Leukemia

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´Infectious mononucleosis (Epstein-Barr Virus)

´Cytomegalovirus

´Infectious lymphocytosis

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1

´Infectious mononucleosis (Epstein-Barr Virus)

´Cytomegalovirus

´Infectious lymphocytosis

Non-malignant Lymphocytosis Associated with Viral Infections

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B-Lymphocytes

Epstein-Barr virus (EBV) infects

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Infectious Mononucleosis

´Common in the 14 – 24 age group with symptoms ranging from malaise, muscle weakness, fatigue, soar throat, fever to pharyngitis, lymphadenopathy and splenomegaly.

´

Transmitted through nasopharyngeal secretions and saliva, hence the term “kissing disease”.

´Lymphocytes usually >50% of the WBCs with 20% being reactive T lymphocytes attacking affected B lymphocytes.

(+) Positive = heterophile antibody test

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4

Cytomegalovirus (CMV)

´Symptoms similar to Infectious mononucleosis (mono).

´Transmission is by blood transfusions, saliva exchange and other body fluids.

´90% of lymphocytes can be reactive.

´(-) Negative = heterophile antibody test

´Transfused blood products are often tested for CMV.

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coxsackie A virus

Infectious lymphocytosis is associated with

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Infectious lymphocytosis

´Associated with adenovirus and coxsackie A virus.

´Contagious disease mostly affecting young children.

´After a 12 – 21 day incubation period, symptoms appear and include vomiting, fever, rash, diarrhea, and possible CNS involvement.

´Lymphocytosis with no reactive lymphocytes.

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LEUKEMIA

originates in the bone marrow and is initially systemic

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LYMPHOMA

originates in the lymphoid tissue and is initially localized

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Bone Marrow Examination

´Use to aid in diagnosis.

´Investigations include:

´Investigation of peripheral blood abnormalities, such as unexplained cytopenias.

´Staging and management of patients with certain lymphomas or solid tumors.

´On-going monitoring of response to therapy in patients with malignancy.

´Optimal sample for examination includes both aspirate and core biopsy specimen.

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Posterior superior iliac crest

most commonly used site for bone marrow examination

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Anterior iliac crest

less commonly used site for bone marrow examination

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Acute

survival is weeks to months without treatment (death is due to infection and bleeding)

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Chronic

survival is years without treatment

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14

immature/blast

AML - myeloblast

ALL - lymphoblast

predominant cell type in acute

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15

maturing/mature cell

CML - granulocytes

CLL - lymphocytes

predominant cell type in chronic

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30% bone marrow blast

FAB classification is based on cellular morphology and cytochemical stain results. FAB defines acute leukemia as __________

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≥20% bone marrow blast.

´WHO Classification is based on cellular morphology and cytochemical stains but also utilizes information obtained from immunologic probes of cell markers, cytogenetic, molecular abnormalities, and clinical syndrome. WHO defines acute leukemia as ______

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18

WHO classification

standard for diagnosis

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ALL

´Unregulated proliferation of the lymphoid stem cell; classified morphologically using FAB criteria, or immunologically using CD Markers to determine cell lineage (T or B cell).

´Clinical Symptoms:

´Fever

´Joint/bone pain

´Bleeding

´Splenomegaly

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(+) PAS (-) SBB and MPO

All lymphoblast

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´FAB L1

´__most common childhood leukemia__ (2-10 years peak); also found in young adults.

´Small lymphoblast, homogenous appearance.

´Best prognosis.

´Most T cell ALLs are FAB L1.

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FAB L1

Most T cell ALLs are ____

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´FAB L2

´Most common in adults.

´Large lymphoblasts, heterogeneous appearance.

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´FAB L3

´Leukemia phase of Burkitt lymphoma.

´Seen in both adults and children.

´Lymphoblast are large and uniform with prominent nucleoli; cytoplasm stain deeply basophilic and may show vacuoles.

´Poor prognosis.

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B

All FAB L3 are of ___ cell linage

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´Burkitt’s Lymphoma

´High-grade non-Hodgkins lymphoma phase of FAB L3 leukemia.

´Endemic in East Africa with high association with Epstein-Barr virus; children present with jaw/facial bone tumors.

´US variant seen in children and young adults; present with abdominal mass.

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East Africa

´Burkitt’s Lymphoma is endemic in

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28

Epstein-Barr virus

Burkitt’s Lymphoma has high association with

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t(8;14) w/ a rearrangement of the MYC oncogene

Genetic Translocations

FAB L3/Burkitt lymphoma

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t(19;22)

Pre-B cell ALL associated with

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t(4;11)

B cell ALL associated w/

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t(7;11)

T cell ALL associated with

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Chronic Lymphocytic Leukemia (CLL)

´Found in adults over 60y/o.

´More common in males (2:1).

´Survival rate: 5-10 years.

´B cell malignancy (CD19, CD20 [+])

´Often asymptomatic and diagnosed secondary to other conditions.

´Laboratory:

´Hypercellular BM

´Absolute lymphocytosis (>5x10˄9/L)

´Homogenous, small hyper-clumped lymphocytes and smudged cell.

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warm autoimmune hemolytic anemia (WAIHA)

Chronic Lymphocytic Leukemia (CLL) frequent complication

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Small lymphocyte lymphoma (SLL)

lymphoma phase of CLL

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Hairy Cell Leukemia (HCL)

´Found in adults over 50 years old; more common in males (7:1).

´B cell malignancy (CD19. CD20 = [+]).

´Massive splenomegaly; extensive BM involvement results in “dry tap” on BM aspiration.

´Laboratory:

´Pancytopenia

´Cytoplasm of lymphocytes shows hairy-like projections

´Hairy cells are TRAP stain [+].

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Prolymphocytic Leukemia (PLL)

´Found in adults; more common in males.

´Can be either B cell (most common) or T cell malignancy.

´Marked splenomegaly.

´Laboratory:

´Lymphocytosis (> 100 x 10˄9/L)

´Many prolymphocytes

´Anemia & Thrombocytopenia

´Both B and T cell types are aggressive and respond poorly to treatment.

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Multiple Myeloma

´Monoclonal gammopathy causes B cell production of excessive IgG (most common) or IgA , with decreased production of the outer immunoglobulins.

´Fund in over 60y/o; incidence higher in males.

´Multiple skeletal system tumors of plasma cells(myeloma cells) cause lytic bone lesions and hyercalcemia.

´Laboratory:

´BM plasma cells >30%

´Marked rouleaux

´Increased ESR

´Blue background to blood smears (increased)

´Plasma cells and lymphocytes in blood smears (increased)

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“M”

Plasma Cell Neoplasms

´Identified on serum protein electrophoresis by an _ spike in the gamma-globulin region; immunoglobulins class determined using immunoelectrophoretical and quantified using an immunoassay method.

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immunoelectrophoretical

Plasma Cell Neoplasms

´Identified on serum protein electrophoresis by an “M” spike in the gamma-globulin region; immunoglobulins class determined using _____ and quantified using an immunoassay method.

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immunoassay method

Plasma Cell Neoplasms

´Identified on serum protein electrophoresis by an “M” spike in the gamma-globulin region; immunoglobulins class determined using immunoelectrophoretical and quantified using an _____.

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42

blood viscosity

´Excessive IgG or IgA production by myeloma cells causes increased ______.

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43

Bence-Jones proteins

Plasma Cell Neoplasms ______ is found in urine toxic to tubular epithelial cells; cause kidney damage.

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´Waldenstroms Macroglobulinemia

´Monoclonal gammopathy causes B cell production of excessive IgM (macroglobulin) decreased production of the other immunoglobulins.

´Found in adults over 60y/o.

´Lymphadenopathy and hepatosplenomegaly; no bone tumors.

´Identified on serum protein electrophoresis by an “M” spike in the gamma-globulin region; immunoglobulins class determined using immunoelectrophoretical and quantified using an immunoassay method.

´Excessive IgM production causes increased blood viscosity.

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45

Lymphoma

´Proliferations of malignant cells in solid lymphatic tissue.

´Initially localized; may spread to BM and Blood.

´´Diagnosis: Tissue biopsy, CD surface markers, cytogenetics, DNA analysis/PCR.

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Lymphadenopathy

Clinical symptoms of Lymphoma

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47

Hodgkin’s, B-cell, and T/NK cell [non-Hodgkin’s] neoplasms

WHO groups the lymphomas into

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Hodgkin Lymphoma (classical)

-40% of lymphomas; patients between 15-35y/o and over 50 y/o.

-Seen more frequently in males; certain subtypes are associated w/ EBV.

-Reed-Sternberg cells found in lymph nodes biopsy are large, multi-nucleated cells w/ each prominent large nucleoli; B cell lineage.

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EBV

Hodgkin Lymphoma (classical) are associated w/

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Nodular sclerosis

Hodgkin Lymphoma (classical)

70% are this subtype; lowest EBV association.

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Mixed cellularity

Hodgkin Lymphoma (classical)

20% are this subtype; highest EBV association.

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´Non-Hodgkin Lymphoma

´60% lymphocytes; seen in patients over 50y/o; more frequent in males.

´Enlarged lymph nodes or gastrointestinal tumors.´

´B cell neoplasms are more common; include Burkitt (lymphoma phase of Burkitt leukemia), mantle cell follicular and other lymphomas.

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precursor cells or mature cells

WHO separates B cell and T/NK cell neoplasms into conditions with

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cutaneous T cell lymphoma

Mycosis fungoides is also known as

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Mycosis fungoides

´Classified by WHO as a T/NK cell neoplasm (non-Hodgkins lymphoma).

´Seen in patients over 50y/o

´Cutaneous lymphoma causes skin itching, leading to ulcerative tumors.

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SEZARY SYNDROME

´a variant of mycosis fungoides, presents as a disseminated disease with widespread skin involvement and circulating lymphoma cells.

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CD2, CD3, and CD4

Lymphoma is ___ positive

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Acute Myeloproliferative Disorders

´Unregulated proliferation of the myeloid stem cell; classified using morphology, cytochemical stains, CD markers, cytogenetics; WHO classification standard for diagnosis; FAB classification is widely taught.

´Platelets, RBC, granulocytes and/or monocytes can be affected.

´Found in mainly middle-aged adults; also children <1y/o.

´Clinical symptoms:

´Fever

´Malaise

´Weight loss

´Petechiae and bruises

´Mild hepatosplenomegaly

´Laboratory:

´Neutropenia

´Anemia

´Thrombocytopenia

´Variable WBC count

´Hypercellular marrow w/ BM blast >20% (WHO) or 30% (FAB).

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´FAB M0

´Blasts exhibit myeloid markers (CD13, 33 & 34) but stain negativey with the usual cytochemical stains (MPO & SBB).

´

Constitutes <5% of AMLs.

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CD13, 33 & 34

´FAB M0 exhibit myeloid marker

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61

´FAB M1 (AML without maturation)

´Shows 90% or more marrow myeloblasts.

´May have Auer rods.

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t(8;21)

´FAB M1 (AML without maturation) chromosome abnormality

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63

SBB, MPO and specific esterase = POSITIVE.

Both FAB M1 and M2 are

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50

´FAB M1 and M2 accounts for ___% of AMLs.

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CD13 and CD33

pan myeloid markers) = positive (+) for Fab M1 and M2

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´FAB M3 (Acute Promyelocytic Leukemia or APL)

´Characterized by >30% marrow promyelocytes with bundles of Auer rods (faggot cells).

´Heavy azurophilic granulation.

´Accounts for 5% of the AMLs.

´**(+) =** SBB, MPO and specific esterase; CD13 and CD33

´Clinical symptoms:

´Severe bleeding

´Hepatomegaly and DIC

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(t15;17); PML/RAPA oncogene involved

´FAB M3 (Acute Promyelocytic Leukemia or APL) diagnostic chromosome abnormality

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´FAB M4 (Acute Myelomonocytic Leukemia or AMML)

´WHO classification >20% / FAB classification >30% myeloblast, with >20% cells of monocytic of origin.

´May have Auer rods.

´Proliferation of CFU-GM  that gives rise to both granulocytes and monocytes.

´Accounts for 30% of AMLS.

´

Increase urine/serum lysozymes.

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SBB, MPO, specific esterase and non specific esterase

´CD13 & CD33 (granulocytes) CD14 (monocytes)

´FAB M4 (Acute Myelomonocytic Leukemia or AMML) (+)

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´FAB M5 (Acute Monocytic Leukemia or AMoL)

´WH) (>20%)/FAB (>30%) marrow monoblast.´

10% of AMLs.

´Non-specific esterase NEGATIVE; and CD14 positive.

´Contains 2 variants:

´M5a – seen in children w/ >80% monoblast in BM.

´M5b – seen in middle-aged adults with <80% monoblast in the BM.

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71

M5a

´FAB M5 (Acute Monocytic Leukemia or AMoL)

seen in children w/ >80% monoblast in BM

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´M5b

FAB M5 (Acute Monocytic Leukemia or AMoL)

seen in middle-aged adults with <80% monoblast in the BM.

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73

De Guglielmo syndrome

FAB M6 (Acute Erythroleukemia / AEL / can also be called as

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´FAB M6 (Acute Erythroleukemia / AEL / De Guglielmo syndrome)

´Characterized by >20% or >30%  marrow myelobast and 50% marrow displastic normoblast.

´Accounts for 5% of AML.

´Malignant pronormoblast are PAS (+); the myeloblast are SBB & MPO (+).

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´FAB M7 (Acute Megakaryocytic Anemia / AMegL)

´Proliferation of megakaryoblast and atypical megakaryocytes in the BM.

´<1% of AML

´Marrow aspiration causes dry tap.

´Blood shows pancytopenia.

Difficult to diagnose w/ cytochemical stains

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pancytopenia

´FAB M7 (Acute Megakaryocytic Anemia / AMegL) blood shows

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CD41, CD 42, CD 61 (platelet marker)

´FAB M7 (Acute Megakaryocytic Anemia / AMegL) (+)

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Bileneage leukemias

´contain 2 cell populations (1 from myeloid antigens, 1 from lymphoid antigens)

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Biphenotypic leukemias

´occur when myeloid and lymphoid antigens are expressed on the same cell; poor prognosis.

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≥20%

´The WHO classification of acute myeloid leukemias has more than 20 subtypes; all have ___ marrow blasts.

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CML

´Characterized by hypercellular marrow, erythrocytosis, granulocytosis and monocytosis.

´Defect of the myeloid stem cell.

´Named for the cell lineage most greatly affected.

´All may terminate in acute leukemia.

´Presents with excess granulocytes proliferation.

Molecular diagnostic studies are helpful in identifying oncogenes

´Clinical symptoms:

´Weight loss

´Splenomegaly

´Fever

´Night sweats

´Malaise

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82

JAK2 oncogene

´is implicated in polycythemia vera (80%), Chronic idiopathic myelofibrosis (50%) and essential thrombocytopenia (40%).

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83

BCR/ABL

oncogene is associated with chronic myelogenous leukemia

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45y/o

CML is ´Found mainly in adults ____ and older; often diagnosed secondary to other conditions.

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neutrophilic leukemoid reaction (NLR) , LAP

´CML can mimic ______ – use ___ score to differentiate.

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CML

´Laboratory Findings:

´Increase M:E ration of the BM.

´Mild anemia

´WBC between 50-100x10˄9/L

´Shift to the left (all stages of granulocyte production)

´May have few circulating blasts and immature granulocytes.

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87

Philadelphia chromosome t(9;22), Lymphocytes

CML ________ is present virtually in all patients. All cells are affected except ________

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Essential Thrombocytopenia (ET)

´Characterized by megakaryocyte proliferation.

´

Common on 60 y/o or older.

´Must be differentiated from reactive thrombocytosis and polycythemia vera.

´Laboratory findings:

´Platelets > 1000x10˄/

´Giant forms of platelets

´Platelet function abnormalities

´Leukocytosis

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reactive thrombocytosis, polycythemia vera.

Essential Thrombocytopenia (ET) Must be differentiated from ______ and -----

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Polycythemia vera

´Malignant hyperplasia of the multipotential myeloid stem cell causes increase in all cell lines (polycythemia); erythrocytes most greatly increased despite decrease EPO (inappropriate erythropoiesis).

´Increase cell content = High blood viscosity = high blood pressure, stroke and heart attack

´Found in adults 50 y/o or older.

´Increased RBC, Hgb, and Hct

´Increased leukocytes and platelets

´Normal plasma volume

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20 years

´PV is a chronic disease w/ a life expectancy after diagnosis of up to _____.

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92

´Therapeutic phlebotomy

´Splenectomy

´Chemotherapy

Polycythemia vera treatment

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93

´Secondary polycythemia

´Increase in RBC mass is an appropriate response to increased EPO or tissue hypoxia. Plasma volume, leukocyte count and platelet count are normal.

´Can be caused by smoking, emphysema, or high altitude.

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94

´Relative (pseudo) polycythemia

´Decreased plasma volume with a normal RBC mass caused by dehydration (diarrhea, diuretics, or burns).

´Increased Hgb, normal WBC and platelet count, normal EPO.

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95

Chronic idiopathic Myelofibrosis

´Myeloid stem cell disorder characterized by proliferation of erythroid, granulocytic and megakaryocytic precursors in marrow with dyspoiesis.

´Progressive marrow fibrosis.

´Found in adults 50y/o and older.

´Clinical symptoms:

´Bleeding due to abnormal platelet function

´Hepatomegaly and splenomegaly(increase hematopoiesis)

´Laboratory:

´Anisocytosis, poikilocytosis w/ tear-drop cells.

´Leukoerythroblastic anemia (immature neutrophil and NRBC in curculation)

´Abnormal morphology in all cell lines.

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Myelodysplastic Syndrome

´Group of acquired clonal disorders affecting the pluripotential stem cell (blood cytopenia despite BM hypereplasia).

´MDS development can be triggered by chemotherapy, radiation and chemicals.

´Found in adults; rarely found in children & young adults.

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97

chemotherapy, radiation and chemicals.

MDS development can be triggered by ____

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98

Refractory Anemia (RA)

´Anemia that is refractory (not responsive) to therapy.

´Laboratory:

´Oval macrocyte

´Reticulocytopenia

´Dyseryhtropoiesis

´BM blast <5% and peripheral blood blasts <1%.

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99

Chronic Myelomonocytic leukemia (CMML)

´The one MDS that usually presents with leukocytosis.

Absolute monocytosis (>1.0x10˄/L)

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100

5-20%, <5%

Chronic Myelomonocytic leukemia (CMML) ´BM blasts ___ and peripheral blood blasts _

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