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Leukemia -

:




: : :
:
leukemia

source

19 2012








,,





J

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Leukemia -

Hematological malignancy
,, Hematological malignancies
Malignancy in general
under stress
Hematological malignancy ,,

hematology Oncology

malignancy
Malignancy ,, clinical
written
Oriented Hematological malignancy
leukemia lymphoma
,,
:
,, ,,
,,
!!! ,, ,,

,,
:
:
,, ,,
,, ,, ,,


,,
,, ,,

,, ,,

) ,, ,,

,, ,,
,,

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Leukemia -

,,
,,,
,, ,,
,, (
,,
Malignancy
,, ,, malignancy : uncontrolled cell division
,, control

,, replication
,,
Organ

maturation of the cell

,,

,,
,, ,, Under division
immature cell

,, ,,
Non functioning cell

,,
Malignancy ,, Uncontrolled cell division
,, division

Maturation

,,
,, malignant cell
,, Is an immature cell Non functioning cell
,,

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Leukemia -

,, Hematological malignancy
Leukemia

Leukemia

Leukemia Malignant transformation WBCs colonies

WBCs
,,
Leukemia

acute leukemia
chronic leukemia
,,

,,
Acute leukemia & chronic leukemia
acute leukemia
% 97 leukemia ,, acute
leukemia acute

,,
% 3 chronic
chronic leukemia
,,
acute
,,
acute common :
lymphatic ,,
Lymphatic colonies acute lymphoblastic leukemia
acute lymphocytic leukemia ,,

,,

acute lymphoblastic leukemia

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Leukemia -

,, acute non lymphoblastic Myeloid

acute myeloid leukemia
:

Acute lymphoblastic leukemia

Acute myeloid leukemia

,,
acute lymphoblastic leukemia
% 80 % 80 ) acute ( Leukemia
% 80 acute leukemia acute lymphoblastic
acute myeloid
% 20 ) acute leukemia leukemia ,, In
( general

,,
,, prognosis acute
chronic
acute
,, acute cure rate

% 80
,,

acute type ,, Most common

,, acute lymphoblastic myeloid
Prognosis
acute lymphoblastic Prognosis
acute myeloid
,,
acute lymphoblastic Most common
,,
classification Leukemia
:

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Leukemia -

Chronic
Acute
acute :
Acute lymphoblastic
Acute myeloid

,, Prognosis
acute lymphoblastic leukemia

,,
,,
leukemia
,,

,,

written
,,

malignancy

: ,, ,, malignancy
malignancy
,,
,, leukemia
Malignancy
etiology ,, Unknown

,, ,,
malignancy
hematological
malignancy ,, the exact etiology is unknown
,,
interaction factor
Malignancy
factors Malignancy
factors Malignancy

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Leukemia -

factors
Malignancy

.1 ,, ,,
environmental factors

,, bronchogenic carcinoma
environmental factors
,, ,,
Incidence of cancer

,, smoking active Passive smoking

,,

,, ,, fibers

Incidence of cancer
cancer skin
,, environmental factors

,,
,,
leukemia ,, environmental factor
environmental factor Leukemia

) (
,,

,, mask

:

,,
acute myeloid leukemia
leukemia

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Leukemia -

,,
,,

,,
,,

,,
,, ,,

,,
,, start walking

,, ,,


Leukemia
) ,,
,, (
,,



,,
,,

acute leukemia
,, acute myeloid leukemia Prognosis is so bad

,, environmental factor
,, virus infections triggering factor
Leukemia Lymphoma
Epstein Bar virus
Epstein Bar virus nasopharyngeal carcinoma

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Leukemia -

Burkitt lymphoma African type

whatever
,, environmental factors viral infections

environmental factors
.2 ,,
Immune system
immunity
Immunity malignancy
,,

Malignant cell
,, tissue macrophages


Out of control

tissue macrophages attack

,,
Immune system Malignant cell

,,
,, Immune
deficiency ,,, what ever Immune deficiency
Incidence of malignancy
,,,
,,, ,,, HIV Immune deficiency

Immune deficiency ,, Liable
Malignancy

immune system Protective mechanism

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Leukemia -

malignant transformation malignant cell

.3 genetic susceptibility
genetic factors

,,
genetic factors

,, malignancy common identical
twins

,, lymphoma Identical twin
Lymphoma Identical twin
20 Normal population

,, leukemia

,,
Down syndrome
Leukemia 20

chromosomal abnormalities
susceptibility malignancy
Leukemia

,,
exact etiology of malignancy
Is unknown

,,
malignancy Interaction : three factors
.1 environmental factors ,, whatever
.2 Immune deficiency ,,
.3 ,, genetic susceptibility
,,
clinically Leukemia
clinical manifestations of leukemia
clinically

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Leukemia -

clinical manifestations
malignant transformation
bone marrow
,, femur
Marrow cavity
marrow
:
RBCs mother cells
megakaryocytes platelets
mothers cells WBCs ,, whatever Lymphatic myeloid
,,
Malignancy leukemia colony
WBCs
Malignancy ,, Uncontrolled cell division

,,
:
still under division Immature cells

Malignant transformation colony WBCS

,, lymphatic myeloid
whatever ,,
,, total count
,,
,, ,, Immature cells
WBCs
immature cells
WBCs
Infection
,,
leukemia

repeated infections

11

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Leukemia -

,,


,, otitis media


:
,,
,,

,,
,,

History of repeated infection

WBCs immature
Organism manifestations
,,
WBCs Marrow cavity
,, marrow cavity
space Marrow cavity

,,
Megakaryocytes RBCs

,, megakaryocytes
,, Marrow Megakaryocytes
It is a giant cell

,, replication
Platelets

,, megakaryocytic function

12

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Leukemia -

,,
Megakaryocytes
platelets
Platelet count
,, platelet count
petechiae Purpura ecchymosis
,,
:
: stretch ,, skin ,,
bleeding under the skin
,,
Organomegaly Lymphadenopathy

Immune thrombocytopenic purpura
ITP
,,
Hematology
: ITP
in a good general condition
,, in a good general condition
,,
,, pallor
organomegaly
source of infection
Generally ,,
,,
,, Otitis media
,,
pyelonephritis

ITP ,, generally

13

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Leukemia -

leukemia ,, aprexia Loss of weight

feverish all the time
,, ITP

general condition it is so bad ,,

:
ITP ,, bone marrow is mandatory
: bone marrow is mandatory
ITP
early stage of leukemia
,,
Purpuric eruption ,,
bone marrow
,, RBCs production
RBCs production
pallor
Manifestations of anemia
purpura ,, Purpura pallor

,,
Marrow is so crowded ,,

marrow distention
distended
distended periosteum of the bone
) tension traction (
Periosteum of the bone

traction periosteum of the bone

,,
generalized bone aches
:
:

14

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Leukemia -

: ,,

,,
,,
,,
,, sternum
Whatever

touching baby
baby will cry

generalized bone ache
generalized bone ache
mild distention of the bone marrow
distention of the malignant cells
distention
Periosteum
,, pain
Still , the malignant cells inside the marrow cavity

,,
,,
malignant cells
blood stream
blood stream
dissemination Organ Malignant cells
Can be implanted in any site

Liver spleen
,,
,,, Hepatomegaly splenomegaly
Liver spleen
lymph nodes
generalized lymphadenopathy

,,.

15

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Leukemia -

,,,



:
projectile vomiting ,, Not proceeded by nausea
manifestations of increased intra cranial tension
neurological deficits
facial palsy
iridocyclitis
,,, just iridiocyclitis
eye ,, Part of the brain
dissemination brain
manifestations of cerebellar ataxia
convulsions
whatever ,, malignant cell brain

,,
manifestations of increased intra cranial pressure
neurological insult CNS

,,
Malignant cells genitourinary system
Males

: ,,
one testicle
,,
enlarged testis
sonar

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Leukemia -

: Infiltration testis abnormal cells

biopsy malignant cells
testicular infiltration

skin rash
skin rash
Itchy
,,
,,
biopsy ,,, Infiltrated blast cells
Leukemia

,,
: Malignant cells
kidney

:

Hematuria
sonar Kidney
biopsy Kidney ,, Infiltrated blast cells leukemia
systemic dissemination

,,

,, ,,
malignancy Oncology
oncology
,,
malignancy
malignancy
advanced stage
CNS
pallor Purpura hepatosplenomegaly Lymphadenopathy

17

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Leukemia -

Leukemia
It is advanced stage of leukemia

Prognosis so bad
in a late presentation

repeated infections
purpuric eruption
hematology

,,
cure rate Purpura
,,
pallor
lymphadenopathy splenomegaly
cure rate % 95
dissemination
disease
,,

Purpura ,, You must exclude leukemia
Message
,,

,, Purpura bone marrow to exclude
leukemia

:

,, Lymphocytic
lymphocytic ,, ,,
Lymphoblastic
:
Liver Lymph nodes

18

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Leukemia -

,,
,,
bone marrow Liver spleen
lymph node
,,
CNS
CNS
,,
CNS
Liver spleen

lymph adenopathy
Organomegaly
,,
Liver spleen

,,
,,

,, clinical manifestations of leukemia

,,,
Leukemia

: ,, leukemia
,, ,, : leukemia



:
) CBC ( complete blood count
CBC
,, CBC RBCs platelets

19

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Leukemia -

CBC
Malignant cells in the peripheral blood
blast cells

,, blast cells Peripheral blood

professional
,, blast cells diagnostic for acute leukemia

,,
,, blast cells Peripheral blood

:
bone marrow
,, blast cells leukemia
bone marrow aspirate
bone marrow aspirate

,,
bone marrow ,,
tibia
tibial tubersity two fingers breadth
chin of the tibia
Marrow cavity
,,
,, iliac crest
,,
sternal
Whatever

bone marrow aspirate

bone marrow aspirate

,, diagnostic
:
,,, Leukemia
diagnostic
Prognostic ,,

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Leukemia -

prognostic
,,
hematology
,, bone marrow
slide direct
blast cells
) FAB classification ( French American British classification

Lymphatic myeloid ,, chronic leukemia

,,
: classification
lymphatic L1 L2 L3
myeloid ,, M1 M7
clinical pathology
,,
prognostic factor
lymphatic : L1
L3 :

Prognosis
Prognostic value
,,
,, slide histopathological classification
,,
,,

cytogenetics
cytogenetics malignant cells cluster
of differentiation
CD marker

CD marker
,,
,, Oncology

,,

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Leukemia -

cluster of differentiation CD marker

CD marker
Malignant cells ,,

professional
: ,, Lymphatic Myeloid
lymphatic B cells T cells

Newborn
,, genitalia
genitalia
:
: ,, ambiguous genitalia
genitalia

Karyotyping

XY XX

,,
B cells T cells
B maturation ,, T maturation

CD marker
CD marker :
B cells T cells
B Mature ,,

22

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Leukemia -

immune phenotyping ,,
bone marrow

Peripheral blood ,, malignant cells

peripheral blood
,,
bone marrow
Immune phenotyping :
Prognosis
of chemotherapy

,,
:

bone marrow
bone marrow slide
clinical pathology
cytogenetics Immune
phenotyping

24 ,, Protocol of
chemotherapy
24
,,

work up
work up
work up
lumbar puncture
Lumbar puncture
,,

23

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Leukemia -

CNS infiltration CNS infiltration

,,
,, lumbar puncture
symptoms

lumbar puncture CNS

,,
chest X - ray
lung infiltrate
mediastinum lymph nodes Infiltration
Mediastinum lymph nodes

abdominal sonar
abdominal sonar : Liver spleen
kidney
para aortic lymph nodes Porta hepatis

,,

: ,, Liver function renal function
electrolytes
assessment
,, Uric acid
Uric acid
Malignant cells Organ

Uric acid
base line of uric acid

chemotherapy
,, malignant cells
chemotherapy

,, chemotherapy
uric acid
,, uric acid nephropathy

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Leukemia -

base line of uric acid
tumor lysis syndrome
,,
,,
occular manifestations

skin skin biopsy
Whatever
,, Testicular biopsy testis

,,
,, work up


,, ,,


: ,,, prognostic factors leukemia
,,
,,
system
conference decision making
,,
Personal decision making
,,
:
,,
data ,, staff
Oncology

comment
which protocol of chemotherapy

,,

,,,

25

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Leukemia -

risk factors
,,
:
: ,
It is a good prognosis

,,
category of bad prognosis
,,
Male female
male :

score prognostic factor
male bad prognosis

,,
female ,, is a good prognosis

androgens ,,, One of the factors malignant cells

male Prognosis
,,
: ,, initial presentation
clinically
: , CNS manifestations
,, Headache ,, projectile vomiting ,,
,, Lumbar puncture blast cells CSF
CNS infiltration
bad prognosis
testis ,, enlarged
,, : Infiltration testis
biopsy

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Leukemia -

bad prognosis
chest X - ray
chest X -ray
bad prognosis

,, mediastinum lymph nodes

,, T cell type
T cell leukemia ,, is very aggressive type of leukemia
,,
,, CNS ,, mediastinal testicular
Prognosis so bad
,,
clinical data
,,
: Lab
: , ,, CBC bone marrow
: bone marrow
Histopathological classification
FAB
,, Lymphoblastic ,, myeloid chronic
,, lymphoblastic
,, myeloid
,, chronic

Prognosis

,,
,, lymphoblastic ,,
Lymphoblastic pathology : L1 L2 L
3
,, L3 : bad prognosis
,, Prognosis
,, bone marrow
,, Immune phenotyping

27

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Leukemia -

T B cells

,, mature cells Prognosis

,,
,,, ,,

CBC
thrombocytopenia
,,
,, thrombocytopenia prognosis

,, WBCs count
50,000 ,, WBCs
,, malignant cells blast cells
20,000 bad prognosis

count
,, blast cells 20,000 bad prognosis
,,
,,

,, at time of presentation
prognosis ,, is so bad
,,
,, anemia prognosis

malignant cells ,, spreading
spreading
Of spreading
,, ,,
,, ,, splitting of the cells
,,
,,
,,


,, ,, ,,

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Leukemia -

,,

at time of presentation RBCs count
malignant cells bone marrow
RBCs

,, rapid dissemination
Malignant cells ,, is mature cell
facilities ,,
Prognosis ,,, is so bad

,,

treatment
Treatment

,,,
protocol of chemotherapy
,,
Oncology
,,

Otherwise


Otherwise nothing ,,

general rules treatment
support
,,
) : ,,
hematology
,, ) Oncology

29

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Leukemia -

( ,,
,, ,,
,,

: ,,

:
,,



supportive care
,, supportive care general condition

Infection
You must treat Infection chemotherapy
,,
,, chemotherapy
dissemination of infection
,,

:
,, packed RBCs

,,
,,
,, 80,000
chemotherapy
packed RBCs ,,
Antibiotics
eradication of infection

,,
Nutritional state

30

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Leukemia -

,, ,, ,, generally

general support
general support care

24 ,,

,,
,,
) Intra vneous fluids ( IV fluids
bicarbonates ) allopurinol (

alkalinization of urine

,, chemotherapy Uric
acid
uric acid nephropathy

alkalinization of urine
allopurinol
chemotherapy

chemotherapy
malignant cells
,, induction therapy
malignant cells
,,
,, :
,,
,,
chemotherapy ,,
chemotherapy ,,
,,

,, generally

31

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Leukemia -

Is a good sign
responding to treatment

,,
,,

chemotherapy
,, Induction therapy
,, Induction phase whatever
,, infection
,, infection support antibiotics

,,
induction therapy
,, Induction therapy

resting phase

,, ,,
: CBC
WBCs Normal
Normal
Normal
bone marrow recovery
blast cells


,,
,,
,, chemotherapy
chemotherapy malignant cells bone marrow
malignant cells
CNS

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Leukemia -

chemotherapeutic drugs
water soluble CNS
,,
CNS
chemotherapy Lumbar puncture
needle

needle

) ( chemotherapy
CSF
5 chemotherapy
chemotherapy CNS

,, prophylaxis

,,
cranial irradiation
Malignant cells brain
testicular infiltrate
testicular irradiation
testis chemotherapy

,, malignant cells
Whatever Of chemotherapy

,,

leukemia "
"
Leukemia

33

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Leukemia -

Leukemia

Leukemia





JJJ

leucocyte

myeloid line
lymphoid line
myeloid line
myeloid stem cells
Myeloid stem cells )
( Myeloid line
myeloblast
promyelocyte
myelocyte
metamyelocyte
neutrophils

blast
) bone marrow
blast (
promyelocyte , myelocyte and metamyelocyte
more developed

mature neutrophils

34

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Leukemia -

lymphoid line
lymphoid stem cells
lymphoblast
prelymphocyte
lymphocyte
.... lecocytosis

Mature neutrophils
Mature lymphocyte
leukaemia
leukaemia proliferation Immature stages of WBCs
Myeloid line myeoblast

Acute myeloid leukaemia
lymphoid line neoplasm lymphoblast
Acute lymphoblastic leukaemia

leukaemia pre-lymphocyte chronic lymphocytic

leukaemia

leukaemia promyelocyte metamyelocyte

chronic myeloid leukaemia
acute
blasts proliferation mainly
chronic mature blasts

blasts
aggressive blasts

35

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Leukemia -

proliferation lymphoblast Myeloblast

bone marrow Infiltration bone marrow
failure
myeloblast
Acute myeloblastic leukaemia blasts
bone marrow
neutrophils neutrophils
blasts RBCs platelets
neutropenia neutrophils
anaemia , thrombocytopenia
bone marrow blasts peripheral blood blasts
Acute myeloid leukaemia acute myeloblastic leukaemia
Acute lymphoblastic leukaemia
lymphoblast bone marrow bone
marrow lymphocyte mature
lymphoblast RBCs platelets
early bone marrow failure

acute leukaemia

bone marrow failure

blasts proliferation

bone marrow normal WBCs

RBCs
platelets
chronic leukaemia

bone marrow failure late
chronic more or less

bone marrow failure
so late

leucocytes behavior
leucocytes proliferation bone marrow

36

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Leukemia -

platelets
RBCs
mature WBCs
thrombocytopenic
anaemic
Infection mature WBCs
WBCs RBCs
WBCs Tissue invasion
circulation bone lung
Liver spleen lymph nodes skin
organs Infiltrated WBCs
disturbances
functions

Leukaemia mortality
Anaemia infection hemorrhage Inflitration
vital organs
bone marrow failure
Acute chronic
immature WBCs normally % 3
Immature WBCs
Immature promyelocyte blasts
blast bone marrow
shift to the left
Leucocytosis Immature WBCs

bone marrow
bone marrow

: WBCs

bone marrow


leucocytosis
WBCs Immature

37

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Leukemia -

bone marrow
WBCs
infection, bleeding and hemolysis
bleeding hemolysis
RBCs
bone marrow proliferate
.... platelets
..... WBCs
bone marrow emergency
Infection emergency bone marrow
Infection RBCs
WBCs platelets
RBCs Infection
Infection cytokines
bone marrow RBCs

hemolysis
hemolysis leucocytes platelets RBCs
bone marrow proliferation
hemolysis hemorrhage
shift to the left
shift to the left
WBCs
Immature

Immature WBCs
staff
staph aureus
staff s , t , a, double f J
staff cell staff cells immature neutrophils
staff .......immature neutrophils

38

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Leukemia -

shift to the left

bone marrow ...

leucocytosis with shift to the left

shift to the right

shift to the right

folic acid and B12 deficiency shift to the right

leucocytosis
Leucopenia
neutrophils hyper segmented
B12 and folic acid deficiency
shift to the right

leucopenia neutrophils hypersegmented
leucocytosis Immature
immature
staff cells
staff cells immature neutrophils
character
nucleus not well developed
nucleus segment two segments

neutrophils segments

segments Neutrophils staff cells
immature

hyper segmented folic acid and B12 deficiency

MCQ

39

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Leukemia -

clinical pathology : shift to the

left
leucocytosis immature neutrophils
immature neutrophils staff cells
Infection hemolysis Bleeding

Infection
Infection shift to the left infection
bleeding or hemolysis
toxic granulations
toxic granulations
toxic granulation sign neutrophils
)
(
blood blood
blood clinical pathology 75
40 blood
) (
blood blood

blood bloooooooooood

) (
infection toxic granulations
neutrophils sign toxic granulations
toxic granulaltions
cytoplasm neutrophils vacuoles

infections shift to the left

shift to the left leucocytosis immature WBCs
staff cells
neutrophils Infection
toxic granulations
toxic granulations

40

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Leukemia -

extremely specific infection

Infection
leukaemia toxic granulations

neutrophils

neutrophils

neuturophilia Neutropenia
absolute count neutrophils 7000-2000
percent absolute count
take care percent absolute count
total leucocytic count 10000
neutrophils 50%
neutrophils 50% 10000
absolute count neutrophils 5000
5000 range Normal

neutrophila

pyogenic infection
tissue damage
myocardial infraction
pulmonary infraction
leukaemias
Myeloproliferative
rheumatoid

cortisone
neutrophilia
neutrophils wall blood vessels
adhesion
adhesion
Neutrophils blood stream
neutrophilia

bone marrow WBCs ....

41

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Leukemia -

neutrophils
endothelium blood vessels
Neutrophilia
neutrophilia function neutrophils Impaired
eosinophils

Esinophils

eosinophilia problem
...
neutrophils written oral
eosinophils written oral
neutrophils written 2008
: ... neutrophils
neutrophilia neutropenia
short
neutrophilia full stop

eosinophils specific
eosinophilia allergy parasite
Parasite eosinophilia
hydatid disease fasciola


Liver disease eosinophilia

hydatid disease fasciola

fasciola

fasciola ... hepatitis like...
hepatitis liver enlarged tender
hepatitis eosinophilia

42

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Leukemia -

.N.B amoebic liver eosinophila

eosinophilia
fasciola
fasciola fasciola

fasciola
amoebic liver parasite liver
Liver
amoebic liver
amoebic liver eosinophilia
hydatid

fasciola
biliary system Liver parenchyma
alkaline phophatase transaminases
general


parasite
addison's disease
addison's Addison's

vasculitis Strug strauss vasculitis

primary hypereosinophilic syndrome

eosinophils very high
eosinophils Infiltration Heart Lung vital organ
hypereosinophilic syndrome
eosinophils
steroid

43

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Leukemia -

allergy cortisone
addison's cortisone
Hodgkin's cortisone
vasculitis cortisone
cortisone

cortisone
eosinophils
lymphocytes
Basophils

Basophils

myeloproliferative , chronic myeloid , myelosclerosis
polycythaemia rubra vera
basophils
lymphocyte

lymphocyte
Infection sore thorat

lymphocytosis
lymphocytosis
viral
viral infection T.B. , Brucella and typhoid
leukaemias
Atypical lymphocytosis
infectious mononucleosis
.... Lymphocytosis

chronic lymphocytic leukaemia

infectious mononucleosis

male 65 yrs old . liver , spleen and lymph nodes

persistent lymphocytosis

44

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Leukemia -

chronic lymphocytic leukaemia

infectious mononucleosis
yrs 16 liver , spleen and lymph nodes
Lymphocytosis
Atypical lymphocytosis
Lymphocyte
viral infection infectious
mononucleosis
CMV

sore thorat
infectious mononucleosis very common
Lymphopenia
HIV
Monocytes

Monocytes

bone marrow Peripheral blood tissues
tissue macrophages

value of Bone marrow examination
diagnostic and confirmatory
diagnostic
diagnostic

bone marrow examination is mandatory

...
bone marrow examination

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Leukemia -

... multiple myeloma plasma cells

bone marrow
myelofibrosis fibrous tissues bone marrow
A leukaemic leukaemia blasts bone marrow
peripheral blood
aplastic anaemia
sidroblastic anaemia

confirmatory
leukaemia Peripheral blood
Aleukaemic leukaemia

leukaemia
bone marrow
bone marrow
confirm calssifications
iron deficiency
Megaloblastic
I.T.P bone marrow examination just to confirm
exclude similar condition

I.T.P
idiopathic thrombo cytopenic purpura
exclusion
bone marrow examination
confirm exclude similar
condition

A leukaemic
leukaemia
A leukaemic leukaemia blasts
bone marrow platelets
thrombocytopenia

Idiopathic
bone marrow

I.T.P I.T.P

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Leukemia -

...... bone marrow

:

almost sure I.T.P bone marrow
sternum aspiration

... dry tap

fibrosis
bone marrow


trephine from iliac crest
Local anathesia anterior superior iliac spine



bone marrow

bone marrow fibrous tissue
myelofibrosis
dry tap Myelofibrosis
fibrous tissue bone marrow

leukaemia peripheral blood
Leucocytosis
blasts ...
leukaemia Peripheral blood
Acute leukaemia 100,000 total leucocytic
count
blasts
platelets
RBCs

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Leukemia -

...

leucocytosis 40,000
leukaemia

leukaemia like
leukemoid

oid like

Leukaemia
Infection

leukemoid reaction

leukemoid reaction leukaemia leukaemia
abscess

total leucocytic count may exceed 50,000

usually 50,000

total leucocytic count 100,000

Leukaemia
leukemoid reaction
platelets normal RBCs almost normally
bone marrow normally proliferation

blasts

leucocytes alkaline phosphatase
Normal leucocytes alkaline phosphatase

leucocytes leukaemia ...

leucocytic alkaline phosphatase High leukemoid
reaction

functioning WBCs
immature cells never exceed 5% blasts

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Leukemia -

....
leukaemia blood picture
leukaemia like Leukemoid
Leucocytois platelets RBCs
blasts bone marrow
leucocytic alkaline phosphatase

blood picture fever

problem fever blood picture
neutrophils ...

lymphocyte ... viral

leukaemias Lymphomas
leucocytosis due to infection steroid
infection toxic granulations

MCQ
leukoerythroblastic reaction....

blasts WBCs bone
..... marrow
blasts WBCs peripheral blood
leukaemia
blasts RBCs bone marrow
leukaemia blasts RBCs

common
leukoerythroblastic
blasts leucocytes blasts RBCs
Peripheral blood

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Leukemia -

bone marrow bone marrow
blasts Peripheral blood

bone marrow infiltration
myeloma
leukaemia
lymphoma
.. .T.B bone marrow infiltration
bone marrow infiltration
blasts RBCs WBCs

leukoerythroblastic reaction
option
bone marrow infiltration
leukaemia , lymphoma , T.B. , myeloma
leukoerythroblastic reaction
41

clinical pathology
leukaemia

:
.1 Infiltration bone marrow bone marrow failure
acute leukaemia
.2 immune disorder WBCs antibody auto
immune Infection
.3 tissue infiltration
acute leukaemia
bone marrow failure

Bone marrow failure

aetiology
genetic chemicals ionizing radiation
retrovirus

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Leukemia -

leukaemia ) retrovirus HTLV1 ( human T-cell lymphotropic
) ( virus

Acute leukaemia

proliferation blasts
blasts lymphcyte acute lymphoblastic leukaemia
blasts myelocyte acute myeloid leukaemia

acute lymphoblastic leukaemia
acute myeloid leukaemia young adult
very aggressive
acute myeloid leukaemia

acute lymphoblastic leukaemia
ALL %85
common adult

acute myeloid leukaemia very aggressive

acute lymphoblastic leukaemia

lymphoblast
acute myeloid
myeloblast promyelocyte Myelocyte
bone marrow
acute myeloid leukaemia N0 to
N7 very aggressive leukaemia
leukaemia acute lymphoblastic leukaemia

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Leukemia -

.......

.........
myeloid

clinical pictures of acute leukaemia

infection fever
sore thorat
anaemia fatigue pallor
mature neutrophils Infection
purpuric eruption epistaxis
fever , anaemia and bleeding

tissue infiltration
sternum Pain bone marrow
tender sternum

liver , spleen and lymph nodes enlargement common with lymphoblastic

Myeloid leukaemia

acute myeloid
Lymph nodes liver , spleen

13

sore thorat , fever , liver , spleen and lymph node enlargement

...
Infectious mononucleosis
acute lymphoblastic leukaemia

child , sore thorat , liver , spleen and lymph node enlargement

infectious mononucleosis
acute lymphoblastic leukaemia
sore thorat infectious mononucleosis
acute leukaemia
thrombocytopenic anaemic

leukaemia
Investigations
total leucocytic count is variable
Page |

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Leukemia -

25% WBCs 50,000

50% WBCs 50,000-5,000
WBCs
acute leukaemia
excessive blast in bone marrow

blasts bone marrow peripheral blood
bone marrow
peripheral blood
blasts
peripheral blood blasts
acute leukaemia
blasts bone marrow

bone marrow
A leukaemic leukaemia
blasts bone marrow peripheral blood

How can you suspect Aleukaemic leukaemia
blasts blasts
bone marrow
infection blasts
... bone marrow neutrophils
fever sore thorat
RBCs bone marrow anaemia....
platelets thrombocytopenia
Infection , sore thorat blood
pictures thrombocytopenia
...
normocytic normochromic

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Leukemia -

hypochromic microcytic ......iron deficiency

anaemia
female usually haemoglobin

normocytic normochromic
Hypochromic microcytic
very mild iron deficiency aneamia
Iron

neutrophils Peripheral blood

neutropenia
peripheral blood neutrophils
RBCs Platelets
.I.T.P

thrombocytopenia platelets
bone marrow examination

blasts bone marrow bone
marrow

Aleukaemic leukaemia
examination RBCs
platelets
..... bone marrow examination
Auer rods
blasts lymphoblast myeloblast
Auer rods
differential diagnosis
fever with sore thorat acute leukaemia
Infectious mononucleosis
Infectious mononucleosis

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Leukemia -

poor prognosis
total count 100,000 platelets
L3

general

anaemia
bleeding platelets
Infections antibiotic aerobes and anaerobes
Positive negative acyclovir
gancyclovir CMV sutrim
pneumocystis carnii

Lysis tumor lysis

acute lymphoblastic leukaemia
remission induction
induction of remission

chemotherapy
acute lymphoblastic leukaemia
chemotherapy
bone marrow suppression
bone marrow blasts normal
blasts peripheral blood

bone marrow malignant
bone marrow malignant
chemotherapy malignant fossi bone marrow
residual normal bone marrow blasts
Peripheral blood

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Leukemia -

vincristine , adriamycin , predinsolone and L-asparaginase

doses )

(
dose
dose
cardiology
dose doses cardiology
dose vincristine leukaemia
!!
dose haematology

haematology dose
Leukaemia

) Remission consolidation (4weeks

cyclophosphamide cytosine arabinoside
consolidation C
C cyclophosphamide cytosine arabinoside

acute lymphoblastic leukaemia leukaemia
Meninges
prophylaxis CNS CSF methotrexate
cytotoxic drugs CSF

CNS prophylaxis

........ ...
CNS prophylaxis
leukaemia

four doses courses text

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Leukemia -

Haematology

Maintenance therapy
maintenance M m
mercaptopurine and methotrexate

acute lymphoblastic leukaemia

remission induction vincristine , adriamycin,
prednisolone and L-asparaginase

signs of remission
clinical picture
blasts bone marrow % 5
blasts peripheral blood
consolidation consolidation
C C cyclophosphamide

cytosine arabinoside
prophylaxis CNS methotrexate CSF
maintenance M M
mercaptopurine methotrexate

Acute myeloid leukaemia

remission
cytosine arabinoside Thioguanine-6
cytosine arabinoside ara-c ara-c
C ara
Thioguanine-6

remission consolidation Medication

maintenance
remission bone marrow transplantation

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Leukemia -

leukaemia very aggressive Maintenance

FAB classification clinical pathology
FAB classification
of acute lymphoblastic leukaemia L1, L2, L3
L1
L2
L3 complication
Prognosis L3
acute myeloid acute myeloblastic
leukaemia
myeloblasts acute lymphoblastic
myeloblast

bone marrow

..............
acute myeloid predominant
cell myelobalsts

M0 Undifferentiated
M1 myeloblasts Maturation
M3 promyelocytic DIC
megakaryocytic bone marrow fibrosis
M5 monocytic hypertrphy gum
calssification acute myeloid
M0

immunological
classification

antigens
Myeloid leukaemia antigen
CD cluster differentiation
antigen CD
leukaemias
!!!!
Immune classification cluster of differentiation

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Leukemia -

antigen Malignant cells acute myeloid

chronic myeloid leukaemia

male middle age massive

splenomegaly
male
middle age
massive splenomegaly myeloid

chronic myeloid leukaemia lymphocytic
Lymphnode

spleen
spleen proliferation WBCs
chronic myeloid leukaemia
bone marrow failure late
leukaemia
spleen
bone marrow failure late
WBCs Mature
platelets
leukaemia
chronic myeloid leukaemia

spleen spleen
obese
spleen
anaemia bone marrow failure
thrombocytopenia
WBCs mature Infection anaemia

accidently discovered male
spleen
blood pictures ) -
(

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Leukemia -

function of neutrophils and platelets Infection

bleeding
huge spleen
blast crisis
chronic myeloid

acute myeloid Leukaemia

chronic myeloid
blast crisis acute myeloid leukaemia
bone marrow blasts
blast crisis
chronic myeloid chronic myeloid

myeloid line
36 myeloid line myeloblast
promyelocyte myelocyte metamyelocyte neutrophils
acute myeloid leukaemia
blasts bone marrow
chronic myeloid
blasts bone marrow

bone marrow
promyelocyte Myelocyte
spleen....
Myelocyte promyelocyte peripheral blood
mature neutrophils
platelets
bone marrow failure
suddenly bone marrow myeloblast
myeloblast platelets RBCs

chronic myeloid leukaemia
blast crisis

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Leukemia -

blast crisis accelerated phase

accelerated phase ...
bone marrow Infiltrated anaemic
thrombocytopenic
blast crisis
blast crisis acute myeloid leukaemia

blood pictures
Total leucocytic count 25,000
100,000
chronic myeloid leukaemia WBCs

acute leukaemia
acute leukaemia 100,000

chronic

It is mainly of myeloid series, in the form of myelocytes , promyelocytes

Mature neutrophils
Myeloblasts
Myeloblast blast crisis
Basophilia and eosinophilia
leukaemia
investigations
uric acid hyper urcaemia
Philadelphia (ph) chromosome
bone marrow chromosomes
and 22 9 Philadelphia
chromosome
Philadelphia
Philadelphia chromosome proliferating
programmed cell death
rapidly dividing cells ... bone marrow GIT

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Leukemia -

tongue
desquamation

folic acid and B12 ... GIT
Bone marrow
Philadelphia chromosome

WBCs malignant
bone marrow leukaemia
bone marrow infiltration
leukaemia WBCs
... blast crisis

chronic myeloid
blast crisis
chronic myeloid RBCs platelets
mature
neutrophils
behavior

Leucocytic alkaline phosphatase is low

chronic myeloid leukaemia

..... ....
WBCs tissue infiltration
leucostasis blood vessel
...
Hydroxyurea Myelosupressive
WBCs or 300,000 200,000 20,000
15,000
Leukaemia ...

interferons

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Leukemia -

Radiotherapy spleen

... leucopharesis malignant
hydroxyurea Myelosupressive
leukaemia
... Imatinib
Interferon imatinib
hydroxyurea Hydra
imatinib
blast crisis acute myeloid leukaemia
Imatinib blast crisis
chronic myeloid
spleen WBCs proliferation

...
platelets haemoglobin bone marrow
failure

WBCs functioning
spleen ...

WBCs hydroxyurea
... blast crisis

chronic myeloid
leukaemia Imatinib

chronic lymphocytic leukaemia

Leukaeima ) (
lymphocyte
proliferation ... Lymphoid tissue

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Leukemia -

liver, spleen and lymph nodes

bone marrow failure Late

chronic myeloid
leukaemia hydroxyurea spleen

blast crisis
chronic lymphocytic lymphocyte
antibody
Liable to infection
Lymphocytes auto antibody
RBCs
Infection
blast crisis
character
cell of origin
B-lymphocytes Infiltration Liver , spleen
immunoglobulins Infection
abnormal immune reaction auto immune hemolytic

problem
male liver , spleen and lymph node
Persistent lymphocytosis infection
MRSA
stages
Stage A lymph node Lymphocytes
Stage B
Stage C bone marrow failure
Investigations
diagnosis ....
sustained absolute lymphocytosis

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Leukemia -

) ( fever
chest infection antibiotic
0000

..

investigation feverish ....
CBC

CBC Lymphocytosis

...
...
..

..

viral infection
antipyretic
infection
viral lymphocytosis
viral viral bacterial
antipyretic antibiotic viral
...... .. lymphocytosis
chronic lymphocytic leukaemia


bone
marrow failure ... platelets RBCs
.. Infection ... viral
bacterial infection





investigations
Coomb's test
leukaemia auto immune hemolytic

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Leukemia -

infection antibiotic
bone marrow failure
Stage C bone marrow failure
Prednisolone
chemotherapy More aggressive cases
cytoctoxic
C chronic leukaemia chronic C
Chlorambucil cyclophosphamide
episode
...
chronic myeloid leucocytes
.. myeloid myelosuppressive
hydroxyurea
chronic lymphocytic C chronic C
cyclophosphamide
Chlorambucil
Lymph nodes
auto immune hemolytic cortisone

Rituximab
Rituximab monoclonal antibody 80-70


...
chemotherapy

hairy cell leukaemia

leukaemia MCQ
chronic lymphocytic bone
marrow fibrosis
leukaemia splenomegaly erythema nodosum

Bone marrow fibrosis WBCs cytoplasmic projection

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Leukemia -

Interferon therapy
leukaemia interferon
Chronic myeloid leukaemia Interferon
Imatinib
Hairy cell leukaemia viral retrovirus
interferon dry tap
dry tap dry tap
needle bone marrow bone marrow

Myelofibrosis
Leukaemia .... Hairy cell
leukaemia interferon

neutropenia and agranulocytosis

neutropenia agranulocytosis

WBCs neutrophils
RBCs normal platelets Normal
aplastic anaemia

viral infection
hypersplenism bone marrow aplasia bone marrow aplasia
neutrophils
hypersplenism neutrophils
Hypersplensim Mono cytopenia
Hypersplenism Pan
.... ... mono cytopenia Neutropenia ...
thrombocytopenia

drug phenylbutazone antithyroid

choloramphincol

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Leukemia -

clinical pictures
sore thorat
sore thorat
ulcers Pus dead polymorph
Polymorph Pus
Minimal signs of inflammation Inflammation
organsim neutrophils

.
thorat ulcers Hyperemia signs of
inflammation Minimal scanty pus
blood picture
neutrophils Platelets normal RBCs
Normal
bone marrow examination

antibiotic

blood disease presented with sore thorat and fever

acute leukaemia

acute leukaemia blasts anaemia thrombocytopenia
blasts bone marrow Peripheral blood
anaemia thrombocytopenia
blood disease
agranulocytosis

neutropenia platelets RBCs

Normal

aplastic anaemia
Pancytopenia
Neutropenia RBCs platelets

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Leukemia -

agranuloctyosis and aplastic anaemia

scanty pus and minimal signs of inflammation
thorat ulcers
throat ulcers minimal signs of
inflammation scanty pus

Myeloproliferative disorders
myeloproliferative
myeloproliferative
Leukaemia proliferation
WBCs platelets RBCs
Proliferation panhyper cellularity of bone marrow
bone marrow hyper cellular
WBCs RBCs platelets fibroblast Hyper cellular
dominant
RBCs dominant polycythaemia rubra vera
WBCs dominant chronic myeloid
platelets dominant essential thromobocythemia

polycythemia rubra vera

polycythima rubra vera Pan hyper
cellularity bone marrow
Hyper cellular
dominant RBCs
MCQ .... polycythima rubra
vera RBCs .... platelets ....
WBCs
RBCs

plethora
Hyperviscosity RBCs
WBCs Invade tissue
Hyper viscosity
dizziness , vertigo Hyper tension

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Leukemia -

....Hyperviscosity syndrome
spleen splenomegaly
retina engorged veins fundus examination
itching

Criteria

RBCs ... red cell mass

RBCs packed cell volume
red cell mass
... ...

RBCs ... Red cell mass

haematocrit RBCs mass



labled

dilution
degree of dilution
RBCs
More accurate Haematocrit
haematocrit volume of RBCs total blood volume
Red cell mass RBCs mass
RBCs blood volume
haematocrit value
Red cell mass More accurate

secondary polythaemia
hypoxia
RBCs .... Hypoxia RBCs
chest disease secondary to hypoxia
splenomegaly

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Leukemia -

Platelets
criteria B1 platelets 400,000 B2 total
leucocytic count 12,000
B3 High leucocytic alkaline phosphatase WBCs
malignant
B4 serum B12

Blood picture RBCs

Bone marrow RBCs dominant

erythropoietin level Low RBCs

erythropoietin !!!
B12 ... B12 ....
chronic myeloid WBCs chronic myeloid
polycythaemia rubra vera WBCs
transcoblamine

B12 chronic myeloid

polycythemia rubra vera
alkaline phosphatase leucocytes
Uric acid

Venesection
Myeloproliferative splenomegaly
basophilia hydroxyurea B12
.
venesection hydorxyurea

general support Allopurinol

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Leukemia -

Polycythaemia erythrocytosis
erythrocytosis polycythaemia rubra vera hypoxia
COPD
COPD secondary polycythaemia
cor pulmonale dizziness
haemoglobin ...
....
cushing
polycythaemia polycystic kidney disease
hydronephrosis hyper nephroma
hepatoma

secondary hypoxia
.... erythropoietin high
erythropoietin production kidney secondary polycythaemia
Polycythaemia rubra vera bone marrow
suppression erythropoietin
polycythaemia rubr vera itching splenomegaly
erythropoientin level to be differentiated COPD
criteria oxygen Low

Myelofi brosis

elements bone marrow proliferation

dominant fibroblast bone marrow
fibroblast bone marrow bone marrow
fibrous tissue
fibrous tissue
megakaryocyte
megakaryocytes Malignant malignant
megakaryocytes bone marrow fibroblast growth factor

fibroblast
bone marrow fibrous tissue
anaemia spleen extramedullary
haematopoiesis
extra medullary haematopoiesis
bone marrow fibrosis bone marrow
stem cells fibroblast

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Leukemia -

fibrosis stem cells bone marrow

spleen spleen
erythropoiesis
spleen RBCs
extra medullary haematopoiesis thalassaemia

anaemia splenomegaly
WBCs
chronic myeloid leukaemia anaemia... huge spleen
leucocytosis
differential diagnosis huge spleen

chronic myeloid leukaemia chronic
myeloid leukaemia blood pictures bone marrow

written Huge spleen
on examination spleen crossing the
umbilicus Huge
myelofibrosis Tear drop cells
dry tap

... chronic malaria blood film
tropical splenomegaly.. ..
tropical splenomegaly syndrome

differential diagnosis
Parasite
Kala azar leishmaniesis visceral leishmaniesis

specific drug for leishmania

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Leukemia -

amyloidosis spleen

nonhodgkin lymphoma

myelofibrosis
leucoerythroblastic features investigation bone marrow
fibrous tissue precursor
dry tap trephine from iliac crest
Tear drop cells Investigation

supportive
chapter Hydroxyurea hydra

splenoectomy spleen RBCs

hypersplenism RBCs
bone marrow transplantation

www.facebook.com/dr.tafreegh

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Leukemia -

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