5. DEFINE…
Leukemia is defined as:
A. Benign disease of hematopoietic tissue
characterized by replacement of abnormal bone
marrow elements with normal cells
B. Benign disease of hematopoietic tissue
characterized by replacement of normal bone
marrow elements with abnormal cells
C. Malignant disease of hematopoietic tissue
characterized by replacement of abnormal bone
marrow elements with normal cells
D. Malignant disease of hematopoietic tissue
characterized by replacement of normal bone
marrow elements with abnormal cells
6.
7.
8.
9.
10. TRUE or FALSE
Leukemic cells look different than normal
cells and do not function properly.
16. Acute vs Chronic Leukemia
Acute Chronic
Age Children & young Middle age and
adults elderly
Onset Sudden insidious
Duration weeks to months years
WBC count Variable High
17. Acute vs Chronic Leukemia
Acute Chronic
Platelets Low Early: Normal/ High
Late: Low
Anemia High (>90%) None/ mild
Predomi- Blast cells Mature cells
nant cells
AML = myeloblast CML=granulocytes
ALL= lymphoblast CLL=lymphocytes
43. FAB vs WHO Classification
French-American-British (FAB) Cx
Cellular morphology and cytochemical stain
Acute leukemia as > 30% bone marrow blasts
Widely used
World Health Organization Cx
Cellular morphology and cytochemical stain
Immunologic probes of cell markers, cytogenetics,
molecular abnormalities & clinical syndrome
Acute leukemia as > 20% bone marrow blasts
Standard for diagnosis
45. AML classification - WHO
AML not otherwise categorized
1. AML minimally differentiated
2. AML without maturation
3. AML with maturation
4. Acute myelomonocytic leukemia
5. Acute monocytic leukemia
6. Acute erythroid leukemia
7. Acute megakaryocytic leukemia
8. Acute basophilic leukemia
9. Acute panmyelosis with myelofibrosis
55. Which FAB classification shows 3% (+) MPO,
SBB, shows <20% (+) with nonspecific
esterase and contains primarily myelobalst
with distinct nucleoli?
A. M1
B. M2
C. M3
D. M4
56. M2 AML with maturation
Common type
>30% myeloblasts
>10% granulocyte
Kidney shape nucleus
Nucleoli (+)
(+) Auer rods
Eosinophilic granules
>50% MPO, SBB (+)
CD 13, 33
59. Promyelocyte constitute 10% of acute leukemia
with >50% of leukemic cells positive for
peroxidase and Sudan black B. What is the
FAB classification?
A. M1
B. M2
C. M3
D. M4
60. M3 (hypergranular promyelocytic)
Promyelocyte-predominant
Large, kidney shape
(+) Auer rods (faggot cells)
basophilic, bilobed nuclei
CD 13,33
High incidence of DIC
62. M4 Acute myelomonocytic
>30% myeloblast (FAB)
>20% granulocyte
>20% promonocytes and
monocytes
CD 11, 13, 33,14
(+) Auer rods common
High serum lysozyme level
M4Eo = w/ eosinophilia
63. The serum lysozyme level was greatly
increased in this patient. Cells are positive
for CD11 and CD14 by flow cytometry.
Which disease is most likely?
A. Acute myeloblastic leukemia
B. Promyelocytic leukemia
C. Myelomonocytic leukemia
D. Undifferentiated leukemia
64. M5: acute monocytic leukemia
1. M5a – without maturation
Monoblasts , few promonocytes
1. M5b – with maturation
Blast, Promonocytes (BM), Monocytes (Blood)
65.
66. M5a
Monoblast ameboid with
round to oval nuclei,
prominent nucleoli,
<20% promonocytes/mono
Vacuolated cytoplasm
73. M7 – acute megakaryoblastic
>30% megakaryoblasts
platelet like granules on
PAS stain
NSE (but not BE) (+)
Myeloid blasts may
show SBB or MPO (+)
CD 41,42,61
81. Leukemoid CML
reaction
WBC High High
Anemia (-) (+)
PBS Shift to the Left Shift to the left (blast)
Toxic granulation Eosinophilia,
Dohle bodies basophilia
LAP score High Low
Philadelphia (-) (+)
chromosome
82. Chromosomal Leukemia
Abnormality
t(9;22) - Philadelphia CML
chromosome
83. What is the M:E ratio in patients with chronic
myelogenous leukemia?
A. 1:5
B. 1:10
C. 10:1
D. 3:1
84. What is the most common chromosomal
abnormality found in chronic myelogenous
leukemia?
A. t(8;14)
B. t(9:22)
C. t(1;12)
D. Trisomy 12
85. Polycythemia Vera
Malignant hyperplasia of myeloid stem cell
Increase erythrocytes
High blood viscosity (BP)
Secondary polycythemia- High RBC (high EPO)
Normal: Plasma volume, WBC, Platelet ormal
Relative (pseudo) polycythemia
High Hgb
Normal EPO,RBC mass, WBC, platelet
88. A peripheral blood stained smear showed 5%
blasts, anemia, poikilocytosis and nucleated
RBC. What condition should be suspected?
A. Chronic myelogenous leukemia
B. Acute myelogenous leukemia
C. Thalassemia major
D. myelofibrosis
104. Acute Lymphocytic Leukemia
French-American-British (FAB)
Classification
L1 ALL, child
L2 ALL, adult
L3 ALL, (Burkitt)
105. WHO classification- Cytogenetics
Leukemia Chromosomal
Abnormality
ALL-pre B t(1;19)
ALL-T t(11;14)
ALL-Burkitt’s lymphoma t(8;14), t(2;8), t(8;22)
106. Immunophenotyping
Types FAB TdT Tc Ag Bc Ag
Precursor B L1,L2 +, - - +
Precursor T L1,L2 +, + + -
B-cell L3 -,- - +
107.
108. Acute Lymphocytic Leukemia
FAB Class L1
small , uniform cells
scanty cytoplasm
absent nucleoli
70% c-ALL
20% T-ALL
rarely B-ALL or null-ALL
TdT (+)
PAS (+)
109. Acute Lymphocytic Leukemia
FAB Class L2
Large, heterogenous
basophilic cytoplasm
Nucleoli present
50% c-ALL
30% T-ALL
TdT (+)
PAS (+)
110. Acute Lymphocytic Leukemia
FAB Class L3 (Burkitt’s)
large varied cells
deeply basophilic
vacuolated cytoplasm
Nucleoli (+)
Usually B-ALL
TdT (-)
PAS (+)
111. Which of the following stain/reaction show a
positive result in most patient with acute
lymphocytic leukemia?
A. Sudan black and peroxidase
B. Chloroacetate esterase
C. Non specific esterase
D. Terminal deoxynucleotidyl transferase
112. The leukemia commonly associated with
pediatric age group is:
A. Acute myeloblastic leukemia
B. Acute lymphoblastic leukemia
C. Chronic lymphoblastic leukemia
D. Chronic myelocytic leukemia
126. Waldenstrom’s
macroglobulinemia
malignancy involving excess B-lymphocytes
that secrete immunoglobulins
Excessive IgM (viscous)
No bone tumor
Lyphadenopathy, hepatosplenomegaly
M spike in gamma globulin region
138. Cytochemical stain
1. Myeloperoxidase (MPO) stain
(+) AML (granulocyte, monocyte, Auer rods)
(-) ALL
1. Sudan Black B ( phospholipids, proteins)
(+) AML (granulocyte, monocyte, Auer rods)
(-) ALL
139. Cytochemical stain
3. Esterases
Specific esterase stain (napthol AS-D
chloroacetate esterase stain) = granulocyte
(+) FAB M1, M2, M3, M4
(-) FAB M5
Non specific esterase stain (alpha napthyl
acetate and alpha napthyl butyrate) = monocyte
(+) FAB M5
(-) FAB M1, M2, M3, M4
140. Cytochemical stain
4. Periodic Acid Schiff (PAS)
(+) ALL
(+) FAB M6 (erythrolekemia)
5. Leukocyte Alkaline Phosphatase (LAP)
Low LAP score = CML
High LAP score = NLR
Normal LAP score= Hodgkin
141. Cytochemical stain
6. Tartrate Resistant acid Phosphatase (TRAP)
(+) hairy cell leukemia
7. Perl’s Prussian Blue stain
(+) Siderocytes with iron inclusions
(siderocytic granules/pappenheimer bodies)
(+) HA, beta thallasemia major, sideroblastic Anemia
(+) Sideroblasts = nRBC with iron granules
Ringed sideroblasts= iron encircle nucleus
(+) MDS (Refractory anemia, RARS, sideroblastic
anemia)
142. A positive non specific esterase stain indicates
differentiation into which cell type?
A. Monocytic
B. Lymphoid
C. Megakaryocytic
D. Plasmacytoid
143. Which cytochemical stain is used to detect
acute myelogenous leukemia M7?
A. Terminal deoxynucleotidyl transferase (TdT)
B. Myeloperoxidase (MPO)
C. platelet peroxidase
D. Sudan black b (SBB)
144. 2. Immunophenotyping
Principle: Highly specific Ags on cell
surfaces are detected by monoclonal Abs
tagged with fluorescein and the complex are
determined by flow cellcytometry
Examination of the proteins on cell surfaces
and the antibodies
145. Immunophenotyping
Types FAB TdT Tc Ag Bc Ag
c Ag s Ag
Precursor L1,L2 +, - - + -/+ -
B
Precursor T L1,L2 +, + + - - -
B-cell L3 -,- - + + -/+
TdT = Terminal deoxynucleotidyl transferase
CAg= common Ag
Sag= surface antigen
146. CD markers
B cell= C19, CD20
T cell = CD2, CD3, CD5
Myeloid= CD13, CD14, CD33
148. 4. CYTOGENETICS
test to look for certain changes of the
chromosomes (genetic material) of the
lymphocytes
Chromosomal analysis
t(9;22) = Ph1 CML
t(15;17) = M3
149. CYTOGENETICS
1. Culture malignant hematopoietic tissue to
obtain dividing cells in the metaphase stage
where the mitotic process is stopped
2. Cells are fixed
3. Cells are dropped into microscope slide
where chromosome fall in a random pattern
4. Stained with giemsa or quinicrine
5. Chromosome banding (G band or Q band)
150. Cytogenetics
Metaphase after G-
banding in a c-ALL with
t(9;22) so called
Philadelphia
translocation
151. 5. Fluorescence in situ
hybridization
cyto smears of bone marrow or peripheral blood
metaphases and interphase nuclei
fixation 2 h time for hybridization
APL detecting PML-RARA fusion signals in interphase-FISH
interphase FISH (IP-FISH), whole chromosome painting (WCP-) FISH, 24-
color FISH or comparative genomic hybridization (CGH)
Hybridize overnight
interphase FISH (IP-FISH), whole chromosome painting (WCP-) FISH, 24-
color FISH or comparative genomic hybridization (CGH)
152. Metaphase before and after analysis by 24-color FISH in a case
with AML and complex aberrant karyotype
153. 5. Molecular Mtd- PCR
Ficoll Hypaque density gradient centrifugation
for DNA or RNA preparation
sequencing or even gene expression profiling