LEUKEMOID REACTION AND

LEUKEMIA-SLIDE DISCUSSION

By- Dr. Priya Jaswani

Slide discussion of Leukemoid reaction and Chronic Myeloid Leukemia .

CHRONIC MYELOID LEUKEMIAA 39 yr male patient came with c/o abdominal pain-2 week in duration vague dragging pain associated with fullness of abdomen no aggravating or relieving factors

h/o fatigue, fever ,increased sweating,early satiety + ,

h/o loss of appetite + No h/o loss of weight, no h/o bleeding tendency

PAST h/o -> No h/o Tb/HTN/DM PERSONAL h/o -> consumes alcohol occasionally P/A –mild distention of abdomen+ moderate splenomegaly(+) mild hepatomegalySternal tenderness was present .No lymphadenopathy .

PERIPHERAL SMEAR FINDINGS Hemoglobin: 8.5 g/dl RBC series : Moderate

anisopoikilocytosis . Predominantly normocytes are seen . Few macrocytes and tear drop cells seen . Polychromasia also seen .

WBC Series : Total Leucocyte count is 1.80 lakh cells / cumm.

Differential count : Blasts:02% Promyelocyte : 03% Myelocyte :25 % Metamyelocyte : 17% Neutrophils (including band cells):39% Lymphocytes :01% Eosinophils;04% Monocytes :02% Basophils :07% Shift to left seen .Platelets :1.8 lakh /cummNo hemoparasite seen .

Impression : Peripheral smear suggestive of Chronic Myeloid leukemia .

Marked LeukocytosisPredominantly neutrophils, metamyelocytes, myelocytes

Myelocyte bulge.Less 3% are MyeloblastEosinophilia & Basophilia

Absolute basophilia is seen .

Hypogranular basophils were also seen .

Platelets showed variation in size .

Few platelets lacked granulation.with targetoid appearance.

Disturbed platelet function.

BONE MARROW ASPIRATE

Cellularity :Markedly hypercellular (95 %)

M:E ratio : 12:1 Erythroid series : Dimorphic .

Myeloid series : Blasts 02% , Promyelocyte 02% , Myelocytes 25% , Metamyelocytes 21% Neutrophils including band cells 29% . Eosinophils 06% Basophils 13 % lymphocyte 02% .

Megakaryocytes :Slighty Increased in number

Plasma cells :within normal limits.

BONE MARROW ASPIRATE Megakaryocytes are

increased in number with focal clustering .

Megakaryocytes are smaller and hypolobated : ‘Dwarf forms ’.

Evidence of dysmegakaryopoiesis is seen.

LEUKEMOID REACTION A 38 year old female was admitted in medical ward

with the complain of Fever since one month . It was of moderate grade not associated with chills or rigor .

She had cough along with expectoration since one month .

Also she complained of increased frequency of micturition.

Urine Culture :Positive for E.coli. P/A: No hepatomegaly, no splenomegaly

PERIPHERAL SMEAR Hb: 7.4 g/dl RBC series : Mild

anisopoikilocytosis moderate hypochromia .Predominantly microcytic hypochromic cells seen.Few pencil cells , tear drop cells seen .

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WBC Series : Total Leucocyte count is 56,000 cells / cumm. Differential count : Blasts:00 Promyelocyte : 01% Myelocyte :06% Metamyelocyte :19%

Neutrophils (including band cells):56 % Lymphocytes :09% Eosinophils;03% Monocytes :04% Basophils :02% Shift to left seen.

Platelets :1.8 lakh /cummNo hemoparasite seen .

PERIPHERAL SMEAR

Toxic granulation in Neutrophils.

DIFFERENTIATION OF LEUKEMOID REACTION AND LEUKEMIA Leukocytosis, defined as an increase in

white blood cell (WBC) count, is a common finding with a broad differential diagnosis, encompassing both benign and malignant entities.

Classification and diagnosis of leukocytosis require confirmation of automated differential counts and examination of the peripheral blood smear.

Further if increased blasts are seen then it should prompt a workup for acute leukemia.

For confirmation of reactive leucocytosis and chronic leukemias we require flow cytometric test, immunophenotyping and bone marrow examination with cytogenetic and molecular genetic tests.

CONTENTS1.Brief introduction of Myeloid Leukemoid reaction Chronic Myeloid Leukemia Chronic Neutrophilic leukemia2.Differentiation between above three on the basis of Peripheral smear, Bone marrow aspirate picture Bone marrow biopsy picture LAP score Cytogenetics Immunophenotyping3.Brief discussion of Lymphoid leukemoid reaction and

eosinophilic leukemoid reaction .

LEUKEMOID REACTION Leukemoid reaction — a secondary

reversible significant increase in the number of leukocytes in response to a stimulus, accompanied by the appearance in the blood of immature forms of leukocytes.

It is defined by a leukocyte count greater than 50,000 cells/μL, caused by reactive causes outside the bone marrow

RATIONALE

As reactive changes in blood are similar to hematological malignancies, it is important to differentiate them from leukemia.

Careful history, good physical examination,

and limited imaging studies may assist in

revealing the underlying cause of leukemoid reaction .

MYELOID LEUKEMOID REACTION AND LEUKEMIA

The diagnosis of Myeloid Leukemoid Reaction is based on the exclusion of chronic myelogenous leukemia (CML) and

chronic neutrophilic leukemia (CNL).

Chronic Neutrophilic Leukemia is a rare, distinct myeloproliferative syndrome with a poor prognosis.

The differential diagnosis between Leukemoid Reaction and Chronic Neutrophilic Leukemia may be difficult or even impossible because both conditions share identical morphological features, including a raised LAP score and the absence of the bcr/abl translocation .

ETIOLOGY AND PATHOGENESISMYELOID TYPE LEUKEMOID

REACTION : Leukemoid reactions of myeloid type develop

in various infectious and noninfectious processes.

ACUTE BACTERIAL INFECTIONS: Pneumonia, Pyogenic meningitisCellulitisInfected burnsDiphtheria

ACUTE STRESS STATES : Post surgery Post hemorrhage Myocardial InfarctionMISCELLANEOUS : Steroid therapy Gout Rheumatoid arthritis

AGELEUKEMOID REACTION

CML CNL

Any age Middle age (40-65 years)

Elderly (54-85 years)

CLINICAL COURSEIn leukemoid reaction the clinical course is related to

cause .

In CML clinical course is :Progressive .The progression of Ph+ CML that occurs when thecondition is left untreated is described in three phases:

Chronic Accelerated Blast

CLINICAL FEATURESLEUKEMOID REACTION

CML CNL

Features of underlying cause

• Fatigue, lethargy, weight loss,sweats• Splenomegaly in >75 percent; maycause (L) hypochondrial pain,satiety and sensation of abdominalFullness.• Gout, bruising/bleeding, and occasionallypriapism• Signs include moderate to largesplenomegaly (40% >10 cm),hepatomegaly (2%),

Fatigue, lethargy, weight loss . Hepato-spenomegaly present.

TOTAL LEUCOCYTE COUNTLeukemoid Reaction

CML CNL

TLC is > 50,000 cells/cumm .

TLC ranges from 30,000 cells/cumm to 10 lakh cells /cumm.

TLC > 25,000 cells /cumm .

PERIPHERAL SMEARLEUKEMOID REACTION CML CNLLeucocytes consist mostly of mature neutrophils.The differential count discloses a marked left shift, asevidenced by the presence of myelocytes and metamyeocytes .

In addition PS discloses toxicgranulation, Doëhle bodies, and cytoplasmic vacuoles inthe neutrophils of patients with an LR attributed to aninfection.

In CML, there are more immature cells, absolute basophilia , andEosinophils.

Marked neutrophilia with fewer metamyelocytes and myelocytes (<5%).Immature granulocytes:promyelocytes, myelocytes, metamyelocytes are <10 % .Blasts <1% .

Band forms

promyelocyte

myelocyte

metamyelocyte

CML PERIPHERAL SMEAR CHRONIC PHASE

BONE MARROW ASPIRATION Leukemoid reactiom

CML( Chronic phase )

CNL

Increased cellularity with myeloid hyperplasia .But NO marrow fibrosis

Markedly hypercellular. M:E ratio 15:1 to 32: 1.Myeloblast <5 %.Megakaryocytes show clustering and Dwarf forms.Pseudogaucher cells may be seen

Hypercellular , majority are neutrophils , M;E ratio > 20:1 , Megakaryocytes are normal in number .

BONE MARROW ASPIRATION LEUKEMOID REACTION Increased

cellularity with myeloid hyperplasia is the principle picture of an Leukemoid Reaction.

No fibrosis is present.

BONE MARROW ASPIRATION CML

Marrow is hypercellular with granulocytic predominance.

Megakaryocytes are increased in number with abnormal morphology.

Increase in reticulin fibrosis.

Blasts less than 5%.

PSEUDO-GAUCHER CELLS, SEA-BLUE HISTIOCYTES

Scattered amongst marrow cells are macrophages with linear striations or granular cytoplasm (Pseudo-Gaucher cells ) , some with sea blue colored granules resembling Sea-blue histiocytes .

BONE MARROW BIOPSY Two types of

CML Granulocytic

CML Granulocytic –

megakaryocytic CML.

LEUCOCYTE ALKALINE PHOSPHATASE (LAP) SCORE(40-100)Leukemoid reaction

CML CNL

Stimulated neutrophils of an LR haveincreased LAP scores

LAP Score is markedly diminished to 0-20 and is characteristic finding .

LAP Score is high .

LEUKOCYTE ALKALINE PHOSPHATASE (LAP) SCORE

VITAMIN B12-BINDING CAPACITY .Leukemoid reaction

CML CNL

Normal Elevated Elevated

In CML there is increase in uric acid level lactate dehydrogenase. Increase in the level of angiogenic

factors

CYTOGENETICS

Entire chromosomal complement is evaluated to identify philadelphia chromosome and other abnormalities.

Can be done on both peripheral blood and bone marrow .

Cytogenetics cannot identify complex translocations.

The presence of the Philadelphia chromosome – shortened chromosome 22.

t(9,22)( q34,q11)

Nearly 95 % patients demonstrate Ph chromosome .

For CML patients who are cytogeneticallyPh-chromosome–negative (Ph-) the following

special techniques can be used to detect BCR-ABL Fusion:

• Fluorescence in situ hybridization (FISH)• Reverse transcriptase polymerase chain reaction (RT-PCR) %

MOLECULAR PROBES : FISH (FLUORESCENCE IN SITU HYBRIDIZATION

Normal in Leukemoid reaction

Detect the BCR-ABL fusion gene on chromosome 22

Qualitative in CML.

RT-PCR Detects different length products

corresponding to chimeric BCR-ABL proteins of 190,210 and 230 kda.

So helps in distinguishing CML from ALL and CNL.

FLOW CYTOMETRY Immunopheno

typing is necessary for assigning specific lineage to CML Blast crisis cells.

Leukemoid reaction

CML CNL

Peripheralblood

Mature neutrophils,marked “left shift”

Immature cells,basophils, and eosinophils

Marked neutrophilia, no immature cells

Bone marrow

Myeloid hyperplasia, orderlymaturation, normal morphology

Basophilia, eosinophilia, monocytosis, slightincrease in blasts and reticulin fibrosis.

Similar morphology with LR, packed bonemarrow, slight increase in reticulin .

LAP score High Low High

LEUKEMOID REACTION

CML CNL

Cytogeneticanalysis

No cytogenetic abnormality .

Bcr-abl fusion . T (9,22) q11 , q34.Ph + chromosome in 95 % patients .

Cytogenetic abnormalities in 37% of cases

Immunopheno-typing

CD13 (+++), CD15 (+++), CD34 (−)HLA-DR (−)

CD13 (+++), CD15 (+++), CD34(−)HLA-DR (+)

CD13 (+++) CD15(+++), CD34 (−)HLA-DR (+)

Serum G-CSF High Low Low

LEUKEMOID REACTION

CML CNL

Clonalitystudies

Polyclonal Monoclonal Monoclonal

LYMPHOCYTIC TYPE:ACUTE

INFECTIONS: Infectious

mononucleosis,

Chicken pox, Scarlet fever, Mumps Measles Rubella.

CHRONIC INFECTIONS:

Tuberculosis Brucellosis Syphilis

DIFFERNTIATING FEATURES .

LYMPHOID LEUKEMOID REACTION .

CLL / SLL

AGE Any age. > 60 years of age .

SYMPTOMS/SIGN Malaise , Fever , pharyngitis , etc .

Asymptomatic .

ONSET Acute . (Enlargement of lymph node / spleen) .

Indolent (Enlargement of lymph nodes / spleen)

Lymphoid leukemoid reaction .

CLL/SLL

CBC Lymphocytosis . Lymphocytosis .

PERIPHERAL SMEAR

Atypical lymphocytes .

Small lymphocytes .

Lymphoid leukemoid reaction

CLL /SLL

CLINICAL COURSE

Self- limiting Progressive .

Flow cytometry

Normal . Abnormal .

INFECTIOUS MONONUCLEOSIS AND CLL

-Left: Atypical lymphocytes-> viruses irritate the lymphocytes caused them to become bigger and nucleus changes shape-> cytoplasm gives shape of "ballerina skirt cells" 

-Right: Small lymphocytes-> Normal, small, rounded, slightly bigger than RBC, scant cytoplasm, round mature nuclei

PERIPHERAL SMEAR OF A PATIENT WITH VIRAL INFECTION SHOWING ACTIVATED LYMPHOCYTES—ABUNDANT DEEP BASOPHILIC CYTOPLASM

LEUKEMOID EOSINOPHILIC REACTION TYPE ALLERGIC STATES:AsthmaUrticariaHay feverDrug dermatitis

MISCLLANEOUS :Tropical eosinophilaEosinophilic PneumoniaEosinophilic

granuloma.

PARASITIC DISEASES:

Roundworm infestation

Hookworm infestation.

Filariasis .Trichinosis .

Chronic eosinophilic leukemia (CEL) is a myeloproliferative disorder characterized by clonal proliferation of eosinophilic precursors .

Persistent eosinophilia >1500/cumm. Myeloblasts <20% in blood and bone

marrow . There is multilobation,vacuolation and

degranulation of eosinophils .

LEUKEMOID REACTION MONOCYTIC TYPE INFECTIONS: Tuberculosis Kala azar Malaria Trypanosomiasis Bacterial

endocarditis

Needs to be differentiated from :

Chronic Myelo-monocytic Leukemia

AML M4 and M5 Hodgkin’s

disease