Lab Manual Leukemia PDF

PRACTICAL HEMATOLOGY LEUKEMIA PROF MADYA DR ZARIYANTEY ABD HAMID  HEMATOPOIEISIS The monocyte and the lymphocytes comprise the agranulocytes, as opposed to the granulocytes (basophil, neutrophil and eosinophil) that are produced during granulopoiesis. B., N. and E. stan...

PRACTICAL HEMATOLOGY LEUKEMIA PROF MADYA DR ZARIYANTEY ABD HAMID  HEMATOPOIEISIS The monocyte and the lymphocytes comprise the agranulocytes, as opposed to the granulocytes (basophil, neutrophil and eosinophil) that are produced during granulopoiesis. B., N. and E. stand for Basophilic, Neutrophilic and Eosinophilic. The T and B lymphocyte are split to better indicate that the plasma cell arises from the B-cell. Note that there is no difference in the appearance of B- and T-cells unless specific staining is applied. TYPE OF BLAST CELLS  HEMATOPOIETIC BLAST CELLS In histology, it is very difficult to distinguish it from the other "-blast" cells (lymphoblast, proerythroblast, myeloblast, monoblast, and megakaryoblast). The cytoplasm is blue in an H&E stain, indicating that it is basophilic. Fig. 1 Early erythropoiesis. (a) The earliest recognizable red cell precursor is the large dark proerythroblast with loosely arranged nuclear chromatin (1). Below are two orthochromatic erythroblasts (2), on the right a metamyelocyte (3). (b) Pro- erythroblast (1). Fig. 2. Proerythroblast (1) next to a myeloblast (2), lower region of image shows a promyelocyte (3). Toward the upper left are a metamyelocyte (4) and a segmented neutrophilic granulocyte (5). ACUTE LEUKEMIA  Morphological and Cytochemical Cell Identification of AML After a first-line diagnosis of acute leukemia has been made on the basis of the cell morphology, the diagnosis must be refined by cytochemical testing of blood cells or bone marrow (on fresh smears). A peroxidase test allows leukemias to be classified as peroxidase- positive (myeloid or monocytic) or peroxidase-negative (lymphoblastic). The next step is the immunological classification based on cell markers (immunophenotyping method)  Acute Myeloid Leukemias (AML) Morphological analysis makes it possible to group the predominant leukemic cells into myeloblasts, promyeloblasts, monoblast, erythroblast or megakaryoblast. A morphological subclassification of these main groups was put forward in the French–American–British (FAB) classification  Acute Myeloblastic Leukemia Morphologically, the cell populations that dominate the CBC and bone marrow resemble myeloblasts with coarser chromatin structure, more prominently defined nucleoli, and relatively narrow cytoplasm. Compared with lymphocytes, the analyzed cells may be up to threefold larger. The cytoplasm may contains crystalloid azurophilic needle-shaped primary granules (Auer bodies-type M1 onward). Auer bodies (rods) are collection of azurophilic granules. A few cells may begin to display promyelocytic granulation. Cytochemistry shows that from stage M1 on- ward, more of the blasts are peroxidase-positive.  Acute leukemia, M0–M2. (a) Undifferentiated blast with dense, fine chromatin, nucleolus (arrow), and narrow basophilic cytoplasm without granules. This cell type is typical of early myeloid leukemia (M0–M1); the final classification is made using cell surface marker analysis. (b) The peroxidase reaction, characteristic of cells in the myeloid series, shows positive only for stage M1 leukemia and higher. The image shows a weakly positive blast (1), strongly po- sitive eosinophil (2), and positive myelocyte (3).  (c) and (d) Variants of M2 leukemia. Some of the cells already contain granules (1) and crystal-like Auer bodies (2). Auer Rod bodies  (a) Blood analysis in promyelocytic leukemia (M3): presence of cytoplasmic granules. (b) In type M3, multiple Auer bodies are often stacked like firewood (so-called faggot cells). (c) Blood analysis in variant M3v with dumbbell-shaped nuclei. Auer bodies is noticable Acute Lymphoblastic Leukemia (ALL)  Acute Lymphoblastic Leukemia (ALL) ALL are the leukemias in which the cells do not morphologically resemble myeloblasts, promyelocytes, or monocytes, nor do they show the corresponding cytochemical pattern. Common attributes are a usually slightly smaller cell nucleus and denser chromatin structure. Insufficiently close morphological analysis can also result in possible confusion with chronic lymphocytic leukemia (CLL), but cell surface marker analysis will correct this mistake. Advanced diagnostics start with peroxidase and esterase tests on fresh smears, performed in a hematology laboratory, together with immunological marker studies Acute lymphocytic leukemias. (a) Screening view: blasts (1) and lymphocytes (2) in ALL. Further classification of the blasts requires immunological methods. (b) Same case as a. The blasts show a dense, irregular nuclear structure and narrow cytoplasm. Lymphocyte (2). (c) ALL blasts with indentations must be distinguished from small-cell non-Hodgkin lymphoma by cell surface marker analysis. (d) Bone marrow: large, vacuolated blasts, typical of B-cell ALL.  Chronic Myeloid Leukemia In 95% of cases, CML shows a specific chromosome aberration (Philadelphia chromosome with a specific BCR-ABL translocation) and may make the transition into a blast crisis. Morphologically, blood smear and bone marrow smear show increased numbers of immatured blast cells and matured myeloid cells at differential maturation staging. Left shift as far as myeloblasts, proliferation of eosinophils and basophils suggest chronic myeloid leukemia (CML) (a) Blood analysis in chronic myeloid leukemia (chronic phase): segmented neutrophilic granulocytes (1), band granulocyte (2) , myelocyte (3), and promyelocyte (4). (b) and (c) Also chronic phase: myeloblast (1), promyelocyte (2), myelocyte (3), immature eosinophil (4), and basophil (5) (the granules are larger and darker, the nuclear chromatin denser than in a promyelocyte).  Bone marrow is hypercellular with an increase in granulocytes and their precursors. The myeloid:erythroid ratio is greater than 10:1 and there is a low number of erythroid precursors (white arrows). All stages of granulocytic maturation are increased, the pattern is the same as in peripheral blood. Chronic Lymphocytic Leukemia  Bone marrow smear shows a uniform population of lymphocytes and a few basket cells (green arrows). Monoclonal gammopathy can occur in some cases of CLL; this can manifest itself as the rouleaux formation of erythrocytes (red arrows).  This is another example of bone marrow aspiration smear in a classic variant of CLL. All cells shown in the image are neoplastic elements; smudge cells or basket cell are also present (green arrows). What are basket/smudge cells? Smudge cells are remnants of cells that does not have any identifiable nuclear structure or cytoplasmic membrane They also called basket cells Seen mostly in CLL Higher percentage of smudge cells indicate poor prognosis  SUMMARY AML ALL M0- immature blast without cells do not morphologically granules , negative peroxidase CLL resemble myeloblasts, M1-onward: positive peroxidase uniform population of and auer rods promyelocytes, or monocytes, nor do they show the lymphocytes and a M1-M2- blast with granules, positive peroxidase, Auer rods corresponding cytochemical few basket / smudge M3- promyelocyte series, positive pattern. cells. peroxidase, Auer rods immunological marker studies M4-myelomonocyte: mixture of to confirm diagnosis myeloblast [peroxidase+) and Monoclonal monoblast / promonocyte large, vacuolated blasts, [esterase+] typical of B-cell ALL. gammopathy can M5-monocytic : monoblast / occur in some cases of promonocyte [esterase+] CLL; this can manifest M6-erythroleukemia : mixture of CML itself as the rouleaux myeloblast and erythroblast, formation of M7-megakaryoblast with / without mixture of immature myelofibrosis : surface marker myeloblast and all stages erythrocytes analysis to confirm diagnosis. Bone marrow is replaced with fibrous of granulocytic maturation tissue are increased THANK YOU