnormalities M1 --- --- --- M2 --- t (8q; 21q) --- M3 DIC T (15; 17) Prolonged PT/ PTT Tissue infiltrates Chromosome 16 M4 Increased lysozyme CNS involvement (M4e) M5 Same as M4 T (9; 11) (M5a) Increased lysozyme Peripheral M6 --- --- normoblastosis M7 Myelosclerosis Chromosome 21 Platelet peroxidase  Acute Myeloproliferative Leukemia SG Origin Nucleus Cytoplasm 1 nucleoli Few azurophilic gran M1 Myelocytic Fine stippled chromatin Auer rods Num. azurophilic gran M2 Myelocytic Same as M1 Auer rods Heavy granulation M3 Myelocytic Reniform or bilobed Bundles of Auer rods Myelocytic M4 --- --- Monocytic  Acute Myeloproliferative Leukemia SG Origin Nucleus Cytoplasm Basophilic, M5a Monocytic Lacy chrom. w/ nucleoli pseudopods, occasional gran. Grayish, ground glass M5 Monocytic Cerebriform w/ nucleoli Fine azurophilic gran Multiple lobes, nuclei PAS (+) Erythrocytic M6 Nuclear fragments Gigantism’; Myelocytic Megaloblastic changes vacuolization Scant; blebs & M7 Megakaryocytic Dense chromatin vacuoles; platelet shedding  Acute Myeloproliferative Leukemia Chromosomal abnormalties 90% of AML t(9;22)9q34;q11): 10-15% of M1 Poor prognosis t(8;21)(q22;q22): 20-25% of M2 favorable prognosis t(15;17)(q22;q21): 70-80% M3 RAR-PML fusion gene Abn. of Ch.16 20-25% M4 favorable prognosis Abn. of Ch.11 30-40% M5 poor prognosis Absence or deletions of Ch.5 or 7 poor prognosis  Acute Lymphoblastic Leukemia ALL primarily a disease of the children and young adults according to morphology of lymphoblasts FAB L1: 85% (childhood) 35% (adult) L2: 15% (childhood) 65% (adult) L3: 1-2% leukemic manifestations of Burkitt’s Prognosis: more than 90% of children with ALL can be cured ALL in children between 2-10 years old with early pre-B phenotype and hyperdiploidy in the range of 51-60 chromosomes: most favorable  Acute Lymphoblastic Leukemia L1 Childhood ALL Lymphoblast are small and homogenous (vary little in size) Common in CHILDREN  Acute Lymphoblastic Leukemia L2 Adult ALL Lymphoblasts are large and heterogenous (vary in size) Common in ADULT  Acute Lymphoblastic Leukemia L3 (Burkitt Type) Rare Lymphoblasts are large and homogenous (vary little in size) VACUOLATED Acute Lymphoblastic Leukemia  Thank you ! ___END___ MCVG, RMT, MPH ”Nothing worth having comes easy, trust and enjoy the process.” References: Lotspeich-Steininger e.t al; Clinical hematology principles, procedures, correlations, Lippincott Company, 1992 Turgeon, Clinical Hematology: Theory and Procedures 5ht ed., Lippincott Williams & Wilkins, 2012 Keohane et. al, Rodak’s Hematology: Clincal Principles 6th ed., Elsevier, 2020  Myelodysplastic Syndromes Ma. Christy V. Gonzales, RMT, MPH School of Medical Technology Emilio Aguinaldo College MCC4 31 (Hematology 1) Lecture Characteristics of MDS group of acquired clonal hematologic disorders characterized by progressive cytopenias in the peripheral blood defects in erythroid, myeloid, megakaryocytic maturation increased risk to transform into AML median age of diagnosis: _______ cause: mutation in normal hematopoietic stem cells leads to a clonal expansion at the expense of normal HSCs CHIP occurring in healthy patients but do not develop hematologic disorder precursor state of MDS and other disorders 2 morphologic findings common to all types of MDS 1. Presence of progressive cytopenias despite cellular bone marrow 2. Dyspoiesis in one or more cell lines Characteristics of MDS has ineffective hematopoiesis due to disruption of apoptosis early stage: apoptosis is increased when peripheral blood cytopenias are evident late stage: apoptosis is decreased when progression toward leukemia is apparent → allows increased neoplastic cell survival and expansion of the abnormal clone 2016 WHO classification recognizes patients who have a predisposition to develop MDS inherited bone marrow failure syndromes Fanconi anemia Diamond-Blackfan anemia Shwachman- Diamond syndrome Characteristics of MDS Genetic mutations in HSC that lead to MDS 1. De novo mutations (primary MDS) most of the cases 2. Therapy-related MDS median onset of MDS is 4-7 years after chemotherapies and therapeutic radiation are known to cause genetic mutations and cellular disruptions chemotherapies may apply a selective pressure to the BM → allows preexisting mutations to accumulate patients who received cytokines(G-CSF or GM-CSF,) to stimulate BM are also at an increased risk for developing t-MDS 3. Secondary to exposure to chemicals or radiation not associated with prior disease treatment 4. Inherited inherited Morphologic abnormalities of MDS 1. Dyserythropoiesis morphologic finding in peripheral blood: ______________ in the presence of normal vitamin B12 and folate ______________________ in the presence of adequate iron stores dimorphic RBC population poikilocytosis, basophilic stippling, Howell-Jolly bodies, and siderocytes Morphologic abnormalities of MDS 1. Dyserythropoiesis morphologic finding in bone marrow: multinucleated RBC precursors or abnormal nuclear shapes normally round nucleus may have lobes or buds nuclear fragments may be present in the cytoplasm presence of internuclear bridging Morphologic abnormalities of MDS 1. Dyserythropoiesis morphologic finding in bone marrow: basophilic stippling or heterogeneous staining in cytoplasm ring sideroblasts megaloblastoid cellular development in the presence of normal vitamin B12 and folate values erythrocytic hyperplasia or hypoplasia Morphologic abnormalities of MDS 2. Dysmyelopoiesis morphologic finding in peripheral blood: ___________________________: basophilia in WBC cytoplasm abnormal granulation of the cytoplasm of neutrophils hypogranulation or the absence of granules agranular bands mistaken as monocytes hyposegmentation, hypersegmentation, or nuclear rings Morphologic abnormalities of MDS 2. Dysmyelopoiesis morphologic finding in bone marrow: ___________________________: basophilia in WBC cytoplasm uneven staining → dense ring of basophilia around the periphery with a clear unstained area around the nucleus or whole sections of cytoplasm unstained, with the remainder of the cytoplasm stained normally agranular promyelocytes mistaken for blasts → lead to misclassification in AML Morphologic abnormalities of MDS 2. Dysmyelopoiesis morphologic finding in bone marrow: abnormal granulation of the cytoplasm in which promyelocytes or myelocytes or both → absence of primary granules primary granules may be larger than normal secondary granules may be reduced or absent presence of occasional Auer rod hypersegmentation or hyposegmentation and ring-shaped nuclei granulocytic hypoplasia or hyperplasia monocytic hyperplasia ______________________________________: characteristic finding in BM biopsy Morphologic abnormalities of MDS 3. Dysmegakaryopoiesis morphologic finding in peripheral blood: giant platelets and abnormal platelet granulation (hypogranulation or agranulation) platelets with large fused granules circulating micromegakaryocytes Morphologic abnormalities of MDS 3. Dysmegakaryopoiesis morphologic finding in bone marrow: large mononuclear megakaryocytes micromegakaryocytes micromegakaryoblasts bilobed or multiple small, separated nuclei of these cells Myelodysplastic Syndrome _________ is not sufficient evidence of MDS conditions with similar dysplasia with MDS Vitamin B12 or folate deficiency Exposure to heavy metals Copper deficiency Fanconi anemia and congenital dyserythropoietic anemia Parvovirus B19 and Human immunodeficiency virus Paroxysmal nocturnal hemoglobinuria Myelodysplastic Syndrome cells produced by abnormal maturation not only have an abnormal appearance but also have abnormal function type and degree of dysfunction depend on the mutation present in the HSC granulocytes: decreased adhesion, deficient phagocytosis, decreased chemotaxis, or impaired microbicidal capacity decreased levels of myeloperoxidase and alkaline phosphatase red blood cells shortened survival, and erythroid precursors may have a decreased response to erythropoietin that may contribute to anemia platelets increased bleeding despite adequate platelet numbers Classification of MDS French-American-British (FAB) Classification 1. Refractory anemia 2. Refractory anemia with ring sideroblasts (RARS) 3. Refractory anemia with excess blasts (RAEB) 4. Chronic myelomonocytic leukemia 5. Refractory anemia with excess blasts in transformation 6. (RAEB-t) categorized based on the amount of dysplasia and number of blasts in BM reliance on morphology alone limited its usefulness as a prognostic indicator did not address therapy-related MDS, hereditary forms, or childhood MDS Classification of MDS World Health Organization Classification 1. MDS With Single Lineage Dysplasia 2. MDS With Multilineage Dysplasia 3. MDS With Ring Sideroblasts 4. MDS With Excess Blasts 5. MDS With Isolated del(5q) (5q– Syndrome) 6. MDS, Unclassifiable 7. Childhood Myelodysplastic Syndromes Classification of MDS World Health Organization Classification 1. MDS With Single Lineage Dysplasia (MDS-SLD) formerly known as refractory cytopenia with unilineage dysplasia (WHO, 2016) symptoms related to cytopenia: fatigue or shortness of breath (anemia) increased infections (neutropenia) petechiae, bruising, or bleeding (thrombocytopenia)