DATE: 18.10.

2023 HDPCS PRACTICAL P2

THEME: HAEMATOLOGICAL MALIGNANCIES

TOPIC: EXAMINATION OF PERIPHERAL SMEAR IN MYELOID LEUKEMIA (AML, CML) AND
LYMPHOID LEUKEMIA.

OBJECTIVE:
At the end of the exercise the student should be able to identify the morphologic changes in
the WBCs in acute and chronic myeloid leukemia, lymphoid leukemia.

INSTRUCTION:
1) Label:
i. Acute Myeloid Leukemia (AML)
ii. Chronic Myeloid Leukemia (CML)
iii. Acute Lymphoblastic Leukemia (ALL)
iv. Multiple Myeloma
2) For the above conditions, list the clinical manifestations (symptoms and signs) of the
disease based on the morphologic findings
ACUTE MYELOID LEUKEMIA, SLIDE NO. 86

Leukemia is a group of malignancy of either lymphoid or hematopoietic cell origin. The

number of circulating leukocytes is greatly increased. Bone marrow is diffusely infiltrated with
leukemic cells with consequent failure of normal WBC, RBC, and Platelet production
resulting in anemia, infection, or hemorrhage.

Risk factors:
1. Chemicals
2. Smoking
3. Chemo/radiotherapy
4. Myelodysplastic syndrome
5. Atomic bomb blast
6. Weak immune system

AML Occurs most often in adults. A predominance of myeloblasts and early promyelocytes
in the bone marrow and peripheral blood is characteristics.

Smear shows increased WBCs number, and most of these WBCs are myeloblasts having
large nuclei with few prominent nucleoli (2-5) and delicate nuclear chromatin. The cytoplasm
of the myeloblasts has fine granules. Auer rods can be seen.
Characteristic features of Myeloblast:
 Fine homogenous nuclear chromatin.
 2-5 prominent nucleoli.
 Cytoplasm more abundant as compared to lymphoblast.
 Cytoplasmic granules and Auer rods can be seen.
 Auer rods (Fused azurophil granules)- only present in AML (M2 & M3)
 They are not present in myeloblast in CML.

Signs and symptoms of acute myelogenous leukaemia include:

1. Common in adults from 15-39 years of age.

2. Fever, bone pain, lethargy, and fatigue.

 3. Shortness of breath, pale skin, frequent infections.

4. Easy bruising, unusual bleeding, such as frequent nosebleeds and

bleeding from the gums.

5. Special stain used for diagnosis: MPO (Myeloperoxidase), Sudan

Black B positive, and NSE (Nonspecific esterase), positive in M4
and M5 AML.

6. AML responds to current therapy more poorly than ALL.

CHRONIC MYELOID LEUKEMIA, SLIDE NO. 87

CML is a neoplastic clonal proliferation of myeloid stem cells. This is one of the
myeloproliferative syndromes which includes:

1. CML
2. Polycythemia vera
3. Chronic idiopathic myelofibrosis and
4. Essential thrombocythemia.

Proliferation of one or more myeloid series cell types.

Increased in peripheral blood basophils and nucleated RBC.
Increased serum uric acid.
Prominent splenomegaly.

Karyotyping reveals Philadelphia Chromosome which is characterized by distinctive

translocation between 9:22 chromosome (ABL gene in chromosome 9 and BCR gene in
chromosome 22).

Diagnosis:
1. Peripheral Blood Film: Leukocytosis, presence of neutrophils, myelocytes,
metamyelocytes and few blasts (<10%). Eosinophilia and basophilia.
2. Bone Marrow examination: Hypercellular with myeloid hyperplasia. Megakaryocytes
increased in number (small dysplastic forms).
3. FISH, RT-PCR also be used.
Smear shows marked leukocytosis with many neutrophils & neutrophil precursors, including
myelocytes, metamyelocytes, band form and few myeloblasts. Basophils are also increased
in number. RBCs are normocytic & normochromic. The platelets count is increased.

Clinical Features include:

1. Common in adults 35-50 years.

2. Weakness, Fatigue, Night sweats, Weight loss.

3. Fever, Bone pain (caused by leukemia cells spreading from the marrow cavity to the
surface of the bone or into the joint),

4. An enlarged spleen (felt as a mass under the left side of the ribcage).
5. Pain or a sense of "fullness" in the belly.

6. Karyotyping: reveals the Philadelphia chromosome (t 9:22) in 90% of cases.

ADDITIONAL READING:
 Kumar V, Abbas AK, Aster JC. Robbins & Cotran Pathologic Basis of Disease, 9 th edition.
Elsevier Saunders. ISBN-978-1-4557-2613-4. Chapter-13. Page no.586, 611-614 and 616-618.
 A.V. Hoffbrand, P.A.H. Moss. Essential Haematology, 6th edition. Wiley-Blackwell
Publishing Company. 2011. ISBN: 978-1-4051-9890-5. Chapter-13, Page No.179-190 and
Chapter-14, Page No.192-199.
DATE: 18.10.2023 HDPCS PRACTICAL P2

THEME: MYELOPROLIFERATIVE DISORDERS & HAEMATOLOGICAL MALIGNANCIES

TOPIC: EXAMINATION OF PERIPHERAL SMEAR IN LYMPHOPROLIFERATIVE DISORDERS
(ALL).

OBJECTIVE:
At the end of the exercise the student should be able to identify the morphologic changes in
the lymphoid precursors in ALL.

ACUTE LYMPHOBLASTIC LEUKEMIA, SLIDE NO. 88

ALL is the malignancy of lymphoid precursor cells which originate in the bone marrow or
thymus.

75-80% CASES are of B-precursor cells.

20-25% CASES are of T-precursor cells.

The hallmark is the presence of blasts in the peripheral blood and bone marrow with
reduction of normal haemopoietic cells.

Smear shows a large number of lymphoblasts having large nuclei, absent or inconspicuous
nucleoli, and scanty agranular cytoplasm.

Characteristic features of Lymphoblasts:

 Nuclear chromatin is clumped and coarse (more condensed)
 1-2 nucleoli (Lymphoblasts have fewer nucleoli than myeloblasts)
 Scanty agranular cytoplasm (Cytoplasmic granules are absent)
 PAS is positive.
Diagnosis:

 Clinical features
 Leukocytosis with increased number of blasts.
 Cytochemistry, Immunophenotyping
 Bone Marrow is hypercellular flooded with blasts. Lymphoblasts should be >25%.
 Myeloid markers like anti MPO, CD117, CD13, and CD33, are employed to rule out
myeloid lineage.

Clinical features include:

1. Majority of cases are aged 1-5 years. Second peak is observed in adults 30-40
years of age.

2. Feeling tired, weak, dizzy, or lightheaded, Shortness of breath.

3. Fever, Infections that do not go away or keep coming back, bruising easily.

4. Bleeding, such as frequent or severe nosebleeds and bleeding gums.

5. PAS positive.

6. Terminal deoxynucleotidyl transferase (TdT) is a biochemical marker for acute

lymphoblastic leukemia (ALL).

7. Prognosis: Better prognosis in children who are <1 year or >10 years old.
ADDITIONAL READING:
 Kumar V, Abbas AK, Aster JC. Robbins & Cotran Pathologic Basis of Disease, 9 th
edition. Elsevier Saunders. ISBN-978-1-4557-2613-4. Chapter-13. Page no.590-593,
588, 590, 609, 611 and 598-602.
 A.V. Hoffbrand, P.A.H. Moss. Essential Haematology, 6th edition. Wiley-Blackwell
Publishing Company. 2011. ISBN: 978-1-4051-9890-5. Chapter-17, Page No.224-
228; Chapter-19, Page No.246-250 and Chapter-21, Page No.273-282.