LEUCOCYTIC DISORDERS Group : 958 – 968

Supervised by :DR. DALIA NAFEA

AGENDAo INTRODUCTIONo LEUKOPENIA

I) HEREDITARY LEUKOPENIA

II) ACQUIRED LEUKOPENIA o LEUKOCYTOSIS

I) GRANULOCYTOSIS

II) MONOCYTOSIS

III) LYMPHOCYTOSIS

INTRODUCTION

Mohamed samir mohamed elsaid (958)

WBCs: “Leucocytes” Are cells of the immune systems

involved in defending the body against both infectious disease and foreign materials.

WBCs

GranulocytesN

eutrophils

Eosinophils

Basophils

A granulocytes

Monocytes

Lymphocytes

T -lymphocytes B -lymphocytes Types:

Genesis:

1=myeloblast. 7=polymorphnuclear neutrophil. (13-16)=stages of monocyte 2=promyelocyte. 8=eosinophil myelocyte. formation. 3=megakaryocyte. 9 = eosinophil metamyelocyte. 4=neutrophil myelocyte 10= polymorphonuclear eosinophil. 5=metamyelocyte. 11=basophil myelocyte. 6="band" metamyelocyte 12= polymorphonuclear basophil.

I. NEUTROPHILSThey have a distinctive multilobed nucleus (hence the name polymorph) and neutral staining granules.

Normal value: (2.5 – 7.5 x 109 /L)

Function:ingest & kill bacteria, fungi and damaged cells, either directly or by (opsonization) to make them more ingestible as neutrophils have Fc and C3b receptors

II.EOSINOPHILSThey are slightly larger than neutrophils and are characterized by a nucleus with usually 2 lobes and large cytoplasmic granules that stain deeply red.Normal value: (O.O4 –O.4 x109 /L)

Function :The main role is protection against multicellular parasites such as worms (helminthes). This is achieved by the release of toxic, cationic proteins e.g:.

Major basic protein (MBP). Eosinophil cationic protein (ECP).

Eosinophil neurotoxin. Eosinophil peroxidase

III.BASOPHILS The nucleus of basophils is similar to that of neutrophils but the cytoplasm is filled with large black granules.The granules contain histamine, heparin, and enzymes such as myeloperoxidase. Normal value:( o.o1 – o.1 x109 /L)Function:(Unknown)

Binding of IgE causes the cells to degranulate and release histamine and other contents involved in acute hypersensitivity reactions

IV.MONOCYTES They are slightly larger than neutrophils .

The nucleus has a variable shape and may be round, indented or lobulated. The cytoplasm contains few granules than neutrophils.Normal value: (o.2 – o.8 x 10 9 /L)Function:precursors of tissue macrophages and dendritic cells

V.LYMPHOCYTESThey are small cell, a little larger than RBCs, with a dark-staining central nucleus.There are 2 main types: T and B lymphocytes Normal value: (1.5 – 3.5 x 109/L) Function:The T cells mediate cellular immunity The B cells mediate humoral immunity

Hereditary LeukopeniaMohamed salama alradi ahmed (959)

LEUKOPENIADefinition A reduction in the total numbers of circulating

white cells, this may be due to a reduction in all types of white cells or individual cell types.

Leucopenia may occur in isolation or as apart of pancytopenia.

In general, an ANC of - 1000-1500/μL indicates mild neutropenia - 500-1000/μL  indicates moderate neutropenia - less than 500/μL indicates severe neutropenia.Classification I) Hereditary II) Acquired

Hereditary Leukopenia Causes

Infantile Genetic Agranulocytosis (kostamann Syndrome)

Familial Chronic Benign Neutropenia

Congenital Aleukia or Reticular Dysgenesis

Isoimmune Neonatal Neutropenia

Periodic or Cyclic Neutroprnia (Cyclical Haematopoiesis)

KOSTAMANN SYNDROMEBackground It is inherited as an autosomal recessive disease.The absolute neutrophil count (ANC) is

characteristically less than 200/μL. Severe persistent neutropenia results in an increased susceptibility to frequent bacterial infections.

Consanguinity of the parents was reported.IncidenceNeutropenia occurs in 1-2 cases per million population.Mortality/MorbidityThe mortality rate is 70% within the first year of life in

the absence of medical intervention with granulocyte colony-stimulating factor (G-CSF), bone marrow transplantation, or peripheral blood stem cell transplantation.

KOSTAMANN SYNDROMEPathophysiologyMutations in the gene (ELA2) encoding neutrophil

elastase appear to be present in most patients. These mutations may be responsible for the untimely initiation of apoptosis in myelocytes, producing their premature destruction, and interrupting the normal cycle of maturation.

RaceMost of the initial patients reported by Kostmann were

seen in in northern Sweden.SexIncidence is equal in males and females.AgeClassic Kostmann disease is recognized in early infancy.

KOSTAMANN SYNDROMEClinical History Symptoms of Kostmann disease include the following: -Temperature instability in newborn period - Fever - Irritability - Localized site(s) of infection Physical Signs and symptoms of Kostmann disease include : - Oral ulcers, Gingivitis. - Pharyngitis, Sinusitis, otitis media - Lymphadenopathy, lymphadenitis - Bronchitis, pneumonia - Splenomegaly - Neurological symptoms, including epilepsy and

neuropsychological deficits

KOSTAMANN SYNDROMELaboratory Studies With regard to CBC count with differential: - An absolute neutrophil count (ANC) less than 200/μL is seen in

classic cases. Monocytosis and eosinophilia may be evident. - Total leukocyte counts are frequently normal because of the

monocytosis. - Mild anemia may be present from chronic inflammation, and

thrombocytosis may be present.

Quantitative immunoglobulins may show hypergammaglobulinemia. Patients have a normal response to vaccinations.

Complement levels are typically normal.

Antineutrophil antibodies are absent but should be checked to exclude an autoimmune etiology.

Electrolyte levels and renal and liver function test results are within the reference range.

KOSTAMANN SYNDROMENormal neutrophils transfusion in the affected patients

left the blood at approximately normal rates, suggesting that the defect is in cell production rather than in increased cell destruction.

The transfer of normal plasma did not alleviate the neutropenia or alter the appearance of the bone marrow.

Bone marrow aspiration or biopsyReveals an arrest of neutrophil precursor maturation at

the promyelocyte or myelocyte level. Cytogenetic analysis typically reveals a normal bone marrow karyotype.

Vacuoles and atypical nuclear shapes are prominent in the promyelocyte and myelocyte and atypical erythroid forms also have been noted.

KOSTAMANN SYNDROMETreatment Bone marrow transplantation Because normal neutrophils differentiation has

been induced by addition of conditioned medium (CSF) to cultures of patient´s marrow.

Colony-stimulating factors(Filgrastim) These agents are used to stimulate neutrophil

production and act as hematopoietic growth factors that stimulate the development of granulocytes. They are used to treat or prevent neutropenia.

In patients treated with rhG-CSF, the blood neutrophils concentration increased to greater than 1000/μL.

CYCLIC NEUTROPENIAIt is inherited as an autosomal dominant trait.It is congenital in 75 % of patients. It is characterized by recurrence of malaise,

fever, mild infection, cervical lymphadenopathy and the association of these symptoms with neutropenia is well established.

Episodes recur at approximately 3- weeks intervals and symptomatic periods may last free or four to ten days.

The course of the disorder in affected individual is marked by recurrent infections with periods of well-being interspersed.

CYCLIC NEUTROPENIABlood pictureDuring the symptomatic period, the blood

neutrophil concentration is reduced, and lymphocytosis, monocytosis, and/or eosinophilia has been noted in some patients.

Thrombocytopenia has been reported in a few patients.

Between attacks, the symptoms disappear completely, and the neutrophil count returns to nearly normal levels.

CYCLIC NEUTROPENIAExamination of the B.M. demonstrated that

granulocyte precursors disappear prior to the onset of neutropenia and reappear before neutrophils reappear in the blood.

The findings suggest that the disorder results from a periodic failure of blood cell production, most likely at the pleuripotent stem cell level.

This hypothesis has been supported further by (1) Failure to find leukoagglutinins in the serum.(2) Inability to inhibit in vitro neutrophil migration or

phagocytic capacity by relapse phase serum.(3) Failure to produce neutropenia or clinical

manifestations in persons transfused with patient's serum.

CYCLIC NEUTROPENIATreatmentAntibiotics decrease the severity of bacterial infections and

reduce the likelihood of dissemination and death.Splenoectomy repoted to result in fewer symptoms in older

patients and in those with splenomegaly although not eliminating the cycling.

Adrenal corticosteroids and androgenic hormones

reported to eliminate the cell cycling in blood and bone marrow especially in adult patients.

CYCLIC NEUTROPENIATreatmentRecombinant human CSF Daily IV and SC injection of rhG-CSF was shown : (1) to increase the mean neutrophil from about 700

cell /µl to 9800 cells/µl. (2) to reduce the duration of severe neutropenia (<200

cells/µl) from about 12.7 to 0.7 days /month. (3) although cycling persisted in all but one patients,

the duration of the cycle was reduced from 21 to 14 days. In addition, treatment with G-CSF reduced the severity and number of clinical manifestations dramatically with minimal side effects.

ACQUIRED LEUKOPENIAMOHAMED SABER ABOHASSEN (965)

Acquired leukopenia

I- Causes & pathogenesis

II- Investigations

III- Treatment

I - CAUSESA- Infectious causes

VIRAL BACTERIAL PROTOZOAL CMV & EBV

TUBERCULOSIS BRUCELLOSIS BILHARZIA MALARIA

B- Haematological1-Megaloblastic anaemia (folic acid ,vitB12 deficiency)

2-Bone marrow failure a- Aplastic anaemia b- myelofibrosis c- myelodysplasia d- neoplasm (leukemia,lymphoma,secondries)

C - Anaphylactic shock

D - Immune mediated:

a- Systemic Lupus Erythamatous b-Felty syndrome c-HCV

d-Autoimmune neonatal neutropenia

E - drugs

II. INVESTIGATIONSA-laboratory investigations

1- CBC 2-Folate & VitB12 serum level 3-ANCA&ANTIDNA 4-Serology (if suspect infection) (e.g Widal test)

B - Radiology 1-X_RAY

2-ULTRASOUND

3-CT

C-Interventional 1- Culture(if suspect infection)

2-Bone Marrow Aspiration

3- Trephine Bone Marrow Biopsy (in cases of pancytopenia to avoid dry tab)

III. TREATMENT 1- IF hypersplenism splenctomy 2-IF drugs stop it 3-vitB12 &folate deficiency ( give parenteral vitB12 or oral folate) 4- Immune: a-high dose of corticosteroid b- splenectomy c - anticd20(ratixumab) 5-Infection(give suitable antibiotic or antiviral or anti parasitic) 6- IF anaphylactic shock make appropriate management

LEUKOCYTOSIS MOHAMED SEIF ELNASER (961)

DefinitionElevation of WBC count above the mean value of

circulating white cells. The usual explanation for leukocytosis is neutrophilia.

leukocytosis is considered when total WBC count exceeds 11000/mm³. 

Classification

1.Granulocytosis:Neutrophilia Eosinophilia Basophilia

2.Monocytosis 3.Lymphocytosis

NeutrophiliaElevation of the absolute neutrophil count "ANC" which is calculated byANC= (%band + %mature) × WBCNeutrophilia :when neutrophilic count exceeds 7,500/mm³. Mechanisms1. Increased production.2. Accelerated/early release from

marrow→blood.3. Demargination (marginal pool→circulating

pool)

Granulocytosis

ClassificationPrimary causes

Hereditary neutrophiliaChronic idiopathic

neutrophiliaAML and CML Familial

myeloproliferative disease

Congenital anomalies Leukocyte adhesion

factor deficiency (LAD)Familial cold urticaria

Secondary causes

Acute infection Inflammation e.g. rhematoid arthritisStress neutrophiliaDrug inducedNon-hematologic

malignancyGeneralized marrow

stimulation as in hemolysisAsplenia and hyposplenism

Primary causes of neutrophilia1. Hereditary neutrophilia

Usually associated with splenomegally and widened diploe of the skull.

The defect seemed to be dominatly inherited.The LAP score are usually high. The neutrophil function and CD18/CD11b expression in the affected individuals are normal

2. Chronic idiopathic neutrophiliaChronic leukocytosis occurring in patients who are otherwise well. Bone marrow aspirations, LAP scores are normal. Normal subjects fall outside of the 95th percentile with respect to WBC. A diagnosis of exclusion

3. AML and CML will be discussed in details later on.

4. Familial myeloproliferative diseaseMPD with monosomy 7 may have familial featuresAll of the affected subjects had low LAP scores.JAK2 mutations

5. Congenital anomalies and leukemoid reaction e.g. Tetralogy of fallot and down syndrome.

6. Leukocyte adhesion factor deficiency"LAD" The diagnosis is established by demonstration of marked reduction or absence in the CR3 receptor(CD11b/CD18) on granulocytes.

7. Familial cold urticaria and leukocytosisThe skin rash in these patients is characterized histologically by a marked infiltration by neutrophils.

Secondary causes of neutrophilia1. Acute infection

The most common cause of leukocytosis.Modest (uncommonly >30 × 10⁹/L), associated with a left shift and toxic granulationsCertain bacteria such as pneumococcus or staphylococcus may cause particularly high leukocyte counts.

2. Acute and chronic inflammation e.g. trauma, infarction, vasculitis, rheumatoid arthritis, burns….. It is due to release of cytokines by inflammatory cells

3.Stress neutrophiliaWithin minutes of exercise , stress or

epinephrine injections caused by movement of neutrophils from the marginated pool into the circulatory pool.Pretreatment with propranolol can block neutrophilia.

Post-operative period, there is doubling of leukocyte count approximately 3 hours after surgery.Interesting association between leukocyte count and MI??

4. Drug induced

Steroids through inducing release of neutrophils from bone marrow.Leukocytosis as high as 200,000/mm³ in neonates has been associated with maternal steroid administration.

β agonists through releasing neutrophils from marginated pool also anticonvulsants e.g. phenytoin.Lithium through production of "CSF" and has been used for treatment of neutropenia.

Other drugs include tetracycline and granulocyte CSF

5. Non-hematologic malignancyTumors from lung "frequently large cell

lung cancer", stomach, breast and neuroblastoma in children through irritation of WBC precursors.

Solid tumors of tongue, lung and kidney produce CSF "paraneoplasic syndrome".

6. Marrow stimulationAs in hemolytic anemia, immune thrombocytopenia. e.g. sickle cell anemia (2 mechanisms?) and ITP

leukemoid reactionDefinition

a reactive and excessive leucocytosis characterized by the presence of immature cells (band forms, metamyelocytes, myelocytes and occasionally promyelocytes and myeloblasts) in the peripheral blood.

Causesi. Acute infections, ii. Malignant infiltration of the bone marrow ,iii. Tuberculosis iv. Others: haemorrhage or haemolysis.

leukemoid reaction

Toxic granules ,vavuoles and Döhle body

Differences between CML and leukemoid reactionCML Leukemoid reaction

WBC >50,000 <50,000

Basophilia +ve -ve

NAP score low high

Toxic granulations -ve +ve

Cytogenetics Philadelphia +ve -ve

Splenomegaly Huge splenomegaly No huge splenomegaly

Effect of antibiotics No rsponse Good response"usually infectious"

Leukoerythroblastic responseDefinition Presence of immature RBCs "Nucleated red cells,

teardrop-shaped erythrocytes" and white cell precursors "Promyelocyte and myelocytes" in the peripheral blood.

Causes1. Marrow infiltration with metastatic carcinoma, 2. Myelofibrosis, 3. Granulomatous reactions e.g. tuberculosis4. Others: non-hodgkin lymphoma,myeloma,

osteopetrosis, severe hemolytic or megaloblastic anemia.

It is due to irritative or inflammatory process in the marrow itself.

Leukoerythroblastic reaction

Clinical approach to a case of neutrophilia

HistoryHistory of infection e.g. fever or any other inflammatory

conditions "e.g. rheumatoid arthritis, trauma, burn…", Symptoms of malignancy e.g. persistent low grade fever

and weight lossSymptoms of bone marrow infiltration by leukemic cells

e.g. anemia "easy fatigue, dyspnea, palpitation…" and thrombocytopenia "bleeding".

History of drugs e.g. steroids and history of operations. ExaminationWe should examine the patient for signs of infection

"e.g. elevated temperature" or an underlying haematological disorder "e.g. huge splenomegaly in CML".

InvestigationWBC count and blood film: Extremely high leukocytic counts (may >200

×10⁹/L) suggest →CMLModest (uncommonly >30 × 109/L), associated

with a left shift and toxic granulations→acute infection.

Moderate neutrophilia following steroid therapy.

Mild neutrophilia may be induced by stress or exercise.

Blast cells → acute leukemiaLeucoerythroblastic blood film

is due to → bone marrow invasion by tumour, fibrosis or granuloma formation and is an indication for a bone marrow biopsy..

NAP score: low in CML, high in leukemoid reaction.

Cytogenetics: Philadelphia chromosome is positive in more than 95% of cases of CML. Also it is useful to diagnose familial myeloproliferative disorders.

Cell markers"CDs": absence of the CR3 receptor(CD11b/CD18) on granulocytes occurs in LAD, but normally expressed in hereditary neutrophilia.

ESR: highly elevated in malignancy and collagenic diseases

ACUTE MYELOGENOUS LEUKEMIA

MOHAMED SAID ABOUSHOSHA (960)

INTRODUCTIONAcute myelogenous leukemia (AML) is the

final common pathway of a finite number of mutational events in hematopoietic marrow-derived stem cells resulting in increased proliferation, decreased apoptosis, and failure to differentiate into red cells, granulocytes, monocytes and platelets.

Marrow failure ensues rapidly, leading to death (hyperleukocytosis).

Epidemiology15% to 20% of acute leukemia in children and adolescents

and 90% in adults.AML is a disease of aging, the median age at diagnosis of

AML was 64 years.

Risk Factorsage has a particular impact in incidence of AML cases

arising from prior myelodysplastic syndrome.Rare cases of congenital diseases associated with

chromosome breakage or defective DNA repair ( e.g. Fanconi's anemia ) are at increased risk for development of AML.

Children with congenital neutropenia associated with a mutated granulocyte colony-stimulating factor ( G-CSF) receptor ( kostmann's syndrome) are also at risk.

By far the greatest risk for AML, however, is associated with receipt of cytotoxic therapy

patients treated for breast cancer, lymphoma, and childhood acute lymphocytic leukemia. Such AML is called " Secondary " or treatment-related AML.

Secondary AML assumes two forms. Alkylating agent-associated AML occurs within 5-10 and becomes rare thereafter. Topoisomerase II inhibitor-associated AML occurs with a latency of less than 5 years and is seen after use of drugs such as anthracyclines and epipodophyllotoxins.

Environmental exposures

Because most patiens given alkylating agents or exposed to benzene do not develop AML, other factors including genetic predisposition likely to play a rule.

Pathophysiology It is becoming increasingly apparent that AML has a multistep pathogenesis and an evolving clinical process.

Bone MarrowNormal blast

AML blast

Diff. cells with normal ability diff. cells with reduced ability

Ery. G/M Megakaryocytic Ery. G/M Megakaryocytic

Blood

RBC’s G/M Platelets

Circulating blasts

Blood RBCs G/M Platelets Circulating

blasts

hyperleucocytosis

Organ affection

Infection, Bleeding, Organ failure Organ failure

DEATH

ClassificationThe FAB classification was developed in 1985 by the " French-

American-British cooperative group" based in particular on morphological and cytohemical characteristics.

FAB systemAML minimally differentiated (M0)AML without maturation (M1)AML with maturation (M2)Acute promyelocytic leukemia (M3)Acute myelomonocytic leukemia (M4)Acute monocytic leukemia (M5)Acute erythroid leukemia (M6)Acute megakaryocytic leukemia (M7)WHO Classification: more recent, take into account

additional molecular and immunphenotypical characteristics.

Clinical PictureNon specific general symptoms usually with brief

medical history: reduced performance status, fever, night sweats, fatigue, loss of appetie, weight loss, bone pain and flu-like sumptoms.

Impairment of normal HaematopoiesisAnemia: weakness, fatigue, tachycardia, pallor of

skin and mucous membranes.Thrombopenia: increased bleeding tendency, with

petechia and ecchymosis, haematoma, epistaxis.Granulocytopenia: skin infection, pneumonia,

sepsis.

Leukemia cell proliferation, organ infiltrationHepatosplenomegalyChloroma (extramedullar tumorous manifestations)Cns involvement with headache, nausea/vomiting, visual

impairment, central nervous disturbances. Leukostasis (frequent with leukocytes > 100.000/mgl) :

pulmonary symtoms ( dyspnea, pulmonary leukemic infiltrates), cerebral stasis ( ischemia, hemorrhage), arterial embolism

Dissemunated intravascular coagulation( DIC), especially in AML M3 due to the presence of pro-coagulants granules.

Skin infiltrates, gingival hyperplasia, CNS involvement. In particular with AML M4/M5.

Chloroma gingival hyperplasia

Skin infiltration

InvestigationsLaboratory tests Complete blood count, differential blood count Increased white blood cell count with blasts in peripheral blood Anemia Granulocytopenia Thrombocytopenia No blasts in the peripheral smear is rare (aleukemic leukemia)

Bone marrow examination Acute leukemias are defined by the presence of >20% blasts in bone

marrow.

Routine laboratory tests with liver and renal parameters ( uric acid), electrolytes, LDH.

Coagulation parameters (DIC) Microbiological diagnostics if febrile, virus serum titres HLA typing of patient and all siblings ( search for HLA-identical family

donor for possible matched related allogenic blood stem cell transplantation)

CSF cytology (cerebrospinal fluid ) in selected cases.

ImagingChest x-ray, abdominal ultrasound, ECG, Echocardiography before anthracycline treatment ( of

possible cardiotoxicity).

Differential diagnosis1) Myelodysplastic syndrome ( 20% blasts as the minimal

diagnostic criteris for AML, patients below there cutoffs but with excess blasts (>5%) have myelodysplastic syndrome. However, the decision to treat a patient as having AML rather than myelodysplastic syndrome should rest at least as much on the clinical as on the morphological picture, and may have similar outcome)

2) CML in blast crisis3) Lymphoblastic leukemia4) Aplastic anemia5) Leukemoid reaction

TreatmentSupportive treatment Sperm cryopreservation (prior to induction therapy, if possible) Prophylaxis of tumor lysis syndrome: fluid replacement, urine

alkalization, allopurinol, rasburicase. Prevention and treatment of infection Substitution of red cells and platelet concentrates ( in DIC and/or

AML M3 keep platelets>50,000mgl) Substitution of coagulation factors, if necessary treatment of DIC. In hyperleukocytosis/leukostasis: immediate treatment with

hydrooxyurea, oxygen therapy, fluid substitution, restrictive substitution of red cells, possibly dexamethasone i.v.emergency leukapheresis may be required.

Suppression of menstruation in premenopausal females.

Induction treatment Objective: reaching complete remission (CR) i.e. normalization of

blasr count in bone marrow (<5%) as well as normal platelet and granulocyte counts

Using " 7&3": 7-days continous IV infusion of cytaraine at 100 mg/m2/day and 3-day bolus IV infusion of anthracycline.

CR rates in the 60-80%

Consolidation: further reduction of the malignant clone by additional chemotherapy cycles after reaching complete remission

Intensification: according to risk factors,

Allogenic transplantation in first remission ( related or unrelated donor): with " poor risk" and " intermediate risk"karyotype.

All other stages: no remission ( refractory leukemia), relapse

Second CR: allogenic transplantation from related or unrelated donor.

CHRONIC MYELOID LEUKEMIA MOHAMED SHERIF AHMED (962)

PathophysiologyThe genetic hallmark of CML is translocation

t(9;22)(q34;q11) resulting in creation of Philadelphia chromosome .On the molecular level ,this translocation fuses sequences of the BCR gene on chromosome 22 with sequences of ABL gene on chromosome 9. Resulting in abnormal fusion protein (p210) with increased tyrosine kinase activity.

In most newly diagnosed patients, the Ph chromosome is found in almost all cells of granulocytic, erythroid, and megakaryocytic series. It is present in B lymphocytes and a small proportion of T lymphocytes but not in marrow fibro blasts or other tissues.

The PH chromosome is found in about 90% of patients with clinical manifestations of CML; about 10% of patients have morphologically normal appearing 9 and 22 chromosome therefore classified as Ph chromosome-negative CML

This group identified by fluorescent in situ hybridization with fluorochrome-labeled probes for BCR and ABL genes.

Clinical and hematologic

features

Chronic Phase DiseaseClinical features:

splenomegaly, hemorrhage, or anemia, but many are diagnosed only as a result of routine blood tests.

Symptoms when present include lethargy, loss of energy, shortness of breath on exertion, weight loss, and hemorrhage from various sites. Increased sweating is characteristic.

The patient may have severe pain or discomfort in splenic area, often associated with splenic infarction, or have noticed a mass in left upper abdomen

The liver is frequently also enlarged. Very high leukocyte count may produce features of leukostasis with retinal vein engorgement and respiratory insufficiency.

 

Hematologic valuesPatients with splenomegaly are usually anemic,

where as the hemoglobin concentration may be normal in patients with early disease.

The leukocyte count at diagnosis is usually between 20 and 200×109/L, but the diagnosis of CML can be established in patients with persistent leukocytosis in range 12 to 20×109/L. occasionally patients present with leukocyte numbers above 200×109/L, very rarely above 500×109/L. The Platelet numbers are usually high in range of

300 to 600×109/L, but may be normal or even reduced.

Advanced phase diseaseClinical featuresIn some cases the patient is asymptomatic

and diagnosis is based on blood and marrow finding.

In other patients may develop fevers, excessive sweating, anorexia, weight loss, bone pain.

Occasionally, patient presents with generalized lymphadenopathy

Hematologic values

Blastic transformation is defined by presence of more than 20% in marrow and blood.

About 70% of patients have that resemble cells that characterize acute myeloid leukemia.

20% of patients have lymphoid blast cells.

10% have mixed lymphoid and myeloid characteristics.

Treatment

Chronic phase diseaseChemotherapy

Imatinib mesylate: the single most important agent for chronic-phase disease. Imatinib is an ABL tyrosine kinase inhibitor

Interferon Alfa: it has anti viral and antiproliferative properties. Hydroxyurea: targets mature progenitors in proliferative cycle. Busulfan: infrequently used now as profound leukopenia is

produced

Stem cell transplantation

Allogeneic SCT: many patients recovered to normal hematopoiesis, with disappearance of both their leukemia and PH chromosome.

Autologous SCT: Early in the course of CML leukemia stem cells coexist with normal stem cells.

Advanced phase diseaseChemotherapy

Patients may be managed with minor alteration in their cytotoxic drug regimen.

Myeloid transformation can be treated with drugs used to induction remission in acute myeloid leukemia

Lymphoid transformation can be treated with drugs used in management of adult acute lymphoblastic leukemia

Stem cell transplantation

Allogeneic SCT can be performed in accelerated-phase CML. SCT performed in overt blastic transformation nearly always fails.

Variants of chronic myeloid

leukemia

Chronic myelomonocytic leukemia The patient may present with features of anemia

or hemorrhage. The spleen is typically enlarged thus the clinical picture superficially resembles CML. Marrow cells lack Ph chromosome. Blood monocytes as high as 50×109/L.

Chronic Neutrophilic Leukemia: Rare disorder usually diagnosed incidentally. The

patient has raised blood neutrophil count without mature granulocyte nor basophilia or eosinophilia

EOSINOPHOLIA, BASOPHILIA & MONOCYTOSIS

MOHAMED SABER METWALI (964)

EosinophiliaEosinophilia is a condition in which the

eosinophil count in the peripheral blood exceeds 450/μl.

Causes:1. Parasitic infection e.g. :filariasis ,

shistosomiasis , facioliasis ,hook worm ,ascariasis and toxocariasis.

2. Allergic disorders as :bronchial asthma ,hay fever, allergic vasculitis

3. Recovery from acute infection.4. Skin diseases as : eczema.5. Pulmonary esinophilia as: loffler's

syndrome(ascariasis).6. Hyperesinophilic syndrome .7. Polyarteritis nodosa .8. Other malignant diseases as: Hodgkin disease,

angioimmunoblastic lymphadenopathy, metastatic carcinoma

BasophiliaBasophilia is a condition where the basophil

quantity is abnormally elevated (more than 1010 basophils per liter of blood)

Basophils in peripheral blood resemble tissue mast cells both:i. Release histamine. ii. Have receptors for IgE and participate in

the degranulation of white blood cells that occurs during allergic reactions, including anaphylaxis 

Causes:1. Hypersensitivity states.2. Rheumatoid arthritis, chronic ulcerative colitis .

3. Viral infection 4. Post irradiation.5. in neoplastic disorders.

MonocytosisMonocytosis is an increase in the number of

monocytes circulating in the blood Above 950/μL which is considered as the upper limit of normal.

Monocytes are white blood cells that give rise to macrophages and dendritic cells in the immune system.

Causes: Monocytosis often occurs during chronic inflammationInfections: tuberculosis, brucellosis,

subacute bacterial endocarditis, syphilis, and other viral infections and many protozoal and rickettsial infections (e.g. malaria).

Blood and immune causes: chronic neutropenia and myeloproliferative disorders

Autoimmune diseases and vasculitis: SLE, RA, IBD..

Malignancies: Hodgkin’s disease and certain leukemias , such as chronic myelomonocytic leukemia(CMML) and monocytic leukemia.

Miscellaneous causes: Sarcoidosis and storage lipid disese.

LYMPHOCYTOSISMOHAMED SABRY AHMED (967)

Lymphocytosis Increased blood lymphocyte count

(lymphocytes > 4.0 x109/L in adults and > 9.0 x109/L in children )

InfectionsPertussis or whooping is frequently

accompanied by a lymphocytosis

Toxoplasmosis may cause lymphocytosis similar to infectious mononucleosis

Brucellosis and Syphilis may occasionally cause an atypical lymphocytosis.

Infectious mononucleosis caused by an Epstein-Barr virus infection of B lymphocytes.

CMV occasionally causes a lymphocytosis with symptoms similar to IM .

Infectious lymphocytosis It may be related to coxsackievirus A or B6, echovirus, and adenovirus 12.

HTLV-1 may produce a transient lymphocytosis with fever, rash, and little lymphadenopathy.

Disorders of the SpleenPatients who have undergone

splenectomy, or whose splenic function is otherwise reduced, may have a lymphocytosis.

Lymphoproliferative disordersi. B cell lymphoproliferative disorders B cell chronic lymphocytic leukaemia (B-

CLL) is by far the most common

ii. T cell and NK cell lymphoproliferative disorders CD4 T cell, CD8 T cell and NK lymphoproliferative disorders are much less common than their B cell counterparts

Specific causes of lymphocytosis include: Acute lymphocytic leukemiaChronic lymphocytic leukemiaCrohn`s diseaseCytomegalovirus (CMV) infectionMononucleosisMultiple myeloma Other viral infectionsTuberculosisUlcerative colitisVascuilitisWhooping cough

ACUTE LYMPHOBLASTIC LEUKEMIAMOHAMED SOBHY (966)

Acute lymphoblastic leukemia (ALL)

• Clonal proliferation and accumulation of blast cells in blood, bone marrow and other organs

• Disorder originates in single B or T lymphocyte progenitor

• Heterogenous disease with different biological subtypes

• Incidence : peaks between age 2 age 4 slightly more in boys and much lower in black children than in white children

Acute lymphoblastic leukemia (ALL)Etiology - unknown But associated with some risk factors

as:1-Down syndrome .2-Increased chromosomal fragility

(ataxia telangiectasia & bloom syndrome).

3-Neurofibromatosis 4-Shwach-man syndrome5-Li fraumeni syndrome 6-klienefelter's syndrome7-Environmental exposure 8-Twins

Acute leukemias - clinical features

1. Bleeding Petechiae, Ecchymosis.2. Fever/infection3. Bone/joint pain4. Hepatomegaly and splenomegaly5. Signs of anaemia (pallor, fatigue& dysnea) 6. Lymphadenopathy and anterior mediastinal mass7. CNS involvement

Acute leukemias - laboratory findings (1)1. Blood examination

- Anemia,- Thrombocytopenia, neutropenia - Variable leukocyte count, usually increased,- Blood morphology: presence of blast cells

2. Bone marrow morphology- Hypercellular with presence of blast cells,- Suppression of normal hematopoiesis

Acute leukemias - Laboratory findings (3)

3. Cytochemical stains 4. Immunophenotyping5. Cytogenetics (by flow cytometry) changes include aneuploidy ,invasion ,deletions and translocation6. Molecular studies

Morphologic subtypes of acute lymphoblastic leukemias (FAB classification)

Subtype Morphology Occurrence (%)L1 Small round blasts

75clumped chromatin

L2 Pleomorphic larger blasts 20

clefted nuclei, fine chromatinL3 Large blasts, nucleoli,

5vacuolated cytoplasm

Acute lymphoblastic leukemias - reactivity with cytochemical staining

Subtype Peroxidase or Non-specific Periodic Sudan black esterase acid-

SchiffL1 - - +++

L2 - - +++ L3 - - +++

Immunologic classification of acute lymphoblastic leukemias

B- lineage (80%) MarkersPro-B

CD19(+),Tdt(+),CD10(-),CyIg(-),Common

CD19(+),Tdt(+),CD10(+),CyIg(-),Pre-B

CD19(+),Tdt(+),CD10(+),CyIg(+),SmIg(-)Mature-B

CD19(+),Tdt(+),CD10(±),CyIg(±),SmIg(+)

T-lineage (20%) Pre-T CD7(+), CD3(-), Tdt(+),Mature-T CD7(+), CD3(+), Tdt(+),

Acute leukemias and CNS

leukemic blast cells can be identified in the CSF of one third of patients at diagnosis, but only 2-3% of patients have an overt CNS leukaemia with the presence of cranial palsy.

predicts an increased risk of CNS relapseRequires more intensive intrathecal therapy

Various metabolic abnormalitiesHyperurecemia, hyperphosphatemia, Elevated serum lactate dehydrogenase

(LDH). The degree of abnormality reflects the

leukemic cell burden and destruction (lysis)

Differential diagnosisAcute myelocytic leukemiaNon-Hodgkin LymphomaAnemia, AcuteOsteomyelitisAnemia, FanconiParvovirus B19 Infection Juvenile Rheumatoid ArthritisRhabdomyosarcomaLeukocytosisMononucleosis and Epstein-Barr Virus InfectionNeuroblastomaAplastic anemia Idiopathic thrombocytopenic purpura (ITP)

Treatment strategy in ALL

In ALL the choice of treatment-strategy depends on:

1. Risk qualification2. Age and biological condition3. Immunophenotype of leukemic cells

- T lineage,- early B lineage,- mature B lineage,

General supportive treatmentReplacement therapy of blood cells may be

required - pre-existing deficiency due to ALL can be profoundly aggravated by chemotherapy.

Growth factors to alleviate profound myelosuppression, e.g. (GCSF) during induction for faster recovery of neutrophils and platelets, and a shorter hospital stay.

Antibiotics and antifungal agentsAllopurinol during induction therapy to

control uric acid levels.A central venous catheter is usual, given the

frequent requirements for venous access.

Remission induction therapy in ALL

.To achieve remission or less than 5% blasts in the bone marrow.

.Drugs: glucocorticoid , vincristine, asparginase, anthracycline

.Treatment duration: 4-8 weeks .No of courses: 1- 2

Consolidation and Re-induction in standard-risk ALL

Soon after remission is achieved o for 3-6 month o to further reduce the leukemic cell

burden before the emergence of drug resistance and relapse

o Consolidation therapy also appears to improve the long-term survival of patients with standard-risk disease.

o Regimens commonly : high-dose MTX

and 6-MP or dexamethasone, vincristine, L-asparaginase and doxorubicin followed by thioguanine, cytarabine, and cyclophosphamide.

Maintenance

1) 2.5-3 yrs using daily oral 6-MP at night on empty stomach and weekly MTX IV

2) Attempts to reduce this time result in high relapse rates after therapy is stopped

CNS diseaseTreatment of subclinical CNS leukemia is an

essential component of acute lymphoblastic leukemia therapy.

cranial irradiation effectively prevents overt CNS relapse

concern about subsequent neurotoxicity and brain tumors has led to replace irradiation with intensive intrathecal and systemic chemotherapy for most patients

Treatment Of mature B-cell: Short intensive chemotherapy including high-

dose methotrexate (MTX), cytarabine, and cyclophosphamide.

Course for 2-8-month.

Relapse Relapsed cells acquire resistance to exposed

chemotherapy drugs. treatment of relapse is intensive and often

includes SCT. Most patients are referred for trial 'salvage'

therapies …outcome of relapse is poor.

PrognosisOverall, the cure rate for childhood acute

lymphoblastic leukemia is more than 80%. However, the prognosis depends on the clinical and laboratory features.

In general, the prognosis is best in children aged 1-10 years.

Adolescents have intermediate outcomes.Infants younger than 1 year have a poor

outcome, with cure rates of about 30%.Survivors may experience late effects from

treatment, which involve all organ systems. Therefore, lifelong follow-up is necessary

Treatment results in ALL

AdultsComplete remission (CR) 80-

85%Leukemia-free survival (LFS)

30-40%

ChildrenComplete remission (CR) 95-

99%Leukemia-free survival (LFS)

70-80%

Complications1- Tumor lysis syndrome 2- Renal

failure3-Sepsis 4- Bleeding5-Thrombosis 6- Cognitive

defects7-Neuropathy 8-

Encephalopathy9- Secondary malignancy 10- Seizures

11-Short stature (if craniospinal radiation)

CHRONIC LYMPHOCYTIC LEUKEMIAMOHAMED SABRY ROSTEM (968)

Chronic lymphocytic leukemiaChronic lymphocytic leukemia (CLL) is the

most common form of adult leukemia in the Western hemisphere.

CLL, a chronic malignant disease characterized by a multitude of clinical features, was initially described as an accumulative disorder of abnormal lymphocytes.

EPIDEMIOLOGY• It is diagnosed in about 10,000—15,000 new cases per year in the

united States.

• CLL is more frequent in males.

• The median age at diagnosis is approximately 66 years old.

• There have been associations linking CLL to farming and to chemical agents used in agriculture.

• CLL is one type of leukemia that has NOT been associated with radiation exposure.

• families have recently been identified with a definite proclivity for developing this disease.

PATHOPHYSIOLOGY• The transforming event to neoplasia

occurs in a common lymphocyte precursor cell (CLP). In utero, all fetal B cells are CD5+ve. This proportion of cells markedly declines in number after birth.

• The CLP cell undergoes change resulting in a monoclonal population of B cells with a characteristic antigenic expression pattern. The leukemic cells are identified by CD5+CD19+CD23+ features.

• although the leukemic cells have difficulty in undergoing apoptosis related to the expression of specific antiapoptotic proteins (e.g., Bcl-2. Mcl-1, etc.), there is also a proliferative compartment resulting in an overproduction of the malignant cells.

• Circulating malignant B cells are frequently seen in this disease, and most organs are infiltrated with these cells.

• Accumulation of the cells within the bone marrow results in ultimate progressive infiltration,– The bone marrow pattern

initially may be interstitial, – and then will develop nodular

infiltrates that are nontrabecular.

– As the disease burden progresses, the bone marrow will become diffusely infiltrated, resulting in anemia, thrombocytopenia, and neutropenia.

CLINICAL FEATURES AND DIAGNOSIS• Symptoms and Signs

– No symptoms or signs of disease (30-50% of patients at presentation).

– Fatigue (most common symptom either with or without anemia).

– Organ enlargement (lymph nodes, splenomegaly, hepatomegaly).

– Fever, night sweats, or weight loss.

Complications• Frequent infections (most common cause of

serious morbidity & death).

• Dysregulated immune system (e.g.. Evans's syndrome, hemolytic anemia & immune thrombocytopenia, paraneoplastic pemphigus, pure red cell aplasia).

• Secondary malignancies.

• Transformation to high-grade hematologic malignancy (e.g..Richter's syndrome with large-cell lymphoma, CLL/prolymphocytic transformation).

Laboratory Features• Blood count.

– Hb normal or low; – WBC raised, and may be

very high; with lymphocytosis (criteria for diagnosis > 5 × 109/L),

– platelets normal or low.

• Blood film. – Small or medium sized

lymphocytes. – May see smudge cells in

vitro.

• Bone marrow. – > 30% lymphoid cells on aspirate; – biopsy will show nodular, interstitial or diffuse pattern of

infiltration

• Immunophenotyping shows mainly CD19+, CD5+, CD23+ with a weak expression of CD20 and CD79b and surface immunoglobulin (kappa and lambda light chains).

• Coombs' test. May be positive if there is haemolysis.

• Hypogammaglobulinemia (about 60% of patients).

DIFFERENTIAL DIAGNOSIS        Positive Markers[*]

Disease

Lymphadenopathy

(%)Splenomegaly (%)

Cell of Origin (B/T) SmIg CD5

CD19, CD20 (%) Other

Chronic lymphocyt

ic leukemia

(CLL)

75 50 B (20:1)

Weak >90% ≥90 Mouse red blood cell receptors

Prolymphocytic

leukemia (PLL)

33 95 B (4:1) Bright T-cell PLL

75 FMC-7

High peripheral lymphoid cell

countHairy cell leukemia

<10 80 B (T rare)

Bright — >90 CD25, CD11C, CD103

Lymphoid cells an irregular outline

owing to the presence of filament-like cytoplasmic projections

Prognostic Features• Classic Clinical Staging Systems

– Modified Rai or Binet Systems– Bone marrow pattern of lymphoid cell

infiltration (diffuse worse than nodular/interstitial)

– Increased number of prolymphocytes in peripheral blood

– Increased serum markers reflecting disease burden (lactate dehydrogenase, β2-microglobulin, soluble CD23, and thymidine kinase)

– Lymphocyte doubling time (<6-12 months)

• Additional Prognostic Features– Chromosomal abnormalities: del(17pl3.1); del

(11q22.3); trisomy 12ql3; normal cytogenetics, and del(13q14)

• Mutation or deletion p53 gene– High percentage of lymphoid cells positive for

CD38 expression (should gate on CD5, CD19, and CD20 populations)

– Mutational status of Ig VH genes (unmutated worse than mutated)

– ZAP-70 protein expression high in CLL cells (research test not yet validated by' commercial laboratories

A high-risk patient• unmutated Ig VH gene;

• FISH demonstration of cells with either 17p deletion or 11q23 deletion;

• cells highly positive for CD38 expression

• or for ZAP-70 protein expression.

System and stage

Risk Manifestations Percent of patients

Median survival (years)

Recommended treatment

Rai staging system

0 Low Lymphocytosis 31 > 10 Watch and wait

I Intermediate Lymphadenopathy 35 9 Treat only with progression†

II Intermediate Splenomegaly, lymphadenopathy,

or both

26 7 Treat only with progression†

III High Anaemia, organomegaly

6 5 Treatment indicated in most cases

IV High One or more of the following: anaemia,

thrombocytopenia and organomegaly

2 5 Treatment indicated in most cases

Binet staging system

A Low Lymphocytosis, < 3 lymphoid

areas enlarged‡

63§ > 10 Watch and wait

B Intermediate ≥ 3 Lymphoid areas enlarged‡

30 7 Treatment indicated in most cases

C High Anaemia, thrombocytope

nia or both

7 5 Treatment indicated in most cases

TREATMENT• General/supportive treatment

– Anaemia due to haemolysis is treated with steroids.– If it is refractory or recurrent, or if splenic discomfort is

a problem, a splenectomy is performed.

– Anaemia and thrombocytopenia due to marrow infiltration is treated with chemotherapy and, when necessary, transfusion.

– Infection is treated with antibiotics, with prophylactic therapy being given during periods of chemotherapy. Immunoglobulin replacement may be helpful.

– Allopurinol is given to prevent hyperuricaemia.

Specific treatment• In older patients requiring control of bulk

disease or progressive elevation of their counts, the use of either chlorambucil or cyclophosphamide has been effective.

• It was reported that fludarabine was useful in achieving responses in heavily treated patients.

• Several studies show that combined therapy using either fludarabine and simultaneous Rituxan or fludara bine and cyclophosphamide produce a higher complete response rate than fludarabine alone.

• The triple combination of fludarabine, cyclophosphamide, and Rituxan produced the highest complete response rate yet.

• Bone marrow transplantation using either allogeneic or autologous.