HAEMATOPATHOLOGY Development of Haemopoiesis: Yolc sac, liver Bone marrow Newborn : active marrow in all bones 18 years : haemopoiesis only in central bones! (calvarium, sternum, ribs, vertebrae, prox.epiph. femur, humerus) HAEMOPOIESIS normal: fat:1 hemop:1 erythroid :1 myeloid: 3 CLASSIFICATION CLASSIFICATION OF OF ANAEMIA ANAEMIA ACCORDING ACCORDING TO TO UNDERLYING UNDERLYING MECHANISM MECHANISM I. BLOOD LOSS A. Acute: trauma B. Chronic: lesions of GI tract, gyn. disorders II. INCREASED RATE OF DESTRUCTION (HEMOLYTIC ANAEMIAS) (A. INTRINSIC ( INTRACORPUSCULAR) ABNORMALITIES OF RED CELLS hereditary 1. Red cell membrane disorders a. Disorders of membrane cytosceleton : spherocytosis, elliptocytosis b. Disorders of membrane lipid ; membrane lecithin (stomatocytosis) 2. Red cell enzime deficiencies a. Glycolytic enzymes b. Enzimes of hexose monophosphate shunt 3. Disorders of Hgb. synthesis a. Deficient globin synthesis: thalassaemia syndromes b. Structurally abnormal globin synthesis: sickle cell anaemia Aquired: Membrane defect:paroxysmal nocturnal haemoglobinuria II. HAEMOLYTIC ANAEMIAS II. B. EXTRINSIC EXTRACORPUSCULAR) ABNORMALITIES 1. Antibody mediated a. Isohaemagglutinins: tra. fo, b. Autoantitbodies: idiopathic, malignant neoplasms , mycoplasmal 2. Mechanical.trauma to red cells a. Microangiopathic: TTP,DIC, b. Cardiac prosthetic valves 3. Infections: malária 4. Chemical injury: lead poisoning 5. Hypersplenism erythroblastosis foetalis drug-associated, SLE, infection mucin producing tumors Diseases of the white blood cells Leukocytosis - causes Normal homeostasis Precursor Storage pool (mature pool Marginating pool Tissue pool Circulating pool Leukocytosis - causes Neutrofilic~ Bact.inf., (pyogenic organisms), tissue necrosis Eosinofilic ~ Allergic, autoimmune diseases, vasculitides, lymphomas (Hodgkin, non-Hodgkin) Basofilic ~ Rare, myeloproliferative diseases Monocytosis Autoimmune diseases, chronic infections (TBC, rickettsiosis, malaria, bacterial endocarditis) Lymphocytosis Accompanies monocytosis, viral infections, whooping cough Lymphadenitides Acute, non-specific Chronic, non-specific….. Follicular hyperplasia Parafollicular hyperplasia Sinus histiocytosis Neoplastic proliferations of the white cells Lymphoid neoplasms phenotypically closely resemble the particular normal stage of lymphoid differentiation Classification is based on this Myeloid neoplasms diseases of the hematopoietic cells Acute leukaemias Myelodysplastic syndromes Chronic leukaemias Histiocytoses histiocytes, and dendritic cell diseases Langerhans cell histiocytosis Diseases of the white cells - frequent chromosome aberrations Ig gene TCR Congenital gene disorders Bloom sy, Fanconi anemia, NF I, Down Viruses HTLV-1, KSHV/HHV8, EBV Other infections HP, HIV Iatrogenic factors Irradiation, chemotherapy Lymphomas, leukaemias - definition Leukaemia – bm involvement, tumor cells in the peripheral blood Lymphoma – lymphoid cell proliferation in the tissues Hodgkin – non-Hodgkin Plasma cell neoplasias BM THYMUS DN CLP Precursor Blymphoblastic lymphoma / leukaemias BLB CLL / SLL MyMu Precursor T lymphoblastic lymphoma / leukaemias DP NBC CD4 PC CD8 LYMPH NODE Mantle zone lymphoma MC FollLy Burkitt DLBL PTC GC MZ HL DLBL, MZL, SLL/CLL Peripheral T cell lymphomas Acute leukaemias BM CELLS can’t maturate Cell proliferation is not quicker than normal Normal haemopoiesis is arrested Normal blasts are suppressed LEUKAEMIAS AND MYELOPROLIFERATIVE DISORDERS Leukaemia : neoplasms of BM stem cells Types: ACUTE LYMPHOID MYELOID CHRONIC LYMPHOID MYELOID ACUTE LEUKAEMIAS Basis of disease: maturation defect of BM stem cells Cell proliferation is frequently s lo w e r than normal!!! abnormal blasts dominate the BM picture normal haemopoietic elements are blocked – this is due not only to space occupation lymphoid leukaemias belong to lymphoma/ leukaemia group CLINICAL CLINICAL APPEARANCE APPEARANCE OF OF ACUTE ACUTE LEUKAEMIAS LEUKAEMIAS Weakness Fever, infection Hemorrhage - anaemia granulocytopenia thrombocytopenia (anywhere in the body) Bone pain, tenderness - Meningeal symptoms (headache, nausea, vomit, - cerebral palsy, - subperiosteal leukaemic infiltration CNS involvement / subarachnoidal bleeding intracerebral, meningeal infiltration) Symptoms, specific to certain leukaemias AMLM3 - (promyelocytic) DIC AMLM1-2 - soft tissue,or subperiostal infiltration AML4-5 - skin, gum infiltration LABORATORY FINDINGS Anaemia WBC variable severity 50 % < 10000/mm3 20 % > 100000/mm3 Rarely : aleukaemic leukaemia Blasts both in peripheral and BM smears, HIATUS LEUKAEMICUS Thrombocyte < 100000 / mm3 Peripheral pancytopaenia : BM biopsy- RULE OUT aplastic anaemia LABORATORY FINDINGS CYTOCHEMISTRY PAS Tdt myeloperoxidase NON spec. esterase ALL + + (95 % ) - AML - (95 %) + (M1-3) + (M4-5) PROGNOSIS , THERAPY ALL - 2-10 5 year survival over 60 % CHEMOTHERAPY T cell, and adult form- grave AML - BM TRANSPLANTATION ACUTE ACUTE MYELOID MYELOID LEUKAEMIA LEUKAEMIA 20 20 %of %of childhood childhood leukaemias, leukaemias, occurrence occurrence :: 15-40y 15-40y Further Further classification classification according according to to maturation maturation arrest arrest stage stage M0 Minimally diff AML M1 Minimally diff AML M2 AML with slight maturation M3 Acute promyelocytic leukaemia 2-3 % Blasts express myeloid AB, ultrstructurally resemble myeloblasts, but MPO neg. 20 % 2-3% of blasts MPO +. Few cytoplamic granules (Auer rods), myeloblasts show minimal maturation. 30-40 % Full range of myeloid maturation. Auer rods, t(8:21) slightly better prognosis 5-10% Majority of cells are hypergranulated promyelocytes, (Auer rods),- DIC t(15:17), (PML-RARα) M4 Acute myelo-monocyte leukaemia 15-20% M2, +monoblasts, (non-spec esterase+), 16Chr abn: good pr M5aAcute monocyte leukaemia M5bAcute monocyte leukaemia 10% Monoblasts, monocytes in BM and periphery Mature monocytes in peripheral blood, organomegaly, lymphadenopathy, tissue infiltration, older age M6 Acute erythroleukaemia 5% Dysplastic erythroid precursors, megaloblastoid forms, 30% myeloblasts, most cases therapy induced M7 Acute megakaryocyte leukaemia 1% Megakaryoblasts dominate, react with GIIb/IIIa AB-s, BM reticulin elevated ACUTE ACUTE MYELOID MYELOID LEUKAEMIA LEUKAEMIA M0 Minimally diff AML 2-3 % M1 Minimally diff AML 20 % Blasts express myeloid AB, ultrstructurally resemble myeloblasts, but MPO neg. 2-3% of blasts MPO +. Few cytoplamic granules (Auer rods), myeloblasts show minimal maturation. ACUTE ACUTE MYELOID MYELOID LEUKAEMIA LEUKAEMIA M0 Minimally diff AML M1 Minimally diff AML M2 AML with slight maturation 2-3 % Blasts express myeloid AB, ultrstructurally resemble myeloblasts, but MPO neg. 20 % 2-3% of blasts MPO +. Few cytoplamic granules (Auer rods), myeloblasts show minimal maturation. 30-40 % Full range of myeloid maturation. Auer rods, t(8:21) slightly better prognosis ACUTE ACUTE MYELOID MYELOID LEUKAEMIA LEUKAEMIA M0 Minimally diff AML 2-3 % M1 Minimally diff AML 20 % M2 AML with slight maturation 30-40 % M3 Acute promyelocytic leukaemia 5-10% Blasts express myeloid AB, ultrstructurally resemble myeloblasts, but MPO neg. 2-3% of blasts MPO +. Few cytoplamic granules (Auer rods), myeloblasts show minimal maturation. Full range of myeloid maturation. Auer rods, t(8:21) slightly better prognosis Majority of cells are hypergranulated promyelocytes, (Auer rods),- DIC t(15:17), (PML-RARα) ACUTE ACUTE MYELOID MYELOID LEUKAEMIA LEUKAEMIA M0 Minimally diff AML M1 Minimally diff AML M2 AML with slight maturation M3 Acute promyelocytic leukaemia 2-3 % Blasts express myeloid AB, ultrstructurally resemble myeloblasts, but MPO neg. 20 % 2-3% of blasts MPO +. Few cytoplamic granules (Auer rods), myeloblasts show minimal maturation. 30-40 % Full range of myeloid maturation. Auer rods, t(8:21) slightly better prognosis 5-10% Majority of cells are hypergranulated promyelocytes, (Auer rods),- DIC t(15:17), (PML-RARα) M4 Acute myelo-monocyte leukaemia 15-20% M2, +monoblasts, (non-spec esterase+), 16Chr abn: good pr M5aAcute monocyte leukaemia 10% Monoblasts, monocytes in BM and periphery M5bAcute monocyte leukaemia Mature monocytes in peripheral blood, organomegaly, lymphadenopathy, tissue infiltration, older age ACUTE ACUTE MYELOID MYELOID LEUKAEMIA LEUKAEMIA M0 Minimally diff AML M1 Minimally diff AML 2-3 % 20 % M2 AML with slight maturation M3 Acute promyelocytic leukaemia 30-40 % 5-10% M4 Acute myelo-monocyte leukaemia 15-20% M5aAcute monocyte leukaemia M5bAcute monocyte leukaemia M6 Acute erythroleukaemia Blasts express myeloid AB, ultrstructurally resemble myeloblasts, but MPO neg. 2-3% of blasts MPO +. Few cytoplamic granules (Auer rods), myeloblasts show minimal maturation. Full range of myeloid maturation. Auer rods, t(8:21) slightly better prognosis Majority of cells are hypergranulated promyelocytes, (Auer rods),- DIC t(15:17), (PML-RARα) M2, +monoblasts, (non-spec esterase+), 16Chr abn: good pr 10% Monoblasts, monocytes in BM and periphery Mature monocytes in peripheral blood, organomegaly, lymphadenopathy, tissue infiltration, older age 5% Dysplastic erythroid precursors, megaloblastoid forms, 30% myeloblasts, most cases therapy induced ACUTE ACUTE MYELOID MYELOID LEUKAEMIA LEUKAEMIA M0 Minimally diff AML 2-3 % Blasts express myeloid AB, ultrstructurally resemble myeloblasts, but MPO neg. M1 Minimally diff AML 20 % 2-3% of blasts MPO +. Few cytoplamic granules (Auer rods), myeloblasts show minimal maturation. M2 AML with slight maturation 30-40 % Full range of myeloid maturation. Auer rods, t(8:21) slightly better prognosis M3 Acute promyelocytic leukaemia 5-10% Majority of cells are hypergranulated promyelocytes, (Auer rods),- DIC t(15:17), (PML-RARα) M4 Acute myelo-monocyte leukaemia 15-20% M2, +monoblasts, (non-spec esterase+), 16Chr abn: good pr M5aAcute monocyte leukaemia10% Monoblasts, monocytes in BM and periphery M5bAcute monocyte leukaemia Mature monocytes in peripheral blood, organomegaly, lymphadenopathy, tissue infiltration, older age M6 Acute erythroleukaemia 5% Dysplastic erythroid precursors, megaloblastoid forms, 30% myeloblasts, most cases therapy induced M7 Acute megakaryocyte leukaemia 1% Megakaryoblasts dominate, react with GIIb/IIIa AB-s, BM reticulin elevated V.S. Female, 75 1979 (20 years before) examination for headache, dizziness 1982 surgical ,then combined chemo/radioth for breast cancer 1999 febr.: cough, dyspnoe at rest for 3 weeks . Symptoms ameliorated after AB administration Labor.: pancytopenia, ESR , dizziness OVSZ: peripheral blastosis, Trephine biopsy: MYELODYSPLASTIC MYELODYSPLASTIC SYNDROMES SYNDROMES Myeloid stem cells can mature, but the cells are defective (ineffectiv haemopoiesis) Diseased sten cell is genetically instable, with worsening capacity of differenciation, end stage: AML in 30% Pancytopenia at periphery (clin signs are equal with those of acute leukaemia) BM hypercellular, (ring sideroblasts, megaloblastoid maturation, polypoid blasts, agranular granulocytes, hypolobulated megakaryocytes), blasts less than 20%-! Morphological subtypes : according to cells in the BM and periphery Some cases de novo, (MDS), most patients after therapy with alkilating agents, radiotherapy (tMDS) Chromosome aberrations: 5, 7 monosomy, 5q, 7q , 20q del., 8 trisomy CHRONIC MYELOPROLIFERATIVE DISEASES CML POLYCYTHAEMIA VERA MYELOID METAPLASIA WITH MYELOFIBROSIS ESSENTIAL THROMBOCYTAEMIA CML 15-20 % - leukaemias Philadelphia chromosome t(9;22)bcr-c-abl fusion gene gene product has tyrosin kinase aktivity (erythroid, megakaryocyte precursors) Disease of the pluripotent or multipotent stem cell granulocyte precursor dominates NO MATURATION ARREST, CELL PROLIFERATION IS SLOWER THAN PHYSIOLOGICAL BM: number of cells of granulocyte line are 20 fold higher than the normal! CML-Clinical signs : -slow progression -splenomegaly - frequently the first sign -weakness -loss of weight anorexia - leukocyte count > 100000 / mm3, many segments, full range of myeloid elements -thrombocytosis at the beginning in 50% of cases LACK OF GRANULOCYTE ALKALINE PHOSPHATASE diff. dg- (leukaemoid reaction) After variable period, in half of the cases a c c e l e r a t e d phase: -failure of response to treatment - increasing anaemia, thrombocytopenia BLAST CRISIS 70 % AML 30 % ALL (in half of the cases, blast crisis occurs without accelerated phase ) CHEMOTHERAPY not sufficient in chronic phase: BONE MARROW TRANSPLANTATION POLYCYTHAEMIA POLYCYTHAEMIA VERA VERA Both (erythroid, megakaryoid, myeloid) cell lines involved, but ERYTHROID CELLS DOMINATE RBC count high, ( erythropoietin unmeasurable) Morphological changes: Blood volume and viscosity - extremely high Plethora and congestion in all organs! Hepatosplenomegaly, myeloid metaplasia Leading symptoms: THROMBOSIS, INFARCTION! Haemorrhage in 30% due to blood vessel distension, abnormal thrombocyte function BM: - hypercellular, with full range of cells of all three cell lines deposition of reticulin , than fibrosis, increased blasts Laboratory findings: - RBC: 6-10 mill. / mm3 - WBC: 80000 / mm3 (granulocyte alk.phosph. -diff.dg.CML!) - thr.: > 500000 /mm3 (funct. morph. abnormalities) Clinical: - dizziness, headaches - GI bleedings , + ulcers ( basophilia, histamin level ) - pruritus ( basophilia, histamine level ) - abdominal pain, splenic, renal infarctions! - hyperuricaemia , gout Death: thrombotic sequales Therapy: PHLEBOTOMY (chemotherapy, BM irradiation-sequales!) Sequales - myelofibrosis with myeloid metaplasia AML ( 2 %, with phlebotomy only) AML (15%, after chemo, radiotherapy!) MYELOID MYELOID METAPLASIA METAPLASIA WITH WITH MYELOFIBROSIS MYELOFIBROSIS BM: fibroblasts, fibrosis, Spleen: neoplastic stem cells proliferate - sometimes burnt out polycythaemia vera, or CML -more frequently primary (agnogenic , idiopathic ) BM FIBROBLASTS DON’T BELONG TO THE NEOPLASTIC CLONE (neoplastic thrombocytes, megakaryocytes produce PDGF, TGFb) Tumor cells first proliferate in BM, than „move” to spleen, liver Morphology: -splenomegaly , extramedullary hemopoiesis, with all three cell lines - hepatomegaly – due to hemopoiesis -lymph nodes – hemopoiesis might occur - BM- hypercellular first , (clinically inapparent) fibrosis in central bones, hemopoiesis in small bones of the limbs Laboratory findings: - anaemia (normochromic, normocytic, teardrop-shape, numerous normoblasts) -WBC count: high or low full range of maturation, basophilia - platelet count: high, many abnormal forms Signs: haemorrhage, thrombosis, infarction, infection Diff.dg: - CML ( alk. phosph., Philadelphia chr. ) - myelophtisis-anamnestic data Therapy transfusion Prognosis: relatively good 5-10 % - AML Essential thrombocytaemia Diagnosis of exclusion! Platelet count at periphery 600.000! BM: mild hypercellularity, many atypical megakaryoblasts, other blasts appear norm. NO marked fibrosis Perif: atypical, large megakaryocytes, mild leukocytosis Clin: haemorrhage, thrombosis, overall survival: 12-15 y REAL REAL classification classification of of Lymphoid Lymphoid neoplasms neoplasms (Revised (Revised European-American European-American Classification Classification of of Lymphoid Lymphoid Neoplasms) Neoplasms) I. Precursor B- cell lymphoma group ( Precursor B lymphoblastic leukaemia/ lymphoma ) III. Peripheral B cell lymphomas Chronic lymphoid leukaemia, / Small lymphocytic lymphoma Lymphoplasmocytic lymphoma Mantle cell lymphoma Follicular lymphoma Cyt. Grade I.,II.III Marginal zone lymphoma Hairy cell leukaemia Plasmocytoma, / plasma cell myeloma Diffuse large B cell lymphoma Burkitt lymphoma REAL classification of Lymphoid neoplasms (Revised European-American Classification of Lymphoid Neoplasms) II. Precursor T- cell lymphoma group ( Precursor T lymphoblastic leukaemia/ lymphoma ) IV. Peripherial Tcelllymphomas T cell chronic leukaemia Large, granular cell lymphoid leukaemia Mycosis fungoides-Sézary syndrome Periferal T cell lymphoma Angioimmunoblastic T cell lymphoma Intestinal T cell lymphoma Adult T cell leukaemia / lymphoma Large cell, anaplastic lymphoma ACUTE LYMPHOID LEUKAEMIA I. Precursor B- cell lymphoma group ( Precursor B lymphoblastic leukaemia/ lymphoma ) I. Precursor T- cell lymphoma group ( Precursor T lymphoblastic leukaemia/ lymphoma Most frequent childhood leukaemia Classification:based on morphological, surface immunglobulins (flow cytometry) Maturation, prognosis correlates with spec. chromosomal aberrations Hyperdiploidy, (t12:21), (-early precursor, - age: 2-10,-good prognosis Pseudodiploidy (t9;22)(t4;11)-early B-worse prognosis Special characteristics: hepato-splenomegaly, lymph node enlargement, BM failure, testicular, CNS involvement! T T cell cell ALL ALL -- Precursor Precursor TT- cell cell lymphoma lymphoma group group (( Precursor Precursor T T lymphoblastic lymphoblastic leukaemia/ leukaemia/ lymphoma lymphoma )) -- thymus enlargement, liver, spleen , BM - involvement mikr. „starry sky” adolescents, young adults CLL, small lymphocytic lymphoma „Mildest ” leukaemia 5.6.decade males: 2 females:1 95% B cell , equal with chronic lymphoid leukaemia Neoplastic B cells: - surface immunglobulins (IgM, IgD) monoclonal - Tdt , CD10 negative - CD5, CD19, CD20 positive - long life time, no diff to plasma cell, - few proliferating cells lymphoid infiltrate BM, blood, lymph nodes Chromosomal Chromosomal abnormalities: abnormalities: 12 12 trisomy, trisomy, 14. 14. or or 11 11 chr. chr. abnormalities, abnormalities, needs needs treatment treatment worse worse progn. progn. Other: Other: hypogammaglobulinaemia, hypogammaglobulinaemia, but but AUTOANTIBODIES AUTOANTIBODIES ,, HAEMOLYSIS! HAEMOLYSIS! No No blastic blastic crisis, crisis, but but Richter Richter syndrome syndrome can can occur! occur! Stage A B C Characteristics less, then 3 lymphoid regions involved, lymphocytosis, anaemia, thrombocytopenia, more, than 3 regions involved anaemia, thr.cytopenia, any regions can be involved Overall survival 10 years 5 years 2 years Aplastic anaemia Aquired Idiopathic Primary stem cell defect Immune mediated Chemical egents Dose related Alkilating agents Antimetabolites Benzene Chloramphenicol Inorganic arsenicals Idiosyncratic Chloramphenicol Phenylbutazone Organic arsenicals Idiosyncrratic contd. Methylphenylethylhydantoin Streptomycin Chlorpromazine Insecticides Physical agents (irradiation) Viral infections Viral hepatitis CMV Epstein-Barr Herpes-Varicella-Zooster Miscellaneous Other drugs and chemicals Inherited Fanconi anaemia Aplastic anaemia