血液腫瘤科病房注意事項血液腫瘤科病房注意事項

黃炯棠醫師 黃炯棠醫師

高雄醫學大學附設醫院高雄醫學大學附設醫院血液腫瘤內科血液腫瘤內科

來 來 Hema Hema 要學會的東西要學會的東西

Performance Performance status(ECOG)status(ECOG)

scorescore definitiondefinition

00 Fully active, without restrictionFully active, without restriction

11 Slightly impairedSlightly impaired

22 > 50% of waking hours, capable > 50% of waking hours, capable of all self-careof all self-care

33 Confined to bed or chair > 50% of Confined to bed or chair > 50% of waking hours, limited self carewaking hours, limited self care

44 Totally confined to bed or chair, Totally confined to bed or chair, cancan’’t carry on any self caret carry on any self care

Blood smear Blood smear 製作製作 用 用 blood lancet blood lancet 採血採血 (( 採血部位採血部位 :: 手指 手臂 耳垂 腳指 腳手指 手臂 耳垂 腳指 腳

底底 )) 取半滴血置於載玻片一端，以另一推片靠取半滴血置於載玻片一端，以另一推片靠血滴前方接觸，使血液沿玻片擴散後，呈血滴前方接觸，使血液沿玻片擴散後，呈3030 度緩緩定速推向另一端，立即快乾度緩緩定速推向另一端，立即快乾

Staining of blood smear Reagent

Liu’s A solution ： Eosin Y, 1.8 g ； Methylene blue, 0.5 g ； Methanol, 1 LLiu’s B solution ： KH2PO4, 12.5 g ； Na2HPO4 ． 12H2O, 25.2 g ； Methylene blue, 1.4 g ； Azur I,1.4 g ； H2O, 1 L

操作

滴適當份量 Liu’s A 於玻片上染 30”加滴約 2 倍份量 Liu’s B ，輕吹混合，染1’30” （此時液面可見金屬光澤）小心地水洗

MorphologyMorphology Cytochemistry studyCytochemistry study Immunological studyImmunological study Molecular genetic studyMolecular genetic study

Pluripotential stem cell

LymphocyteStem cell

TLymphoblast

BLymphocyte

TLymphocyte

BLymphoblast

Plasmacell

Myeloid stem cell

Pronormoblast

Basophilicnormoblast

Polychromaticnormoblast

Orthochromicnormoblast

PolychomaticErythrocyte

(Reticulocyte)

Erythrocyte

Megakaryoblast

Megakaryocyte

Platelets

Monoblast

Promonocyte

Monocyte

Macrophage

Myeloblast

PolymorphonuclearNeutrophil(Segment)

Band

Metamyelocyte

Myelocyte

Promyelocyte

EosihophilicMyelocyte

BasophilicMyelocyte

Eosihophilicmetayelocyte

BasophilicMetamyelocyte

EosihophilicBand

BasophilicBand

Eosinophil Basophil

PMN SeriesPMN Series

Myeloblast

Segment form

Band form

Metamyelocyte

MyelocytePromyelocyte

Eosinophilic myelocyte

Eosinophilic Metamyelocyte

Eosinophilic Band

Basophilic myelocyteBasophilic Metamyelocyte

Basophilic Band

PronormoblastBasophilic normoblast

Polychromatic normoblast

Orthochromatic normoblast

Polychromatic erythrocyte(Reticulocyte)

Megakaryblast Immature Megakarycyte

Mature MegakarycytePlatelets

Monoblast Promonocyte

MonocyteMacrophage

LymphoblastProlymphocyte

lymphocyte

Plasma cell

Anemia:General Anemia:General ConsiderationsConsiderations

Table 26.3 Methods of Correcting the Reticulocyte Count for the Degree of Anemia

Reticulocyte count = % reticulocytes in RBC populationCorrected reticulocyte count = % reticulocytes × (patient Hct/45)Reticulocyte production index  = Corrected reticulocyte count × maturation time in peripheral blood in days  (Normal values of all of above 0.5–1.5%)Absolute reticulocyte count = % reticulocytes × RBC count/L3

  (Normal values for the absolute reticulocyte count are from 25 to 75 × 109/L;  values <100 × 109/L indicate an inappropriately low erythropoietic response to anemia.)a Reticulocyte maturation time = 1 day for Hct ≥40%; 1.5 days for Hct 30–40%; 2.0 days for Hct 20–30%; 2.5 days for Hct <20%.From Hillman RS, Finch CA. Red cell manual, 5th ed. Philadelphia: FA Davis, 1985.

Table 26.4 Pathogenetic Classification of Megaloblastic Anemia

Combined folate and vitamin B12 deficiency Tropical sprue

 Gluten-sensitive enteropathyInherited disorders of DNA synthesis

 Orotic aciduria Lesch-Nyhan syndrome

 Thiamine-responsive megaloblastic anemia Methyl-tetrahydrofolate reductase

 Formiminotransferase Dihydrofolate reductase

 Transcobalamin II deficiency Homocystinuria and methylmalonic aciduria

Drug- and toxin-induced disorders of DNA synthesis Folate antagonists (e.g., methotrexate)

 Purine antagonists (e.g., 6-mercaptopurine) Pyrimidine antagonists (e.g., cytosine arabinoside)

 Alkylating agents (e.g., cyclophosphamide) Zidovudine (AZT, Retrovir)

 Trimethoprim Oral contraceptives

 Nitrous oxide Arsenic

 Chlordane Erythroleukemia

Vitamin B12 deficiency Dietary deficiency (rare) Lack of intrinsic factor Pernicious anemia Gastric surgery Ingestion of caustic materials Functionally abnormal intrinsic factor Biologic competition for vitamin B12

 Small bowel bacterial overgrowth Fish tapeworm disease Familial selective vitamin B12 malabsorption (Imerslund-Gräsbeck syndrome) Drug-induced vitamin B12 malabsorption Chronic pancreatic disease Zollinger-Ellison syndrome Diseases of the ileum Previous ileum resection Regional enteritisFolate deficiency Dietary deficiency Increased requirements Pregnancy Infancy Chronic hemolytic anemia Alcoholism Congenital folate malabsorption Drug-induced folate deficiency Extensive intestinal resection, jejunal resection

Table 26.6 Pathogenic Classification of Microcytic Anemias

Disorders of iron metabolism Iron deficiency anemia  Anemia of chronic disorders Disorders of globin synthesis α- and β-thalassemias  Hemoglobin E syndromes (AE, EE, E-β-thalassemia)  Hemoglobin C syndromes (AC, CC)  Unstable hemoglobin disease Sideroblastic anemias  Hereditary sideroblastic anemia X-linked Autosomal Acquired sideroblastic anemia Refractory anemia with ringed sideroblasts Malignancies Myeloproliferative disorders Reversible acquired sideroblastic anemia Alcoholism Drugs (isoniazid, chloramphenicol)Lead intoxication (usually normocytic)

Microcytic anemia

Table 26.9 Classification of the Normocytic Anemias

Anemia associated with appropriately increased erythrocyte production Posthemorrhagic anemia Hemolytic anemiaDecreased erythropoietin secretion Impaired source Renal: Anemia of renal insufficiency Hepatic: Anemia of liver disease  Reduced stimulus (decreased tissue oxygen needs) Anemia of endocrine deficiency  Protein-calorie malnutrition Anemia of chronic disorders Anemia with impaired marrow response Bone marrow hypoplasia Red blood cell aplasia  Acquired pure red cell aplasia in adults Transient erythroblastopenia of childhood Transient aplastic crises associated with hemolysis Aplastic anemia (pancytopenia)  Bone marrow infiltrative disorders Leukemia  Myeloma  Other myelophthisic anemias Myelodysplastic anemias  Dyserythropoietic anemias (congenital dyserythropoietic anemia type II)  Iron deficiency (early)

Macrocytosis >9 micrometers

in diameter

Schistocytes(fragmented cells)TTP/HUS,DIC,HELLP syndrome

Malignant hypertension

Acanthocytes(speculated cell with irregular

Projection)Liver diseaseMDS,hypothyroidismVitamin E deficiency

Crenated/Burr cellEchinocytes

Renal failure and UremiaPyruvate kinase dificiencyPremature,MA hemolytic

Bite cellHemolytic anemia(G6PD)

Spleen phagocyte removed Heinz body

Sphercytes( dense, 沒有 Central pallor)Immune hemolytic anemia and

Hereditary spherocytosisBurn

Sickle cellBeta chain 上 第六對 amino acid(Glutamic acid)

被 valine 所取代 , 而形成 alpha2/beta S2

Tear-drop cellMyelofibrosis,Myelophthisic states

Thalassemia

Ovalocyte(elliptical cell)Membrances cytoskeleton 不正常

Megaloblastic anemiaThalassemia major,IDA

Howell-Jolly bodies(DNA 殘餘物 nuclear)Small,single purple cytoplasmic inclusions

Splenectomy, Hemolytic anemia, megaloblastic anemia

Basophilic stippling( Dark-purple inclusions,multiple)RNA 殘餘

Lead poisoning, Thalassemia

Pappenheimer bodies(Iron composition)Splenectmy,Hemolytic anemia

Sideroblastic anemia,Hemoglobinopathy

Cabot ring( mitotic spindle 的殘留物 ):MDS,megaloblastic anemia

Heinz bodies(Precipitate RNA)Violet crystal 所染出 inclusions

表示 denatured Hgb氧化後的 G6PD, erythrocyte maturation

Rouleaux formation因為 red cell 上 coating 不正常Paraprotein, 使的 Electrostatic

charge repelling 不正常Ex:Multiple myeloma

Brilliant cresyl blue:染 Reticulocyte

Diagnosis and Diagnosis and Classification of the Classification of the Acute Leukemias Acute Leukemias

Two hit model of Two hit model of leukemogenesisleukemogenesis

Hematopoietic cellsHematopoietic cells

Class I mutation Class II mutationClass I mutation Class II mutation Proliferation/survival Proliferation/survival

Transcription/Differentiation Transcription/Differentiation FLT3/ITD, FLT3/TKD, RAS

KIT, PTPN11, JAK2

AML1/RUNX1, CEBPA, NPM1MLL/PTD, AML1-ETO

CBFb-MYH11, PML-RARa

ChromosomesAngiogenesis

Micro RNA

Epigenetics

WT1, ASXL1TET2,IDH1/IDH2??

MorphologyMorphology Cytochemistry studyCytochemistry study Immunological studyImmunological study Molecular genetic studyMolecular genetic study

Acute Leukemia FAB Acute Leukemia FAB ClassificationClassification

Myeloid (AML)Myeloid (AML) Mo:minimally Mo:minimally

differentiateddifferentiated M1:without maturationM1:without maturation M2:with maturationM2:with maturation M3:hypergranular M3:hypergranular

promyelocyticpromyelocytic M4:myelomonocyticM4:myelomonocytic M5:a).monoblastic M5:a).monoblastic

b).monocyticb).monocytic M6:erythroleukemiaM6:erythroleukemia M7:megakaryoblasticM7:megakaryoblasticRare type,e.g.eosinophilicRare type,e.g.eosinophilic

Lymphoblastic (ALL)Lymphoblastic (ALL) L1:small,monomorphicL1:small,monomorphic L2:largeheterogeneousL2:largeheterogeneous L3:Burkitts cell type L3:Burkitts cell type

Mo M1

M2

M3

M5

M6

M7

L1 L2 L3

M4

Table 79.3 Classification of Acute Myeloid Leukemia

Acute myeloid leukemia with recurrent genetic abnormalitiesAcute myeloid leukemia with t(8;21)(q22;q22), (RUNX1 - RUNX1T1;AML1/ETO)Acute myeloid leukemia with abnormal bone marrow eosinophils inv(16)(p13q22) or t(16;16)(p13;q22) (CBFβ/MYH11)Acute promyelocytic leukemia (AML with t(15;17)(q22;q12), (PML/RARα) and variantsAcute myeloid leukemia with t(9;11)(p22;q23), (MLLT3-MLL)Acute myeloid leukemia with t(6;9)(p23;q34), (DEK-NUP214)Acute myeloid leukemia with inv(3)(q21q26.2) or t(3;3)(q21;q26.2), (RPN1-EVI1)Acute myeloid leukemia (megakaryoblastic) with t(1;22)(p13;q13), (RBM15-MKL1)Provisional entity: AML with mutated NPM1Provisional entity: AML with mutated CEBPAAcute myeloid leukemia with multilineage dysplasiaFollowing a myelodysplastic syndrome or myelodysplastic syndrome/ myeloproliferative disorderWithout antecedent myelodysplastic syndromeAcute myeloid leukemia and myelodysplastic syndromes, therapy-relatedAlkylating agent–relatedTopoisomerase type II inhibitor-related (some may be lymphoid)Other typesAcute myeloid leukemia not otherwise categorizedAcute myeloid leukemia minimally differentiatedAcute myeloid leukemia without maturationAcute myeloid leukemia with maturationAcute myelomonocytic leukemiaAcute monoblastic and monocytic leukemiaAcute erythroid leukemiaAcute megakaryoblastic leukemiaAcute basophilic leukemiaAcute panmyelosis with myelofibrosisMyeloid sarcomaAcute leukemia of ambiguous lineage

MPO stain 染酵素染 Myeloid precursor cell

Sudan black B stain 染 Lipid染 Myeloid precursors

α-Naphthyl butyrate stain: 染 Monoblast(Non specific esterase)

Periodic acid-Schiff stain: 染 Lymphoblast染肝醣

M1 M2

Auer rods in faggot cellbilobed grooved nuclei with

granules in some nuclear grooves

Dysplastic eosinophil precursors M5

Erythroblastic leukemia Dysplastic blasts resemble normal erythroblasts with

occasional cytoplasmic vacuoles

Acute megakaryoblastic leukemia

Cytochemical stains of use in the diagnosis and classification of acute leukaemia

Cytochemical stain Specificity

Myeloperoxidase Stains primary and secondary granules of cells of neutrophil lineageEosinophil granules, Monocyte granules,Auer rodsBasophils granules 不會染出來

Sudan black B Neutrophil granules,eosinophil granules,Monocyte granules,Auer rodsBasophils granules 通常是 Negative

α-Naphthyl butyrate stain(Non-specific esterase)

染 Monocyte, macrophage

Periodic acid-Schiff 染 Neutrophil granular,Eosinophil cytoplasm( 不染 Granular),Basephil cytoplasm,T/B lymphocyte

Naphthol AS-D chloroacetate esterase(Specific esterase)

染 neutrophil and mase cell granules, 染不出 Auer rods( 除非 AML的病人 t(15;17),t(8;21) 的話就可以染出來 )

Acid phosphatase Neutrophils,T lymphocyte, macrophage,plasma cells, Megakaryocyte

Toluidine blue Basophil and mast cell granules

Perls’ stain Erythroblasts 的 haemosiderin, Macrophage and plasma cells

Table 77.1 Flow Cytometry Markers for Acute Leukemia Diagnosis

Lineage Antigen

Precursor-B ALL CD19, CD10, CD79a, TdT, cCD22*, HLA-DR, cCD79a*

Precursor-T ALL CD1, CD2, CD3, CD4, CD5, CD7 CD8, TdT, cCD3*

Burkitt leukemia CD19, CD10, CD20, CD22, CD79a, sIg, bright CD45

Acute myeloid leukemia CD33, CD13, CD117, CD4+CD2-, HLA-DR, cMPO*

   With monoblastic differentiation CD11b, CD16, CD14, CD64

   True erythroleukemia Glycophorin A

   Acute megakaryocytic leukemia CD41, CD61, cCD41*, cCD61*

Lineage-independent antigens HLA-DR, CD45, CD34. CD10

*Most antigens are only lineage-associated. Antigens marked with an asterisk are considered lineage-specific

Minimally differentiated Minimally differentiated Acute myeloid Acute myeloid leukemia(M0)leukemia(M0)

<3% MPO and Sudan black B-positive<3% MPO and Sudan black B-positive >20% expressing myeloid antigens >20% expressing myeloid antigens

(CD13,33,117)(CD13,33,117) CD2,CD7 and TdT (+)CD2,CD7 and TdT (+) CD3,CD22,CD79 are negativeCD3,CD22,CD79 are negative Complex karyotype, similar to MDS and Complex karyotype, similar to MDS and

secondary leukemiasecondary leukemia Occur in older patientsOccur in older patients CR rate and survival are poorCR rate and survival are poor

Acute Myeloid leukemia Acute Myeloid leukemia without maturation(M1)without maturation(M1)

Blast>90% of bone marrow non-erythroid Blast>90% of bone marrow non-erythroid cellscells

>3% of blasts positive for Sudan black B >3% of blasts positive for Sudan black B or Myeloperoxidaseor Myeloperoxidase

Bone marrow maturing monocytic Bone marrow maturing monocytic component<10% of Non-erythroid cellscomponent<10% of Non-erythroid cells

Bone marrow maturing granulocytic Bone marrow maturing granulocytic component < 10% of non-erythroid cellscomponent < 10% of non-erythroid cells

Acute Myeloid leukemia Acute Myeloid leukemia with maturation(M2)with maturation(M2)

AML2: 29%~40% has t(8;21)AML2: 29%~40% has t(8;21) First described by Rowley in 1973First described by Rowley in 1973 Morphology: Marrow eosinophilia with salmo-Morphology: Marrow eosinophilia with salmo-

colored granules,cytoplasmic globules and vcuolescolored granules,cytoplasmic globules and vcuoles Two genes involved in t(8;21) are AML1 at 21q22 Two genes involved in t(8;21) are AML1 at 21q22

and ETO at 8q22and ETO at 8q22 t(8;21) occurs in de novo AML t(8;21) occurs in de novo AML

– predicts an excellent response predicts an excellent response – to chemotherapy to chemotherapy – high remission rate and high remission rate and – long survival long survival

Acute Promyelocytic Acute Promyelocytic leukemia(M3)leukemia(M3)

Translocation between chromosomes 15 and 17Translocation between chromosomes 15 and 17 Median age of 30 to 38 years, rarelyoccurs before Median age of 30 to 38 years, rarelyoccurs before

age 10age 10 The disease was recognized in the 1950s and The disease was recognized in the 1950s and

associated with early mortality ,caused by associated with early mortality ,caused by intracranial hemorrhage (DIC)intracranial hemorrhage (DIC)

Leukemia cell characteristically Leukemia cell characteristically – prominent Granules prominent Granules – Bundles of Auer rodsBundles of Auer rods

– Faggot cellsFaggot cells

Acute Promyelocytic Acute Promyelocytic leukemia(M3)leukemia(M3)

t(15;17) of APL are the retinoic acid receptor RAR-a t(15;17) of APL are the retinoic acid receptor RAR-a gene on chromosome 17q12 and the PML gene on gene on chromosome 17q12 and the PML gene on chromosome 15q22chromosome 15q22

There are 3 different genomic breakpoints in the PML There are 3 different genomic breakpoints in the PML genegene– Bcr1 (55% of cases) or long frmBcr1 (55% of cases) or long frm– Bcr2(5%) or variable formBcr2(5%) or variable form– Bcr3(40%) short form: associated with pediatric APL, Bcr3(40%) short form: associated with pediatric APL,

higher leukocyte counts and worse prognosishigher leukocyte counts and worse prognosis Long and short form are responsive to ATRA, variable Long and short form are responsive to ATRA, variable

form reduced sensitivity to ATRAform reduced sensitivity to ATRA APL with t(11;17) is resistant to ATRAAPL with t(11;17) is resistant to ATRA

Acute Promyelocytic Acute Promyelocytic leukemia(M3)leukemia(M3)

Therapy of APL changed dramatically with the introduction of all-Therapy of APL changed dramatically with the introduction of all-trans-retinoic acid (ATRA) into clinical trials in Shanghai in 1986trans-retinoic acid (ATRA) into clinical trials in Shanghai in 1986– in early trials using ATRA, patients with t(15;17) had a 95% in early trials using ATRA, patients with t(15;17) had a 95%

CR rateCR rate– ATRA :oral dose 45mg/m2/day , induces hematologic ATRA :oral dose 45mg/m2/day , induces hematologic

remission with 1~3 months without marrow aplasia, but does remission with 1~3 months without marrow aplasia, but does not induce a molecular remission not induce a molecular remission

– ATRA treatment with retinoic acid syndrome: occurs in up to ATRA treatment with retinoic acid syndrome: occurs in up to one fourth of patients, particularly in those with high one fourth of patients, particularly in those with high leukocyte countsleukocyte counts

Capillary leak syndrome with feverCapillary leak syndrome with fever Respiratory failure, renal impairment ad cardiac failureRespiratory failure, renal impairment ad cardiac failure

– ATRA prevents DIC:ATRA prevents DIC: related to Protection of related to Protection of endothelium from procoagulants such as tissue endothelium from procoagulants such as tissue factorfactor

Acute Promyelocytic leukemia(M3)Acute Promyelocytic leukemia(M3) Chinese investigators also identified arsenic Chinese investigators also identified arsenic

troxide(As2O3) as effective therapy for APLtroxide(As2O3) as effective therapy for APL Western studies have confirmed CR rate of Western studies have confirmed CR rate of

90% in relapsed or refractory APL90% in relapsed or refractory APL

Acute Myelomonocytic Acute Myelomonocytic leukemia(M4)leukemia(M4)

Blast >20% of bone marrow nucleated cellsBlast >20% of bone marrow nucleated cells Bone marrow maturing monocytic component>20% of Bone marrow maturing monocytic component>20% of

Non-erythroid cellsNon-erythroid cells 5~10% AML5~10% AML Median age 40~45Median age 40~45 Organomegaly is commonOrganomegaly is common Hyperleukocytosis(20%)Hyperleukocytosis(20%) Extramedullary 19~30%LymExtramedullary 19~30%Lym Skin, Ovaries,CNS(Extramedu)Skin, Ovaries,CNS(Extramedu)

Acute Myelomonocytic Acute Myelomonocytic leukemia(M4)leukemia(M4)

AML4 with abnormal eosinophils AML4 with abnormal eosinophils and inversion of chromosome 16, and inversion of chromosome 16, the syndrome was first described the syndrome was first described by Arthur and Bloomfield. Five by Arthur and Bloomfield. Five patient with a deletion of the long patient with a deletion of the long arm of chromosome 16arm of chromosome 16

Acute Myelomonocytic Acute Myelomonocytic leukemia(M4)leukemia(M4)

81~93% CR rate of AML with inversion of 81~93% CR rate of AML with inversion of chromosome 16chromosome 16 to chemotherapy has been to chemotherapy has been higher than for most other subtypes of AMLhigher than for most other subtypes of AML

Prognosis is good with DFS of 48~63%.Prognosis is good with DFS of 48~63%. The absence of CBFB may not be required The absence of CBFB may not be required

for prolonged clinical remissionfor prolonged clinical remission Residual disease can be monitored by Residual disease can be monitored by

quantitative RT-PCR to identifyquantitative RT-PCR to identify patients at patients at risk for relapserisk for relapse

Acute Monocytic leukemia and Acute Monocytic leukemia and 11q23 abnormalities(M5)11q23 abnormalities(M5)

AMoL accounts for 2~10% of AML casesAMoL accounts for 2~10% of AML cases M5 subdivided into M5 subdivided into

– M5a, poorly differentiated(>80% monocytic cells M5a, poorly differentiated(>80% monocytic cells including monoblasts)including monoblasts)

– M5b, well differentiated(80% monocytic, M5b, well differentiated(80% monocytic, predominantly promonocytes and monocytes)predominantly promonocytes and monocytes)

M5a tend to be youngerM5a tend to be younger– (75% are<25 years of age)(75% are<25 years of age)

M5 49% normal karyotypeM5 49% normal karyotype 21% 11q23 abnormality21% 11q23 abnormality 21% trisomy 821% trisomy 8 11q23 and Trisomy 8 is higher in M5a11q23 and Trisomy 8 is higher in M5a FLT3 mutation more common in M5bFLT3 mutation more common in M5b

Acute Monocytic Acute Monocytic leukemia(M5)leukemia(M5)

The gene(11q23) involved on The gene(11q23) involved on chromosome 11 is called mixed-chromosome 11 is called mixed-lineage leukemialineage leukemia

Extramedullary disease occurs in Extramedullary disease occurs in >50% of patients with >50% of patients with AMoL( cutaneous lesions, gum AMoL( cutaneous lesions, gum infiltration, testicular infiltration, testicular involvement, CNS disease)involvement, CNS disease)

Erythroleukemia(M6)Erythroleukemia(M6) 2~4% AML and is prominent component of 2~4% AML and is prominent component of

erythroblastserythroblasts Erythroid/myeloid leukemia(M6a) has >50% Erythroid/myeloid leukemia(M6a) has >50%

erythroid precursors in the nucleated erythroid precursors in the nucleated population and >20% myeloidblasts in the population and >20% myeloidblasts in the nonerythroid populationnonerythroid population

Pure erythroid leukemia(M6b):>80% of the Pure erythroid leukemia(M6b):>80% of the marrow cells are immature erythroids without marrow cells are immature erythroids without significant number of myeloblastssignificant number of myeloblasts

M6c: >30% nonerythroid blasts andM6c: >30% nonerythroid blasts and >30% >30% pronormoblastspronormoblasts

Erythroleukemia(M6)Erythroleukemia(M6)

Peripheral blood smear: Peripheral blood smear: – schistocytes, teardrop, pincered red cell and basophilic schistocytes, teardrop, pincered red cell and basophilic

stippling, hypogranulation and hyposegmentation, Giant stippling, hypogranulation and hyposegmentation, Giant plateletsplatelets

Bone marrow usually Bone marrow usually – hypercellular with megaloblastic changes, erythroid hypercellular with megaloblastic changes, erythroid

precursors commonly have multinuclearity, karyorrhexis, precursors commonly have multinuclearity, karyorrhexis, morulae and cytoplasmic vacuolizationmorulae and cytoplasmic vacuolization

Erythroleukemia(M6)Erythroleukemia(M6)

PAS reaction may stain abnormal erythroid PAS reaction may stain abnormal erythroid cells in a coarse globular(16%) or diffuse cells in a coarse globular(16%) or diffuse pattern(57%)pattern(57%)

Immunophenotypic markers are Immunophenotypic markers are – glycophorin 7glycophorin 7– transferrin receptor(CD71)transferrin receptor(CD71)

Hepatomegaly and splenomegaly occur in Hepatomegaly and splenomegaly occur in 20~40%20~40%

Hypergammaglobulinemia and positive Hypergammaglobulinemia and positive rheumatoid factor, antinuclear atibody and rheumatoid factor, antinuclear atibody and coombs test may be found in patients with coombs test may be found in patients with bone painbone pain

Acute Megakaryocytic Acute Megakaryocytic leukemia(M7)leukemia(M7)

0.6~1.2% of adult AML0.6~1.2% of adult AML Myeloid surface marker and expression of Myeloid surface marker and expression of

at least one platelet antigen( CD41, at least one platelet antigen( CD41, CD42b,CD61 or factorVIII-related antigen) CD42b,CD61 or factorVIII-related antigen) on the leukemia cellson the leukemia cells

Bone marrow may be difficult to aspirate Bone marrow may be difficult to aspirate and more than two thirds of patients have and more than two thirds of patients have significant fibrosissignificant fibrosis

Higher incidence of AMgL in Down Higher incidence of AMgL in Down syndrome (good response to therapy)syndrome (good response to therapy)

Acute panmyelosis with Acute panmyelosis with myelofibrosis (APMF)myelofibrosis (APMF)

APMFwas first described in 1963 by Lewis and APMFwas first described in 1963 by Lewis and SzurSzur

Acute myelosclerosis or acute myelofibrosisAcute myelosclerosis or acute myelofibrosis Peripheral : Pancytopenia with <5% blastsPeripheral : Pancytopenia with <5% blasts Marrow is hypercellular with various degrees Marrow is hypercellular with various degrees

of hyperplasia of the three cell lineagesof hyperplasia of the three cell lineages Prognosis is extremely poor with a median Prognosis is extremely poor with a median

survival of<2 months in some seriessurvival of<2 months in some series

True mixed lineage True mixed lineage leukemialeukemia

Leukemic cells co-expressLeukemic cells co-express– MPO and CD79a or cIg uMPO and CD79a or cIg u– Or MPO and CD3Or MPO and CD3– Or CD3 and cIg uOr CD3 and cIg u

AML( expressing aberrant AML( expressing aberrant lymphoid markers)lymphoid markers)

B lineage ALL(Expressing B lineage ALL(Expressing aberrant myeloid antigens)aberrant myeloid antigens)

T Lineage ALL( expressing T Lineage ALL( expressing aberrant myeloid antigens)aberrant myeloid antigens)

李李 X:25868161X:25868161

75 year-old male with a history of 75 year-old male with a history of Diabetes, hypertensionDiabetes, hypertension

Chief complaint: Hematuria for 2 daysChief complaint: Hematuria for 2 days Lab data: WBC:450000/ul, Lab data: WBC:450000/ul,

Hgb:13/dl,PLT:89000/ul, PT:>100/11.5, Hgb:13/dl,PLT:89000/ul, PT:>100/11.5, PTT:>120/28.5, Fibrinogen:18 PTT:>120/28.5, Fibrinogen:18 mg/dl,GOT/GPTmg/dl,GOT/GPT

Differential count revealed Blast cellDifferential count revealed Blast cell WhatWhat’’s the diagnosis for this patient? s the diagnosis for this patient?

(Non-specific esterase)

Myeloperoxidase

Sudan black B

HLA-DR+:98.3%HLA-DR+:98.3% CD10:4.9%CD10:4.9% CD7:0.9%CD7:0.9% CD19:0.2%CD19:0.2% CD11b:78.8%CD11b:78.8% CD33:99.8%CD33:99.8%

CD15:93.7%CD15:93.7% CD13:87.4%CD13:87.4% CD5:1.7%CD5:1.7% TdT:0%TdT:0% CD14:47.5%CD14:47.5% CD64:98.1%CD64:98.1%

王王 XX 榮榮 :25856243:25856243

28 year-old male with a history of 28 year-old male with a history of mental retardmental retard

Chief complaint: Fever up to 38.3C Chief complaint: Fever up to 38.3C for 3 daysfor 3 days

Lab data:WBC:383000/ul, Lab data:WBC:383000/ul, Hgb:13.5/dl,PLT:81000/ul,UA:17.8,Hgb:13.5/dl,PLT:81000/ul,UA:17.8,BUN/Cr:11.6/1.3, NA:135,K:5.4BUN/Cr:11.6/1.3, NA:135,K:5.4

Differential count: Blast cell was Differential count: Blast cell was notednoted

HLA-DR+:2.9%HLA-DR+:2.9% CD10:11.4%CD10:11.4% CD7:79.4%CD7:79.4% CD19:1.6%CD19:1.6% CD11b:1.7%CD11b:1.7% CD33:1.7%CD33:1.7%

CD5:96.4%CD5:96.4% CD3:9.7%CD3:9.7% TdT:87.6%TdT:87.6% CD20:1.8%CD20:1.8%

Newborn with Down Newborn with Down syndromesyndrome

Multiple myelomaMultiple myeloma

Decreased normal immunoglobins, immunodeficiency

Monoclonal protein BM infiltration

Cytokine release

Bone destruction

Infections

Anemia

Hypercalcemia Bone pain

Amyloidosis

Hyperviscosity

Renal failure

Neurologic

Clinical manifestations Clinical manifestations of MMof MM

Pathophysiology of myeloma bone Pathophysiology of myeloma bone diseasedisease

Terpos E et al. Ann Oncol 2009;20:1303-17

Multiple MyelomaMultiple Myeloma

Rouleaux

Flaming cell

Russell body

Russell body

Gaucher-like cell

Myeloproliferative Myeloproliferative DiseasesDiseases

Table 85.1 2008 World Health Organization Classification of Myeloproliferative NEOPlasms (MPN)

Chronic myeloid leukemia

Polycythemia vera

Essential thrombocythemia

Primary myelofibrosis

Chronic neutrophilic leukemia

Chronic eosinophilic leukemia/not otherwise categorized

Hypereosinophilic syndrome

Mast cell disease

MPNs, unclassifiable

Table 85.7 2008 World Health Organization Classification of Myelodysplastic/ Myeloproliferative Disorders

Chronic myelomonocytic leukemia

Atypical chronic myeloid leukemia

Juvenile myelomonocytic leukemia

Myelodysplastic/myeloproliferative diseases, unclassifiable

History backgroundHistory background

1960 Philadelphia chromosome (22q-)

1973 Reciprocal translocation

t(9;22)(q34;q11)

1980 Unique fusion gene BCR-ABL

Hematopoietic disease of malignant expansion of bone marrow stem cells

Hematological picturesHematological pictures Disease statusDisease status

– Chronic phaseChronic phase– Accelerating phaseAccelerating phase– Blast crisisBlast crisis

Ph1 chromosomePh1 chromosome– 95% in CML95% in CML– 5% of children ALL5% of children ALL– 15%-30% of adults 15%-30% of adults

with ALLwith ALL– 2 o/o AML2 o/o AML

Pseudo-Gaucher cell

Sea-Blue histiocyte

Table 85.5 Characteristic Pathologic Findings in the Peripheral Blood and Bone Marrow in Chronic-Phase CML

Peripheral bloodLeukocytosis (white blood cell count usually >50 × 109/L, range 20 to >500 × 109/L)Full spectrum of granulocytes and precursors with rare blasts <(5%)Absolute basophilia

Bone marrowHypercellular (usually 100%)Granulocytic predominance (M:E ratio >10:1) with spectrum similar to bloodCharacteristic small, hypolobated megakaryocytesBlasts <5%

Table 85.3 Diagnosis of Accelerated and Blast Phase in CML

Accelerated phaseBlasts 10–19% in the peripheral blood and/or bone marrowBasophils ≥20% in the peripheral bloodPersistent thrombocytopeniaIncreasing spleen size and white blood cell count despite therapyCytogenetic evidence of clonal evolution

Blast phaseBlasts ≥20%Extramedullary blast proliferationLarge aggregates or clusters of blasts in the bone marrow

CytogeneticsCytogenetics

FISH

G-banding22q- Ph1 chromosome

9q+

CML CML 的病理生理學的病理生理學

CML

ALL

Leukemogenesis of BCR-ABL oncoprotein

Dysregulated tyrosine kinase activity

Physiologic regulation by normal ABL protein and dysregulation by BCR-ABL oncoprotein

N Engl J Med 2003;349:1455

N

C

會何會 Mutation 是因為 loss ABL 的 N-terminal region: 結果導致 tyrosine phsphorylation 增加f-actin binding 增加 , nuclear translocation 減少

Table 84.5 Proposal for Revising WHO Criteria for the Diagnosis of Polycythemia Vera

Major Criteria

•Hemoglobin >18.5 g/dl in men, >16.5 g/dl in women or evidence of increased red cell volume•Presence of JAK2 mutation

Minor Criteria •Hypercellular bone marrow biopsy with panmyelosis with prominent erythroid, granulocytic, and megakaryocytic hyperplasia •Low serum erythropoietin level •Endogenous erythroid colony formation in vitro

2 Major or1 Major+2minor

Structure of JAK2Structure of JAK2

Leukemia and lymphoma, 2006

NEJM 2006; 355: 2452-2466

Table 84.8 Proposed Modification of the WHO Criteria for Essential Thrombocythemia

•Sustained platelet count ≥450 × 109/L •Bone marrow biopsy showing proliferation of enlarged, mature megakaryocytes, without significant increase or left-shift of granulopoiesis or erythropoiesis •Exclusion of WHO criteria for PV, CIMF, CML, MDS, or other myeloid neoplasm •JAK2 mutation or other clonal marker, or if no clonal marker, then exclusion of reactive thrombocytosis

4 Major

Table 55.2 Causes of Thrombocytosis

Clonal Thrombocytosis Reactive Thrombocytosis

Essential thrombocythemiaPolycythemia veraMyelofibrosis with myeloid metaplasia (overtly fibrotic)Myelofibrosis with myeloid metaplasia (cellular phase)Chronic myeloid leukemiaMyelodysplastic syndromeAtypical myeloproliferative disorderAcute leukemia

InfectionTissue damageChronic inflammationMalignancyRebound thrombocytosisRenal disordersHemolytic anemiaPostsplenectomyBlood loss

MyelodysplasticMyelodysplasticSyndromesSyndromes

Table 83.3 World Health Organization Classification of the Myelodysplastic Syndromes

Classification Peripheral Blood Bone Marrow

Refractory anemia Anemia Erythroid dysplasia only

  No or rare blasts <5% blasts

    <15% ringed sideroblasts

Refractory anemia with ringed sideroblasts

Anemia >15% ringed sideroblasts

  No blasts Erythroid dysplasia only

    <5% blasts

Refractory cytopenia with multilineage dysplasia

Cytopenias (bicytopenia or pancytopenia)

Dysplasia in >10% of the cells of two or more myeloid lines

  No or rare blasts <5% blasts in the marrow

  No Auer rods No Auer rods

  <1 × 109/L monocytes <15% ringed sideroblasts

Refractory cytopenia with multilineage dysplasia and ringed sideroblasts

Cytopenias (bicytopenia or pancytopenia)

Dysplasia in >10% of the cells of two or more myeloid lines

  No or rare blasts <5% blasts in the marrow

  No Auer rods >15% ringed sideroblasts

  <1 × 109/L monocytes No Auer rods

Table 83.3 World Health Organization Classification of the Myelodysplastic Syndromes

Classification Peripheral Blood Bone Marrow

Refractory anemia with excess blasts 1 Cytopenias Unilineage or multilineage dysplasia

  <5% blasts 5–9% blasts

  No Auer rods No Auer rods

  <1 × 109/L monocytes  

Refractory anemia with excess blasts 2 Cytopenias Unilineage or multilineage dysplasia

  5–19% blasts 10–19% blasts

  Auer rods present Auer rods present

  <1 × 109/L monocytes  

Myelodysplastic syndrome, unclassified Cytopenias Unilineage dysplasia: one myeloid cell line

  No or rare blasts <5% blasts

  No Auer rods No Auer rods

  Anemia Normal to increased megakaryocytes with hypolobated nuclei

MDS associated with isolated deletion 5q Usually normal or increased platelet count

<5% blasts

  <5% blasts Isolated del(5q) cytogenetic abnormality

    No Auer rods

LymphomaLymphoma

HodgkinHodgkin’’s lymphomas lymphoma

- Reed-Sternberg cell - Reed-Sternberg cell ““owl-eye cellowl-eye cell”” Non-HodgkinNon-Hodgkin’’s lymphomas lymphoma

- Treatment: rituximab + CHOP- Treatment: rituximab + CHOP

- Prognosis: IPI score- Prognosis: IPI score

(age, ECOG, LDH, stage, extranodal (age, ECOG, LDH, stage, extranodal sites)sites)

B symptoms: weight loss, fever, night B symptoms: weight loss, fever, night sweatssweats

LymphomaLymphoma

t(8;14), Burkitt lymphomat(8;14), Burkitt lymphoma t(14;18), follicular lymphomat(14;18), follicular lymphoma t(11;14) , mantle cell lymphomat(11;14) , mantle cell lymphoma t(4;11), B cell lineage ALLt(4;11), B cell lineage ALL

The Ann Arbor staging system developed in 1971 for Hodgkin The Ann Arbor staging system developed in 1971 for Hodgkin lymphoma (HL) was adapted for staging non-Hodgkin lymphoma (HL) was adapted for staging non-Hodgkin

lymphomas (NHLs)lymphomas (NHLs) This staging system focuses on the number of tumor sites (nodal and extranodal), location, This staging system focuses on the number of tumor sites (nodal and extranodal), location,

and the presence or absence of systemic ("B") symptomsand the presence or absence of systemic ("B") symptoms Stage I refers to NHL involving Stage I refers to NHL involving

– a a single lymph node regionsingle lymph node region (stage I) (stage I) – single extralymphatic organ or site (stage IE)single extralymphatic organ or site (stage IE)

Stage II refers to Stage II refers to – two or more involved lymph nodetwo or more involved lymph node regions on the regions on the same side of the same side of the

diaphragmdiaphragm (stage II) (stage II)– with localized involvement of an extralymphatic organ or site (stage IIE) with localized involvement of an extralymphatic organ or site (stage IIE)

Stage III refers to lymph node involvement on Stage III refers to lymph node involvement on – both sides of the diaphragmboth sides of the diaphragm (stage III) (stage III)– localized involvement of an extralymphatic organ or site (stage IIIE) or localized involvement of an extralymphatic organ or site (stage IIIE) or

spleen (stage IIIS), or both (stage IIIES) spleen (stage IIIS), or both (stage IIIES) Stage IV refers to the presence of Stage IV refers to the presence of

– diffuse or disseminated involvement of one or more extralymphatic diffuse or disseminated involvement of one or more extralymphatic organs (eg, liver, bone marrow, lung), with or without associated lymph organs (eg, liver, bone marrow, lung), with or without associated lymph node involvement node involvement

The presence or absence of systemic symptoms should be noted The presence or absence of systemic symptoms should be noted with each stage designation. (A = asymptomatic. B = presence of with each stage designation. (A = asymptomatic. B = presence of fever, sweats, or weight loss >10 percent of body weight for 6 fever, sweats, or weight loss >10 percent of body weight for 6 months)months)

Groupe d'Etude Lymphomes Folliculaire Groupe d'Etude Lymphomes Folliculaire (GELF). In this system, any one of the (GELF). In this system, any one of the following characteristics qualifies as a following characteristics qualifies as a

high tumor burden:high tumor burden: Systemic symptoms Systemic symptoms Three or more lymph nodes sites >3 cm in Three or more lymph nodes sites >3 cm in

diameter diameter A single lymph node site >7 cm in diameter A single lymph node site >7 cm in diameter Platelets <100,000/microL or absolute Platelets <100,000/microL or absolute

neutrophils <1000/microL neutrophils <1000/microL Circulating lymphoma cells >5000/microL Circulating lymphoma cells >5000/microL Marked splenomegaly, compressive Marked splenomegaly, compressive

symptoms, pleural effusion, or ascites symptoms, pleural effusion, or ascites

International prognostic indexInternational prognostic index — —  Institutions in the Institutions in the United States, Canada, and Europe participated in United States, Canada, and Europe participated in an International non-Hodgkin lymphoma an International non-Hodgkin lymphoma

Prognostic Factors ProjectPrognostic Factors Project Age >60 Age >60 Serum lactate dehydrogenase Serum lactate dehydrogenase

(LDH) concentration greater than (LDH) concentration greater than normal normal

ECOG performance status ≥2 ECOG performance status ≥2 Ann Arbor clinical stage III or IV Ann Arbor clinical stage III or IV Number of involved extranodal Number of involved extranodal

disease sites >1 disease sites >1

Follicular lymphoma IPI Follicular lymphoma IPI (FLIPI)(FLIPI)  

Age >60 years Age >60 years Ann Arbor stage III or IVAnn Arbor stage III or IV Hemoglobin level <12.0 g/dL Hemoglobin level <12.0 g/dL Number of involved nodal areas >4 Number of involved nodal areas >4 Serum lactate dehydrogenase level Serum lactate dehydrogenase level

greater than the upper limit of greater than the upper limit of normal normal

NeutropeniaNeutropenia

Bodey, GP, Buckley, M, Sathe, YS, et al. Quantitative relationships between circulating leukocytes and infection in patients with acute leukemia. Ann Intern Med 1966; 64:328.

ANC<1000: 733 個病人 , ANC<100:125 個病人

Fever in a neutropenic patient is Fever in a neutropenic patient is usually defined asusually defined as – a single temperature of >38.3a single temperature of >38.3ººC C

(101(101ººF), or a F), or a – sustained temperature >38sustained temperature >38ººC C

(100.4(100.4ººF) for more than one hour F) for more than one hour Neutropenia is defined as a Neutropenia is defined as a

– neutrophil count of <500 cells/mm3, neutrophil count of <500 cells/mm3, or a or a

– count of <1000 cells/mm3 with a count of <1000 cells/mm3 with a predicted decrease to <500 predicted decrease to <500 cells/mm3. cells/mm3.

2002 Guidelines for the use of antimicrobial agents in neutropenic patients with cancer. Clin Infect Dis 2002; 34:730

age <60 years age <60 years (children not (children not included)included)

absence of chronic absence of chronic pulmonary diseasespulmonary diseases

absence of diabetes absence of diabetes mellitusmellitus

absence of confusion absence of confusion or other signs of or other signs of mental status mental status alterationalteration

absence of blood lossabsence of blood loss absence of absence of

dehydrationdehydration no history of fungal no history of fungal

infectioninfection

Platelet TransfusionPlatelet Transfusion

1U = ~0.3 x 101U = ~0.3 x 101111

2500 2500 –– 5000 /microliter 5000 /microliter CCI (corrected count increment)CCI (corrected count increment)

= = ΔΔPLT x BSA / No. of platelet transfused PLT x BSA / No. of platelet transfused (10(101111))

- normal CCI- normal CCI

at 1 hr: >7500at 1 hr: >7500

at 12 hr: >6000at 12 hr: >6000

at 18-24 hr: >4500at 18-24 hr: >4500

SD-PLT: 1U:3X10 11RD-PLT: 1U:3X10 10

At 1hr :CCI<7500/ulAutoimmune1hr:CCI>7500/ul,24hrs<4500/ul-->Splenomegaly,sepsis,Bleeding,DIC

Adverse reactions to Adverse reactions to blood transfusionblood transfusion

Immune-mediatedreactions

Acute hemolytic transfusion reactios

Delayed hemolytic and serologic transfusion reactions

Febrile Nonhemolytic transfusion reaction

Graft-versus-Host disease

Transfusion-related acute lung injury

Recipient antibody 會 lyse donor erythrocytes

Antibody 對抗 donor leukocyte 和 HLA antigen體溫 >1oC

Donor T lymphocyte 會去辨識 Host HLA antigen當作外來物而產生 immune response

Donor anti-HLA antibodies 會去結合Recipient leukocytes 而之後產生

Pulmonary vasculature,capillary permeability的增加

Thanks for your attentionThanks for your attention