2014_CURS_HEMATOLOGIE_-BAZA-1.ppt

8/11/2019 2014_CURS_HEMATOLOGIE_-BAZA-1.ppt

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Universitatea Titu Maiorescu

CURS MEDICINA INTERNA

Hematologie

Prof univ dr Ion C.Tintoiu



Overview of Hematology



3

Basic scheme

• Blood leaves the heart inarteries• Branching of arteries until

they become tinycapillaries

– Oxygen and nutrients diffuse out – CO2 and wastes diffuse in

• Capillaries formveins going to the heart• The blood leaves the right side of the heart for the

lungs to pick up O2 and release CO2• Blood goes back to the left side of the heart to start all

over

Note: vessels goingto the heart areveins ; thoseleaving the heart arearteries



Summary of blood forming

organs



5

Composition of blood• Specialized connective tissue• Blood cells (formed elements) suspended in plasma

• Blood volume: 5-6 liters (approx 1.5 gal) in malesand 4-5 liters in females



6

Blood• Centrifuged (spun) to separate

• Clinically importanthematocrit – % of blood volume consisting of erythrocytes (red

blood cells) – Male average 47; female average 42

• Plasma at top: water with many ions,molecules, and 3 types of important proteins: – Albumin

– Globulins – Fibrinogen



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• Serum – Blood that is allowed to stand clots – Clot is a tangle of the ―formed elements‖ (some are not

truly cells)• RBCs lack nuclei and organelles• Platelets are fragments• Most cannot divide

– Clear fluidserum is left = plasma without the clottingfactors

When spun in centrifuge, buffy coat lies betweenRBCs and plasma: ofleukocytes (white blood cells)and platelets



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• Blood isexamined in a

―smear‖ • Smears are

stained

Scanning EM

Light microscope



9

Hematopoiesis

• Formation of blood cells

• Occurs mostly in red bone marrow• All cells arise from sameblood stem cell (pluripotent hematopoietic stem cells)

• Recently some have been found in adultswhich aremesenchymal stem cells , which canalso form fat cells, osteoblasts, chondrocytes,fibroblasts and muscle cells



10



11

Blood stem cells divide into:1.myeloid stem cells or2.lymphoid stem cells

All except forlymphocytes arisefrom myeloid stemcells

All originatein the bonemarrow

Not shownare mast

cells,osteoclasts,dendriticcells



12

Erythrocytes• Also called RBCs or red blood

cells• Biconcave discs and flexible• Plasma membrane but no nuclei or

organelles

• Packed with hemoglobinmolecules – Oxygen carrying protein – 4 chains of amino acids, each with

iron which is binding site for oxygen;CO2 carried also• Young ones still containing

ribosomes are calledreticulocytes• Live 100-120 days

heme

iron atom



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Leukocytes

AKA WBCs:white bloodcells



14

Leukocytes

AKA WBCs: white blood cells

Are complete cellsFunction outside the blood

Note the size difference

compared to erythrocytes

neutrophil eosinophil

basophil

small lymphocyte monocyte

__ RBC



15

Leukocyte types

• Artificial division into granulocytes andagranulocytes

• Granulocytes: neutrophils, eosinophils, basophils (according to how stain) – Granules – Lobed nuclei

– All are phagocytic• Agranulocytes: lymphocytes, monocytes



16

All except forlymphocytesarise frommyeloid stemcells

All originate in the bone marrow

Not shown are mast cells,

osteoclasts, dendritic cells

Remember thisslide?See the artificial division?



17

Neutrophils

• 60% of all WBCs• Nuclei of 2-6 lobes• Other names:

– Polymorphonuclear cells (PMNs, polys, segs) – Granules have enzymes – Can damage tissue if severe or prolonged – Pus



18

Eosinophils

• 1-4 % of leukocytes• Bilobed• Granules have digestive enzymes

• Role in ending allergic reactions and infighting parasitic infections



19

Basophils

• Rarest WBC• Bilobed nucleus• Dark purple granules• Later stages of reaction to allergies and

parasitic infections



20

Lymphocytes*

• Most importantWBC

• 20-45%

• Most areenmeshed inlymphoidconnective tissue,

e.g. lymph nodes,tonsils, spleen

*



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Lymphocytes:

nucleus occupies most of thecell volume

Response to antigens (foreign proteins or parts of cells)is specific

Two main types attack antigens in different waysT cellsB cells plus ―natural killer cells‖



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T cells attack foreign cells directly

• Killer cells (―cytotoxic‖), or CD8+ is amain type



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B cells

• Differentiate intoplasma cel ls

• Plasma cells secrete antibodies

• Antibodies flag cells for destruction bymacrophages (see stem cell chart)



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Monocytes*

• 4-8% of WBCs• In connective tissue

they transform intomacrophages (phagocytic cellswith pseudopods)

*



25

Platelets*

• Not cells• Small fragments

broken off frommegakaryocytes

• Important informingclots indamaged vessels

• AKAthrombocytes*



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Clots

Undesirable clots:

– Thrombus – Embolus Platelet and several RBCs trappedin a fibrin mesh

Platelet__________________



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Significantyoung cells

• Reticulocytes * (youngerythrocytes): 1-2%ofall RBCs

– ―retic count‖ helpsdetermine if producingRBCs at accelerated rate(anemia, move to a highclimate, etc.)

• Bands * (youngneutrophils): 1-2% ofall WBCs – Increases with acute

bacterial infections**



28

Disorders of Blood cells

• .



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Disorders of Erythrocytes• Polycythemia: too many cells• Anemia: not enough cells• Sickle cell disease: genetic disease AR

– 1/400 African Americans – Defect in hemoglobin

• Plus many others



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Disorders of Leukocytes

• Leukemia: too many, abnormal, crowd outnormal marrow• Classified into

– Lymphoblastic or myeloblastic – Acute or chronic

Disorders of Platelets• Thrombocytopenia

– Causes internal bleeding – Many causes



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Laboratory

CBC: complete blood count (to review…)

• Hemoglobin (gm/dl)• Hematocrit (%)• RBC count

• WBC in thousands/cumm – Differential if ordered: broken down to amount of eachtype WBC

• Platelet count in thousands/cumm



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Laboratory continuedClotting: “coags”

– for preop evaluation (before surgery) – to evaluate effectiveness of anticoagulant drugs, e.g.

aspirin, heparin, coumadin

• Bleeding time• PT - Protime• PTT - Partial thromboplastin time• INR

ESR – erythrocyte sedimentation rate – Indicator of infection or inflammation



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Blood TypingABO blood groups: A, B, AB, and O



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If a blood transfusion is given to a person who

has antibodies to that type of blood, then thetransfused blood will be attacked anddestroyed (transfusion reaction)



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ABO blood group types

Bloodtype

Antigen onrbc

Antibodies inblood

Can receive blood from: Can donate blood to(usually RBCs only):

Frequencyin US

A A anti-B AOnot B (you have anti-B) *

not AB (you have anti-B) *

AAB

40%

B B anti-A BO (no Ags so you won‟t reject) not A (you have anti-A) *not AB (you have anti-A) *

BAB

10%

AB A and B none toA or B

AB AB is uni versal recipientABO

AB 4%

O not A nor B Anti-A and anti-B not A (have anti-A)*not B (have anti-B)*not AB (have both antibodies)*O

ABABO O i s universal donor

46%

Ag = antigen on red blood cell*=transfusion reaction (hemolysis of new cells)

The blood types are ―codominant‖ – i.e. if genotype is AB, then you have bothA and B antigens on your RBCs



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Rh factor• The ―Rh factor‖ is another major antigen on the RBC, called

– is autosomal recessive – DD and Dd: Rh+ – dd: Rh-

• If mom is Rh- and baby is Rh+, then small amount of bloodleaks into mom‘s blood through placenta, and she makes

antibodies to D antigen; first Rh- pregnancy usually ok, butnot later Rh- ones (can be lethal to baby)• If mom is Rh-then give ―Rhogam‖ during pregnancy [(is anti-

Rh(D): Rh(D) Ig (immunoglobin)], an antibody which willdestroy any of the baby‘s RBCs which leak into mom‘s bloodduring the pregnancy so she will not mount an immuneresponse to the D antigen

• If father is Rh+: – If DD then all pregnancies will be Rh+ – If Dd then half of the pregnancies with this mom will be Rh- (no Rh

incompatibility problems)



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Rhogam (FYI)• Risks to the baby• If the baby‘s blood cells are attacked and depleted during pregnancy it can lead to anemia, jaundice,

mental retardation and heart failure. It can even be fatal in utero or shortly after delivery. Thecondition is known as Hemolytic Disease of the Newborn. Luckily, appropriate treatment withRhogam can almost completely eliminate the risk.

•

• [edit ] Rh Negative treatment with Rhogam• Rhogam is a sterile solution that is injected intramuscularly. It is made from human plasma thatcontains anti-D. Most often Rhogam is given to women at28 weeks of pregnancy. The Rh negativemother is most likely to be exposed to the baby‘s blood in the last3 months of pregnancy, so asecond dose is often given within 72 hours of delivery if the baby is found to be Rh positive. Amother must also receive a dose after any invasive procedure such as amniocentesis or after aninduced termination, miscarriage or ectopic pregnancy.

• [edit ] Side effects• Side effects of Rhogam are mild and include soreness tenderness, warmth or a rash at the injection

site. Other side effects can include:• Fever• Chills• Headache• Fatigue

• http://wikiparenting.parentsconnect.com/wiki/Rhogam_in_pregnancy

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http://wikiparenting.parentsconnect.com/wiki?title=Rhogam_in_pregnancy&action=edit&section=4

http://wikiparenting.parentsconnect.com/wiki/Pregnancy_Week_by_Week:_Week_28










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FYI



Blood

• Blood is the fluid of life• Blood is composed of:

– Plasma – RBC – WBC

– Platelets



Plasma

• Plasma consists of: – 90% water.

– 10 % solutes: albumin, electrolytes and proteins.

– Proteins consist of clotting factors, globulins,circulating antibodies and fibrinogen.



Red Blood Cells

• RBC‘s travel through the body deliveringoxygen and removing waste.

• RBC‘s are red because they contain a protein chemical called hemoglobin whichis bright red in color.

• Hemoglobin contains iron, making it anexcellent vehicle for transporting oxygenand carbon dioxide.



RBC‘s • Average life cycle is 120

days.• The bones are continually

producing new cells.



White Blood Cells

• The battling blood cells.• The white blood cells are continually on the

look out for signs of disease.• When a germ appears the WBC will:

– Produce protective antibodies. – Surround it and devour the bacteria.



WBC‘s

• WBC life span is from a few days to a fewweeks.

• WBC‘s will increase when fightinginfection.



Platelets• Platelets are irregularly-

shaped, colorless bodiesthat are present in blood.

• Their sticky surface letsthem form clots to stop bleeding.



Blood Values

• CBC with differential and platelet count. – Hgb:

• Normal levels are 11 to 16 g / dl• Panic levels are:

– Less than 5 g / dl – More than 20 g / dl



Hematocrit

• Normal hematocrit levels are 35 to 44%. – Panic levels:

• Hmct less than 15 %• Hmct greater than 60%



Hemoglobin and Hematocrit

• Can be used as a simple blood test to screenfor anemia.

• The CBC with differential would be used tohelp diagnose a specific disorder.

• A bone marrow aspiration would be themost conclusive in determining cause ofanemia – aplastic / leukemia.



Bone Marrow

Bone marrow is the spongy substance foundin the center of the bones.

• It manufactures bone marrow stem cells,which in turn produce blood cells.• Red blood cells – carry oxygen to tissue

• Platelets – help blood to clot• White blood cells – fight infection



Bone Marrow Transplant• Donor is placed under anesthesia.• Marrow is aspirated out of the iliac crest.

• Marrow is filtered and treated to remove bits of bone and other unwanted cells anddebris, transferred to a blood bag, and isinfused into the patient‘s blood just like attransfusion.



WHAT IS HEMATOLOGY?

• Hematopoiesis formation anddevelopment of blood cells. – Cells of the blood are constantly being lost

or destroyed. to maintain homeostasis, r.This system involves:

• Proliferation of progeny stem cells• Differentiation and maturation of the stem

cells into the functional cellular elements.• In normal adults,the proliferation,

differentiation, and maturation of thehematopoietic cells (RBCs, WBCs, and platlets)is limited to the bone marrow

H i i



Hematopoiesis



What is hematology?

Hematopoiesis – Hematopoiesis in the bone marrow is calledmedullary hematopoiesis

– Hematopoiesis in areas other then the bone marrow

is calledextramedullary hematopoiesis• Extramedullary hematopoiesis may occur in fetalhematopoietic tissue (liver and spleen) of an adult when the bone marrow cannot meet the physiologic needs of thetissues. This can lead to hepatomegaly and/orsplenomegaly (increase in size of the liver and/or spleen because of increased functions in the organs).

• Hematopoietic tissue includes tissues involvedin the proliferation, maturation, and destructionof blood cells



What is hematology? – The mononuclear phagocytic system (also called the

reticular endothelial system or RES) is involved incellular destruction and it includes:

• Circulating blood monocytes

• Fixed macrophages in the bone marrow, liver, spleen, andlymph nodes

• Free macrophages – These cells are involved in:

» Engulfing particulate matter» Processing of antigens for lymphocyte presentation» Removal of damaged or senescent (aged) cells



What is hematology? – Spleen – contains the largest collection of

lymphocytes and mononuclear phagocytes in the body. The spleen functions in:

• Filtering and destruction of senescent (aged) ordamaged RBCS – also called culling

• Removal of particles (are found in some types of anemia)from RBC membranes – alsocalled pitting – this causes adecrease in the surface to volume ratio of the RBC resultingin the formation of spherocytes (more on this later)

• Enforcing close contact of blood borne antigens with

lymphocytes and phagocytic cells – this is more importantin children particularly in protection of the host frominfections due toenveloped organisms



What is hematology?• Sequestering 1/3 of the platlet mass – in massivesplenomegaly this can lead to peripheralthrombocytopenia

(decrease in platlets in the peripheral blood)• After asplenectomy(removal of the spleen), RBC

inclusions and abnormal RBC shapes are seen. Culling istaken over by the liver which is less effective in performingall of the splenic functions• Hypersplenism (splenomegaly) – in a number of conditionsthe spleen may become enlarged and through anexaggeration of its normal functions of filtering, anddestruction and sequestering, it may causeanemia (may becaused by decreased RBCs),leukopenia(decreased WBCs),

or thrombocytopenia or combinations of these cytopenias.When all three cell types are decreased this is called pancytopenia.There are two types of hypersplenism:



What is hematology? – Primary – no underlying disease has been

identified – Secondary – caused by an underlying disorder

such as:» Inflammatory diseases» Infectious diseases» Blood disorders that cause compensatory or

workload hypertrophy of the organ such as:

Abnormal blood cells, antibody coated blood cells,hereditary spherocytosis, idiopathicthrobocytopenic purpura (ITP)The effects of these are relieved by splenectomy



What is hematology?Lymph nodes – the lymphatic system iscomposed of lymph nodes and lymphatic vessels thatdrain into the left and right lymphatic duct. Lymphis formed from blood fluid that escapes into the

connective tissue.• Lymph nodes are composed of lymphocytes,macrophages, and a reticular network.

• They act as filters to remove foreign particles by phagocyticcells

• As antigens pass through the lymph nodes, they come intocontact with and stimulate immunocompetent lymphocytesto proliferate and differentiate into effector cells.



What is hematology?• The structure of the lymph node consists

of : – An inner area called the medulla which

containsplasma cells – An outer area called the cortex which contains

folli cleswithB lymphocytes surrounded byT lymphocytes and macrophages



What is hematology? – Thymus – this organ is well developed at birth

and increases in size until puberty at which time itstarts to decrease in size.

• It serves as a compartment for thematuration of Tlymphocytes into immunocompetent T cells. The hormonethymosin plays a role in this process.

• The structure of the thymus consists of: – An outer area called thecortex which is densely packed

with small lymphocytes and macrophages – An inner area called themedullawhich is less cellular

with a few lymphocytes, macrophages, and epithelialcells.



What is hematology?Bone marrow – is located inside spongy bone

• In a normal adult, ½ of the bone marrow ishematopoietically active(red marrow) and ½ is inactive,fatty marrow (yellow marrow).

• The marrow contains both Erythroid (RBC) and leukocyte(WBC) precursors as well as platlet precursors.

• Early in life most of the marrow is red marrow and itgradually decreases with age to the adult level of 50%.

• In certain pathologic states the bone marrow can increase itsactivity to5-10X its normal rate.

– When this happens, the bone marrow is said to behyperplastic because it replaces the yellow marrowwith red marrow.

Wh i h l ?



What is hematology? – This occurs in conditions where there is

increased or ineffective hematopoiesis. – The degree to which the the bone marrow

becomeshyperplastic is related to the severityand duration of the pathologic state.

– Pathologic states that cause this include:» Acute blood loss in which there is a temporaryreplacement of the yellow marrow

» Severe chronic anemia – erythropoiesis (RBC production) may increase to the extent that themarrow starts to erode the bone itself.

» Malignant disease – both normal red marrow andfatty marrow may be replaced by proliferatingabnormal cells.



What is hematology?• The hematopoietic tissue may also become

inactive or hypoplastic. This may be dueto:

– Chemicals – Genetics – Myeloproliferative disease that replaces

hematopoietic tissue with fiberous tissue



HEMATOPOIEZA

FIZIOLOGIA SERIEI ERITROCITARE



HEMATOPOIEZADefiniţie

= procesul de formare al elementelor figurate ale sângelui:• proliferarea• diferenţierea

• trecerea în circulaţie

- cuprinde:• eritropoieza = formarea eritrocitelor

• leucopoieza = formarea leucocitelor• trombocitopoieza = formarea trombocitelor

HEMATOPOIEZA



HEMATOPOIEZASediu

• Măduva roşie hematogenă - celule stem hematopoietice (30-70%):- stromă reticulo- vasculară (celule stromale,

- ţesut adipos, fibrocite, ţesut conjunctiv extracelular,sinusoide vasculare).

• Celulele hematopoietice - 3 mari grupe:

1. Celule stem pluripotente2. Celule progenitoare hematopoietice3. Celule ale liniilor sanguine

HEMATOPOIEZA



1. Celule stem pluripotente (CSP) = celule de origine ale tuturor liniilor sanguine- au capacitate de autoregenerare şi diferenţiere

2. Celule progenitoare hematopoietice

- iau naştere din CSP- au capacitate - limitată de autogenerare

- mai restânsă de diferenţiere - celule progenitoare mieloide : Eritrocite

Leucocite (N, Eo, B, Mo)

Trombocite- celule progenitoare limfoide : Limfocite B şi T

3. Celule ale seriilor sanguine- în diverse stadii de maturaţie

HEMATOPOIEZACelule hematopoietice

HEMATOPOIEZA





FIZIOLOGIA SERIEI

ERITROCITARE







ERITROPOIEZA

2. după naştere

imediat postnatal: măduva hematogenă în toate oasele

treptat, măduva hematogenă se restrânge:- până la 18 ani : în epifizele proximale humerus, femur şi tibie, oase scurte şi plate.- la adult : în oasele scurte şi plate (coxale, stern, corpurilevertebrelor, oasele late ale craniului).

În celelalte oase: măduvă galbenă nehematogenă(ţesut adipos).



ERITROPOIEZA

Etapele eritropoiezei 1. multiplicare şi maturarea

precursorilor eritrocitari(BFU-E, CFU-E, proeritroblast,eritroblaşti)

2. expulzia nucleului(eritroblast oxifil reticulocit)

3. eritrodiabaza(trecerea din măduvă în circulaţie).

ERITROPOIEZA



Tipuri celulare deevoluţie

Caracteristicigenerale

Aspectemorfo-

funcţionale 1. CSP(celula stempluripotentă)

- au receptori pt.eritropoietină - au capacitate de proliferare şidiferenţiere

celule nucleate

2. BFU-E(Burst FormingUnit-E; celuleformatoare de coloniieritroide "de tip

exploziv")3. CFU-E(Colony FormingUnit-E; celulaformatoare de coloniieritroide)

ERITROPOIEZAEtape

ERITROPOIEZA



Tipuri celulare deevoluţie

Caracteristici generale Aspectemorfo-

funcţionale

4. Proeritroblast= celula cap deserie a seriei roşii

- au receptori pentrueritropoietină - au capacitate de proliferareşi diferenţiere- sintetizează Hb şi enzime

celulănucleată

5. Eritroblastbazofil6. Eritroblastpolicromatofil7. Eritroblastoxifil (normoblast)

- capacitate de proliferare- sinteză de Hb şi enzime - evoluează spre reticulocit

celulă cunucleu mic

ERITROPOIEZAEtape

ERITROPOIEZA



ERITROPOIEZAEtape

Tipuricelulare de

evoluţie

Caracteristici generale Aspectemorfo-

funcţionale 8. Reticulocit - nu are capacitate de proliferare

- trece în sânge = eritrodiabazădupă 1 -2 zile- în sânge (5- 15‰) sematurează în splină, care extrageresturile de mitocondrii şi ribozomi - sintetizează Hb şi enzime până lapierderea ribozomilor şimitocondriilor

celulă anucleată cu resturi deribozomi şi mitocondrii

9. Eritrocitmatur

- nu are capacitate de proliferare- nu sintetizează Hb, enzime - durată de viaţă = 100-120 zile

celulă anucleată, fără ribozomi,fără

mitocondrii

ERITROPOIEZA



ERITROPOIEZAMaturarea eritrocitelor:

reducerea dimensiuniicreşterea volumului citoplasmatic + mai puţin bazofilă,reducerea dimensiunii nucleului expulzia lui.

Durata de evoluţie CSP- reticulocit = 5 - 7 zile .Producţia eritrocite/zi = Distrugere eritrocite/zi =25 ml

= 50 ml sânge.



ERITROPOIEZASubstanţe necesare eritropoiezei

Proteineb. Minerale: fier, cupru, cobalt, zinc

c. Vitamine: B12, acid folic, B6, C

MINERALE



MINERALEFierul

Fierul din organism = 4 g 3 compartimente :

1. Compartimentul sanguin (65%):- în eritrocite, sub formă de Hb- în plasmă (legat de transferină; = 60-150 microg/dl)

2. Compartiment de depozit (30%)- în splină, ficat, măduvă hematogenă - 2 forme:- feritina , compus hidrosolubil, eliberează uşor Fe 3+;- hemosiderina = feritină parţial degradată; conţine fier greu mobilizabil.

3. Compartimentul tisular (5%)- în muşchi, sub formă de mioglobină (4%) - în structura enzime (citocromi, peroxidaze etc.)(1%)

MINERALE



Necesarul de fier = 1 mg/zi , asigurat de aportul alimetar uzual;- necesar în stări fiziologice (sarcină, cicluri menstruale

)

Aportul de fier - dietă normală = 10 mg/zi (se abs. 5 - 10%)- fierul rezultat din hemoliza normală.

Pierderile fier (prin păr, piele, urină, scaun) = 1 mg/zi

MINERALEFierul



Metabolismulşi transportul

Fierului în plasmă

Fe3+ fixat detransferină(GP cu originehepatică) transportat la nivelulMH

depozitat

MINERALE



Utilizare Majoritatea celulelor, inclusiv precursorii eritrocitari dinMH (normoblaştii) au receptori pentru transferină. Depozite de fier din organism = ficat, splină şi MH (cel.SRE)

Carenţa de fier anemie feriprivă microcitară hipocromă

(E, Ht, Hb, DEM, VEM, IC)

MINERALEFierul

ALTE MINERALE



ALTE MINERALE

Minerale RoluriCupru - intră în structura sistemelor

enzimatice care asigură fixareafierului în hemoglobină rol în

sinteza Hb.- carenţa de cupru anemiehipocromă.

Cobalt intră în structura vitaminei B12, careeste absolut necesară eritropoiezei

Zinc intră în compoziţie sistemelorenzimatice necesare eritropoiezei

VITAMINE



VITAMINEVitamina B12

= vitamină hidrosolubilă sintetizată exclusiv de microorganisme- Principala sursă: alimentele de origine animală.

Necesar = 2-5 g/ziAport – exclusiv alimentar(dietă normală=5-30 g/zi - se abs. 1-5 g/zi).

Absorbţia - condiţionată de prezenţa factorului intrinsec al lui Castle (FI) =glicoproteină sintetizată de celulele parietale gastrice

• STOMAC :



• STOMAC :fixare vitamina B12 deFI complex

• INTESTIN (ileon terminal):Complexul vit. B12 - FI sefixează pe receptori specifici absorbţie

- FI este reciclat- Vitamina B12se leagă de

transcobalamina II trece în circulaţie transport înMH şi ficat

Concentraţia serică normală = 200-900 pg/ml .

VITAMINE



Roluri în reglarea eritropoiezei :· induce sinteza de ARN şi ADN· activează formarea, creşterea şi maturarea E· participă la transformarea acidului folic în acid tetrahidrofolic

= forma activă a acidului folic.

Deficitul de vitamina B12 – în:- gastrite atrofice, rezecţie gastrică (prin deficit de FI)- afecţiuni ale ileonului terminal (cu reducerea absorbţiei)

- parazitoze (captare B12 de către parazit).

anemie macrocitară hipercromă (pernicioasă sau Biermer)(E, Ht, Hb , DEM, VEM şi IC ).

VITAMINEVitamina B12



Eritrocite normale

Macrocitoză Hipercromie

Anemie pernicioasă (prin deficit devit. B12)

Microcitoză Hipocromie

Anemie feripri(deficit de Fe)



ACID FOLIC (necesar 100 MICROG/ZI)Forma activă : acid tetrahidrofolic ( FH 4)Roluri în:- sinteza purinelor şi pirimidinelor necesare formării ADN, A

- stimularea proliferării, diferenţierii şi maturării E. VITAMINA B6 (necesar 3-5 mg/zi)Roluri: - indispensabilă pentru sinteza Hb

- favorizează absorbţia intestinală a vitaminei B12.

Vitamina E (tocoferol)(20 mg/zi)Roluri:- factor antioxidant (ex. previne oxidarea vitaminei C)- menţine fierul în forma Fe2+ favorizează abs. intestinală.

Vitamina C acidul ascorbic 50-75 m /zi

ALTE VITAMINE

VITAMINE ŞI MINERALE



ŞNECESARE ERITROPOIEZEI

Vitamina Rol Consecinţelecarenţei

Vitamina B 12 Sinteză ADN Anemiemacrocitară

Acid folic Sinteză ADN şi ARN

Anemiemacrocitară

Vitamina C(acid ascorbic) Metabolism Fe Anemie

Vitamina E(tocoferol)

Acţiuneantioxidantă

Fragilitatemembranară

Fier Sinteza Hb Anemiemicrocitară

Reglarea eritropoiezei



eg a ea e t opo e eEritropoietina

1. Eritropoietina= GPsintetizată de rinichi (90%)- producţia depinde deconcentraţia tisulară a O2:

hipoxia - ef. stimulator hiperoxia – ef. inhibitor

- senzorul pentru O2 = proteină hemrenală cudouă forme:- formă activă (dioxi), în caz de hipoxie eritropoietina- formă inactivă (oxi), în caz de hiperoxie eritropoietina

Efecte : creşte masa eritrocitelor circulante prin:- stimularea proliferării CFUE - stimulareadiferenţierii precursorilor eritrocitarişi scurtarea timpului dematurare- favorizareaîncărcării cu Hb reticulocitelor E mature

- activareaeritrodiabazei






Mecanism : legare de receptor membranar de tip tirozinkinaziclocalizat pe membrana precursorilor eritrocitari.

Factori care influenţează sinteza de eritropoietină:• capacitatea de transport a O 2 la ţesuturi:

Ex. transport oxigen (ex. anemie, irigaţiei tisulare, volumuluisanguin) eritropoieza prin mecanism de feedback

• hormoni:· cu efectinhibitor : estrogenii· cu efectstimulator : androgenii,

catecolaminele,glucocorticoizii,hormonul decreştere (STH),hormonii tiroidieni

g pEritropoietina




Factorul celulei stem (SCF) = citokină care stimulează CSP şi induce diferenţierea, proliferareaşi maturarea precursorilor eritrocitari.

Factorul de stimulare a coloniilor de granulocite şi macrofage(GM-CSF) = citokină care stimulează CSP şi induce diferenţierea, proliferareaşi maturarea de granulocite şi macrofage,dar şi a precursoriloreritrocitari.

Interleukina-3 (IL-3) - stimulează CSP, inducând diferenţierea, proliferarea şi maturarea precursorilor eritrocitari.

g pAlţi factori

CINETICA



ERITROCITELOR

1. Formarea eritrocitelor (eritropoieza)

2. Perioada de eritrocit circulant funcţional = 100-120 zile , perioadă în care suntîşi realizează funcţiile şi sunt supuse la

numeroasesolicitări funcţionale:străbat zilnic 1-1,5 kmîşi modifică forma la trecerea prin capilare (fusiforme)şi se deplasează înfişicuri stagnează în vasele sanguine sinuoase (ex. circ.splenică)

transportă gazele respiratorii O2 şi CO2 participă la menţinerea constantă a pH-ului sanguin (prin sistemul tampoal hemoglobinaţilor) sunt influenţate de factori extraeritrocitari (pH,substanţe toxice), care le pot modifica morfo-funcţional (ex. acidoza/alcalozadetermină / volumului eritrocitar).

CINETICA



3. Distrugerea eritrocitelor (hemoliza fiziologică)

Solicitările mecanice şi chimice epuizare energetică şi enzimatică a E

E senescent, rigid, lipsit de plasticitate E esteîndepărtat din circulaţie, prin eritrofagocitoză.

Normal, sediile principale ale hemolizei sunt:•Splina - cu caracteristici funcţionale care accentuează sechestrareaeritrocitelor (sinusoide mai înguste decât în alte zone).•Ficatul (debitul sanguin - de 6 ori mai decât la nivelul splinei).

ERITROCITELOR



STRUCTURA MORFOFUNCŢIONALAA ERITROCITULUI

1 Caracteristici morfo funcţionale



1. Caracteristici morfo- funcţionale

1. Numărul de eritrocite = 4 – 5,5 mil/mm3 - bărbaţi =4,9 0,7 mil/mm3;- femei = 4,3 0,6 mil/mm3. 2. Forma eritrocitului - disc biconcav, cu marginile rotunjite- asigură suprafaţa mare la volum 3. Dimensiunile eritrocitelor - DEM = 6,8 – 7,7 m;

- GEM = 1,7 – 2,5 (2) m;(în centru - cu 1 m < decât periferic) 4. Culoarea eritrocitelor - dată de Hb eritrocitară

- eritrocitul normal colorat = normocrom.



VARIAŢII De număr numărului de eritrocite = anemie

numărului de eritrocite = poliglobulie

De formă ovale = ovalocitecu forme negeometrice, bizare = poikilociteeritrocite sferice = sferocite

în seceră = drepanocitecu excrescenţe = acantocite

Dedimensiuni = microcite 9 m (10-12) = macrocite (megalocite) şi grosime = platicite

De culoare palide, slab colorate = hipocromeintens colorate = hipercrome

E normo-, hipo-, hipercrome = anizocromie

Sf it dit ă



Sferocitoza ereditară

3 P i il i i l



1. Plasticitate = proprietatea E mature de a îşi modifica forma la trec prin capilare cu diametru < diametrul eritrocitar.

2. Plachetarea = prop. E de a se deplasa în fişicuri la nivelul capilare

3. Rezistenţa globulară = rezistenţa E la solicitări mecanice, chimice- Uzual: RG în soluţii cu hipotonicitate progresiv crescândă.- Normal:RG min. (hemoliză incipientă) = 0,40-0,44 g% NaCl,RG max. (hemoliză totală) = 0,32- 0,28 g% NaCl.

3. Proprietatile eritrocitelor

Plasticitatea E



DHAG e-m#328



Plachetarea E

Rezistentaglobulara



Normale

Fragile

globulara

3 P i t til it it l



4. Sedimentarea = proprietatea E lăsate în repaus de asedimenta în virtutea gravitaţiei (recoltare peanticoagulant)- Normal:VSH = 1-10 mm/h la femei;

2-13mm/h la bărbaţi 0,5 - 1 mm/h la nou-născut.

5. Scintilaţia = proprietatea E de a reflecta razele delumină

3. Proprietatile eritrocitelor

4. Structura eritrocitelor



Membrana eritrocitară - particularităţi:- cu Ag de suprafaţă şi receptori membranari- strat mijlociu lipidic foarte mobil asigură plasticitatea- strat intern -asigură rezistenţa, forma E

Compoziţie:60% apă 33-35 % Hb5-7% alte substanţe:

– 2% enzime (cu rol în ciclul glicolitic, şuntul pentozo-fosfaţilor, enzime de apărare împotriva acţiunilor oxidative) – pompe ionice (pompa Na+-K +, pompa de Ca+) – schimbător Cl-/HCO3

-

4. Structura eritrocitelor



= element esenţial pentru realizarea funcţiei respiratorii a E= 95% din proteinele solubile ale eritrocitului- Sinteză:în cel. tinere nucleate ale seriei roşii din MRH: eritroblast bazofil

policromatofil şi oxifil- în reticulocit.

A. Structura Hb= cromoproteină porfirinică care conţine fier – din:

4 molecule de hem (cu 1 atom de Fe2+ - leagă O2, CO2)4 catene polipeptidice (globine).

Hemul = partea fiziologic activă

= fero- protoporfirină IX: atomul de Fe în centrul ineluluiPorfirinic; - fierul heminic =Fe 2+

Globina = tetramer din 4 lanţuri pp., două câte două identice. - fiecare lanţ pp are ataşată o grupare hem la ext. moleculei

Fiziologia hemoglobinei



l b l f l



Hb embrionare - sintetizate din săptămâna a 3-a de viaţă embrionară - există 3 Hb embrionare (Hb Gower 1, 2 şi Hb Portland) Hb fetală (HbF)- înlocuieşte Hb embrionare din luna a 3-a de gestaţie = principala Hb din cursul dezvoltării fetale( 2 2)- la naştere = 70-80% din totalul Hb, apoi sinteza rapidHb de tip adult

- sinteza începe din perioada fetală, după naştere înlocuiesc rapid HbF - la adultul normal există: 97-98% HbA1 ( 2 2)2-3% HbA2 ( 2 2)sub 1% HbF (2 2)

Hemoglobinele fiziologice

H l bi l i



- peste 150 variante de Hb patologice , rezultate prin:• substituirea unuia/mai multor AA din lanţurile globinice • lipsa unuia sau mai multor AA.

Anomaliile structurale ale moleculei de Hb modificarea proprietăţilorfizico-chimice şi funcţionale ale Hb. Ex. înlocuirea restului glutamil cu un rest valil în poziţia6 a lanţului din

molecula de HbA1 hemoglobina S. Clinic: eritrocite în formă deseceră şi predispoziţie la hemoliză (anemie falciformă sau

drepanocitoză).

Hemoglobine patologice

Drepanocitoză



Catabolismul hemoglobineiLa adult: degradare Hb = 6-7 g/zi

Globina - reutilizată ca sursă de AA în proc. Metabolice



Globina reutilizată ca sursă de AA în proc. Metabolice Hemul - degradat Fe + biliverdina

1. Reducerea biliverdinei B indirectă/neconjugată (BI) - transportată în sânge legată de albumine

2. BI este conjugată la nivel HEPATIC cu acid glicuronic B directă/conjugată (BD)

3. BD este eliminată prin bilă în căile biliare

4. INTESTIN GROS: sub acţ. enzimelor reducătoareale florei microbiene: BD urobilinogen(Ubg)

5. Majoritatea Ubg este oxidat stercobilinogen şi stercobilină seelimină prin materiile fecale.

6. O fracţiune din Ubg se abs.la nivel intestinal v. portă - ficat reexcretat în bilă (ciclul entero-hepatic).7. O cant. de Ubg din sânge este excretat de rinichi ca urobilină

( 1%).



Normal: Bilirubina (directă şi indirectă) = 0,4-1mg%.Patologic : hiperbilirubinemie colorare în galben tegumente şi mucoase; în:• hemoliză excesivă (icter hemolitic )• obstacol în calea scurgerii bilei în intestin (de obicei calculi în căile biliare)(icter mecanic )• hepatocitoliză (icter hepatic ).



METABOLISMULERITROCITAR

1 M t b li l l i



- Cantitatea de energie necesară E = foarte redusă şi rezultă din metabolizaglucozei

- glucoza = principalul substrat metabolic.- nu are rezerve de glicogen depinde de glucoza din mediul ambiant.

În eritrocit, degradarea glucozei se realizează: · 90-95% prin glicoliza anaeroba (Embden-Mayerhof)· 5-10 % prin şuntul pentozelor.

1. Metabolismul glucozei

Calea Embden Mayerhof (glicoliza anerobă)



1. fosforilarea glucozei glucozo-6 fosfat (G-6 P)

2. transformarea G-6 P fructozo-6 P fructozo-1,6 diP

3. fructozo-1,6 difosfat esteclivat G-3 P + DHAP

4. G-3 P este transformat în1,3-DPG piruvat lactat

difuzează î n afara Eşi suntmetabolizate î n ţesuturi.

Calea Embden- Mayerhof (glicoliza anerobă)




Ciclul Rappaport-Luebering (sauciclul 2,3-DPG).

- sub acţiunea 1,3-DPG-mutazei: 1,3-DPG 2,3-DPG (ireversibil)

- 2,3-DPG este hidrolizat de 2,3-DPG-fosfataza: 3-PG piruvat

lactatRol : 2,3-DPG afinitatea Hb pentru O2

elib. a O2 la ţesuturi





Importanţa căii glicolitice1. formare 2 molecule de ATP/1 mol de

glucoză, în două trepte:(1) 1,3-DPG 3-PG;(2) acid fosfoenol-piruvic acid piruvic

2. formarea de NADH (folosit de sist.methemoglobin reductazic)

3. formarea 2,3-DPG (carefavorizează cedarea O2 la ţesuturi).


Ş t l t l t



1. conversia glucozei-6 fosfat î nribuloză-5 fosfat (cu formarea a 2molecule de NADPH2)

2. clivarea ribulozei-5 fosfat î n 3fosfogliceraldehidă şi fructoză-6fosfat

Şuntul pentozelor - etape

Importanţa şuntului pentozelor 1. formarea NADPH (2 NADPH/pentru 1

mol glucoză) utilizat de sistemulmethemoglobin-reductazic2. formare de pentozofosfat care este

antrenat î n calea glicolizei anaerobe,contribuind la generarea de ATP

Fi i l i 2 3 DPG



- se formează din metab. G - ciclul Rappaport-Luebering

Rolul 2,3-DPG- scade afinitatea pentru O 2 a Hb cedarea O 2 la ţesuturi.

- mecanism: se fixeaza echimolecular pe lanţurile b ale HbA ( 2 2) modificări conformaţionale cu eliberarea O 2 de pe HbO2.

- deplasează curba de disociere a HbO 2 la dreapta, mărind

eliberarea O 2 la nivel tisular.Obs : La făt - E conţin Hb fetală (HbF, 2 2) 2,3-DPG nu

influenţează eliberarea O 2 la ţesuturi

Variaţii ale producţiei intraeritrocitare de 2,3 -DPG

Factori stimulatori Factori inhibitoriIntensificarea glicolizei:(alcaloză E, efort fizic, hipoxiecr., hipertiroidism)

Reducerea glicolizei(acidoză E) Perturbarea c.RapaportConservarea sg

Fiziologia 2,3 DPG

Fiziologia sistemelor reducătoareit it



- Oxidarea Hb trecerea Fe 2+ î n Fe 3+ formare MetHbNormal : sub 2% MetHb(deoarece este redusă pe cale enz.+ neenz.) Patologic: - MetHb culoare brună a sângelui- MetHb > 15%: cianoza (cul. albastră tegumente) - î n: intoxicaţia cu nitriţi, nitraţi,

adm. medicam. oxidante (nitroglicerină)

Sistemele reducătoare eritrocitare sunt: 1. Sistemul methemoglobin reductazic2. Glutationul redus3. Albastrul de metilen4. Vitamina C

eritrocitare

Fiziologia sistemelor reducătoare



1. Sistemul methemoglobin reductazica. M ethemoglobin reductaza-NAD dependentă sau diaforaza 1 – rol

major- foloseşte NADH din glicolizaanaerobă pentru reducerea Fe3+ la Fe2+ b. M ethemoglobin reductaza-NADP dependentă sau diaforaza 2 - rol

sec.- utilizează NADPH rezultat dinşuntul pentozelor pentru reducerea Fe3+

la Fe2+

Fiziologia sistemelor reducătoareeritrocitare

NADH 2 NAD

MetHb (Fe 3+) Hb (Fe 2+)NADPH 2 NADP

MetHb (Fe 3+) Hb (Fe 2+)

Fiziologia sistemelor reducătoare



2. Glutationul redus - se produce în E dinglutamat+glicină+cisteină (cu consum ATP)- este regenerat de către glutation reductaza NADPH-dep.- Formeleoxidată (G-SS-G)/redusă (GSH) = sistem redox (75%/ 25%)

Rol: protejează de oxigen SH-enzimele, membranaeritrocitară, Hb (careconţine 6 grupări SH).

3. Alţi agenţi reducători ai MetHb: - Albastrul de metilen

= agentreducător al MetHb (administrat iv)- acţionează enzimatic prin activareaMetHb-reductazei NADPH-dep.

· - Vitamina C= agentreducător al MetHb(administrată iv. sau oral)- reduce MetHb pe cale neenzimatică

Fiziologia sistemelor reducătoareeritrocitare

Funcţiile eritrocitelor 1 Funcţia de transport a O şi CO



La nivelul plămânilor au loc: La nivelul ţesuturilor au loc:

- fixarea O 2 pe hemoglobină - eliberarea CO 2 din HbCO 2- fixarea H +

- eliberarea 2,3-DPG.

- eliberarea O 2 de pe HbO 2 - captarea de către Hb a protonilor- fixarea CO 2 carbamaţi

- fixarea 2,3-DPG.

1. Funcţia de transport a O 2 şi CO 2

1.1. Transportul O 2 dizolvat fizic în plasmă (1%); proporţional cu PO 2 . combinat cu hemoglobina (99%).

- Reacţia Hb cu O 2 : rapid, fiecare atom de Fe2+

al grupărilor hempoate fixa o moleculă de O 2, fără modificarea valenţei Fe 2+ =oxigenare- Fixarea şi eliberarea O 2 de pe molecula de Hb are loc succesiv,cu viteză progresiv crescândă



Factorii care influenţează afinitatea Hb pentru O2



Factori care crescafinitatea pentru O 2

Factori care diminuăafinitatea pentru O 2

determina intensificareafixării O 2

deplasarea spre stânga acurbei de disociere aoxihemoglobinei.

favorizează eliberareaoxigenului la nivelulţesuturilor deplasarea spre dreapta acurbei de disociere aoxihemoglobinei.

[H + ]( pH),[CO 2],[2,3 DPG], temperaturii,

HbF

[H + ] ( pH),[CO 2],[2,3 DPG], temperaturii,

HbA

p



Funcţiile eritrocitelor 1. Funcţia de transport a O 2 şi CO 2



Transportul CO 2

1. Forma dizolvată f izic a CO 2 (5%)= parteadifuzibilă - determină sensulşi mărimea difuziunii,fixarea subformă de carbamat/bicarbonat

2. F orma combinată cu pr oteinele plasmatice şi hemoglobina (4,5%). CO2 fixat degrupările aminice ale:

- proteinelor plasmatice carbamaţi - Hb carbHb

3. CO 2 tr anspor tat sub formă de bicarbonat (90%)- KHCO3 intraeritrocitar si NaHCO3 în plasmă.

În plasmă: o cantitate CO2 se hidratează spontan H2CO3 HCO3- + H+


Funcţiile eritrocitelor 1. Funcţia de transport a O 2 şi CO 2



Controlulformării şi eliberării CO2 de pe Hb gradul de oxigenare al Hb (efect Haldane): O2 tindesă elibereze CO2.

- la ţesuturi: elib. O2 de pe Hbfavorizează fixarea CO2 - la plămâni: O2 determină eliberarea CO2 din HbCO2

Curba de disociere-fixare a CO 2 - esteinfluenţată de PCO2 şi de saturaţia în O2 a Hb.- nu atinge platou;creşterea progresivă a PCO2 cantitatea de CO2 dizolvată în plasmă nuexistă pct. desaturaţie - sângele arterial -curbă de fixare-disociere a CO

2 mai deprimată faţă de

cea a sângelui venos(explicaţie: eritrocitele cu oxiHb pot fixa mai putinCO2 ).

- Laţesuturi: fixarea CO2 se faceuşor datorită PO2 şi a pH-ului mai acid.- La plămâni cedarea CO2 estedeterminată de PO2 şi pH ceva mai alcalin.




Funcţiile eritrocitelor 2 Rolul eritrocitelor în menţinerea EAB



Prin:- sistemele tampon eritrocitare: HbK/HbH, HbO2K/HbO2H, care

asigură ¾ din capacitatea tampon a sângelui - fixarea CO2 sub formă de HbCO2- creşterea capacităţii tampon a plasmei (NaHCO3), ca urmare a

fenomenului Hamburger

2. Rolul eritrocitelor în menţinerea EAB

St t f b



Structure of bone marrow

BONE MARROW



Normal

Hypoplastic

Hyperplastic

What is hematology?



What is hematology? – Liver – contains phagocytic cells known asKupffercells that act as a filter for damaged

or aged cells in a manner similar to, but lessefficient than the phagocytic cells in thespleen.

• If the bone marrow cannot keep up with the physiologic demand for blood cells, the liver mayresume the production of blood cells that it beganduring fetal life

Derivation of blood cells



Derivation of blood cells• Mature blood cells have a limited life span andwith the exception of lymphocytes, are

incapable of self-renewal. – Replacement of peripheral hematopoietic cells is a

function of the pluripotential (totipotential) stem cells found in the bone marrow• Pluripotential stem cells can differentiate into all of the

distinct cell lines with specific functions and they are able toregenerate themselves.

• The pluripotential stem cells provide the cellular reserve forthe stem cells that are committed to a specific cell line.

Derivation of blood cells



– The committed lymphoid stem cells will be involved inlymphopoiesis to produce lymphocytes

– The committed myeloid stem cell can differentiate intoany of the other hematopoietic cells includingerythrocytes, neutrophils, eosinophils, basophils,monocytes, macrophages, and platlets.

– Hematopoietic cells can be divided into threecellular compartments based on maturity:

• Pluripotential stem cell capable of self-renewaland differentiation into all blood cell lines.

• Committed proginator stem cells destined to

develop into distinct cell lines• Mature cells with specialized functions

Hematopoiesis



Hematopoiesis



Hematology



138

Hematology

Hematology



139

Hematology

Basic scheme



140

• Blood leaves the heart inarteries

• Branching of arteries untilthey become tinycapillaries – Oxygen and nutrients diffuse out – CO2 and wastes diffuse in

• Capillaries formveins going to the heart• The blood leaves the right side of the heart for the

lungs to pick up O2 and release CO2• Blood goes back to the left side of the heart to start allover

Note: vessels goingto the heart areveins ; thoseleaving the heart arearteries

Summary of blood forming



y gorgans

Composition of blood



142

Composition of blood• Specialized connective tissue• Blood cells (formed elements) suspended in plasma

• Blood volume: 5-6 liters (approx 1.5 gal) in malesand 4-5 liters in females

Blood• Centrifuged (spun) to separate



143

Centrifuged (spun) to separate• Clinically importanthematocrit

– % of blood volume consisting of erythrocytes (red blood cells)

– Male average 47; female average 42

• Plasma at top: water with many ions,molecules, and 3 types of important proteins: – Albumin – Globulins – Fibrinogen

• Serum – Blood that is allowed to stand clots



144

– Clot is a tangle of the ―formed elements‖ (some are not

truly cells)• RBCs lack nuclei and organelles• Platelets are fragments• Most cannot divide

– Clear fluidserum is left = plasma without the clottingfactors

When spun in centrifuge, buffy coat lies betweenRBCs and plasma: ofleukocytes (white blood cells)and platelets

Scanning EM



145

• Blood isexamined in a―smear‖

• Smears arestained

Light microscope

Hematopoiesis



146

Hematopoiesis• Formation of blood cells• Occurs mostly in red bone marrow• All cells arise from sameblood stem cell

(pluripotent hematopoietic stem cells)• Recently some have been found in adults

which aremesenchymal stem cells , which can

also form fat cells, osteoblasts, chondrocytes,fibroblasts and muscle cells



147

Blood stem cells

divide into:1.myeloid stem cells or2.lymphoid stem cells



148

All except for

lymphocytes arisefrom myeloid stemcells

All originatein the bonemarrow

Not shownare mastcells,osteoclasts,dendriticcells



149

• As the cells divide they become ―committed,that is, they can only become one kind of cell

• Also called CFU‘s (colony-forming units)

• Structural differentiation occurs

CBC is probably commonest test done(―complete blood count‖-how much of each type of cell)



150

• Hemoglobin (gm/dl)usually 15

• Hematocrit (%)• RBC count

• WBC in thousands/cumm – Differential if ordered:

broken down to amount ofeach type WBC

• Platelet count inthousands/cumm

Erythrocytes• Also called RBCs or red blood



151

Also called RBCs or red bloodcells

• Biconcave discs and flexible• Plasma membrane but no nuclei or

organelles• Packed with hemoglobin

molecules – Oxygen carrying protein – 4 chains of amino acids, each with

iron which is binding site for oxygen;CO2 carried also

• Young ones still containingribosomes are calledreticulocytes

• Live 100-120 days

heme

iron atom

Leukocytes



152

AKA WBCs:white bloodcells

Leukocytes

__ RBC



153

Leukocytes

AKA WBCs: white blood cells

Are complete cellsFunction outside the

blood

Note the size differencecompared to erythrocytes

neutrophil eosinophil

basophil

small lymphocyte monocyte

Leukocyte types



154

• Artificial division into granulocytes andagranulocytes

• Granulocytes: neutrophils, eosinophils, basophils (according to how stain) – Granules – Lobed nuclei – All are phagocytic

• Agranulocytes: lymphocytes, monocytes

Remember this

slide?See the artificial division?



155

All except forlymphocytesarise frommyeloid stemcells

All originate in the bone marrow

Not shown are mast cells,osteoclasts, dendritic cells

Neutrophils



156

Neutrophils

• 60% of all WBCs• Nuclei of 2-6 lobes

• Other names: – Polymorphonuclear cells (PMNs, polys, segs) – Granules have enzymes

– Can damage tissue if severe or prolonged – Pus

Eosinophils



157

• 1-4 % of leukocytes

• Bilobed• Granules have digestive enzymes• Role in ending allergic reactions and in

fighting parasitic infections

Basophils



158

Basophils

• Rarest WBC• Bilobed nucleus

• Dark purple granules• Later stages of reaction to allergies and

parasitic infections

Lymphocytes*



159

• Most importantWBC• 20-45%• Most are

enmeshed inlymphoidconnective tissue,e.g. lymph nodes,

tonsils, spleen*

Lymphocytes:



160

nucleus occupies most of thecell volume

Response to antigens (foreign proteins or parts of cells)is specific

Two main types attack antigens in different waysT cellsB cells plus ―natural killer cells‖

T cells attack foreign cells directly



161

g y

• Killer cells (―cytotoxic‖), or CD8+ is amain type

B cells



162

• Differentiate intoplasma cel ls

• Plasma cells secrete antibodies

• Antibodies flag cells for destruction bymacrophages (see stem cell chart)

Monocytes*



163

• 4-8% of WBCs• In connective tissue

they transform intomacrophages (phagocytic cellswith pseudopods)

*

Platelets*



164

• Not cells• Small fragments

broken off frommegakaryocytes

• Important informingclots indamaged vessels

• AKAthrombocytes*

Clots



165

Undesirable clots: – Thrombus – Embolus Platelet and several RBCs trapped

in a fibrin mesh

Platelet__________________

Significantyoung cells



166

• Reticulocytes * (youngerythrocytes): 1-2%ofall RBCs – ―retic count‖ helps

determine if producingRBCs at accelerated rate(anemia, move to a highclimate, etc.)

• Bands * (youngneutrophils): 1-2% ofall WBCs – Increases with acute

bacterial infections**

Disorders of Erythrocytes• Polycythemia: too many cells



167

y y y

• Anemia: not enough cells• Sickle cell disease: genetic disease AR – 1/400 African Americans

– Defect in hemoglobin• Plus many others

Disorders of LeukocytesL k i b l d



168

• Leukemia: too many, abnormal, crowd outnormal marrow

• Classified into – Lymphoblastic or myeloblastic

– Acute or chronic

Disorders of Platelets

• Thrombocytopenia – Causes internal bleeding – Many causes

Laboratory



169

y

CBC: complete blood count (to review…)

• Hemoglobin (gm/dl)• Hematocrit (%)• RBC count• WBC in thousands/cumm

– Differential if ordered: broken down to amount of eachtype WBC

• Platelet count in thousands/cumm

Laboratory continuedClotting: “coags”



170

Clotting: coags

– for preop evaluation (before surgery) – to evaluate effectiveness of anticoagulant drugs, e.g.aspirin, heparin, coumadin

• Bleeding time

• PT - Protime• PTT - Partial thromboplastin time• INR

ESR – erythrocyte sedimentation rate – Indicator of infection or inflammation

Blood Typing



171

yp gABO blood groups: A, B, AB, and O



172

If a blood transfusion is given to a person whohas antibodies to that type of blood, then thetransfused blood will be attacked anddestroyed (transfusion reaction)

ABO blood group typesThe blood types are ―codominant‖ –i e if genotype is AB then you have both



173

Bloodtype

Antigen onrbc

Antibodies inblood

Can receive blood from: Can donate blood to(usually RBCs only):

Frequencyin US

A A anti-B AOnot B (you have anti-B) *not AB (you have anti-B) *

AAB

40%

B B anti-A BO (no Ags so you won‟t reject) not A (you have anti-A) *not AB (you have anti-A) *

BAB

10%

AB A and B none toA or B

AB AB is uni versal recipientABO

AB 4%

O not A nor B Anti-A and anti-B not A (have anti-A)*not B (have anti-B)*not AB (have both antibodies)*O

ABABO O i s universal donor

46%

Ag = antigen on red blood cell*=transfusion reaction (hemolysis of new cells)

The blood types are ―codominant‖ – i.e. if genotype is AB, then you have bothA and B antigens on your RBCs

Rh factor• The ―Rh factor‖ is another major antigen on the RBC, called

l



174

‖ j g – is autosomal recessive – DD and Dd: Rh+ – dd: Rh-

• If mom is Rh- and baby is Rh+, then small amount of bloodleaks into mom‘s blood through placenta, and she makesantibodies to D antigen; first Rh- pregnancy usually ok, but

not later Rh- ones (can be lethal to baby)• If mom is Rh-then give ―Rhogam‖ during pregnancy [(is anti-Rh(D): Rh(D) Ig (immunoglobin)], an antibody which willdestroy any of the baby‘s RBCs which leak into mom‘s bloodduring the pregnancy so she will not mount an immuneresponse to the D antigen

• If father is Rh+: – If DD then all pregnancies will be Rh+ – If Dd then half of the pregnancies with this mom will be Rh- (no Rh

incompatibility problems)

Rhogam (FYI)



175

g ( )• Risks to the baby• If the baby‘s blood cells are attacked and depleted during pregnancy it can lead to anemia, jaundice,

mental retardation and heart failure. It can even be fatal in utero or shortly after delivery. Thecondition is known as Hemolytic Disease of the Newborn. Luckily, appropriate treatment withRhogam can almost completely eliminate the risk.

• • [edit ] Rh Negative treatment with Rhogam• Rhogam is a sterile solution that is injected intramuscularly. It is made from human plasma that

contains anti-D. Most often Rhogam is given to women at28 weeks of pregnancy. The Rh negativemother is most likely to be exposed to the baby‘s blood in the last 3 months of pregnancy, so asecond dose is often given within 72 hours of delivery if the baby is found to be Rh positive. Amother must also receive a dose after any invasive procedure such as amniocentesis or after aninduced termination, miscarriage or ectopic pregnancy.

• [edit ] Side effects• Side effects of Rhogam are mild and include soreness tenderness, warmth or a rash at the injection

site. Other side effects can include:

• Fever• Chills• Headache• Fatigue

• http://wikiparenting.parentsconnect.com/wiki/Rhogam_in_pregnancy

FYI












176

Blood



• Blood is the fluid of life• Blood is composed of:

– Plasma – RBC – WBC – Platelets

Plasma



• Plasma consists of: – 90% water.

– 10 % solutes: albumin, electrolytes and proteins.

– Proteins consist of clotting factors, globulins,circulating antibodies and fibrinogen.

Red Blood Cells



• RBC‘s travel through the body deliveringoxygen and removing waste.

• RBC‘s are red because they contain a protein chemical called hemoglobin whichis bright red in color.

• Hemoglobin contains iron, making it anexcellent vehicle for transporting oxygenand carbon dioxide.

RBC‘s



• Average life cycle is 120days.• The bones are continually

producing new cells.

White Blood Cells



• The battling blood cells.• The white blood cells are continually on the

look out for signs of disease.• When a germ appears the WBC will: – Produce protective antibodies.

– Surround it and devour the bacteria.

WBC‘s



• WBC life span is from a few days to a fewweeks.

• WBC‘s will increase when fightinginfection.

Platelets



• Platelets are irregularly-shaped, colorless bodiesthat are present in blood.

• Their sticky surface lets

them form clots to stop bleeding.

Blood Values



• CBC with differential and platelet count. – Hgb:

• Normal levels are 11 to 16 g / dl• Panic levels are:

– Less than 5 g / dl – More than 20 g / dl



Hemoglobin and Hematocrit



• Can be used as a simple blood test to screenfor anemia.

• The CBC with differential would be used tohelp diagnose a specific disorder.

• A bone marrow aspiration would be themost conclusive in determining cause ofanemia – aplastic / leukemia.

Bone Marrow



Bone marrow is the spongy substance foundin the center of the bones.

• It manufactures bone marrow stem cells,which in turn produce blood cells.• Red blood cells – carry oxygen to tissue• Platelets – help blood to clot• White blood cells – fight infection

Bone Marrow Transplant



• Donor is placed under anesthesia.• Marrow is aspirated out of the iliac crest.• Marrow is filtered and treated to remove

bits of bone and other unwanted cells anddebris, transferred to a blood bag, and isinfused into the patient‘s blood just like at

transfusion.

Bone Marrow Aspiration



Treatment Modalities



• Transfusion: – Packed red blood cells – anemia – Platelets – platelet dysfunction – Fresh frozen plasma – coagulation factors

Blood Transfusions



• 3 types of transfusion reactions – Hemolytic – Allergic – Febrile

Hemolytic Reaction



• Refers to an immune response againsttransfused blood cells.

• Antigens, on the surface of red blood cells,are recognized as ―foreign proteins‖ and canstimulate B lymphocytes to produceantibodies to the red blood cell antigens.

Hemolytic reaction



• Flank pain• Fever

• Chills• Bloody urine• Rash

• Low blood pressure• Dizziness / fainting

Nursing Management



• Stop the blood transfusion.• Start normal saline infusion.• Take vital signs with blood pressure

• Call the MD• Obtain blood sample and urine specimen.• Return blood to blood bank.

• Document

Febrile Reaction



• Often occurs after multiple bloodtransfusions.

• Symptoms:fever, chills, and diaphoresis.• Interventions:

– Slow transfusion and administer antipyretic. – Administer antipyretic prior to administration.

Allergic Reaction



• Symptoms: rash,urticaria, respiratorydistress, or anaphylaxis.

• Interventions:

– administer antihistamine before transfusion – Physician may order

washed rbc‘s

Hematologic Conditions



Alteration in Hematologic Status



• Disorders of hemostasis or clotting factors• Structural or quantitative abnormalities in

the hemoglobin.• Anemias• Aplastic Anemia

Genetic Implications



• The following have a genetic link:implications for genetic screening and fetaldiagnosis – Sickle cell anemia – Thalassemia – Hemophilia

Bleeding Disorders



• Three types Hemophilia: males only – Type A most common – factor VIII deficiency – Type B - lack of factor IX (Christmas Disease) – Type C – lack of factor XI

Von Willebrand Disease – 1% of population – men or women – prolonged bleeding time

Hemophilia Type A



• Hemophilia type A is the deficiency ofclotting factor VIII. – A serious blood disorder – Affects 1 in 10,000 males in the US – Autoimmune disorder with lowered level of

clotting factor

– All races and socio economic groups affectedequally

Hemophilia



• Hemophilia is a sex-linked hereditary bleeding disorder

• Transmitted on the X chromosome• Female is the carrier• Women do not suffer from the disease itself

Historical Perspective



• First recorded case in Talmud Jewish text by an Arab physician – documentation oftwo brothers with bleeding aftercircumcision.

• Queen Victoria is carrier and spread thedisease through the male English royalty.

Goals of Care



• Goals of care: – Provide factor VIII (IX) to aid blood in clotting. – To decrease transmission of infectious agents in

blood products; hepatitis & AIDS. – Future: gene therapy to increase production of

clotting factor.

Symptoms



• Circumcision may produce prolonged bleeding.

• As child matures and becomes more activethe incidence of bleeding due to traumaincreases

Symptoms



• May be mild, moderate or severe• Bleeding into joint spaces, hemarthrosis

• Most dangerous bleed would beintracranial.

Diagnosis



• Presenting symptoms• Prolonged activated aPTT and decreased

levels of factor VIII or IX.• Genetic testing to identify carriers

Treatment



• Products used to treat hemophilia are: – Fresh frozen plasma and cryoprecipitate which

are from single blood donors and requirespecial freezing.

– Second generation of factor VIII are made withanimal or human proteins.

Nursing Diagnoses



• Risk for injury• Pain with bleed especially into a joint

• Impaired physical mobility• Knowledge deficit regarding disease andmanagement of disease



Teaching



• Avoid aspirin which prolongs bleeding time in peoplewith normal levels of factor VIII.

• A fresh bleeding episode can start if the clot becomes

dislodged.• Natural reactions in the body cause the clot that is nolonger needed to ―break down. This process occurs5days after the initial clot is formed.

Family Education



• Medic-Alert bracelet• Injury prevention appropriate for age

• Signs and symptoms of internal bleeding orhemarthrosis• Dental checkups

• Medication administration

Long Term Complications



• 20% develop neutralizing antibodies thatmake replacement products less effective.

• Gene therapy providing continuous production of the deficient clotting factorcould be the next major advance inhemophilia treatment.

Disseminated IntravascularCoagulation or DIC



g

• DIC is an acquired coagulopathy that ischaracterized by both thrombosis andhemorrhage.

• DIC is not a primary disorder but occurs asa result of a variety of alterations in health.

Assessment



• The most obvious clinical feature of DIC is bleeding.• Renal involvement = hematuria, oliguria, and anuria.• Pulmonary involvement = hemoptysis, tachypnea,

dyspnea and chest pain.• Cutaneous involvement = petechiae, ecchymosis,

jaundice, acrocyanosis and gangrene.



Nursing Diagnoses



• Altered tissue perfusion• Risk for injury

• Anxiety

Nursing Interventions



• Rigorous ongoing assessment of all bodysystems

• Monitor bleeding• No rectal temps• Avoid trauma to delicate tissue areas

• All injections sites and IV sites need to betreated like an arterial stick.

Prognosis



• Depends on the underlying disorder and theseverity of the DIC.

ITP



• Idiopathic thrombocytopenic purpura – Idiopathic = cause is unknown – Thrombocytopenic = blood does not have

enough platelets – Purpura = excessive bleeding / bruising

Immune ThrombocytopenicPurpura



• Antibodies destroy platelets• Antibodies see platelets as bacteria and

work to eliminate them• ITP is preceded by a viral illness

– URI – Varicella / measles vaccine – Mononucleosis – Flu

Symptoms



• Random purpura• Epistaxis, hematuria, hematemesis, and

menorrhagia• Petechiae and hemorrhagic bullae in mouth

Diagnostic Tests



• Low platelet count• Peripheral blood smear

• Antiplatelet antibodies

Normal platelet count: 150,000 to 400,000

Management



• IV gamma globulin to block antibody production, reduce autoimmune problem

• Corticosteroids to reduce inflammatory process

• IV anti-D to stimulate platelet production

Sickle Cell Anemia



• Autosomal recessive disorder• Defect in hemoglobin molecule

• Cells become sickle shaped and rigid• Lose ability to adapt shape to surroundings.• Sickling may be triggered by fever and

emotional or physical stress

Pathophysiology



• When exposed to diminished levels ofoxygen, the hemoglobin in the RBCdevelops a sickle or crescent shape; the cellsare rigid and obstruct capillary blood flow,leading to congestion and tissue hypoxia;clinically, this hypoxia causes additional

sickling and extensive infarctions.



Whaley & Wong Text

Crescent Shaped Cells



Body Systems Affected by SS



• Brain: CVA – paralysis - death• Eyes: retinopathy – blindness• Lungs: pneumonia

• Abdomen: pain, hepatomegaly, splenomegaly(medical emergency due to possible rupture• Skeletal: joint pain, bone pain – osteomyelitis• Skin: chronic ulcers – poor wound healing

Vaso-occlusive Crisis



Stasis of blood with clumping of cell in themicrocirculation, ischemia, and infarction

• Most common type of crisis; painful• Signs include fever, pain, tissue

engorgement

Splenic Sequestration



• Life-threatening / death within hours• Pooling of blood in the spleen

• Signs include profound anemia,hypovolemia, and shock• Abdominal distention, pallor, dyspnea,

tachycardia, and hypotension

Aplastic Crisis



• Diminished production and increaseddestruction of red blood cells

• Triggered by viral infection or depletion offolic acid

• Signs include profound anemia, pallor

Nursing Diagnoses



• Altered tissue perfusion• Pain

• Risk for infection• Knowledge deficit regarding disease process

Nursing Management - Hospital



• Increase tissue perfusion – Oxygen – Blood transfusion if ordered

– Bed rest• Pain management• Hydration

– IV fluids as ordered – Oral intake of fluids

Nursing Management



• Adequate nutrition• Emotional Support• Discharge instructions

• Information about disease management

• Daily folic acid• Control of triggers• Prophylactic antibiotics• Immunizations / Pneumococcal

Patient Education



• Necessity of following plan of care• Signs and symptoms of impending crisis.• Signs and symptoms of infection• Preventing hypoxia from physical and

emotional stress

• Proving adequate rest



RBC Characteristics



– Microcytosis = small insize

– Hypochromia = decreasehemoglobin

– Poikilocytosis = abnormalshape

Treatment / Prognosis



• Supportive• Blood transfusions as needed• Bone marrow transplant

Poor prognosis / death within 1st

year due to septicemia orheart failure.

Iron Deficiency Anemia



• Most common nutritional deficiency• Depletion of iron stores

Abnormal Laboratory Values



• Hemoglobin levels less than 8 g/dL

• Decreased levels of Serum Iron or TotalIron Binding or Serum Ferritin

• Microcytic and hypochromic red blood cells

IDA



• Occurs in children experiencing: – Rapid physical growth – Low iron intake – Inadequate iron absorption – Loss of blood

Symptoms



• Associated with low oxygenation of tissue: – Pallor – Fatigue – Shortness or breath – Irritability – Intolerance of physical work / exercise

Management



• Iron supplementation – Given in a.m. on an empty stomach – To avoid staining of teeth, give using a syringe,

dropper or straw – Instruct caretaker that child may have dark-

colored stools

Management



• Nutritional counseling• Infants younger than 12 months should be

on formula until around 12 months of age• Infants 12 months or older

– Decrease intake of milk – Introduce solid foods

• Children: iron fortified cereals, foods, meat,green leafy vegetables• Teenagers: reduce junk food



Causes



• Exposure to drugs• Exposure to chemicals• Exposure to toxins• Infection• Idiopathic in nature



Management



• Immunosuppressive therapy

– Antithymocyte globulin• Administered IV over 4 days• Response seen within 3 months

• Bone Marrow Transplant



Hyperbilirubinemiaf



• Many babies have some jaundice. When they are a fewdays old, their skin slowly begins to turn yellow. Theyellow color comes from the color of bilirubin. When red blood cells die, they break down and bilirubin is left. Thered blood cells break down and make bilirubin. Innewborns, the liver may not be developed enough to getrid of so much bilirubin at once. So, if too many red bloodcells die at the same time, the baby can become veryyellow or may even look orange. The yellow color doesnot hurt the baby's skin, but the bilirubin goes to the brainas well as to the skin. That can lead to brain damage.

Signs and symptoms



• Very yellow or orange skin tones (beginning at thehead and spreading to the toes)

• Increased sleepiness, so much that it is hard to

wake the baby• High-pitched cry• Poor sucking or nursing

• Weakness, limpness, or floppiness

Photo Therapy



Fiberoptic Blanket



Nursing Interventions

M i bili bi l l



• Monitor bilirubin levels• Assess activity level – muscle tone – infant

reflexes• Encourage po intake: May need to supplement

with formula if inadequate breastfeeding• Weight daily to assess hydration status• Monitor stools – amount and number• Cover eyes while under bili-lights• Facilitate parent - infant bondingLoss of moro or startle reflex can indicate possible brain damage due to

Kernicterus

Blood Components

Pl



• Plasma: – The liquid part of blood. All the blood cells are

suspended in this liquid. – Contains dissolved salts (electrolytes) and proteins

• Albumin helps keeps blood vessels from leaking and carrieshormones and drugs to different parts of the body.• Antibodies (immunoglobulins) that defend the body against

viruses, fungi, and cancer cells – Serves as a reservoir that can absorb replenish or absorb

water from tissues when necessary. – Prevents blood vessels from collapsing and clotting by

keeping them filled and circulating – Plays a role in warming and cooling the body

Blood ComponentsRed Blood Cells

E th t M k 40% f th bl d‘ l



– Erthrocytes: Make up 40% of the blood‘s volume – Produced in the bone marrow – Contain hemoglobin, a protein that gives blood its red color and

enables it to carry oxygen.• White Blood Cells

– Leukocytes: Fewer in number than RBCs (1:660) – Primary responsibility: Defend the body against infection

• Platelets – Thrombocytes: cell-like particles smaller than RBCs and WBCs.

– Help with clotting process by gathering at bleeding site andclumping together to form a plug that helps seal the blood vessel.



.



Lymphoma

L h li t lif ti f



• Lymphomas are a malignant proliferation oflymphocytes – either B or T

• 3% of all cancers in the US result fromlymphomas

• The lymphomas are classified by the appearanceof malignant lymphocytes on biopsy of tumor

• 3 categories

– Low-grade – Intermediate-grade – High-grade

Functional Presentation ofLymphoma

People present ith s ollen



• People present with swollen,growing lymph glands(nodal disease) or tumors inother organs (extramodaldisease)

• Person can be asymptomatic• Common B symptoms

include fever, drenchingnight sweats, loss of 10% of body weight, and pruritis(severe itching)

Staging of Lymphoma

St I i l t f i l l h d



• Stage I – involvement of a single lymph noderegion or single extranodal organ or site

• Stage II – involvement limited to one side of thediaphragm with 2 or more lymph node regions

• Stage III – involvement of lymph node regions on

both sides of the diaphragm

• Stage IV – diffuse or disseminated involvement ofone or more extralymphatic organs

Skin Lymphoma and ShoulderLymphoma



Treatment and Prognosisof Lymphoma

Si th j it f l h t i



• Since the majority of lymphomas present inmultiple areas of the body, localized surgery orradiation is rarely curative

• Primarily, treatment is chemotherapy• Prognosis is dependent on the grade and stage• For people who do not respond to primary

treatment, bone marrow transplantation is

increasingly used• Biological agents and vaccine therapy were beingtested

Leukemia

A t l k i i h t i d b b l



• Acute leukemia is characterized by an abnormal proliferation of immature white blood cells, called blasts or progenitor cells

• Two main forms of acute leukemia – Acute lymphoblastic leukemia

• A cancer at the earliest stages of lymphocyte maturation• Occurs more often in the young

– Acute nonlymphoblastic leukemia• Usually a malignancy of the myeloblast• More common in adults

A B



A : Picture of bone marrow smear (control); Normal granulocytes and erythroblasts areevident.B : Acute lymphoid leukemia (ALL); There is a marked proliferation of small lymphoblasts.C : Acute myeloid leukemia (AML); There is a marked proliferation of large myeloblasts.D : Chronic myeloid leukemia (CML); There is a marked proliferation of granulocytes atvarious stages of maturation.

DC

Functional Presentation ofLeukemia

P l ith l k i t ith ig



• People with leukemia present with signsand symptoms of low red blood cell count(anemia), decreased white blood cells

(granulocytopenia) with infection and fever,and a low platelet count (thrombocytopenia)with bleeding

• People will usually present critically

Physical appearance & leukemia• Specific lesions (leukemia



• Specific lesions (leukemiacutis) are localized ordisseminated infiltrations of theskin by malignant leukemiccells which may involve all

layers of the skin.• Chemotherapy needed for

treatment of Leukemia usuallyresults in hair loss

Treatment of Leukemia

• The course of treatment includes red blood cell



• The course of treatment includes red blood celltransfusions to correct the anemia, treatments forinfections caused by the lack of mature white blood cells, platelet transfusions to stop any bleeding, and starting chemotherapy to kill theleukemia cells

• Once chemotherapy stops, tumor cells die, thenormal stem cells in the marrow that are resistantto chemotherapy divide, and their progeny cellsmature and repopulate the marrow over the next 3weeks

Vocational Implications ofLymphoma and Leukemia

• Depression sleep disorder and anxiety over



• Depression, sleep disorder, and anxiety over personal appearance are common

• Long-term survivors also have persistent problemsincluding decreased energy level, negative bodyimage, depression, employment problems, andmarital problems

• Vocational implications and accommodations aresimilar to other cancers and are based onsymptoms and side effects of treatment

Hemophilia• Hemophilia is a sex-linked

hereditary blood diseasecharacterized by greatly



characterized by greatly prolonged coagulation time – Hemophilia A is due to a

deficiency of bloodcoagulation Factor VIII

• Accounts for 75% ofhemophilia

• Incidence is 1 in 10,000 male births

– Hemophilia B is due to adeficiency of bloodcoagulation Factor IX

• Incidence is 1 in 75,000 male births• Is clinically indistinguishable

from hemophilia A

Functional Presentation ofHemophilia

• The person can present with mild moderate or



• The person can present with mild, moderate, orsevere hemorrhagic disease, depending on theamount of active protein produced

– People with mild hemophilia rarely bleedspontaneously and usually are discovered afterexcessive bleeding secondary to trauma or surgery

– People with moderate hemophilia have rare episodes of

spontaneous bleeding, but can hemorrhage with anytrauma – People with severe hemophilia have frequent

spontaneous hemorrhage from early childhood

Functional Presentation ofHemophilia

• People with hemophilia canbleed n here b t



People with hemophilia can bleed anywhere, but bleeding into joints(hemarthrosis), soft tissue(such as muscle), urine

(hematuria), and the brainare common• Chronic bleeding into joints

or an acute bleed into the brain or spinal canal can leadto chronic disabilities, bothfunctional and psychological

Treatment and Prognosisof Hemophilia

• The general principle of treatment of hemophilia



• The general principle of treatment of hemophiliais, first, to avoid drugs than can interfere withclotting, particularly aspirin and other NSAIDSthat inhibit platelet function

• Second, early recognition of bleeding episodes or potential trauma and treatment with replacementFactor VIII or IX is imperative

• Prognosis has improved with the advent of factorconcentrate treatment in the 1960s, with fewersevere bleeds, less crippling arthritis fromhemarthrosis, and less intracranial bleeding

Vocational Implications ofHemophilia

• Vocational training should stress jobs that limit



• Vocational training should stress jobs that limit potentially hazardous situations

• People with hemophilia who are on effectivereplacement therapy can compete equally for most jobs

• For people with severe hemophilia, the ability toself-infuse agents effectively reduces morbidityand loss of work time

Sickle Cell Disease• Sickle cell disease causes

the red cell to assume anonpliable sickle shape



nonpliable sickle shape• The resultant cellular defect

leads to the mainmanifestations of thedisease, which include: – premature death of the cells

(hemolytic anemia) – vascular occlusion of vessels

and subsequent tissueinfarction – increased susceptibility to

infection

Sickle Cell Disease

• A person with sickle cell



A person with sickle cellis homozygous for theabnormal gene, therefore, both parents must beheterozygous for theabnormal gene

• The frequency of oneabnormal gene is the

African-American population is 1 in 12 andthe incidence of sickle cellanemia is 1 in 650

Functional Presentation of SickleCell Disease

• People with sickle cell diseaseusually present in the first



People with sickle cell diseaseusually present in the firstdecade of life withcomplications of the threemain characteristics of thedisorder

– Anemia

– Vascular occlusion (resultingin necrosis)

– Increase susceptability toinfections, particularly pneumococcal pneumonia

Humeral head infarction and osteonecrosis in 50 year old female with sickle cell disease

Complications of Sickle CellDisease

• pain episodes • kidney damage and



• pain episodes• strokes• increased infections

• leg ulcers• bone damage (osteo-necrosis)

• yellow eyes or

jaundice• early gallstones• lung blockage

• kidney damage andloss of body water inurine

• painful erections inmen (priapism)

• blood blockage in thespleen or liver(sequestration)

• eye damage• anemia• delayed growth

Treatment of Sickle Cell Disease• There is no specific treatment for sickle cell

disease therefore most therapy is supportive in



disease, therefore, most therapy is supportive intreatment of the complications

• Early recognition of infection, administration of prophylactic antibiotics, and vaccination mayforestall or prevent other complications

• If a painful crisis persists or there is infection ofa major organ (brain, lung, or heart), exchangetransfusion is performed to remove some of thesickle red cells - the effect is temporary

Treatment of Sickle Cell Disease

• General guidelines



General guidelines – Taking the vitamin folic acid (folate) daily to help

make new red cells – Daily penicillin until age six to prevent serious

infection – Drinking plenty of water daily (8-10 glasses foradults)

– Avoiding too hot or too cold temperatures

– Avoiding over exertion and stress – Getting plenty of rest – Getting regular check-ups from knowledgeable health

care providers

Prognosis of Sickle Cell Disease

• Prognosis has improved with good supportive



Prognosis has improved with good supportivecare, and many people with sickle cell diseasesurvive into middle age

• However, frequent admissions for painful crises,the complication of sickle cell disease, narcoticuse and abuse due to chronic pain, and absencefrom school and work lead to significant psychological and vocational problems

Vocational Implications of SickleCell Disease

• The greatest dysfunction was found in the areas of



The greatest dysfunction was found in the areas ofemployment, finances, sleep habits, and performance of daily activities

• The implications of these findings suggest a strongneed for vocational rehabilitation services, trainingin areas of communication and self-esteem,medical treatment, and psychological help fordepression and drug dependence

• Advisable that these individuals stay away from jobs that cannot be interrupted to take fluids, jobsthat involve extreme temperature changes, and jobs with lower O2 concentration

Additional Resources and Informationfrom the Web• Leukemia and Lymphoma Society (www.leukemia.org)• Lymphoma Information Network (www.lymphomainfo.net • Lymphoma Research Foundation (www lymphoma org)

http://www.leukemia.org/

http://www.lymphomainfo.net/

http://www.lymphoma.org/


http://www.lymphomainfo.net/

http://www.leukemia.org/



• Lymphoma Research Foundation (www.lymphoma.org)• Children's Leukemia Research Association

(www.childrensleukemia.org)• World Federation of Hemophilia (www.wfh.org)• National Hemophilia Foundation (www.hemophilia.org)• Sickle Cell Society (www.sicklecellsociety.org)• Sickle Cell Information Center (www.scinfo.org/)

Chapter 37Hematology


http://www.childrensleukemia.org/

http://www.wfh.org/

http://www.hemophilia.org/

http://www.sicklecellsociety.org/

http://www.scinfo.org/

http://www.scinfo.org/

http://www.sicklecellsociety.org/

http://www.hemophilia.org/

http://www.wfh.org/

http://www.childrensleukemia.org/




Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Objectives

• Describe physiology of blood components



Describe physiology of blood components

• Discuss pathophysiology and signs andsymptoms of specific hematologicaldisorders

• Outline general assessment andmanagement of patients with hematologicaldisorders


Scenario

You are called to a day camp on a sweltering summer dayt f hild h f i t d Y 6 ld ti t‘



y p g yto care for a child who fainted. Your 6-year-old patient‘slips and nail beds appear pale against her bronze skin. Herrespirations and heart rate are rapid, and she is veryanxious. She has a history of sickle cell disease and iscomplaining of severe abdominal pain. Counselors tell youthey had just finished a strenuous game when shecomplained of a headache and then passed out.


Discussion• Based on your present information, discuss

the urgency of this call



the urgency of this call

• What complications of her disease could

cause her present illness?• What additional assessments do you need to

perform?

• What are your priorities of care for thischild?


Hematological System

• Blood and blood-forming organs



Blood and blood forming organs

• Dysfunction affects other body systems

• Results in diffuse clinical manifestations


Blood and Blood Components

• Cells



• Formed elements – Red blood cells

(erythrocytes) – White blood cells

(leukocytes) – Cell fragments (platelets)

• Surrounded by plasma



• Chief functions



Chief functions – Delivery of substances needed for cellular

metabolism in tissues

– Defense against invading microorganisms andinjury – Acid-base balance



• Blood cells formed in red bone marrow



Blood cells formed in red bone marrow – Adults — Red marrow in membranous bone

• Vertebrae

• Pelvis• Sternum• Ribs

– Yellow marrow produces some white cells• Composed mainly of connective tissue and fat


Other Blood-Forming Organs• Lymph nodes

– Produce lymphocytes and antibodies



oduce y p ocytes a d a t bod es

• Spleen

– Produces lymphocytes, plasma cells, antibodies – Stores large quantities of blood

• Liver – Blood-forming organ during intrauterine life – Important role in coagulation process


Plasma• 92% water



• Three proteins – Albumin

• Most plentiful• Gives blood gummy texture• Keeps water concentration of blood low so that

water diffuses from tissues into blood

– Globulins — Transport proteins• Provide immunity to disease – Fibrinogen — Blood clotting




Red Blood Cells (RBCs)

• Most abundant cells in the body



Most abundant cells in the body

• Responsible for tissue oxygenation

• Mainly water and hemoglobin


Red Blood Cells (RBCs)

• Life span of about 120 days



Life span of about 120 days – As cells age:

• Internal chemical machinery weakens

• Lose elasticity• Become trapped in small blood vessels in bonemarrow, liver, and spleen

– Destroyed by specialized white blood cells• Macrophages


Mature Erythrocytes




Red Blood Cells (RBCs)• Hemoglobin (Hgb) normal levels

– Men: 13.5-18 g/100 mL

– Women: 12-16 g/100 mL



• RBCs: 4.5-5 million cells/mm3

• Hematocrit (Hct) – Fraction of total volume of blood that is RBCs – Normally about 45%

• Reticulocyte count

– Information about rate of RBC production


Hemoglobin Molecule




White Blood Cells (WBCs)• Arise from bone marrow



• Functions – Destroy foreign substances – Clear bloodstream of debris

• Leukocyte production increases wheninfection occurs – Elevated WBC count in blood


White Blood Cells (WBCs)

• Normal WBC count



– 5000-10,000 cells/mm3 – Monocytes: 5%

• Increase with chronic infections – Lymphocytes: 27.5% – Neutrophils: 65%

– Eosinophils and basophils together: 2.5%


White Blood Cells (WBCs)

• Leukocyte disorders



y – Leukemia

• Increased WBCs in tissues and/or blood

– Leukocytosis• Abnormal increase in circulating WBCs – Leukopenia

• Abnormal decrease in WBCs


The Inflammatory Process

• Redness, heat, swelling, pain



, , g, p

• Injured cells release histamine and othersubstances: – Cause blood vessels in injured tissue to dilate – Increased blood flow carries neutrophils and

monocytes (phagocytic cells) to site of injury


The Inflammatory Process

• Histamine and other substances cause wallsf bl d l l k



of blood vessels to leak – Fluid that collects in tissues contains fibrinogen

• Fluid and irritating chemicals accumulate atinjured site – Stimulate pain receptors


Immunity

• Cellular immunity



y

• Humoral immunity

• Autoimmune diseases

• Alterations in immunologic responseCopyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Platelets (Thrombocytes)

• Small, sticky cells



• Role in blood clotting

• Blood vessel is cut: – Platelets to site, swell into irregular shapes – Adhere to damaged vessel wall – Platelets ―plug‖ leak; cells stick to them, forming clot

– If vessel damage is too great, platelets signal clotting cascade


Platelets

• Clotting time normally 7-10 min



g y

• Prothrombin time (PT time) – Time it takes plasma to clot

• International normalized ratio (INR) – Assesses clotting efficiency


Blood Groups

• Mixed with foreign plasma, red blood cellsi h l h d



g p ,either clump together or do not

• Four types of human blood – A, B, AB, and O – Type A blood has anti-B antibodies

• Will clump type B blood – Type B blood has anti-A antibodies

• Will clump type A bloodCopyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Blood Groups

• Type AB blood has neither antibodyU i l i i t



yp y – Universal recipient

• Type O blood has both anti-A and anti-Bantibodies – Can only receive type O

• Type O blood has neither antigen – Can be given to any blood type – Universal donor


Rh Factor

• Presence or absence of Rh antigen onf f d bl d ll



gsurface of red blood cells – Person with the factor is Rh positive

– Person without it is Rh negative

• Antibodies to Rh factor acquired throughexposure to Rh-positive blood




Anemia• Hemoglobin or erythrocytes below normal

• Causes



– Chronic or acute blood loss – Decreased production of erythrocytes – Increased destruction of erythrocytes

• Iron-deficiency anemia

• Hemolytic anemia


.

Hematologic System



Hematologic System,Oncologic Disorders &

Anemias

19/04/2011 314

Hematology

• Study of blood and blood forming tissues• Key components of hematologic system



• Key components of hematologic systemare:

– Blood – Blood forming tissues• Bone marrow• Spleen• Lymph system

19/04/2011 315

What Does Blood Do?• Transportation

– Oxygen



– Nutrients – Hormones

– Waste Products• Regulation

– Fluid, electrolyte

– Acid-Base balance• Protection – Coagulation–

19/04/2011 316

Components of Blood• Plasma

– 55%



• Blood Cells – 45% – Three types

• Erythrocytes/RBCs• Leukocytes/WBCs

• Thrombocytes/Platelets

19/04/2011 317

Erythrocytes/Red Blood Cells

• Composed of hemoglobin• Erythropoiesis



• Erythropoiesis – = RBC production

• Stimulated by hypoxia• Controlled byerythropoietin – Hormone synthesized in kidney

• Hemolysis – = destruction of RBCs – Releases bilirubin into blood stream – Normal lifespan of RBC = 120 days19/04/2011 318

Leukocytes/White Blood Cells• 5 types

– Basophils



– Eosinophils – Neutrophils – Monocytes – Lymphocytes

19/04/2011 319

Types and Functions ofLeukocytes

Granulocytes

TYPE CELL FUNCTION



Neutrophil

EosinophilBasophil

Phagocytosis, early phase ofinflammationPhagocytosis, parasitic infectionsInflammatory response, allergicresponse

AgranulocytesLymphocyte

Monocyte

Cellular, humoral immune response

Phagocytosis; cellular immuneresponse

19/04/2011 320

Thrombocytes/Platelets

• Must be present for clotting to occurI l d i h i



• Involved in hemostasis

19/04/2011 321

Normal Clotting Mechanisms

• Hemostasis – Goal: Minimizing blood loss when injured



g j1. Vascular Response

– vasoconstriction

2. Platelet response – Activated during injury – Form clumps (agglutination)

3. Plasma Clotting Factors

– Factors I – XIII – Intrinsic pathway – Extrinsic pathway

19/04/2011 322

Anticoagulation

• Elements that interfere with blood clottingC t h i t bl d l tti



• Countermechanism to blood clotting — keeps blood liquid and able to flow

19/04/2011 323

Structures of the Hematologic System

• Bone MarrowLi



• Liver• Lymph System

19/04/2011 324

Bone Marrow

• Bone Marrow – Soft substance in core of bones



– Blood cell production(Hematopoiesis):The production of alltypes of blood cells generated by aremarkable self-regulated system that isresponsive to the demands put upon it.

• RBCs• WBCs• Platelets

19/04/2011 325

Liver

Receives 24% of the cardiac output (1500ml of blood each minute)• Liver has many functions



• Liver has many functions• Hematologic functions:

– Liver synthesis plasma proteins

includingclotting factors andalbumin – Liver clears damaged and non-functioning RBCs/erythrocytes fromcirculation

19/04/2011 326

Spleen

• Located in upper L quadrant ofabdomen

• Functions



• Functions – Hematopoietic function

• Produces fetal RBCs – Filter function

• Filter and reuse certain cells – Immune function

• Lymphocytes, monocytes

– Storage function• 30% platelets stored in spleen

19/04/2011 327

Effects of Aging on theHematologic System

• CBC Studies– Hemoglobin (Hb or Hgb)



– Hemoglobin (Hb or Hgb) – response to infection (WBC)

– Platelets=no change• Clotting Studies

– PTT

19/04/2011 328

Assessment of the Hematologic System

• Subjective Data– Important Health Information



– Important Health Information• Past health history• Medications• Surgery or other treatments

19/04/2011 329

Assessment ofthe Hematologic System (cont.)

– Functional Health Patterns• Health perception – health management• Nutritional– metabolic



Nutritional metabolic• Elimination• Activity – exercise

• Sleep – rest• Cognitive – perceptual• Self-perception – self-concept• Role – relationship

• Sexuality – reproductive• Coping – stress tolerance• Value – belief

19/04/2011 330

Assessment ofthe Hematologic System (cont.)

• Objective Data – Physical Examination

Ski



• Skin• Eyes• Mouth• Lymph Nodes• Heart and Chest• Abdomen• Nervous System

• Musculoskeletal System

19/04/2011 331

Diagnostic Studies of the Hematologic System:Complete Blood Count (CBC)

• WBCs – Normal 4,000 -11,000 µ/ℓ – Associated with infection, inflammation, tissue injury or death– Leukopenia -- WBC

http://en.wikipedia.org/wiki/Image:CBC_with_Hct.jpg




Leukopenia WBC – Neutropenia -- neutrophil count

• RBC

– ♂ 4.5 – 5.5 x 106

/ℓ – ♀ 4.0 – 5.0 x 106/ℓ

• Hematocrit (Hct) – The hematocrit is the percent of whole blood that is composed

of red blood cells. The hematocrit is a measure of boththenumber of red blood cells and the size of red blood cells.

19/04/2011 332

Diagnostic Studies of the Hematologic System:Complete Blood Count (CBC) Cont‘d

• Platelet count– Normal 150 000- 400 000

http://www.nlm.nih.gov/medlineplus/ency/article/003644.htm







– Normal 150,000- 400,000 – Thrombocytopenia- platelet count

– Spontaneous hemorrhage likely when count is below 20,000

• Pancytopenia• Decrease in number of RBCs, WBCs, and platelets

19/04/2011 333

Diagnostic Studiesof the Hematologic System

• Radiologic Studies– CT/MRI of lymph tissues



CT/MRI of lymph tissues• Biopsies

– Bone Marrow examination – Lymph node biopsies

19/04/2011 334





19/04/2011 336

Common Laboratory Tests for Hematologic and Lymphatic Disorders



19/04/2011 337



19/04/2011 338

Common Laboratory Tests for Hematologic and Lymphatic Disorders



19/04/2011 339

Hematologic Disorders



Hematologic Disorders

CBC Normal Adult Values

• WBC 5,000 – 10,000/mm3

• RBC 4.5 – 5.5 million/mm3 (4 – 5 females)H b 14 17 /dl (12 16 f l )



• Hgb 14 – 17 g/dl (12 – 16 females)• Hct 42 – 52% (36 – 48 females)

• MCV 84 – 96 fL• MCH 28 – 34 pg/cell• MCHC 32 – 36 g/dl• Platelets 140,000 – 400,000/mm3• RDW 11.5 – 14.5%• MPV 7.4 – 10.4 fL

WBC Differential

• Segs/Polys: 50 – 62%• Band/Stabs 3– 6%



Band/Stabs 3 6%• Eos 0 – 3%• Baso 0 – 1%• Monos 3 – 7%• Lymphs 25 – 40%• Metas 0 – 1%

Alterations in Erythrocyte Function

• Anemias– reduction in the total number of circulating



reduction in the total number of circulatingerythrocytes or a decrease in the quality orquantity of hemoglobin

– Etiology• Impaired Erythrocyte Production• Blood Loss

• Increased Erythrocyte Destruction• Combination of the Above Causes

Anemias

• Classification based on Morphology – Size: normocytic, macrocytic, microcytic



y , y , y – Color: normochromic, hypochromic,

hyperchromic – Other• Anisocytic – varied size• Poiilocytosis – varied shape

Measures of Morphology

• Mean Corpuscular Volume (MCV) – (Hct X 10)/RBC



( )• Mean Corpuscular Hemoglobin (MCH)

– (Hgb X 10)/RBC• Mean Corpuscular Hemoglobin

Concentration (MCHC) – (Hgb/Hct) X 100

Clinical Manifestations of Anemia

• Gradual vs. Sudden – gradual = usually less symptomatic because ofcompensation



p – sudden = usually more symptomatic

• Magnitude – Hgb of 8 g would be more likely to be symptomatic – Hgb of 12 g would be less likely to be symptomatic

• Classic Signs of Anemia – Pallor – Fatigue – Dyspnea on Exertion (DOE) – Dizziness

Clinical manifestations

• Compensatory Manifestations – Cardiovascular (stress response) to pump the decreased amount ofoxygen to the vital organs most efficiently

• Tachycardia



• Tachycardia• Palpitations• Vasoconstriction

• Respiratory – to increase the effectiveness of breathing inorder to optimize the uptake of oxygen – tachypnea – increased breathing depth

• Other – increased plasma volume – interstitial fluid moves into the vascularspace – salt and water retention ( because of activation of the Renin-

Angiotensin-Aldosterone (RAA) system)

Macrocytic-Normochromic Anemia(Megaloblastic)

• Characterized by defective DNA synthesis that produces a pattern of ineffective erythropoiesis,resulting in unusually large stem cells in the bone



resulting in unusually large stem cells in the bonemarrow called megaloblasts that mature into

unusually large and fragile erythrocytes that maydie prematurely resulting in increased bilirubinlevels.

• CBC characteristics

– Anemia – Macrocytic – Normochromic or Hyperchromic

Megaloblast Anemias

• Pernicious Anemia – Vit B12 Deficiency – Pernicious means highly injurious or destructive,i di i i f l i l if d



indicating its fatal potential if untreated• Etiology

– Chronic condition caused by malabsorption of vitaminB12

– Decreased intake of Vitamin B12 (strict vegetarians)• Animal products

– Meat, shellfish – Milk, eggs

• Stored in liver for 3-5 years

Pernicious Anemia cont

• Etiology – Defective gastric secretion of Intrinsic factor



g(IF) from parietal cells of gastric mucosa

• Congenital• Following partial or complete gastrectomy• Autoimmune gastric atrophy• Chronic atrophic gastritis

– Heavy alcohol, hot tea, smoking – More common in elderly

Pernicious Anemia

• Clinical Manifestations – Classic signs of anemia – Neurologic manifestations with severe anemia (<7 g/dl)



g ( g )• Vitamin B12 is necessary for the synthesis of myelin• Parasthesias of feet and fingers

• Ataxia• Loss of position and vibration sense• Spasticity

– Sore tongue, beefy red (unknown cause) – Hyperbilirubinemia

• Jaundice/icterus• ―Lemon yellow‖ skin – combination of pallor and jaundice

– Hepatosplenomegaly – enlarged liver and spleen

Pernicious Anemia

• Evaluation – CBC analysis



– Clinical manifestation analysis – B12 levels – Schilling test – Vit B12 absorption is measured

by administering radioactive Vitamin B12 andmeasuring its excretion in the urine

– Intrinsic factor evaluation – Bone marrow aspiration and analysis



Vitamin B12

• Cyanocobalamin – Routes: PO, Intranasally, IM, SC



• Oral Preferred

– Adverse effects: hypokalemia – PO: 1000-10,000 micrograms/day tx6 micrograms/day dietary supplement

– IM, SC: typically 30 micg/day x 5-10daysthen 100 to 200 micg/month

– Intranasal 500 micg/spray once a week

B12 Treatment Considerations

• Monitor B12 levels• Monitor Hemogram and reticulocytes



g y• Give Folic acid with B12 for severe anemia• Folic acid caution

Folate Deficiency

• Megaloblastic anemia• Etiology low folic acid levels• Sources: liver yeast fruits leafy vegetables eggs milk



Sources: liver, yeast, fruits, leafy vegetables, eggs, milk – Absorbed in upper small intestine and is not IF

dependent – Circulates through the liver with very little storage – Deficiency is most common with select groups

• Pregnancy and lactation (increased need)• Fad diets with decreased intake of folate• Alcoholic persons (ETOH interferes with folate metabolism)• Chronically malnourished• Sprue

Folate deficiency anemia

• Clinical Manifestations – Classic signs of anemial f



– No neurologic manifestations – Manifestations related to malnourishment

• painful ulcerations of cheeks and tongue• fissuring of lips and mouth

– Gastrointestinal symptoms

• Dysphagia• Flatulence• Watery diarrhea

Folate Deficiency Anemia

• Evaluation – CBC



– Clinical Manifestations

– Folic acid levels – Bone marrow aspiration and analysis

Folate deficiency anemia

• Treatment – Folic acid requires B12 to be converted toactive form



active form – In large amounts, Folic acid is converted via an

alternate pathway – Two forms of treatment are available

• Active form: leucovorin, folinic acid, citrovorumfactor

• Inactive form: folacin, folate, pterolyglutamic acid,folic acid• Inactive form is more common

Folic Acid

• Indications – Treatment of Folic acid deficiency anemia



– Prophylaxis for deficiency during pregnancy

– Initial tx of severe B12 deficiency• Adverse effects: no known• Routes: PO, IM, SC, IV

• Dosage: 1000 – 2000 micrograms/day400 micrograms/day

Folic Acid

• Treatment Guidelines – Monitor CBC and reticulocytes



– If malabsorption is cause, diet alone will not be

sufficient – Oral is preferred



Fe Deficiency Anemia

• Pathophysiology – The body maintains a balance between iron thatis in use as Hgb and iron that is in storage for



is in use as Hgb and iron that is in storage forfuture Hgb synthesis

– As old RBCs are broken down, iron is recycled – Inadequate intake of iron-rich foods

• Children with increased need related to growth• Pregnancy• Iron poor diet


• Pathophysiology cont – Increased iron loss through bleeding,• Menorrhagia– excessive menstrual bleeding



• Menorrhagia – excessive menstrual bleeding• Medications that cause GI bleeding (ASA, NSAIDS)

• Hemorrhoids• Ulcerative Colitis (bloody diarrhea)• Chronic blood loss with gastric or duodenal ulcers• Neoplasms which erode into blood vessels

– Decreased iron related to parasitic infection (i.e.hookworms metabolize iron)


• Clinical Manifestations – Classic signs of anemia – Structural and functional changes in epithelial tissue as

lt f i i d ill i l ti ( ll t



a result of impaired capillary circulation (usually not present unless the anemia is severe, < 7 g/dl)

• nails – brittle, thin, coarsely ridged, spoon-shaped(koilonychia)• Tongue – sore, red, burning caused by atrophy of the papillae

(glossitis)• Sore, dry skin at the corners of the mouth called ―angular

stomatitis‖

• Difficulty swallowing related to a mucous web at the level ofthe hypopharynx and epiglottis (consisting of mucous &inflammatory cells)


• Clinical manifestations – Deficient iron containing enzymes• gastritis



gastritis• headache

– Neuromuscular changes probably related to hypoxia(gait problems are rare)• numbness• tingling

– Confusion, disorientation, memory loss (elderly) – Pica


• Evaluation – CBC analysisClinical manifestation analysis



– Clinical manifestation analysis – Serum Iron profile

• Plasma Iron (Fe)• Total Iron Binding Capacity (TIBC)• Transferrin – carrier protein for iron• Ferritin – storage form of iron

• Free Erythrocyte Protoporphyrin (FEP) – indicator of hemesynthesis within erythrocytes – Bone Marrow aspiration and analysis


• Treatments – eliminate causes of blood loss



– administer iron

– offer dietary counseling – blood transfusion – monitor reticulocyte count for evidence of

responseto therapy

Iron Therapy

• Oral Iron Preparations – Iron Saltslf ( )



• Ferrous Sulfate (DOC)• Ferrous Fumarate• Ferrous Gluconate

– Carbonyl Iron – Parenteral Iron

• Iron Dextran• Sodium-ferric Gluconate Complex ad Iron Sucrose

Ferrous Sulfate

• Least expensive• Standard by which other therapies arejudged



judged

• Indications – Tx of Iron Deficiency Anemia – Prophylaxis

• Adverse Effects – GI side effects – Staining of teeth (liquid forms

Ferrous Sulfate

• Toxicity – Rare from therapeutic dosing



– Mostly accidental or intentional overdosing

– Adult fatality rare – Child mortality common• NVD, shock, then acidosis, gastric necrosis, hepatic

failure, pulmonary edema, vasomotor collapse• Early dx saves lives :Fe levels and gastric x-ray

Ferrous Sulfate

• Drug Interactions – Antacids decrease iron absorptionTetracyclines decrease absorption of both



– Tetracyclines decrease absorption of both – Ascorbic acid increases absorption and side

effects• Formulations IR and SR• Dosage and administration

– Elemental Iron is key – Relationship to meals

Carbonyl Irons

• Pure elemental Iron



Parenteral Iron

• Iron Dextran anaphylaxis precautions• Other



– Sodium-Ferric Gluconate

– Iron Sucrose

Microcytic Hypchromic Anemia

• Sideroblastic Anemia – – group of hereditary and acquired microcytichypochromic anemias characterized by



hypochromic anemias characterized byinefficient iron uptake resulting indysfunctional hemoglobin synthesis

Normocytic-Normochromic Anemia

• Characterized by erythrocytes that arerelatively normal in size and hemoglobincontent but insufficient in number



content, but insufficient in number

• CBC characteristics – Anemia – Normocytic

– Normochromic

Aplastic Anemia

• Pathophysiology – Caused by bone marrow failure (hypoplasia oraplasia)



aplasia) – Pancytopenia is common (RBC, WBC, &

platelet counts are all low) – Pure red cell aplasia (PRCA) is an associated

condition - only red cells are affected

Aplastic Anemia• Etiology

– Acquired• Primary - Idiopathic• 50% of all confirmed cases



• 80% of Aplastic anemia occuring over age 50 – Secondary

• Chemicals – Benzene – Chloramphenicol – Chemotherapy for cancer treatment

• Ionizing radiation

– Hereditary – Fanconi anemia – rare genetic anemia – Has been observed to be a precursor to leukemia for some persons(preleukemic condition)

Aplastic Anemia

• Clinical manifestations – Classic signs of anemiaIf WBC l t i f ti



– If WBCs are low – expect infection

– If platetets are low – expect bleeding• Evaluation – CBC

– Bone Marrow Biopsy analysis

Aplastic Anemia

• Treatment – Treat underlying disorderP t f th t l g t



– Prevent further exposure to causal agent

– Blood transfusions – Bone Marrow Transplant

Post-Hemorrhagic Anemia

• Pathophysiology – Caused by acute blood lossI di t ff t th f l



– Immediate effects are those of volumedepletion

• Fluid Volume Deficit• Hypovolemic Shock

– The stress response attempts to compensate forthe volume loss

Post Hemmorhagic Anemia

• Clinical Manifestations – Sympathetic Nervous system (SNS) stimulation – If greater than 50% blood loss



g• Shock

• Lactic Acidosis• Death – Classic Signs of anemia – If the blood loss becomes chronic – loss of iron

recycling results in the development of iron deficiencyanemia – with clinical manifestations as describedabove


• Evaluation – CBC analysisVital signs assessment &Physical examination



– Vital signs assessment &Physical examination

– History driven• Look for bleeding if not obvious


• Treatment – Stop the bleedingAdminister fluids



– Administer fluids

– Blood transfusion

Hemolytic Anemia

• Pathophysiology – Premature, accelerated destruction of RBCsErythropoiesis is normal and often accelerates



– Erythropoiesis is normal and often acceleratesin an attempt to compensate for the increaseddestruction

– Elevated Bilirubin levels often occur as aconsequence of the increased destruction

• Jaundice• Icterus (scleral icterus)

Hemolytic Anemia

• Etiology – Acquired• Immune Mediated



• Immune Mediated• Traumatic• Infectious• Toxic• Physical

• Hypophosphatemic

Hemolytic Anemia

• Etiology cont. – Hereditary• Structural Defects



Structural Defects• Enzyme Deficiencies• Defects of Globin synthesis or structure

– Sickle cell anemia – Thalassemia

Hemolytic Anemia

• Clinical Manifestations – Classic Signs of Anemia – Jaundice



– Splenomegaly

• Evaluation – CBC analysis – Bone Marrow studies – Clinical Manifestation analysis – Other tests for immune status or Hgb examination etc.

depending on the cause of the hemolysis

Hemolytic Anemia

• Treatment – Remove the causeTreat the underlying disorder



– Treat the underlying disorder

– Blood transfusions – Splenectomy if that is a site where hemolysis isoccurring

– Corticosteroids to treat immune mediatedhemolysis

– Administration of folate, iron, erythropoietin

Anemia of Chronic Disease (ACD)

• Pathophysiology – Most common anemia in the hospitalizedpatient



patient – Three pathogenic mechanisms cause ACD

• Decreased erythrocyte lifespan• Failure of mechanisms of compensatory

erythropoiesis

• Disturbances of the iron cycle


• Etiology – Chronic Infections• HIV



HIV• Hepatitis C

– Chronic inflammatory diseases• RA• SLE

• IBD – Malignancies


• Clinical Manifestations – Classic signs of anemia– Usually normocytic-normochromic but may be



– Usually normocytic-normochromic but may bemicrocytic-hypochromic if iron cycle isseverely affected

– Manifestations of Iron deficiency anemia ifmicrocytic-hypochromic


• Evaluation – CBC analysis– Screening for malignancies if chronic infection



– Screening for malignancies if chronic infectionor inflammation is not present

• Treatment – Treat the underlying disorder – Administer Erythropoietin – Blood transfusion

Hemoglobin Blood Products• Packed Red Blood Cells (PRBCs)

– No plasma; easier to store – Less likelihood of fluid overload

• Whole Blood



Whole Blood – Contains clotting factors and proteins

• Both – Used to replace blood losses – Contains hemoglobin – Can transmit viruses – Carry oxygen to cells – Contain citrates – may affect calcium levels

PRBCs and Whole Blood• Poor shelf life, expensive (testing), availability varies• Must be typed and cross-matched (time consuming)• Many patients have developed antibodies against all blood

groups (patients with prior blood transfusions), and PRBCs



groups (patients with prior blood transfusions), and PRBCsand whole blood must be "washed" to remove antigens

• Can transmit viruses and other pathogens• Adverse (allergic) reactions common

– RN must follow strict protocols when transfusing – Nursing students are not allowed to transfuse PRBCs and whole

blood !!!

Other Blood Products

• Frosh Frozen Plasma (FFP)• Albumin• Platelets



• Platelets

• Clotting Factors

Anemia

• Anemia is a reduction in the numberof RBCs, the quantity of hemoglobin,or the volume of RBCs



• Because the main function of RBCs isoxygenation, anemia results in varyingdegrees of hypoxia

19/04/2011 397

Anemia

• Prevalent conditions – Blood loss– Decreased production of erythrocytes



Decreased production of erythrocytes

– Increased destruction of erythrocytes

19/04/2011 398

Anemia (cont’d)• Clinical Manifestations:

1. Pallor.2. Fatigue, weakness.3. Dyspnea.4 P l i i h di



4. Palpitations, tachycardia.

5. Headache, dizziness, and restlessness.6. Slowing of thought.7. Paresthesia.

19/04/2011 399

Anemia (cont’d)Nursing Management:

1. Direct general management toward addressing the causeof anemia and replacing blood loss as needed to sustainadequate oxygenation.

2 Promote optimal activity and protect from injury



2. Promote optimal activity and protect from injury.

3. Reduce activities and stimuli that cause tachycardia andincrease cardiac output.4. Provide nutritional needs.5. Administer any prescribed nutritional supplements.

6. Patient and family education

19/04/2011 400

Nursing Actions for a Patient who is Anemicor Suffered Blood Loss

• Administer oxygen as prescribed• Administer blood products as prescribed• Administer erythropoietin as prescribed



• Allow for rest between periods ofactivity

• Elevate the pt‘s head on pillows duringepisodes of shortness of breath

• Provide extra blankets if the pt feels cool• Teach the pt/family about underlying

pathophysiology and how to manage the19/04/2011 401

Anemia Caused by Decreased ErythrocyteProduction

• Iron Deficiency Anemia• Thalassemia• Megablastic Anemia



• Megablastic Anemia

19/04/2011 402

Iron-Deficiency AnemiaEtiology

1. Inadequate dietary intake• Found in 30% of theworld‘s population



2. Malabsorption• Absorbed in duodenum• GI surgery

3. Blood loss

• 2 mls blood contain 1mg iron• GI, GU losses4. Hemolysis19/04/2011 403

Iron-Deficiency Anemia• Clinical Manifestations

– Most common: pallor – Second most common: inflammation of the tongue

(glossistis) – Cheilitis=inflammation/fissures of lips

S iti it t ld



– Sensitivity to cold

– Weakness and fatigue• Diagnostic Studies – CBC – Iron studies Diagnostics: – Iron levels: Total iron-binding capacity (TIBC), Serum

Ferritin. – Endoscopy/Colonscopy

19/04/2011 404

Iron-Deficiency Anemia• Collaborative Care

– Treatment of underlying disease/problem – Replacing iron – Diet



– Drug Therapy

• Iron replacement – Oral iron

» Feosol, DexFerrum, etc» Absorbed best in acidic environemtn» GI effects

– Parenteral iron» IM or IV» Less desirable than PO

19/04/2011 405

Iron-Deficiency AnemiaNur sing M anagement

• Assess cardiovascular & respiratory status

• Monitor vital signs• Recognizing s/s bleeding

– Monitor stool, urine and emesis for occult blood



• Diet teaching — foods rich in iron• Provide periods of rest• Supplemental iron• Discuss diagnostic studies• Emphasize compliance• Iron therapy for 2-3 months after the hemoglobin

levels return to normal19/04/2011 406

Thalassemia• Etiology

– Autosomal recessive genetic disorder ofinadequate production of normal hemoglobinFound in Mediterranean ethnic groups



– Found in Mediterranean ethnic groups

• Clinical Manifestations – Asymptomatic major retardation life

threatening

– Splenomegaly, hepatomegaly

19/04/2011 407

ThalassemiaColl aborative Care

• No specific drug or diet are effective intreating thalassemia• Thalassemia minor



– Body adapts to ↓ Hgb• Thalassemia major

– Blood transfusions with IV deferoxamine (usedto remove excessiron from the body)

19/04/2011 408

Megaloblastic Anemias• Characterized by large

RBCs which are fragileand easily destroyedC f f

http://en.wikipedia.org/wiki/Iron

http://en.wikipedia.org/wiki/Iron



• Common forms ofmegaloblastic anemia1. Cobalamin deficiency2. Folic acid deficiency

This picture shows large, dense,oversized, red blood cells (RBCs)that are seen in megaloblasticanemia.

19/04/2011 409

Cobalamin (Vitamin B12)Deficiency

• Cobalamin Deficiency--formerly known as

pernicious anemia• Vitamin B 12 (cobalamin) is an important water- soluble vitamin.

• I t i i f t (IF) is required for cobalamin



• Intrinsic factor (IF) is required for cobalamin

absorption• Causes of cobalamin deficiency – Gastric mucosa not secreting IF – GI surgery loss of IF-secreting gastric mucosal cells – Long-term use of H2-histamine receptor blockers cause

atrophy or loss of gastric mucosa. – Nutritional deficiency – Hereditary defects of cobalamine utilization19/04/2011 410

Cobalamin (Vitamin B12)Deficiency

• Clinical manifestations – General symptoms of anemia – Sore tongue

Anorexia



– Anorexia

– Weakness – Parathesias of the feet and hands – Altered thought processes

• Confusion dementia

19/04/2011 411

Cobalamin DeficiencyDiagnostic Studies

• RBCs appear large• Abnormal shapes• Structure contributes to erythrocyte



Structure contributes to erythrocyte

destruction• Schilling Test: a medical investigation usefor patients withvitamin B12 deficiency.

The purpose of the test is to determine if t patient has pernicious anemia.19/04/2011 412

Cobalamin Deficiency

• Collaborative Care – Parenteral administration of cobalamin – ↑ Dietary cobalamin does not correct the anem

http://en.wikipedia.org/wiki/Vitamin_B12

http://en.wikipedia.org/wiki/Pernicious_anemia

http://en.wikipedia.org/wiki/Pernicious_anemia





y

• Still important to emphasize adequate dietary intake – Intranasal form of cyanocobalamin (Nascobal)is available

– High dose oral cobalamin and SL cobalamin cause be used

19/04/2011 413

Cobalamin Deficiency• Nursing Management

– Familial disposition• Early detection and treatment can lead to reversal of

symptoms



symptoms

– Potential for Injury r/t patient‘s diminishedsensations to heat and pain – Compliance with medication regime – Ongoing evaluation of GI and neuro status

• Evaluate patient for gastric carcinoma frequently

19/04/2011 414

Folic Acid Deficiency• Folic Acid Deficiency also causes

megablastic anemia (RBCs that are largeand fewer in number)• Folic Acid required for RBC formation an



q

maturation• Causes – Poor dietary intake – Malabsorption syndromes – Drugs that inhibit absorption – Alcohol abuse–

19/04/2011 415

Folic Acid Deficiency • Clinical manifestations are similar to those of

cobalamin deficiency• Insidious onset: progress slowly• Absence of neurologic problems• Treated by folate replacement therapy



• Encourage patient to eat foods with large amounts offolic acid

• Leafy green vegetables• Liver• Mushrooms• Oatmeal (ش و ر ج م ل ن ف (ل• Peanut butter• Red beans19/04/2011 416

Anemia of Chronic Disease• Underproduction of RBCs, shortening of RBC

survival• 2nd most common cause of anemia (after irondeficiency anemia

• Generally develops after 1-2 months of sustained



• Generally develops after 1-2 months of sustained

disease• Causes – Impaired renal function – Chronic, inflammatory, infectious or malignant disease – Chronic liver disease – Folic acid deficiencies – Splenomegaly – Hepatitis19/04/2011 417

Aplastic Anemia• Characterized by Pancytopenia

– ↓ of all blood cell types • RBCs• White blood cells (WBCs)



• Platelets – Hypocellular bone marrow

• Etiology – Congenital

• Chromosomal alterations – Acquired

• Results from exposure to ionizing radiation, chemical agents,viral and bacterial infections

19/04/2011 418

Aplastic Anemia • Etiology

– Low incidence• Affecting 4 of every 1 million persons

– Manageable with erythropoietin or blood transfusion – Can be a critical condition



• Hemorrhage• Sepsis

19/04/2011 419

Aplastic Anemia • Clinical Manifestations

– Gradual development – Symptoms caused by suppression of any or all bonemarrow elements

– General manifestations of anemia



• Fatigue• Dyspnea• Pale skin• Frequent or prolonged infections• Unexplained or easy bruising• Nosebleed and bleeding gums• Prolonged bleeding from cuts• Dizziness• headache19/04/2011 420

Aplastic Anemia

• Diagnosis – Blood tests• CBC



– Bone marrow biopsy

19/04/2011 421

Aplastic Anemia

• Treatment – Identifying cause – Blood transfusions

Antibiotics



– Antibiotics – Immunosuppressants (neoral, sandimmune)

• Corticosteroids (Medrol, solu-medrol) – Bone marrow stimulants

• Filgrastim (Neupogen)• Epoetin alfa (Epogen, Procrit)

– Bone marrow transplantation19/04/2011 422

Aplastic Anemia • Nursing Management

– Preventing complications from infection andhemorrhage

– Prognosis is poor if untreated



• 75% fatal

19/04/2011 423

Anemia Caused By Blood Loss• Acute Blood Loss• Chronic Blood Loss



19/04/2011 424

Acute Blood Loss

• Result of sudden hemorrhage – Trauma, surgery, vascular disruption• Collaborative Care



1.Replacing blood volume2.Identifying source of hemorrhage3.Stopping blood loss

19/04/2011 425

Chronic Blood Loss• Sources/Symptoms

– Similar to iron deficiency anemia – GI bleeding, hemorrhoids, menstrual blood

loss



• Diagnostic Studies – Identifying source – Stopping bleeding

• Collaborative Care – Supplemental iron administration

19/04/2011 426

Anemia caused by Increased ErythrocyteDestruction

• Hemolytic Anemia – Sickle Cell disease (peds) – Acquired Hemolytic Anemia



– Hemochromatosis – Polycythemia

19/04/2011 427

Hemolytic Anemia• Destruction or hemolysis of RBCs at a rate that exceeds

production

• Third major cause of anemia• Intrinsic hemolytic anemia

– Abnormal hemoglobin– Enzyme deficiencies



Enzyme deficiencies

– RBC membrane abnormalities• Extrinsic hemolytic anemia – Normal RBCs – Damaged by external factors

• Liver• Spleen• Toxins• Mechanical injury (heart valves)19/04/2011 428

Sequence of Events in Hemolysis



Fig. 30-119/04/2011 429

Acquired Hemolytic Anemia• Causes

– Medications – Infections

• Manifestations



a estat o s – S/S of anemia

• Complications – Accumulation of hemoglobin molecules can

obstruct renal tubules Tubular necrosis• Treatment

– Eliminating the causative agent19/04/2011 430

Potential Nursing Dx for Patients withAnemia

• Activity Intolerance r/t weakness, malaise m/bdifficulty tolerating↑‘d activity • Imbalance nutrition: less than body requirements r/t poor intake, anorexia, etc. m/b wt loss, serumalbumin, iron levels, vitamin deficiencies, below idealbody wt



body wt.• Ineffective therapeutic regimen management r/t lackof knowledge about nutrition/medications etc. m/b

ineffective lifestyle/diet/medication adjustments• Collaborative Problem: Hypoxemia r/t hemoglobin

19/04/2011 431

Hemochromatosis• Iron overload disease• Over absorption and

storage of iron causingdamage especially to



damage especially toliver, heart and pancreas

19/04/2011 432

Polycythemia• Polycythemia is a condition in which

there is a net increase in the total numberof red blood cells• Overproduction of red blood cells may



p y

be due to – a primary process in the bone marrow (a so-called myeloproliferative syndrome)

– or it may be a reaction to chronically lowoxygen levels or

– malignancy19/04/2011 433

Polycythemia

• Complications – ↑d viscosity of blood – hemorrhage and thrombosis



• Treatment – Phlebotomy – Myelosupressive agents: A number of new

therapeutic agents such as, interferon alfa-2b (Intron A) therapy,

agents that target platelet number (e.g., anagrelide [Agrylin]), and platelet function (e.g., aspirin).

19/04/2011 434

Thrombocytopenia• Disorder of decreased platelets

• platelet count below 150,000• Causes – Low production of platelets – Increased breakdown of platelets



p

• Symptoms – Bruising – Nosebleeds

– Petechiae (pinpoint microhemorrhages)

19/04/2011 435

Thrombocytopenia• Types of Thrombocytopenia

– Immune Thrombocytopenic Purpura• Abnormal destruction of circulating platelets• Autoimmune disorder• Destroyed in hosts‘ spleen by macrophages



• Destroyed in hosts spleen by macrophages

– Thrombotic Thrombocytopenic Purpura• d agglutination of platelets that from microthrombi

19/04/2011 436

Heparin-Induced Thrombocytopenia (HIT)

– HIT

• Associated with administration of heparin• Develops when the body develops an antibody, or allergy to heparin• Heparin (paradoxically) causes thrombosis• Immune mediated response that casues intense platelet activation and

relaese of procoaggulation particles



relaese of procoaggulation particles.

– Clinical features• Thrombocytopenia• Possible thrombosis after heparin therapy

– Can be triggered by any type, route or amount of heparin

19/04/2011 437

ThrombocytopeniaDiagnostic Studies

– Platelet count – Prothrombin Time (PT) – Activated Partial Thromboplastin Time (aPTT)

Hgb/Hct



– Hgb/Hct

• Treatment – Based on cause – Corticosteroids – Plasmaphoresis – Splenectomy – Platelet transfusion

19/04/2011 438

Iron-Deficiency Anemia

• Iron critical to bind oxygen – Lack of iron inhibits hemoglobin production in bone marrowCells small and pale centered



– Cells small and pale centered – Reduced oxygen-carrying capacity


Iron-Deficiency Anemia

• Causes – Diet low in iron – Vitamin deficiency

NSAID ASA th



– NSAID or ASA therapy – GI disorders – Bleeding (internal or external) – Gastrectomy


Hemolytic Anemia• Premature red cell destruction

– Hemolysis

• Inherited disorder inside red cell– Abnormal rigidity of cell membrane



Abnormal rigidity of cell membrane

• Acquired disorder – Mechanical forces disrupt RBCs – Autoimmune disorders – Microorganisms


Anemia — Signs and Symptoms• Fatigue and headaches

• Sore mouth or tongue

• Brittle nails



• Severe - breathlessness and chest pain

• Fever

• Skin or mucous membrane bleedingCopyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Anemia

• Treatment to correct, modify, or diminish process leading to: – Defective red cell production

Reduced red cell survival



– Reduced red cell survival

• Diagnosis – History – Laboratory tests


Leukemia

• Several types of cancer

• Disorganized proliferation of WBCs in bone



marrow

• Impairs normal RBC production

• Acute or chronicCopyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Leukemia — Signs and Symptoms• Fatigue• Bone pain• Elevated temperature• Diaphoresis• Heat intolerance

• Bruising• Headache• Weight loss• Night sweats• Enlarged lymph nodes



• Heat intolerance• Abdominal fullness• Bleeding

Enlarged lymph nodes• Enlarged spleen, testes,

liver


Leukemia

• Diagnosed by bone marrow biopsy• Treatment

Transfusion



– Transfusion – Antibiotics – Anticancer drugs – Radiation – Bone marrow transplant


Lymphomas

• Group of diseases

• Slowly growing chronic disorders to rapidly



evolving, acute conditions

• Hodgkin‘s disease

– Others called non-Hodgkin‘s lymphomas Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Hodgkin‘s Disease • Malignant disorder of lymphoid tissue

– Mainly in lymph nodes and spleen

• Enlargement of lymph nodes – Cancer cells multiply – Displace healthy lymphocytes – Suppress immune system



• Sign and symptoms

• Diagnosis

• TreatmentCopyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Hodgkin‘s Disease • Swollen nodes in neck, armpits, groin

• Fatigue

• Chills

• Night sweats



• Itching, cough, weight loss

• Shortness of breath, chest pain

• Peak incidence in 20s


Hodgkin‘s Disease

• Confirmed by finding Reed-Sternberg cells

• Treatment varies



– Radiation – Chemotherapy

• Curable cancerCopyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Non-Hodgkin‘s Lymphomas • Nature and activity of abnormal cells

– Over 10 types of non-Hodgkin‘s lymphoma – Vary in severity



• Signs and symptoms – Lymph node swelling – Enlarged liver, spleen

– Fever – Abdominal painCopyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Non-Hodgkin‘s Lymphomas

• Cause mostly unknown – Some linked to Epstein-Barr virus, HIV



• Treatment – Radiation therapy – Anticancer drugs – Bone marrow transplantation


Polycythemia

• Excess production of RBCs, WBCs, and platelets



• Response to hypoxia (secondary polycythemia)

• Unknown reasons (primary polycythemia)Copyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Polycythemia Vera

• Increased RBC production• Headache, dizziness• Blurred vision



• Itching• Red hands/feet; red-purple complexion• Hypertension

• SplenomegalyCopyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Disseminated Intravascular Coagulopathy(DIC)

• Complication of severe injury, trauma, or disease

– Abnormal clotting disorder

• Disrupts balance between: – Procoagulants and inhibitors



– Thrombus formation and lysis

• Signs and symptoms

• ManagementCopyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

DIC• Dyspnea, bleeding, hypotension

• Two phases – Free thrombin in blood, fibrin deposits,

aggregation of platelets



– Hemorrhage from depletion of clotting factors

• Management

– Correction of underlying disorder – Blood productsCopyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Hemophilia• Inherited bleeding disorder

– Hemophilia A• Deficiency of factor VIII

– Hemophilia B• Deficiency of factor IX



• Bleeding may occur after minor injury orduring procedures – Tooth extraction


Hemophilia• Hemorrhage can occur anywhere

– Joints, deep muscles, urinary tract, andintracranial sites most common

• Controlled by infusions of factor VIII



Controlled by infusions of factor VIII

• Most hemophiliacs seek emergency care for

complicated problems and traumaCopyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Sickle Cell Disease• Sickle cell anemia

• Debilitating recessive genetic illness

• Affects persons of African descent – Less commonly Mediterranean origin)



• Signs and symptoms• Pathophysiology

• Management


Sickle Cell Disease — Signs and Symptoms• Weakness

• Aching

• Chest pain and dyspnea

• Bony deformities

• Jaundice

• Fever



• Severe abdominal pain • Joint pain


Sickle Cell versus Normal Erythrocyte




Sickle Cell Crisis

• Triggered by: – Dehydration – Stress – Infection



– Trauma – Exposure to temperature extremes – Lack of oxygen – Strenuous physical activity


Sickle Cell Crisis

• Management – Oxygen – IV therapy – Analgesia



g – Transport for additional care


Multiple Myeloma• Malignant neoplasm of bone marrow

• Tumor destroys bone



• Results in: – Pain – Fractures – Hypercalcemia – Skeletal deformities–


Multiple Myeloma• Diagnosed by:

– X-ray – Blood studies – Biopsy



• Treatment – Chemotherapy

– Radiation – Bone marrow transplantCopyright © 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.

Assessment and Management• Many emergency presentations

• Call to manage change in condition

• Management – Oxygen



– IV – Analgesia – Other symptomatic care – Transport to hospital, where patient receives primary care if

possible


Conclusion

The paramedic‘s knowledge of hematologicdiseases enhances assessment skills and provides an understanding of treatment

strategies needed for these patients.



st ateg es eeded o t ese pat e ts.


Questions?




MONOCYTE• 5-10 % Circulating

WBCs• When stimulated

become Macrophages



and dentritic cells inthe tissue• Clean up the debris

EOSINOPHIL• 1-5% Circulating

WBCS• Involved in parasitic

infections



• Involved withmechanism associatedwith allergy andasthma

• ↑In case of w.w.w.

BASOPHIL• < 1% circulating

WBCS• Involved with allergic

and inflammatory



response• Release histaminesand cytokines

HematologicalSymptoms



Hematological Symptoms• Neutropenia — defined as ANC<1000/mm3• Anemia--↓RBC & Hgb • Thrombocytopenia — low PLT <100,000• Leukopenia — decrease in WBC, below the



plower limit

• Pancytopenia-an abnormal deficiency in all blood cells, RBC, WBC, & PLT; usually

associated with bone marrow tumor or withaplastic anemia)

Risk factors for febrile neutropenia• Previous Hx Chemo/Type of chemo/prior

radiation Tx• Age>65/ female gender• Poor nutritional status• Advanced cancer and bone marrow involvement



• ↑LDH, ↓Hgb • Leukemia/lymphoma/lung cancer• Open wounds• DM• COPD

Prevention of Neutropenia• Growth stimulating factors activate

production of bone marrow cells. It can begiven prophylactically or therapeutically

• BMT give GCSF on day+4 of stem cell



SCT• GCSF-/filgrastim 5mcg/kg• Pegfilgrastim--Neulasta 6mcg/kg

Neutropenic Precautions• Limit exposure of pts to infections• Hand washing ↓spread • Avoid crowds



• Avoid fresh fruits /vegetables/flowers• Avoid caring for animals esp. cleaningexcretes

• Avoid gardening

Infections• Mechanical barriers — skin, mucous

membranes• Chemical barriers-pH of tissues• Inflammatory and immune responses



y p

Risks of Infections• High risk• Intermediate risk• Low risk



High Risk for infection• Allogeneic BMT• Acute Leukemia's• GVHD tx ↑dose steroids • Neutropenic lasting >10 days



• Break in skin/mucosal barrier• Prolonged ABX or steroid use• Poor nutrition• Invasive procedure• Poor personal hygiene

Intermediate Risks for infections• Autologous BMT• Lymphoma/MM/CLL• Neutropenic anticipated to last >7-10 days



Low Risk for infections• Standard Chemotherapy• Neutropenia <7 days



PT AND PTT• PT (PROTIME) Test the extrinsic pathway• PTT Tests the intrinsic pathway• COUMADIN (WARFARIN) Affects the

Vitamin K factors (II,VII,IX,X ) of which



( , , , )factor VII is the most labile

• Hemophilia is a factor VIII deficiency

• INR: Method for standardizing Protimes. Itis a ration of tested results : control

COAGULATION PRODUCTS• Fresh Frozen Plasma• Cryoprecipitate: Factor VIII, Fibrinogen• Activated Products: Factor IX



Chemistry Tests• Liver Function Studies• Renal Function• Electrolytes — Na, K, Ca, Mg, Po4, Co2



LIVER FUNCTION

Hepatocelluar Enzymes:• AST(ASPARTATE AMINOTRANSFERASE)

• ALT (ALANINE AMINOTRANSFERASE)



• SGGT (very specific)

• LDH (Lactate Dehydrogenase)

LIVER FUNCTIONALKALINE PHOSPHATASE-AP not specific to liver

AP= LARGE COMPONENT IN BONE

BILIRUBIN -2 TYPESDIRECT OR CONGUGATED AND INDIRECT OR

UNCONGUGATED.



• AP / BILIRUBIN the first enzymes torise with liver GVHD

• INDIRECT BILIRUBIN associatedwith hemolysis

LDH• Nearly every type ofcancer , as well as many other

diseases, can cause LDH levels to be ↑, cannot beused to dx a particular type of cancer.

• LDH levels can be used to monitor treatment of

http://www.medterms.com/script/main/art.asp?articlekey=13931






some cancers, includingtesticular cancer , Ewing'ssarcoma, non-Hodgkin's lymphoma, and sometypes ofleukemia

• Elevated LDH levels can be caused by a numberof noncancerous conditions, including heartfailure,hypothyroidism, anemia, and lung orliverdisease.

RENAL• BUN(BLOOD UREA NITROGEN)

Elevated with:Kidney dysfunction, Dehydration, excess protein

in blood such as TPN, High protein diet, GI bleeding

• Creatinine:chemical waste is generated from















muscle metabolism. Creatinine is produced fromcreatine, a molecule of major importance forenergy production in muscles. Creatinine istransported through the bloodstream to thekidneys. The kidneys filter out most of thecreatinine and dispose of it in theurine.

CREATININECONT.

• The ratio of BUN : creatinine determines renal

dysfunction VS pre-renal dysfunction such asdehydration .

• CALCULATED CREAT. CLEARANCE:

http://www.medicinenet.com/script/main/art.asp?articlekey=16045






in ml/min---CRCL=(140-AGE) x ideal B.W./Scr. x 72 (x0.85 for females)

ELECTROLYTES• SODIUM• POTASSIUM• CALCIUM



• PHOSPHORUS• MAGNESIUM• CO2

SODIUM/POTASSIUM• SODIUM

/POTASSIUMMEMBRANE PUMP



CALCIUM/PHOSPHORUS• DIRECT

INTERACTION• IF GIVEN

CONCOMBINETLY:



NaPO4 + CaCO3=

CALCIUM• Calcium in plasma is bound to Albumin. If

Albumin is low, you get a falsely low serumcalcium.

• 2 ways to get a more accurate Calcium:



IONIZED CALCIUMCORRECTED CALCIUM

• CORRECTED Calcium:[(4.0 – serum alb) x 0.8 ] + s Ca = correctedCa

MAGNESIUM• Very important for Cardiac, Nervous and GI

systems.• Interacts with calcium and Potassium.• Difficult to get a Normal serum level of



Potassium if Mg is low.

CO2• Gives a rough idea of pH and buffer system

in blood• Infections typically have low venous CO2



Bone marrow Biopsy-aspirate• Used in Identi. metastatic Dz, esp

hematological malignancies• Assess iron stores• Assess megaloblastic maturation, in Vit

d f l d f



B12 and folate deficiencies or in MDS• Assess fat atrophy, aplasia or fibrosis

Other tests done in Hem/Onc• Fractionated bilirubin — to differentiate

cause of hyperbilirumia• Stool guaiac--? bleeding• Coombe‘s test— direct/indirect



• Haptoglobin level — to detect hemolyticanemia

• Hgb electropheresis----

MICROBIOLOGY• BACTERIA• VIRUS• FUNGAL/YEAST

PROTOZOAN



• PROTOZOAN

BACTERIA• CATAGORIZED BY SHAPE AND

STAINING PROPERTIES• GRAM‘S STAIN • SHAPES ARE COCCI, RODS, AND

SPIROCHETES



SPIROCHETES

BACTERIAL SHAPES• COCCI

• RODS• SPIROCHETES



GRAM‘S STAIN • INTERACTS WITH THE BACTERIAL

MEMBRANE AND STAINS IT EITHER BLUE ORRED

• BLUE IS GM (+)• RED IS GM (-)



GRAM POSITIVE• COCCI: 1. STAPHALOCOCCUS

EITHER COAGULASE (-) OR (+)COAG NEG=STAPH EPID.COAG POS= STAPH AUREUS



2. STREP, ENTEROCOCCUS• RODS: BACILLUS, LISTERIA,

CORYNEBACTERIA DIPTHERIA

Staph aureus



GRAM NEGATIVE• COCCI: NEISSERIA, MORAXELLA,

ACINETOBACTER• RODS: E.COLI, PSEUDOMONAS,

SHIGELLA, SALMONELLA,KLEBSIELLA PROTEUS



KLEBSIELLA, PROTEUS,ENTEROBACTER, VIBRIO

Gram Negative rods



FUNGUS• MOLDS:

ASPERGILLUS ,MUCOR,

• YEAST AND

YEAST LIKECANDIDA



YEAST-LIKE:CANDIDA,TORULOPSIS,HISTOPLASMOSIS,

CRYPTOCOCCUS,BLASTO.

FUNGUS



VIRUS• CYTOMEGALOVIRUS• EPSTEIN-BAR• BK

ADENOVIRUS



• ADENOVIRUS• INFLUENZA A & B• PARAINFLUENZA

• RSV

PNEUMOCYSTIS CARINII• PREVIOUSLY

CONSIDERED APROTOZOAN BUT NOW IN FUNGUSCLASS



References• Demetri, G. (2001) Anemia and its functional consequences in

cancer pts, current challenges in management & prospects forimproving therapy. British Journal of Cancer,84,31-37

• Dessypris, E, Erythropoiesis (1988). Lee G R, Foster J, Lukens J,Wintrobe M M, eds.Wintrobe‘s clinical hematolology. Pa:Lippincott Williams & Williams 1998. 169-192.

• Ludwig H, & Strasser K.(2001) Symptomatology of anemia. Seminars in

oncology 28 7-10



oncology, 28, 7 10• Means, R. (1999). The anemias of chronic disorders. Lee GR, Foerster J,

Lukens J, Paraskeras F, Greer J P, Rodgers GM, eds. WIntrobe‘sClinical hematolgoy.10th ed, Pa. Lippincott Williams & Wilkin;1999:1011-1021

• National Comprehensive Cancer Network (2007). Cancer and treatmentrelated anemias, version 3.2007

Shortcut to DSC 03990.lnk The End



Hematology, also spelledhaematology ,is the branch ofinternal medicine, physiology,pathology, clinical laboratory work,and pediatrics that is concerned



and pediatrics that is concernedwith the study of blood, the blood-forming organs, and blood diseases.

• Hematology includes the study of etiology,diagnosis, treatment, prognosis, and preventionof blood diseases. The laboratory work that goesinto the study of blood is frequently performed by a medical technologist. Hematologists physicians also very frequently do further studyin oncology the medical treatment of cancer



in oncology - the medical treatment of cancer.

RBCs DisordersAnemias&Others

WBCs DisordersBenign & Malignant

HematologicalDisorders



Hemostatic Disorders

ry2ry &1

Transfusion

Medicine

TopicsHematopoiesisComplete bloodcount (CBC)AnemiaP l th i

lymphomaMyelomaCoagulation

Transfusion



PolycythemiaLeukopenia

Leukemia and

Transfusion

BloodSuspension of cells in a soluteof water, proteins, and

electrolytesAverage volume is 5 liters70mL per kg body weight

PlasmaBlood from which the cellular(



Blood from which the cellularcomponents (RBCs, WBCs, platelets) have been removed bycentrifuge

Color is yellowContains coagulation proteins(clotting factors)

HematopoiesisDevelopment of blood cells and other formed elementsSites vary throughout development

Fetal: yolk sac, liver, spleenPediatric: axial and appendicular skeletonAdult: axial skeleton (sternum and pelvis)

Stem cellsPrimitive; self-replicate and differentiate to becomeincreasingly specializedprogenitor cells which form mature



increasingly specialized progenitor cells which form maturecellsProcess regulated by growth factors (interleukins, erythropoietin,thrombopoietin, G-CSF)

Early lineage division between progenitors for lymphoid andmyeloid cells

Hematopoiesis



Complete Blood Count• White blood cells (WBC)

– Differential• Neutrophils, lymphocytes, monocytes, eosinophils, basophils, bands

• Must specify whether to include when ordering study

• Red blood cells (RBC Hgb Hct)



• Red blood cells (RBC, Hgb, Hct)• Platelets (PLT)• Mean corpuscular volume (MCV)

• Red cell distribution width (RDW)

Red Blood Cells• Transport oxygen via hemoglobin from

lungs to peripheral tissues and organs

• Normal lifespan = 120 days• Reticulocytes – Immature red blood cells

• Calculating proportion within circulationassists in determining cause of anemia

– Normal is 1-2%t d d d ti



– Low suggests decreased production(i.e. nutritional or marrow problem)

– High suggests bleeding or prematuredestruction of red blood cells (i.e.hemolysis)

Red Blood CellsPeripheral blood smear

Normal



Anemia• Defined by measurement of hemoglobin

concentration – Normal – 15 in males ; 14 in females – Patients are ―anemic‖ when hgb is >2 standard

deviations below normal

– Determining reticulocyte count and MCV are first



Determining reticulocyte count and MCV are firststeps in determining etiology

• Almost 1/3 of the world population is anemic!



Anemia• Mechanisms

– Blood loss / hemorrhage• Initial focus in ALL anemic patients

– Gastrointestinal tract, menstruation

– Hemolysis

• Shortened RBC survival time not explained by bleedingD t il l t



Shortened RBC survival time not explained by bleeding• Details later – Decreased production (hypoproliferative)

• Nutritional deficiency (iron, B12, and folate)• Systemic illness (CKD, cancer, rheumatologic disease,

etc.)•

Microcytic AnemiaMicrocytosis – small cells (MCV <80)Most common type of anemia encountered in

primary careDifferential diagnosisHemoglobinopathy (inherited)Iron deficiency

Chronic disease (may also be normocytic)I fl i



Chronic disease (may also be normocytic)InflammationLead poisoning

Check iron studies for clarificationBe familiar with interpretation (see next slide)

Microcytic AnemiaPeripheral blood smear

Microcytosis, Hypochromic



Microcytic AnemiaDx Ferritin Serum Fe TIBC Saturation

Irondeficiency

Chronicdisease

N or N or

RDW is often elevated in iron deficiency anemia ;

look for this along with low MCV on CBC report



g p



Hemolytic Anemia• History and physical findings

– Review of PMH, FH, and medications – Jaundice is common – Occasional LUQ abdominal discomfort

(splenomegaly)

• Lab findingsElevated reticulocyte count



Lab findings – Elevated reticulocyte count• Reflects bone marrow compensating for peripheral RBC

destruction

– Elevated LDH – Elevated total bilirubin (indirect/unconjugated)–

Hemolytic Anemia• Congenital

– Membrane defects• Hereditary spherocytosis

• Hereditary elliptocytosis – Enzyme defects• G6PD deficiency



Hemolytic AnemiaCongenital, continuedHemoglobin defects – diagnosed by hemoglobinelectrophoresis

ThalassemiasGroup of diseases characterized by globin chain (alpha and beta) imbalance



Hemolytic Anemia• Congenital, continued

– Sickle cell disease• RBCs become sickle-shaped hemolysis, vascular occlusion

• Hgb S gene carried by 8% of African Americans – 1:625 have disease – Genetic counseling available



Hemolytic Anemia• Acquired

– Classified according to site of RBC destruction and whether mediated byimmune system

• Intravascular• Extravascular• Autoimmune• Non-immune

– Many causes… be aware of these – • Transfusion of incompatible blood (details later…) • Autoimmune

– Warm (IgG-mediated) ; most commonCold (IgM mediated)



– Cold (IgM-mediated)• Prosthetic valves• TTP/HUS• DIC• Cancer• Drugs

Polycythemia / Erythrocytosis• Abnormalelevation of hemoglobin – Rule out ―relative‖ polcythemia caused by contraction of plasma volume, e.g.

dehydration – Primary

• Polycythemia Vera – RBC production independent of EPO

» EPO level is low / positive JAK-2 is diagnostic – Uncommon – May be associated with leukocytosis, thrombocytosis, splenomegaly – Hyperviscosity

» Headache, vertigo, visual changes, mental confusion

– Risk of transformation into acute leukemia – Refer to hematology



gy – Secondary

• RBC production in response to increased EPO production – EPO level is usually high

• Very common• Usual etiology is chronic hypoxia (COPD, sleep apnea)• Phlebotomy (250-500 mL) to maintain hct 45-50% ; treat underlying problem!

White Blood Cells• Differential

– Neutrophils 45-65%• ―Segs‖ / ―Polys‖

– Lymphocytes 15-40% – Monocytes 2-8%

– Eosinophils 0-5%



p – Basophils 0-3%

• Do you remember the physiologic role of eachtype of WBC?

Benign WBCs Disorders



Leukopenia• Neutropenia is most common cause

– Absolute neutrophil count (ANC) < 1.5 x 109 cells/L – Many causes

• Benign racial neutropenia common – African Americans and Yemenite Jews may have ANC as low as 1.0• Viral infections

– Epstein-Barr, Hepatitis B, HIV• Drugs *

– Careful review of medications ; be suspicious of any medication recentlystarted in patient with acute onset neutropenia

– See next slide



– See next slide• Splenomegaly• Autoimmune disorders

– SLE (lupus), Rheumatoid Arthritis, etc.• Bone marrow disorders

NeutropeniaCommon Medicinal Causes of Neutropenia

Cytotoxic agentsAntibiotics (Penicillins, Cephalosporins, Sulfonamides)Anticonvulsants NSAIDsAntithyroid agents (Methimazole, PTU)Phenothiazines

AllopurinolCi tidi



CimetidineDiuretics (HCTZ, Spironolactone)

LeukocytosisWBC count > 11,000Determine whichtype of WBC is leading to theleukocytosis

Neutrophilia = most commonInfectionConnective tissue disordersMedications (especially steroids, growth factors)Cancer (CML and solid tumors)Myeloproliferative disordersCig rette smoking



Cigarette smokingStress (physiologic)

Pain, seizure, traumaIdiopathic

Leukocytosis• Patients with acute bacterial infection often

present with neutrophilia andband formation ;i.e. ―left shift‖ – Bands = young neutrophils

• Viral infections are usually associated withlow

WBCs ; leukocytosis may suggest complication



WBCs ; leukocytosis may suggest complication – Ex: bacterial pneumonia with underlying influenza

infection

Leukocytosis• Lymphocytosis

– Viral infections• HBV, HCV, EBV, CMV

– Tuberculosis – Pertussis

– Drug Reaction



g – Stress (physiologic)

• Trauma, MI, cardiac arrest, sickle crisis

– Malignancy• ALL, CLL, lymphoma

Malignant WBCs DisordersTypes of Hematopoietic Malignancies

Leukemias• Acute leukemias

• Acute myeloid leukemia• Acute lymphoblastic leukemia

• Chronic leukemias• Chronic myeloproliferative disorders• Chronic lymphoproliferative disorders

Lymphomas• Non-Hodgkin's lymphoma



• Hodgkin's disease

Plasma cell disorders • Myeloma

Myeloid vs. Lymphoid Myeloid malignancies • Acute myeloid leukemia• Chronic myeloproliferative disordersLymphoid malignancies • B-cell malignancies • Acute lymphoblastic leukemia, B-cell type

• Non- Hodgkin’s lymphoma, B -cell types • Myeloma



• T-cell malignancies • Acute lymphoblastic leukemia, T-cell type • Non- Hodgkin’s lymphoma, T -cell types

• Hodgkin’s disease

Chronic Leukemia• Chronic myelogenous leukemia(CML)

– Translocation between long arms of chromosomes 9and 22; ―Philadelphia Chromosome‖ ; bcr/abl protein



Chronic Leukemia• Chronic lymphocytic leukemia(CLL) – Clonal malignancy of B-lymphocytes – Course is usually indolent ; affects older patients, average age at diagnosis is 70

years• Often found incidentally• Fatigue, lymphadenopathy common• Hepatosplenomegaly

– Immunodeficiency is major clinical concern• Lymphocytes are defective ; do not make antibodies in response to antigens

– Treatment• Observation• Indications for therapy include progressive fatigue, symptomatic lymphadenopathy, anemia

or thrombocytopenia



• Rituximab (Rituxan®) and fludarabine +/- cyclophosphamide is initial approach• Gamma globulin (IVIG) used in patients with recurrent or severe bacterial infections• Allogeneic BMT is potentially curative but reserved for select patients• Prognosis improving ; survival is 10-15 years with early disease

Acute LeukemiaAcute Myelogenous Leukemia(AML)

Most common in adultsUsually no apparent cause

Exposure to radiation, benzene, and certain chemotherapy drugs (alkylators)associated with leukemiaUnderlying myelodysplastic syndrome (MDS) is risk factor

Symptoms and signsRelated to replacement of marrow space by malignant WBCs

Patients often very ill for period of justdays or weeks

Skeletal painBleeding



BleedingGingival hyperplasiaInfectionPancytopenia with circulating blasts is hallmark ; bone marrow biopsy required

» Auer rods on peripheral smear are pathognomonic

Acute LeukemiaAML, continuedManagement

Immediate referral to hematologistPatients often hospitalized for therapy

» Anthracycline (daunorubicin or idarubicin) pluscytarabine results in CR in 80% of patients < 60years

Additional high dose chemotherapy following CR leads to



g py gcure rate of 35-40%

Acute Lymphocytic Leukemia(ALL)

More often seen in children

Lymphoma• Hodgkin‘s disease

– Malignancy of B-lymphocytes• Reed-Sternberg cells

• Various subtypes ; ―nodular sclerosing‖ is mostcommon



Lymphoma• Non-Hodgkin‘s Lymphoma (NHL)

– Heterogeneous group of cancers affecting lymphocytes• Usually classified by histologic grade (low to high)

– Follicular lymphoma – Small lymphocytic lymphoma – Diffuse large B-cell lymphoma – Burkitt‘s lymphoma – Many others



Myeloma• Malignancy of plasma cells

– Abnormal paraproteins are created leading tosystemic problems

• IgG – 60%• IgM – 20%• Must be able to recognize in primary care setting

– ―CRAB‖ – calcium, renal, anemia, bone



– Primarily disease of elderly (median age 65 years) – Males > Females – Most common hematologic malignancy among

African Americans ; #2 among Caucasians

Myeloma• Osteolytic lesions



Hemostasis



Hemostatic EventsTissue Injury• Vasoconstriction

– Neural

– Platelet-reinforced• Platelet Activation – Adhesion – Aggregation

• Coagulation – Blood Clot

• Thrombin generation• Fibrin polymerizationFib i l i



• Fibrinolysis – Blood Clot Dissolution

• Vascular Patency Restored

Secondar yHemostasis

PrimaryHemostasi

s

Categories of Hemostasis(page 572)

• Primary – Vascular System

• Endothelia• Sub endothelia/collagen

– Platelets• Secondary

– Coagulation System

• Plasma Proteins• Cells: Platelets



– Fibrinolytic System• Plasma proteins• Cells: Platelets, Endothelia

Graphic accessed at URLhttp://www.acta-ortho.gr/v55t4_4/Figure1.jpg 9/18/08.

Graphic accessed at URLhttp://www.kup.at/journals/abbildungen/gross/746.html 9/18/08.

Bleeding DisordersCoagulation cascade

http://www.acta-ortho.gr/v55t4_4/Figure1.jpg

http://www.kup.at/journals/abbildungen/gross/746.html

















Causes of Bleeding(1)

Thrombocytopenia:Primary:• ITP

• Neonatal Isoimmune• TAR Syndrome• Wiskott-Aldrich Syn.

Secondary:*Malignancy

*Aplastic Anemia*DIC*Sepsis

*HUS*Hypersplenism



Hypersplenism*Autoimmune(SLE)


Coagulopathy:Primary:• vWF Deficiency

• Hemophilia• Platelet dysfunction

Secondary:• DIC

• Anticoagulants• Vit K deficiency• Hepatic Failure

• Renal Failure• Maternal



MaternalAnticonvulsant

Causes of Bleeding(3)Vascular(Non-Hematologic)• Child Abuse• Vasculitis• Ulcer• Varices

• Ehlers-Danlos Syndrome• Telangiectasia



Telangiectasia• Angiodysplasia

Characteristic Primaryhemostasis

Secondary hemostasis

Onset Spontaneous andimmediate

Delayed after trauma

Usual site Skin, mucous membranes Deep tissues /hemarthrosis

Bleeding DisordersPatterns of bleeding

Primary hemostasis – platelet and vascular function

Secondary hemostasis – clotting factors



hemarthrosisOther sites Rare Retroperitoneum, CNSExamples Thrombocytopenia,

platelet defects (vWD)Factor deficiency orinhibitor

Bleeding DisordersPetechiae in patient with acute ITP ; plateletcount = 10,000



Secondar yHemostasis

PrimaryHemostasi

s

Categories of Hemostasis(page 572)

• Primary – Vascular System

• Endothelia• Sub endothelia/collagen

– Platelets• Secondary

– Coagulation System

• Plasma Proteins• Cells: Platelets



– Fibrinolytic System• Plasma proteins• Cells: Platelets, Endothelia

Graphic accessed at URLhttp://www.acta-ortho.gr/v55t4_4/Figure1.jpg 9/18/08.

Graphic accessed at URLhttp://www.kup.at/journals/abbildungen/gross/746.html 9/18/08.


Thrombocytopenia:Primary:• ITP

• Neonatal Isoimmune• TAR Syndrome• Wiskott-Aldrich Syn.

Secondary:*Malignancy

*Aplastic Anemia*DIC*Sepsis

*HUS*Hypersplenism



















yp p*Autoimmune(SLE)


Coagulopathy:Primary:• vWF Deficiency

• Hemophilia• Platelet dysfunction

Secondary:• DIC

• Anticoagulants• Vit K deficiency• Hepatic Failure

• Renal Failure• Maternal



Anticonvulsant

Causes of Bleeding(3)Vascular(Non-Hematologic)• Child Abuse• Vasculitis• Ulcer• Varices

• Ehlers-Danlos Syndrome• Telangiectasia



Telangiectasia• Angiodysplasia

Characteristic Primaryhemostasis

Secondary hemostasis

Onset Spontaneous andimmediate

Delayed after trauma

Usual site Skin, mucous membranes Deep tissues /hemarthrosis

Bleeding DisordersPatterns of bleeding

Primary hemostasis – platelet and vascular function

Secondary hemostasis – clotting factors



Other sites Rare Retroperitoneum, CNSExamples Thrombocytopenia,

platelet defects (vWD)Factor deficiency orinhibitor

Bleeding DisordersPetechiae in patient with acute ITP ; plateletcount = 10,000



Thrombosis• Venous thromboembolism (VTE) – DVT and PE are very common in hospital setting

• 20% among general medical patients ; up to 80% of critical care patients• Be familiar with risk factors –

– Obesity – Oral contraceptives – Pregnancy – Tobacco abuse – Prolonged immobility – Surgery

– Malignancy• Considerprophylaxis– Compression stockings and sequential compression devices



Compression stockings and sequential compression devices – Lovenox® 40 mg SQ once daily – Arixtra® 2.5 mg SQ once daily – Unfractionated heparin 5000 units q 8-12 hours

Transfusion Medicine• History – 19th century – experimentation with animal and human blood transfusion – 1900 – ABO blood groups first described

– 1936 – First US hospital blood bank established• Blood donation – Approximately 450 mL whole blood collected ; later processed into RBC,

plasma, and platelets – Apheresis – removing whole blood, separating a portion, and returning the

rest to donor• Used for plasma and platelet donation

– RBC storage period ranges 35-42 days depending on preservative



RBC storage period ranges 35 42 days depending on preservative• Up to 25% of transfused RBCs will be cleared from recipient circulation within 2

hours of delivery

Transfusion Medicine• Review of physiology – Anti-A and Anti-B are naturally occurring and develop in first months of life

in those lacking A or B antigens on RBC surface – Rh factor (D-antigen) absent in 15% of population

• These patients may develop anti-D antibodies following pregnancy or transfusionwith Rh+ blood leading to severe reactions• Pretransfusion testing

– ABO and Rh typing – Antibody screen (Coomb‘s test)

• If positive, further testing required to identify specific antibody ; donor unit is thenchecked

– Crossmatch• Donor RBC mixed with recipient serum and incubated to check for compatibility



• Donor RBC mixed with recipient serum and incubated to check for compatibility – Type O negative blood may be used in emergency

• Limited supply ; only 15% of donors

Transfusion Medicine• When to transfuse

blood? Use clinical judgment! – No single hgb/hct limit;

general indications

include:• Symptomatic anemia



y – Tachypnea, Tachycardia,

Cyanosis

• Blood loss (>15% volume)• Chronic hypoproliferativeanemia (i.e. MDS)

Transfusion Medicine• Platelet transfusion

– Platelet count < 10,000 – Active bleeding in setting of significant

thrombocytopenia – Platelet count of 50,000 adequate for most surgical

procedures – Single apheresis unit will generally raise platelet



g p g y pcount by 30,000

• Anticipatelow yield with splenomegaly, DIC, sepsis• Immune factors may also cause patients to be refractory

– Consider ordering HLA-matched platelets

Transfusion Medicine• Plasma transfusion – Indications

• Coagulation factor deficiency – Consider factor concentrates if available

• Rapid reversal of warfarin effect• Hemorrhage in patients with liver disease• DIC (controversial)



Transfusion Medicine• Transfusion Reactions – Acute hemolytic reaction

• Intravascular hemolysis (hemoglobinuria) – Fever, chills, pain, nausea, dyspnea, hypotension

– May lead to ARF, DIC, and death• ABO incompatibility (human error) is most common cause – Proper labeling and patient identification is essential for prevention

• STOP transfusion and notify blood bank immediately – Delayed hemolytic reaction

• Occur days to weeks later• Caused by RBC antibodies not detected by pretransfusion testing

– Febrile non-hemolytic reaction• Common in patients with multiple prior transfusions• Caused by cytokines or recipient antibodies to donor leukocytes



– Allergic reaction• Associated with plasma ; may be related to residual plasma in PRBC specimen• Usually mild ; pruritis, flushing, urticaria• Occasional anaphylaxis

Transfusion MedicineTransfusion reactions, continuedHypotensive reaction

Caused by bradykinin generationPatients on ACE inhibitors at higher risk

Hypotension and tachycardia shortly after beginning transfusion ; BP returns to baseline upon interruptionUsually safe to resume at slower rate upon recovery

Bacterial contaminationSeptic shock ; high mortalityRare but unpredictable

Transfusion-related acute lung injury (TRALI)Occurs during or shortly after transfusionCauses leakage of pulmonary capillaries presenting as pulmonary edema in absence o



g p y p p g p yheart diseaseResolves within 48-72 hoursMortality rate is 10%

Pediatric Hematological Disorders

Whaley and WongChapters 35, 36



p ,

Components of the Blood• Blood:

– Plasma• water, albumin, electrolytes, clotting factors

– Cellular Components

• RBCs, WBCs, Platelets• All formed in the red bone marrow (after birth)l h l



– In utero- spleen, thymus, liver• lymphatic system regulates maturation

Erythrocytes• RBCs

– carry hemoglobin which is attached to oxygen- provides O2 to the tissues

– life span 120 days

– manufacture regulated by erythropoetin – Normal Hematocrit- 35-45%



– Normal Hemoglobin- 12-16 grams

Problems of Erythrocyte Production• Anemia – reduction of RBC volume or Hgb

concentration below normalClassifications:

1. Etiology/Pathophysiology – causes of RBC/Hgb depletion

2 M h l h i RBC



2. Morphology – changes in RBCsize, shape, and color

Causes of Anemia• Nutritional deficiency – iron, folate, B12• Increased destruction of RBCs – sickle

cell anemia• Impaired or decreased rate of

production – aplastic anemia



• Excessive blood loss - hemophilia

Iron Deficiency Anemia• Causes

- inadequate supply of iron- impaired absorption- blood loss- excessive demands for iron req‘d for



growth

- inability for form Hgb

Iron Deficiency Anemia• Signs and Symptoms: due to tissue hypoxia

> lack of energy, easy fatigability, pallor• Diagnosis: CBC with diff, red cell indices

(MCV, MCH, MCHC), iron studies,

physical exam• Medical Treatment: supplement with



Medical Treatment: supplement withferrous sulfate (dosages vary with age),

dietary counseling

Iron Deficiency Anemia• Nursing Assessment and Interventions:

- educate parents about nutrition- explain laboratory testing- teach parents proper administration

of iron preparations, caution about



high toxicity of iron

Sickle Cell AnemiaCauses: genetic transmission, 2 parents with

the trait have 25% chance of having childwith SCD, found primarily in Blacks, occHispanics

• Hgb A is partly or completely replaced byHgb S



g• With dehydration,acidosis, hypoxia, and

temp elevations, Hgb S ―sickles‖

Sickle Cell AnemiaPathophysiology:- vaso-occlusion from sickled RBCs- increased RBC destruction- splenic congestion and enlargement- hepatomegaly, liver failure- renal ischemia, hematuria



- osteoporosis, lordosis, kyphosis

- cardiomegaly, heart failure, stroke

Sickle Cell AnemiaSigns/Symptoms:• Exercise intolerance• Anorexia• Jaundiced sclera• Gallstones

h l l



• Chronic leg ulcers•

Growth retardation

Sickle Cell Anemia• Diagnosis

- Sickledex- Hgb electrophoresis- Stained blood smear

• Vaso-occlusive crisis- mild to severe bone pain- acute abdominal pain



- acute abdominal pain- priapism

- arthralgia

Sickle Cell AnemiaMedical management

• Supportive/symptomatic tx of crises- bed rest- hydration- electrolyte replacement- analgesics for pain- blood replacement



- blood replacement- antibiotics

- oxygen therapy

Sickle Cell Anemia Nursing care:

• Minimize tissue deoxygenation• Promote hydration• Minimize crises

• Pain management• Administering blood transfusions



• Encourage screening and genetic counseling

• Parent education

Thalassemia• Autosomal recessive disorder – Greeks,

Italians, Syrians• Signs/symptoms – microcytic anemia >

splenomegaly,jaundice,epistaxis, gout• Diagnosis – Hgb electrophoresis

M di l T f i h l i



• Medical Treatment – transfusions, chelation

Hemophilia• Factor 8 or factor 9 deficiency

– prolonged bleeding any where in the body!• Cause: X-linked recessive disorder, defects

in platelets and clotting factors• Diagnosis: history of bleeding episodes,

evidence of x-linked inheritence, labs



,• Medical Management: Factor VIII

concentrate, DDAVP (vasopressin)

Hemophilia Nursing care:• Prevent bleeding• Recognize and control bleeding (RICE)

- Rest- Ice- Compression

Elevation



- Elevation• Prevent crippling effects of bleeding• Client education

Idiopathic Thrombocytopenic Purpura• Causes: acquired hemorrhagic disorder of

unknown origin, probably an autoimmuneresponse to disease-related antigens• Diagnosis: platelet count < 20,000, abnl

bleeding time and clot retraction• Signs and Symptoms: petechiae, bruising,

bleeding from mucous membranes prolonged



bleeding from mucous membranes, prolonged bleeding from abrasions

• Medical management: supportive, steroids, Anti-Dantibody, splenectomy

Idiopathic ThrombocyticPuerpera

Nursing Considerations:

• Client/Parent teaching• No contact sports• No aspirin• Prevent infection



Blood Transfusions Nursing Care

• Take VS BEFORE administering blood• Check ID of recipient with donor‘s blood type • Administer 50 mL or 1/5 volume SLOWLY – STAY

WITH THE CHILD• Administer with NS on piggyback set-up• Use appropriate filter• Use within 30 mins – infuse within 4 hrs



• If reaction suspected: Stop the transfusion, maintain patentIV line with NS, take VS, notify practitioner

Myeloid Cell Disorders

M2 Hematology/Oncology SequenceJohn Levine, MD



Winter 2009

Myeloid Cell Disorders: Goals

• Define members of the myeloid series• Understand:

– white blood cell maturation – the white blood cell count and differential – „philias‟ and „penias‟ of the myeloid series

members and associated clinical settings

– recruitment of WBC from the circulation.

• Associate white blood cell defects with



Associate white blood cell defects withfunction

596

Maturation of Myeloid Cells

GM-CSFG-CSF



597UMN Hematography Plus, Labeled by J. Levine

Mature Myeloid Cells

Neutrophil Eosinophil

http://www1.umn.edu/hema/pages/matchart.html

http://www1.umn.edu/hema/pages/matchart.html



Basophil Monocyte598Source Undetermined (All Images)

Assessment of Circulating WBC

• The total white blood cell count (WBC ) anddifferential are measured in an automated counter

• WBC reflects thecirculating pool of myeloid andlymphoid cells

• WBC in each microliter (l;mm3) is reported• Relative proportion of each type of WBC is

indicated by a percentage• Absolute number is the percentage of each type ofWBC lti li d b th t t l WBC



WBC multiplied by the total WBC

599

White Blood Cell Counts: Normal Ranges

WBC PMN Band Lymph Mono Eos Baso

Birth

(0-1m)

6-30K 42-80% 2% 26-36% 3-8% 0-5% 0-2%

Child(1m – 12m)

6-18K 18-44% 3% 46-76% 3-8% 0-5% 0-2%

Child(1y – 16y)

5-14K 37-75% 3% 25-57% 3-8% 0-5% 0-2%



Adult 4-10K 36-75% 2% 20-50% 3-8% 0-5% 0-2%

600J. Levine

White Blood Cell Counts: Disease States

WBC PMN Band Lymph Mono Eos Baso

Bacterial

Infection

16K ↑ 79%↑ 8%↑ 8% 3% 1% 1%

SteroidTherapy

12K ↑ 79%↑ 4% 14% 3% 0% 0%

Splenectomy 13K ↑ 50% 2% 40% 5% 2% 1%

ViralInfection

3.5K ↓ 50% 2% 40% 5% 2% 1%



Infection

Chemo <3K ↓ 65% 0% 20% 12%↑ 2% 1%

601J. Levine

Neutrophil Maturation

25% 65% 8% 2%

Proliferation Maturation Intravascular6-7 days 6-7 days 12 h

Tissues12h



Bone Marrow

602J. Levine

Neutrophil Maturation - Proliferative Phase

25 %Proliferation



Myeloblast Promyelocyte Myelocyte 603Source Undetermined (All Slides)

65 % of myeloid cells

Maturation 6-7 days

Neutrophil - Maturation Phase



Metamyelocyte Band Neutrophil 604Source Undetermined (All Slides)

8% 2%

12 h

Tissues

12h

Intravascular

Approximately 10% of the developing neutrophils are in the

Circulating

Marginating

Fate of the mature neutrophil



Approximately 10% of the developing neutrophils are in thecirculation, marginated or in the tissue.

605

Disorders of Neutrophil Numbers

Definition

NeutropeniaLess than 1500/ l

NeutrophilaGreater than 7700/ l

AcquiredOr

Inherited



606

J. Levine

Definition of Neutrophilia - too many

• Normal ANC is 1500-7700/ l• Neutrophilia: abnormally high ANC

• Shift to the left: ↑‟d release of precursorsfrom the bone marrow – not necessarily associated with

neutrophilia



607

Neutrophilia• Chronic Stimulation – Excess cytokine stimulates

proliferative pool

• Causes: – Infection – Down's Syndrome – Pregnancy/Eclampsia

– Chemotherapy recovery – Myeloproliferative

disorders

• Acute shift frommarginating tocirculating pool – ↑ measured WBC, not total

WBC• Causes:

– Steroid treatment – Exercise

– Epinephrine – Hypoxia – Seizures



disorders – Marrow metastases – Other stress

608

Example: exercise induced neutrophilia



609Source Undetermined

Neutropenia: too few

• Neutropenia

– Definition: ANC < 1500/µl – ANC 500-1000 increased risk of infection from

exposure

– ANC < 500: increased risk of infection fromhost organisms• African Americans: lower normal



• African-Americans: lower normalneutrophil counts (1000-1200)

610

Acquired Causes of NeutropeniaDecreasedProduction

IncreasedDestruction

Shift toMarginating Pool

Bone marrow Peripheralcirculation

Move from thecirculating pool to

attach along thevessel wall

Medication:

ChemotherapyAntibiotics, etc

Autoimmune

diseases(Rheumatoid

arthritis, SLE, etc)

Severe infection

Endotoxin releaseHemodialysis

Cardiopulmonary



Cardiopulmonarybypass

611

Increased Destruction

Uptake and



Anti-neutrophilantibody

Neutrophil-AntibodyComplex

destruction ofneutrophil by the

RE system

612J. Levine

Shift to Marginating Pool

Circulating

Marginating

Circulating

Marginating

Severe infection / Endotoxin releaseHemodialysis



Cardiopulmonary bypass

613J. Levine

Evaluation of Neutropenia

• If visit prompted by a fever and ANC islow, treat promptly for infection

• Suspect medication: major cause ofneutropenia• If no culprits, bone marrow exam for:

– Malignancy – Infiltration by non-marrow cells– Arrest of cell growth



Arrest of cell growth – Myeloproliferative disorder

614

Cyclic Neutropenia

• 21 day cycle• autosomal dominant

• fever, mouth ulcers• Treatment G-CSF• usually improves after

puberty



615

Source Undetermined

Congenital Neutropenia• Maturation arrest

• frequent infections,often serious• mouth sores

– may lose teeth or

develop severe guminfections• Increased risk of



leukemia

• Tx: G-CSF, BMT616

Source Undetermined

Role of Neutrophil

• Responds tochemotactic factors released from damagedtissue

• Rolls and attaches to the endothelial cell wall – protein and carbohydrate interactions (selectins and their ligands).

• Becomesactivated by chemotactic factors• Tightly adheres through the integrin family of proteins.• Migrates across the endothelial cell wall.• Phagocytizes organisms so that they are contained within a

vesicle or phagosome.• Releases granule products and reduced oxygen species (e.g.

hydrogen peroxide and superoxide) to kill organisms



hydrogen peroxide and superoxide) to kill organisms

617

Function of the Circulating Neutrophil

Chemoattractant

Attachment/rolling Activation AdhesionMigration



Phagocytosis

618J. Levine

Disruption of NeutrophilFunction

• Steps where defects in structural

components of neutrophils results inimpaired ability to fight infection – Recruitment from the circulation

– Adhesion and subsequent migration – Defective production in active oxygenmetabolites



metabolites – Deficiency in granules

619

Defect in Attachment/RollingAttachment/rolling

Sialyl Lewis X

Selectins

Cell surface molecules expressing Sialyl Lewis X

interact with selectin proteins on the cellsurface of endothelial cells

Chemoattractant



LAD-2 Impaired expression of sialyl LewisX -Neutrophils do not attach and are not recruited to the site of inflammation

620J. Levine

Defect in Adhesion

Chemoattractant

Adhesion

Integrins on the surface ofneutrophils mediate tight adhesionto the endothelial cell wall.Cells then migrate.

Migration

Integrin

LAD-1 results from a defect in leukocyte integrins.



Decreased to absent expression on the cell surface.Cells can not adhere and subsequently cannot migrate.

621J. Levine

Clinical manifestations: LAD



622Source Undetermined (Both Images)

PhagocytosisChemoattractant

Bacteria are engulfed and contained in a phagosome.

CGD: NADPH-Oxidase-defectiveCannot produce active oxygen species

Chediak-Higashi Syndrome: Defect in granule formation



Bacteria are engulfed and contained in a phagosome.Contents of the granules are released.

Oxygen metabolites (superoxide and H2O

2) kill bacteria

623J. Levine

Chediak-Higashi Syndrome




Chediak-Higashi Syndrome

• Oculocutaneousalbinism

– Photophobia – Sun sensitivity• Neuropathy• Infections, esp Staph

aureus



• TX: BMT

625

W. B. SaundersAdv NeonatalCare

Chronic granulomatous disease (CGD)




Chronic granulomatous disease: CGD• Catalase positive organisms

– Staph aureus – Serratia marcescens – Burkholderia cepacia

– Fungal• Skin, lungs, bones, abscessesG l f ti f h i



• Granuloma formation from chronic

infection627

Myeloperoxidase deficiency• One of the more common disorders

– 1: 4000• Decreased production of hypochlorous acid

(HOCl)

• Killing takes longer than normal• Clinically silent for most people



628

Diseases with Neutrophil Defects

Disease Step Molecular DefectLAD-2 Rolling Sialyl Lewis X

Carbohydrate

LAD-1 AdhesionPhagocytosis

Integrinexpression

Chediak-Higashi

Syndrome

MigrationDegranulation

Vacuolar sortingprotein (large

granules interferewith traversingendothelial wall)



629

Diseases with Neutrophil Defects



630

Monocyte-Macrophages – Monocytes: circulating precursor of thetissue macrophage.

– Also known as the reticuloendothelialsystem

– Average count 300 cells / l

– Range 0-800 cells/ l



631

Proliferation

M a t u r a t

i o n

I n t r a v a s c u l a r

30-48 hours 24 hours 72 h

Bone Marrow

T i s s u e :

D i f f e r e n t i a t i o n

i n t o M a c r o p h a g e s

Monocyte Differentiation



Bone Marrow


Function of Monocytes and MacrophagesAntigen presentation of phagocytized particles to T Cells

C tokines/



Cytokines/chemokines

633J. Levine

Monocyte Function

Chemoattractant

Follow neutrophils to sites of inflammation within 12-24hNumber 1/30th that of neutrophilsPts w/ CGD, CHS and LAD also have defects in monocyte fxn



Phagocytosis634J. Levine

Disturbances in Monocytes• Low counts – glucocorticoids – stress

• Elevated counts – Malignancy – Granulomatous disease – Marrow recovery – Infections

• malaria

• TB• Rocky Mountain Spottedfeverl i h i i



• leishmaniasis• brucellosis

635

Eosinophils


9 days 3-8hours

T i s s u e s

Bone Marrow

M

a t u r a t i o n

Proliferation

2.5days



Myelocyte Eosinophil 636

Eosinophil Function• Bright red granules• IgE on cell surface (not on neutrophils)• Play a key role in killing parasites• Average absolute count 200/l• Non allergic individuals usually <400/l



637

Eosinophilia

• Conditions: – Neoplasm (Hodgkin‘s disease, lymphoma other tumors) – Allergies-drugs, environmental (grass, trees, dust) – Asthma – Collagen vascular diseases-vasculitis – Parasitic infection

• Idiopathic hypereosinophilia: elevated eosinophil countassociated with organ dysfunction (GI, skin, CNS,cardiovascular). – > 5000/µl requires treatment with immunosuppressives

and antihistamines



and antihistamines

638

Maturation of Basophils and Mast cells


T i s s u e s

MaturationProliferation

2.5days

7 days

Basophil

Mast Cell

days

a t u r a t i o n

T i s s u e s

Proliferation



M a i n

639J. Levine

Basophil Function• Basophils and mast cells

– Function remains obscure but may play arole in host defense against certain parasites



640

Disturbances in Basophil Count• Low count

– hypersensitivity – glucocorticoids

• High count – Allergies

– infection – endocrinopathies – myeloproliferative

disorders – Systemic mastocytosis

• symptoms due to excesshistamine release



641

Disorders of Blood Cells &Blood Coagulation









CBC• WBC count• RBC count

• WBC differential• Hemoglobin (HGB)• Hematocrit (HCT)

– % of volume occupied by RBCs

• Red cell indices – Mean cell volume (MCV)

• average size of RBC

– Mean cell hemoglobin (MCH)• average amount of hemoglobin in

an average RBC – Mean cell hemoglobin

concentration (MCHC)• average concentration ofhemoglobin/unit of volume in anaverage RBC





Major Determinants of Disease• Blood cells have a short life span & require continuous replacement• Most diseases of blood cells feature too many or too few cells because

of an imbalance in the production or loss of cells• Hemoglobin must be properly assembled & produced for effective O2 transport• White blood cells are critical in the defense against infection• Diseases of lymphoid cells differ importantly from diseases of myeloid

cells

• Malignancies of myeloid cells are associated with circulation ofmalignant cells in the blood (leukemia)• Malignancies of lymphoid cells are associated with malignant cells in

the blood (leukemia) or masses in lymph nodes & other tissue(lymphoma)



• Most diseases that affect platelets cause a low platelet count

Anemia• Abnormally low hemoglobin

• Caused by – decreased numbers of RBCs – decreased amount of hemoglobin

– both• Sign of an underlying condition• Diagnose



• Diagnose

– CBC



Hemorrhage• Loss of O2 carrying capacity• Loss of iron• Most common cause of iron deficiency anemia is

chronic blood loss – abnormal menstrual bleeding

– intestinal bleeding• IRON DEFICIENCY ANEMIA IN A MAN ORIN A POST-MENOPAUSAL WOMAN IS TOBE CONSIDERED BLEEDING FROM GI



BE CONSIDERED BLEEDING FROM GI

CANCER UNTIL PROVEN OTHERWISE

Hemolytic Anemia• Associated with

– active, hypercellular bone marrow – high reticulocytes – increased LDH

– low blood haptoglobin – increased bilirubin• Genetic & non-genetic causes



g

Hereditary Spherocytosis• Disorder of astructural protein in

the cell membrane• Results in splenic

hemolysis



G6PD Deficiency• Lacking enzyme that protects the RBC

from oxidation



Sickle Cell Anemia• Hemoglobin S

• Sickling precipitated by – low O2 tension – infections

– dehydration – acidosis





Thalassemias• Molecularly correct but notenough produced

• Several varieties – thalassemia major is most severe – most common type is a severe

microcytic hypochromic anemia

• stimulates iron absorption• can lead to hemachromatosis



Non-Genetic Hemolytic Anemia• Immune hemolytic anemia

– antibodies directed against

RBC antigens• Mechanical hemolytic

anemia – hemolyzed as they pass

through mechanical devicessuch as artificial heartvalves

• Associated with malaria



Iron Deficiency Anemia• About 80% of iron is in hemoglobin with the rest stored as ferritin &

hemosiderin• Plasma ferritin levels vary directly with the amount of ferritin in bone

marrow• Transferrin transports iron – TIBC measures total transferrin – % saturation of TIBC is measuring how much iron is actually bound to the

transferrin• TIBC is high• Plasma iron is low• % saturation is low• Most common cause is chronic blood loss

– menstrual abnormalitiesGI bl di



– GI bleeding



Macrocytic Anemia• aka megaloblastic anemia• Due to vitamin B12 or folic acid deficiencies

– needed for DNA synthesis• Hyperactive, hypercellular bone marrow• Most common cause is defective intestinal absorption

– intrinsic factor

– gastrectomy – surgical resection of ileum – inflammatory bowel disease

• Pernicious anemia



– autoimmune disease

– associated with chronic atrophic gastritis



Aplastic Anemia• Failure to produce all blood cells

• Idiopathic• Results in pallor & fatigue• Thrombocytopenia

• Low WBC count• Hypocellular bone marrow





Myelophthisis• Bone marrow replaced by tumor or fibrosis

• Fibrosis usually due to radiation but could be a manifestation of a myeloproliferativesyndrome



Polycythemia• Too many RBCs• Relative

– low plasma volume such

as in dehydration – ―stress polycythemia‖ • Absolute

– primary• polycythemia vera

– secondary• due to

– hypoxia from chronic lungdiseasehigh altitude



– high altitude

Leukopenia• Low WBC count

• Caused by – hypersplenism – autoimmune disease – sepsis – bone marrow problem

• Agranulocytosis– severe neutropenia



severe neutropenia

– caused mostly by drugs

Leukocytosis• Too many WBCs

• Can be reactive or malignant





Leukemias• Acute

– immature cells – aggressive – short course – abrupt onset – symptoms include

• anemia• infections• bleeding• bone pain

• Chronic – mature cells – less aggressive – longer course – insidious onset – symptoms include

• fatigue• pallor• night sweats• infections



• enlarged lymph nodes • splenomegaly• hepatomegaly



Infectious Mononucleosis• Acute, self-limited• Atypical lymphocytes• Epstein-Barr virus

– infects B cells – heterophile antibodies

• Signs/symptoms – fever – sore throat – enlarged lymph nodes



g y p

• Monospot test

Lymph Node Response• Infection

• Malignancy• Immune reactions• Autoimmune disease



Lymphadenopathy• Enlarged nodes – tender = infectious – non-tender = malignant

• Lymphadenitis – lymph node is infected

• Reactive hyperplasia

– acute• dental infections, sore throat,genital infections

– chronic• TB



TB

Acute Lymphocytic Leukemia• ALL• Uncommon

– mostly in children & youngadults• Immature B cells• Abrupt onset• Results in

– bone pain – lymphadenopathy



– hepatosplenomegaly



Chronic Lymphocytic Leukemia• CLL• B cells• About 1/3 of all

leukemias• Difficult to distinguish

from small celllymphocyticlymphoma

• Mostly in adults



• Slow developing



Plasma Cell Dyscrasias• Activated B cells

• Make too much of a particular antibody• On electrophoresis, appears as a dark bandcalled an M-spike

• Light chains can pass through glomerulus &into urine – Bence-Jones proteins





Multiple Myeloma• Malignant cells appear as nodular masses in

bone marrow






bone marrow• ―punched out‖ lesions in skull & spine






bone marrow• ―punched out‖ lesions in skull & spine • Hypogammaglobinemia

• Susceptible to infections• Elderly most commonly affected



Lymphomas

• Neoplasms of lymphocytes or lymphoblasts that grow



• Neoplasms of lymphocytes or lymphoblasts that growas nodular masses usually in lymph nodes

Hodgkin Lymphoma• EBV• Characteristic cell is Reed-Sternberg

(RS) cell

• Most common neoplasm between 10-30 yrs old• Usually have poor T cell immunity• Arises in a single lymph node or chain

of nodes & spreads in an orderlymanner• Rarely involves anything but lymph

nodes



• Usually painless, non-tender enlarged lymph

node in neck• Weight loss• Night sweats• Fever• Fatigue• Infection• Good survival but at risk

for other malignancies



for other malignancies

Non-Hodgkin Lymphomas• B cells

• Aggressive• Usually in advanced stage when diagnosed• 1/3 arise in organs other than lymph nodes

• Tend to spread widely



Follicular Lymphoma• About 50%• Less aggressive• Painless, enlarged lymph nodes



Diffuse Lymphomas• About 50%

• No follicles• Usually over 60 except for childhoodlymphomas & those in AIDS

• Appear quickly & grow rapidly• Lethal unless treated



Acute Myelocytic Leukemia• AML• Myeloblasts• Usually in middle age & older adults• Sudden onset• Marrow failure

– anemia – infection – bleeding – bone pain – lymphadenopathy



– hepatosplenomegaly



Chronic Myeloproliferative Disorders• 2 features occur to some degree in each disorder• Myelofibrosis

– bone marrow replaced by fibrous tissue – due to fibrogenic factors released by megakaryocytes

• Extramedullary hematopoiesis – blood cell production outside of the marrow



Chronic Myelocytic Leukemia• CML• Granulocytes

• Middle-aged adults usually• About 15% of adult leukemias• Slow onset but progressively

worsens• > 100,000 cells• May end in a ―blast crisis‖



Polycythemia Vera• Red cell precursors• Middle-aged adults

• Appears slowly• HCT > 60%• High WBC count &

platelet count• May see giant platelets



Malignant Thrombocythemia• aka essentialthrombocythemia

• Rare• 500,000/ml or greater• Thrombosis &

hemorrhage• Survival is about 10-15

years



Myeloid Metaplasia withMyelofibrosis

• Marrow fibrosis predominates

• Fibrogenic factors• Older adults• Extramedullary hematopoiesis

• Increased basophils• Thrombosis & hemorrhage• May end in ―blast crisis‖



y ‖













Major Determinants of Disease• Excessive bleeding is always associated with at least 1 of 3

factors – fragile blood vessels – low platelet count or defective platelet function – decreased coagulation factor activity

• Bleeding related to platelet disorders usually occurs fromcapillary-sized blood vessels

• Bleeding related to coagulation factors usually occurs fromlarger vessels

• Most coagulation factors are proteins made by the liver, &severe liver disease is often accompanied by excessive bleeding

• Intravascular clotting is always abnormal & secondary to



Intravascular clotting is always abnormal & secondary toanother disease

Hemorrhage• Usually due to vascular injury• If excessive, called hemorrhagic diathesis• Platelet problems or fragile small blood

vessels usually present as petechiae,nosebleed, hematuria, or excessive menses

• Coagulation factor deficiencies usually bleed into deep tissues, joints, & bodyspaces



Fragile Small Blood Vessels• Usually trauma

• Seen in elderly• Autoimmune vasculitis• Scurvy



Thrombocytopenia• Characterized by petechiae in skinor mucous membranes

• 130,000 – 400,000/ml is normal• No concern until < 100,000/ml

• No excessive bleeding until <50,000/ml• Spontaneous hemorrhage at

20,000/ml• Abnormal bleeding time

• Causes include – primary bone marrow disorder – toxicity due to drugs – nutritional deficiencies – hypersplenism



Immune Thrombocytopenic Purpura• ITP• Common cause of low platelet count

• Platelets destroyed by immune system – covered with antibodies & removed by spleen• Insidious onset• Usually presents as

– easy bruising – epistaxis – bleeding gums – unusual bleeding after minor trauma



– subungual or conjunctival petechiae

Classic Hemophilia• aka Hemophilia A

• Factor VIII deficiency• X linked• Most common serious inherited coagulation

disorder• Normal bleeding time, PT, & platelet count• PTT is prolonged



von Willebrand Disease• Deficiency of von Willebrand factor (vWF)

– made in endothelial cells & megakaryocytes• One of the most common inherited

coagulation disorders

• Prolonged bleeding time• Normal platelet count• Platelets cannot adhere to endothelium well



Severe Christmas Disease• aka Hemophilia B

• Factor IX deficiency• Named for 1st patient it was identified in• X linked



Disseminated IntravascularCoagulation

• DIC• Clotting inside vessels

• May cause obstruction insmaller vessels• Eventually begin to bleed

due to consumption ofcoagulation factors – consumptive coagulopathy

• Not a primary disease• Anemia, thrombosis, &

hemorrhage

• Initiated by – obstetrical complications

• toxemia• abruptio placentae

– infections• gram-negative sepsis• malaria

– neoplasms – tissue trauma

• crush injuries• burns

– others• snakebite



• heat stroke

Venous Thrombosis• Usually due to local turbulence or endothelial

injury

• Can be due to abnormalities of coagulation proteins – lupus anticoagulant

• anti-phospholipid antibody• interferes with blood coagulation tests suggesting a deficit

when there is not• suspect if PT or PTT is prolonged with no evidence of bleeding disorder

– factor V Leiden• abnormal form of factor V• autosomal recessive



HEMATOLOGY/HEMATOPOIESIS

Introduction



HEMATOLOGYIntroduction

• Study of blood & its components• Window of rest of body



BLOODRaison d’etre

• Delivery of nutrients – Oxygen

– Food – Vitamins

• Removal of wastes – Carbon dioxide

– Nitrogenous wastes – Cellular toxins

• Repair of its conduit• Protection versus invading microorganisms



g g• Multiple cellular & acellular elements

HEMATOLOGYDivisions

• Red Blood Cells/Oxygen & CO 2transport

• White Blood Cells/Protection versus microorganisms

• Coagulation/platelets/Maintenance ofvascular integrity



HEMATOLOGYHematopoiesis

• In humans, occurs in bone marrowexclusively

• All cellular elements derived frompluripotent stem cell (PPSC)

• PPSC retains ability to both replicate

itself and differentiate• Types of differentiation determined by

the influence of various cytokines



HEMATOPOIESISCommitted StemCells



RED BLOOD CELLSIntroduction

• Normal - Anucleate, highly flexiblebiconcave discs, 80-100 femtoliters involume

• Flexibility essential for passage throughcapillaries

• Major roles - Carriers of oxygen to &carbon dioxide away from cells





ERYTHROPOIETIN• Cytokine - Produced in the kidney• Necessary for erythroid proliferation and

differentiation• Absence results in apoptosis

(programmed cell death) of erythroid

committed cells• Anemia of renal failure 2 ° to lack of

EPO



ERYTHROPOIETINMechanism of Action




• Binds specifically to ErythropoietinReceptor

• Transmembrane protein; cytokinereceptor superfamily

• Binding leads to dimerization of receptor• Dimerization activates tyrosine kinase

activity




• Multiple cytoplasmic & nuclear proteinsphosphorylated

• Nuclear signal sent to activate

production of proteins leading toproliferation and differentiation



ERYTHROPOIETINRegulation of Production





ErythropoietinResponse to Administration

0

10

20

30

40

50

Time

H e m a t o c r i t



rhuEPO 150 u/kg 3x/wk

RBC Precursors• Pronormoblast• Basophilic normoblast• Polychromatophilic Normoblast• Orthrochromatophilic Normoblast• Reticulocyte• Mature Red Blood Cell• 5-7 days from Pronormoblast to

Reticulocyte













RBC Assessment• Number - Generally done by automated

counters, using impedance measures

• Size - Large, normal size, or small; all samesize versus variable sizes (anisocytosis).Mean volume by automated counter

• Shape - Normal biconcave disc, versus spherocytes, versus oddly shaped cells(poikilocytosis)

C l G ll if f i f ll



• Color - Generally an artifact of size of cell



Red Blood CellsNormal Values

RBC Parameters Normal Values

Hematocrit

Females 35-47%

Males 40-52%

Hemoglobin

Females 12.0-16.0 gm/dl

Males 13.5-17.5 gm/dl

MCV 80-100 fl

Reticulocyte Count 0.2-2.0%



RETICULOCYTE• Young red blood cell; still have small amounts

of RNA present in them

• Tend to stain somewhat bluer than matureRBC’s on Wright stain (polychromatophilic) • Slightly larger than mature RBC• Undergo removal of RNA on passing through

spleen, in 1st day of life• Can be detected using supravital stain• Important marker of RBC production





RETICULOCYTE COUNT Absolute Value

• = Retic % x RBC Count – eg 0.01 x 5,000,000 = 50,000

• Normal up to 100,000

• More accurate way to assess body’sresponse to anemia



ANEMIACauses

• Blood loss• Decreased production of red blood cells

(Marrow failure)• Increased destruction of red blood cells

– Hemolysis

• Distinguished by reticulocyte count – Decreased in states of decreased production – Increased in destruction of red blood cells





RBC DESTRUCTION -EXTRAVASCULAR

Markers • Heme metabolized to bilirubin in macrophage;

globin metabolized intracellularly

• Unconjugated bilirubin excreted into plasma &carried to liver• Bilirubin conjugated in liver &excreted into bile &

then into upper GI tract

• Conjugated bilirubin passes to lower GI tract &metabolized to urobilinogen, which is excretedinto stool & urine



RBC DESTRUCTION -

INTRAVASCULAR• Free Hemoglobin in circulation leads to

– Binding of hemoglobin to haptoglobin,yielding low plasma haptoglobin

– Hemoglobin filtered by kidney &reabsorbed by tubules, leading to

hemosiderinuria – Capacity of tubules to reabsorb protein

exceeded, yielding hemoglobinuria



INTRAVASCULAR

HEMOLYSIS

Serum Haptoglobin

Hemosiderinuria

Hemoglobinuria



HEMOLYTIC ANEMIACommonly used Tests

Test Result

Reticulocyte Count Increased

Unconjugated Bilirubin IncreasedLactate Dehydrogenase Increased

Haptoglobin Decreased

Urine Hemoglobin Present

Urine Hemosiderin Present

Problems with sensitivity & specificity



Problems with sensitivity & specificity

Introduction to Leukemia

• Definition

• Historic Perspective• Etiology and Risk Factors• Incidence• Classification• Comparison of Acute and Chronic

L k i



Leukemia

Leukemia

Definition

Leukemia is a malignant disease of hematopoietissue characterized by the accumulation abnormwhite cells (neoplastic or leukemic) in the bonmarrow leading to bone marrow failure, a rais

circulating white cell count (leukocytosis) aninfiltrate organs (e.g liver, spleen, lymph node brain)



Leukemia

Historic Perspective

•1945•The initial description of leukemia as a clinicentity was made by Bennett in Scotland and Germany.



Leukemia

Etiology and Risk Factors

The etiology of leukemia is unknown.

• Oncogenes mutation and tumor suppressorgene alteration.

• Host factors.• Environmental factors



Leukemia

Myeloid series Lymphoid series

Stem Cell

? ?

? ?

Oncogene mutationTumor suppressor geneChromosomal abnormalityGene rearrangement



Host Factors

• Congenital chromosomalabnormalities

Increased frequency in patients with congenitadisorders that have tendency for chromosomaabnormality.

Such as : Bloom‘s syndrome, Fanconi anemiaDown‘s and Klinefelter‘s syndromes.

18-20 fold increase incidence of AL is seen inchildren win DS



children win DS.

• ImmunodeficiencyAn unusually high incidence of lymphoidleukemia and lymphoma has been describedin patients with hereditary immunodeficiencystates (ataxia-telangiectasia and sex-linkedagamaglobulinemia).

Usually related to T and B-lymphocyte generearrangement.



Chronic bone marrow dysfunction

• Patients with CBMD syndromes have an

increased risk of acute leukemictransformation.• Examples include the myelodypalstic

syndromes, myeloproliferative disorders,aplastic anemia and PNH



Environmental factors

Ionizing radiation• Leukemia is associated with exposure to

ionizing radiation such as nuclear weaponsin Hiroshima and Nagasaki.

• Both acute and chronic forms of leukemiaincluding AML, ALL and CML wereassociated.



Chemical drugs

• A variety of chemicals and drugs have beenassociated with the development ofleukemic transformation

• Examples: Benzene, Chloramphenecol,Phenylbutazone and Cytotoxic alkylatingchemotherapeutic agents.



Viruses• The human T-cell leukemia-lymphoma virus-I

(HTLV-I) has been implicated as a causative agent

of adult T-Cell leukemia-lymphoma.• Another related virus HTLV-II has been isolated

from patients with atypical hairy cell leukemia(CLL)

• The Epstein‘s Barr virus has been linked toBurkitt‘s lymphoma.



Incidence

• In the USA 8-10 new cases per 100,000individuals annually.

• Approximately 28,600 new cases werereported about 50% acute and 50% chronic

• Leukemia strike more in adult than children(10:1) and has slightly increase incidence inmales than females (1-2:1)



Classification of leukemiaMain classification

Chronic leukemia Acute leukemia

Lymphoid LymphoidMyeloid MyeloidFAB

AMLM0M1M2M3M4M5

M6M7

CMLPVET

IMF



M7

Introduction to leukemia

Acute leukemias



Introduction to leukemia• Leukemia is a malignant disease characterized

byunregulated proliferation of one cell type. – It may involve any of the cell lines or a stem cell

common to several cell lines. – Leukemias are classified into 2 major groups

• Chronic in which the onset is insidious, the disease isusually less aggressive, and the cells involved are usuallymore mature cells

• Acutein which the onset is usually rapid, the disease is veryaggressive, and the cells involved are usually poorlydifferentiated with many blasts.



Introduction to leukemia• Both acute and chronic leukemias are further classified

according to the prominent cell line involved in theexpansion:

– If the prominent cell line is of the myeloid series it is amyelocytic leukemia (sometimes also called

granulocytic) – If the prominent cell line is of the lymphoid series it is alymphocytic leukemia

– Therefore, there arefour basic types of leukemia» Acute myelocytic leukemia – AML- (includes

myeloblastic, promyelocytic, monocytic,myelomonocytic, erythrocytic, and megakaryocytic)

» Acute lymphocytic leukemia – ALL- (includes T cell, Bcell, and Null cell)

» Chronic myelocytic leukemia – CML - (includesmyelocytic and myelomonocytic)



Introduction to leukemia» Chronic lymphocytic leukemia – CLL - (includes

plasmocytic {multiple myeloma}, Hairy cell, prolymphocytic, large granular cell lymphocytic,Sezary‘s syndrome, and circulating lymphoma)

– Etiology – theexact cause is frequently not known,

but predisposing factors are known:• Host factors – Some individuals have aninherited increased

predisposition to develop leukemia – There is an increased incidence in those with an

inherited tendency for chromosome fragility or

abnormality or those with increased numbers ofchromosomes (such as Down‘s syndrome).» Many of these diseases are characterized by

chromosomal translocations.



Introduction to leukemia – There is an increased incidence in those with hereditary

immunodeficiencies. – There is an increased incidence in those with chronic

marrow dysfunction such as those with

myeloproliferative diseases, myelodysplasticsyndromes, aplastic anemia, or paroxsymal nocturnalhemoglobinuria.

• Environmental factors: – Exposure to ionizing radiation – Exposure to mutagenic chemicals and drugs – Viral infections



Introduction to leukemia – Incidence

• Acute leukemias can occur in all age groups – ALL is more common in children

– AML is more common in adults• Chronic leukemias are usually a disease of adults

– CLL is extremely rare in children and unusual beforethe age of 40

– CML has a peak age of 30-50



Introduction to leukemia – Comparison of acute and chronic leukemias:

Acute ChronicAge all ages usually adultsClinical onset sudden insidiousCourse (untreated) 6 mo. or less 2-6 yearsLeukemic cells immature >30% blasts more mature cellsAnemia prominent mildThrombocytopenia prominent mildWBC count variable increasedLymphadenopathy mild present;often prominentSplenomegaly mild present;often prominent



Introduction to leukemia• Acute leukemia –

– Is a result of:• Malignant transformation of a stem cell leading to

unregulated proliferation and• Arrest in maturation at the primitive blast stage. Remember

that a blast is the most immature cell that can be recognizedas committed to a particular cell line.

– Clinical features• Leukemic proliferation, accumulation, and invasion of

normal tissues, including the liver, spleen, lymph nodes,central nervous system, and skin, cause lesions rangingfrom rashes to tumors.

• A humoral mediator from the leukemic cells may inhibit proliferation of normal cells.



Introduction to leukemia• Failure of the bone marrow and normal

hematopoiesis may result in pancytopenia withdeath from hemorrhaging and infections.

– Lab evaluation• The lab diagnosis is based on two things – Finding a significant increase in the number of

immature cells in the bone marrow including blasts, promyelocytes, promonocytes (>30% blasts isdiagnostic)

– Identification of the cell lineage of the leukemic cells



Introduction to leukemia – Peripheral blood:

• Anemia (normochromic, normocytic)• Decreased platlets• Variable WBC count

– The degree of peripheral blood involvement determinesclassification:

» Leukemic – increased WBCs due to blasts» Subleukemic – blasts without increased WBCs» Aleukemic – decreased WBCs with no blasts

– Classification of the immature cells involved may bedone by:



Introduction to leukemia• Morphology – an experienced morphologist can look at the

size of the blast, the amount of cytoplasm, the nuclearchromatin pattern, the presence of nucleoli and the presenceof auer rods (are a pink staining, splinter shaped inclusion

due to a rod shaped alignment of primary granules foundonly in myeloproliferative processes) to identify the blasttype:

– AML – themyeloblast is a large blast with a moderateamount of cytoplasm, fine lacey chromatin, and prominent nucleoli. 10-40% of myeloblasts containauer rods .



Myeloblasts with auer rods



Introduction to leukemia – ALL – in contrast to the myeloblast,the lymphoblast is

a small blast with scant cytoplasm, dense chromatin,indistinct nucleoli, andno auer rods



Introduction to leukemia• Cytochemistry – help to classify the lineage of a

leukemic cell (myeloid versus lymphoid) – Myeloperoxidase – is found in the primary granules of

granulocytic cells starting at the late blast stage.Monocytes may be weakly positive.



Sudan black – Sudan black stains phospholipids, neutral fats and

sterols found in primary and secondary granules ofgranulocytic cells and to a lesser extent in monocyticlysosomes. Rare positives occur in lymphoid cells



Nonspecific Esterase – Nonspecific esterase – is used to identify monocytic

cells which are diffusely positive. T lymphocytes mayhave focal staining



Acid phosphatase – Acid phosphatase may be found in myeloblasts and

lymphoblasts. T lymphocytes have a high level of acid phosphatase and this can be used to help make adiagnosis of acute T-lymphocytic leukemia.



Leukocyte Alkaline phosphatase – Leukocyte alkaline phosphatase – is located in the

secondary granules of segmented neutrophils, bandsand metamyelocytes. The LAP score is determined bycounting 100 mature neutrophils and bands. Each cell isgraded from 0 to 5. The total LAP score is calculated by adding up the scores for each cell.



Leukocyte alkaline phosphatase



Introduction to leukemia• Immunologic markers (immunophenotyping) – these are

used mainly for lymphocytes, i.e., for determining B cell orT cell lineage. These tests rely on antibodies made againstspecific surface markers.

– They constitute what we would call the primaryantibody and in anindirect assay they are allowed toreact with the cells and unbound antibody is thenwashed away.

– Fluorescently labeled antibody (secondary antibody)against the primary antibody is added and allowed toreact and then unbound secondary antibody is washedaway.

– The cells are then sent through aflow cytometer thatwill determine the number of cells that have afluorescent tag and which are thus positive for the presence of the surface marker to which the primaryantibody was made.

– In adirect assay, the primary antibody is fluorescentlylabeled.



Direct versus indirect labeling of

antigens

B or T Cellmarker

B or T cellspecific Ab

B or T cellspecific Ab

B or T Cell marker



Flow cytometer



Terminal deoyxtidyl transferase• This is a unique DNA polymerase present

in stem cells and in precursor B and Tlymphoid cells.

• High levels are found in 90% oflymphoblastic leukemias.

• It can also be detected using appropriate

antibodies and flow cytometry.



Introduction to leukemia• Cytogenetics – cytogenetics studies can now be used for

diagnosis and for prognosis of hematologic malignancies. – Many leukemias (and lymphomas) are characterized by

specificchromosomal abnormalities, including specifictranslocations and aneuploidy. The specific type ofmalignancy can be identified based on the specificabnormality or translocation. These may be identified by

» Looking at the karyotypes of the chromsomes from theabnormal cells

» DNA based tests – these tests are very useful forfollowing the course of the disease

» RT-PCR» Southern blotting – A normal karyotype is usually associated with a better

prognosis.



Chromosomal translocation



Chromosome karyotyping



Acute leukemias

• Acute lymphoblastic leukemia – – They may beclassified on the basis of the cytologicalfeatures of the lymphoblasts into;

• L1 - This is the most common form found in children and ithas the best prognosis.

– The cell size is small with fine or clumped homogenousnuclear chromatin and absent or indistinct nucleoli.

– The nuclear shape is regular, occasionally clefting orindented.

– The cytoplasm is scant, with slight to moderate

basophilia and variable vacuoles.• L2 – This is the most frequent ALL found in adults. – The cell size is large and heterogenous with variable

nuclear chromatin and prominent nucleoli. – The nucleus is irregular, clefting and indented.

– The cytoplasm is variable and often moderate toabundant with variable baso hilia and variable vacuoles.



abundant with variable baso hilia and variable vacuoles.

ALL-L1



ALL-L2



Acute leukemias• L3 – This is the rarest form of ALL.

– The cell size is large, with fine, homogenous nuclearchromatin containing prominent nucleoli.

– The nucleus is regular oval to round. – The cytoplasm is moderately abundant and is deeply

basophilic and vacuolated.



ALL-L3



Acute leukemias – ALL may also be classified on the basis of

immunologic markers into:• Early pre-B ALL

• Pre-B ALL• B ALL• T ALL• Null or unclassified ALL (U ALL) - lack B or T

markers and may be the committed lymphoidstem cell)



B cell maturation



T cell maturation



Acute leukemias – Incidence – ALL is primarily a disease of

young children (2-5 years), but it can alsooccur in adults

– Clinical findings – pancytopenia withresulting fatigue, pallor, fever, weight loss,irritability, anorexia, infection, bleeding, and bone pain.

– L1 occurs in children, L2 in adults, and L3 iscalled Burkitts leukemia





Acute leukemias• Acute leukemias with mixed lineage –

occasionally there are acute leukemias that are biphenotypic and display phenotypes for twodifferent lineages – B lymphoid/myeloid – T lymphoid/myeloid – B/T lymphoid – Myeloid/Natural killer – A rare trilineage leukemia has also been seen (was

B/T lymphoid/myeloid!)



Acute leukemias• Acute myeloid leukemia (also called acute

granulocytic leukemia) – classification dependsupon – Bone marrow blast morphology – Degree of cell maturation – Cytochemical stains – Immunophenotyping – AML is divided into 7 different classifications:

• M1 – myeloblastic without maturation – The bone marrow shows 90% blasts and < 10%

promyelocytes – The disease occurs in older adults



AML – M1• Note the myeloblasts and the auer rod:



Acute leukemias• M2 – myeloblastic with maturation

– The bone marrow shows 30-89% blasts and > 10% promyelocytes;

– This is characterized by an8,21 chromosomaltranslocation

– This occurs in older adults• M3 – hypergranular promyelocytic

– This form of AML has a bone marrow with >30% blasts

– Is more virulent than other forms – Occurs with a medium age of 39 – The WBC count is decreased – Treatment causes a release of the granules and may

send the patient into disseminated intravascularcoagulation and subsequent bleeding

– It is characterized by a15,17 chromosomaltranslocation



AML – M2• Note myeloblasts and hypogranulated

PMNs:



AML – M3• Note hypergranular promyelocytes:



Acute leukemias• M3m – hypogranular promyelocytic –

– The bone marrow has > 30% blasts – The WBC count is increased. – Like the M3 type, treatment causes a release of the

granules and may send the patient into disseminatedintravascular coagulation and subsequent bleeding and – It is characterized by a15,17 translocation

• M4 – acute myelomonoblastic leukemia – Both myeloblasts and monoblasts are seen in the bone

marrow and peripheral blood – Infiltration of extramedullary sites is more common

than with the pure granulocytic variants



AML – M3M• Note hypogranular promyelocytes:



AML – M4• Note monoblasts and promonocytes:



Acute leukemias• M5 – acute monoblastic leukemia

– >80% of the nonerythroid cells in the bone marrow are monocytic – There is extensive infiltration of the gums, CNS, lymph nodes and

extramedullary sites – This form is further divided into

» M5A - Poorly differentiated (>80% monoblasts)» M5B - Well differentiated (<80% monoblasts)• M6 – erythroleukemia

– This is rare and is characterized by a bone marrow having a predominance of erythroblasts

– It has 3 sequentially morphologically defined phases;» Preponderance of abnormal erythroblasts» Erythroleukemia – there is an increase in both

erythroblasts and myeloblasts» Myeloblastic leukemia – M1, M2, or M4

– Anemia is common



AML – M5A• Note monoblasts:



AML-M5B• Note monoblasts, promonocytes, and

monocytes:



AML – M6• Note M1 type monoblasts



Acute leukemias• M7 - Acute megkaryoblastic leukemia

– This is a rare disorder characterized by extensive proliferation of megakaryoblasts, atypicalmegakaryocytes and thrombocytopenia

• Treatment of leukemias – – There are 2 goals:• Eradicate the leukemic cell mass• Give supportive care

– Except for ALL in children, cures are not common but complete remission (absence of any leukemiarelated signs and symptoms and return of bonemarrow and peripheral blood values to within normalvalues) is



Acute leukemias – There are four general types of therapy

• Chemotherapy – usually a combination of drugsis used

• Bone marrow transplant• Radiotherapy• Immunotherapy – stimulate the patients own

immune system to mount a response against themalignant cells

• Monoclonal antibodies – examples includeRituxin



Therapeutic Options



Primary Goal of Therapy for CML

a Complete Cytogenetic Response• Elimination of the Ph chromosome

– Cytogenetic/molecular response

• Other therapeutic goals – Hematologic response – Disappearance of splenomegaly – Normal physical examination



Therapeutic Options for CML

• Allogeneic stem cell transplantation(SCT)

• IFN- – based treatments

• Chemotherapy with hydroxyurea,busulfan

• Imatinib mesylate (formerly STI571)



Allogeneic SCT, the Only Known Cure, Is AssociWith High Morbidity and Mortality Rates in CM

National Marrow Donor Program (NMDP) overview slide presentation. Available at http://www.marrow.org/NMDP/SLIDESET/sld031.htm#slide. Accessed June 17, 2002.

Survival by Disease Stage, June 2001,based on transplants 1987 – Feb 2001.

P =.0001

0 1 2 3 4 5

100

90

70

60

50

40

30

20

10

0

80

100

90

70

60

50

40

30

20

10

0

80

Years After Transplant

S u r v

i v a

l ( % )

S ur vi v al ( %

)

Blast Phase (n=159)

Accelerated and 2 nd CP (n=744)

First Chronic Phase (n=1903)



Mechanism of Action of STI571

Goldman JM. Lancet . 2000;355:1031 – 1032.

Bcr-Abl

ATP

Substrate

STI571

Y = TyrosineP = Phosphate

Bcr-Abl

Substrate

PPP

P



Imatinib Mesylate Inhibits the Growth oBcr-Abl – Positive Cells

Gambacorti-Passerini C et al. Blood Cells Mol Dis .

1997;23:380-394.

*Bcr-Abl –negative celllines.

†Bcr-Abl –positive celllines.

Imatinib Mesylate Concentration ( M)

U937*KG1*SU DHL1*

KCL22 †

K562 † KU812 †

% C

o n

t r o l C P M



Imatinib MesylateClinical Trials



IRIS Study Design: Imatinib MesylateVersus IFN- + ara-C

S

Imatinib Mesylate

IFN- + ara-C

R Crossover

IF: Loss of MCR or CHR Increasing WBC count Intolerance of treatment Failure to achieve MCR at 12 months* Failure to achieve CHR at 12 months* Request to discontinue IFN- *

Progression Increasing WBC count Loss of MCR or CHR Accelerated phase or blast crisis Death

S = screening.R = randomization.

*Independent Data Monitoring Board Recommended Protocol Amendments

1106 patients enrolled from June 2000 to January 2001



Major Cytogenetic Responses WithImatinib Mesylate Were Rapid

Imatinib mesylate

IFN- + ara-C

Months Since Randomization

% R

e s p o n d

i n g

83%

20%

0 10 20

30 40 50 60

70 80 90

100

0 3 6 9 12 15 18 21



Complete Hematologic ResponsesWere Rapid With Imatinib Mesylate

96%

67%

0 10 20

30 40 50 60

70 80 90

100

0 3 6 9 12 15 18 21

% R

e s p o n d

i n g

Months Since Randomization

Imatinib mesylate

IFN- + ara-C

R i I i ib M l O



Resistance to Imatinib Mesylate OccursPredominantly During Advanced Phase CM

• Advanced stage cancers arecharacterized by multiplegenetic changes

• Patients in advance phase

often relapse with thedevelopment ofchemotherapy resistance

• Some patients in blast crisisCML initially respond to

imatinib mesylate but thentend to relapse

Chronic Phase Blast Crisis Relapse

Ph+ Ph+ blasts Ph-negative Ph+ imatinib mesylateresistant blasts

H e m a

t o p o

i e t i c

d i f f e r e n

t i a t i o n

B on

em

ar r o

w t o

p er i ph

er al b l o o

d

Courtesy of Charles L. Sawyers, MD, UCLA.



CML• Bcr-abl is necessary and sufficient for the development and

maintenance of the CML phenotype

• Secondary genetic and epigenetic events may contribute tothe progression of CML

• The ―bench‖ has provided the opportunity fo thedevelopment of targeted therapies for CML via inhibitionof bcr-abl



M3*

M4

M5 M6 M0, M1, M2

58% 7%

M0, M1, M2 M7 M6 M5

M4

M3*

52%

9%

Adults Adults Children Children

Frequency of Acute Myeloid Leukemia Subtypes Frequency of Acute Myeloid Leukemia Subtypes









Prognostic Factors• Prognostic factors: for CR, relapse risk

– From multivariate models – Prior hematologic disorder/chemotherapy – Age >60 years

• Increased number of deaths from toxicity• Adverse cytogenetics, prior MDS

• Tendency to undertreat – WBC

MDS = myelodysplastic syndrome.



Cytogenetics and PrognosisRisk

Group Inc ludes %pts Relapse

@5 yrsSurv.

@5yrs

Good t(8;21)

inv16t(15;17)

25% 34% 72%

Std Other 65% 51% 43%

Poor -5/5q-, -73q

Complex

10% 75% 17%



Cytogenetics and Treatment

Outcome5 yrSurvival

Chemo. Al lo . Auto.

G o o d70% 72% 77%

Std 45% 66% 57%

Poor 19% 38% 29%

Allo = Allogenic; Auto = autologous.



Asp

Mut

Asp

Extracellular domain



TM

TM

TM

ITD

Intracellular domain



Flt3 mutations in AML



Clinical development of Flt-3 inhibitors

• PKC412 (Novartis Pharmaceuticals)

•

CT53518 (Millennium Pharmaceuticals)• CEP-701 (Cephalon Inc)

•

SU11248 (Sugen/Pharmacia)



Leukemia Genome Project

• Definable set of mutations contributesto pathogenesis of AML

• Single hematopoietic progenitor• Defining these mutations at the DNA levelessential for development of new therapies

• Defining germline mutations involvedin susceptibility



How to look for mutations andtherapeutic targets in AML



The overall hypothesis

• A definable set of genetic mutationscontributes to the pathogenesis of AML

• These mutations must be defined at thelevel of DNA

• Leukemogenic pathways and outcomes may be determined by these mutations



How do we find the key mutations?

• Targeted assessment of genes likely to beinvolved in AML

• Comprehensive analysis to detectunsuspected contributors

• Use of mice and selected human models todefine new candidates that were notsuspected



The Critical Role of Mice

• A tool toidentify candidate genes for AML pathogenesis

• A tool toverify the biologic significance ofmutations

• A preclinical platform toevaluate newtherapies



Verifying the biology of potential

mutations in mice• Retroviral transductions of GFP-tagged

cDNAs into hematopoietic stem and progenitor cells• Lineage and development-specific

transgenesis• Loss of function via knockouts• Regulated, targeted mutations via knockins• Roles of cooperating mutations



M3*

M4

M5 M6 M0, M1, M2

58% 7%

M0, M1, M2 M7 M6 M5

M4

M3*

52%

9%

Adults Adults Children Children

Frequency of Acute Myeloid Leukemia Subtypes Frequency of Acute Myeloid Leukemia Subtypes



Genetic Changes Contributing to

AML PathogenesisSusceptibility

GermlineFPD (Runx1)SCN (ELA2)DNA repair (FA)others

Initiation

SomaticPML-RAR AML-ETOCBFB-MYH11MLL fusionsothers

Progression

Somatica FLT3a KITa RASothers

Relapse/Resistance

SomaticPML-RAR Efflux Transportersothers



What infrastructure will be

required to define thesemutations?

f f



Draft sequences of the relevant genomes



A Genome Sequencing Center

WUMS GSC -One of the largest academic

sequencing centers in the world

-3 million reads/month

-Vast capability for generating,storing, analyzing, annotating,and exporting sequence data

-Custom Array Facility

-Extensive Informatics support



AML Patients

Stem Cell Transplant/Leukemia Service

-300 Transplants/year

-100 New AMLs/year

-Uniform Treatment

-Clinical Database

-7 faculty attendings(inc. 4 PPG members)



AML patient samples (tumor and

germline)SCC Tumor Bank/GAML Bank

-Skin for germline

-BM/PB for tumorbanking

-DNA/RNA preps

-QC

-Affy-based arrayfacility



An NCI designated Cancer

Center-Siteman Cancer Center

-NCI Designated 2001

-Hematopoietic Devel-opment and MalignancyProgram

-Bioinformatics Core-Biostatistics Core-Tissue Bank Core-Array Core-ES Cell Core



Mouse Modeling Facilities and

Expertise-39,000 barrier cages

at WUMS-5 PPG investigatorsexperienced withmurine AML models(2,500 cages)



Stem Cell Transplant/Leukemia Program Mouse Models of AML

Siteman Cancer Center& Cores

Genome SequencingCenter

Genomics of AMLDiagnostics & Therapeuticsfor AML patients







Treatment of AML usingHypomethylating Agents

John F. DiPersio, MD, PhDDivision of OncologySiteman Cancer Center

Washington University School of Medicine





Hypermethylation in AML• p15 methylation increases with MDS disease

evolution toward AML* – 78% patients have methylation at time of

transformation

• Additional methylated genes: ER, MYOD1,PTX2, GPR37, MDR1, ID4, and SDC4&

• Methylation may be associated with disease progression or development of chemo-resistance&

* Quesnel et al, Blood 1998; 91: 2985; Uchida et al, Blood 1997; 90: 1403& Blum W et al., Clinical Advances in Hematology & Oncology . 2005;3:855-882

http://img.medscape.com/fullsize/migrated/563/885/nrc563885.fig1.gif







C fi Ph III AZA T i l S d D i



Confirmatory Phase III AZA Trial Study Desig

• 354 patients

• RAEB/RAEB-T INT-2 or High

• AZA: 75mg/m 2/sc qd x 7 q 28 days x 6 cycles max.

• “Conventional” care: - best supportive care

- low dose Ara-C: 20 mg/m 2 sc qd x 14 d q 28-42d- standard 7 + 3 anti-leukemic chemotherapy



Vidaza Significantly Extends Overall

Survival• Vidaza median OS = 24.4 months• Conventional care regimens (CCR) median OS =

15 months (p = .001)• Vidaza 2 yr survival = 58.8% vs. CCR = 22%• Median # of Vidaza treatment cycles = 9

• 1:1 randomization Vidaza vs. CCR

D i bi Ph 3



Decitabine Phase 3Study Design (D-0007)

• Open-label, 1:1 randomized, multicenter study in US andCA

• Schedule: 3-hour infusion of 15 mg/m 2 q 8 hrs x 3 days

EligiblePatients(n = 170)

Decitabine + Supportive Care*(n = 89) R

ANDO

MIZED

Supportive Care*

(n = 81)

Stratification• IPSS ≥ 0.5;• All FAB subgroups• Prior chemotherapy

• Study center

*Antibiotics, growth factors, and/or transfusions .Kantarjian , et al. Cancer . 2006;106:1794-1803.

Primary Endpoints:• Response Rate (CR+PR)

• Time to AML or deathSecondary Endpoints:

• Duration of Response,

Cytogenetic Response,Transfusion Requirement,QOL, Survival, Toxicity





AML Survival in Patients over

Age 55

Rowe, Hematology, 2001

ECOG Trials since 1973

Chemotherapy-Based Trials



Chemotherapy Based Trialsin Older Adults with AML*

• Remarkably similar induction rate, toxic death rate, and poor overall survivalacross studies:

Med age CR Toxic death Survival – CALGB 8923 69 52% 25% 9.6 mo

– SWOG 9031 68 45% 16% 8.5 mo – HOVON AML 9 68 42% 18% 9.5 mo – CALGB 9720 70 46% 20% 10 mo – ECOG 3351 68 42% 17% 7.5 mo – SWOG 9333 68 43% 18% 9 mo

Stone et al. N Engl J Med. 1995;332(25):1671-1677; Godwin et al. Blood. 1998;91(10):3607-3615; Lowenberg et al. J Clin Oncol.1998;16(3):872-881; Baer et al. Blood. 2002;99(1):252-257; Anderson et al. Blood . 2002;100(12):3869-3876; Rowe et al. Blood.2004;104(2):558-560.

* Deemed chemotherapy candidates, all age > 55.



Decitabine in AMLClinical Monotherapy Studies

D i bi Ph III



Decitabine Phase IIIResponse in Patients with AML

Subgroup analysis

*IWG AML Response Criteria. †One patient was a CRi (morphologic complete remission withincomplete blood count recovery). Cheson et al. J Cl in Oncol . 2003;21:4642-49;

Kantarjian HM, et al. Cancer . 2006;106:1794-1803; Data on File, MGI PHARMA.

2 (22)

3 (33)

5 (56)

Decitabinen = 9 (%)

0 (0)

0 (0)

0 (0)

SupportiveCare

n = 3 (%)

PartialResponse

Complete

Response†

OverallResponse*



Low dose Decitabine in AML

Relapsed/Refractory Patients• Phase 1 Study: Decitabine doses of 5-20 mg/m2 x 5 days for 2 weeks• Results: 14% (5/37) CR and 8% (3/37) PR• Median duration of response = 8 weeks

• Three patients remained disease-free at last follow-up, including 1 patient with relapsed AML after allogeneic transplantation• Adverse events included elevations in liver function tests, fever,

infection and myelosuppression

Issa JP et al., Blood. 2004;103:1635-1640 .



Phase II Decitabine AML Study

Preliminary Results (IWG Criteria) • 53 Patients Treated; 32 Evaluable Patients• 11/32 (34%) Overall Response

– 5 CR, 6 CRi

• Median time to response was 3 cycles• Two patients with leukemia cutis experienced complete resolution ofskin lesions

• Most common adverse events: myelosuppression, fatigue and nausea

Cashen, A, et al. Blood. 2006;108:561a-562a.Abstract 1984.

Patient Characteristics



Patie nt AM L diagnos iscytogenetic

risk ECOG best response

time tores ponse (#

cycles)total #cycles

1 de novo poor 0 PD 32 MDS poor 1 CR 3 relapsed 103 secondary intermediate nd PD 2

4 de novo poor 1 SD 45 MDS poor 1 16 07 08 MDS intermediate 0 SD 79 MDS intermediate 1 CRi 2 5

10 MDS intermediate 0 PD 1111 de novo poor 1 expired 012 MDS intermediate 1 expired 213 CMML intermediate 1 CRi 3 relapsed 614 de novo intermediate 2 expired 2

15 MDS intermediate 0 CRi 4 relapsed 816 secondary poor nd expired 117 MDS intermediate 0 SD 618 MDS poor 2 CR 3 1919 MDS intermediate 0 CR 2 620 de novo intermediate 0 SD 421 de novo intermediate 0 CR 5 1922 de novo poor 0 SD 523 de novo intermediate nd expired 124 025 de novo intermediate 1 SD 326 de novo intermediate 0 CRi 6 1227 de novo intermediate 1 SD 528 de novo poor 1 expired 129 de novo poor 0 CRi 5 relapsed 830 031 de novo intermediate 0 CR 4 1332 de novo poor 1 SD 133 de novo intermediate 2 CRi 4 relapsed 834 de novo intermediate 2 PD 735 de novo intermediate 0 PD 3

36 de novo intermediate 1 SD 3





CR CRi Total Response Rate (>SD)

Overall response (n=32) 5 6 34% (11/32)

AML diagnosis

De novo (n=19) 2 3 26% (5/19)

Prior MDS (n=11) 3 3 55% (6/11)

Secondary (n=2) 0 0 0

Cytogenetic risk

Poor (n=11) 2 1 27% (3/11)

Intermediate (n=21) 3 5 38% (8/21)

Resp on se Rates



Kinetics of Response

• Median time to CR or CRi was 4 cycles(range, 2-12)

• Median number of cycles received was 5(range 1-19)• Six patients (19%) died during the first 2

cycles



Non-Hematologic Toxicities



Hematologic Toxicities

Our Study Design



Our Study DesignN=53 patients >60 yr with AML

DAC 20 mg/m2 IV qd x 5 d

ProteomicsRNA profilingGermline DNA

Methylation

Limited resequencing

AML DNAMethylation

Limited resequencing

AML DNA

Methylation

Germline DNA

Methylation ProteomicsRNA profiling

Two cycles and assess response

Chemotherapy-Based Trials



pyin Older Adults with AML*

• Remarkably similar induction rate, toxic death rate, and poor overall survival

across studies:

Med age CR Toxic death Survival – CALGB 8923 69 52% 25% 9.6 mo – SWOG 9031 68 45% 16% 8.5 mo – HOVON AML 9 68 42% 18% 9.5 mo – CALGB 9720 70 46% 20% 10 mo – ECOG 3351 68 42% 17% 7.5 mo – SWOG 9333 68 43% 18% 9 mo

Stone et al. N Engl J Med. 1995;332(25):1671-1677; Godwin et al. Blood. 1998;91(10):3607-3615; Lowenberg et al. J Clin Oncol.1998;16(3):872-881; Baer et al. Blood. 2002;99(1):252-257; Anderson et al. Blood . 2002;100(12):3869-3876; Rowe et al. Blood.2004;104(2):558-560.

* Deemed chemotherapy candidates, all age > 55.



TRM for treatment of elderly

AML Standard “ 7 +3 ”induction : 43% 23% 9.0 mo

Decitabine (Cashen et al): 34% 19% ?

Azacitidine (Sudan et al) : 45% 15% ?

Regimen Rem% TRM OS

Conclusions



Conclusions

•The role of hyomethylating agents for the treatment of AMLremains to be determined

•Toxicities appear to be acceptable but TRM may not besignificantly different than standard “ 7+3 ”.

•? Increased RR in AML evolving from MDS vs. de novo AML

•Understanding the genomics, and epigenetics of AML and MDSmay improve future therapies

•Combination therapies should be developed

especially for the elderly AML patients similarto MDS

•Should a randomized study ever be done in AML >60 comparinghypomethylating therapy to 7+3 (?>60 yr <70 yr)



Acknowledgements

Washington Univ/Division of Oncology: Tim Ley

WUGSC: Rick Wilson

Center for Cancer Genomics (Siteman Cancer Center)

Orion Biosciences: Nate Lakey

WUSM BMT/Leukemic TeamAmanda Cashen



LEUKEMIA

DR. AYESHA JUNAIDMBBS,MCPS,FCPS.Professor of PathologyConsultant HaematologyIncharge Blood Transfusion Services-SIH



Leukemia

OBJECTIVES

What is leukemia?What is the Pathogenesis of Leukeima?How do we classify leukemia?

(WHO 2008 classification)



Leukemia

OBJECTIVES

What is their clinical presentation?How do we diagnose leukemia in

laboratory?What are the basic principles ofmanagement?



Leukemia vs Leukemoid Reaction

• Leucocytosis•

Neutrophilia,Eosinophilia,Lymphocytes

• Leucopenia• Leukemoid Reaction• Leukemia



Leukemia

Myeloid cells•

Mitotic pool (blast to myelocytes)• Maturation pool (ends with the

mature neutrophil)• Storage pool (Mature neutrophils

residing in the bone marrow)



LEUKEMIA

Leukemia is a disease resulting fromthe neoplastic proliferation ofhemopoeitic or lymphoid cells



LEUKEMIA

It results from the mutation in asingle stem cellThe progeny of which form a clone ofleukemic cells



LEUKEMIA

• Genetic events contributing to malignanttransformation include

Inappropriate expression of oncogenesLoss of function of TSG



LEUKEMIA CLASSIFICATION

LINEAGE & DEGREE OF MATURATION

MORPHOLOGYCYTOCHEMICALCYTOGENETICSIMMUNOPHENOTYPICALIMMUNOHISTOCHEMISTRYMOLECULAR GENETICS



LEUKEMIA CLASSIFICATION

WHO 2008• Evidence based classification for daily

therapeutic decisions.

• Provides a flexible framework forintegration of new data



LEUKEMIA • Acute leukemia• Chronic leukemia

• Acute Myeloid Leukemia• Acute Lymphoid Leukemia• Chronic Myeloid Leukemia• Chronic Lymphoid Leukemia



ACUTE LEUKEMIA

Heterogeneous group of clonal disorders

arising from• Pluripotent stem cells• Clinical course•

Response to therapy



ACUTE LEUKEMIA

• Acute leukemia accounts forapproximately 10% of all humancancers

• Is the leading cause of cancer deathsin adults younger than 35 years ofage



BONEMARROWTREPHINEHIGH AND

LOW POWER



CYTOCHEMISTRY• It identifies diagnostically useful enzymes or other

cytoplasmic substances of hemopoietic cells

• Particularly useful for identification ofimmature cellsin leukemia

• SUDAN BLACK B• PERIODIC ACID SCHIFF(PAS)• ACID PHOSPHATASE

Leukemia



Leukemia



AML/ALL MORPHOLOGYDifferentiation on morphological groundsalone is not possible

Morphological features favoring lymphoidderivation include

Blasts including relatively condensed

chromatinAbsence of conspicuous nucleoliPresence of scanty agranular cytoplasm

CYTOCHEMISTRY



CYTOCHEMISTRY

CYTOCHEMISTRY



PAS



ACUTE LEUKEMIAAMLALL



ACUTE LEUKEMIA

CLINICAL FEATURESONSET

Abrupt, acuteInsidious, slowly progressiveBone marrow malfunction

Anemia, infection & bleeding

ACUTE LYMPHOBLASTIC



ACUTE LYMPHOBLASTICLEUKEMIA

CLINICAL FEATURES Bone pain & tenderness

Lymphadenopathy Splenomegaly Hepatomegally

CNS manifestations Testicular involvement Skin



LEUKEMIA

LABORATORY EVALUATION

•

Anemia• Leukocytosis/leukopenia/normal TLC• Thrombocytopenia• Bone marrow examination

Aspirate & biopsy





LEUKEMIA



Chronic Myeloid Leukemia and otherMyeloproliferative Neoplasms (MPNs)

Dale Bixby, M.D., Ph.DClinical Assistant ProfessorAssistant Program Director

Division of Hematology and OncologyDepartment of Internal Medicine

University of Michigan

Winter 2010



Definitions

Myeloproliferative Neoplasms (MPNs): are a group of clonalmyeloid neoplasms in which a genetic alteration occurs in

hematopoietic progenitor cell leading to its proliferatioresulting in an increase in the peripheral blood white blood ce(WBCs), red blood cells (RBCs), platelets, or a combination these cells.



Hematopoietic Progenitors and MPNs

GeneticMutation

National Cancer Institute

http://www.cancer.gov/




More Definitions

The type of disorder is often based on the predominant cell line that is affected, b because blood counts are often abnormal in more than one cell line, diagno based upon blood counts alone may be inaccurate.

Four Main MPNs: Additional MPNs:1. Chronic Myelogenous Leukemia (CML) 1. Systemic Mastocytosis2. Polycythemia Vera (PV) 2. Hypereosinophilic Syndrome3. Essential Thrombocytosis (ET) 3. Chronic Myelomonocytic Leukemia4. Primary Myelofibrosis (PMF) 4. Chronic Neutrophilic Leukemia

5. Chronic Eosinophilic Leukemia



MPN overview

In CML, the predominant feature is a leukocytosis with a left shift. A mild anemia, norto elevated platelet count, and a peripheral blood basophilia is often seen.

In PV, the predominant features are elevated red blood cell indicies (RBC couhemoglobin, and hematocrit). Patients often also have a mild leukocytosis athrombocytosis.

In ET, the predominant feature is an elevated platelet count. Patients also often have a mleukocytosis and polycythemia.

In PMF, the predominant feature is evidence of extramedullary hematopoiesis in the formhepatomegaly, splenomegaly, and lymphadenopathy. Patients often have a mild anem but their WBC and platelet counts can be quite variable.Leukoerythroblastosis(teardrops, nucleated RBCs and early myeloid progenitors (including blasts) are often seenthe peripheral blood.

Clonal Genetic Abnormalities Define Many MPNs



Figure showingclassificationand molecular

pathogenesis ofthe MPDremoved

Original source: Levine et al. Role of JAK2 in the pathogenesis and therapy ofmyeloproliferative disorders. Nature Reviews – Cancer 2007;7:673-683

See online at:http://img.medscape.com/fullsize/migrated/563/885/nrc563885.fig1.gif













Chronic Myeloid Leukemia (CML)



Epidemiology of CML

Approximately 5,050 cases in the U.S. in 2009 (11% of all leukemias) with anincidence that increases significantly with age (median age ~ 55)

Risk Factors include:

▪ prior high dose radiation exposure (WW II / Chernobyl / etc…)▪ exposure to certain organic solvents (benzene)▪ age▪ gender (male > female)

A very small percentage (< 0.1%) of individuals can express Bcr-Abl but notdevelop CML (wrong cell of origin, multiple genetic mutations leading to non-viability, immune surveillance)

CML Pathophysiology



CML – Pathophysiology – the Philadelphia Chromosome

Source UndeterminedSource Undetermined



Bcr-Abl and CML

Source Undetermined

Source Undetermined



Multiple Breakpoints in Bcr-Abl

Sources Undetermined

Pathophysiologic Result



Pathophysiologic Resultof the Expression of Bcr-Abl

Bcr-Abl expressionalone is necessary and sufficient for the develo

Stephen B. Marley and Myrtle Y. Gordon. Chronic myeloidleukaemia: stem cell derived but progenitor cell driven ClinicalScience (2005) 109, (13*25)

Chronic Myeloid Leukemia

http://www.clinsci.org/cs/109/0013/cs1090013f01.htm?resolution=HIGH



Chronic Myeloid LeukemiaClinical Presentation

▪ Asymptomatic (~ 30%)

▪ Fatigue, weight loss, fever

▪ Abdominal fullness, pain and/or early satiety due to splenomegaly (~ 50-90%)

▪ Easy bruising and purpura

▪ Leukostasis

▪ Pulmonary symptoms▪ Neurologic symptoms



CML – Peripheral Blood and BM Findings

Peripheral smear can only give a presumptivediagnosis of CML [you need to confirm the t(9;22)]:1) leukocytosis with a ‗left shift‘ 2) normocytic anemia3) thrombocytosis in 50% of pts4) absolute eosinophilia with a normal % of Eos.5) absolute and relative increase in basophils6) LAP score is low (not frequently employed)

Source Undetermined



Diagnosing Chronic Myeloid Leukemia

Diagnostic Considerations in



Diagnostic Considerations inChronic Myeloid Leukemia

Karyotyping in CML

1) Allows for the diagnosis of CML2) Requires a bone marrow aspirate for

optimal metaphases3) Allows for evaluation of clonal evolution as

well as additional chromosomal abnormalitiesin the non-Ph+ clones

4) Occasional cryptic and complex karyotypescan result in the missed identification of thet(9;22)

Demonstrating the presence of the t(9;22) or its gene prodabsolutely essential in diagnosing a patient with CML

Source Undetermined

Diagnostic Considerations in




Fluorescence in-situ hybridization(FISH) in CML:

1) Allows for the diagnosis of CML2) Does not require a bone marrow aspirate foroptimal results

3) Allows for the identification of potentialduplications of the Ph chromosome

4) Allows for the identification of the loss of theder (9) chromsome

5) Allows for the identification of cryptictranslocations involving Bcr-Abl

Bcr- Ch 22

Abl – Ch 9

Bcr-Abl Fusion

Source Undetermined



FISH in CML

Red → Bcr probe Green → Abl Probe

→

Ch 9 Ch 22

Bcr- Ch 22Abl – Ch 9

Bcr-Abl Fusion

Source Undetermined

Source Undetermined




Chronic Myeloid Leukemia

Bcr-Abl

Bcr

Abl

cDNA

Quantitative RT-PCRfor Bcr-Abl in CML

1) Allows for the diagnosis of CML2) Does not require a bone marrow aspirate for

optimal results3) Can quantify the amount of disease4) Allows for the identification of cryptic

translocations involving Bcr-Abl5) Many primers sets only detect the p190 and/or

the p210 translocation and may miss the p230or alternative translocations

Source Undetermined



Quantitative RT-PCR for Bcr-Abl in CML

0 3 6 9 12 15 18 21 24 27 3033 36

PCR Cycle Number

Amount ofFluorescence

High Concentration

ModerateConcentration

Low Concentration

CT(~13.5)

CT(~28)

D. Bixby

Disease Diagnosis andMonitoring in CML



Monitoring in CML

Test Target Tissue Sensitivity (%)* Use

Cytogenetics Ph chromosome BM 1-10 ▪ Confirm diagnosis of CML▪ Evaluate karyotypic abnormalities other than Ph chromosome (ie, clonal evolution)

FISH Juxtaposition ofbcr and abl

PB/BM 0.5-5 ▪ Confirm diagnosis of CML▪ Routine monitoring of cytogenetic response in clinically stable patients▪ Routine measurement of MRD

RT-PCR bcr-abl mRNA PB/BM 0.0001-0.001 ▪ Routine measurement of MRD▪ Determine the breakpoints of the fusion genes

*Number of leukemic cells detectable per 100 cells.BM = bone marrow; FISH = fluorescence in situ hybridization; PB = peripheral blood;MRD = minimal residual disease; RT-PCR = reverse transcriptase polymerase chain reaction.

Wang et al.Genes Chromosomes Cancer . 2001;32:97

Chronic Myeloid Leukemia -Diagnostic Criteria for the 3 Phases of the Disease



Diagnostic Criteria for the 3 Phases of the Disease

D. Bixb



Therapeutic Options inChronic Myeloid Leukemia

Hi f CP CML Th i



History of CP-CML Therapies

→ Interferon – α +/- AraC

→ Hydrea, or radiation therapyor Busulphan

→ intensive chemotherapy→ early Interferon – α trials

Quintas-Cardama et al. Mayo Clin Proc 2006; 81(7):973-988

Imatinib (Gleevec, Novartis)ll l l t i ki i hibit



a small molecule tyrosine kinase inhibitor

X

Source Undetermined

Frontline Therapy in Chronic Phase - Chronic



pyMyeloid Leukemia

Hochhaus A, Druker B, Larson R, et al. Blood (ASH AnnualMeeting Abstracts), Nov 2007; 110: 25.

Hochhaus A, O‘Brien S, Guilhot F, et al., Leukemia (2009) 23,1054 – 1061.

Treatment Milestones for CMLAmount of Dz



Definitions of Responses to Treatments

Hematologic Response

Complete Hematologic response

1) Normal PB counts (WBC < 10 and plt < 450)

2) Normal WBC differential

3) No Dz symptoms

4) Normalization of the size of the liver and spleen

Cytogenetic Responses: Ph + Metaphases

1) complete: 0%

2) partial: 1% - 35%

3) minor: 36% - 65%

4) minimal: 66% - 95%

5) none: 96% - 100%

Molecular Responses: ratio of Bcr-Abl/Abl

Major Molecular Response

3-log 10 reduction from initial diagnosis sample(i.e. 25 →0.025)

Amount of Dz

1X1012

1X1011

1X1010

1X108-9

D. Bixby

Imatinib has Revolutionizedth T t t f CML



the Treatment of CML – IRIS Trial 1

1. Newly diagnosed CML patients were randomized to receive either Imatinib 400 mg daily or Interferon-α at approximately 5X106 U/dayas well as Ara-C 20 mg/m2 d1-10 q 8 days. Graph shows outcomes of 553 pts randomized to Imatinib.

96% 98%

85%

69%

92%

87%

Druker et al. N Engl J Med 2006; 355(23): 2408-2417.

2009 ELN Recommendationsfor Response Assessment for Treatment



for Response Assessment for Treatment

Baccarani M, Cortes J, Pane F, et al., J Clin Oncol. 2009 Dec 10;27(35):6041-51.

Mechanisms of Imatinib Resistance



Mechanisms of Imatinib Resistance

Resistance Mechanisms1) Bcr-Abl Kinase mutations

▪ > 50 known mutations within Abl sequence whichinhibits Imatinib from binding▪ mutations identified in 30-80% of individuals withresistant disease

2) Bcr-Abl duplicationduplication of the Bcr-Abl sequence has beenidentified in cell lines with Im resistance

3) Pgp over-expressionexport pump of many chemotherapeuticsleading tolower intracellular Im concentration

4) hOct-1 under-expressionimport pump for Im which may lead to lowerintracellular levels of IM

5) Src-Family kinase (SFK) expressionactivation may circumnavigate the Bcr-Abl‗addiction‘ of the transformed cell

Primary resistance▪failure to achieve preset hematologic and/orcytogenetic milestones

▪IRIS data indicates a rate of ~ 15% by failing to a achieve a PCyR at 12 monthsand 24% by failing to achieve a CCyr by 18 months of therapy.

▪rates higher in accelerated and blast phasedisease

Secondary resistance ▪loss of a previously achieved hematologicor cytogenetic milestone

▪rates may be 10-15% on Imatinib, but become rarer as time on therapy progresses

▪rates higher in accelerated and blast phasedisease



Bcr-Abl

imatinib

Mut. Bcr-Abl imatinib

Mut. Bcr-Abl dasatinibD. Bixby



Redaelli S, Piazza R, Rostagno R, et al. Activity of bosutinib, dasatinib, and nilotinib against 18 imatinib-resistant BCR/ABL mutants. J Clin Oncol. 2009;27(3):469-471, PMID: 19075254.

Imatinib Poorly Control Advanced Phase Disease



Imatinib Poorly Control Advanced Phase Disease

Kamb et al. The value of early detection, the right drug and the right patient population. Nature Reviews Drug Discovery 2007; 6: 115-120.

Treatment Options for Resistant Disease



1) Dose Escalation of imatinib

2) Second Generation TKIs

3) Bone Marrow Transplant

4) Clinical Trial Participation

Dose Escalation of imatinib



START-R Trial 1

Patients resistant to 400mg-600 mg of imaitnib were treated with either 70 mg BID of dasatinib or800 mg of imaitnib

▪ primary endpoint of the trial was the rate of MCyR at 12 weeks and this was equal(D=36%; IM=29%; p= .40)

▪ At a minimum follow-up of 2 years, dasatinib demonstrated higher rates of:▪ complete hematologic response (93% vs 82%; P = .034)

▪ major cytogenetic response (MCyR) (53% vs 33%; P = .017)▪ complete cytogenetic response (44% vs 18%; P = .0025)

The depth of the previous response to imatinib may be associated with the proportionof patients responding to dose escalation. Patients having achieved a prior majorcytogenetic response (MCyR) with imatinib reported a greater than 50% chance of reachieving that response with high-dose imaitnib, yet only 7% of patients who did notachieve any cytogenetic response on standard dose imatinib were able to achieve aMCyR.

Kantarjian H, Pasquini R, Levy V, et al. Dasatinib or high-dose imatinib for chronic-phase chronic myeloid leukemia resistant to imatinib at a dose of 400 to 600 milligramsdaily: two-year follow-up of a randomized phase 2 study (START-R). Cancer. 2009.

Second GenerationTyrosine Kinase Inhibitors (TKIs)



Tyrosine Kinase Inhibitors (TKIs)

The FDA has approved 2 additional oral TKIs for the treatment ofimatinib relapsed/refractory or imatinib intolerant CML

dasatinib (Sprycel – BMS)

▪ oral multi-kinase inhibitor▪ ~ 325 times more potent than IM▪ active against the ‗open‘ and ‗closed confirmation of Bcr-Abl

▪ active against many of the identifiedkinase domain (KD) mutations

▪ active against the SFKs▪ may not be a substraight for Pgp orhOct 1

nilotinib (Tasigna –

Novartis)

▪ oral multi-kinase inhibitor▪ ~ 30 times more potent thanIM▪ active against only theclosedconfirmation of Bcr-Abl

▪ active against many of the

KD

Bone Marrow Transplantation



Bone Marrow Transplantation

Allogeneic bone marrow transplant remains the only known curative option in CML

Associated with an increased morbidity and mortality (TRM -10%-30%)

Therefore, not typically applied for upfront therapy for CML▪ considered only in cases of matched-related Txp for extremely young pts (pediatrics)

However, often considered in those with relapsed/refractory disease to TKI based therapies▪ efficacy of the transplant dependent upon the phase of the disease at the time of thetransplant: CP>AP>BP

Clinical Trial Options in CML



Clinical Trial Options in CML

D. Bixby



Polycythemia Vera (PV)

Polycythemia



Polycythemia

A hematocrit greater than 48%(♀) or 52 % (♂) constitutes polycythemia

Likewise, a hemoglobin of >16.5 g/dL (♀) or >18.5 g/dL (♂) raises the suspicion for polycythemia

Absolute polycythemia is characterized by an increase in red blood cell (RBC) mass▪ Five common causes include: 1) primary polycythemia, 2) hypoxia, 3) carboxyhemoglobinemia,4) cushing‘s syndrome or corticosteroids, and5) erythropoietin-secreting tumors

Relative polycythemia is characterized by a decrease in plasma volume.Two common causes:

▪ Dehydration (e.g., from vomiting, diarrhea, excessive sweating, or diuretics) can deplete plasmavolume, leading to a relative polycythemia.

▪ Stress erythrocytosis (Gaisböck‘s polycythemia) actually results from contraction of the plasmavolume and is therefore a misnomer. This benign disorder is seen most often in hypertensive,obese men.

Red Blood Cell Mass Assay:▪ used to distinguish an absolute versus a relative polycythemia▪ does not subclassify absolute polycythemias

Clinical Presentation of Primary PV



Clinical Presentation of Primary PV

Symptoms:▪ non-specific complaints: headache, weakness, dizziness, and excessive sweating▪ pruritus, especially following a warm bath or shower▪ erythromelalgia, or burning pain in the feet or hands accompanied by erythema, pallor, or

cyanosis

▪ symptoms related to either an arterial or venous thrombosis (CVA, MI, DVT,Budd Chiari syndrome or other portal venous thrombosis)

Signs:▪ facial plethora (ruddy cyanosis)▪ splenomegaly

▪ hepatomegaly▪ gouty arthritis and tophi

Diagnostic Criteria for Primary PV



2008 WHO Diagnostic Criteria for Primary Polycythemia

Major Criteria▪ Elevated RBC mass

>36 cc/kg in men>32 cc/kg in women

▪ Oxygen saturation >92%▪ Splenomegaly

Minor Criteria▪ Plt count > 400,000▪ WBC > 12,000▪ Elevated LAP score (>100)▪ Serum vitamin B12 >900 pg/mLor serumunbound B12 binding capacity >2,200 pg/mL

→ All 3 major criteria OR the first 2 major and any 2 minor criteria ←

Polycythemia Vera Study Group (PVSG) Criteria for PV

Major Criteria1) Hgb > 18.5g/dl (♂) or 16.5g/dl (♀)

orHgb or Hct > 99%

orHgb > 17g/dl (♂) or 15 g/dl (♀) and

a documented increase of 2 g/dlorRBC mass > 25% of mean normal

2) Presence of a JAK2 V617F or similarmutation

Minor Criteria 1) Bone marrow trilineage expansion2) Subnormal EPO level3) Endogenous erytyhroid colony growth

→ two major or first major and two minor criteria← Tefferi et al. Leukemia 2008 22 14 – 22

JAK2 Mutations Seen in Three Different MPNs



Figure showingclassificationand molecular

pathogenesis ofthe MPDremoved

Original source: Levine et al. Role of JAK2 in the pathogenesis and therapy ofmyeloproliferative disorders. Nature Reviews – Cancer 2007;7:673-683

See online at:http://img.medscape.com/fullsize/migrated/563/885/nrc563885.fig1.gif

JAK2 Mutations and MPNs













JAK2 Mutations and MPNs

▪ Receptor Tyrosine Kinase - maps to chromosome 9p

▪ Valine to phenylalanine substitution at amino acid 617 (V617F) in pseudokinasedomain of JAK2 allows for the constitutive activation of the receptor

▪ Somatic acquired mutation

▪ High incidence in PCV (~95%)▪ Not present in every patient with PCV

▪ Lower incidence in ET (~50%) and PMF (~50%)

JAK2 Mediated Signaling



Nature Reviews | Cancer

Outcomes and Treatment of PV

http://www.nature.com/nrc/journal/v7/n9/images/nrc2210-f2.jpg

http://www.nature.com/nrc/journal/v7/n9/images/nrc2210-f2.jpg



Outcomes and Treatment of PV

Survival outcomes in PV are affected by:1) hyperviscosity and associated ischemic sequela2) thromboses independent of hyperviscosity3) transformation to myelofibrosis or acute myeloid leukemia (

Therapeutic Options in PV:1) Low Risk : phlebotomy (to an Hct of <45 in♂ and <42 in♀) + lo

(81 mg daily) – decreases risk of thrombosis2) High Risk : phlebotomy + ASA + hydroxyurea

High Risk for Thrombosis: ▪ age over 70

▪ prior thrombosis

JAK2 Inhibitors in MPNs



A number of inhibitors of the JAK2 kinase have been developed and inhibit the proliferaand survival of JAK2 V617F transformed cell lines in-vitro

Clinical studies (Phase I and Phase II) have been initiated and demonstrate sosymptomatic improvement as well as improvement in splenomegaly in a numbe patients, but unlike CML, the percentage of JAK2+ progenitor cells have not beensignificantly altered. However, a large number of trials continue at this time.

Leads to speculation that JAK2 may not be sufficient for the development of MPNs and

may be an earlier genetic mutation that is driving the phenotype.



Essential Thrombocythemia (ET)

Thrombocytosis



y

Etiology of ThrombocytosisPrimary - if the thrombocytosis is caused by a myeloproliferative neoplasm, the

platelets are frequently abnormal and the patient may be prone to both bleedingand clotting events.

Secondary - if thrombocytosis is secondary to another disorder (reactive), even patients with extremely high platelet counts (e.g., > 1,000,000 cells/μl) areusually asymptomatic.

Differential Diagnosis of secondary thrombocytosis:1. Malignancies2. Infections and inflammatory disorders (e.g., Crohn‘s disease) 3. Post surgical status4. Connective tissue disorders5. Iron deficiency anemia6. Splenectomy7. Recovery of the bone marrow from a stress (chemotherapy or alcohol)8. Essential Thrombocythemia

Definition: thrombocytosis is defined as a platelet count > 450,000 cells/μL

Clinical Presentation ofE i l Th b h i (ET)



Essential Thrombocythemia (ET)

Asymptomatic (~ 30-50%)

Vasomotor symptoms including headache, syncope, atypical chest pain, acral paresthesia, livedo reticularis, and erythromelalgia

Thrombosis and hemorrhage occur to various degrees in 5%-25% of patients

Early satiety and abdominal bloating due to splenomegaly

JAK 2+ (V617F) in approximately 50% of patients

Diagnostic Criteria for ET



g

→ Diagnosis of essential thrombocythemia requires meeting all four major criteria←

Teferri et al. Leukemia (2008) 22, 14 – 22

2008 WHO Diagnostic Criteria for Essential Thrombocytosi 1. Platelet count > 450,0002. Megakaryocytic proliferation with large, mature morpho

with little granulocytic or erythroid expansion3. Not meeting WHO criteria for CML, PV, PMF, MDS or o

myeloid neoplasm

4. Demonstration of the JAK2V617F or other clonal marke of evidence of a secondary (reactive thrombocytosis)

Outcomes in ET



Most patients with ET enjoy a normal life expectancy

Like PV, the major risks are secondary to thrombosis and disease transformation:▪ 15-year cumulative risks:

▪ thrombosis - 17% risk▪ clonal evolution into either myelofibrosis (4%) or AML (2%)

High risk for thrombosis:▪ age ≥60▪ prior thrombosis▪ long-term exposure to a plt count of > 1,000,000

Treatment of ET



Low Risk:

▪ Age <60 years▪ No previous history of thrombosis▪ Platelet count <1 million/μl→ aspirin (81 mg daily) if vasomotor Sx or other medical need for ASA→ if otherwise low risk and plt >1.5 X 106, screen for an acquired

von Willebrand disease before instituting ASA

High Risk:▪ Age ≥60 years▪ A previous history of thrombosis→ hydroxyurea + aspirin (81 mg daily)→ if plt >1.5 X 106, screen for an acquired von Willebrand disease

before instituting ASA→ anagrelide is an option, but when c/w hydroxyurea, it was assn with

an increased risk of arterial thrombosis, venous thrombosis, serioushemorrhage, or death from vascular causes



Primary Myelofibrosis (PMF)

Primary Myelofibrosis(Chronic Idiopathic Myelofibrosis)



(Chronic Idiopathic Myelofibrosis)

Signs and Symptoms:▪ asymptomatic (15% - 30%)▪ severe fatigue▪ splenomegaly▪ hepatomegaly▪ fever and night sweats▪ signs or symptoms of anemia or thrombocytopenia▪ foci of extramedullary hematopoiesis may occur in almost any organ▪ bone or joint involvement

CBC Findings:▪ anemia (hgb<10 in 50% of pts); anisocytosis, poikilocytosis, teardrop-shaped red blood cells (dacrocytes), and nucleated red blood cells

▪ leukoerythroblastosis (increased presence of immature myeloid cells andnucleated erythrocytes in the circulating blood.▪ WBC and Plt counts are variable (ranging from low to high) with

increased circulating CD34+ precursor cells▪ BM Biopsy shows increased fibrosis (reticulin fibers or mature collagen)▪ JAK2+ (V617F) in approximately 50% of cases

Diagnostic Criteria for PMF



→ Diagnosis of primary myelofibrosis (PMF) requires meeting all three major criteria and two minor criteria← Teferri et al. Leukemia (2008) 22, 14 – 22

2008 WHO Diagnostic Criteria for Primary MyelofibroMajor:1. Megakaryocytic proliferation and atypia with either reticulin

or collagen fibrosisorIf no fibrosis, mekakaryocytic expansion must be assn. w/increased BM cellularity

2. Does not meet WHO criteria for CML, PV, MDS, or othermyeloid neoplasm3. Demonstration of the JAK2 V617F mutation or other cloanl

markeror

no other evidence of a reactive marrow fibrosisMinor:1. Leukoerythroblastosis (immature RBCs and WBCs in the PB)2. Increased LDH3. Anemia4. splenomegaly

DDx of Myelofibrosis



Myeloid Neoplasms

PMF

CML

ET

PV

MDS

Acute myelofibrosis (potentially assn. w/ FAB M7 AML)

AML

Mast Cell Disease

Lymphoid Neoplasms

lymphoma

Hairy Cell Leukemia

Multiple Myeloma

Non-Hematologic DisordersMetastatic cancer

Connective tissue diseases

Rickets

Infections

Renal Osteodystrophy

Source Undetermined

Outcomes in PMF



As fibrosis progresses, cytopenias worsen leading to a transfusion dependency▪ symptoms related to extrmedullary hematopoiesis increase (worseningsplenomegaly and ‗B‘ symptoms) also are frequently identified

Rarely do patients transform to Acute Leukemia (~ 4%)

▪ clonal evolution was common in these patients▪ some evidence that in all MPNs, cases of JAK2(-) Acute Leukemiaarise out of a JAK + MPN, causing speculation that there are additionalgenetic changes that either initiate and/or propagate these diseases

Despite the lack of transformation to leukemia, three-year survival rate isapproximately 52%

Risk Assessment in PMF



Mayo Scoring System(pts age < 60)

Score MedianSurvival

0 173 mo

1 61 mo

≥ 2 26 mo

Risk Factors: Hemoglobin <10 g/dLWhite blood cell count <4000/μl or >30,000/μlAbsolute monocyte count >1000μLPlatelet count <100,000/μL

Transplant Scoring System(pts age < 55)

Score Median

Survival0 or 1 15 yrs

≥ 2 3 yrs

Risk factors: Hemoglobin <10 g/dL‗B‘ symptoms present (eg, fever, NS, weight loss)Circulating blasts >1 percent

Elliott et al. Leuk Res. 2007;31(11):1503-9. Dupriez et al. Blood 1996 Aug 1;88(3):1013-8.

Treatment of PMF



Risk stratification is critical in deciding on therapeutic options(see previous scoring systems)

‗Low Risk‘ without symptoms – expectant management

‗Low Risk‘ with symptoms – hydroxyureaandrogenic and corticosteroidssplenectomy if adequate BM hematopoiesissplenic irradiation

thalidomide or lenalidomide‗High Risk‘ and age <55(?) – consider a reduced intensity allogeneic BMT

One Genetic Abnormality and Three Diseases PossibleRole of Allele Burden



Role of Allele Burden

Larsen et al. Eur J Hemeatology 2007; 79: 508-515

Review Question # 1



42 yo woman with no past medical Hx presented to her PCP for an annual healthmaintenance examination. Physical exam was normal. A CBC was drawn andrevealed a WBC of 14.2 (normal differential), Hbg of 13.5 and a plt count of 752,000.

Her diagnosis is:

A) Polycythemia Vera (PV)B) Essential Thrombocythema (ET)C) Chronic Myeloid Leukemia (CML)D) Reactive ThrombocytosisE) Not sure – need more data

Review Question #1 (cont)



Iron studies are normal and there was no evidence of inflammation on history or examination. Thewas no history of recurrent infections or connective tissue diseases. Further blood testingdemonstrated no evidence of the JAK2 V617F mutation by gene sequencing.

Her diagnosis is:

A) Polycythemia Vera (PV)B) Essential Thrombocythema (ET)C) Chronic Myeloid Leukemia (CML)D) Reactive ThrombocytosisE) Not sure – need more data




Additional testing of her peripheral blood demonstrated a negative RT-PCR for the Bcr-Abl p210 and p190 gene products but the peripheral blood FISH for the Bcr-Abl translocation was positive in72% of cells. Repeat testing confirmed both of these findings.

Her diagnosis is:A) Polycythemia Vera (PV)B) Essential Thrombocythema (ET)C) Chronic Myeloid Leukemia (CML)D) Reactive ThrombocytosisE) Not sure – need more data




Source Undetermined

Review Question #2



A 34 yo woman presents for her annual HME and a CBC reveals a WBC count of 11.2, hgb of 17and a platelet count of 390,000. Peripheral blood was sent to evaluate for the JAK2 mutatand was negative. What is the most appropriate next step in the evaluation of the patient?

A) Bone marrow biopsy to evaluate for a myeloproliferative neoplasmB) Repeat CBC in 3 monthsC) Repeat JAK2 testing to ensure laboratory accuracyD) Red cell mass assay to determine a primary versus a seconday erythrocytosisE) Referral to hematology

Review Question#2 (cont)



The patient underwent a red cell mass assay that demonstrated a true erythrocytosis (increasedred cell mass). Upon further questioning, she states that she was previously treatedwith phlebotomy for the elevated Hgb and felt horrible for 3-4 weeks. She alsoindicates that her brother has a similar condition as did her mother and her motherssister, but no one has been able to find a cause. What is the most appropriate next stepin the management of this patient.

A) Repeat phlebotomy, but take only 250 cc/sessionB) Initiate treatment with low dose aspirin (81 mg/day) and hydroxyureaC) Repeat phlebotomy, but take only 250 cc/session and also treat with low dose aspirin

(81 mg/day)

D) Evaluate for an inherited cause of polycythemia



Hemoglobin (Hb) Ypsilanti is a rare, high-oxygen-affinityhemoglobin first described in 1967 and named for the Michigan

city in which the index family resided.1-3 Like other high-oxygen-affinity hemoglobins, of which there arenow substantially more than 100 described, Hb Ypsilanti manifesas a true erythrocytosis.

Phlebotomy in individuals with an appropriate erythrocytosis (higaffinity Hgb, CO poisoning, living at altitude, sleep apnea) willincrease sym ptoms because the erythrocytosis is an appropriate

1. Rucknagel DL, Glynn KP, Smith JR. Hemoglobin Ypsilanti, characterized by increased oxygen affinity, abnormal polymerization, and erythremia [abstract].Clin Res.1967;15:270.2. Glynn KP, Penner JA, Smith JR, et al. Familial erythrocytosis: a description of three families, one with hemoglobin Ypsilan ti. Ann Intern Med. 1968;69:769-776.3. Mais DD , Boxer LA , Gulbranson RD , Keren DF . Hemoglobin Ypsilanti: a high-oxygen-affinity hemoglobin demonstrated by two automated high-pressure liquid chromatographsystems. Am J Clin Pathol. 2007 Nov;128(5):850-3.

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Mais%20DD%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Boxer%20LA%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Gulbranson%20RD%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus

http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=Search&Term=%22Keren%20DF%22%5BAuthor%5D&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_RVAbstractPlus











CHRONIC MYELOIDLEUKAEMIA

Dr Rosline HassanDepartment of HaematologySchool of Medical SciencesUniversiti Sains Malaysia





Leukaemias



• What are Leukemias – Neoplasm of white blood cell and its precursor – Clonal proliferations and accumulation of cells

in marrow – Classify as

• Acute leukaemias

• Chronic leukaemias

Types of Leukaemia



Acute : Nomaturationbeyond blast

Chronic :Maturationbeyond blast

Lymphocytic (Bor T lineage)

ALL CLL

Myeloid – granulocytes

ErythroidsMonocytesPlatelets

AML CML

Introduction- CML



• Clonal malignant myeloproliferative disordercharacterized by increased proliferation of thegranulocytic cell line without the loss of theircapacity to differentiate

• Results in increases in myeloid cells, erythroidcells and platelets in peripheral blood and markedmyeloid hyperplasia in the bone marrow

• Originate in a single abnormal haemopoietic stemcell



Introduction- CML



• Incidence :1 per 100,000 (UK)• Accounts for 7-15% of all leukaemia in

adults• Median age : 53 years• All age groups, including children, can be

affected

Introduction- CML



• Etiology – Not clear – Little evidence of genetic factors linked to the

disease – Increased incidence

• Survivors of the atomic disasters at Nagasaki &

Hiroshima• Post radiation therapy



Leukaemogenesis



Leukaemogenesis



• Philadelphiachromosome is anacquired cytogeneticanomaly that ischaracterizes in allleukaemic cells in CML

• 90-95% of CML ptshave Ph chromosome

• Reciprocal translocation

of chromosome 22 andchromosome 9



Leukaemogenesis



• BCR (breakpoint cluster region) gene onchromosome 22 fused to the ABL (Ablesonleukemia virus) gene on chromosome 9

• Ph chromosome is found on myeloid,monocytic, erythroid, megakaryocytic, B-cells and sometimes T-cell proof that CMLderived from pluripotent stem cell

Leukaemogenesis



• Molecular consequence of thet(9;22) is the fusion proteinBCR – ABL, which hasincreased in tyrosine kinaseactivity

• BCR-ABL protein transformhematopoietic cells so thattheir growth and survival become independent ofcytokines

• It protects hematopoietic cellsfrom programmed cell death(apoptosis)

Clinical Features



• Disease is biphasic,sometimes triphasic

• 40% asymptomatic• Chronic phase

• Splenomegaly oftenmassive• Symptoms related to

hypermetabolism – Weight loss

– Anorexia – Lassitude – Night sweats

Clinical Features



• Clinical features cont… • Features of anaemia

– Pallor, dyspnoea, tachycardia• Abnormal platelet function

– Bruising, epistaxis, menorrhagia• Hyperleukocytosis

– thrombosis – Increased purine breakdown : gout – Visual disturbances – Priapism

Lab features



• Peripheral blood film – Anaemia – Leukocytosis (usu >25 x 109/L, freq> 100 x

109/L – WBC differential shows granulocytes in all

stages of maturation

– Basophilia – thrombocytosis





Lab features



• Bone marrow – Hypercellular (reduced fat

spaces) – Myeloid:erythroid ratio –

10:1 to 30:1 (N : 2:1) – Myelocyte predominantcell, blasts less 10%

– Megakaryocytes increased& dysplastic

– Increase reticulin fibrosisin 30-40%

Lab features



• Other lab features : – NAP reduced – Serum B12 and transcobalamin increased – Serum uric acid increased – Lactate dehydrogenase increased – Cytogenetic : Philadelphia chromosome

Laboratory- summary



• Lab investigation to confirm diagnosis – Full blood picture – Neutrophil alkaline phosphatase – Bone marrow cytogenetic



Phases



• Accelerated phase – Median duration is 3.5 – 5 yrs before evolving to more

aggressive phases – Clinical features

• Increasing splenomegaly refractory to chemo• Increasing chemotherapy requirement – Lab features

• Blasts>15% in blood• Blast & promyelocyte > 30% in blood

• Basophil 20% in blood• Thrombocytopenia• Cytogenetic: clonal evolution

Phases



• Blastic phase – Resembles acute leukaemia – Diagnosis requires > 30% blast in marrow – 2/3 transform to myeloid blastic phase and 1/3

to lymphoid blastic phase – Survival : 9 mos vs 3 mos (lym vs myeloid)





General Management



• Discussion with family – The disease & diagnosis – Prognosis – Choices of treatment

• Cytotoxic drug vs bone marrow transplant• Side effect

CML - principles of treatment



• Relieve symptoms of hyperleukocytosis,splenomegaly and thrombocytosis – Hydration

– Chemotherapy (bulsuphan, Hydoxyurea)• Control and prolong chronic phase (non-curative)

– alpha interferon+chemotherapy – imatinib mesylate – chemotherapy (hydroxyurea)

CML - principles of treatment



• Treatment cont… • Eradicate malignant clone (curative)

– allogeneic transplantation – alpha interferon ? – imatinib mesylate/STI 571 ?(Thyrosine kinase

inhibitor)

Chemotherapy



• Busulphan – Alkylating agent – Preferred in older pts (not candidate for

transplant) – Side effect :• prolonged myelosuppression• Pulmonary fibrosis• Skin pigmentation• infertility

Chemotherapy



• Hydoxyures – Fewer side effect – Acts by inhibiting the enzyme ribonucleotide reductase

• Haematological remissions obtain in 80% for bothdrugs• However disease progression not altered and

persistence of Ph chromosome containing clone

Chemotherapy



• Recombinant human α- Interferon – Prolong chronic phase and increase survival – Haematogical and cytogenetic remission – Side effect

• Flu like symptoms• Fever and chills

• Anorexia• Depression



CML - prognosis



• Median survival 3.5 yrs (range 2-8 yrs)• Interferon + chemotherapy :6 years

• Transplant : 5+ years• imatinib mesylate ?

Thank you



Acute lymphoblastic leukemia(ALL)



• Clonal proliferation and accumulation ofblast cells in blood, bone marrow and otherorgans

• Disorder originates in single B or Tlymphocyte progenitor

• Heterogenous disease with differentbiological subtypes

• Incidence in adults : 20% of acute leukemias• Etiology - unknown

Acute leukemias - clinical features



1. Bleeding2. Fever/infection

3. Bone/joint pain4. Hepatomegaly5. Splenomegaly

6. Lymphadenopathy7. CNS involvement

Acute leukemias - laboratoryfindings (1)



1. Blood examination- anemia,- thrombocytopenia,

- variable leukocyte count, usually increased,- blood morphology: presence of blast cells

2. Bone marrow morphology

- presence of blast cells,- suppression of normal hematopoiesis

Acute leukemias - Laboratory findings(2)



3. Cytochemical stains4. Immunophenotyping5. Cytogenetics6. Molecular studies

Morphologic subtypes of acutelymphoblastic leukemias (FAB

classification)



Subtype MorphologyOccurrence (%)

L1 Small round blasts75clumped chromatin

L2 Pleomorphic larger blasts20

clefted nuclei, fine chromatinL3 Large blasts, nucleoli,

Acute lymphoblastic leukemias- reactivity with special stains



Subtype Peroxidase or Non-specific PeriodicSudan black esterase acid-Schiff

L1 - - +++L2 - - +++

L3 - - +++

Immunologic classification ofacute 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(+), CD2(-), Tdt(+),Mature-T CD7(+), CD2(+), Tdt(+),

Chromosomal/molecularabnormalities with prognosticsignificance in ALL



Better prognosis- normal koryotype - hyperdiploidy

Poor prognosis- t (8; 14)- t (4; 11)

Very poor prognosis- t (9; 22); BCR/ABL (+)

Risk classification in ALL



1. Standard risk2. High risk3. Very high risk

High-risk ALL



1. Pre - T2. Pro - B

3. Age > 35 years,4. WBC > 30 G/L in B-ALL> 100 G/L in T-ALL

5. No remission after 4 weeks ofinduction

therapy

Very high-risk ALL



y g

Chromosome Philadelphia -positive or BCR/ABL (+)



Treatment strategy in ALL

In ALL the choice oftreatment-strategy depends on:



1. Risk qualification2. Immunophenotype of leukemic cells

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

3.Age and biological condition4. Goal of treatment

Remission induction therapy inALL

1. Antineoplastic treatment



a/Drugs: prednisone, vincristine, asparginase,cyclophosphamide

duanorubicin/adriablastin/epirubicin,

cytosine arabinoside, b/Treatment duration: 4-8 weeksc/ No of courses: 1- 2

2. CNS prophylaxis3. Supportive care4. Treatment of complications

Post-remission therapy in standard-risk ALL



1. Chemotherapya/. Maintenance therapy: 6-mercaptopurine,

methotrexate - for 2-3 years.b/. Intensification treatment periodically

repeated: daunorubicin/adriablastin,prednisone, vincristine,

cyclophosphamide.2. CNS prophylaxis

Post-remission therapy in high-riskALL



1. Intensification treatment: amsacrine,mitoxantrone, idarubicine, high dosecytosine arabinoside, high dosemethotrexate, high dosecyclophosphamide.

2. Hematopoietic stem cell transplantation

- high-dose therapy- reduced intencity conditioning

Post-remission therapy in veryhigh



-risk ALL - High-dose therapy ( reduced-intencity

?) +allogeneic stem cell transplantation

Treatment results in ALL



• Adults – Complete remission (CR)

80-85% – Leukemia-free survival (LFS)

30-40%

• Children – Complete remission (CR)

95-99%

AutoHSCT in ALL



• Treatment related mortality (TRM) 2-8%• CR1

• LFS 42% (15-65%)• RI ( relapse incidence) 51%

• CR2• LFS 24% (20-25%)

• RI 60%

AlloHSCT in ALL

• Sibling donor



CR1 >CR2relapsed/refractory

LFS 51% (21-80) 34% (13-42) 20% (12-33)

RI 26% (9-50) 47% (40-69) 71% (59-76)

TRM 29% (12-42)

• Matched unrelated donor

LFS 39% (38-42)RI 22% (19-23)TRM 48%



Lymphoma

David Lee MD, FRCPC



Lymphomas: The Basics

Brad Kahl, MDAssistant Professor of Medicine

Director, UW Lymphoma Service

Lymphomas: NHL vs Hodgkin‘s



• EPIDEMIOLOGY• Biology• Classification• Approach to the Patient

Hodgkin‘s Disease



• Epidemiology – 14% of malignant lymphomas – 0.5% of all malignancies – approximately 8000 new cases/yr in US – approximately 1500 deaths/yr – over past 30 years

• age adjusted incidence rates declined appreciably• mortality rates declined substantially

Hodgkin‘s Disease



• Epidemiology – men > women – whites > blacks > Asians – no clear risk factors, several implicated

• EBV (pathogen or passenger)• HIV

• woodworking, farming• rare familial aggregations

NHL: Epidemiology



• Most common hematologic malignancy• 60,000 new cases annually• 6th leading cause of cancer death• incidence rising

– overall incidence up by 73% since 1973 – ―epidemic‖ – 2nd most rapidly rising malignancy

NHL: Epidemiology



• Why the increase? – Increase noted mostly in farming states – MN #1, WI #7 NHL incidence – possible role of herbicides, insecticides, etc.

• Other environmental factors?

NHL: Epidemiology



• Other risk factors – immunodeficiency states

• AIDS, post-transplant, genetic

– autoimmune diseases• Sjogrens• Sprue

– infections• H. pylori, EBV, HHV-8

Epidemiology



• SEER 5 year survival data• NHL Hodgkin‘s

– 1974-76: 47.2 71.1% – 1977-79: 48.1 73.0% – 1980-82: 51.1 74.3% – 1983-90 52.0 78.9%

Hodgkin‘s Disease



• Epidemiology• BIOLOGY• Classification• Approach to the Patient

Hodgkin‘s Disease



• Background – first described in 1832 by Dr. Thomas Hodgkin – characterized by the presence of Reed-

Sternberg cells• multinucleated giant cells• described by Sternberg in 1898 and Reed in 1902

– classified as an infectious disease until 1950‘s

Reed-Sternberg Cell



Hodgkin Biology



• RS is a ―crippled‖ germinal center B cell – does not have normal B cell surface antigens – micromanipulation of single RS followed by PCR

demonstrates clonally rearranged, but non functionalimmunoglobulin genes

• somatic mutations result in stop codon (no sIg)• no apoptotic death malignant transformation

– unclear how this occurs; ? EBV – unclear how cells end up with RS phenotype

Hodgkin‘s Disease



• Epidemiology• Biology• CLASSIFICATION• APPROACH TO THE PATIENT

Hodgkin Lymphoma Classification

‖



• ―Classic‖ Hodgkin‘s Disease • nodular sclerosis• mixed cellularity

• lymphocyte depleted (very rare)• classical lymphocyte rich

– HRS cells CD30 and CD15 positive

• nodular lymphocyte predominant – HRS cells (L&H cells) have B cell markers• CD 20 and surface Immunoglobulin

Classic Hodgkin Lymphoma



Nodular SclerosingHodgkin Lymphoma



Approach to the Patient



• Hodgkin‘s Disease – approach dictated mainly by where the disease

is located rather (results of staging) than the

exact histologic subtype• NHL

– approach is dictated mainly by the histologic

subtype rather than the results of staging

Hodgkin‘s Disease

h h



• Approach to the Patient – staging evaluation

• H & P

• CBC, diff, plts• ESR, LDH, albumin, LFT‘s, Cr • CT scans chest/abd/pelvis• bone marrow evaluation• **PET or gallium scan**• **lymphangiogram or laparotomy**

Ann Arbor Staging System• Stage I : single lymph node region (I) or single

l h i i (I)



extralymphatic organ or site (IE)• Stage II : > 2 lymph node regions on same side of

diaphragm (II) or with limited, contiguousextra lymphatic tissue involvement (IIE)

• Stage III : both sides of diaphragm involved, may includespleen (IIIS) or local tissue involvement (IIIE)

• Stage IV : multiple/disseminated foci involved with > 1extralymphatic organs (i.e. bone marrow)

• (A) or (B) designates absence/presence of ―B‖symptoms

Ann Arbor Staging System for Hodgkin'sDisease and Non-Hodgkin's Lymphoma



Stage I Stage II Stage III Stage IV

Reprinted with permission. Adapted fr om Skarin.Dana-F arber Cancer I nstitu te Atl as of

Diagnostic Oncology . 1991.

Modified Ann Arbor Staging

E‖ d i i f d l di



• ―E‖ designation for extranodal disease • B symptoms

• recurrent drenching night sweats during previous month• unexplained, persistent, or recurrent fever with temps above 38

C during the previous month• unexplained weight loss of more than 10% of the body weight

during the previous 6 months

• Criteria for bulk – 10 cm nodal mass – mediastinal mass > 1/3 thorax diameter



Hodgkin Lymphoma

T



• Treatment – approach depends upon stage, prognostic factors,

and co-morbidities

– Stage I-II• consider XRT, chemotherapy, or combined therapy – Bulky stage I-II

• combined modality therapy

– Stage III-IV• ABVD x 6-8 cycles gold standard

Hodgkin Lymphoma

Ad ti f t f t I & II (EORTC d t )



• Adverse prognostic features for stage I & II (EORTC data)• more than 3 nodal sites• bulky adenopathy• ESR > 50• B symptoms• invasion into critical organs• male• age > 40• MC or LD subtype

– should probably not receive XRT alone if any of the above present (excessive relapse rate)

Hodgkin Lymphoma

I d d d i f



• Independent adverse prognostic factors – advanced stage (III-IV)

• male sex

• age > 45• albumin < 4 gm/dl• HgB < 10.5 mg/dl• stage IV disease• WBC count > 15,000/mm3 • lymphocyte count < 600/mm3

(Hasenclever et al, NEJM 339,1506-1514;1998)

Hodgkin‘s Disease

R l f S C ll T l i



• Role for Stem Cell Transplantation – clinical trials show benefit for patients who

receive high dose chemotherapy followed by

SCT for patients who have relapsed after initialtherapy or for patients are primary refractory

Hodgkin‘s Disease

R lt f T t t



• Results of Treatment• stage 5 year overall survival

– I 90% – II 90% – III 80% – IV 65%

Hodgkin Lymphoma

L t C li ti



• Late Complications – depends upon treatment modality utilized – XRT vs. MOPP vs. ABVD vs. CMT

– issues depends upon the age of patient• relative risks higher in younger patients• absolute risks higher in older patients

– major focus of current clinical trials to to maintain highcure rate while minimizing late complication

• shorter courses of chemotherapy with lower radiation doses insmaller fields

• elimination of radiotherapy

Hodgkin‘s: future directions

Li it d t g d g d g i d d t g



• Limited stage and good prognosis advanced stage – cure rate high – current goal is to minimize late complications

– trials looking at CMT with less chemotherapy and lessradiation• Advanced stage

– cure rate around 50-70%

– trial comparing ABVD to Stanford V• Clinical Trials

NHL

E id i l g



• Epidemiology• BIOLOGY• Classification• Approach to the Patient

Lymphoma Biology

• Indolent vs Aggressive NHL



• Indolent vs. Aggressive NHL – key principle in understanding biology, and approach to

the patient – Indolent = incurable – Aggressive = curable – WHY?

• Chromosomal Abnormalities in NHL – frequent chromosomal translocations into Ig gene loci

• t(8;14), t(2;8), t(8;22) Burkitt‘s • t(14;18) follicular NHL

Lymphoma Biology

Agg i NHL



• Aggressive NHL – short natural history (patients die within months

if untreated)

– disease of rapid cellular proliferation• Indolent NHL

– long natural history (patients can live for many

years untreated) – disease of slow cellular accumulation

NHL

Epidemiolog



• Epidemiology• Biology• CLASSIFICATION• Approach to the Patient

NHL: Classification

Historically a mess



• Historically- a mess – 1940s Gail and Mallory – 1950s Rappaport – 1970s Lukes-Collins – 1970s Kiel – 1982 Working

– 1994 REAL – 1999 WHO



NHL: Classification

• Key Points



• Key Points – cell size: small cell vs. large cell – nodal architecture: follicular vs. diffuse

• Principle – More aggressive: diffuse, large cell – More indolent: follicular, small cell

NHL: Classification

• Terminology (refers to natural history)



• Terminology (refers to natural history) – low grade = indolent – intermediate grade = aggressive – high grade = aggressive

• Principle – indolent: slow growing, incurable – aggressive: rapidly growing, curable

NHL

• Epidemiology



• Epidemiology• Biology• Classification• APPROACH TO THE PATIENT

NHL: Approach to the Patient

• Approach dictated mainly by histology



• Approach dictated mainly by histology – reliable hematopathology crucial

• Approach also influenced by: – stage – prognostic factors – co-morbidities


• Staging evaluation



• Staging evaluation – History and PE – Routine blood work

• CBC, diff, plts, electrolytes, BUN, Cr, LFT‘s, uricacid, LDH, B2M

– CT scans chest/abd/pelvis – Bone marrow evaluation

– Other studies as indicated (lumbar puncture,gallium, etc…)




• Indolent NHL: typical scenario



• Indolent NHL: typical scenario – patient presents with painless adenopathy – otherwise asymptomatic – follicular small cell histology – average age 59 – usually stage III-IV at diagnosis






• Indolent NHL: guiding treatment principle



• Indolent NHL: guiding treatment principle• early treatment does not prolong overall survival

– When to treat?

• constitutional symptoms• compromise of a vital organ by compression or

infiltration, particularly the bone marrow• bulky adenopathy

• rapid progression• evidence of transformation


• Indolent NHL: typical scenario



• Indolent NHL: typical scenario – watchful waiting: 2-4 years – first remission length: 3-4 years

– second remission: 2-3 years – third remission: 1-2 years – each subsequent remission shorter than prior

– median survival 8-12 years for FLSC


• Indolent NHL: treatment options



Indolent NHL: treatment options – watchful waiting – radiation to involved fields – single agent chemotherapy

• chlorambucil + prednisone, fludarabine – combination chemotherapy

• CVP, CF, FND, CHOP – chemotherapy + interferon – chemotherapy + monoclonal antibodies – monoclonal antibodies – radiolabeled monoclonal antibodies – stem cell transplantation


• Aggressive NHL: typical scenario



• Aggressive NHL: typical scenario – patients notes B symptoms of several weeks

duration

– work-up reveals pathologic adenopathy – histology: diffuse large cell lymphoma – about 50% patients stage I-II, 50% stage III-IV

– average age 64 – IPI score






• Aggressive NHL: treatment approach



Aggressive NHL: treatment approach – Stage I-II: combined modality therapy

• CHOP chemotherapy x 3 + IF radiotherapy

• cure rate around 70% – Stage III-IV (also bulky stage II)

• (R)CHOP chemotherapy x 6-8 cycles• cure rate around 40%

– (R)CHOP is the standard


• International Prognostic Index



International Prognostic Index – Risk Factors (0-5)

• age > 60

• two or more extranodal sites• performance status > 2• elevated LDH• stage III-IV

– Age adjusted IPI (0-3)

CR and OS stratified by IPI

# RF‘s CR 5 yr OS



# CR 5 yr OS

0,1 87% 73%

2 67% 51%

3 55% 43%

4,5 44% 26%


• Is CHOP the best we can do?



Is CHOP the best we can do? – R-CHOP may be better – National Trials opening looking at alternative

strategies in poor prognosis DLCL• age adjusted IPI > 2• CHOP vs. CHOP + SCT

– Risk stratification is the current trend in NHL• Sorting out role for stem cell transplantation• Sorting out role for innovative combinations


• Role for Autologous Stem Cell Transplantation



Role for Autologous Stem Cell Transplantation• Aggressive NHL

– clear benefit when used for aggressive NHL in

first relapse in appropriately selected patients – 1/3 of these patients can be cured by SCT

• Indolent NHL

– no indication that patients are cured – no indication that OS is prolonged

NHL: future directions• Indolent

– monoclonal antibodies (Rituximab)



( ) – radiolabeled monoclonal antibodies – chemotherapy combined with antibodies

– antibodies combined with immunomodulators• Aggressive – risk stratification – CHOP vs. CHOP plus SCT – chemotherapy plus antibodies

• Clinical Trials

Summary

• NHL incidence increasing, Hodgkin‘s decreasing



c de ce c eas g, odg s dec eas g• Hodgkin‘s cure rate quite high

– approach is dictated mainly by disease stage

• NHL cure rate mediocre – approach is dictated mainly by histologic subtype – indolent vs. aggressive

• indolent: watchful waiting perfectly acceptable for

asymptomatic patients• aggressive: require aggressive treatment ASAP to achieve cure

Lymphoma Clinic

• Multidisciplinary



Multidisciplinary – radiotherapy-Dr. Scott Tannehill – hematopathology-Dr. Catherine Leith

• Emphasis on clinical trials – formal testing of promising new therapies

• Every Wednesday• Clinic phone #: 608-263-7022

Overview

• Concepts, classification, biology



Concepts, classification, biology• Epidemiology• Clinical presentation• Diagnosis• Staging

• Three important types of lymphoma

Conceptualizing lymphoma

• neoplasms of lymphoid origin, typically



neoplasms of lymphoid origin, typicallycausing lymphadenopathy

• leukemia vs lymphoma• lymphomas as clonal expansions of cells at

certain developmental stages

ALL MMCLL Lymphomas

Lymphoid progenitor T-lymphocytes

Plasmacells

B-lymphocytes

naïve



Hematopoieticstem cell

Neutrophils

Eosinophils

Basophils

Monocytes

Platelets

Red cells

Myeloid progenitor

Myeloproliferative disordersAML

B-cell development

stemcell

memoryB-cell

CLLgerminal

centerB-cell

maturenaive



ce

lymphoid progenitor

progenitor-B

pre-Bimmature

B-cell plasma cell

DLBCL,FL, HL

ALLMM

B cellnaiveB-cell

Clinically usefulBiologically rational

Classification



Clinically usefulclassification

Diseases that have distinct• clinical features• natural history• prognosis• treatment

Biologically rationalclassification

Diseases that have distinct• morphology• immunophenotype• genetic features• clinical features

Lymphoma classification(2001 WHO)

• B-cell neoplasms



B cell neoplasms – precursor – mature

• T-cell & NK-cell neoplasms – precursor – mature

• Hodgkin lymphoma

Non-

HodgkinLymphomas

A practical way to think of lymphomaCategory Survival of

untreatedpatients

Curability To treat ornot to treat

Non Indolent Years Generally not Generally



Non-Hodgkinlymphoma

Indolent Years Generally notcurable

Generallydefer Rx ifasymptomatic

Aggressive Months Curable insome

Treat

Veryaggressive

Weeks Curable insome

Treat

Hodgkinlymphoma

All types Variable – months toyears

Curable inmost

Treat

Mechanisms oflymphomagenesis

• Genetic alterations



• Infection• Antigen stimulation• Immunosuppression

Epidemiology of lymphomas

• 5th most frequently diagnosed cancer in both



q y gsexes

• males > females• incidence

– NHL increasing – Hodgkin lymphoma stable

Incidence of lymphomas in comparison witother cancers in Canada

000/yr

6070

l



Year

1985 1990 1995 2000age

adjustedincidence/100,0

0

10

20

30

40

50

60

Hodgkinlymphoma

NHL

breastcolorectallung

Age distribution of new NHL cases inCanada

um

100



Age (years)

0-1

1-4

5-9

10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85+

Incidence/10

0,000/annu

0

20

40

60

80

Age distribution of new Hodgkinlymphoma cases in Canada

m6



Age (years)

0-1

1-4

5-9

10-14

15-19

20-24

25-29

30-34

35-39

40-44

45-49

50-54

55-59

60-64

65-69

70-74

75-79

80-84

85+

incidence/100,000/annu

0

1

2

3

4

5

Risk factors for NHL

• immunosuppression or immunodeficiency



pp y• connective tissue disease• family history of lymphoma• infectious agents• ionizing radiation

Clinical manifestations• Variable

• severity: asymptomatic to extremely illl k h



• time course: evolution over weeks, months, or years

• Systemic manifestations• fever, night sweats, weight loss, anorexia, pruritis

• Local manifestations• lymphadenopathy, splenomegaly most common• any tissue potentially can be infiltrated

Other complications oflymphoma

• bone marrow failure (infiltration)



( )• CNS infiltration• immune hemolysis or thrombocytopenia• compression of structures (eg spinal cord,

ureters)• pleural/pericardial effusions, ascites

Diagnosis requires an adequate biopsy

• Diagnosis should be biopsy-proven beforei i i i d



g p y ptreatment is initiated

• Need enough tissue to assess cells andarchitecture – open bxvs core needle bxvs FNA

Stage I Stage II Stage III Stage IV

Staging of lymphoma



A: absence of B symptomsB: fever, night sweats, weight loss



Relative frequencies of differentlymphomas



Hodgkinlymphoma

NHLDiffuse large B-cellFollicular

Other NHL

Non-Hodgkin Lymphomas

~85% of NHL are B-lineage

Follicular lymphoma

• most common type of ―indolent‖ lymphoma ll id d t t ti



yp ‖ y p• usually widespread at presentation• often asymptomatic

• not curable (some exceptions)• associated with BCL-2 gene rearrangement

[t(14;18)]

• cell of origin: germinal center B-cell

• defer treatment if asymptomatic (―watch-and-wait‖)

• several chemotherapy options ift ti



symptomatic• median survival: years• despite ―indolent‖ label, morbidity and

mortality can be considerable• transformation to aggressive lymphoma can

occur

Diffuse large B-cell lymphoma

• most common type of ―aggressive‖l mphoma



‖lymphoma

• usually symptomatic• extranodal involvement is common• cell of origin: germinal center B-cell• treatment should be offered• curable in ~ 40%

Hodgkin lymphoma



Thomas Hodgkin(1798-1866)

Classical Hodgkin Lymphoma



Hodgkin lymphoma

• cell of origin: germinal centre B-cellR d S b ll ( RS i ) i h



• Reed-Sternberg cells (or RS variants) in theaffected tissues

• most cells in affected lymph node are polyclonal reactive lymphoid cells, notneoplastic cells

Reed-Sternberg cell



RS cell and variants



popcorn celllacunar cellclassic RS cell(mixed cellularity) (nodular sclerosis) (lymphocyte

predominance)

A possible model of pathogenesis

transformingevent(s) loss of apoptosis



germinalcentreB cell

event(s)

RS cell inflammatoryresponse

EBV?

cytokines

Hodgkin lymphomaHistologic subtypes

• Classical Hodgkin lymphomanodular sclerosis (most common subtype)



– nodular sclerosis (most common subtype) – mixed cellularity

– lymphocyte-rich – lymphocyte depleted

Epidemiology

• less frequent than non-Hodgkin lymphomall M>F



• overall M>F• peak incidence in 3rd decade

Associated (etiological?) factors

• EBV infectionll f il i



• smaller family size• higher socio-economic status• caucasian > non-caucasian• possible genetic predisposition• other: HIV? occupation? herbicides?

Clinical manifestations:

• lymphadenopathytig d



• contiguous spread• extranodal sites relatively uncommon

except in advanced disease• ―B‖ symptoms

Treatment and Prognosis

Stage Treatment Failure-free

Overall 5year



freesurvival

yearsurvival

I,II ABVD x 4& radiation

70-80% 80-90%

III,IV ABVD x 6 60-70% 70-80%

Long term complications oftreatment

• infertility– MOPP > ABVD; males > females



MOPP > ABVD; males > females – sperm banking should be discussed – premature menopause

• secondary malignancy – skin, AML, lung, MDS, NHL, thyroid, breast...

• cardiac disease

Overview

• Concepts, classification, biology• Epidemiology



• Epidemiology• Clinical presentation• Diagnosis• Staging• Three important types of lymphoma

Non-Hodgkin‘s Lymphoma



Luis Fayad, MDAssistant ProfessorClinical Medical Director Lymphoma/Myeloma Department

Non-Hodgkin‘s Lymphoma

• Non-Hodgkin‘s lymphomas (NHL) are a heterogeneousgroup of malignant lymphomas. There are many differentb f h l ifi i i d d



subtypes, every few years the classification is updated.Today, morphology, immunophenotype, molecular,cytogenetics, and other techniques are used for diagnosis.

• Treatment generally depends on the aggressiveness of thedisease (indolent, aggressive, or very aggressive)

• Current ICD-9-CM diagnosis code range 200.0_ – 200.8_and 202.0_ – 202.9_



WHO/REAL Classification of Lymphoid NeoplasmsB-Cell Neoplasms

Precursor B-cell neoplasmPrecursor B-lymphoblastic leukemia/lymphoma

(precursor B-acute lymphoblastic leukemia)Mature (peripheral) B-neoplasmsB-cell chronic lymphocytic leukemia / small lymphocytic

lymphomaB-cell prolymphocytic leukemiaLymphoplasmacytic lymphoma ‡ Splenic marginal zone B-cell lymphoma

(+ villous lymphocytes)*Hairy cell leukemia

Mature (peripheral) T neoplasmsT-cell chronic lymphocytic leukemia / small

lymphocytic lymphomaT-cell prolymphocytic leukemiaT-cell granular lymphocytic leukemia II Aggressive NK leukemiaAdult T-cell lymphoma/leukemia (HTLV-1+)

Extranodal NK/T-cell lymphoma, nasal type#

Enteropathy-like T-cell lymphoma**Hepatosplenic γδ T-cell lymphoma*Subcutaneous panniculitis-like T-cell lymphoma*



Hairy cell leukemiaPlasma cell myeloma/plasmacytomaExtranodal marginal zone B-cell lymphoma of MALT typeNodal marginal zone B-cell lymphoma

(+ monocytoid B cells)*Follicular lymphoma

Mantle cell lymphomaDiffuse large B-cell lymphoma

Mediastinal large B-cell lymphomaPrimary effusion lymphoma †

Burkitt‟s lymphoma/Burkitt cell leukemia§

T and NK-Cell NeoplasmsPrecursor T-cell neoplasm

Precursor T-lymphoblastic leukemia/lymphoma(precursor T-acute lymphoblastic leukemia

‡Formerly known as lymphoplasmacytoid lymphoma or immunocytomaII Entities formally grouped under the heading large granular

lymphocyteleukemia of T- and NK-cell types

* Provisional entities in the REAL classification

Mycosis fungoides/Sézary syndromeAnaplastic large cell lymphoma, T/null cell,

primary cutaneous typePeripheral T-cell lymphoma, not otherwise characterizedAngioimmunoblastic T-cell lymphoma

Anaplastic large cell lymphoma, T/null cell,primary systemic type

Hodgkin‟s Lymphoma (Hodgkin‟s Disease) Nodular lymphocyte predominance Hodgkin‟s lymphoma Classic Hodgkin‟s lymphoma

Nodular sclerosis Hodgkin‟s lymphoma (grades1 and 2)Lymphocyte- rich classic Hodgkin‟s lymphoma Mixed cellularity Hodgkin‟s lymphoma

Lymphocyte depletion Hodgkin‟s lymphoma

† Not described in REAL classification§ Includes the so-called Burkitt-like lymphomas** Formerly known as intestinal T-cell lymphoma# Formerly know as angiocentric lymphoma

Indolent (35%)

Mantle cell (6%)

Peripheral T-cell (6%)

Other subtypes with a

Frequency of NHL Subtypes in Adults



Diffuse largeB-cell (31%)Armitage et al. J Clin Oncol. 1998;16:2780 – 2795.

ypfrequency 2% (9%)

Compositelymphomas (13%)

Marginal Zone Lymphoma

• Indolent• Currently codes to 202.8



Currently codes to 202.8_• Accounts for ~10% of all lymphomas

• Subcategories – MALT (XRT?) – Nodal – Extra Nodal – Splenic

Mantle Cell Lymphoma

• Aggressive• Currently codes to 202 8



• Currently codes to 202.8_• Accounts for ~ 6% of all lymphomas• Considered ―incurable‖ with traditional RX • Stem cell transplant is offered often as

front-line consolidation treatment in―younger‖ patients

Primary CNS Lymphoma




• Currently codes to 202.8_• Accounts for ~ 1-2% of all lymphomas• Different chemotherapy treatments• Often requires radiation to the brain:

» Brain dysfunction in younger patients

» Dementia in older patients

Anaplastic Large CellLymphoma (ALCL)




• Currently codes to 202.8_• Accounts for ~ 2% of all lymphomas

– Two groups: – ALCL ALK-1+ better prognosis, more common in

younger patients and children – ALCL ALK-1-negative : as bad as any other T-cell

lymphoma

Peripheral T-cell Lymphoma




• Currently codes to 202.8_• Accounts for ~ 7% of all lymphomas• Worse prognosis, often associated with

extranodal presentation• Often requiring salvage treatment and

transplant

Large Cell Lymphoma

• Very Aggressive• Currently codes to 200 0



Currently codes to 200.0_• Accounts for ~ 31% of all lymphomas

Other Recommendations

• Changes to terminology• Changes in disease process



Changes in disease process

Questions?



N H d ki ' L h



Non Hodgkin's Lymphoma

Questions?

• What is Hodgkin's?

• What is a Lymphoma?



• What does Non-Hodgkin's mean?

Lymphomas and leukemias

A Leukemia is a tumor that produces abnormal white bloodcells in the blood stream. A lymphoma is a tumor of the lymph



cells in the blood stream. A lymphoma is a tumor of the lymphnodes that causes them to expand, invade other organs andcause the abnormal growth of lymphoid tissue elsewhere.

Leukemias are tumors of the bone marrow, while lymphomas are tumors of the lymphoid organs and lymphatics

Classification of NHLHodgkin's vs. Non Hodgkin's • through microscopy, if the tumor presents with Reed-Sternberg

cells, then the disease is classified as Hodgkin's Lymphoma . Allother forms are classified as non-Hodgkin's.

• The original classification known as the "Working Formula"addressed the NHL into 16 different groups, classified by

h l l l b h d



aggressiveness. There is little correlation between the stages, andthus, the REAL (Revised European-American Lymphoma) andWHO classifications are currently more adapted into medicallanguage.

• These classifications organize the lymphomas into over 43distinguishable diseases.

• They still classifiy Hodgkin's lymphoma, but do not specificallyidentify NHL. People still use the term, although due to it's broadspectrum, provides little clinical relevance.

Hodgkin's Lymphoma



WHO Classification OverviewClassifications are based on the morphological presentation as opposed to theaggressiveness.

B cell Neoplasms

• Precursor B cell Neoplasms • Mature B cell Neoplasms (most common) o Follicular B cell lymphoma



o Diffuse Large B cell Lymphoma • B cell proliferations unclassified

T cell and NK cell Neoplasms • Precursor T and NK cell neoplasms • Mature T and NK cell Neoplasms • T and NK proliferations unclassified

Hodgkin's Lymphoma

Histiocytic Neoplasms

Dendritic cell Neoplasms

Lymphoma classification

B cell Lymphomas

90% of cases are Mature B cell Lymphomas , < 1% areprecursor B cell lymphoma



p y pFollicular B cell Lymphoma Mantle Cell Lymphoma Marginal Zone Lymphoma Interfollicular Lymphomas Burkitt Lymphoma Diffuse Large B cell Lymphoma Primary Effusion Lymphoma

Diffuse Large B cell Lymphoma



Follicular B cell Lymphoma



B cell Developement



Lymphoma Classification continued

T cell Lymphomas

< 12% of cases are T cell and NK cell Lymphomas, althoughuncommon, they are one of the most aggressive lymphomas.



y gg y p

Peripheral T cell Lymphoma, unspecified Anaplastic Large Cell Lymphoma Angioimmunoblastic T cell Lymphoma Primary Cutaneous T cell Lymphoma

Lymphoma Classification continued

Rare Lymphomas

Histiocytic tumors • Similar to Anaplastic Large cell Lymphoma, within the



dermis or gastrointestinal tract. Express a "histiocytic"phenotype, but has no specific markers, thus the diagnosis is

that of exclusion. Dendritic Cell Tumors • Neoplasms related to accessory cells (DC). Extremely

rare, and present a significant diagnosticchallenge. Symptoms are unpredictable, showing forms ofindolence to lethality.

Risk Factors ForNHL• Systemic Lupus

• Rheumatoid arthritis • Celiac Disease • AIDS



• Organ Transplant recipients • Congenital Immunodeficiency disorders • Chromosomal abnormalities, specifically with chromosomes

2, 8, 14, and 22 (seen in ~ 60% of cases)

Typical Patient Signs and Symptoms• Over the age of 55 • Severe night sweats (often times drenching the bed sheets) • Itchiness, generally all over • Fever

W i h L



• Weight Loss • Loss of appetite

• Weakness and Fatigue, along with typical signs of anemia • Breathlessness, primarily due to swelling of the face and/orneck

Physical ExamFollicular B cell Lymphoma

Waxing and waninglymphadenopathy often presentfor long periods prior to diagnosis

**This disease progresses slowly


Nodal enlargement commonlyfound in the neck and theabdomen.

Masses can be found outside the



This disease progresses slowly Masses can be found outside thelymphatic system: thegastrointestinal tract, testes,thyroid, skin, breast, bone orbrain

40% cases present withextranodal extramedullary

disease.

**This is an aggressive disease

LabsFollicular B cell Lymphoma

• Normal CBC (may showwith signs of anemia)

• Peripheral smear normal • Lymph node biopsy


• Normal CBC (may show withsigns of anemia)

• Peripheral smear normal • Flow cytometry-Immunophenotype generally



Immunophenotype generallyincludes pan-B-cell antigenssuch as CD19, CD20, CD22and CD79a

• Excisional tissue biopsy

Both biopsies require the distinction between: benign vs. malignant lymphoma vs. nonlymphoid malignancies T cell vs. B cell lymphoma HL vs. NHL subtyping of HL and NHL

Prognosis

• Variable

Depends upon: the amount of dissemination,the staging of the disease



and the type of lymphoma

when first diagnosed the disease has spread throughout thebody in 70-90% of patients

although most patients develop progressive disease over 2-6years, survival rate is 75% over 5-years

Treatments

Traditional Treatments:

• consists of radiation and/or chemotherapy• and occasional splenectomy



o remission rates presently 70-90% at 5-years with thattreatment

Treatments

• Naturopathic Treatments:o

Nutrition o Hydrotherapy



o Botanicals

o Supplements

o Manipulation

o Homeopathy



Treatments

• Hydrotherapy 1. fever treatment

2. constitutional hydrotherapy



3. castor oil packs: over abdominal area and spleen, add

phytolacca oil, 2x/week, 1 hour 4. Epsom salt baths: 2x/week, 20-30 min. end with coldfriction, dry and stay warm

Treatments• Botanicals (General cancer/neoplasm):

1.Arctium lappa: alterative for the lymphatic system2.Berberis aquifolium: dyscrasiae due to cancerous

cachexia 3 C l d l ffi i li f l h i



3.Calendula officinalis: for lymphatic system4.Echinacea spp.: increases interferon production, purifies

blood 5. Galium aparine: specific for enlarged lymph nodes 6.Gentiana lutea: bitter; promotes appetite, improves

digestion in chronic debility 7.Iris versicolor (toxic): soft glandular swellings 8.Rumex crispus: to prevent early stages of cancer 9.Taraxacum officinale: loss of appetite, weak digestion 10. Trifolium pratense: alterative; purifies blood, cancerous

diathesis; with daily use; patient are slower in developing

Treatments

• Supplementso 1. beta carotene (150,000 IU QD) o 2. vitamin C (to bowel tolerance) o 3. vitamin E (400 IU TID)

4 l i (200 )



o 4. selenium (200mcg TID)

Treatments

• Manipulation o check and align T5, T10-12



Treatments

• Homeopathy 1. Apis: on neck with hectic fever; edema of skin and mucusmembranes 2. Arsenicum album: great exhaustion; burning pains;l h k i h h i f i h h l i i



lymphoma on neck with hectic fever, with holes as in a sieve 3. Arsenicum iodatum: weakness, night sweats 4. Belladonna: sore throat, swollen face, dry cough 5. Graphites: with fever 6. Phosphorus: with fever, suddenness of symptoms, withnervous debility; emaciation 7. Pulsatilla: with digestive problems 8. Rhus toxicodendron: restlessness and soreness

Multiple Myeloma



p yBy Dr.Sujith S.

Introduction

Malignant proliferation of plasma cellsderived from single clone.



Osteoclasts Activating Factor



Plasma cell





A variety of chromosomal alterations - mostcommon translocations aret(11;14)(q13;q32) and t(4;14)(p16;q32)



t(11;14)(q13;q32) and t(4;14)(p16;q32),

Mutations in p53 and Rb-1 have also beendescribed.

Myeloma increases in incidence with age.The median age at diagnosis is 68 years; itis uncommon under age 40



is uncommon under age 40.

The yearly incidence is around 4 per100,000 .Males are more commonly affected than

femalesBlacks have twice the incidence of whites

Clinical Features

Bone pain (70%)



Mechanism of lytic lesion in the bone

Site of involvementBack & Ribs,Pain precipitated by movement

Clinical features(cont.d)

ComplicationsPathological fracture-persistent pain at the local site



Spinal Cord Compression due to collapse of the vertebrae


Increase susceptibility to bacterialinfections.Th i f i



The most common infections are

pneumonias and pyelonephritis Organisms in the lungs- Streptococcus

pneumoniae , Staphylococcus aureus , and

Klebsiella pneumoniae. Organisms in the urinary tract- Escherichiacoli and other gram-negative

Contributory causes




Renal failure occurs in nearly 25% ofmyeloma patients,Hypercalcemia



– Hypercalcemia

– Glomerular deposits of amyloid,hyperuricemia, recurrent infections, frequentuse of nonsteroidal anti-inflammatory agentsfor pain control, use of iodinated contrast dye

for imaging, bisphosphonate use, myelomacells infiltrates – Tubular damage associated with the excretion

Clinical Features(cont.d)

The earliest manifestation of this tubulardamage is the adult Fanconi syndrome (atype 2 proximal renal tubular acidosis)



type 2 proximal renal tubular acidosis),


Glomerular function is usually normal



Proteinuria is uncommon


Decreased anion gap because the Mcomponent is cationicH t i ( d h t i )



Hyponatremia (pseudohyponatremia)

susceptible to acute renal failure if they become dehydrated


Anemia - 80% .

ll d h



It is usually normocytic and normochromic


Some have megaloblastic anemia due to eitherfolate or vitamin B12 deficiency.



Granulocytopenia and thrombocytopenia are veryrare.

Clotting abnormalities may be seen₋ failure of antibody-coated platelets to function properly₋ interaction of the M component with clotting factors I,

II, V, VII, or VIII.


Deep venous thrombosis is also observedRaynaud's phenomenon and impairedcirculation may result if the M component



circulation may result if the M component

forms cryoglobulins

Hyperviscosity

Depends on the physical properties of the Mcomponent (most common with IgM, IgG,and IgA paraproteins)



and IgA paraproteins).

Paraprotein concentrations of ~40 g/L (4g/dL) for IgM, 50 g/L (5 g/dL) for IgG3,

and 70 g/L (7 g/dL) for IgA.

Symptoms: headache, fatigue, visual

Hypercalcemia - lethargy, weakness,depression, and confusion.Bony damage and collapse cord



Bony damage and collapse - cord

compression, radicular pain, and loss of bowel and bladder control.Infiltration of peripheral nerves by amyloid-

cause of carpal tunnel syndrome sensory,motor mono and polyneuropathies.Sensory neuropathy is also a side effect of

Variants of Myeloma

Solitary bone plasmacytomas may recur inother bony sites or evolve into myeloma.Extramedullary plasmacytomas



Extramedullary plasmacytomas

submucosal lymphoid tissue ofnasopharynx or paranasal sinus withoutmarrow plasmacytosis

rarely recur or progress

Both hi hl res onsive to local radiation

Diagnostic features

Plasmacytosis in marrowMonoclonal protein in serum or urineL i di f b



Lytic disease of bone









Asymptomatic Multiple Myeloma

• M protein in serum>30g/L• Bone marrow clonal plasma cells > 10%N l l t d g ti



• No myeloma-related organ or tissue

impairment (no end organ damage,including bone lesions) or symptoms

Symptomatic Multiple Myeloma

• M protein in serum and/or urine• Bone marrow (clonal) plasma cells orplasmacytoma



plasmacytoma

• Myeloma-related organ or tissueimpairment (end organ damage, including bone lesions

Nonsecretory Myeloma

• No M protein in serum and/or urine withimmunofixation• Bone marrow clonal plasmacytosis 10%



• Bone marrow clonal plasmacytosis 10%

• Myeloma-related organ or tissueimpairment (end organ damage, including bone lesions)

Solitary Plasmacytoma of Bone

• No M protein in serum and/or urine

• Single area of bone destruction due toclonal plasma cells



clonal plasma cells

• Bone marrow not consistent with multiplemyeloma• Normal skeletal survey (and MRI of spine

and pelvis if done)• No related organ or tissue impairment (noend organ damage other than solitary bone

Myeloma-related organ or tissueimpairment (ROTI)

• Calcium levels increased• renal insufficiency• anemia



anemia

• bone lesions• symptomatic hyperviscosity,• amyloidosis,

• recurrent bacterial infections (>2 episodes in12 months)

Investigations

• CBC with differential may reveal anemia• ESR is elevated.• Rare patients (~2%) may have plasma cell



• Rare patients (~2%) may have plasma cell

leukemia with >2000 plasma cells/L.• Serum calcium, urea nitrogen, creatinine,

and uric acid levels may be elevated.

• Protein electrophoresis and measurement ofserum immunoglobulins and free lightchains.

Cont.d

• A 24-h urine specimen is necessary toquantitate protein excretion• Serum alkaline phosphatase is usually



Serum alkaline phosphatase is usually

normal• It is also important to quantitate serumBeta2-microglobulin.

• Serum soluble IL-6 receptor levels and C-reactive protein may reflect physiologic IL-6 levels in the patient

Serum M Component

• IgG in 53% of patients, IgA in 25%, andIgD in 1%• 20% of patients will have only light chains



20% of patients will have only light chains

in serum and urine.• Bence Jones protein is falsely negative in~50% of patients with light chain myeloma.

Serum M Component

• Fewer than 1% of patients have noidentifiable M component- have light chainmyeloma



y

• About two-thirds of patients with serum Mcomponents -urinary light chains.

Criteria for Diagnosis of MultileMyeloma

Durie Salmon Diagnostic CriteriaMajor CriteriaI Plasmacytoma on tissue biopsy



I-Plasmacytoma on tissue biopsy.

II-Bone marrow plasmacytosis(>30% plasma cells)III-Monoclonal immunoglobulin spike

IgG>3.5g/dl or IgA>2g/dlkappa/lamda chain excretion>1g/dayin

Minor Criteriaa)Bone marrow plasmacytosis(10-30%plasma cells). b)Lesser magnitude of Ig spikec)Lytic lesionsd)Normal IgM:<50mg/dl



) g g Normal IgA<100mg/dl or Normal IgG<600 mg/dlI plus b, c, or d

II plus b, c, or dIII plus a, c, or da plus b plus ca plus b plus d

Durie-Salmon staging• Staging system is based on the

• hemoglobin, calcium, M component, and degree of skeletalinvolvement

• low (stage I), intermediate (stage II), or high (stage III),



• stages are further subdivided on the basis of renal function

[A if serum creatinine <2 mg/dL, B if >2 mg/dl].• stage IA have a median survival of >5 years and those instage IIIB about 15 months.

• This staging system has been found not to predict prognosis after treatment with high-dose therapy or thenovel targeted therapies that have emerged.

Stage I

• Estimated Tumor Burden < 0.6 (x 1012 cells/m2) H gl bi >100 g/L (>10 g/dL)



• Hemoglobin >100 g/L (>10 g/dL)• Serum calcium <3 mmol/L (<12 mg/dL)• Normal bone x-ray or solitary lesion• Low M-component production

– IgG level <50 g/L (<5 g/dL) – IgA level <30 g/L (<3 g/dL)

Stage III

• Hemoglobin <85 g/L (<8.5 g/dL)• Serum calcium >3 mmol/L (>12 mg/dL)



( g )

• Advanced lytic bone lesions• High M-component production – IgG level >70 g/L (>7 g/dL)

– IgA level >50 g/L (>5 g/dL) – Urine light chains >12 g/24 h

International Staging System

• Beta2M < 3.5, alb 3.5• Beta2M < 3.5, alb < 3.5or Beta2M = 3.5 – 5.5



2 2

• Beta2M > 5.5

Disorder Associated with MonoclonalProtein

Neoplastic cell proliferationmultiple myelomasolitary plasmacytomaWaldenstrom macroglobulinemia



Waldenstrom macroglobulinemia

heavy chain disease primary amyloidosisUndetermined significance

monoclonal gammopathy of undeterminedsignificance (MGUS)

Disorder Associated with MonoclonalProtein

• Transient M protein – viral infection– post-valve replacement



– post-valve replacement

• Malignacy – bowel cancer, breast cancer• Immune dysregulation

– AIDS, old age• Chronic inflamation

Monoclonal gammopathy ofundetermined significance ( MGUS)

M protein presence, stablelevels of M protein: IgG < 3.5g IgA < 2gLC<1g/day



LC<1g/day

normal immunoglobulins - normal levelsmarrow plasmacytosis < 10%complete blood count - normalno lytic bone lesionsno signs of disease

Monoclonal gammopathy ofundetermined significance ( MGUS)

• M protein – 3% of people > 70 years – 15% of people > 90 years



– MGUS is diagnosed in 67% of patients withan M protein – 10% of patients with MGUS develop

multiple myeloma

Treatment

• Patients with symptomatic and/or progressivemyeloma require therapeutic intervention.



• symptomatic supportive care to prevent serioumorbidity from the complications of thedisease.

• Therapy can significantly prolong survival andimprove the quality of life for myeloma patients.

Treatment - Transplant

• Alkylating agents such as melphalan should beavoided since they damage stem cells, leadingt d d bilit t ll t t ll f



to decreased ability to collect stem cells forautologous transplant.

• High-dose pulsed glucocorticoids have beenused either alone or VAD combination for 3weeks for initial cytoreduction.

Treatment - Transplant

• Initial therapy is continued until maximalcytoreduction.



• Agents bortezomib, a proteasome inhibitor,and lenalidomide, an immunomodulatoryderivative of thalidomide, have similarly beencombined with dexamethasone and obtainedhigh response rates without compromisingcollection of stem cells for transplantation

Treatment - Chemotherapy Only

• Intermittent pulses of an alkylating agent, L-



phenylalanine mustard (L-PAM, melphalan)and prednisone administered for 4 – 7 daysevery 4 – 6 weeks.

• The usual doses of melphalan/prednisone (MPare melphalan, 8 mg/m2 per day, and

Treatment - Chemotherapy Only

• In patients >65 years, combining thalidomide



with MP (MPT) obtains higher response ratesand overall survival than MP alone

• MPT is the standard therapy for patients whoare not transplant candidates

• High-dose melphalan therapy (HDT) withhematopoietic stem cell support have shownth t HDT hi high ll



that HDT can achieve high overall responserates and prolonged progression-free andoverall survival;

• Only few patients are cured.• Complete responses are rare (<5%) with

standard-dose chemotherapy, HDT achieves–

Refractory Myeloma

• lenalidomide and/or bortezomib.• These agents target not only the tumor cell but

l h llb



also the tumor cell – bone marrow interaction• These agents in combination with

dexamethasone can achieve up to 60% partialresponses and 10 – 15% complete responses in patients with relapsed disease

• Thalidomide, if not used as initial therapy, canhi i f



achieve responses in refractory cases.• High-dose melphalan and stem cell transplant,

if not used earlier, can be used



Supportive Treatment

• Supportive care directed at the anticipatedcomplications of the disease may be asimportant as primary antitumor therapy.



HypercalcemiaDehydrationARF

HyperviscosityUTI

-

Supportive Treatment

• Patients developing neurologic symptoms inthe lower extremities, severe localized backpain or problems with bowel and bladder



pain, or problems with bowel and bladdercontrol may need emergency MRI andradiation therapy for palliation.

• Most bone lesions respond to analgesics andchemotherapy

• The anemia associated with myeloma may

Prognosis

• The median overall survival of patients withmyeloma is 5 – 6 years,S b f i i i 10



• Subsets of patients surviving over 10 years.• The major causes of death are

– progressive myeloma, – renal failure, sepsis, or – therapy-related acute leukemia or myelodysplasia. – intercurrent age related illnesses: myocardial

Myelodysplastic syndrom



Achievements in understanding and treatmen

• Clonal hematopoietic stem cell disorder characterized byineffective hematopoiesis and peripheral cytopenias

• Although a substantial proportion of MDS cases evolve acute myeloid leukemia (AML) the natural history of th

Myelodysplastic syndrome



acute myeloid leukemia (AML), the natural history of th

syndromes ranges from more indolent forms of the diseaspanning years to those with a rapid evolution to AMLthe leukemic disorder in which neoplastic clone that has been established may or may not fully progress to acuteleukemia

• Refractory anemia (RA): cytopenia of one PB lineage;normo- or hypercellular marrow with dysplasias; < 1% PBblasts and <5% BM blasts

• Refractory anemia with ringed sideroblasts (RARS):cytopenia, dysplasia and the same % blasts involvement inBM and PB as RA. Ringed sideroblasts account for > 15%of nucleated cells in marrow.

• R f t i ith f bl t (REAEB)

Mye o ysp ast c syn romesFAB classification system



• Refractory anemia with excess of blasts (REAEB):Cytopenia or two or more PB lineages; dysplasia involvingall 3 lineages; < 5% PB blasts and 5-20% BM blasts

• Refractory anemia with excess blasts in transformation: (REAEB-t): hematologic features identical to RAEB. >5%

blasts in PB or 21-30% blasts in BM, or the presence ofAuer rods in the blasts• Chronic myelomonocytic leukemia (CMML): monocytosis

in PB>10 9/L < 5% blast in PB and u to 20% BM balsts

Myelodysplastic syndromes:• Refractory anemia (RA)With ringed sideroblasts (RARS)Without ringed sideroblasts• Refractory cytopenia (MDS) with multilineage dysplasia

(RCMD)

Mye o ysp ast c syn romesWHO classification system



• Refractory anemia with excess blasts (RAEB)• 5q- syndromeMyelodysplastic syndrome, unclassifiable• Myelodysplastic/Myeloprolipherative diseases• Chronic myelomonocytic leukemia (CMML)• Atypic chronic myelogenous leukemia (aCML)

Marrow blast percentage:• < 5 0• 5-10 0.5• 11-20 1.5

• 21-30 2.0Cytogentic fetures• Good prognosis 0(–Y 5q- 20q-)

Mye o ysp ast c syn romesIPSS risk-based classification system



( Y, 5q , 20q)

• Intermediate prognosis 0.5 (+8, miscellaneous singleabnormality, double abnormalities)

• Poor prognosis 1.0(abnor. 7, complex- >3 abnor.)Cytopenias • None or one type 0• 2 or 3 type 0.5

Overall score: Median survival:low • 0 5.7 yearsIntermediate• 1 (0 5 or 1) 3 5 years

Mye o ysp ast c syn romesOverall IPSS score and survival



• 1 (0.5 or 1) 3.5 years

• 2 (1.5 or 2) 1.2 yearsHigh• > 2.5 0.4 years

Known molecular abnormalities inMDS

Gene Type of anomaly Incidence(%)

RAS(N or K)

Point mutation(codon 12 13 or 61)

10-30%



(N or K) (codon 12, 13 or 61)

P53 Point mutation ordeletion of other allele

5

FMS

(encodes M-CSFreceptor)

Point mutation

(codon 969 or rarely 301)

5-10

Diagnosis of MDS

• Aplastic anaemia and some diseaseaccompanied by marrow dysplasia,including wit. B12 and/or folate deficiency,exposure to haevy metals recent cytotoxic



exposure to haevy metals, recent cytotoxictherapy and ongoing inflamation (includingHIV and chronic liver disease/alcohol use)should be ruled out

MDS – clinical findings• These are non-specific, and are usually the

consequences of cytopenias, including:- symptoms of anaemia- infections due to neutropenia, but also to the



p

frequently associated defect in neutrophil function- bleeding due to thrombocytopenia (may also occurin moderately thrombocytopenic patients or evenin patients with normal platelets count, because of

thrombocytopathy)

Myelodysplastic features in MDSMDS Bone marrow and/or

peripheral blood findingsBone marrow: multinuclearity, nuclear



Dyserythropoiesis

y

fragments, megaloblastoidchanges, cytoplasmicabnormalities, ringedsideroblasts

Peripheral blood:Poikilocytosis,anisoc tosis nucleated red

Myelodysplastic features in MDSMDS Bone marrow and/or

peripheral blood findings Nuclear abnormalitiesincluding: hypolobulation,



Dysgranulopoiesis

g yp

ring-shaped nuclei,hypogranulationDysmegakariopoiesis Micromegakariocytes

Large mononuclear formsMultiple small nuclei

Bone marrow biopsy• Blood examination and bone marrow

aspirate are sufficient for a diagnosis ofMDS

• It is obviously important in cases of difficult



y p

diagnosis , and it could brink additional prognostic information in some cases- normal or increased cellularity is seen in 85-

90% od cases- abnormal localization of immature

precusors (ALIP)

Dysplasia, apoptosis andcytokines in MDS• Despite increased proliferation of the marrow,

there is an increased rate of prgrammed celldeath kinetically the apoptosis prevails over theincreased proliferation, causing the peripheral



cytopenia• Cytokines derived from unselected marrowmononuclear cells are belived to be extrinsicfactors predisposing to apoptosis (TNF - inhibitnormal and MDS colony growth; INF, IL1, TGF - have also be implicated in causing apoptosis)

Evidence for an immune – mediated suppression of the

marrow in MDS• T cells inhibit MDS CFU-E• CD8+ cells inhibit CFU-GM• Immunosuppressive agents improve cytopenia in

MDS and eliminate autosuppressive T cells



MDS and eliminate autosuppressive T cells• T cells are activated in MDS• T cell are show a skewed T cell receptor V-

repertoire

• HLA-DR 15 over representation in MDS andaplastic anemia

Chronic Neutrophilic Leukemiaand Leukemoid Reaction



Andrea HoneycuttAM Report

egu at on o ematopo es s



PMN development



Chronic Neutrophilic Leukemia:Incidence

• The disease is rare, with approximately 150reported cases to date.• Median age at diagnosis is approximately

67 years



67 years• The disease is equally prevalent in both

sexes.

Chronic Neutrophilic Leukemia:Clinical Presentation

• Fatigue is the most common presentingsymptom.• Other reported symptoms include weight

loss easy bruising bone pain and night



loss, easy bruising, bone pain, and nightsweats.

• Most patients have palpable splenomegalyat diagnosis.

Chronic Neutrophilic Leukemia:Clinical Presentation

• Most patients are mildly anemic at presentation.• The platelet count is often normal.



• However, later in the clinical course,thrombocytopenia accompanies progressivesplenomegaly.



Chronic Neutrophilic Leukemia:Diagnosis

• The differential diagnosis of CNL includesreactive leukocytosis, plasma cell proliferative disorders, AML, CML, MPD,and MDD



and MDD.• Reactive leukocytosis might accompany

chronic infections and inflammatory ormalignant conditions.

Chronic Neutrophilic Leukemia:Diagnosis

• Neutrophilia seen in association with plasma cell proliferative disordersrepresents a reactive phenomenon.



Chronic Neutrophilic Leukemia:Prognosis• The disease course is heterogeneous and includes a

clinically indolent chronic phase followed over avariable period by an accelerated or blast phase.

• Disease acceleration is heralded by progressive



treatment-refractory neutrophilia, markedsplenomegaly, anemia, thrombocytopenia, and theappearance of immature myeloid progenitor cells inthe peripheral blood.

Chronic Neutrophilic Leukemia:Prognosis• Median survival is approximately 2 years.• Causes of death include blast transformation

(always myeloid), progressive diseasewithout blast transformation bleeding and



without blast transformation, bleeding, andinfection.

Chronic Neutrophilic Leukemia:Treatment• Treatment reports of CNL have included

splenic irradiation, splenectomy,cytoreductive agents includinghydroxyurea, busulfan, 6-thioguanine, low-



hydroxyurea, busulfan, 6 thioguanine, lowdose cytarabine, cladribine, AML-likeinduction chemotherapy, and allogeneicstem cell transplantation (ASCT).

Chronic Neutrophilic Leukemia:Treatment• Hydroxyurea as first-line therapy and

expect response in 75% of patients.• Responses often last for a median of 12

months.



• Second-line treatment, interferon alfa basedon reports of successful use in a smallnumber of patients.

Chronic Neutrophilic Leukemia:Treatment• Splenectomy is generally not recommend

because of the potential for exacerbatingleukocytosis.

• Acute myeloid leukemia – like induction



chemotherapy is ineffective in CNL• ASCT is a potentially curative treatmentmodality for transplant-eligible recipients

who are still in chronic phase.

Leukemoid Reaction: Definition• A leukemoid reaction (LR) is a hematological

disorder, defined by a leukocyte count greater than50,000 cells/mcL with reactive causes outside the bone marrow

• LR is characterized by a significant increase in



LR is characterized by a significant increase inmature neutrophils in the peripheral blood and adifferential count showing marked left shift.

• The diagnosis of LR is based on the exclusion ofchronic myelogenous leukemia (CML) andchronic neutrophilic leukemia (CNL).

Leukemoid Reaction Major Causes:Infections• Clostridium difficile colitis• Severe shigellosis• Disseminated tuberculosis• Serious bacterial infections



• Work up of LR should include cultures of blood,sputum, and bone marrow for common bacteriaand mycobacteria. Stool cultures should not beoverlooked.

Leukemoid Reaction Major Causes:Infections• C. difficile colitis with an LR appears to be

associated with a much higher mortality rate(approx 50%).



Leukemoid Reaction Major Causes:Drugs/Toxins• Corticosteroids• Minocycline• Recombinant hematopoietic growth factors



• Ethylene glycol

Leukemoid Reaction Major Causes:Malignancy• Carcinomas (lung, oropharyngeal,

gastrointestinal, genitourinary)• Hodgkin's lymphoma



• Melanoma• Sarcoma

Leukemoid Reaction Major Causes:Malignancy• Leukemoid reactions can present

simultaneously with malignancy, late in thecourse of the disease, or precede thediagnosis by as many as 4 years.



g y y y• In a study of 227 patients with carcinoma of

the lung, 33 patients (14.5%) werediagnosed with tumor-related leukocytosisand 6 patients (2.6%) with LR.

Leukemoid Reaction Major Causes:Malignancy

• The mechanism of the generation of an LR inassociation with a neoplasm has not been fullyelucidated.

• It is likely that various cytokines produced



irregularly by the tumor cells, includinggranulocyte colony-stimulating factor (G-CSF),granulocyte-macrophage colony-stimulating factor(GMCSF), and interleukin 6 (IL-6), may underliethe pathogenesis of LR in such conditions.

Leukemoid Reaction versus CNLversus CML• CML:

– immature cells, basophilia or monocytosis – decreased leukocyte alkaline phosphatase (LAP) score – bcr/abl translocation.

• The differential diagnosis between LR and CNL



may be difficult or even impossible because bothconditions share: – identical morphological features – increased LAP score – absence of the bcr/abl translocation.

Leukemoid Reaction versus CNLversus CML: The Smear• In CML, there are more immature cells,

basophils, and eosinophils.• In LR, consist mostly of mature neutrophils.

The differential count discloses a marked



left shift, presence of myelocytes andmetamyelocytes.• In CNL, there is marked neutrophilia with

no immature cells

Leukemoid Reaction versus CNLversus CML: The Bone Marrow• In CML, basophilia, eosinophilia, monocytosis, or

even a minimum percentage of blasts arecharacteristic.

• Increased cellularity with myeloid hyperplasia is



seen in both LR and CNL.• In LR there is marked proliferation and orderlymaturation of all normal myeloid elements withnormal morphology, without fibrosis.

Leukemoid Reaction versus CNLversus CML: The Bone Marrow• Similar morphological features are present

in CNL and LR, but a packed bone marrow biopsy, together with a slight increase inreticulin fibrosis, may help differentiate it



from a reactive process.

Leukemoid Reaction versus CNLversus CML: Cytogenetics• The presence of Philadelphia 1 chromosome

in the karyotype or the detection of t(9;22)translocation (creating the bcr/abloncogene) by molecular techniques is the



hallmark for CML and excludes CNL/LR.

Leukemoid Reaction versus CNLversus CML: LAP score• LAP is an enzyme present in the cytoplasmic

microsomes of neutrophils, bands,metamyelocytes, and myelocytes, but not inlymphocytes or monocytes.



• Immature neutrophils, such as those observed inCML, have decreased LAP scores.• Stimulated neutrophils of an LR have high LAP

scores.

Leukemoid Reaction versus CNLversus CML: LAP score• Leukocyte alkaline phosphatase (LAP)

score is high in infection/inflammation, polycythemia vera and CNL.

• LAP score is low in CML.



Leukemoid Reaction versus CNLversus CML: Cytokine Levels• Although G-CSF, GM-CSF, and IL-6 are not

included in diagnostic criteria for CNL,measurement of enzyme-linked immunosorbentassay (ELISA) have been used to elucidatecytokine-producing tumor and the development of



an LR.• Generally CML and CNL patients have

significantly low G-CSF levels, suggesting thatneoplastic granulopoiesis can exert a suppressoreffect on G-CSF synthesis.

Chronic Myeloid Leukemia and other

Myeloproliferative Neoplasms (MPNs)

Dale Bixby, M.D., Ph.DClinical Assistant Professor



Assistant Program DirectorDivision of Hematology and OncologyDepartment of Internal Medicine

University of Michigan

Winter 2010

Definitions

Myeloproliferative Neoplasms (MPNs): are a group of clonalmyeloid neoplasms in which a genetic alteration occurs in hematopoietic progenitor cell leading to its proliferatioresulting in an increase in the peripheral blood white blood ce



(WBCs), red blood cells (RBCs), platelets, or a combination these cells.

Hematopoietic Progenitors and MPNs

GeneticMutation



National Cancer Institute

More Definitions

The type of disorder is often based on the predominant cell line that is affected, b because blood counts are often abnormal in more than one cell line, diagno based upon blood counts alone may be inaccurate.

Four Main MPNs: Additional MPNs:





1. Chronic Myelogenous Leukemia (CML) 1. Systemic Mastocytosis2. Polycythemia Vera (PV) 2. Hypereosinophilic Syndrome3. Essential Thrombocytosis (ET) 3. Chronic Myelomonocytic Leukemia4. Primary Myelofibrosis (PMF) 4. Chronic Neutrophilic Leukemia

5. Chronic Eosinophilic Leukemia

Evaluation of Thrombocytopenia



ByDr. Stephen Szabo

Figure 1. The granular appearance of the platelets helps to distinguish them from artifact inthe peripheral smear



Copyright ©2005 American Society of Hematology. Copyright restrictions may apply.

Maslak, P. ASH Image Bank 2005;2005:101353

Brief history of the platelet• Studies by Osler, Hayam, and Bizzozero identified

small particles in the blood, these were believed to be either bacteria or red cell fragments• James Homer Wright ―Wright Stain‖ identified

platelets as a distinct hematopoetic componentarising from megakaryocytes



a s g o ega a yocytes• William Duke in 1910 described 3 patients with

low platelet counts that had hemorrhagic disease• Duke created a venous shunt from a normal donor

to a thrombocytopenic recipient and showed thatthe platelet count could rise and the bleedingwould cease

Practical Importance of AssessingThrombocytopenia• 1/3 of all Hematology Consults in a General

Hospital are for thrombocytopenia• 5 to 10% of all hospital patients are

thrombocytopenic in the ICU the number



increases to 35%• Thrombocytopenic patients in the hospital

suffer a twofold greater mortality rate thanthose who are not

Platelet Kinetics

• Normal circulating platelet count – 150 to 450 K in Northern Europeans – 90 to 300 K in people of Mediterranean descent

• 1/3 of platelets are sequestered in the spleen



• Half life of a platelet is 9 to 10 days• Platelet production is the function of the

multinucleated megakaryocyte

• 15 to 45 K platelets are produced daily tomaintain steady state

Figure 1. Platelets can be seen as individual structures forming on the periphery of thismegakaryocyte





Figure 1. Clusters or chains of platelets are shed from the megakaryocyte and carried off intothe bloodstream





Thrombopoietin (TPO)

• TPO is the primary regulatory protein in the production of platelets

• TPO gene is on chromosome 3• TPO is expressed in the liver, kidneys, and smooth

muscle cells



• Has a plasma half life of 30 hours• The receptor for TPO is c-MPL which is present

on the megakaryocytes and platelest

• TPO rises with platelet fall and declines as themegakaryocyte and platelet mass increase

Stratifying levels of thrombocytopenia

• The primary reason for evaluatingthrombocytopenia is to assess the risk of bleedingand assess the presence of underlying disorders(TTP, HIT etc.)



– < 20 K increased risk of bleeding – 20K to 50 K rarely have increase risk ofspontaneous bleeding but increase risk of bleeding from procedures

– 50K to 100K no increased risk of spontaneous bleeding and can undergo most procedures

Relation of bleeding risk and plateletcount• Bleeding time increases in a linear fashion below a

platelet count of 100 K• In leukemic children major forms of hemorrhage

occurred at platelet counts <10 K



• Slichter et al tagged RBC and found fecal bloodloss – 10 K 5 cc/day

– 5 to 10 K 10 cc/day – < 5 K 50 cc/day

Organization of Thrombocytopenia

• DecreaseProduction – Marrow Damage

• Aplasia• Drugs

• IncreaseDestruction – Non Immune

• DIC• TTP



g• Malignancy

– Congenital Defects – Ineffective

Production• B12, Folic AcidDef

• HELLP – Immune

• ITP

• HIT• SLE, AIDS• TTP

Figure 3. EDTA may produce this effect causing a spurious decrease in the platelet count




Maslak, P. et al. ASH Image Bank 2002;2002:100523

Reasons to Suspect a Congenital PlateletDisorder• Persistence of neonatal thrombocytopenia

or onset of bleeding symptoms in childhood• Family history of thrombocytopenia or

mucocutaneous bleeding



• Platelet count unresponsive to typicaltreatments for ITP

Congenital Causes of Thrombocytopenia

Low MPV Normal MPV Large

MPV____WAS X linked FPD/AML Bernard

SoulierTAR Platelet type



vWDAT/RS MYH9CAT Grey Platelets11q- disorder GATA1

Treatment of Bleeding generally involves the use of plateletsif ossible as well as the use of DDAVP and rFVIIa

Figure 1. Giant platelets are larger than red cells





Types of Autoimmune thrombocytopenia

Neonatal Thrombocytopenia

Isoimmune, Associated with Maternal ITP, Drug-RelatedDrug Induced

Quinidine, Quinine, Sulfa, Gold Salts, Abx (Vanco etc),Heparin



LymphomaAutoimmune disorders

Thyroiditis, SLE, Colitis, SarcoidosisInfections

HIV, Rubella, viral Hepatitis, CMV, Lyme diseasePostransfusion PurpuraITP

Immune Mediated ThrombocytopeniaPurpura• ITP is defined as isolated thrombocytopenia with no

clinically apparent associated conditions or other causes ofthrombocytopenia• ITP is a high prevalence disease 16 to 27 per million per

year



• Incidence increases with age• Female predominance under the age of 60 but not over the

age of 60• It can have an abrupt onset or insidious onset. It is

generally abrupt in onset with children

Pathogenesis of ITP

• Increased platelet destruction caused byantiplatelet antibodies

• Lack of compensatory response bymegakaryocytes due to suppressive effect of



antiplatelet antibodies• Pathogenesis was proved by Harrington

when he infused himself with plasma from awomen with ITP

Evaluation of ITP

• Features consistent with the diagnosis of ITP – Thrombocytopenia with normal or slightly large

platelets – Normal RBC morphology and number (may have

associated iron def or thallasemia etc.)



– Normal white cell number and morphology – Splenomegaly rare

• Features not consistent with the diagnosis of ITP

– Giant platelets – RBC abnormalities ie schisotocytes – Leukocytosis or Leukopenia

Laboratory evaluation of ITP

• Not Much !!!!!!! – Platelet associated immunoglobulin reflect

plasma concentration and alpha granuleconcentration



– Bone Marrow not very helpful as initial test• May be helpful in patient over 50 years and

concerned about MDS• If patient has failed initial treatment and diagnosis is

in question – TSH and HIV test helpful, Peripheral Smear

hel ful

Management of ITP

• Most patients with ITP do not haveclinically significant bleeding – Risk of intracranial bleed 0.1 to 1% (This is an

overestimate)



– Wet Purpura ie epistaxis, gingival bleeding is arisk factor for major bleeding

• In asymptomatic patients with platelets

counts greater then 20 K observation isreasonable

Acute Pharmacologic Management ofITP• Steroids

– Prednisone 1mg/kg/day with taper over 2 to 3months

– Decadron 40 mg/day x 4 days



– Solumedrol 1 gram/day x 2 days• Antibodies

– IVIG 1 gram/day x 2 days

– Anti-D 50 mcg/kg IV x1

Chronic Management of ITP

• Splenectomy – Immunize with Pneumovax, Hib,

Meningococcal• Chronic Anti-D therapy

h d



– Does not put the disease in remission• Rituximab• AMG 531, Eltrombopag c-MPL agnonists• Observation

Management of ITP in pregnancy

• Gestational Thrombocytopenia – Platelet count >70K, occurs late in gestation,

not associated with fetal thrombocytopenia,resolves after pregnancy



• ITP in pregnancy – Treat if symptoms intermittent IVIG,Prednisone, anti-D

– Epidural anesthesia appears safe if platelet

count > 50K – Monitoring for neonatal thrombocytopenia

TTP Thrombotic ThrombocytopeniaPurpura• TTP is characterized my microangiopathic

hemolytic anemia and profoundintravascular platelet clumping

• The disease was first reported in 1923 byl h h l



Dr. Eli Moschowitz at Beth Israel in NYC – 16 year old girl who presented with anemia,

petechia ultimate coma and death

– Terminal arterioles and capillaries wereoccluded by hyaline thrombi mostly composedof platelets

Figure 1. Peripheral smear showing microangiopathic hemolytic features with numerous RBCfragments (helmet cells/schistocytes)




Lazarchick, J. ASH Image Bank 2001;2001:100174

Figure 2. Peripheral smear showing RBC fragmentation consistent with a microangiopathichemolytic process




Lazarchick, J. ASH Image Bank 2001;2001:100174

Clinical and Lab Manifestations of TTP

• Severe thrombocytopenia and hemolytic anemiawith one or several fragmented red cells in high power oil >1% total number of RBC

• Neurologic Manifestations, abdominal pain

F d R l Ab li i i h



• Fever and Renal Abnormalities occur in theminority of patients• Thrombocytopenia range from <30 K to 75 to 100

K• Elevated LDH• Initially coagulation studies are normal

Type of TTP

• Familial chronic relapsing• Acquired idiopathic• Drug related

– Ticlopidine, Clopidogrel



• Thrombotic Angiopathies that resembleTTP – Mitomycin, cyclosporine, tacrolimus, quinine – Chemotherapy, gemcitabine, TBI – BM and Solid organ transplant



Proposed Relation among the Absence of ADAMTS 13 Activity in Vivo, Excessive Adhesion andAggregation of Platelets, and Thrombotic Thrombocytopenic Purpura



Moake J. N Engl J Med 2002;347:589-600

Differential Diagnosis of TTP• Hemolytic-uremic syndrome• DIC• Evans Syndrome• Malignant Hypertension

M lf ti i th ti di l



• Malfunctioning prosthetic cardiac valves• Severe vasulitis• Pregnancy

– Preeclampsia/eclampsia – HELLP

Treatment of TTP

• Infusion of FFP 30 cc/kg/day until ready for plasma exchange

• Daily plasma exchange with either FFP orcryopoor FFP (45 to 55 cc/kg/day)St id (P d i 1 /k /d )



• Steroids (Prednisone 1 mg/kg/day)• Red Blood Cells if needed• Platelets only if absolutely necessary

Heparin Induced Thrombocytopenia

• Described in 1958 by Rodger Weismannand Richard Tobin after extracting plateletfibrin thrombi that formed after 1 to 2 weekcourse of heparinHIT i th f lti l l



• HIT is the presence of a multimolecularcomplex between platelet factor 4, andheparin

• HIT is associated with thrombosis despite profound thrombocytopenia



Clinical Features of HIT

• Timing – Onset between days 5 and 10 after heparin

initiation – Rapid onset if previously exposed to heparin

Th b t i di b t 15 K t



• Thrombocytopenia nadir between 15 K to150 K

• >50% develop a new thrombosis bothvenous and arterial

• Absence of petechia

Diagnosis of HIT

• Clinical Suspicion (ie greater then 50%drop in platelets in the setting of heparinuse)

• Laboratory Studies

Platelet Activation Studies (Complicated and



– Platelet Activation Studies (Complicated and physiologic) – PF4/Polyanion Studies (Less time consuming

but not necessarily physiologic)

• Even without evidence of thrombosis patient should get lower extremity dopplers

Treatment of HIT

• Removal of all Heparin products• Begin direct thrombin inhibitor (DTI)

(Argatroban or Refludan)• Treat with DTI until platelet count

li th b gi ti g ti



normalizes then may begin anticoaguationwith coumadin

• Fondaparinux (Arixtra) is a reasonableagent to use for DVT prophylaxis in patientwith history of HIT

Practical Aspects for the management ofthrombocytopenia

• What is an adequate platelet count for procedures? – Routine Dentistry >10K – Dental Extraction >30K – Regional Dental Block >30K – Minor Surgery >50K

Major Surgery>80K



– Major Surgery>80K – Epidural is okay at platelet count 50K for patient with

ITP• The target platelet count for a bleeding patient is

generally >40K• Prophylactic platelet transfusions for platelets <10K

Essential Thrombocythemia

Jennifer Pagliei



Jennifer PaglieiJuly 31, 2006

Essential Thrombocythemia• Also called essential thrombocytosis or primary

thrombocytosis.• First described over 70 years ago.• A subgroup of the chronic myeloproliferative

disorders (CMPDs)



disorders (CMPDs).• The most common myeloproliferative disorder.• The only CMPD that is a diagnosis of exclusion.

• It is heterogeneous both clinically and biologically.

Pathogenesis• Neither thrombopoietin (TPO), the key hormone in the

regulation of megakaryocyte differentiation and proliferation, nor its receptor, c-Mpl, has been implicatedin the pathogenesis of ET.

• Mutations involving the c-Mpl gene have not beenidentified in ET.

• Serum TPO levels are inappropriately normal or elevated



• Serum TPO levels are inappropriately normal or elevated. – A clonal defect in platelet and megakaryocyte expression of c-Mpl

receptors causes impaired binding of TPO and thus increased bonemarrow production of TPO.

– Also seen in reactive thrombocytosis.

Epidemiology• Incidence rate of 2.5 new cases/100,000

people per year.• In the US, approximately 6,000 people are

diagnosed with ET each year.

• A female preponderance exists with a



• A female preponderance exists with afemale to male ratio of approximately 2:1.• The median age at diagnosis is 60 years.

• Up to 20% of patients are younger than 40years old.

Clinical Presentation• Up to 50% of patients may be totally

asymptomatic at presentation.• The remaining 50% of patients may have

―vasomotor‖ symptoms, thrombotic events,or hemorrhagic complications



or hemorrhagic complications.

Clinical Presentation• Vasomotor symptoms include:

– Headache – Lightheadedness – Syncope – Atypical chest pain – Acral paresthesia – Livedo reticularis– Erythromelalgia



Erythromelalgia• Burning pain of the hands or feet associated with erythema and

warmth – Transient visual disturbances

• Amaurosis fugax• Scintillating scotomata• Ocular Migraine

Vasomotor Symptoms• Usually controlled by treatment with low or

standard doses of aspirin (40 to 325mg/day).

• Some patients may be resistant toantiplatelet therapy and require



antiplatelet therapy and requirecytoreductive therapy.

Thrombosis• A common complication of ET.

• Incidence rates in ET vary between 9 and 22%.• Thrombotic events include: – Stroke – Transient ischemic attacks

– Retinal artery or venous occlusionsCoronary artery ischemia



Retinal artery or venous occlusions – Coronary artery ischemia – Pulmonary embolism – Hepatic or portal vein thrombosis – Deep vein thrombosis – Digital ischemia

Thrombosis• Risk factors include:

– History of prior thrombosis – Age over 60 years – Prolonged exposure to substantial degrees of

thrombocytosisTh l f di l i k f t i



• The role of cardiovascular risk factors isdisputed, however, smoking, hypertension,and obesity have been implicated in somestudies.

Hemorrhage• A less frequent complication of ET.

• Incidence rates in ET vary between 3 and 9%.• Usually involves spontaneous bleeding at

superficial sites such as the skin or mucousmembranes of the GI, respiratory, or GU tracts.

• The risk is significantly associated with:



• The risk is significantly associated with: – Extreme thrombocytosis

• Platelet counts >1 million/microlL, >1.5 million/microL, and>2 million/microL.

– Aspirin in doses greater than 325 mg/day. – Following treatment with NSAIDs.

Hemorrhage• In some patients with platelet counts >1

million/microL, acquired von Willebrand diseasemay develop due to a reduction in highermolecular weight multimers of von Willebrandfactor.

• Increased bleeding may occur in such patients



• Increased bleeding may occur in such patients,especially when treated with aspirin.

• Cytoreduction usually corrects both the clinical

and laboratory abnormalities.

Risk Stratification• Low risk - <2% risk of thrombosis over 4 years

– Age <60 years – No previous history of thrombosis – Platelet count <1,500,000/microL – No cardiovascular risk factors

• High risk– Age >60 years



Age >60 years – A previous history of thrombosis

• Intermediate risk – Patients who do not qualify for either the low or high

risk groups

Disease Transformation• ET may transform into:

– Polychthemia vera (PV) – Agnogenic Myeloid Metaplasia (AMM) – Acute myeloid leukemia (AML)– Myelofibrosis with myeloid metaplasia



Myelofibrosis with myeloid metaplasia(MMM)

• It is not clear whether specific therapy for

ET, including hydroxyurea or anagrelide,modifies the risk of fibrotic transformation.

Pregnancy• Results in spontaneous abortions

approximately 45% of the time, primarilyoccurring in the first trimester.

• The occurrence of abortions cannot bepredicted from the disease course platelet



predicted from the disease course, plateletcount, or specific therapy.

• Aspirin is associated with a decreasedincidence of miscarriage.

Physical Exam• Palpable splenomegaly

– Present in 25 to 48% of patients at diagnosis. – Usually only modest in degree.

• Hepatomegaly and lymphadenopathy areuncommon



uncommon.

Differential Diagnosis• Includes:

– Reactive thrombocytosis – Familial essential thrombocythemia – Chronic myelogenous leukemia (CML)– Polychthemia vera (PV)



Polychthemia vera (PV) – Agnogenic Myeloid Metaplasia (AMM)

Diagnosis• ET is a diagnosis of exclusion.

• May be diagnosed in patients with persistentthrombocytosis only in the absence of a knowncause of reactive or clonal thrombocytosis.

• There are no laboratory findings that arepathognomonic for ET



pathognomonic for ET.• Peripheral blood smear and bone marrow biopsy

may show clusters of giant platelets,megakaryocyte clusters, and/or mild reticulinfibrosis.

Peripheral Smear and Bone MarrowBiopsy



Diagnosis• Confirm thrombocytosis by repeating CBC.

• Examine the peripheral blood smear to exclude spuriousthrombocytosis.• Perform a complete history and physical exam.• Attempt to determine the duration of thrombocytosis.

• Obtain a serum ferritin concentration, ESR, CRP, and plasma fibrinogen level to evaluate for reactive



, , ,p gthrombocytosis. – Consider testing for the JAK2 mutation.

• Perform a bone marrow biopsy with reticulin staining andcytogenetic studies to distinguish among the CMPDs.

Diagnosis• JAK2 mutation:

– Present in approximately 50% of ET patients. – Differentiates patients with myeloproliferative

disease-associated thrombocytosis from thosewith reactive thrombocytosis.

– However, it does not allow differentiation



However, it does not allow differentiationamong ET, PV, and AMM.

– Presence of the mutation does not appear tocarry significant treatment or prognosis relevantinformation.

Diagnostic Criteria• The Polycythemia Vera Study Group (PVSG)

criteria include: – A consistently elevated platelet count >600,000/

microL. – Megakaryocytic hyperplasia on bone marrow aspiration

and biopsy.



p y – Absence of the Philadelphia chromosome on routine

cytogenetic study.• Molecular studies of the BCR/ABL gene rearrangement are

now recommended to exclude cytogenetically masked cases ofCML.

Diagnostic Criteria – Absence of infection, inflammation, and other

causes of reactive thrombocytosis. – Absence of peripheral blood, bone marrow, and

karyotypic evidence for a myelodysplasticdisorder or AMM.

– Normal iron stores as evidenced by normal



– Normal iron stores, as evidenced by normalserum ferritin and normal red cell meancorpuscular volume.

Diagnostic Criteria• The PSVG criteria are the ―gold standard‖

for the diagnosis of ET.• The World Health Organization (WHO)

criteria are similar and include:

– A sustained platelet count >600,000/microL.Bone marrow biopsy showing proliferation of



A sustained platelet count 600,000/microL. – Bone marrow biopsy showing proliferation ofenlarged, mature megakaryocytes.

– No evidence of PV, CML, chronic idiopathicmyelofibrosis, myelodysplastic syndrome, orreactive thrombocytosis.

Treatment• Some patients with ET may have a significantly

decreased life expectancy although many havenormal life expectancy without associated disease-related complications.

• The most frequent symptoms are vasomotor andare easily managed with low dose aspirin (40 to



a e eas y a aged w t ow dose asp ( 0 to325 mg/day).

• Thrombotic events in low-risk patients are

infrequent and therefore cytoreductive therapy isnot indicated.

Treatment• Cytoreductive therapy is indicated in high-risk

patients to prevent thrombosis.• The decision to use drug therapy in intermediate

risk patients should be made on an individual andmay be considered in patients with extremethrombocytosis (platelets >1.5 million/microL).



y (p )• Bleeding complications are less frequent than

thrombosis and may be prevented by the

avoidance of doses of aspirin greater than 325mg/day and avoidance of NSAIDs.

Therapeutic Agents• Hydroxyurea:

– Inhibits DNA synthesis by inhibiting the enzymeribonucleotide reductase, producing a megaloblastic blood picture.

– Initial dose of 15 mg/kg per day po in divided doses.

– Dose is adjusted to keep platelets between 100,000 and400 000/ i L



j p p400,000/microL.

– Rapid onset of action, usually within 3-5 days. – Teratogenic and should not be used in pregnancy,

breast-feeding, or women with childbearing potential.

Hydroxyurea• Side effects are usually minimal and may include:

– Oral ulcers – Hyperppigmentation – Skin rash – Nail changes – Leg ulcers

– Nausea– Diarrhea



Diarrhea – Alopecia – Fever – Abnormal liver function tests

– Anemia – Neutropenia

Therapeutic Agents• Anagrelide:

– An oral imidazoquinazoline derivative thatinhibits platelet aggregation via platelet anti-cyclic AMP phosphodiesterase activity.

– Lowers platelets via interference withmegakaryocyte proliferation and maturation,l i i l l d d i



g y y p ,resulting in platelet underproduction. – Initial dose is 0.5 mg po tid or qid. – Dose is adjusted according to platelet count

response and symptomatology.

Anagrelide• Side effects are mainly related to direct

vasodilatory and inotropic effects andinclude: – Headache

– Palpitations/tachycardia



p y – Fluid retention – Diarrhea

– Congestive heart failure

Hydroxyurea versus Anagrelide• Anagrelide plus aspirin has been shown to

carry a higher risk of arterial thrombosis,venous thrombosis, serious hemorrhage,and death from vascular causes, in additionto a significantly higher rate oftransformation into myelofibrosis at five



transformation into myelofibrosis at fiveyears than hydroxyurea plus aspirin.

• Thus, hydroxyurea plus aspirin is

recommended as first line therapy in ET.

Therapeutic Agents• Alpha Interferon

– High cost and toxicity issues. – Reserved for use in high-risk women of childbearingage, pregnant women, and patients failing treatmentwith hydroxyurea.

• Platelet apheresis – Reduces the platelet count only in the short-term.Restricted to acute cerebrovascular complications



– Restricted to acute cerebrovascular complications,digital ischemia, and rare life-threatening situations.

• Pipobroman

– An alkylating agent. – Not available in the US, but used widely in Europe.

Therapeutic Agents• Low dose aspirin

– 40 to 325 mg/day. – Prevents recurrent vascular events in high-risk groups

as well as thrombosis. – Effective in treating vasomotor symptoms.

• Radiophosphorus



p p – Radioactive phosphorus 32P oral or IV – IV is used only for patients with a life expectancy

estimated to be less than 10 years.

SummaryET i b f h f il f h i

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