HEMATOLOGY 2: LECTURE

Outline ➔ Development occurs in the bone marrow.

I. Qualitative Disorders of Leukocytes ➔ Share a common progenitor with monocytes

II. Abnormalities in White Blood Cells and are distinct from eosinophils and basophils,
Morphology known as the granulocyte monocyte progenitor
III. Nuclear Abnormalities (GMP).

➔ nuclei are segment or lobulated

Leukocytes

➔ Also known as White Blood Cells ◆ Neutrophils

➔ Number varies depending on whether they ◆ Basophils
are being viewed under light microscope ◆ Eosinophiles

Classification of Leukocytes

1. Granulocyte Granulocyte ➔ major cytokine

➔ A group of leukocytes colony-stimulati responsible for the
whose cytoplasm, is ng factor, or stimulation of neutrophil
filled with granules G-CSF
➔ nuclei are segment or
lobulated
◆ Neutrophils
◆ Basophils
◆ Eosinophiles
Three Pools of ◆ The Stem Cell Pool
2. Mononuclear ➔ Have nuclei that are not Developing ◆ The Proliferation Pool
cells segmented but are Neutrophils in ◆ The Maturation Pool
round, oval, intended or the Bone Marrow
folded.

◆ Monocyte
Myeloblast ➔ make up 0% to 3% of
◆ Lymphocytes the nucleated cells in
the bone marrow
Kinetics ➔ measure 14 to 20 mm
in diameter
➔ Subdivided into:
➔ Movement of cells through developmental ◆ Type I - a high
stages, into the circulation, and from the nucleus-to-cytoplas
circulation to the tissues. m
◆ Type II - shows the
presence of
Granulocytes dispersed primary
(azurophilic)
1. Neutrophils granules in the
cytoplasm
HEMATOLOGY 2: LECTURE

◆ Type III - darker

chromatin and a Metamyelocytes ➔ constitute 3% to 20% of
more purple nucleated marrow cells.
cytoplasm
➔ From this stage forward,
the cells are no longer
capable of division and
Promyelocytes ➔ comprise 1% to 5% of the major morphologic
the nucleated cells in the change is in the shape of
bone marrow the nucleus.

➔ relatively larger than the ➔ chromatin is increasingly

myeloblast cells clumped.

➔ measure 16 to 25 mm in ➔ Nucleoli are absent

diameter

➔ chromatin clumping
(heterochromatin) may Bands ➔ make up 9% to 32% of
be visible, especially nucleated marrow cells
around the edges of the
nucleus. ➔ 0% to 5% of the
nucleated peripheral
blood cells.

Myelocytes ➔ make up 6% to 17% of ➔ All evidence of RNA

the nucleated cells in the (cytoplasmic basophilia)
bone marrow is absent, and tertiary
granules continue to be
➔ the final stage in which formed during this stage.
cell division (mitosis)
occurs

➔ During this stage, the Segmented ➔ make up 7% to 30% of

production of primary neutrophils nucleated cells in the bone
granules ceases and the marrow.
cell begins to
manufacture secondary ➔ Secretory granules
(specific) neutrophil continue to be formed
during this stage. The only
granules.
morphologic difference
between segmented
➔ sometimes divided into
neutrophils and bands is
early and late
the presence of between
myelocytes.
two and five nuclear lobes
connected by thread-like
filaments
HEMATOLOGY 2: LECTURE
➔ Neutrophil kinetics involves the movement of
neutrophils and neutrophil precursors between the
different pools in the bone marrow, the peripheral
blood, and tissues.
➔ The major function of neutrophils is phagocytosis
and destruction of foreign material and
microorganisms.
2. Eosinophil
➔ make up 1% to 3% of nucleated cells in the bone
marrow
➔ slightly more than a third are mature, a quarter are
eosinophilic metamyelocytes, and the remainder
are eosinophilic promyelocytes or eosinophilic
myelocytes.
➔ established through the
interaction between the
cytokines interleukin-3
(IL-3), IL-5 (induced by
IL-33), and GM-CSF and
three transcription factors
(GATA-1 (hematopoietic
transcription factor), PU.1,
and c/EBP). IL-5 and IL-33
Eosinophil lineage
are critical for eosinophil
growth and survival.
➔ Eosinophils have a
circulating half life of
roughly 18 hours; however,
the half-life of eosinophils is
prolonged when
eosinophilia occurs.
Functions
● Are full of a large number of previously synthesized
proteins, including:
■ Cytokines
■ Chemokines
■ Growth factors
■ Cationic proteins that degranulate in an
inflammatory process
● Play important roles in immune regulation
● Transmigrate into the thymus of the newborn and are
believed to be involved in the deletion of
double-positive thymocytes
● Increased in infection by parasitic helminths
● In vitro studies have found that eosinophils is capable
of destroying tissue-invading helminths
1. Basophils
● Are rue leukocytes because they mature in the bone
marrow and circulate in the blood as mature cells with
granules
● least numerous of the WBCs, making up between 0%
and 2% of circulating leukocytes
● Less than 1% of nucleated cells in the bone marrow
Development
● Derived from progenitors in the bone marrow and
spleen, where they differentiate under the influence of
a number of cytokines
● Immature basophils have round to somewhat lobulated
nuclei with only slightly condensed chromatin.
● Mature basophils contain a lobulated nucleus that is
often obscured by its granules
Kinetics
● Poorly understood because of their very small
numbers
● This life span is relatively longer than that of the other
granulocytes, 60 hours
Functions
● Regarded as “poor relatives” of mast cells and minor
players in allergic inflammation because it results in
granule release
● Functions in both innate and adaptive immunity
● Capable of releasing large quantities of subtype 2
helper T cell TH2) cytokines such as IL-4 and IL-13
that regulate the TH2 immune response.
HEMATOLOGY 2: LECTURE

debris and dead cells at sites of infection or tissue

Mast Cells damage, destruction of senescent red blood cells
● Are not considered to be leukocytes. They are tissue
effector cells of allergic responses and inflammatory
reactions 2. Lymphocytes
● Divided into three major groups:
Mononuclear Cells ○ T cells - major players in adaptive immunity
○ B cells - adaptive immunity
1. Monocytes
○ Natural killer - cells make up a small percentage
● Monocytes make up between 2% and 11% of
of lymphocytes and are part of the innate immunity
circulating leukocytes

Lymphocyte Development
Development
● Antigen-independent - occurs in the bone marrow
● Similar to neutrophil development because both cell
and thymus
types are derived from the GMP
● Antigen-dependent - development occurs in the
● Macrophage colony-stimulating factor (M-CSF) -
spleen, lymph nodes, tonsils, and mucosa-associated
the major cytokine responsible for the growth and
lymphoid tissue
differentiation of monocyte
● B lymphocytes develop initially in the bone marrow
● Morphologic Stages of Monocyte
and go through three stages known as pro-B, pre-B,
○ Monoblast
and immature B cells
○ Promonocytes
● T lymphocytes develop initially in the thymus—a
○ Monocytes
lymphoepithelial organ located in the upper
mediastinum
Monocyte/ Macrophage Kinetics
● Under normal circumstances, promonocyte undergo
Lymphocyte Functions
two mitotic division in 60 hours to produce a total of
● B lymphocytes are essential for antibody production
four monocyte
● They have a role in antigen presentation to T cells and
● Under conditions of increased demand for monocytes,
may be necessary for optimal CD4 activation
promonocytes undergo four divisions to yield a total of
● T lymphocytes can be divided into CD41 T cells and
16 monocytes in 60 hours
CD81 T cells.
● No storage pool of mature monocytes in the bone
● CD41 effector lymphocytes are further subdivided into
marrow
TH1, TH2, TH17, and Treg (CD41CD251 regulatory T)
● Monocyte in the peripheral blood can be found in a
cells
marginal pool and circulating pool
● CD81 effector lymphocytes are capable of killing target
cells by secreting granules containing granzyme and
Monocyte/ Macrophage Function
perforin
● Subdivided into: ● nK lymphocytes function as part of innate immunity
○ Innate immunity - recognize a wide range of and are capable of killing certain tumor cells and
bacterial pathogens by means of pattern virus-infected cells without prior sensitization
recognition receptors (Toll-like receptors) that
stimulate inflammatory cytokine production and
phagocytosis
○ Adaptive immunity - Both macrophages and
dendritic cells degrade antigen and present
antigen fragments on their sur[1]faces
(antigen-presenting cells)
○ Housekeeping functions - include removal of
 HEMATOLOGY 2: LECTURE

Outline Hypersegmentation
● Abnormality in the maturation of neutrophil
I. Pelger-Huet Anomaly ● It has more than five (>5) lobes
II. Pseudo or Acquired pelger-huet Anomaly ● Associated with megaloblastic anemia
III. Hypersegmentation ● Myelodysplastic syndrome (myeloid dysplasia)
IV. Abnormalities in Granules ● Hereditary neutrophil hypersegmentation
V. Abnormalities in Functions
VI. Cell Exhibiting Phagocytosis
VII. Abnormal Lymphocytes Abnormalities in Granules
VIII. Abnormality in Plasma Cells
Alder Reilly Anomaly
IX. Abnormalities in
● Resembles toxic granulation
Monocyte/Macrophages/Histiocytes
● Large purple-black coarse cytoplasmic granules
X. Quantitative Disorder of Leukocytes
● Accumulation of partially digested
mucopolysaccharides
Pelger-Huet Anomaly
● Autosomal recessive
● Also known as HYPOSEGMENTATION or TRUE ● Associated with Hurler's syndrome and Hunter's
PELGER - HUET ANOMALY syndrome
● Inherited autosomal dominant disorder which the
nuclei of several types of white blood cells (neutrophils
and eosinophils) have unusual shape Auer Rods
● Its shape is PEANUT, PINCE-NEZ, or SPECTACLE ● Fused or aggregated primary granules (peroxidase
LIK positive)
● It also has unusual structure or decreased nuclear ● Found in cytoplasm of myeloblasts, monoblasts,
segmentation and promyelocytes
● This is a mutation on a “lamin beta-receptor gene” ● Pink or red rod-shaped structures
(lamin beta-receptor is an inner nuclear membrane ● The bundle of auer rods is known as faggot cells
protein that combines b-type lamins and
heterochromatin and plays a major role in leukocyte
nuclear shape changes that occur during normal Chediak-Higashi Granules
maturation) ● Associated with chediak-higashi syndrome
● Giant red, blue to grayish round inclusions
● Mutation in CHS1 LYST gene on chromosome
Pseudo or Acquired Pelger-Huet Anomaly 1q42.1-2 [CHS1 LYST gene
● Hematologic malignancies: ● Encodes for the protein that involve in vesicle
○ Myelodysplastic syndrome fusion/fission
○ Acute Myeloid Leukemia
○ Chronic Myeloproliferative Neoplasms
● Also, this can affect by Drugs: Mycophenolate mofetil
[prevents rejection in organ transplantation], valproate, Dohle-Amato Bodies
sulfisoxazole [prevents the growth of bacteria], ● Aggregates of free ribosomes of of Rough
ganciclovir [treat infection of Cytomegalovirus], Endoplasmic Reticulum
ibuprofen, and chemotherapies such as paclitaxel and ● Single or multiple light blue or grayish inclusions
docetaxel ● Represent localized failure of the cytoplasm to mature
● Also, it can be affected by HIV infections, TB, M. ● Confused or look-alike May-Hegglin (but DAB is more
pneumonae and other bacterial infections. smaller)
HEMATOLOGY 2: LECTURE
● Seen in Infections, poisoning, burns and px
undergone chemotherapy
May-Hegglin Anomaly
● Variable thrombocytopenia, giant platelet and large
Dohle body-like inclusion (but MH is bigger)
● Mutation in MYH9 gene on chromosome 22q12-13
which is a disorder in Myosin heavy chain type IIA
(which affects megakaryocyte maturation and platelet
fragmentation)
Toxic Granulation
● Large purple to black granules or dark blue-black
granules
● Though to be primary granules showing increased
ALP/Alkaline Phosphatase activity
● Like DAB, it is also seen in infections, toxic
states, drug poisoning and burns
Abnormalities in Functions
Job’s Syndrome
● Has abnormal chemotactic activity
● Mutation in STAT 3 gene
● Associated with hyperimmunoglobulinemia E
syndrome
● Also, increased in IgE levels
Lazy Leukocyte Syndrome
● Abnormal random and chemotactic activity
● Neutropenia (findings)
● Infections involving the gums, mouth, and ears
● Has defects in acid filaments
Chronic Granulomatous Disease
● Impaired NADPH oxidase/ oxidative metabolism/
respiratory burst NADPH - nicotinamide adenine
dinucleotide phosphate
● Evaluated using chemiluminescence and NBT
● Inability of phagocytes to kill ingested microorganisms
Cell Exhibiting Phagocytosis
Lupus Erythematosus Cell (LE Cells)
● Neutrophil with large purple homogenous round
inclusion
● Appear smooth and evenly stained
Tart Cell
● Monocyte with ingested lymphocyte
● Appear rough and unevenly stained
Abnormal Lymphocyte
Downey Classification
● Discovered by Dr. Hai Downey
Type 1 or Turks Irritation Cells
● Has a large block of chromatin
Type 2
● Looks like a ballerina skirt under the microscope
Type 3
● Swiss cheese like
Basket Cell or Smudge Cell
● May be caused by pressure in making the blood smear
● Also, it can be found in chronic lymphocytic
leukemia
● Degenerated/disintegrated nucleus of a ruptured WBC
Hairy Cell
● Associated with hairy cell leukemia
● Lymphocyte with hair-like cytoplasmic projections
surrounding nucleus
Sezary Cell
● Cerebri form lymphocyte
● Found in Sezary syndrome and Mycosis fungoides
Abnormality in Plasma Cells
HEMATOLOGY 2: LECTURE

Flame Cell
● Found in multiple myeloma Abnormal Lymphocyte
● Plasma cell with red to pink cytoplasm Neutrophils
● Associated with increased immunoglobulin (igA)
Neutrophilia
● Neutrophilia means increase
Russell Bodies ○ >7.0 x 109 /L - adults
● Large, red staining, individual globules of ○ >8.5 x 109 /L – children
immunoglobulins ● Causes:
○ Emotional
○ Strenuous exercise
Grape Cell ○ Trauma/injury
● Also known as Berry cell, Morula, Mott cell ○ Pregnancy: labor and delivery
○ Postsurgery
○ Acute hemorrhage/hemolysis
Honeycomb Appearance ○ Infections: bacterial, some viral
● Plasma cell with vacuoles and large protein globules ○ Burns
● Accumulation of Russell bodies ○ Surgery
○ Myocardial Infarction
○ Pancreatitis
Dutcher’s Bodies
○ Vasculitis
● Intranuclear protein inclusions ○ Colitis
○ Autoimmune disease
○ Steroids
Abnormalities in Monocyte/Macrophages/Histiocytes
○ Lithium
Gaucher’s Disease ○ Colony-stimulating factors (G CSF)
● Deficiency in glucocerebrosidae or ○ Smoking
beta-glucosidase ○ Chronic Blood Loss
● Accumulation of glucocerebroside ○ Metabolic Ketoacidosis
● Has a wrinkled/crumples cytoplasm ○ Uremia
○ Eclampsia
○ Malignancy
Niemann-Pick Disease ○ Leukocyte adhesion deficiency
● Deficiency in sphingomyelinase ○ Familial cold Urticaria
● Accumulation of sphingomyelin ○ Hereditary neutrophilia
● Has a foamy cytoplasm

Neutropenia
Tay-Sachs ● Neutropenia means decrease
● Deficiency in hexosaminidase A ○ <2.0 x 10⁹/L - white adults
● Accumulation of glycolipid and ganglioside ○ <1.3 x 109 /L - black adults
● It also has a vacuolated cytoplasm ● Causes:
○ Drugs
○ Radiation
Sea Blue Histiocytes ○ Toxins
● Unknown Deficiency ○ Immune Mediated
● Has a blue green cytoplasm
HEMATOLOGY 2: LECTURE

● >3.5 x 10⁹/L-neonates
Eosinophils ● Causes:
○ Chronic inflammation/infection
Eosinophilia
○ Immunologic conditions
● >0.4 x 10⁹/L
○ Hypersensitivity reactions
● Causes:
○ Cytokine stimulation (IL3 & IL5)
○ Parasitic infection Monocytopenia
○ Allergic conditions ● <0.2 x 10⁹/L
○ Scarlet Fever ● Causes:
○ HIV ○ Steroid therapy
○ Fungal Infection ○ Hemodialysis
○ Autoimmune disorder ○ Sepsis
○ Hypersensitivity to antibiotics ○ Viral Infection (EBV)
○ Anti-seizure medication

Lymphocytes
Eosinopenia
● <0.09 x 10⁹/L Lymphocytosis
● Causes: ● 2 weeks and younger than 8-10 years higher than in
○ Marrow hypoplasia adults
○ Absolute eosinopenia also been reported ● >10.0 x 10⁹/L children
in: ● >4.5.0 x 10⁹/L adults
○ Autoimmune disorder
○ Steroid therapy
Lymphocytopenia
○ Stress
○ Sepsis ● <2.0 x 10⁹/L – children
○ Acute inflammatory states ● <1.0 x 10%/- adult
● Inherited / acquired

Basophils
Basophilia
● >0.15 x 10⁹/L
● Causes:
○ Malignant myeloproliferative neoplasm -
○ Allergic rhinitis
○ Hypersensitivity to drugs or food
○ Chronic infections
○ Hypothyroidism
○ Chronic Inflammatory conditions
○ Radiation therapy
○ Bee stings

Monocytes
Monocytosis
● >1.0 x 10⁹/L-adults
HEMATOLOGY 2: LECTURE
HEMATOLOGY
Chapter 33: Myeloproliferative Neoplasms

MYELOPROLIFERATIVE NEOPLASMS ➢ This is a combination of

overproduction of
(MPNs)
hematopoietic cells and
stimulation of fibroblast
● These are clonal hematopoietic disorders caused by production leading to
genetic mutations in the hematopoietic stem cells that ineffective hematopoiesis
result in expansion, excessive production, and accumulation with resultant peripheral
of erythrocytes, granulocytes, and platelets blood cytopenias
● Present as stable chronic disorders that may transform first
to a subacute, then to an aggressive cellular growth phase, OTHER LESS COMMON MPN CONDITIONS
such as:
○ Acute myeloid leukemia (AML) 1. Chronic Neutrophilic Leukemia (CLN)
○ Acute lymphoblastic leukemia (ALL) 2. Chronic Eosinophilic Leukemia (CEL), Not Otherwise
● Familial MPNs have been described in families in which Specified
two or more members are affected 3. Mastocytosis
4. Myeloproliferative Disorder, Unclassifiable

Due to hypersensitivity or
independence of normal cytokine I. Chronic Myelogenous Leukemia
Myeloproliferation regulation that reduces cytokine levels
(CML)
through negative feedback systems
normally induced by mature cells
● An MPN arising from a single genetic translocation in a
Occurs in varying combinations in the pluripotential hematopoietic stem cell producing a clonal
Expansion bone marrow, peripheral blood, and overproduction of the myeloid cell line, resulting in a
tissues preponderance of immature cells in the neutrophilic line
● (1) Chronic clinical phase -> (2) accelerated phase (if
untreated for 3-4 years) -> (3) Acute leukemia
FOUR PREDOMINANT DISORDERS OF MPNs
(According to WHO) ★ Frequent infection
★ Anemia
Chronic ★ Bleeding
Myelogenous Overproduction of Clinical ★ Splenomegaly
1
Leukemia granulocytes features of CML ★ All secondary to massive pathologic
(CML) accumulation of myeloid progenitor
cells in bone marrow, peripheral
Also known as: blood, and extramedullary tissues
● Polycythemia rubra vera
Polycythemia Vera ★ Neutrophilia with all maturational
2
(PV) Seen in stages present
➢ This is the overproduction
of erythrocytes peripheral ★ Basophilia
blood ★ Eosinophilia
Characterized by increased ★ Thrombocytosis
Essential (primary)
megakaryocytopoiesis and
3 Thrombocytopenia
peripheral blood ● In affected cells = ONE isoenzyme is active
(ET) thrombocytosis ● In non affected cells = TWO isoenzymes are active
● It occurs at all ages but is seen predominantly in those aged
Also known as: 46 to 53 years
● Agnogenic myelofibrosis ● It represents about 20% of all cases of leukemia, is slightly
Primary
with myeloid metaplasia more common in MALES than in females, and carried a
4 Myelofibrosis
● Chronic idiopathic mortality rate of 1.5 per 100,000 per year in the era prior to
(PMF) myelofibrosis the development of imatinib mesylate (Gleevec)

1
HEMATOLOGY
Chapter 33: Myeloproliferative Neoplasms

IMATINIB
● A tyrosine kinase inhibitor that has changed the prognosis
Breakage in the BCR1 Contributes exons 1 to 13 or 1 to
and treatment for CML
gene in the major BCR 14

★ Fatigue Breakage in the ABL1

★ Decreased tolerance of exertion Contributes exons 2 to 11
gene in the major BCR
★ Anorexia
Symptoms ★ Abdominal discomfort ➔ The two breakpoints in the major BCR differ by only one
★ Weight loss exon. Thus, the chimeric protein product is essentially the
★ Symptomatic effects from splenic same size and is designated as the p210 protein
enlargement
Contributes only exon one from
Breakage in the BCR1, which joins with the same
PHILADELPHIA CHROMOSOME minor BCR exons 2 to 11 of ABL1 to produce a
p190 protein
● A unique chromosome that is present in proliferating
Contributes exons 2 to 19 from
hematopoietic stem cells and their progeny in CML and
BCR1, which fuse with ABL1 exons
must be identified to confirm the diagnosis Micro BCR breakpoint
2 to 11, producing the p230
● Cause: UNKNOWN protein
● Appears more frequently in populations exposed to ionizing
radiation ➔ Therefore, the four possible BCR1 breakpoints produce
● Appearance of the Philadelphia chromosome in donor cells four different chimeric genes, resulting in a total of three
after allogeneic bone marrow transplantation indicates the different protein products
possibility of a transmissible agent
● First identified as a short chromosome 22 in 1960 by Nowell
and Hungerford in Philadelphia
PATHOGENIC MECHANISM

BCR1
When in its usual location on chromosome
Wild-type
9, codes for p125, which exhibits normal
● Involved in the Philadelphia translocation ABL protein tyrosine kinase activity
● The wild-type (normal) BCR1 gene is approximately 100 kb
with 20 exons ➔ Produces p160
➔ Expresses serine and threonine kinase
BCR on chromosome 22 was defined as a BCR1 genes activity
➔ Thought to function in the regulation of
5-exon region involving exons 12 to 16 that
Major BCR cell growth
was the area of breakage in the traditional
t(9;22)
Enzymes that catalyze the transfer of
phosphate groups from adenosine
Two other areas of breakage were identified on Protein
triphosphate (ATP), guanosine triphosphate,
chromosome 22: kinases and other phosphate donors to receiver
proteins
(1) Minor BCR One near the 59 (head) of the BCR1 gene
Tyrosine Transfers the phosphate group to a tyrosine
(2) Micro BCR One in the 39 end (tail) of the BCR gene kinase amino acid on the receiver protein

➔ Two areas of breakage in the major BCR, one breakpoint

area in the minor BCR, and one breakpoint region in the
ABL PROTEIN
micro BCR produce four versions of the BCR gene that
combine with the ABL1 gene to form four versions of the
● For its kinase activity to occur, it must be first be
BCR/ABL1 chimeric gene
phosphorylated through autophosphorylation

2
HEMATOLOGY
Chapter 33: Myeloproliferative Neoplasms

● It has three primary domains (SH1, SH2, SH3) that Myeloblasts and Present at a rate of approximately
together express and regulate the kinase activity promyelocytes 1% and 5%, respectively

SH1 Binding site for ATP Present and often show an absolute
Lymphocytes and
increase in number but a relative
SH2 Docking point for phosphate receiver proteins monocytes decrease in percentage

SH3 Domain that controls the phosphorylation activity Nucleated RBCs

RARE
(NRBCs)

➔ In most physiologically normal

intracellular pathways, it activates
the RECEIVER PROTEINS
Protein ➔ Initiates a cascade of
phosphorylation phosphorylation events, each
activating the next protein until a
transcription factor becomes
activated
These activation cascades are
Signal designed to activate GENES necessary
transduction to control cell proliferation,
pathways differentiation, and natural cell death
(apoptosis)
In Bone Marrow
★ An intense hypercellularity is present due to
granulopoiesis, marked by broad zones of immature
granulocytes, usually perivascular or periosteal,
differentiating into more centrally placed mature
granulocytes
★ Normoblasts = reduced
★ Megakaryocytes = normal or increased (may appear in
clusters and exhibit dyspoietic cytologic changes)
★ Often appear small with reduced nuclear size (by
approximately 20%) and reduced nuclear lobulations
★ Reticulin fibers = increased
★ Presence of pseudo-Gaucher cells

PERIPHERAL BLOOD AND BONE MARROW

PROGRESSION

In Peripheral Blood
★ Accompanied by:
Often elevated, reflecting the ○ An increase in the frequency and number of clinical
Platelet count myeloproliferative nature of the symptoms
disease ○ Adverse changes in laboratory values
○ Poorer response to therapy than in the chronic phase
May involve sinusoids and ★ Additional chromosome abnormalities associated with
Extramedullary medullary cords in the spleen and enhanced dyshematopoietic cell maturation patterns and
granulopoiesis sinusoids, portal tract zones, and increases in morphologic and functional abnormalities in
solid areas of the liver blood cells
★ An increasing degree of anemia (often)
Readily apparent at scanning
Leukocytosis
microscopic powers
In the Peripheral Blood
● Segmented
INCREASED DECREASED
neutrophils
● Bands They all predominate ● Basophils
● Metamyelocytes ● Abnormal platelets ● Mature leukocytes
● Myelocytes ● Megakaryocytes ● Platelets
● Megaryocytic fragments
Immature and
mature eosinophils INCREASED Blast
and basophils

3
HEMATOLOGY
Chapter 33: Myeloproliferative Neoplasms

The circulating blast count increases to 10% to 19%

Diagnostic criterion Total blast percentage, or a II. Polycythemia Vera (PV)

for the accelerated combination of 20% blasts and
phase promyelocytes
● It is a neoplastic clonal myeloproliferative disorder that
commonly manifests with panmyelosis in the bone marrow
Blast Crisis and increases in erythrocytes, granulocytes, and platelets in
the peripheral blood
Blast crisis leukemia is usually AML or ALL, but origins from
other hematopoietic clonal cells are possible
PATHOGENESIS
★ Severe anemia
★ Leukopenia of all WBCs except
● This is due to mutations involving JAK2, or rarely CALR or
blasts
LNK mutations in hematopoietic stem cells that lead to
★ Thrombocytopenia
sustained activation of JAK2 kinase, which causes excess
★ Chromosome abnormalities that
blood cell production
Clinical symptoms accumulate with disease
(that mimic those of progression are:
acute leukemia) ○ Additional Philadelphia DIAGNOSIS
chromosome(s)
○ Isochromosome 17
○ Trisomy 8 WHO Criteria for PV Diagnosis
○ Loss of Y chromosome
○ Trisomy 19 1. Hemoglobin > 18.5 g/dL in men, >16.5
g/dL in women or other evidence of
May occur as lymphocytic or increased red blood cell volume
Extramedullary Major Criteria
myelogenous cell proliferations 2. Presence of JAK2 V617F or other
growth (granulocytic sarcoma) functionally similar mutation such as
JAK2 exon 12 mutation
Observed at many sites or locations
Extramedullary in the body and may precede a 1. Panmyelosis in the bone marrow
sarcoma marrow blast crisis 2. Low serum erythropoietin levels
Minor Criteria
3. Autonomous, in vitro erythroid colony
formation

RELATED DISEASES

● Chronic Neutrophilic Leukemia

● Chronic Monocytic Leukemia
● Juvenile Myelomonocytic Leukemia
● Adult Chronic Myelomonocytic Leukemia

TREATMENT

● Nitrogen mustard
● Busulfan
● Hydroxyurea
● 6-mercaptopurine
● Interferon-a
● Cytarabine
● Bone marrow and stem cell transplantation
● Imatinib

4
HEMATOLOGY
Chapter 33: Myeloproliferative Neoplasms

● It is a clonal MPN with increased megakaryopoiesis and

PERIPHERAL BLOOD AND BONE MARROW thrombocytosis, usually with a count greater than 600 x
109/L and sometimes with a count greater than 1000 x 109/L.
However, WHO criteria require a sustained thrombocytosis
with a platelet count of 450 x 109/L or greater

PATHOGENIC MECHANISM

● Most of the mutations described in PV also occur in ET but

usually at a lower frequency
● The JAK2 V617F occurs in approximately 55% of patients
with ET

DIAGNOSIS

● ET must be differentiated from secondary or reactive

thrombocytoses and from other MPNs
● Thrombocytosis may be secondary to chronic active blood
loss, hemolytic anemia, chronic inflammation or infection, or
non hematogenous neoplasia

ET Diagnostic Criteria

This is first proposed by the PVSG to distinguish ET from

TREATMENT AND PROGNOSIS other MPNs

➔ Platelet count: >600 x 109/L

TREATMENT
➔ Hemoglobin: <13 g/dL (or a normal erythrocyte mass)
➔ Stainable iron in the bone marrow or a failure of iron
● Therapeutic phlebotomy therapy
● Low-dose aspirin
● Hydroxyurea The diagnosis are supported by the following:
● Busulfan
● Modern JAK inhibitors ★ Philadelphia chromosome negativity
★ Absence of marrow collagen fibrosis (less than one third
PROGNOSIS of a biopsy specimen is fibrous)
★ No splenomegaly
Median Survival Exceeding 15 to 20 years ★ Absence of leukoerythroblastic reaction
★ No known cause of reactive thrombocytosis
The diseases progresses to acute
Progression
leukemia in 15% of patients

III. Essential Thrombocythemia (ET)

● Also called as:

○ Primary thrombocytosis
○ Idiopathic thrombocytosis
○ Hemorrhagic thrombocythemia
5
HEMATOLOGY
Chapter 33: Myeloproliferative Neoplasms

PERIPHERAL BLOOD AND BONE MARROW 20 years

Median Survival for
(including cases in which the process
ET patients
arises in younger patients)

IV. Primary Myelofibrosis (PM)

● Previously known as:

○ Chronic idiopathic myelofibrosis
○ Agnogenic myelofibrosis
○ Myelofibrosis with myeloid metaplasia
● It is a clonal MPN6 in which there is splenomegaly and
ineffective hematopoiesis associated with areas of marrow
hypercellularity, fibrosis, and increased megakaryocytes

MYELOFIBROSIS

● The myelofibrosis in this disease consists of three of the five

types of collagen: I, III, and IV

Collagen
Explanation
Type

TREATMENT AND PROGNOSIS Type I Increases due to staining with trichrome

Increases are detected by silver

Type III
impregnation techniques
TREATMENT
➔ Increases due to the presence of
● Alkylating agent (hydroxyurea)
osteosclerosis, which may be
● Hydroxyurea therapy
diagnosed from increased radiographic
● Interferon-a and busulfan
bone density
● Low-dose aspirin
➔ Along with laminin, this are normally
● JAK2 inhibitors Type IV
discontinuous in sinusoidal membranes
● INCB018424 (ruxolitinib)
but appear as stromal sheets in
● CEP701 (Lestaurtinib)
association with neovascularization and
endothelial cell proliferation in regions
PROGNOSIS
of fibrosis

★ Headache
★ Dizziness
PATHOGENIC MECHANISM
Other symptoms ★ Visual disturbances
★ Dysesthesias (decreased
sensations) ● As with PV and ET, the JAK2 V617F mutation is involved in
the pathogenesis and is found in 65% of PMF patients
★ Bleeding from oral and nasal ● The MPL W515L/K occurs in an additional 10% of patients to
mucous membranes or include:
Hemorrhagic
gastrointestinal mucosa ○ CBL (6%),
complications ★ Appearance of cutaneous ○ TET2 (7.7% to 17%)
ecchymoses ○ ASXL1 (13% to 23%)

6
HEMATOLOGY
Chapter 33: Myeloproliferative Neoplasms

○ LNK (3% to 6%)

● Androgen therapy ● Interferon-a
○ EZH2 (13%)
● Prednisone ● Interferon-g
○ IDH1/2 (4.2%)
● Danazol ● Radiotherapy
● Thalidomide ● Splenectomy
PERIPHERAL BLOOD AND BONE MARROW ● Lenalidomide ● Chemotherapy
● Glucocorticosteroids ● Single-agent
● Hydroxyurea chemotherapy
● PMF presents with a broad range of changes in laboratory ● Busulfan ● Allogeneic stem cell
test values and peripheral blood film results, but transplantation
examination of the bone marrow biopsy specimen
provides MOST of the information for diagnosis
PROGNOSIS

OBSERVATIONS Average Survival 5-15 years

● Abnormalities in erythrocytes noted on peripheral ★ More severe anemia

blood films include: and
○ Presence of dacrocytes thrombocytopenia
Adverse Prognostic
○ Other bizarre shapes ★ Greater
Indicators hepatomegaly
○ Nucleated RBCs
○ Polychromatophilia ★ Unexplained fever
● Granulocytes that: ★ Hemolysis
○ Are variable in number (may be normal, increased, or
decreased) It is associated with:
○ May include immature granulocytes, blasts, and cells
with nuclear or cytoplasmic anomalies ★ Infection
○ May exhibit impairment of physiologic functions such ★ Hemorrhage
Mortality
as phagocytosis, oxygen consumption, and hydrogen ★ Post splenectomy
peroxide generation, and decreased myeloperoxidase complications
and glutathione reductase activities (these are ★ Transformation to acute
neutrophils) leukemia
● Platelets that:
○ Are variable in number (may be normal, increased, or
decreased) with a mixture of normal and abnormal
morphologic features
○ Show impaired aggregation in response to OTHER MYELOPROLIFERATIVE NEOPLASMS
epinephrine, decreased adenosine diphosphate
concentration in dense granules, and decreased
activity of platelet lipoxygenase I. Chronic Neutrophilic Leukemia (CNL)
● Megakaryocytes
● Bone marrow biopsy specimens that exhibit:
○ Intense fibrosis ● It is a clonal disorder in which a hyperproliferation of
○ Granulocytic and megakaryocytic hypercellularity neutrophilic cells in the bone marrow produces sustained
○ Dysmegakaryopoiesis neutrophilia in the peripheral blood and
○ Dysgranulopoiesis hepatosplenomegaly
○ Numerous dilated sinuses containing luminal
hematopoiesis PERIPHERAL BLOOD AND BONE MARROW

TREATMENT AND PROGNOSIS

PERIPHERAL BLOOD

TREATMENT ● WBC Count

○ >25 x 10.9/L with a slight left shift
● Neutrophils
7
HEMATOLOGY
Chapter 33: Myeloproliferative Neoplasms
○ Dominate, but the increase in bands,
metamyelocytes, myelocytes, and promyelocytes in
combination usually comprise fewer than 5% of
WBCs but can be as many as 10%
○ DO NOT appear dysplastic, but they often contain
toxic granules
● RBC and Platelet
○ Their morphology are normal in the peripheral
blood
BONE MARROW
● It reflects the peripheral blood in that it is hypercellular with
predominantly a proliferation of neutrophils, including
myelocytes, metamyelocytes, bands, and segmented
neutrophils
● Myeloid-to-erythroid ratio
○ 20:1
● RBCs and platelets
○ Normal in number, and no cell line exhibits
significant dysplastic morphology
DIAGNOSIS
● WBC count
○ >25 x 109/L
○ Mature neutrophils: >90%
○ Immature neutrophilic cells: <10%
○ Blasts: <1%
● Bone marrow - shows an increase in normal-appearing
neutrophilic cells with fewer than 5% myeloblasts
● Megakaryocytes - normal or slightly left-shifted
● Splenomegaly - must be present and is often
accompanied by hepatomegaly
● Reactive neutrophilia must be excluded by eliminating
infection, inflammation, and tumors as a cause of the
neutrophilia
● A diagnosis of CNL CAN still be made in the presence of a
reactive process if clonality of the myeloid line can be
documented by karyotyping or molecular analysis
● There should be NO evidence of:
○ Philadelphia chromosome
○ BCR/ABL mutation
○ Rearrangements of the PDGFRA, PDGFRB, or FGRF1
genes
○ PV, PMF, ET, MDS, or MDS/MPN disorders
PROGNOSIS
● CNL is a slow, smoldering condition, and patient survival
ranges from as short as 6 months to longer than 20 years
● The neutrophilia does progress, and some patients develop
myelodysplasia and can experience transformation into AML
II. Chronic Eosinophilic Leukemia, Not Otherwise
Specified
● It is a clonal proliferation of eosinophils from eosinophil
precursors that dominate in the bone marrow and peripheral
blood
● Eosinophils are found in other peripheral tissues, including
heart, lungs, central nervous system, gastrointestinal tract,
and skin
● Hepatosplenomegaly is observed in approximately 30%
to 50% of patients
● Infiltrating eosinophils degranulate to release cytokines,
enzymes, and other granular proteins that damage the
surrounding tissue, which results in organ dysfunction
PERIPHERAL BLOOD AND BONE MARROW
● Peripheral eosinophilia must be observed, with the majority
of eosinophils appearing normal
● Some evidence of eosinophil abnormality is found, however,
and includes the presence of eosinophilic myelocytes and
metamyelocytes, hypogranulation, and vacuolization
● Common finding: Neutrophilia
● Less common findings:
○ Mild monocytosis
○ Basophilia
○ Presence of blasts
● BONE MARROW
○ Hypercellular owing to eosinophilic proliferation and
can demonstrate Charcot-Leyden crystals
● Myeloblast numbers are elevated but below the 20%
threshold necessary to classify the disorder as an acute
leukemia
● Erythrocytes and megakaryocytes are normal in number
but sometimes demonstrate dysplastic morphologic
features
BONE MARROW FIBROSIS
● Occurs due to the release of eosinophilic basic protein and
eosinophilic cationic proteins from the eosinophil granules
8
HEMATOLOGY
Chapter 33: Myeloproliferative Neoplasms

● Contributes to the premature release of eosinophils into the range of severities

circulation, and they deposit in a variety of tissues

Seven subcategories of mastocytosis according to WHO

DIAGNOSIS group

1 Cutaneous mastocytosis
DIAGNOSIS OF CEL REQUIRES
2 Indolent systemic mastocytosis
★ Eosinophilia with a count more than .5 x 109 cells/L and
the presence of malignant features Systemic mastocytosis with associated clonal
★ Elimination of reactive eosinophilia and other 3
hematologic non-mast-cell-lineage disease
malignancies that have concomitant eosinophilia
4 Aggressive systemic mastocytosis
DIFFERENTIAL DIAGNOSIS EXCLUDES
5 Mast cell leukemia
★ Reactive conditions like:
○ Parasitic infections
6 Mast cell sarcoma
○ Allergies
○ Loeffler syndrome (pulmonary disease)
7 Extracutaneous mastocytoma
○ Cyclical eosinophilia
○ Angiolymphoid hyperplasia of the skin
○ Collagen vascular disorders
○ Kimura disease DIAGNOSIS
★ Other malignancies that can produce a concomitant
eosinophilia:
○ T cell lymphoma First diagnostic clue to
Typical skin lesion
○ Hodgkin lymphoma mastocytosis
○ Systemic mastocytosis
○ Chronic myelomonocytic leukemia Cutaneous mastocytosis occurs in
○ Atypical CML THREE FORMS
○ ALL
(which all occur predominantly in children):

Note: Mast cells are confined to the

These disorders lead to the release of a variety of interleukins 1. Urticaria Pigmentosa skin and form aggregates in
that can drive a secondary eosinophil reaction the dermis

2. Diffuse Cutaneous Mast cells are found in more

PROGNOSIS than one cutaneous location
Mastocytosis

● Survival is variable, but approximately 80% of patients will 3. Mastocytosis of the

-
live 5 years after diagnosis Skin
● UNFAVORABLE PROGNOSIS:
○ Features of dysplasia
○ An increase in karyotype abnormalities Systemic Mastocytosis
○ An increase in blasts

● Mast cells are observed in one area of the bone marrow

III. Mastocytosis
● It is a broad term referring to a clonal neoplastic proliferation
of mast cells, which accumulate in one or more organ
systems, but it can present differently and manifest in a
with fibrosis
● Other areas of the bone marrow are hypercellular with
panmyelosis
● Mast cells are identified in other extracutaneous sites
● In addition to the major criteria just described, at least one
of four minor criteria must be met:
(1) more than 25% of mast cells must be immature or have
9
HEMATOLOGY
Chapter 33: Myeloproliferative Neoplasms

atypical morphology, like a spindle shape months after diagnosis

(2) mast cells must express a KIT mutation at codon 816 ● Signs and symptoms that predict a poorer prognosis
(3) mast cells must express normal markers and CD2 include:
and/or CD25 ○ Elevated lactate dehydrogenase and alkaline
(4) total serum tryptase must be above 20 mg/mL phosphatase
○ Anemia
Six Types of Systemic Mastocytosis ○ Thrombocythemia
○ Abnormal peripheral blood morphology
○ Bone marrow hypercellularity
Indolent systemic ➔ Characterized by a low–mast
1 ○ Hepatosplenomegaly
mastocytosis cell burden

Systemic Presents with:

mastocytosis IV. Myeloproliferative Neoplasm, Unclassifiable
● Myelodysplastic syndrome
with associated
● Myeloproliferative neoplasm
2 clonal ● It is designed to capture disorders that clearly express
● AML
hematologic myeloproliferative features but either fail to meet the criteria
● Lymphoma
non–mast-cell-li of a specific condition or have features that overlap two or
● Another hematopoietic
more specific conditions
neage disease neoplasm

➔ Usually does not manifest with Most patients with MPN-U fall into one of three groups:
skin lesions or mast cells in
Aggressive circulation but does have Patients with an early stage of PV, ET, or PMF in which the
3 systemic mast cells in bone marrow, 1 criteria that define the disorders are not yet fully
mastocytosis dysplastic hematopoietic developed
changes, and/or
hepatosplenomegaly Patients presenting with features indicative of advanced
2 disease resulting from clonal evolution that masks the
➔ Characterized by more than potential underlying condition
Mast cell 20% atypical mast cells in the
4
leukemia bone marrow and more than Patients who have clear evidence of an MPN but who
10% in the peripheral blood 3 have a concomitant condition like a second neoplasm or
an inflammatory condition that alters the MPN features
● Presents as a single unifocal
Mast cell
5 mast cell tumor with a
sarcoma high-grade pathology In patients with
MPN-U in the
● Exhibits a unifocal mast cell ➢ The MPN-U may be reclassified to a
Extracutaneous early stages of
6 tumor, but it is of low-grade specific category of MPN once the
mastocytoma development or
pathology disease begins to express typical
with a
features or the secondary condition
concomitant
subsides
disorder like
PROGNOSIS inflammation

➢ The disorder may be reclassified as

● Cutaneous mastocytosis in children has a favorable In patients with
an acute leukemia once the blast
prognosis and may regress spontaneously around puberty an advanced
criterion of more than 20% blasts in
● Milder versions like cutaneous mastocytosis and indolent MPN
the bone marrow is met
cutaneous mastocytosis follow a benign course and are
associated with a normal life span
● Hematologic involvement usually evolves into the
corresponding hematologic disease
● Patients with aggressive systemic mastocytosis, mast cell
leukemia, and mast cell sarcoma are often treated with
cytoreductive chemotherapy but may survive only a few
10
HEMATOLOGY
Chapter 34: Myelodysplastic Syndromes

HISTORY ◆ Inherited hematologic disorders

● The pattern of abnormalities was referred to as: ➔ The mutated stem cell produces a
○ Refractory anemia pathologic clone of cells that
○ Smoldering leukemia expands in size at the expense of
○ Oligoblastic leukemia normal cell production. Because
○ Preleukemia each mutation produces a unique
clone with a specific cellular defect,
● In 1982, the French-American-British (FAB) Cooperative
MDSs have a multitude of
Leukemia Study Group proposed terminology and a
expressions.
specific set of morphologic criteria to describe what are
now known as myelodysplastic syndromes (MDSs)
● In 1997, a group from the World Health Organization
Apoptosis
(WHO) proposed a new classification that included
molecular, cytogenetic, and immunologic criteria in
● Programmed cell death
addition to morphologic features. The WHO classification
● Regulates cell population by decreasing cell survival
was revised in 2008
During early disease when
Apoptosis is INCREASED
peripheral blood cytopenias
MSDs in MDS are evident

● Are a group of acquired clonal hematologic disorders When progression toward

characterized by progressive cytopenias in the peripheral leukemia is apparent, allowing
Apoptosis is DECREASED
blood, reflecting defects in erythroid, myeloid, and/or the increase of neoplastic cell
in MDS survival and expansion of the
megakaryocytic maturation
● Rarely affect individuals younger than age 50 (because the abnormal clone
median age at diagnosis is 70) unless preceded by
chemotherapy or radiation for another malignancy
Other Important Factors

ETIOLOGY ★ Levels of antiangiogenic cytokines

★ Tumor necrosis factor
● MDS may arise de novo (primary MDS) or as a result of ★ Cellular components of the immune system
therapy (therapy-related MDS) ★ Interaction between MDS clonal cells
★ Hematopoietic inductive microenvironment

Primary MDS Note:

Patients with MDS have increased levels of angiogenic growth
● The initiating defect in most cases is at the level of the factors, including vascular endothelial growth factor
myeloid stem cell
● It may be that the affected hematopoietic stem cell has lost
its lymphopoietic potential, because only rarely does MDS Therapy-related MDS (t-MDS)
transform to acute lymphoblastic leukemia
● It is often more aggressive and may evolve quickly into
➔ May be the result of the cumulative acute myeloblastic leukemia (AML)
Abnormal stem
effects of environmental exposure in
cell susceptible individuals MEDIAN ONSET
➔ Varies with the agents used and is usually 4 to 7 years after
➔ May be caused by: therapy was initiated
◆ Chemical insult
Mutations ◆ Radiation PATIENTS AT RISK
◆ Viral infection ➔ Those who have been treated previously with chemotherapy
◆ Smoking or radiotherapy or both

1
HEMATOLOGY
Chapter 34: Myelodysplastic Syndromes

➔ Those who have received cytokines, such as G-CSF or

GM-CSF, for bone marrow stimulation

MORPHOLOGIC ABNORMALITIES IN PERIPHERAL BLOOD

AND BONE MARROW
Are ALL indications that the
erythrocyte has undergone abnormal
● In MDS, each of the three major myeloid cell lines has development
dyspoietic morphologic features

Morphologic Findings in the Bone Marrow

1. Dyserythropoiesis
★ RBC precursors with more than one nucleus or abnormal
nuclear shapes
Morphologic Findings in Peripheral Blood ★ The normally round nucleus may have lobes or buds
★ Nuclear fragments may be present in the cytoplasm
★ Internuclear bridging is occasionally present
★ Abnormal cytoplasmic features may include basophilic
stippling or heterogeneous staining
★ Ring sideroblasts are a common finding
Oval macrocytes ★ Megaloblastoid cellular development in the presence of
normal vitamin B12 and folate values is another indication
➔ Most common in
of MDS
dyserythropoiesis
➔ Can be associated with MDS if
seen in the presence of normal
2. Dysmyelopoiesis
vitamin B12 and folate values

In the Peripheral Blood

★ Persistence of basophilia in the cytoplasm of otherwise

Hypochromic
mature white blood cells (WBCs), indicating
microcytes nuclear-cytoplasmic asynchrony
★ Abnormal granulation of the cytoplasm of neutrophils, in
Associated with MDS if seen in the the form of larger than normal granules, hypogranulation,
presence of adequate iron stores or the absence of granules, is a common finding
★ Agranular bands can be easily misclassified as
monocytes
★ Abnormal nuclear features may include
hyposegmentation, hypersegmentation, or nuclear rings
Dimorphic red
blood cell (RBC)
In the Bone Marrow
Another indication of the clonality of
the disease ★ Nuclear-cytoplasmic asynchrony
★ Cytoplasmic changes include uneven staining, such as a
● Poikilocytosis dense ring of basophilia around the periphery with a clear
● Basophilic unstained area around the nucleus or whole sections of
stippling cytoplasm unstained, with the remainder of the
cytoplasm stained normally
● Howell-Jolly
★ Abnormal granulation of the cytoplasm in which
bodies
promyelocytes or myelocytes or both are devoid of
● Siderocytes primary granules
○ Primary granules may be larger than normal

2
HEMATOLOGY
Chapter 34: Myelodysplastic Syndromes
○ Secondary granules may be reduced in number or
absent
★ There may be an occasional Auer rod
★ Agranular promyelocytes may be mistaken for blasts
○ This could lead to misclassification of the disease in
the AML scheme
★ Abnormal nuclear findings may include
hypersegmentation or hyposegmentation and possibly
ring-shaped nuclei
★ Granulocytic hypoplasia or hyperplasia
★ Monocytic hyperplasia
★ Abnormal localization of immature precursor
○ A characteristic finding in bone marrow biopsy
specimens from patients with MDS
○ Cells located centrally instead of along the endosteal
surface
3. Dysmegakaryopoiesis
In the Peripheral Blood
★ Giant platelets
★ Abnormal platelet granulation (either hypogranulation or
agranulation)
★ Some platelets may possess large fused granules
★ Circulating micromegakaryocytes may be present in
peripheral blood from patients with MDS
In the Bone Marrow
★ Large mononuclear megakaryocytes
★ Micromegakaryocytes or micromegakaryoblasts
★ The nuclei in these cells may be bilobed or have multiple
small, separated nuclei
DIFFERENTIAL DIAGNOSIS
● Dysplasia by itself is NOT sufficient evidence for MDS,
because several other conditions can cause similar
morphologic features. Some examples are:
○ Vitamin B12 or folate deficiency, which can cause
pancytopenia and dysplasia, and exposure to heavy
metals
○ Copper deficiency may cause reversible
myelodysplasia
○ Some congenital hematologic disorders, such as
Fanconi anemia and congenital dyserythropoietic
anemia
○ Parvovirus B19 and some chemotherapeutic agents
may give rise to dysplasia similar to that in MDS
○ Paroxysmal nocturnal hemoglobinuria has similar
features, as does human immunodeficiency virus
(HIV)
ABNORMAL CELLULAR FUNCTION
● Granulocytes may have:
○ Decreased adhesion
○ Deficient phagocytosis
○ Decreased chemotaxis
○ Impaired microbicidal capacity
● Decreased levels of myeloperoxidase and alkaline
phosphatase may be found
● The RBCs may exhibit shortened survival
● Erythroid precursors may have a decreased response to
erythropoietin that may contribute to anemia
● Patients may experience increased bleeding despite
adequate platelet numbers
CLASSIFICATION OF MYELODYSPLASTIC SYNDROMES
A. French-American-British Classification
CLASSIFICATIONS:
1. Refractory anemia
2. Refractory anemia with ring sideroblasts (RARS)
3. Refractory anemia with excess blasts (RAEB)
4. Chronic myelomonocytic leukemia (CMML)
5. Refractory anemia with excess blasts in transformation
(RAEB-t)
● The FAB classification provided a framework for discussion
of a seemingly heterogeneous group of disorders; however,
its reliance on morphology alone limited its usefulness as a
prognostic indicator
● The FAB classification did not view MDSs in their totality
because it did not address therapy related or hereditary
forms, and childhood MDS was not considered
● The WHO classification retains many of the FAB features,
while recognizing molecular, cytogenetic, and immunologic
characteristics of these disorders. The WHO classification
also removed the problematic categories of CMML and
RAEB-t and placed them in MDS/MPD and acute leukemia,
respectively
B. World Health Organization Classification
● The original modifications from the FAB classification of
MDS included:
3
HEMATOLOGY
Chapter 34: Myelodysplastic Syndromes
○ A reduction in the percentage of blasts required for
diagnosis of AML from 30% to 20%
○ The recognition of two new classifications: (1) refractory
cytopenia with multilineage dysplasia (RCMD) and (2)
del(5q) syndrome
● The 2008 revision of the WHO criteria added the category
of refractory cytopenia with unilineage dysplasia (RCUD),
refined some categories, and added the provisional category
of childhood MDS, also called refractory cytopenia of
childhood
CLASSIFICATIONS:
1. Refractory cytopenia with unilineage dysplasia
2. Refractory anemia with ring sideroblasts
3. Refractory cytopenia with multilineage dysplasia
4. Refractory anemia with excess blast
5. Myelodysplastic syndrome with isolated del(5q)
6. Myelodysplastic syndrome, unclassifiable
7. Childhood myelodysplastic syndrome (provisional)
Refractory Cytopenia with Unilineage Dysplasia
(RCUD)
● In the peripheral blood: <1% blasts
● In the bone marrow: <5% blasts
● Dysplasia must be present in more than 10% of a single
myeloid lineage
● Median survival is generally 2 to 5 years, with only a 2% risk
of transformation to acute leukemia
Symptoms related to cytopenia:
★ Fatigue or shortness of breath if anemia is present
★ Increased infections from neutropenia
★ Petechiae
★ Bruising, or bleeding if thrombocytopenia is present
Included in RCUD is:
★ Refractory anemia with only dyserythropoiesis (but less
than 15% ring sideroblasts)
★ Refractory neutropenia
★ Refractory thrombocytopenia
Refractory Anemia with Ring Sideroblasts
(RARS)
● Anemia and dyserythropoiesis are present
● More than 15% of the bone marrow erythroid precursors are
ring sideroblasts
○ To be considered a ring sideroblast, an erythroid
precursor must contain at least five iron granules per
cell, and these iron-containing mitochondria must circle
at least one third of the nucleus
● In the peripheral blood there may be a dimorphic picture,
with a population of hypochromic cells along with a majority
of normochromic cells
● RARS occurs primarily in the older population
● Mean survival: 69 to 108 months
Refractory Cytopenia with Multilineage Dysplasia
(RCMD)
Categorized by:
★ One or more cytopenias
★ Dysplasia in two or more myeloid cell lines
★ Less than 1% blasts in peripheral blood
★ Less than 5% blasts in the bone marrow
● In RCMD, the myeloblasts do not contain Auer rods; if Auer
rods are noted, the disorder is classified as RAEB-2
● Some cases of RCMD have more than 15% ring sideroblasts,
but the dyspoiesis in more than the erythroid line places
them in the RCMD rather than the RARS category. This
distinction is important, because RCMD has a more
aggressive course than RARS
Refractory Anemia with Excess Blasts
(RAEB)
● Trilineage cytopenias, as well as significant dysmyelopoiesis,
dysmegakaryopoiesis, or both, are common in RAEB
● In the peripheral blood: 2% to 19% blasts
● In the bone marrow: 5% to 19% blasts
● RAEB is distinguished from RCMD by myeloblast
percentage
● Because there are significant differences in survival and
because evolution to AML may occur, the WHO
classification divided RAEB into two types, depending on
the percentage of blasts in blood and bone marrow:
○ RAEB-1 — 5% to 9% blasts in the bone marrow or 2% to
4% blasts in the peripheral blood
○ RAEB-2 — 10% to 19% blasts in the bone marrow and 5%
to 19% blasts in the peripheral blood
● The presence of Auer rods, regardless of blast count,
qualifies a case as RAEB-2
● RAEB with greater than 10% myeloblasts has a more
aggressive course, with a greater percentage of cases
transforming to AML
Myelodysplastic Syndrome with Isolated del(5q)
(5q– Syndrome)
● In patients who have only the deletion of 5q (5q–),
4
HEMATOLOGY
Chapter 34: Myelodysplastic Syndromes
○ MDS represents a fairly well-defined syndrome,
affecting predominantly women and occurring at a
median age of 67
○ These patients typically have refractory anemia without
other cytopenias and/or thrombocytosis, hypolobulated
megakaryocytes, and erythroid hypoplasia
○ There are less than 1% blasts in the peripheral blood,
and Auer rods are not seen
● Patients with MDS with isolated del(5q) have long-term
stable disease (median survival, 145 months)
● The thalidomide analogue lenalidomide (Revlimid) has
proven to be effective in patients with isolated del(5q), as
well as in those with del(5q) and additional cytogenetic
abnormalities
Myelodysplastic Syndrome, Unclassifiable
● Its category refers to subtypes of MDS that initially lack the
specific changes necessary for classification into other MDS
categories
● If characteristics of a specific subtype develop later, the
case should be reclassified into the appropriate group
Childhood Myelodysplastic Syndromes
● De novo MDS in children is very rare, and although some of
the characteristics of adult MDS are present, there are also
some distinct differences
● The 2008 WHO classification introduced a provisional
category of refractory cytopenia of childhood
MYELODYSPLASTIC/MYELOPROLIFERATIVE NEOPLASMS
● The MDS/MPN category includes myeloid neoplasms with
clinical, laboratory, and morphologic features that are
characteristic of both MDS and MPN
Included in this classification are:
➔ Chronic myelomonocytic leukemia
➔ Atypical chronic myeloid leukemia
➔ Juvenile myelomonocytic leukemia
➔ MDS/MPN, unclassifiable, with a provisional subtype of
refractory anemia with ring sideroblasts and thrombocytosis
Chronic Myelomonocytic Leukemia
(CMML)
Characterized by:
★ A persistent monocytosis of more than 1.0 monocyte x 109/L
★ Absence of the BCR/ABL1 fusion gene
★ Less than 20% blasts and promonocytes in the peripheral
blood and bone marrow
★ Dysplasia in one or more myeloid cell line
★ An increased leukocyte count with absolute monocytosis
★ Dysgranulopoiesis, but neutrophil precursors make up less
than 10% of the total leukocytes
★ Splenomegaly due to infiltration of leukemic cells
● Although cytogenetic abnormalities are found in up to 40%
of patients, there is none specific for CMML
● Prognosis varies, depending on the number of blasts plus
promonocytes
➔ In the peripheral blood: <5% blasts and
CMML-1 promonocytes
➔ In the bone marrow: <10%
➔ In the peripheral blood: 5% to 19% blasts and
CMML-2 promonocytes
➔ In the bone marrow: 10% to 19%
Atypical Chronic Myeloid Leukemia, BCR/ABL1 Negative
Characterized by:
★ Leukocytosis with morphologically dysplastic neutrophils
and their precursors
★ Basophilia (may be present, but not a prominent feature)
★ Multilineage dysplasia (common)
★ The BCR/ABL1 fusion gene (not present), but a variety of
other karyotypic abnormalities may be seen
★ Dyspoiesis may be seen in all cell lines, but it is most
remarkable in the neutrophils, which may exhibit
Pelger-Huët–like cells, hypogranularity, and bizarre
segmentation
● The prognosis is poor for patients with aCML, who either
progress to AML or succumb to bone marrow failure
Juvenile Myelomonocytic Leukemia
● It is a clonal disorder characterized by proliferation of the
granulocytic and monocytic cell lines and affects children
from 1 month to 14 years of age
● There is a strong association with neurofibromatosis type 1
● Allogeneic stem cell transplantation is effective in about
50% of patients
5
HEMATOLOGY
Chapter 34: Myelodysplastic Syndromes

Myelodysplastic/Myeloproliferative Neoplasm, Epigenetics

Unclassifiable
● It is used for cases that meet the criteria for MDS/MPN but
do not fit into one of the specified subcategories
● Within this group, there is a provisional entity that has
features of refractory anemia with ring sideroblasts and
thrombocytosis (RARS-T) and also carries the JAK2 V617F
mutation
CYTOGENETICS, MOLECULAR GENETICS, AND EPIGENETICS
● It describes changes in gene expression that occur without
altering the DNA sequence
● Gene function is affected through selective activation or
inactivation, rather than a change in the primary nucleotide
sequence itself
● In oncogenesis, regions of a gene with specific regulatory
functions, such as apoptosis, may be hypermethylated
● Incorporation of demethylating agents into the DNA
appears to slow the progression of MDS, although the
mechanism is not clearly understood

Cytogenetics PROGNOSIS

● Chromosome abnormalities are found in about 50% of ● The basis of the revised system retained three of the
cases of de novo MDS and 90% to 95% of t-MDS original parameters:
● Karyotype has a major effect on prognosis in MDS patients, ○ Cytogenetics
and specific karyotypes can be used cautiously to predict ○ Bone marrow blast percentage
response to certain treatments ○ Cytopenias
● Balanced translocations, which are common among ● Other features that affected survival but not
patients with AML, are found only rarely in cases of de novo transformation into AML included:
MDS. Except for del(5q), no cytogenetic abnormality is ○ Patient age
specific to subtype ○ Serum ferritin
○ Patient performance status
○ Lactate dehydrogenase levels
Most common Chromosomes 5, 7, 8, 11, 13,
abnormalities and 20
TREATMENT

Most common single

Trisomy 8 and monosomy 7
abnormalities ● Supportive care
○ Predominant mode of treatment for most MDS patients,
Less common 12p–, iso 17, –22, and loss of except those who qualify for stem cell transplantation
the Y chromosome ○ Includes administration of blood products (RBCs and
abnormalities in MDS
platelets as necessary) and prevention or treatment of
infections with antibiotics
● Lenalidomide, Azacitidine, and Decitabine
Molecular Alterations ○ Three drugs approved by the U.S. FDA that show
promise when used either alone or in combination with
● Although not specific to MDS, the most common mutations other therapies
include those in the TP53 gene, RUNX1, and TET2
● NRAS has been detected in a small percentage of MDS ➔ A thalidomide analogue that is
patients. It appears that a multistep process is required for less toxic than thalidomide, was
transformation of MDS to AML approved by the FDA in 2005 for
use in patients with low- or
Lenalidomide intermediate-risk MDS
TET2 Confer a more favorable prognosis
(Revlimid; Celgene, ➔ It has shown remarkable
Summit, NJ) promise, especially in patients
TP53 Confer a higher risk of transformation
with the 5q chromosome arm
deletion
➔ It has immunomodulatory and
antiangiogenic effects

6
HEMATOLOGY
Chapter 34: Myelodysplastic Syndromes

Belong to a group of drugs that

deplete intracellular
methyltransferases (DMNTs) and are
Azacitidine and
effective in low dose, with minimal
decitabine side effects, and have improved the
quality of life for patients with
high-grade MDS

● Immunosuppressive therapy
○ Along with drugs such as antithymocyte globulin and
cyclosporine has resulted in decreased risk of leukemic
transformation in patients with low-risk MDS
● Hypomethylating agents
○ Patients with high-risk MDS benefit from treatment
with hypomethylating agents such as azacitidine and, to
a lesser extent, decitabine
● Allogeneic stem cell transplantation
○ Patients with an IPSS score of intermediate 2 or higher
and patients with more than 10% blasts should consider
this

Additional Notes:
● The only cure is hematopoietic stem cell transplantation
● Stem cell transplantation is most successful in patients
younger than age 70 with no comorbidity