Hematology Exam V

Who gets MDS?

-Primarily ≥50 year olds (more males than females) -*Risk increases with age* -Rare in children

Differential diagnosis for primary myelofibrosis.

Differentiate from CML - see differential diagnosis card for CML.

PB for polycythemia vera.

- RBC's normocytic and normochromic in early; microcytic and hypochromic in lager stage. - RBC life span is normal. Functional. - NRBC's may be found. - Retic normal or increased. - Mild leukocytosis usually found with an ↑ in granulocytes. - Slight "shift to the left" but rarely pros and blasts. - Platelets ↑ with abnormal functions. - LAP >100

WHO classification for CMML

-PB monocytosis -Blasts -Dysplasia in one or more cell lines -Negative BCR-ABL1 (If positive, it would be classified as mast cell leukemia) -No rearrangement of PDGFRB

Lab findings for polycythemia vera.

- ↑ RBC count (6-10,000,000) - Hgb: ≥18 - Serum iron becomes low - TIBC is high - Erythropoietin levels → or ∼↓ - Arterial O₂ is normal.

What are the lab findings for CML?

- ↑↑↑ WBC (≥100,000) - Normal/giant platelets are → or ∼↑ -Normocytic, normochromic -NRBC's are often found -Retic is ∼↑ -↑ B12

What does the peripheral blood look like for CML patients?

-"Shift to the left" of granulocytes with the predominant cells being segs and myelos. -All maturational stages present - NO maturation hiatus. -Blasts and Pros not > 20%, usually < 10% -Eos and Basos often ↑ in number -Monos moderately ↑ -Signs of myeloid dysplasia -Pseudo-Pelger-Huet -↓↓ LAP

The most frequent abnormal karyotypes is...

-5 and del(5q), found in 10-20% of MDS. *Often associated with past treatment*

Bone marrow findings for CML.

-90-100% cellular with ↑ in all cell lines, especially the myeloid. -M:E ratio ↑↑ (10:1 to 50:1) -Blasts <20% -All stages of granulocytic maturation found. -Pseudo Gaucher cells common due to ↑ cell turnover (cells can't keep up) -Later in the disease, the BM may become fibrotic (dry tap).

Dysgranulopoiesis

-Abnormal staining of primary granules -Larger than normal granules -Absent of fewer secondary granules (meta, band, seg, eo, and baso) -Pseudo Pelger Huet (acquired) -Hypersegmented neutrophils -↓ LAP -Impaired function of mature forms

RAEB

-At least two cell lines -Dysplastic features in all three lines. -"Pre-leukemia" -*Normal urine and serum lysozyme

PB findings for MDS.

-Cytopenias and dysplasia -*Anemia is the most common findings*, >80% of cases. *Usually macrocytic but can be normocytic.* (not b/c of folate or B12 deficiency). -Bicytopenia in 30% -Pancytopenia in 15% -Dysplastic cells are common -Neutropenia is the second most common cytopenia, about 50% of cases. Can show a left shift. Blasts may be seen. -*Dysgranulopoiesus is a hallmark for MDS*. -Platelets are ↓,↑, or → with qualitative and quantitative abnormalities including aggregation and adhesion. -Micromegakaryocytes can be found. Really rare.

RCMD

-Dysplasia in at least 10% of the cells of *two or more cell lines*. -<5% blasts in BM, ringed sideroblasts can exceed 15%. -Most common subgrops - 30-40% of MDS. -Worse prognosis -10% of these turn into AML.

Clinical findings for MDS.

-Fatigue and weakness due to anemia,, UNRESPONSIVE to treatment. -Possibly hemorrhage and infection due to dysfunctional neuts. -*Infection and bleeding are the most common cause of death.* -*Splenomegaly and hepatomegaly are uncommon.*

What are the clinical findings of myeloproliferative neoplasms?

-Hemorrhage (abnormal plt. function) -Thrombosis abnormal plt. function -Infection (abnormal, immature grans) -Pallor (anemia) -Weakness (anemia) -Insidious onset of disease

Therapy-related myelodysplasia

-MDS occurs secondary to certain chemo/radiation -Development of MDS or acute leukemia seems to be related to: +Duration of therapy +Amount of therapy +Repetition of therapy +Patient's age -Occurs 3-8 years after treatment -Highest risk related to long-term use of DNA alkylating agents. -Cannot predict who will or will not develop MDS after treatment -Pt's in this category appear to be of a younger age then primary MDS, have ↑ issues with thrombocytopenia, and a higher % of pt's with the RAEB subtype. -Pt's often suffer profound marrow failure and the outcome is poor with a median survival of 4-6 months. -Most of these cases have complex karyotypes.

Prognosis of MDS in general

-Medial survival for all types is <2 years -Some can survive longer with supportive therapy -Leukemic transformation is 10-40%

Dyserythropoiesis

-Nucleus: cytoplasm asynchrony -Gaint multi-nucleated RBC precursors -Karryohexis = chromosomes breaking -Irregular staining properties (doesn't pick up stain) -Vacouls -Basophilic stippling

RCUD

-One cell line is affected -Low risk of progression to AML -<1% of blasts in PB, <5% blasts in BM -NO prominent ringed sideroblasts.

MDS associated with isolated del(5q)

-The only chromosomal abnormality is the del(5q) -Good prognosis, low risk of turning into AML -JAK2(V617F) has been found in some cases

RARS

-Unexplained true anemia with erythroid dysplasia -BM has ≥ 15% ringed sideroblasts, is hypercellular with megaloblastoid dyserythropoiesis. -Macrocytic anemia. -Can show a bimodal RBC population.

BM findings for MDS.

-Usually hypercellular with erythroid hyperplasia. -All cells line show dysplasia.

Treatment for MDS

-Variable and dependent on multiple factors -Transfusions, antibiotics, and *thrombopoietin* -Three drugs have been approved -Single most important prognostic indicator with respect to response to treatment is karyotype.

What are the lab findings/PB for myeloproliferative neoplasms?

-↑ in all cell lines (panhypercellularity or panmyelosis), one cell line predominates. -Bizarre, giant, FUNCTIONALLY abnormal platelets. -Myeloid "left shift"

What cell line is affected in CML?

-↑ in all cell lines, especially myeloid cell lines. -Does not affect T cells, somatic cells, or fibroblasts.

WHO classification of subgroups are based upon?

1. % of blasts 2. Degree of cell differentiation 3. Degree of dysplasia 4. Cell line that predominates

What is the prognosis for ET?

1. 50% live for 5 years with better prognosis for younger patients. 2. Most common cause of death is thrombosis due to the hyperaggregable platelets. 3. May transform to AML and PMF.

Multipule types of genetic mutations can be found in MDS:

1. Altered gene function 2. Gene "silencing" 3. Single gene mutations

Symptoms of essential thrombocythemia?

1. Bleeding due to impaired platelet function (GI tract, renal tract, or mucous membranes). 2. Thrombosis due to platelet hyperaggregability. 3. ~Splenomegaly. 4. Most are asymptomatic.

WHO subclasses are:

1. CML (Chronic myelogenous leukemia) - myeloid 2. CNL (Chronic neutrophilic leukemia) - myeloid 3. ET (Essential Thrombocythemia) - megakaryocyte 4. PV (Polycythemia vera) - erythroid 5. PMF (Primary Myelofibrosis) - fibroblasta 6. CEL-NOW (Myeloproliferative Neoplasm, Unclassifiable) - leukocytes and plateletes

What are the three stages of CML?

1. Chronic: -if left untreated, could last for months or ever years. 3-5 years after diagnosis on average. Responds well t treatment. Standard chemo usually restores health for months or year. 2. Accelerated: -more difficult to treat. Often accompanied by additional chromosomal abnormalities. 30% of pt die in this stage w/o progressing to acute phase. 3. Acute phase (Blast crisis): -often indistinguishable rom an acute leukemia. Difficult to treat. Survival 1-2 months, better get TKI therapy. 65-75% of the blast crises are myeloblastic, 25-35% are lymphoblastic. -Spleen is enlarged.

What is the defect in polycythemia vera?

1. Clonal stem cell defect. 2. Unregulated neoplastic proliferation of erythrocytes could be caused by: -Proliferation of neoplastic progrenitor cells, unrelated to erythropoietin -Hypersensitivity of progenitor cells to erythropoietin -Hypersensitivity of progenitor cells to growth factors other than erythropoietin -Inhibition of apoptosis in progenitor cells. 3. Several mutations of janus kinase 2 (JAK2) have been associated with PV. -JAK2 (V617F) is seen in almost all patients (≥95%) with PV (but also in some cases of ET and PMF). -About 5% have mutations on exon 12 of JAK2. -In addition, an MPL mutation has been identified in cases where JAK2 mutations are negative.

Differential diagnosis for CML.

1. Differentiate from leukomoid reaction. a. CML - ↓↓↓ LAP, always Ph positive; splenomegaly usually found. ↑ eos and basos on differential. b. Leukemoid reaction - (extreme neutrophilic reaction to infection), Ph negative; no splenomegaly. Usually eos and basos are not ↑. 2. Differentiate from PMF. a. CML - LAP ↓, B12 ↑↑↑, BM myeloid hyperplasia, WBC ↑↑↑↑, → poik in PB.

What are the BM findings for myeloproliferative neoplasms?

1. Early - hyperplasia 2. Late - fibrotic (↑ in fibroblasts)

Two common clinical findings in CML.

1. Extra-myeloid masses common in liver and spleen - called chloromas. Rich in myeloperoxidase. 2. Onset of blast phase may occur 30-40 months after diagnosis which leads to death in 8 months.

What are the lab findings/PB for essential thrombocythemia?

1. Extreme thrombocytosis - often 1,000,000-5,000,000 2. Giant, bizarre platelets, even fragments of megakaryocytes can be found. BUT, platelet morphology is normal. 3. Abnormal platelet function - aggregation and adhesion. 4. Anemia only if there is bleeding. 5. Leukocytosis (22-40,000) almost always found. 6. Mild shift-to-the-left may be found.

Cause of death for primary myelofibrosis.

1. Infection 2. Hemorrhage 3. Thrombosis 4. Cardiac failure 5. 10-15% terminate with AML or ALL.

Genetics for polycythemia vera.

1. JAK2 (V617F) is found in >95% of patients with PV. 2. Chromosomal aneuploidy and deletions can be found.

What is the cytogenetics for essential thrombocythemia?

1. JAK2 (V617F) is present in about 25-50% of cases. A few carry an MPL gene. 2. No diagnostic cytogenetic abnormality has been associated with ET.

Symptoms for primary myelofibrosis.

1. Lethargy from anemia. 2. Abdominal fullness and tenderness from organmegaly. 3. Pallor (if anemia), petechiae from impaired platelet function.

Pathophysiology of primary myelofibrosis.

1. Marked hyperplasia of abnormal megakaryocytes (both dysplastic and necrotic). Usually only megakaryocytes and granulocytes are involved but erythrocytes can also be involved. 2. Myeloid metaplasia = extramedullary hematopoiesis in the liver and spleen. Extramedullary hematopoiesis kicks in to make up for the hypoplastic BM.

Differential diagnosis for ET.

1. Mostly a diagnosis of exclusion. 2. Must be differentiated from secondary, reactive thrombocytosis. Secondary thrombocytosis rarely exceeds 1,000,000 and is transient (will last for only days or maybe a few weeks). 3. Differentiaitation from PV based upon the marked erythrocytosis and hypervolemia that is more typical of PV then ET.

Differential diagnosis for polycythemia vera.

1. Must be distinguished from relative polycythemia and secondary polycythemia. a. Relative (dehydration, hemoconcentration, Giasbock syndrome) - red cell mass will be normal or decreased. b. Secondary (response to tissue hypoxia, tumors that secrete erythropoietin like substance, high O₂ affinity hemoglobin). -↑ red cell mass -↓ arterial O₂ -Erythropoietin is → or ↑ c. Molecular testing for JAK2 mutations - only positive for PV. Not for primary or secondary.

Other names for primary myelofibrosis.

1. Myelofibrosis with myeloid metaplasia (MMM) 2. Myelofibrosis 3. Agnogenic myeloid metaplasia 4. Chronic idiopathic myelofibrosis (with myeloid metaplasia).

Lab findings for primary myelofibrosis.

1. Normocytic and normochromic. 2. ↑ retic

What therapy is associated with ET?

1. Platelet pheresis to reduce to the platelet mass. 2. Anticoagulants and drugs to inhibit platelet function help to control thrombosis. Aspirin therapy recommended. 3. Chemotherapy can help to lower both the platelet count and the WBC.

Other name for polycythemia vera.

1. Polycythemia rubra vera. 2. Primary polycythemia 3. Erythremia 4. Osler's disease

General characteristics for MDS.

1. Primary neoplastic pluripotential stem cell disorders. 2. One or more peripheral blood cytopenias with marked dyspoiesis (dysplasia) in the bone marrow. 3. PB cytopenias result from ineffective hematopoiesis and ↑ apoptosis. 4. Progressive disorders 5. Some (but not all) evolve to AML, thus the former description of "Preleukemia". 6. Most commonly occur in the elderly; rarely in children.

Other names for Essential thrombocythemia.

1. Primary thrombocythemia 2. Hemorrhagic thrombocythemia 3. Primary thrombocytosis 4. Idiopathic thrombocytosis

Pathophysiology for MDS.

1. Proliferation of stem cells that have acquired a defect that prevents them from differentiating, maturing, and proliferating normally. 2. Affects the myeloid progenitor cells, RARELY lymphocytic cell lines. 3. Many cells that do mature exhibit MARKED DYSPOEISIS resulting in the PB cytopenias. 4. The dyspoiesis includes impaired morphology and cell function. 5. MDS are either primary (60-70%) or secondary (therapy-related). 6. Regardless, MDS result from a combined interaction between abnormal stem cells and a faulty BM microenvironment. 7. 50% of MDS have normal chromosomes but likely display genetic instability of the myeloid stem cell.

Symptoms for polycythemia vera.

1. Pruritis (due to hyperhistaminemia caused by hot showers/baths) 2. Splenomegaly and sometimes hepatomegaly. 3. Fatigue 4. Hypertension from ↑ red cell mass. 5. About 1/3 experience thrombotic or hemorrhagic episodes.

Classification of MDS:

1. RCUD - Refractory cytopenia with lineage dysplasia 2. RARS - Refractory anemia with ringed sideroblasts 3. RCMD - Refractory cytopenia with multilineage dysplasia 4. RAEB - Refractory anemia with excess blasts 5. MDS associated with isolated del(5q) 6. Myelodysplastic syndrome, unclassifiable (MDS-U)

Characteristics for CNL.

1. Sustained ↑ in neutrophils in the PB with a slight left shift. (<10% are immature). 2. WBC - >25,000 3. Rare 4. Treat with hydroxyurea and/or interferon. BM transplant is possible. 5. Median survival about 2 years (in absence of BMT). 6. Differential diagnosis - differentiate from CML or leukemoid reaction.

Characteristics for MPN-U

1. Used for cases that have the characteristics of MPN's but do not meet any of the specific criteria of one of the categories. 2. May be very early stages of one of the well-defined subclasses.

PB for primary myelofibrosis.

1. WBC usually ↑ to 60,000 2. Later in the disease, marked aniso and poik including a few NRBC's, ovalo, and dacrocytes. 3. Basophilic stippling. 4. Blasts <5% 6. Platelets can be ↓, ↑, or →. 7. ↓ platelet function with bizarre/giant platelets. Defects include impaired aggregation or adhesion or hyperaggregability. 8. Basophilia, eosinophilia, or pseudo-Pelger Huet can be found.

BM findings for polycythemia vera.

1. ↑ in hematopoetic marrow 2. M:E ratio usually noraml due to the ↑ in both myeloid and erythroid elements. 3. ↑ in megakaryocytes. 4. Iron stores are depleted. 5. LAP >100

Age group that polycythemia vera affects.

40-60, rare in children.

What age does primary myelofibrosis affect?

>50 year olds. Rare in childhood.

Define myeloproliferative neoplasms

A pluripotential HSC disorder. A clone of abnormal cells are produced that exhibit a ↓ in apoptosis and unchecked proliferation of abnormal cells in the BM.

Genetics for primary myelofibrosis.

About 50% of patients have a somatic mutation of the Janus kinase 2 (JAK2) gene - JAK2(V617F) or Exon 12. OR mutation of the thrombopoietin membrane receptor (MPL) gene in HSC's. Resulting cells are unresponsive to regulation. -

What age does essential thrombocythemia affect?

Age 20-30 (women), but mostly 50-60 (both genders). RARE.

What cell line is ↑ for polycythemia vera?

All cell lines, especially erythrocytic.

What cells are increased in essential thrombocythemia?

All cell lines, especially megakaryocytic but can be megakaryocytic alone.

What is the pathogenicity of CML?

All pt have the acquired translocation mutation called Philadelphia (Ph) chromosome abnormality. This abnormality is seen on 95% of karyotypes, the other 5% need molecular tests like PCR or FISH for the BCR/ABL 1 fusion. The abnormality affects tyrosine receptors for some growth factors. This leads to an ↑ in G-CSF and PDGF and suppression of apoptosis of stem cells.

What is the cause of death for CML?

Blast crisis causes cytopenias, therefor death from complications of acute leukemia.

Myelodysplastic syndrome, unclassificed

Cases that do not fit elsewhere in for MDS.

What is the cause of myeloproliferative neoplasms?

Caused by ACQUIRED genetic mutations of the single mutant stem cell. 1. Most common mutation is the Philadelphia chromosome in CML. 2. The Janus Kinase (JAK2) gene is mutated in most cases of PV and some of ET and PMF.

What are the other names for chronic myelogenous leukemia.

Chronic Granulocytic Leukemia Chronic Myelocytic Leukemia

CML stands for what?

Chronic Myelogenous Leukemia

What does CNL stand for?

Chronic Neutrophilic Leukemia.

Characteristics of CMML

Chronic myelomonocytic Leukemia: -Persistent monocytosis in the PB -Variable dyspoiesis, leukocyte count, neutrophil count ↓ -Appears to arise from an aberrant HSC -20-40% show clonal cytogenetic abnormalities -Most paitnes ≥50 years old, median survival 20-40 months and 15-30% progress to acute leukemia.

Molecular diagnostics

Cytogenetic studies are useful. FISH panels can be used both as diagnostic and prognostic or to monitor treatment.

Epigenetic changes

DNA methylation and histone modification can be found in MDS. Resulting in gene silencing. -Possibly affected are cell cycle regulators, tumor suppressors, DNA repair genes and apoptosis. -*DNA methylation is a significant factor in MDS → AML progression.*

BM findings for primary myelofibrosis.

Early - hypercellular Later - very fibrotic with focal aggregates of megakaryocytes. DRY TAP

What is the onset for polycythemia vera?

Gradual.

What is the onset for primary myelofibrosis?

Gradual.

What is a very common issue in myeloproliferative neoplasms?

Hepatosplenomegaly common due to extramedullary heatopoiesis.

What cell line is affected in primary myelofibrosis?

Increased in 1 or 2 cell lines, usually megakaryocytes and granulocytes) but maybe 3. Eventual fibrosis of the marrow is not part of the primary clonal proliferation but a reactive event to the abnormal hematopoiesis.

What is the cause of the mutation in CML?

It is unknown.

Many patients end up with what in myeloproliferative neoplasms?

Many terminate in acute leukemia, especial those who have CML. Also have the ability to evolve from one form of MPD to another.

What are the BM findings for essential thrombocythemia?

Marked hyperplasia especially in megakaryocytes, but also erythroid and myeloid.

What is the age group for myeloproliferative neoplasms?

Middle aged or elderly.

WHO classified MDS based on what criteria?

Morphology Immunophenotype Genetics Clinical features Prognosis

What does MDS stand for?

Myelodysplastic syndromes

What does MPN-U stand for?

Myeloproliferative neoplasm, unclassifiable

Therapy for polycythemia vera.

No known cure. 1. Therapeutic phlebotomy to reduce RBC mass and to deplete iron stores to slow erythropoiesis. Hematocrit to be kept at <45% 2. Myelosuppressive therapy with chemo - helpful but varies the risk of getting acute leukemia. (Hydroxyurea or Busulphan). 3. Molecular-targeted therapy being investigated.

LAP findings for essential thrombocythemia?

Normal or increased.

LAP for primary myelofibrosis.

Normal or increased.

B12 for primary myelofibrosis.

Normal.

What does PV stands for?

Polycythemia vera.

What does PMF stand for.

Primary myelofibrosis.

What is the typical treatment for CML?

Purpose is to reduce the abnormal leukocytes so normal hematopoiesis can be restored: 1. Chemotherapeutic agents can be used to try to reduce the WBC mass. Interferon alpha proves to be myelosupressve and helps to achieve remission in 3/4 of pt. 2. Leukophoresis if needed. Transfusion if anemia is bad. Antibiotics for infection. 3. BM transplant used to be 1' treatment for long term survival.

Rapid of slow onset for CML?

Slow/insidious.

Cytochemistry of blast cells

Special stains can help to ID the blast lineage.

Balanced mutations such as __ are seen in what cancer?

Such as reciprocal translocations are not usually seen in MDS but are seen in MPN and AML.

Unbalanced genetic abnormalitites such as ___ result in __.

Such as trisomys and deletions result in larger or smaller amounts of DNA in the cell. These are often seen in MDS.

Treatment options for primary myelofibrosis.

Survival - few months - 5 years. a. Stem cell transplant is the only cure but carries a high incidence of mortality due to the age of the patient and conditions of the BM. b. Supportive therapy such as transfusions of RBC's and platelets and steroids and EPO to stimulate erythropoiesis are helpful. c. Splenectomy may help the anemia. d. JAK inhibitors are being investigated.

Prognosis for polycythemia vera.

Without therapy, death within 18 months. With phlebotomy, 3-8 years. With myelosuppressive therapy, 12-14 years.

Oncogenes and tumor supressor genes

mutations of proto-oncogenes and tumor suppressor genes can result in neoplasia.

At what age doe people get CML?

≥55 year olds.