2014 Curs Hematologie - Baza-1

Universitatea Titu Maiorescu
CURS MEDICINA INTERNA

Hematologie

Prof univ dr Ion C.Tintoiu
Overview of Hematology
3
Basic scheme
Blood leaves the heart in
arteries
Branching of arteries until
they become tiny capillaries
Oxygen and nutrients diffuse out
CO2 and wastes diffuse in
Capillaries form veins going to the heart
The blood leaves the right side of the heart for the
lungs to pick up O2 and release CO2
Blood goes back to the left side of the heart to start all
over
Note: vessels going to the heart are veins; those leaving the heart are arteries
Summary of blood forming
organs
5
Composition of blood
Specialized connective tissue
Blood cells (formed elements) suspended in plasma

Blood volume: 5-6 liters (approx 1.5 gal) in males
and 4-5 liters in females
6
Blood
Centrifuged (spun) to separate
Clinically important hematocrit
% of blood volume consisting of erythrocytes (red
blood cells)
Male average 47; female average 42
Plasma at top: water with many ions,
molecules, and 3 types of important proteins:
Albumin
Globulins
Fibrinogen
7
Serum
Blood that is allowed to stand clots
Clot is a tangle of the formed elements (some are not
truly cells)
RBCs lack nuclei and organelles
Platelets are fragments
Most cannot divide
Clear fluid serum is left = plasma without the clotting
factors

When spun in centrifuge,
buffy coat lies between
RBCs and plasma: of
leukocytes (white blood cells)
and platelets

8
Blood is
examined in a
smear
Smears are
stained
Scanning EM
Light microscope
9
Hematopoiesis
Formation of blood cells
Occurs mostly in red bone marrow
All cells arise from same blood stem cell
(pluripotent hematopoietic stem cells)
Recently some have been found in adults
which are mesenchymal stem cells, which can
also form fat cells, osteoblasts, chondrocytes,
fibroblasts and muscle cells

10
11
Blood stem cells divide into:
1.myeloid stem cells or
2.lymphoid stem cells

All except for
lymphocytes arise
from myeloid stem
cells
All originate
in the bone
marrow
Not shown
are mast
cells,
osteoclasts,
dendritic
cells

12
Erythrocytes
Also called RBCs or red blood
cells
Biconcave discs and flexible
Plasma membrane but no nuclei or
organelles
Packed with hemoglobin
molecules
Oxygen carrying protein
4 chains of amino acids, each with
iron which is binding site for oxygen;
CO2 carried also
Young ones still containing
ribosomes are called reticulocytes
Live 100-120 days
heme
iron atom
13
Leukocytes

AKA WBCs:
white blood
cells

14
Leukocytes

AKA WBCs: white
blood cells
Are complete cells
Function outside the
blood

Note the size difference
compared to erythrocytes
neutrophil eosinophil
basophil
small lymphocyte monocyte
__RBC
15
Leukocyte types
Artificial division into granulocytes and
agranulocytes
Granulocytes: neutrophils, eosinophils,
basophils (according to how stain)
Granules
Lobed nuclei
All are phagocytic
Agranulocytes: lymphocytes, monocytes

16
All except for
lymphocytes
arise from
myeloid stem
cells
All originate in the
bone marrow
Not shown are mast cells,
osteoclasts, dendritic cells
Remember this slide?
See the artificial division?
17
Neutrophils
60% of all WBCs
Nuclei of 2-6 lobes
Other names:
Polymorphonuclear cells (PMNs, polys, segs)
Granules have enzymes
Can damage tissue if severe or prolonged
Pus

18
Eosinophils
1-4 % of leukocytes
Bilobed
Granules have digestive enzymes
Role in ending allergic reactions and in
fighting parasitic infections
19
Basophils
Rarest WBC
Bilobed nucleus
Dark purple granules
Later stages of reaction to allergies and
parasitic infections
20
Lymphocytes*
Most important
WBC
20-45%
Most are
enmeshed in
lymphoid
connective tissue,
e.g. lymph nodes,
tonsils, spleen
*
21
Lymphocytes:
nucleus occupies most of the
cell volume
Response to antigens (foreign proteins or parts of cells)
is specific

Two main types attack antigens in different ways
T cells
B cells
plus natural killer cells
22
T cells attack foreign cells directly
Killer cells (cytotoxic), or CD8+ is a
main type
23
B cells
Differentiate into plasma cells
Plasma cells secrete antibodies
Antibodies flag cells for destruction by
macrophages (see stem cell chart)
24
Monocytes*
4-8% of WBCs
In connective tissue
they transform into
macrophages
(phagocytic cells
with pseudopods)
*
25
Platelets*
Not cells
Small fragments
broken off from
megakaryocytes
Important in
forming clots in
damaged vessels
AKA thrombocytes

*
26
Clots
Undesirable clots:
Thrombus
Embolus

Platelet and several RBCs trapped
in a fibrin mesh
Platelet__________________
27
Significant
young cells
Reticulocytes* (young
erythrocytes): 1-2%of
all RBCs
retic count helps
determine if producing
RBCs at accelerated rate
(anemia, move to a high
climate, etc.)
Bands* (young
neutrophils): 1-2% of
all WBCs
Increases with acute
bacterial infections

*
*
28
Disorders of Blood cells
.
29
Disorders of Erythrocytes
Polycythemia: too many cells
Anemia: not enough cells
Sickle cell disease: genetic disease AR
1/400 African Americans
Defect in hemoglobin
Plus many others
30
Disorders of Leukocytes
Leukemia: too many, abnormal, crowd out
normal marrow
Classified into
Lymphoblastic or myeloblastic
Acute or chronic

Disorders of Platelets
Thrombocytopenia
Causes internal bleeding
Many causes
31
Laboratory
CBC: complete blood count (to review)

Hemoglobin (gm/dl)
Hematocrit (%)
RBC count
WBC in thousands/cumm
Differential if ordered: broken down to amount of each
type WBC
Platelet count in thousands/cumm
32
Laboratory continued
Clotting: coags
for preop evaluation (before surgery)
to evaluate effectiveness of anticoagulant drugs, e.g.
aspirin, heparin, coumadin
Bleeding time
PT - Protime
PTT - Partial thromboplastin time
INR

ESR erythrocyte sedimentation rate
Indicator of infection or inflammation
33
Blood Typing
ABO blood groups: A, B, AB, and O
34
If a blood transfusion is given to a person who
has antibodies to that type of blood, then the
transfused blood will be attacked and
destroyed (transfusion reaction)
35
ABO blood group types
Blood
type
Antigen on
rbc
Antibodies in
blood
Can receive blood from: Can donate blood to
(usually RBCs only):
Frequency
in US
A A anti-B A
O
not B (you have anti-B) *
not AB (you have anti-B) *
A
AB
40%
B B anti-A B
O (no Ags so you wont reject)
not A (you have anti-A) *
not AB (you have anti-A) *
B
AB
10%
AB A and B none to
A or B
AB AB is universal recipient
A
B
O
AB 4%
O not A nor B Anti-A and anti-B not A (have anti-A)*
not B (have anti-B)*
not AB (have both antibodies)*
O
A
B
AB
O O is universal donor
46%
Ag = antigen on red blood cell
*=transfusion reaction (hemolysis of new cells)
The blood types are codominant i.e. if genotype is AB, then you have both
A and B antigens on your RBCs
36
Rh factor
The Rh factor is another major antigen on the RBC, called D
is autosomal recessive
DD and Dd: Rh+
dd: Rh-
If mom is Rh- and baby is Rh+, then small amount of blood
leaks into moms blood through placenta, and she makes
antibodies to D antigen; first Rh- pregnancy usually ok, but
not later Rh- ones (can be lethal to baby)
If mom is Rh- then give Rhogam during pregnancy [(is anti-
Rh(D): Rh(D) Ig (immunoglobin)], an antibody which will
destroy any of the babys RBCs which leak into moms blood
during the pregnancy so she will not mount an immune
response to the D antigen
If father is Rh+:
If DD then all pregnancies will be Rh+
If Dd then half of the pregnancies with this mom will be Rh- (no Rh
incompatibility problems)
37
Rhogam (FYI)
Risks to the baby
If the babys blood cells are attacked and depleted during pregnancy it can lead to anemia, jaundice,
mental retardation and heart failure. It can even be fatal in utero or shortly after delivery. The
condition is known as Hemolytic Disease of the Newborn. Luckily, appropriate treatment with
Rhogam can almost completely eliminate the risk.

[edit] Rh Negative treatment with Rhogam
Rhogam is a sterile solution that is injected intramuscularly. It is made from human plasma that
contains anti-D. Most often Rhogam is given to women at 28 weeks of pregnancy. The Rh negative
mother is most likely to be exposed to the babys blood in the last 3 months of pregnancy, so a
second dose is often given within 72 hours of delivery if the baby is found to be Rh positive. A
mother must also receive a dose after any invasive procedure such as amniocentesis or after an
induced termination, miscarriage or ectopic pregnancy.
[edit] Side effects
Side effects of Rhogam are mild and include soreness tenderness, warmth or a rash at the injection
site. Other side effects can include:
Fever
Chills
Headache
Fatigue

http://wikiparenting.parentsconnect.com/wiki/Rhogam_in_pregnancy
38
FYI

Blood
Blood is the fluid of life
Blood is composed of:
Plasma
RBC
WBC
Platelets

Plasma
Plasma consists of:
90% water.

10 % solutes: albumin, electrolytes and
proteins.

Proteins consist of clotting factors, globulins,
circulating antibodies and fibrinogen.

Red Blood Cells
RBCs travel through the body delivering
oxygen and removing waste.
RBCs are red because they contain a
protein chemical called hemoglobin which
is bright red in color.
Hemoglobin contains iron, making it an
excellent vehicle for transporting oxygen
and carbon dioxide.
RBCs
Average life cycle is 120
days.
The bones are continually
producing new cells.
White Blood Cells
The battling blood cells.
The white blood cells are continually on the
look out for signs of disease.
When a germ appears the WBC will:
Produce protective antibodies.
Surround it and devour the bacteria.
WBCs
WBC life span is from a few days to a few
weeks.
WBCs will increase when fighting
infection.

Platelets
Platelets are irregularly-
shaped, colorless bodies
that are present in blood.
Their sticky surface lets
them form clots to stop
bleeding.

Blood Values
CBC with differential and platelet count.
Hgb:
Normal levels are 11 to 16 g / dl
Panic levels are:
Less than 5 g / dl
More than 20 g / dl
Hematocrit
Normal hematocrit levels are 35 to 44%.
Panic levels:
Hmct less than 15 %
Hmct greater than 60%
Hemoglobin and Hematocrit
Can be used as a simple blood test to screen
for anemia.
The CBC with differential would be used to
help diagnose a specific disorder.
A bone marrow aspiration would be the
most conclusive in determining cause of
anemia aplastic / leukemia.
Bone Marrow
Bone marrow is the spongy substance found
in the center of the bones.
It manufactures bone marrow stem cells,
which in turn produce blood cells.
Red blood cells carry oxygen to tissue
Platelets help blood to clot
White blood cells fight infection

Bone Marrow Transplant
Donor is placed under anesthesia.
Marrow is aspirated out of the iliac crest.
Marrow is filtered and treated to remove
bits of bone and other unwanted cells and
debris, transferred to a blood bag, and is
infused into the patients blood just like at
transfusion.
WHAT IS HEMATOLOGY?
Hematopoiesis formation and
development of blood cells.
Cells of the blood are constantly being lost
or destroyed. to maintain homeostasis, r.
This system involves:
Proliferation of progeny stem cells
Differentiation and maturation of the stem
cells into the functional cellular elements.
In normal adults, the proliferation,
differentiation, and maturation of the
hematopoietic cells (RBCs, WBCs, and platlets)
is limited to the bone marrow

Hematopoiesis
What is hematology?
Hematopoiesis
Hematopoiesis in the bone marrow is called
medullary hematopoiesis
Hematopoiesis in areas other then the bone marrow
is called extramedullary hematopoiesis
Extramedullary hematopoiesis may occur in fetal
hematopoietic tissue (liver and spleen) of an adult when the
bone marrow cannot meet the physiologic needs of the
tissues. This can lead to hepatomegaly and/or
splenomegaly (increase in size of the liver and/or spleen
because of increased functions in the organs).
Hematopoietic tissue includes tissues involved
in the proliferation, maturation, and destruction
of blood cells

What is hematology?
The mononuclear phagocytic system (also called the
reticular endothelial system or RES) is involved in
cellular destruction and it includes:
Circulating blood monocytes
Fixed macrophages in the bone marrow, liver, spleen, and
lymph nodes
Free macrophages
These cells are involved in:
Engulfing particulate matter
Processing of antigens for lymphocyte presentation
Removal of damaged or senescent (aged) cells
What is hematology?
Spleen contains the largest collection of
lymphocytes and mononuclear phagocytes in the
body. The spleen functions in:
Filtering and destruction of senescent (aged) or
damaged RBCS also called culling
Removal of particles (are found in some types of anemia)
from RBC membranes also called pitting this causes a
decrease in the surface to volume ratio of the RBC resulting
in the formation of spherocytes (more on this later)
Enforcing close contact of blood borne antigens with
lymphocytes and phagocytic cells this is more important
in children particularly in protection of the host from
infections due to enveloped organisms
What is hematology?
Sequestering 1/3 of the platlet mass in massive
splenomegaly this can lead to peripheral thrombocytopenia
(decrease in platlets in the peripheral blood)
After a splenectomy (removal of the spleen), RBC
inclusions and abnormal RBC shapes are seen. Culling is
taken over by the liver which is less effective in performing
all of the splenic functions
Hypersplenism (splenomegaly) in a number of conditions
the spleen may become enlarged and through an
exaggeration of its normal functions of filtering, and
destruction and sequestering, it may cause anemia (may be
caused by decreased RBCs), leukopenia (decreased WBCs),
or thrombocytopenia or combinations of these cytopenias.
When all three cell types are decreased this is called
pancytopenia. There are two types of hypersplenism:
What is hematology?
Primary no underlying disease has been
identified
Secondary caused by an underlying disorder
such as:
Inflammatory diseases
Infectious diseases
Blood disorders that cause compensatory or
workload hypertrophy of the organ such as:
Abnormal blood cells, antibody coated blood cells,
hereditary spherocytosis, idiopathic
throbocytopenic purpura (ITP)
The effects of these are relieved by splenectomy
What is hematology?
Lymph nodes the lymphatic system is
composed of lymph nodes and lymphatic vessels that
drain into the left and right lymphatic duct. Lymph
is formed from blood fluid that escapes into the
connective tissue.
Lymph nodes are composed of lymphocytes,
macrophages, and a reticular network.
They act as filters to remove foreign particles by phagocytic
cells
As antigens pass through the lymph nodes, they come into
contact with and stimulate immunocompetent lymphocytes
to proliferate and differentiate into effector cells.
What is hematology?
The structure of the lymph node consists
of :
An inner area called the medulla which
contains plasma cells
An outer area called the cortex which contains
follicles with B lymphocytes surrounded by
T lymphocytes and macrophages

What is hematology?
Thymus this organ is well developed at birth
and increases in size until puberty at which time it
starts to decrease in size.
It serves as a compartment for the maturation of T
lymphocytes into immunocompetent T cells. The hormone
thymosin plays a role in this process.
The structure of the thymus consists of:
An outer area called the cortex which is densely packed
with small lymphocytes and macrophages
An inner area called the medulla which is less cellular
with a few lymphocytes, macrophages, and epithelial
cells.
What is hematology?
Bone marrow is located inside spongy bone
In a normal adult, of the bone marrow is
hematopoietically active (red marrow) and is inactive,
fatty marrow (yellow marrow).
The marrow contains both Erythroid (RBC) and leukocyte
(WBC) precursors as well as platlet precursors.
Early in life most of the marrow is red marrow and it
gradually decreases with age to the adult level of 50%.
In certain pathologic states the bone marrow can increase its
activity to 5-10X its normal rate.
When this happens, the bone marrow is said to be
hyperplastic because it replaces the yellow marrow
with red marrow.

What is hematology?
This occurs in conditions where there is
increased or ineffective hematopoiesis.
The degree to which the the bone marrow
becomes hyperplastic is related to the severity
and duration of the pathologic state.
Pathologic states that cause this include:
Acute blood loss in which there is a temporary
replacement of the yellow marrow
Severe chronic anemia erythropoiesis (RBC
production) may increase to the extent that the
marrow starts to erode the bone itself.
Malignant disease both normal red marrow and
fatty marrow may be replaced by proliferating
abnormal cells.

What is hematology?
The hematopoietic tissue may also become
inactive or hypoplastic. This may be due
to:
Chemicals
Genetics
Myeloproliferative disease that replaces
hematopoietic tissue with fiberous tissue
HEMATOPOIEZA

FIZIOLOGIA SERIEI ERITROCITARE
HEMATOPOIEZA
Definiie

= procesul de formare al elementelor figurate ale sngelui:
proliferarea
diferenierea
trecerea n circulaie

- cuprinde:
eritropoieza = formarea eritrocitelor
leucopoieza = formarea leucocitelor
trombocitopoieza = formarea trombocitelor

HEMATOPOIEZA
Sediu
Mduva roie hematogen
- celule stem hematopoietice (30-70%):
- strom reticulo-vascular (celule stromale,
- esut adipos, fibrocite, esut conjunctiv extracelular,
sinusoide vasculare).

Celulele hematopoietice - 3 mari grupe:
1. Celule stem pluripotente
2. Celule progenitoare hematopoietice
3. Celule ale liniilor sanguine
1. Celule stem pluripotente (CSP)
= celule de origine ale tuturor liniilor sanguine
- au capacitate de autoregenerare i difereniere

2. Celule progenitoare hematopoietice
- iau natere din CSP
- au capacitate - limitat de autogenerare
- mai restns de difereniere
- celule progenitoare mieloide: Eritrocite
Leucocite (N, Eo, B, Mo)
Trombocite
- celule progenitoare limfoide: Limfocite B i T

3. Celule ale seriilor sanguine
- n diverse stadii de maturaie

HEMATOPOIEZA
Celule hematopoietice
HEMATOPOIEZA
FIZIOLOGIA SERIEI
ERITROCITARE
= totalitatea elementelor masei eritrocitare (CSP eritrocit mbtrnit,
care este eliminat din circulaie).
= 99% din masa elementelor figurate (1% = L, T).

- constituit din 3 mari compartimente:
1. Compartimentul de generare
= elementele imature de la nivelul MRH
(CSP, proeritroblati, eritroblati, reticulocite)
5 7 zile
2. Compartimentul circulant
= elementele din torentul sanguin: E mature i un nr. + de reticulocite (5-
15)(i exercit funciile)
100-120 zile
3. Compartimentul de distrugere
= eritrocitele mbtrnite i modificate morfofuncional
- n splin, n ficat i MRH.
ERITRON
ERITROPOIEZA
1. nainte de natere

LOCALIZARE Eritrocite, Hb
embrion de cteva sptmni: n celulele
sacului vitelin

n lunile II-III de via fetal:
difereniere n cordoanele Wolf i Pander
primele insule de esut sanguin

n lunile III-VI de via fetal: ficatul i
splina devin organe hematopoietice

n lunile VI-IX: dezvoltarea mduvei
osoase, prezent n toate oasele (n luna IX
dispare hematopoieza hepato-splenic).
E primitive

E nucleate,
Hb embrionar

E nucleate,
Hb fetal

E anucleate
Hb fetal
ERITROPOIEZA
2. dup natere

imediat postnatal: mduva hematogen n toate oasele

treptat, mduva hematogen se restrnge:
- pn la 18 ani: n epifizele proximale humerus, femur i
tibie, oase scurte i plate.
- la adult: n oasele scurte i plate (coxale, stern, corpurile
vertebrelor, oasele late ale craniului).

n celelalte oase: mduv galben nehematogen
(esut adipos).

ERITROPOIEZA
Etapele eritropoiezei
1. multiplicare i maturarea
precursorilor eritrocitari
(BFU-E, CFU-E, proeritroblast,
eritroblati)

2. expulzia nucleului
(eritroblast oxifil reticulocit)

3. eritrodiabaza
(trecerea din mduv n circulaie).

Tipuri celulare de
evoluie
Caracteristici
generale
Aspecte
morfo-
funcionale
1. CSP
(celula stem
pluripotent)
- au receptori pt.
eritropoietin
- au capacitate |
de proliferare i
difereniere
celule nucleate
2. BFU-E
(Burst Forming
Unit-E; celule
formatoare de colonii
eritroide "de tip
exploziv")
3. CFU-E
(Colony Forming
Unit-E; celula
formatoare de colonii
eritroide)
ERITROPOIEZA
Etape
Tipuri celulare de
evoluie
Caracteristici generale Aspecte
morfo-
funcionale
4. Proeritroblast
= celula cap de
serie a seriei roii
- au receptori pentru
eritropoietin
- au capacitate de proliferare
i difereniere
- sintetizeaz Hb i enzime
celul
nucleat
5. Eritroblast
bazofil
6. Eritroblast
policromatofil
7. Eritroblast
oxifil (normoblast)
- capacitate + de proliferare
- sintez + de Hb i enzime
- evolueaz spre reticulocit
celul cu
nucleu mic
ERITROPOIEZA
Etape
ERITROPOIEZA
Etape
Tipuri
celulare de
evoluie
Caracteristici generale Aspecte
morfo-
funcionale
8. Reticulocit

- nu are capacitate de proliferare
- trece n snge = eritrodiabaz
dup 1-2 zile
- n snge (5-15) se
matureaz n splin, care extrage
resturile de mitocondrii i ribozomi
- sintetizeaz Hb i enzime pn la
pierderea ribozomilor i
mitocondriilor
celul
anucleat
cu resturi de
ribozomi i
mitocondrii
9. Eritrocit
matur

- nu are capacitate de proliferare
- nu sintetizeaz Hb, enzime
- durat de via = 100-120 zile
celul
anucleat,
fr
ribozomi,
fr
mitocondrii
ERITROPOIEZA
Maturarea eritrocitelor:

reducerea dimensiunii
creterea volumului citoplasmatic + mai puin bazofil,
reducerea dimensiunii nucleului expulzia lui.
Durata de evoluie CSP - reticulocit = 5 - 7 zile.
Producia eritrocite/zi = Distrugere eritrocite/zi = 25 ml
= 50 ml snge.

ERITROPOIEZA
Substane necesare eritropoiezei
Proteine
b. Minerale: fier, cupru, cobalt, zinc
c. Vitamine: B12, acid folic, B6, C

MINERALE
Fierul
Fierul din organism = 4 g 3 compartimente:

1. Compartimentul sanguin (65%):
- n eritrocite, sub form de Hb
- n plasm (legat de transferin; = 60-150 microg/dl)

2. Compartiment de depozit (30%)
- n splin, ficat, mduv hematogen - 2 forme:
- feritina, compus hidrosolubil, elibereaz uor Fe
3+
;
- hemosiderina = feritin parial degradat; conine fier greu mobilizabil.

3. Compartimentul tisular (5%)
- n muchi, sub form de mioglobin (4%)
- n structura enzime (citocromi, peroxidaze etc.)(1%)

Necesarul de fier
= 1 mg/zi, asigurat de aportul alimetar uzual;
- necesar | n stri fiziologice (sarcin, cicluri menstruale
||)

Aportul de fier
- diet normal = 10 mg/zi (se abs. 5 - 10%)
- fierul rezultat din hemoliza normal.

Pierderile fier
(prin pr, piele, urin, scaun) = 1 mg/zi

MINERALE
Fierul
Metabolismul
i transportul
Fierului n plasm
Fe3+ fixat de
transferin
(GP cu origine
hepatic)
transportat la nivelul
MH
depozitat
Utilizare
Majoritatea celulelor, inclusiv precursorii eritrocitari din
MH (normoblatii) au receptori pentru transferin.
Depozite de fier din organism = ficat, splin i MH (cel.
SRE)

Carena de fier
anemie feripriv microcitar hipocrom
(E, Ht, Hb, DEM, VEM, IC +)

MINERALE
Fierul
ALTE MINERALE
Minerale Roluri
Cupru

- intr n structura sistemelor
enzimatice care asigur fixarea
fierului n hemoglobin rol n
sinteza Hb.
- carena de cupru anemie
hipocrom.
Cobalt intr n structura vitaminei B12, care
este absolut necesar eritropoiezei
Zinc

intr n compoziie sistemelor
enzimatice necesare eritropoiezei

VITAMINE
Vitamina B12
= vitamin hidrosolubil sintetizat exclusiv de microorganisme
- Principala surs: alimentele de origine animal.

Necesar = 2-5 g/zi
Aport exclusiv alimentar
(diet normal=5-30 g/zi - se abs. 1-5 g/zi).

Absorbia
- condiionat de prezena factorului intrinsec al lui Castle (FI) =
glicoprotein sintetizat de celulele parietale gastrice

STOMAC:
fixare vitamina B12 de FI
complex
INTESTIN (ileon terminal):
Complexul vit. B12 - FI se
fixeaz pe receptori specifici
absorbie
- FI este reciclat
- Vitamina B12 se leag de
transcobalamina II
trece n circulaie
transport n MH i ficat

Concentraia seric normal
= 200-900 pg/ml.

Roluri n reglarea eritropoiezei:
induce sinteza de ARN i ADN
activeaz formarea, creterea i maturarea E
particip la transformarea acidului folic n acid tetrahidrofolic
= forma activ a acidului folic.

Deficitul de vitamina B12 n:
- gastrite atrofice, rezecie gastric (prin deficit de FI)
- afeciuni ale ileonului terminal (cu reducerea absorbiei)
- parazitoze (captare B12 de ctre parazit).

anemie macrocitar hipercrom (pernicioas sau Biermer)
(E, Ht, Hb +, DEM, VEM i IC|).

VITAMINE
Vitamina B12
Eritrocite normale
Macrocitoz
Hipercromie
+
Anemie pernicioas
(prin deficit de
vit. B12)
Microcitoz
Hipocromie
+
Anemie feripriv
(deficit de Fe)
ACID FOLIC (necesar 100 MICROG/ZI)
Forma activ: acid tetrahidrofolic (FH
4
)
Roluri n:
- sinteza purinelor i pirimidinelor necesare formrii ADN, ARN
- stimularea proliferrii, diferenierii i maturrii E.

VITAMINA B6 (necesar 3-5 mg/zi)
Roluri: - indispensabil pentru sinteza Hb
- favorizeaz absorbia intestinal a vitaminei B12.

Vitamina E (tocoferol)(20 mg/zi)
Roluri:
- factor antioxidant (ex. previne oxidarea vitaminei C)
- menine fierul n forma Fe2+ favorizeaz abs. intestinal.

Vitamina C (acidul ascorbic)(50-75 mg/zi)
Roluri:
- reduce Fe3+ n Fe2 favorizeaz abs. intestinal
- transformarea acidului folic n acid tetrahidrofolic (FH4)
- agent reductor al methemoglobinei

ALTE VITAMINE
VITAMINE I MINERALE
NECESARE ERITROPOIEZEI
Vitamina Rol
Consecinele
carenei
Vitamina B
12
Sintez ADN
Anemie
macrocitar
Acid folic
Sintez ADN i
ARN
Anemie
macrocitar
Vitamina C
(acid ascorbic)
Metabolism Fe Anemie
Vitamina E
(tocoferol)
Aciune
antioxidant
Fragilitate
membranar
Fier Sinteza Hb
Anemie
microcitar
Reglarea eritropoiezei
Eritropoietina
1. Eritropoietina
= GP sintetizat de rinichi (90%)
- producia depinde de concentraia tisular a O
2:

hipoxia - ef. stimulator
hiperoxia ef. inhibitor
- senzorul pentru O
2
= protein hem renal cu dou forme:
- form activ (dioxi), n caz de hipoxie | eritropoietina
- form inactiv (oxi), n caz de hiperoxie + eritropoietina

Efecte: crete masa eritrocitelor circulante prin:
- stimularea proliferrii CFU
E

- stimularea diferenierii precursorilor eritrocitari i scurtarea timpului de
maturare
- favorizarea ncrcrii cu Hb reticulocitelor E mature
- activarea eritrodiabazei
Mecanism: legare de receptor membranar de tip tirozinkinazic
localizat pe membrana precursorilor eritrocitari.

Factori care influeneaz sinteza de eritropoietin:
capacitatea de transport a O
2
la esuturi:
Ex. transport oxigen + (ex. anemie, + irigaiei tisulare, + volumului
sanguin) eritropoieza | prin mecanism de feedback
hormoni:
cu efect inhibitor: estrogenii
cu efect stimulator: androgenii,
catecolaminele,
glucocorticoizii,
hormonul de cretere (STH),
hormonii tiroidieni

Eritropoietina
- Factorul celulei stem (SCF)
= citokin care stimuleaz CSP i induce diferenierea, proliferarea
i maturarea precursorilor eritrocitari.

- Factorul de stimulare a coloniilor de granulocite i macrofage
(GM-CSF)
= citokin care stimuleaz CSP i induce diferenierea, proliferarea
i maturarea de granulocite i macrofage, dar i a precursorilor
eritrocitari.

- Interleukina-3 (IL-3)
- stimuleaz CSP, inducnd diferenierea, proliferarea i maturarea
precursorilor eritrocitari.

Ali factori
CINETICA
ERITROCITELOR
1. Formarea eritrocitelor (eritropoieza)

2. Perioada de eritrocit circulant funcional
= 100-120 zile, perioad n care sunt i realizeaz funciile i sunt supuse la
numeroase solicitri funcionale:
- strbat zilnic 1-1,5 km
- i modific forma la trecerea prin capilare (fusiforme) i se deplaseaz n
fiicuri
- stagneaz n vasele sanguine sinuoase (ex. circ. splenic)
- transport gazele respiratorii O
2
i CO
2

- particip la meninerea constant a pH-ului sanguin (prin sistemul tampon
al hemoglobinailor)
- sunt influenate de factori extraeritrocitari (pH, substane toxice), care le
pot modifica morfo-funcional (ex. acidoza/alcaloza determin |/+
volumului eritrocitar).
3. Distrugerea eritrocitelor (hemoliza fiziologic)

Solicitrile mecanice i chimice
epuizare energetic i enzimatic a E
E senescent, rigid, lipsit de plasticitate
E este ndeprtat din circulaie, prin eritrofagocitoz.

Normal, sediile principale ale hemolizei sunt:
Splina - cu caracteristici funcionale care accentueaz sechestrarea
eritrocitelor (sinusoide mai nguste dect n alte zone).
Ficatul (debitul sanguin - de 6 ori mai | dect la nivelul splinei).

CINETICA
ERITROCITELOR
STRUCTURA MORFOFUNCIONALA
A ERITROCITULUI

1. Caracteristici morfo-funcionale

1. Numrul de eritrocite
= 45,5 mil/mm
3

- brbai = 4,9 0,7 mil/mm
3
;
- femei = 4,3 0,6 mil/mm
3
.
2. Forma eritrocitului
- disc biconcav, cu marginile rotunjite
- asigur suprafaa mare la volum +
3. Dimensiunile eritrocitelor
- DEM = 6,8 7,7m;
- GEM = 1,7 2,5 (2) m;
(n centru - cu 1 m < dect periferic)
4. Culoarea eritrocitelor
- dat de Hb eritrocitar
- eritrocitul normal colorat = normocrom.
VARIAII
De numr
+ numrului de eritrocite = anemie
| numrului de eritrocite = poliglobulie
De form
ovale = ovalocite
cu forme negeometrice, bizare = poikilocite
eritrocite sferice = sferocite
n secer = drepanocite
cu excrescene = acantocite
De
dimensiuni
u + = microcite
u | >9m (10-12) = macrocite (megalocite)
u | i grosime + = platicite
De culoare
palide, slab colorate = hipocrome
intens colorate = hipercrome
E normo-, hipo-, hipercrome = anizocromie
Sferocitoza ereditar

1. Plasticitate = proprietatea E mature de a i modifica forma la trecerea
prin capilare cu diametru < diametrul eritrocitar.

2. Plachetarea = prop. E de a se deplasa n fiicuri la nivelul capilarelor.

3. Rezistena globular = rezistena E la solicitri mecanice, chimice, biol.
- Uzual: RG n soluii cu hipotonicitate progresiv crescnd.
- Normal:
RG min. (hemoliz incipient) = 0,40-0,44 g% NaCl,
RG max. (hemoliz total) = 0,32- 0,28 g% NaCl.
3. Proprietatile eritrocitelor
DHAG e-
m#328
Plasticitatea E
Plachetarea E
Normale
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Rezistenta
globulara
4. Sedimentarea = proprietatea E lsate n repaus de a
sedimenta n virtutea gravitaiei (recoltare pe
anticoagulant)
- Normal:
VSH = 1-10 mm/h la femei;
2-13 mm/h la brbai
0,5 - 1 mm/h la nou-nscut.

5. Scintilaia = proprietatea E de a reflecta razele de
lumin

3. Proprietatile eritrocitelor
Membrana eritrocitar - particulariti:
- cu Ag de suprafa i receptori membranari
- strat mijlociu lipidic foarte mobil asigur plasticitatea
- strat intern - asigur rezistena, forma E

Compoziie:
60% ap
33-35% Hb
5-7% alte substane:
2% enzime (cu rol n ciclul glicolitic, untul
pentozo-fosfailor, enzime de aprare mpotriva aciunilor oxidative)
pompe ionice (pompa Na
+
-K
+
, pompa de Ca
+
)
schimbtor Cl
-
/HCO
3
-

4. Structura eritrocitelor
= element esenial pentru realizarea funciei respiratorii a E
= 95% din proteinele solubile ale eritrocitului
- Sintez: n cel. tinere nucleate ale seriei roii din MRH: eritroblast bazofil,
policromatofil i oxifil - + n reticulocit.

A. Structura Hb
= cromoprotein porfirinic care conine fier din:
4 molecule de hem (cu 1 atom de Fe
2+
- leag O
2
, CO
2
)
4 catene polipeptidice (globine).

Hemul = partea fiziologic activ
= fero-protoporfirin IX: atomul de Fe n centrul inelului
Porfirinic; - fierul heminic = Fe
2+

Globina
= tetramer din 4 lanuri pp., dou cte dou identice.
- fiecare lan pp are ataat o grupare hem la ext. moleculei

Fiziologia hemoglobinei

Hb embrionare
- sintetizate din sptmna a 3-a de via embrionar
- exist 3 Hb embrionare (Hb Gower 1, 2 i Hb Portland)

Hb fetal (HbF)
- nlocuiete Hb embrionare din luna a 3-a de gestaie
= principala Hb din cursul dezvoltrii fetale (o22)
- la natere = 70-80% din totalul Hb, apoi sinteza + rapid

Hb de tip adult
- sinteza ncepe din perioada fetal, dup natere nlocuiesc rapid HbF
- la adultul normal exist: 97-98% HbA1 (o2|2)
2-3% HbA2 (o2o2)
sub 1% HbF (o22)
Hemoglobinele fiziologice

- peste 150 variante de Hb patologice, rezultate prin:
substituirea unuia/mai multor AA din lanurile globinice
lipsa unuia sau mai multor AA.

Anomaliile structurale ale moleculei de Hb modificarea proprietilor
fizico-chimice i funcionale ale Hb.
Ex. nlocuirea restului glutamil cu un rest valil n poziia 6 a lanului | din
molecula de HbA1 hemoglobina S. Clinic: eritrocite n form de
secer i predispoziie la hemoliz (anemie falciform sau
drepanocitoz).

Hemoglobine patologice

Drepanocitoz
Catabolismul hemoglobinei
La adult: degradare Hb = 6-7 g/zi
O Globina - reutilizat ca surs de AA n proc. Metabolice
O Hemul - degradat Fe + biliverdina

1. Reducerea biliverdinei B indirect/neconjugat (BI) - transportat
n snge legat de albumine

2. BI este conjugat la nivel HEPATIC cu acid glicuronic
B direct/conjugat (BD)
3. BD este eliminat prin bil n cile biliare

4. INTESTIN GROS: sub ac. enzimelor reductoare
ale florei microbiene: BD urobilinogen(Ubg)
5. Majoritatea Ubg este oxidat stercobilinogen i stercobilin se
elimin prin materiile fecale.
6. O fraciune + din Ubg se abs.la nivel intestinal v. port - ficat
reexcretat n bil (ciclul entero-hepatic).
7. O cant. + de Ubg din snge este excretat de rinichi ca urobilin
(~1%).
Normal: Bilirubina (direct i indirect) = 0,4 -1mg%.
Patologic: hiperbilirubinemie colorare n galben tegumente i mucoase; n:
hemoliz excesiv (icter hemolitic)
obstacol n calea scurgerii bilei n intestin (de obicei calculi n cile biliare)(icter mecanic)
hepatocitoliz (icter hepatic).
METABOLISMUL
ERITROCITAR
- Cantitatea de energie necesar E = foarte redus i rezult din metabolizarea
glucozei
- glucoza = principalul substrat metabolic.
- nu are rezerve de glicogen depinde de glucoza din mediul ambiant.

n eritrocit, degradarea glucozei se realizeaz:
90-95% prin glicoliza anaeroba (Embden-Mayerhof)
5-10% prin untul pentozelor.

1. Metabolismul glucozei

1. fosforilarea glucozei
glucozo-6 fosfat (G-6 P)
2. transformarea G-6 P
fructozo-6 P fructozo-
1,6 diP
3. fructozo-1,6 difosfat este
clivat G-3 P + DHAP
4. G-3 P este transformat n
1,3-DPG piruvat
lactat
difuzeaz n afara E i sunt
metabolizate n esuturi.

Calea Embden-Mayerhof (glicoliza anerob)
Ciclul Rappaport-Luebering (sau
ciclul 2,3-DPG).
- sub aciunea 1,3-DPG-mutazei: 1,3-
DPG 2,3-DPG (ireversibil)
- 2,3-DPG este hidrolizat de 2,3-DPG-
fosfataza: 3-PG piruvat
lactat
Rol: 2,3-DPG + afinitatea Hb pentru O
2

elib. | a O
2
la esuturi
Importana cii glicolitice
1. formare 2 molecule de ATP/1 mol de
glucoz, n dou trepte:
(1) 1,3-DPG 3-PG;
(2) acid fosfoenol-piruvic acid
piruvic
2. formarea de NADH (folosit de sist.
methemoglobin reductazic)
3. formarea 2,3-DPG (care favorizeaz
cedarea O
2
la esuturi).

1. conversia glucozei-6 fosfat n
ribuloz-5 fosfat (cu formarea a 2
molecule de NADPH
2
)
2. clivarea ribulozei-5 fosfat n 3
fosfogliceraldehid i fructoz-6
fosfat

untul pentozelor - etape

Importana untului pentozelor
1. formarea NADPH (2 NADPH/pentru 1
mol glucoz) utilizat de sistemul
methemoglobin-reductazic
2. formare de pentozofosfat care este
antrenat n calea glicolizei anaerobe,
contribuind la generarea de ATP

- se formeaz din metab. G - ciclul Rappaport-Luebering

Rolul 2,3-DPG
- scade afinitatea pentru O
2
a Hb cedarea O
2
la esuturi.
- mecanism: se fixeaza echimolecular pe lanurile b ale HbA (o
2
|
2
)
modificri conformaionale cu eliberarea O
2
de pe HbO2.
- deplaseaz curba de disociere a HbO
2
la dreapta, mrind
eliberarea O
2
la nivel tisular.

Obs: La ft - E conin Hb fetal (HbF, o
2
2
) 2,3-DPG nu
influeneaz eliberarea O
2
la esuturi

Variaii ale produciei intraeritrocitare de 2,3-DPG

Factori stimulatori Factori inhibitori
Intensificarea glicolizei:
(alcaloz E, efort fizic, hipoxie
cr., hipertiroidism)
Reducerea glicolizei
(acidoz E)
Perturbarea c.Rapaport
Conservarea sg
Fiziologia 2,3 DPG

- Oxidarea Hb trecerea Fe
2+
n Fe
3+
formare MetHb
Normal: sub 2% MetHb
(deoarece este redus pe cale enz.+ neenz.)
Patologic:
- |MetHb culoare brun a sngelui
- MetHb > 15%: cianoza (cul. albastr tegumente)
- n: intoxicaia cu nitrii, nitrai,
adm. || medicam. oxidante (nitroglicerin)

Sistemele reductoare eritrocitare sunt:
1. Sistemul methemoglobin reductazic
2. Glutationul redus
3. Albastrul de metilen
4. Vitamina C

Fiziologia sistemelor reductoare
eritrocitare
1. Sistemul methemoglobin reductazic
a. Methemoglobin reductaza-NAD dependent sau diaforaza 1 rol
major
- folosete NADH din glicoliza anaerob pentru reducerea Fe
3+
la Fe
2+

b. Methemoglobin reductaza-NADP dependent sau diaforaza 2 - rol
sec.
- utilizeaz NADPH rezultat din untul pentozelor pentru reducerea Fe
3+

la Fe
2+

eritrocitare
NADH
2
NAD
MetHb (Fe
3+
) Hb (Fe
2+
)
NADPH
2
NADP
MetHb (Fe
3+
) Hb (Fe
2+
)
2. Glutationul redus
- se produce n E din glutamat+glicin+cistein (cu consum ATP)
- este regenerat de ctre glutation reductaza NADPH-dep.
- Formele oxidat (G-SS-G)/redus (GSH) = sistem redox (75%/ 25%)
Rol: protejeaz de oxigen SH-enzimele, membrana eritrocitar, Hb (care
conine 6 grupri SH).

3. Ali ageni reductori ai MetHb:
- Albastrul de metilen
= agent reductor al MetHb (administrat iv)
- acioneaz enzimatic prin activarea MetHb-reductazei NADPH-dep.
- Vitamina C
= agent reductor al MetHb (administrat iv. sau oral)
- reduce MetHb pe cale neenzimatic

eritrocitare
La nivelul plmnilor au loc:

La nivelul esuturilor au loc:
- fixarea O
2
pe hemoglobin
- eliberarea CO
2
din HbCO
2
- fixarea H
+

- eliberarea 2,3-DPG.

- eliberarea O
2
de pe HbO
2

- captarea de ctre Hb a protonilor
- fixarea CO
2
carbamai
- fixarea 2,3-DPG.

Funciile eritrocitelor
1. Funcia de transport a O
2
i CO
2
1.1. Transportul O
2
- dizolvat fizic n plasm (1%); proporional cu PO
2 .

- combinat cu hemoglobina (99%).
- Reacia Hb cu O
2
: rapid, fiecare atom de Fe
2+
al gruprilor hem
poate fixa o molecul de O
2
, fr modificarea valenei Fe
2+
=
oxigenare
- Fixarea i eliberarea O
2
de pe molecula de Hb are loc succesiv,
cu vitez progresiv crescnd

Factori care cresc
afinitatea pentru O
2
Factori care diminu
afinitatea pentru O
2
determina intensificarea
fixrii O
2

deplasarea spre stnga a
curbei de disociere a
oxihemoglobinei.
favorizeaz eliberarea
oxigenului la nivelul
esuturilor
deplasarea spre dreapta a
curbei de disociere a
oxihemoglobinei.
[H
+
](|pH),
+[CO
2
],
+[2,3 DPG],
+ temperaturii,
HbF
[H
+
] (+ pH),
|[CO
2
],
|[2,3 DPG],
| temperaturii,
HbA
Factorii care influeneaz afinitatea Hb
pentru O2

Transportul CO
2

1. Forma dizolvat fizic a CO
2
(5%)
= partea difuzibil - determin sensul i mrimea difuziunii,
fixarea sub form de carbamat/bicarbonat

2. Forma combinat cu proteinele plasmatice i hemoglobina (4,5%).
CO
2
fixat de gruprile aminice ale:
- proteinelor plasmatice carbamai
- Hb carbHb

3. CO
2
transportat sub form de bicarbonat (90%)
- KHCO
3
intraeritrocitar si NaHCO
3
n plasm.

n plasm: o cantitate+ CO
2
se hidrateaz spontan H
2
CO
3
HCO
3
-
+ H
+

2
i CO
2
Controlul formrii i eliberrii CO
2
de pe Hb
gradul de oxigenare al Hb (efect Haldane): O
2
tinde
s elibereze CO
2
.
- la esuturi: elib. O
2
de pe Hb favorizeaz fixarea CO
2

- la plmni: O
2
determin eliberarea CO
2
din HbCO
2

Curba de disociere-fixare a CO
2

- este influenat de PCO
2
i de saturaia n O
2
a Hb.
- nu atinge platou; creterea progresiv a PCO
2
cantitatea de CO
2

dizolvat n plasm nu exist pct. de saturaie
- sngele arterial - curb de fixare-disociere a CO
2
mai deprimat fa de
cea a sngelui venos (explicaie: eritrocitele cu oxiHb| pot fixa mai putin
CO
2
).
- La esuturi: fixarea CO
2
se face uor datorit PO
2
+ i a pH-ului mai acid.
- La plmni cedarea CO
2
este determinat de PO
2
| i pH ceva mai alcalin.

2
i CO
2
Prin:
- sistemele tampon eritrocitare: HbK/HbH, HbO
2
K/HbO
2
H, care
asigur din capacitatea tampon a sngelui
- fixarea CO
2
sub form de HbCO
2
- creterea capacitii tampon a plasmei (NaHCO
3
), ca urmare a
fenomenului Hamburger

2. Rolul eritrocitelor n meninerea EAB

Structure of bone marrow
BONE MARROW
Normal
Hypoplastic
Hyperplastic
What is hematology?
Liver contains phagocytic cells known as
Kupffer cells that act as a filter for damaged
or aged cells in a manner similar to, but less
efficient than the phagocytic cells in the
spleen.
If the bone marrow cannot keep up with the
physiologic demand for blood cells, the liver may
resume the production of blood cells that it began
during fetal life
Derivation of blood cells
Mature blood cells have a limited life span and
with the exception of lymphocytes, are
incapable of self-renewal.
Replacement of peripheral hematopoietic cells is a
function of the pluripotential (totipotential) stem cells
found in the bone marrow
Pluripotential stem cells can differentiate into all of the
distinct cell lines with specific functions and they are able to
regenerate themselves.
The pluripotential stem cells provide the cellular reserve for
the stem cells that are committed to a specific cell line.
Derivation of blood cells
The committed lymphoid stem cells will be involved in
lymphopoiesis to produce lymphocytes
The committed myeloid stem cell can differentiate into
any of the other hematopoietic cells including
erythrocytes, neutrophils, eosinophils, basophils,
monocytes, macrophages, and platlets.
Hematopoietic cells can be divided into three
cellular compartments based on maturity:
Pluripotential stem cell capable of self-renewal
and differentiation into all blood cell lines.
Committed proginator stem cells destined to
develop into distinct cell lines
Mature cells with specialized functions

Hematopoiesis
138
Hematology
139
Hematology
140
Basic scheme
Blood leaves the heart in
arteries
Branching of arteries until
they become tiny capillaries
Oxygen and nutrients diffuse out
CO2 and wastes diffuse in
Capillaries form veins going to the heart
The blood leaves the right side of the heart for the
lungs to pick up O2 and release CO2
Blood goes back to the left side of the heart to start all
over
Note: vessels going to the heart are veins; those leaving the heart are arteries
Summary of blood forming
organs
142
Composition of blood
Specialized connective tissue
Blood cells (formed elements) suspended in plasma

Blood volume: 5-6 liters (approx 1.5 gal) in males
and 4-5 liters in females
143
Blood
Centrifuged (spun) to separate
Clinically important hematocrit
% of blood volume consisting of erythrocytes (red
blood cells)
Male average 47; female average 42
Plasma at top: water with many ions,
molecules, and 3 types of important proteins:
Albumin
Globulins
Fibrinogen
144
Serum
Blood that is allowed to stand clots
Clot is a tangle of the formed elements (some are not
truly cells)
RBCs lack nuclei and organelles
Platelets are fragments
Most cannot divide
Clear fluid serum is left = plasma without the clotting
factors

When spun in centrifuge,
buffy coat lies between
RBCs and plasma: of
leukocytes (white blood cells)
and platelets

145
Blood is
examined in a
smear
Smears are
stained
Scanning EM
Light microscope
146
Hematopoiesis
Formation of blood cells
Occurs mostly in red bone marrow
All cells arise from same blood stem cell
(pluripotent hematopoietic stem cells)
Recently some have been found in adults
which are mesenchymal stem cells, which can
also form fat cells, osteoblasts, chondrocytes,
fibroblasts and muscle cells

147
148
Blood stem cells divide into:
1.myeloid stem cells or
2.lymphoid stem cells

All except for
lymphocytes arise
from myeloid stem
cells
All originate
in the bone
marrow
Not shown
are mast
cells,
osteoclasts,
dendritic
cells

149
As the cells divide they become committed,
that is, they can only become one kind of cell

Also called CFUs (colony-forming units)

Structural differentiation occurs
150
CBC is probably commonest test done
(complete blood count-how much of each type of cell)
Hemoglobin (gm/dl)
usually 15
Hematocrit (%)
RBC count
Differential if ordered:
broken down to amount of
each type WBC
Platelet count in
thousands/cumm
151
Erythrocytes
Also called RBCs or red blood
cells
Biconcave discs and flexible
Plasma membrane but no nuclei or
organelles
Packed with hemoglobin
molecules
Oxygen carrying protein
4 chains of amino acids, each with
iron which is binding site for oxygen;
CO2 carried also
Young ones still containing
ribosomes are called reticulocytes
Live 100-120 days
heme
iron atom
152
Leukocytes

AKA WBCs:
white blood
cells

153
Leukocytes

AKA WBCs: white
blood cells
Are complete cells
Function outside the
blood

Note the size difference
compared to erythrocytes
neutrophil eosinophil
basophil
small lymphocyte monocyte
__RBC
154
Leukocyte types
Artificial division into granulocytes and
agranulocytes
Granulocytes: neutrophils, eosinophils,
basophils (according to how stain)
Granules
Lobed nuclei
All are phagocytic
Agranulocytes: lymphocytes, monocytes

155
All except for
lymphocytes
arise from
myeloid stem
cells
All originate in the
bone marrow
Not shown are mast cells,
osteoclasts, dendritic cells
Remember this slide?
See the artificial division?
156
Neutrophils
60% of all WBCs
Nuclei of 2-6 lobes
Other names:
Polymorphonuclear cells (PMNs, polys, segs)
Granules have enzymes
Can damage tissue if severe or prolonged
Pus

157
Eosinophils
1-4 % of leukocytes
Bilobed
Granules have digestive enzymes
Role in ending allergic reactions and in
fighting parasitic infections
158
Basophils
Rarest WBC
Bilobed nucleus
Dark purple granules
Later stages of reaction to allergies and
parasitic infections
159
Lymphocytes*
Most important
WBC
20-45%
Most are
enmeshed in
lymphoid
connective tissue,
e.g. lymph nodes,
tonsils, spleen
*
160
Lymphocytes:
nucleus occupies most of the
cell volume
Response to antigens (foreign proteins or parts of cells)
is specific

Two main types attack antigens in different ways
T cells
B cells
plus natural killer cells
161
T cells attack foreign cells directly
Killer cells (cytotoxic), or CD8+ is a
main type
162
B cells
Differentiate into plasma cells
Plasma cells secrete antibodies
Antibodies flag cells for destruction by
macrophages (see stem cell chart)
163
Monocytes*
4-8% of WBCs
In connective tissue
they transform into
macrophages
(phagocytic cells
with pseudopods)
*
164
Platelets*
Not cells
Small fragments
broken off from
megakaryocytes
Important in
forming clots in
damaged vessels
AKA thrombocytes

*
165
Clots
Undesirable clots:
Thrombus
Embolus

Platelet and several RBCs trapped
in a fibrin mesh
Platelet__________________
166
Significant
young cells
Reticulocytes* (young
erythrocytes): 1-2%of
all RBCs
retic count helps
determine if producing
RBCs at accelerated rate
(anemia, move to a high
climate, etc.)
Bands* (young
neutrophils): 1-2% of
all WBCs
Increases with acute

*
*
167
Disorders of Erythrocytes
Polycythemia: too many cells
Anemia: not enough cells
Sickle cell disease: genetic disease AR
1/400 African Americans
Defect in hemoglobin
Plus many others
168
Disorders of Leukocytes
Leukemia: too many, abnormal, crowd out
normal marrow
Classified into
Lymphoblastic or myeloblastic
Acute or chronic

Disorders of Platelets
Thrombocytopenia
Causes internal bleeding
Many causes
169
Laboratory
CBC: complete blood count (to review)

Hemoglobin (gm/dl)
Hematocrit (%)
RBC count
Differential if ordered: broken down to amount of each
type WBC
Platelet count in thousands/cumm
170
Laboratory continued
Clotting: coags
for preop evaluation (before surgery)
to evaluate effectiveness of anticoagulant drugs, e.g.
aspirin, heparin, coumadin
Bleeding time
PT - Protime
PTT - Partial thromboplastin time
INR

ESR erythrocyte sedimentation rate
Indicator of infection or inflammation
171
Blood Typing
ABO blood groups: A, B, AB, and O
172
If a blood transfusion is given to a person who
has antibodies to that type of blood, then the
transfused blood will be attacked and
destroyed (transfusion reaction)
173
ABO blood group types
Blood
type
Antigen on
rbc
Antibodies in
blood
Can receive blood from: Can donate blood to
(usually RBCs only):
Frequency
in US
A A anti-B A
O
not B (you have anti-B) *
not AB (you have anti-B) *
A
AB
40%
B B anti-A B
O (no Ags so you wont reject)
not A (you have anti-A) *
not AB (you have anti-A) *
B
AB
10%
AB A and B none to
A or B
AB AB is universal recipient
A
B
O
AB 4%
O not A nor B Anti-A and anti-B not A (have anti-A)*
not B (have anti-B)*
not AB (have both antibodies)*
O
A
B
AB
O O is universal donor
46%
Ag = antigen on red blood cell
*=transfusion reaction (hemolysis of new cells)
The blood types are codominant i.e. if genotype is AB, then you have both
A and B antigens on your RBCs
174
Rh factor
The Rh factor is another major antigen on the RBC, called D
is autosomal recessive
DD and Dd: Rh+
dd: Rh-
If mom is Rh- and baby is Rh+, then small amount of blood
leaks into moms blood through placenta, and she makes
antibodies to D antigen; first Rh- pregnancy usually ok, but
not later Rh- ones (can be lethal to baby)
If mom is Rh- then give Rhogam during pregnancy [(is anti-
Rh(D): Rh(D) Ig (immunoglobin)], an antibody which will
destroy any of the babys RBCs which leak into moms blood
during the pregnancy so she will not mount an immune
response to the D antigen
If father is Rh+:
If DD then all pregnancies will be Rh+
If Dd then half of the pregnancies with this mom will be Rh- (no Rh
incompatibility problems)
175
Rhogam (FYI)
Risks to the baby
If the babys blood cells are attacked and depleted during pregnancy it can lead to anemia, jaundice,
mental retardation and heart failure. It can even be fatal in utero or shortly after delivery. The
condition is known as Hemolytic Disease of the Newborn. Luckily, appropriate treatment with
Rhogam can almost completely eliminate the risk.

[edit] Rh Negative treatment with Rhogam
Rhogam is a sterile solution that is injected intramuscularly. It is made from human plasma that
contains anti-D. Most often Rhogam is given to women at 28 weeks of pregnancy. The Rh negative
mother is most likely to be exposed to the babys blood in the last 3 months of pregnancy, so a
second dose is often given within 72 hours of delivery if the baby is found to be Rh positive. A
mother must also receive a dose after any invasive procedure such as amniocentesis or after an
induced termination, miscarriage or ectopic pregnancy.
[edit] Side effects
Side effects of Rhogam are mild and include soreness tenderness, warmth or a rash at the injection
site. Other side effects can include:
Fever
Chills
Headache
Fatigue

http://wikiparenting.parentsconnect.com/wiki/Rhogam_in_pregnancy
176
FYI

Blood
Blood is the fluid of life
Blood is composed of:
Plasma
RBC
WBC
Platelets

Plasma
Plasma consists of:
90% water.

10 % solutes: albumin, electrolytes and
proteins.

Proteins consist of clotting factors, globulins,
circulating antibodies and fibrinogen.

Red Blood Cells
RBCs travel through the body delivering
oxygen and removing waste.
RBCs are red because they contain a
protein chemical called hemoglobin which
is bright red in color.
Hemoglobin contains iron, making it an
excellent vehicle for transporting oxygen
and carbon dioxide.
RBCs
Average life cycle is 120
days.
The bones are continually
producing new cells.
White Blood Cells
The battling blood cells.
The white blood cells are continually on the
look out for signs of disease.
When a germ appears the WBC will:
Produce protective antibodies.
Surround it and devour the bacteria.
WBCs
WBC life span is from a few days to a few
weeks.
WBCs will increase when fighting
infection.

Platelets
Platelets are irregularly-
shaped, colorless bodies
that are present in blood.
Their sticky surface lets
them form clots to stop
bleeding.

Blood Values
CBC with differential and platelet count.
Hgb:
Normal levels are 11 to 16 g / dl
Panic levels are:
Less than 5 g / dl
More than 20 g / dl
Hematocrit
Normal hematocrit levels are 35 to 44%.
Panic levels:
Hmct less than 15 %
Hmct greater than 60%
Hemoglobin and Hematocrit
Can be used as a simple blood test to screen
for anemia.
The CBC with differential would be used to
help diagnose a specific disorder.
A bone marrow aspiration would be the
most conclusive in determining cause of
anemia aplastic / leukemia.
Bone Marrow
Bone marrow is the spongy substance found
in the center of the bones.
It manufactures bone marrow stem cells,
which in turn produce blood cells.
Red blood cells carry oxygen to tissue
Platelets help blood to clot
White blood cells fight infection

Donor is placed under anesthesia.
Marrow is aspirated out of the iliac crest.
Marrow is filtered and treated to remove
bits of bone and other unwanted cells and
debris, transferred to a blood bag, and is
infused into the patients blood just like at
transfusion.
Bone Marrow Aspiration
Treatment Modalities
Transfusion:
Packed red blood cells anemia
Platelets platelet dysfunction
Fresh frozen plasma coagulation factors
Blood Transfusions
3 types of transfusion reactions
Hemolytic
Allergic
Febrile

Hemolytic Reaction
Refers to an immune response against
transfused blood cells.
Antigens, on the surface of red blood cells,
are recognized as foreign proteins and can
stimulate B lymphocytes to produce
antibodies to the red blood cell antigens.
Hemolytic reaction
Flank pain
Fever
Chills
Bloody urine
Rash
Low blood pressure
Dizziness / fainting
Nursing Management
Stop the blood transfusion.
Start normal saline infusion.
Take vital signs with blood pressure
Call the MD
Obtain blood sample and urine specimen.
Return blood to blood bank.
Document
Febrile Reaction
Often occurs after multiple blood
transfusions.
Symptoms:fever, chills, and diaphoresis.
Interventions:
Slow transfusion and administer antipyretic.
Administer antipyretic prior to administration.
Allergic Reaction
Symptoms: rash,
urticaria, respiratory
distress, or anaphylaxis.
Interventions:
administer antihistamine
before transfusion
Physician may order
washed rbcs

Hematologic Conditions
Alteration in Hematologic Status
Disorders of hemostasis or clotting factors
Structural or quantitative abnormalities in
the hemoglobin.
Anemias
Aplastic Anemia
Genetic Implications
The following have a genetic link:
implications for genetic screening and fetal
diagnosis
Sickle cell anemia
Thalassemia
Hemophilia
Bleeding Disorders
Three types Hemophilia: males only
Type A most common factor VIII deficiency
Type B - lack of factor IX (Christmas Disease)
Type C lack of factor XI

Von Willebrand Disease 1% of population
men or women prolonged bleeding time

Hemophilia Type A
Hemophilia type A is the deficiency of
clotting factor VIII.
A serious blood disorder
Affects 1 in 10,000 males in the US
Autoimmune disorder with lowered level of
clotting factor
All races and socio economic groups affected
equally
Hemophilia
Hemophilia is a sex-linked hereditary
bleeding disorder
Transmitted on the X chromosome
Female is the carrier
Women do not suffer from the disease itself
Historical Perspective
First recorded case in Talmud Jewish text
by an Arab physician documentation of
two brothers with bleeding after
circumcision.
Queen Victoria is carrier and spread the
disease through the male English royalty.
Goals of Care
Goals of care:
Provide factor VIII (IX) to aid blood in clotting.
To decrease transmission of infectious agents in
blood products; hepatitis & AIDS.
Future: gene therapy to increase production of
clotting factor.

Symptoms
Circumcision may produce prolonged
bleeding.
As child matures and becomes more active
the incidence of bleeding due to trauma
increases
Symptoms
May be mild, moderate or severe
Bleeding into joint spaces, hemarthrosis
Most dangerous bleed would be
intracranial.

Diagnosis
Presenting symptoms
Prolonged activated aPTT and decreased
levels of factor VIII or IX.
Genetic testing to identify carriers

Treatment
Products used to treat hemophilia are:
Fresh frozen plasma and cryoprecipitate which
are from single blood donors and require
special freezing.
Second generation of factor VIII are made with
animal or human proteins.
Nursing Diagnoses
Risk for injury
Pain with bleed especially into a joint
Impaired physical mobility
Knowledge deficit regarding disease and
management of disease
Nursing interventions
No rectal temps.
Replace the factor as ordered by physician.
Manage pain utilizing analgesics as ordered.
Maintaining joint integrity during acute phase:
immobilization, elevation, ice.
Physical therapy to prevent flexion contraction and to
strengthen muscles and joints.
Provide opportunities for normal growth and
development.
Teaching
Avoid aspirin which prolongs bleeding time in people
with normal levels of factor VIII.
A fresh bleeding episode can start if the clot becomes
dislodged.
Natural reactions in the body cause the clot that is no
longer needed to break down. This process occurs 5
days after the initial clot is formed.
Family Education
Medic-Alert bracelet
Injury prevention appropriate for age
Signs and symptoms of internal bleeding or
hemarthrosis
Dental checkups
Medication administration
Long Term Complications
20% develop neutralizing antibodies that
make replacement products less effective.
Gene therapy providing continuous
production of the deficient clotting factor
could be the next major advance in
hemophilia treatment.
Disseminated Intravascular
Coagulation or DIC

DIC is an acquired coagulopathy that is
characterized by both thrombosis and
hemorrhage.
DIC is not a primary disorder but occurs as
a result of a variety of alterations in health.
Assessment
The most obvious clinical feature of DIC is bleeding.
Renal involvement = hematuria, oliguria, and anuria.
Pulmonary involvement = hemoptysis, tachypnea,
dyspnea and chest pain.
Cutaneous involvement = petechiae, ecchymosis,
jaundice, acrocyanosis and gangrene.
Management of DIC
Treatment of the precipitating disorder.
Supportive care with administration of
platelet concentration and fresh frozen
plasma and coagulation factors.
Administration of heparin (controversial in
children).
Heparin potentates anti-thrombin III which
inhibits thrombin and further development
of thrombosis.
Nursing Diagnoses
Altered tissue perfusion
Risk for injury
Anxiety
Nursing Interventions
Rigorous ongoing assessment of all body
systems
Monitor bleeding
No rectal temps
Avoid trauma to delicate tissue areas
All injections sites and IV sites need to be
treated like an arterial stick.
Prognosis
Depends on the underlying disorder and the
severity of the DIC.
ITP
Idiopathic thrombocytopenic purpura
Idiopathic = cause is unknown
Thrombocytopenic = blood does not have
enough platelets
Purpura = excessive bleeding / bruising
Immune Thrombocytopenic
Purpura
Antibodies destroy platelets
Antibodies see platelets as bacteria and
work to eliminate them
ITP is preceded by a viral illness
URI
Varicella / measles vaccine
Mononucleosis
Flu
Symptoms
Random purpura
Epistaxis, hematuria, hematemesis, and
menorrhagia
Petechiae and hemorrhagic bullae in mouth

Diagnostic Tests
Low platelet count
Peripheral blood smear
Antiplatelet antibodies

Normal platelet count: 150,000 to 400,000
Management
IV gamma globulin to block antibody
production, reduce autoimmune problem
Corticosteroids to reduce inflammatory
process
IV anti-D to stimulate platelet production
Sickle Cell Anemia
Autosomal recessive disorder
Defect in hemoglobin molecule
Cells become sickle shaped and rigid
Lose ability to adapt shape to surroundings.
Sickling may be triggered by fever and
emotional or physical stress
Pathophysiology
When exposed to diminished levels of
oxygen, the hemoglobin in the RBC
develops a sickle or crescent shape; the cells
are rigid and obstruct capillary blood flow,
leading to congestion and tissue hypoxia;
clinically, this hypoxia causes additional
sickling and extensive infarctions.
Whaley & Wong Text
Crescent Shaped Cells
Body Systems Affected by SS
Brain: CVA paralysis - death
Eyes: retinopathy blindness
Lungs: pneumonia
Abdomen: pain, hepatomegaly, splenomegaly
(medical emergency due to possible rupture
Skeletal: joint pain, bone pain osteomyelitis
Skin: chronic ulcers poor wound healing

Vaso-occlusive Crisis
Stasis of blood with clumping of cell in the
microcirculation, ischemia, and infarction
Most common type of crisis; painful
Signs include fever, pain, tissue
engorgement
Splenic Sequestration
Life-threatening / death within hours
Pooling of blood in the spleen
Signs include profound anemia,
hypovolemia, and shock
Abdominal distention, pallor, dyspnea,
tachycardia, and hypotension
Aplastic Crisis
Diminished production and increased
destruction of red blood cells
Triggered by viral infection or depletion of
folic acid
Signs include profound anemia, pallor
Nursing Diagnoses
Altered tissue perfusion
Pain
Risk for infection
Knowledge deficit regarding disease
process
Nursing Management - Hospital
Increase tissue perfusion
Oxygen
Blood transfusion if ordered
Bed rest
Pain management
Hydration
IV fluids as ordered
Oral intake of fluids
Nursing Management
Adequate nutrition
Emotional Support
Discharge instructions
Information about disease management
Daily folic acid
Control of triggers
Prophylactic antibiotics
Immunizations / Pneumococcal

Patient Education
Necessity of following plan of care
Signs and symptoms of impending crisis.
Signs and symptoms of infection
Preventing hypoxia from physical and
emotional stress
Proving adequate rest
Beta-Thalassemia
Hereditary / autosomal defect
Genetic defect on chromosome 11
Mediterranean descent
Defect in the beta globin gene
Beta globin chains are required for
synthesis of hemoglobin A

RBC Characteristics

Microcytosis = small in
size

Hypochromia = decrease
hemoglobin

Poikilocytosis = abnormal
shape
Treatment / Prognosis
Supportive
Blood transfusions as needed
Bone marrow transplant
Poor prognosis / death within 1
st
year due to septicemia or
heart failure.
Iron Deficiency Anemia
Most common nutritional deficiency
Depletion of iron stores

Abnormal Laboratory Values
Hemoglobin levels less than 8 g/dL

Decreased levels of Serum Iron or Total
Iron Binding or Serum Ferritin

Microcytic and hypochromic red blood cells

IDA
Occurs in children experiencing:
Rapid physical growth
Low iron intake
Inadequate iron absorption
Loss of blood
Symptoms
Associated with low oxygenation of tissue:
Pallor
Fatigue
Shortness or breath
Irritability
Intolerance of physical work / exercise
Management
Iron supplementation
Given in a.m. on an empty stomach
To avoid staining of teeth, give using a syringe,
dropper or straw
Instruct caretaker that child may have dark-
colored stools
Management
Nutritional counseling
Infants younger than 12 months should be
on formula until around 12 months of age
Infants 12 months or older
Decrease intake of milk
Introduce solid foods
Children: iron fortified cereals, foods, meat,
green leafy vegetables
Teenagers: reduce junk food

Aplastic Anemia
Acquired or inherited

Normal production of blood cells in the
bone marrow is absent or decreased.

A marked decrease in RBCs, WBCs and
platelets.
Causes
Exposure to drugs
Exposure to chemicals
Exposure to toxins
Infection
Idiopathic in nature
Blood Characteristics

Neutophil less than 500
Platelet less than 20,000
Hemoglobin less than 7
Reticulocytes 1%

Nursing Diagnosis?
Bone marrow reveals hypo-cellular and fatty marrow.
Management
Immunosuppressive therapy

Antithymocyte globulin
Administered IV over 4 days
Response seen within 3 months

Hyper-bilirubinemia
Hyperbilirubinemia
Many babies have some jaundice. When they are a few
days old, their skin slowly begins to turn yellow. The
yellow color comes from the color of bilirubin. When red
blood cells die, they break down and bilirubin is left. The
red blood cells break down and make bilirubin. In
newborns, the liver may not be developed enough to get
rid of so much bilirubin at once. So, if too many red blood
cells die at the same time, the baby can become very
yellow or may even look orange. The yellow color does
not hurt the baby's skin, but the bilirubin goes to the brain
as well as to the skin. That can lead to brain damage.
Signs and symptoms
Very yellow or orange skin tones (beginning at the
head and spreading to the toes)
Increased sleepiness, so much that it is hard to
wake the baby
High-pitched cry
Poor sucking or nursing
Weakness, limpness, or floppiness
Photo Therapy
Fiberoptic Blanket
Nursing Interventions
Monitor bilirubin levels
Assess activity level muscle tone infant
reflexes
Encourage po intake: May need to supplement
with formula if inadequate breastfeeding
Weight daily to assess hydration status
Monitor stools amount and number
Cover eyes while under bili-lights
Facilitate parent - infant bonding

Loss of moro or startle reflex can indicate possible brain damage due to
Kernicterus
Blood Components
Plasma:
The liquid part of blood. All the blood cells are
suspended in this liquid.
Contains dissolved salts (electrolytes) and proteins
Albumin helps keeps blood vessels from leaking and carries
hormones and drugs to different parts of the body.
Antibodies (immunoglobulins) that defend the body against
viruses, fungi, and cancer cells
Serves as a reservoir that can absorb replenish or absorb
water from tissues when necessary.
Prevents blood vessels from collapsing and clotting by
keeping them filled and circulating
Plays a role in warming and cooling the body
Blood Components
Red Blood Cells
Erthrocytes: Make up 40% of the bloods volume
Produced in the bone marrow
Contain hemoglobin, a protein that gives blood its red color and
enables it to carry oxygen.
White Blood Cells
Leukocytes: Fewer in number than RBCs (1:660)
Primary responsibility: Defend the body against infection
Platelets
Thrombocytes: cell-like particles smaller than RBCs and WBCs.
Help with clotting process by gathering at bleeding site and
clumping together to form a plug that helps seal the blood vessel.

Blood cells
Granulocytes
.
Lymphoma
Lymphomas are a malignant proliferation of
lymphocytes either B or T
3% of all cancers in the US result from
lymphomas
The lymphomas are classified by the appearance
of malignant lymphocytes on biopsy of tumor
3 categories
Low-grade
Intermediate-grade
High-grade
Functional Presentation of
Lymphoma
People present with swollen,
growing lymph glands
(nodal disease) or tumors in
other organs (extramodal
disease)
Person can be asymptomatic
Common B symptoms
include fever, drenching
night sweats, loss of 10% of
body weight, and pruritis
(severe itching)
Staging of Lymphoma
Stage I involvement of a single lymph node
region or single extranodal organ or site

Stage II involvement limited to one side of the
diaphragm with 2 or more lymph node regions

Stage III involvement of lymph node regions on
both sides of the diaphragm

Stage IV diffuse or disseminated involvement of
one or more extralymphatic organs
Skin Lymphoma and Shoulder
Lymphoma
Treatment and Prognosis
of Lymphoma
Since the majority of lymphomas present in
multiple areas of the body, localized surgery or
radiation is rarely curative
Primarily, treatment is chemotherapy
Prognosis is dependent on the grade and stage
For people who do not respond to primary
treatment, bone marrow transplantation is
increasingly used
Biological agents and vaccine therapy were being
tested
Leukemia
Acute leukemia is characterized by an abnormal
proliferation of immature white blood cells, called
blasts or progenitor cells

Two main forms of acute leukemia
Acute lymphoblastic leukemia
A cancer at the earliest stages of lymphocyte maturation
Occurs more often in the young
Acute nonlymphoblastic leukemia
Usually a malignancy of the myeloblast
More common in adults
A : Picture of bone marrow smear (control); Normal granulocytes and erythroblasts are
evident.
B : Acute lymphoid leukemia (ALL); There is a marked proliferation of small lymphoblasts.
C : Acute myeloid leukemia (AML); There is a marked proliferation of large myeloblasts.
D : Chronic myeloid leukemia (CML); There is a marked proliferation of granulocytes at
various stages of maturation.
A
D
C
B
Leukemia
People with leukemia present with signs
and symptoms of low red blood cell count
(anemia), decreased white blood cells
(granulocytopenia) with infection and fever,
and a low platelet count (thrombocytopenia)
with bleeding

People will usually present critically
Physical appearance & leukemia
Specific lesions (leukemia
cutis) are localized or
disseminated infiltrations of the
skin by malignant leukemic
cells which may involve all
layers of the skin.

Chemotherapy needed for
treatment of Leukemia usually
results in hair loss
Treatment of Leukemia
The course of treatment includes red blood cell
transfusions to correct the anemia, treatments for
infections caused by the lack of mature white
blood cells, platelet transfusions to stop any
bleeding, and starting chemotherapy to kill the
leukemia cells

Once chemotherapy stops, tumor cells die, the
normal stem cells in the marrow that are resistant
to chemotherapy divide, and their progeny cells
mature and repopulate the marrow over the next 3
weeks
Vocational Implications of
Lymphoma and Leukemia
Depression, sleep disorder, and anxiety over
personal appearance are common

Long-term survivors also have persistent problems
including decreased energy level, negative body
image, depression, employment problems, and
marital problems

Vocational implications and accommodations are
similar to other cancers and are based on
symptoms and side effects of treatment
Hemophilia
Hemophilia is a sex-linked
hereditary blood disease
characterized by greatly
prolonged coagulation time
Hemophilia A is due to a
deficiency of blood
coagulation Factor VIII
Accounts for 75% of
hemophilia
Incidence is 1 in 10,000 male
births
Hemophilia B is due to a
deficiency of blood
coagulation Factor IX
Incidence is 1 in 75,000 male
births
Is clinically indistinguishable
from hemophilia A
Hemophilia
The person can present with mild, moderate, or
severe hemorrhagic disease, depending on the
amount of active protein produced

People with mild hemophilia rarely bleed
spontaneously and usually are discovered after
excessive bleeding secondary to trauma or surgery
People with moderate hemophilia have rare episodes of
spontaneous bleeding, but can hemorrhage with any
trauma
People with severe hemophilia have frequent
spontaneous hemorrhage from early childhood
Hemophilia
People with hemophilia can
bleed anywhere, but
bleeding into joints
(hemarthrosis), soft tissue
(such as muscle), urine
(hematuria), and the brain
are common
Chronic bleeding into joints
or an acute bleed into the
brain or spinal canal can lead
to chronic disabilities, both
functional and psychological
of Hemophilia
The general principle of treatment of hemophilia
is, first, to avoid drugs than can interfere with
clotting, particularly aspirin and other NSAIDS
that inhibit platelet function
Second, early recognition of bleeding episodes or
potential trauma and treatment with replacement
Factor VIII or IX is imperative
Prognosis has improved with the advent of factor
concentrate treatment in the 1960s, with fewer
severe bleeds, less crippling arthritis from
hemarthrosis, and less intracranial bleeding
Vocational Implications of
Hemophilia
Vocational training should stress jobs that limit
potentially hazardous situations

People with hemophilia who are on effective
replacement therapy can compete equally for most
jobs

For people with severe hemophilia, the ability to
self-infuse agents effectively reduces morbidity
and loss of work time
Sickle Cell Disease
Sickle cell disease causes
the red cell to assume a
nonpliable sickle shape
The resultant cellular defect
leads to the main
manifestations of the
disease, which include:
premature death of the cells
(hemolytic anemia)
vascular occlusion of vessels
and subsequent tissue
infarction
increased susceptibility to
infection
Sickle Cell Disease
A person with sickle cell
is homozygous for the
abnormal gene, therefore,
both parents must be
heterozygous for the
abnormal gene

The frequency of one
abnormal gene is the
African-American
population is 1 in 12 and
the incidence of sickle cell
anemia is 1 in 650

The frequency of the gene
is also high in
Mediterranean and
African populations
Functional Presentation of Sickle
Cell Disease
People with sickle cell disease
usually present in the first
decade of life with
complications of the three
main characteristics of the
disorder

Anemia

Vascular occlusion (resulting
in necrosis)

Increase susceptability to
infections, particularly
pneumococcal pneumonia
Humeral head infarction and osteonecrosis in a
50 year old female with sickle cell disease
Complications of Sickle Cell
Disease
pain episodes
strokes
increased infections
leg ulcers
bone damage (osteo-
necrosis)
yellow eyes or
jaundice
early gallstones
lung blockage
kidney damage and
loss of body water in
urine
painful erections in
men (priapism)
blood blockage in the
spleen or liver
(sequestration)
eye damage
anemia
delayed growth
Treatment of Sickle Cell Disease
There is no specific treatment for sickle cell
disease, therefore, most therapy is supportive in
treatment of the complications

Early recognition of infection, administration of
prophylactic antibiotics, and vaccination may
forestall or prevent other complications

If a painful crisis persists or there is infection of
a major organ (brain, lung, or heart), exchange
transfusion is performed to remove some of the
sickle red cells - the effect is temporary
Treatment of Sickle Cell Disease
General guidelines
Taking the vitamin folic acid (folate) daily to help
make new red cells
Daily penicillin until age six to prevent serious
infection
Drinking plenty of water daily (8-10 glasses for
adults)
Avoiding too hot or too cold temperatures
Avoiding over exertion and stress
Getting plenty of rest
Getting regular check-ups from knowledgeable health
care providers
Prognosis of Sickle Cell Disease
Prognosis has improved with good supportive
care, and many people with sickle cell disease
survive into middle age

However, frequent admissions for painful crises,
the complication of sickle cell disease, narcotic
use and abuse due to chronic pain, and absence
from school and work lead to significant
psychological and vocational problems
Vocational Implications of Sickle
Cell Disease
The greatest dysfunction was found in the areas of
employment, finances, sleep habits, and
performance of daily activities
The implications of these findings suggest a strong
need for vocational rehabilitation services, training
in areas of communication and self-esteem,
medical treatment, and psychological help for
depression and drug dependence
Advisable that these individuals stay away from
jobs that cannot be interrupted to take fluids, jobs
that involve extreme temperature changes, and
jobs with lower O
2
concentration
Additional Resources and Information
from the Web
Leukemia and Lymphoma Society (www.leukemia.org)
Lymphoma Information Network (www.lymphomainfo.net
Lymphoma Research Foundation (www.lymphoma.org)
Children's Leukemia Research Association
(www.childrensleukemia.org)
World Federation of Hemophilia (www.wfh.org)
National Hemophilia Foundation (www.hemophilia.org)
Sickle Cell Society (www.sicklecellsociety.org)
Sickle Cell Information Center (www.scinfo.org/)

Chapter 37
Hematology
Copyright 2007, 2006, 2001, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Objectives
Describe physiology of blood components

Discuss pathophysiology and signs and
symptoms of specific hematological
disorders

Outline general assessment and
management of patients with hematological
disorders

Scenario
You are called to a day camp on a sweltering summer day
to care for a child who fainted. Your 6-year-old patients
lips and nail beds appear pale against her bronze skin. Her
respirations and heart rate are rapid, and she is very
anxious. She has a history of sickle cell disease and is
complaining of severe abdominal pain. Counselors tell you
they had just finished a strenuous game when she
complained of a headache and then passed out.
Discussion
Based on your present information, discuss
the urgency of this call

What complications of her disease could
cause her present illness?

What additional assessments do you need to
perform?

What are your priorities of care for this
child?
Hematological System
Blood and blood-forming organs

Dysfunction affects other body systems

Results in diffuse clinical manifestations
Blood and Blood Components
Cells

Formed elements
Red blood cells
(erythrocytes)
White blood cells
(leukocytes)
Cell fragments (platelets)

Surrounded by plasma
Chief functions
Delivery of substances needed for cellular
metabolism in tissues
Defense against invading microorganisms and
injury
Acid-base balance
Blood cells formed in red bone marrow
AdultsRed marrow in membranous bone
Vertebrae
Pelvis
Sternum
Ribs
Yellow marrow produces some white cells
Composed mainly of connective tissue and fat
Other Blood-Forming Organs
Lymph nodes
Produce lymphocytes and antibodies

Spleen
Produces lymphocytes, plasma cells, antibodies
Stores large quantities of blood

Liver
Blood-forming organ during intrauterine life
Important role in coagulation process
Plasma
92% water

Three proteins
Albumin
Most plentiful
Gives blood gummy texture
Keeps water concentration of blood low so that
water diffuses from tissues into blood
GlobulinsTransport proteins
Provide immunity to disease
FibrinogenBlood clotting
Plasma
Functions of plasma proteins
Maintain blood pH
Transport fat-soluble vitamins, hormones, and
carbohydrates
Allow body to digest temporarily for food

Also contains salts, metals, and inorganic
compounds
Red Blood Cells (RBCs)
Most abundant cells in the body

Responsible for tissue oxygenation

Mainly water and hemoglobin
Life span of about 120 days
As cells age:
Internal chemical machinery weakens
Lose elasticity
Become trapped in small blood vessels in bone
marrow, liver, and spleen
Destroyed by specialized white blood cells
Macrophages
Mature Erythrocytes
Hemoglobin (Hgb) normal levels
Men: 13.5-18 g/100 mL
Women: 12-16 g/100 mL

RBCs: 4.5-5 million cells/mm
3

Hematocrit (Hct)
Fraction of total volume of blood that is RBCs
Normally about 45%

Reticulocyte count
Information about rate of RBC production
Hemoglobin Molecule
White Blood Cells (WBCs)
Arise from bone marrow

Functions
Destroy foreign substances
Clear bloodstream of debris

Leukocyte production increases when
infection occurs
Elevated WBC count in blood
Normal WBC count
5000-10,000 cells/mm
3

Monocytes: 5%
Increase with chronic infections
Lymphocytes: 27.5%
Neutrophils: 65%
Eosinophils and basophils together: 2.5%
Leukocyte disorders
Leukemia
Increased WBCs in tissues and/or blood
Leukocytosis
Abnormal increase in circulating WBCs
Leukopenia
Abnormal decrease in WBCs
The Inflammatory Process
Redness, heat, swelling, pain

Injured cells release histamine and other
substances:
Cause blood vessels in injured tissue to dilate
Increased blood flow carries neutrophils and
monocytes (phagocytic cells) to site of injury
The Inflammatory Process
Histamine and other substances cause walls
of blood vessels to leak
Fluid that collects in tissues contains fibrinogen

Fluid and irritating chemicals accumulate at
injured site
Stimulate pain receptors
Immunity
Cellular immunity

Humoral immunity

Autoimmune diseases

Alterations in immunologic response
Platelets (Thrombocytes)
Small, sticky cells

Role in blood clotting

Blood vessel is cut:
Platelets to site, swell into irregular shapes
Adhere to damaged vessel wall
Platelets plug leak; cells stick to them, forming clot
If vessel damage is too great, platelets signal clotting cascade
Platelets
Clotting time normally 7-10 min

Prothrombin time (PT time)
Time it takes plasma to clot

International normalized ratio (INR)
Assesses clotting efficiency
Blood Groups
Mixed with foreign plasma, red blood cells
either clump together or do not

Four types of human blood
A, B, AB, and O
Type A blood has anti-B antibodies
Will clump type B blood
Type B blood has anti-A antibodies
Will clump type A blood
Blood Groups
Type AB blood has neither antibody
Universal recipient

Type O blood has both anti-A and anti-B
antibodies
Can only receive type O

Type O blood has neither antigen
Can be given to any blood type
Universal donor
Rh Factor
Presence or absence of Rh antigen on
surface of red blood cells
Person with the factor is Rh positive
Person without it is Rh negative

Antibodies to Rh factor acquired through
exposure to Rh-positive blood
Hemostasis
Stops bleeding after injury
Interaction of plasma and tissue factors with
platelets and vessels

Leaky vessels sealed within minutes

Vascular components

Coagulation mechanisms
Anemia
Hemoglobin or erythrocytes below normal

Causes
Chronic or acute blood loss
Decreased production of erythrocytes
Increased destruction of erythrocytes

Iron-deficiency anemia

Hemolytic anemia
.
Hematologic System,
Oncologic Disorders &
Anemias
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Hematology
Study of blood and blood forming tissues
Key components of hematologic system
are:
Blood
Blood forming tissues
Bone marrow
Spleen
Lymph system

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What Does Blood Do?
Transportation
Oxygen
Nutrients
Hormones
Waste Products
Regulation
Fluid, electrolyte
Acid-Base balance
Protection
Coagulation
Fight Infections

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Components of Blood
Plasma
55%
Blood Cells
45%
Three types
Erythrocytes/RBCs
Leukocytes/WBCs
Thrombocytes/Platelets
19/04/2011 317
Erythrocytes/Red Blood Cells
Composed of hemoglobin
Erythropoiesis
= RBC production
Stimulated by hypoxia
Controlled by erythropoietin
Hormone synthesized in kidney
Hemolysis
= destruction of RBCs
Releases bilirubin into blood stream
Normal lifespan of RBC = 120 days
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Leukocytes/White Blood Cells
5 types
Basophils
Eosinophils
Neutrophils
Monocytes
Lymphocytes

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Types and Functions of
Leukocytes

Granulocytes
Neutrophil

Eosinophil
Basophil

Phagocytosis, early phase of
inflammation
Phagocytosis, parasitic infections
Inflammatory response, allergic
response
Agranulocytes
Lymphocyte
Monocyte

Cellular, humoral immune response
Phagocytosis; cellular immune
response
TYPE CELL FUNCTION
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Thrombocytes/Platelets
Must be present for clotting to occur
Involved in hemostasis
19/04/2011 321
Normal Clotting Mechanisms
Hemostasis
Goal: Minimizing blood loss when injured
1. Vascular Response
vasoconstriction
2. Platelet response
Activated during injury
Form clumps (agglutination)
3. Plasma Clotting Factors
Factors I XIII
Intrinsic pathway
Extrinsic pathway
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Anticoagulation
Elements that interfere with blood clotting
Countermechanism to blood clotting
keeps blood liquid and able to flow
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Structures of the Hematologic System
Bone Marrow
Liver
Lymph System
19/04/2011 324
Bone Marrow
Bone Marrow
Soft substance in core of bones
Blood cell production
(Hematopoiesis):The production of all
types of blood cells generated by a
remarkable self-regulated system that is
responsive to the demands put upon it.
RBCs
WBCs
Platelets

19/04/2011 325
Liver
Receives 24% of the cardiac output (1500
ml of blood each minute)
Liver has many functions
Hematologic functions:
Liver synthesis plasma proteins
including clotting factors and albumin
Liver clears damaged and non-
functioning RBCs/erythrocytes from
circulation
19/04/2011 326
Spleen
Located in upper L quadrant of
abdomen
Functions
Hematopoietic function
Produces fetal RBCs
Filter function
Filter and reuse certain cells
Immune function
Lymphocytes, monocytes
Storage function
30% platelets stored in spleen
19/04/2011 327
Effects of Aging on the
Hematologic System
CBC Studies
+ Hemoglobin (Hb or Hgb)
+ response to infection (WBC)
Platelets=no change
Clotting Studies
+ PTT

19/04/2011 328
Assessment of the Hematologic System
Subjective Data
Important Health Information
Past health history
Medications
Surgery or other treatments
19/04/2011 329
Assessment of
the Hematologic System (cont.)
Functional Health Patterns
Health perception health management
Nutritional metabolic
Elimination
Activity exercise
Sleep rest
Cognitive perceptual
Self-perception self-concept
Role relationship
Sexuality reproductive
Coping stress tolerance
Value belief
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Assessment of
the Hematologic System (cont.)
Objective Data
Physical Examination
Skin
Eyes
Mouth
Lymph Nodes
Heart and Chest
Abdomen
Nervous System
Musculoskeletal System
19/04/2011 331
Diagnostic Studies of the Hematologic System:
Complete Blood Count (CBC)
WBCs
Normal 4,000 -11,000 /
Associated with infection, inflammation, tissue injury or death
Leukopenia-- + WBC
Neutropenia -- + neutrophil count
RBC
4.5 5.5 x 10
6
/
4.0 5.0 x 10
6
/

Hematocrit (Hct)
The hematocrit is the percent of whole blood that is composed
of red blood cells. The hematocrit is a measure of both the
number of red blood cells and the size of red blood cells.

19/04/2011 332
Diagnostic Studies of the Hematologic System:
Complete Blood Count (CBC) Contd
Platelet count
Normal 150,000- 400,000
Thrombocytopenia-+ platelet count
Spontaneous hemorrhage likely when count is
below 20,000

Pancytopenia
Decrease in number of RBCs, WBCs, and platelets
19/04/2011 333
Diagnostic Studies
of the Hematologic System
Radiologic Studies
CT/MRI of lymph tissues
Biopsies
Bone Marrow examination
Lymph node biopsies

19/04/2011 334
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19/04/2011 336
Common Laboratory Tests for Hematologic and Lymphatic Disorders
19/04/2011 337
19/04/2011 338
Common Laboratory Tests for Hematologic and Lymphatic Disorders
19/04/2011 339
Hematologic Disorders
CBC Normal Adult Values
WBC 5,000 10,000/mm
3
RBC 4.5 5.5 million/mm
3
(4 5 females)
Hgb 14 17 g/dl (12 16 females)
Hct 42 52% (36 48 females)
MCV 84 96 fL
MCH 28 34 pg/cell
MCHC 32 36 g/dl
Platelets 140,000 400,000/mm3
RDW 11.5 14.5%
MPV 7.4 10.4 fL

WBC Differential
Segs/Polys: 50 62%
Band/Stabs 3 6%
Eos 0 3%
Baso 0 1%
Monos 3 7%
Lymphs 25 40%
Metas 0 1%

Alterations in Erythrocyte Function
Anemias
reduction in the total number of circulating
erythrocytes or a decrease in the quality or
quantity of hemoglobin
Etiology
Impaired Erythrocyte Production
Blood Loss
Increased Erythrocyte Destruction
Combination of the Above Causes
Anemias
Classification based on Morphology
Size: normocytic, macrocytic, microcytic
Color: normochromic, hypochromic,
hyperchromic
Other
Anisocytic varied size
Poiilocytosis varied shape
Measures of Morphology
Mean Corpuscular Volume (MCV)
(Hct X 10)/RBC
Mean Corpuscular Hemoglobin (MCH)
(Hgb X 10)/RBC
Mean Corpuscular Hemoglobin
Concentration (MCHC)
(Hgb/Hct) X 100

Clinical Manifestations of Anemia
Gradual vs. Sudden
gradual = usually less symptomatic because of
compensation
sudden = usually more symptomatic
Magnitude
Hgb of 8 g would be more likely to be symptomatic
Hgb of 12 g would be less likely to be symptomatic
Classic Signs of Anemia
Pallor
Fatigue
Dyspnea on Exertion (DOE)
Dizziness

Clinical manifestations
Compensatory Manifestations
Cardiovascular (stress response) to pump the decreased amount of
oxygen to the vital organs most efficiently
Tachycardia
Palpitations
Vasoconstriction
Respiratory to increase the effectiveness of breathing in
order to optimize the uptake of oxygen
tachypnea
increased breathing depth
Other
increased plasma volume interstitial fluid moves into the vascular
space
salt and water retention ( because of activation of the Renin-
Angiotensin-Aldosterone (RAA) system)

Macrocytic-Normochromic Anemia
(Megaloblastic)
Characterized by defective DNA synthesis that
produces a pattern of ineffective erythropoiesis,
resulting in unusually large stem cells in the bone
marrow called megaloblasts that mature into
unusually large and fragile erythrocytes that may
die prematurely resulting in increased bilirubin
levels.
CBC characteristics
Anemia
Macrocytic
Normochromic or Hyperchromic

Megaloblast Anemias
Pernicious Anemia Vit B12 Deficiency
Pernicious means highly injurious or destructive,
indicating its fatal potential if untreated
Etiology
Chronic condition caused by malabsorption of vitamin
B12
Decreased intake of Vitamin B12 (strict vegetarians)
Animal products
Meat, shellfish
Milk, eggs
Stored in liver for 3-5 years
Pernicious Anemia cont
Etiology
Defective gastric secretion of Intrinsic factor
(IF) from parietal cells of gastric mucosa
Congenital
Following partial or complete gastrectomy
Autoimmune gastric atrophy
Chronic atrophic gastritis
Heavy alcohol, hot tea, smoking
More common in elderly

Pernicious Anemia
Clinical Manifestations
Classic signs of anemia
Neurologic manifestations with severe anemia (<7 g/dl)
Vitamin B12 is necessary for the synthesis of myelin
Parasthesias of feet and fingers
Ataxia
Loss of position and vibration sense
Spasticity
Sore tongue, beefy red (unknown cause)
Hyperbilirubinemia
Jaundice/icterus
Lemon yellow skin combination of pallor and jaundice
Hepatosplenomegaly enlarged liver and spleen
Pernicious Anemia
Evaluation
CBC analysis
Clinical manifestation analysis
B12 levels
Schilling test Vit B12 absorption is measured
by administering radioactive Vitamin B12 and
measuring its excretion in the urine
Intrinsic factor evaluation
Bone marrow aspiration and analysis

Pernicicous Anemia
Treatment
Vitamin B12 administration
Injection if IF deficiency is the problem
Orally, IF deficiency is not the problem
Dietary adjustments
Blood transfusion
Monitor reticulocyte count for evidence of
response to therapy

Vitamin B12
Cyanocobalamin
Routes: PO, Intranasally, IM, SC
Oral Preferred
Adverse effects: hypokalemia
PO: 1000-10,000 micrograms/day tx
6 micrograms/day dietary supplement
IM, SC: typically 30 micg/day x 5-10days
then 100 to 200 micg/month
Intranasal 500 micg/spray once a week
B12 Treatment Considerations
Monitor B12 levels
Monitor Hemogram and reticulocytes
Give Folic acid with B12 for severe anemia
Folic acid caution
Folate Deficiency
Megaloblastic anemia
Etiology low folic acid levels
Sources: liver, yeast, fruits, leafy vegetables, eggs, milk
Absorbed in upper small intestine and is not IF
dependent
Circulates through the liver with very little storage
Deficiency is most common with select groups
Pregnancy and lactation (increased need)
Fad diets with decreased intake of folate
Alcoholic persons (ETOH interferes with folate metabolism)
Chronically malnourished
Sprue
Folate deficiency anemia
No neurologic manifestations
Manifestations related to malnourishment
painful ulcerations of cheeks and tongue
fissuring of lips and mouth
Gastrointestinal symptoms
Dysphagia
Flatulence
Watery diarrhea

Folate Deficiency Anemia
Evaluation
CBC
Folic acid levels
Bone marrow aspiration and analysis

Folate deficiency anemia
Treatment
Folic acid requires B12 to be converted to
active form
In large amounts, Folic acid is converted via an
alternate pathway
Two forms of treatment are available
Active form: leucovorin, folinic acid, citrovorum
factor
Inactive form: folacin, folate, pterolyglutamic acid,
folic acid
Inactive form is more common
Folic Acid
Indications
Treatment of Folic acid deficiency anemia
Prophylaxis for deficiency during pregnancy
Initial tx of severe B12 deficiency
Adverse effects: no known
Routes: PO, IM, SC, IV
Dosage: 1000 2000 micrograms/day
400 micrograms/day
Folic Acid
Treatment Guidelines
Monitor CBC and reticulocytes
If malabsorption is cause, diet alone will not be
sufficient
Oral is preferred

Microcytic-Hypochromic
Anemia
Characterized by erythrocytes that are
abnormally small and contain abnormally
reduced amounts of hemoglobin
CBC characteristics
Anemia
Microcytic
Hypochromic

Fe Deficiency Anemia
Pathophysiology
The body maintains a balance between iron that
is in use as Hgb and iron that is in storage for
future Hgb synthesis
As old RBCs are broken down, iron is recycled
Inadequate intake of iron-rich foods
Children with increased need related to growth
Pregnancy
Iron poor diet

Pathophysiology cont
Increased iron loss through bleeding,
Menorrhagia excessive menstrual bleeding
Medications that cause GI bleeding (ASA, NSAIDS)
Hemorrhoids
Ulcerative Colitis (bloody diarrhea)
Chronic blood loss with gastric or duodenal ulcers
Neoplasms which erode into blood vessels
Decreased iron related to parasitic infection (i.e.
hookworms metabolize iron)
Structural and functional changes in epithelial tissue as
a result of impaired capillary circulation (usually not
present unless the anemia is severe, < 7 g/dl)
nails brittle, thin, coarsely ridged, spoon-shaped
(koilonychia)
Tongue sore, red, burning caused by atrophy of the papillae
(glossitis)
Sore, dry skin at the corners of the mouth called angular
stomatitis
Difficulty swallowing related to a mucous web at the level of
the hypopharynx and epiglottis (consisting of mucous &
inflammatory cells)

Deficient iron containing enzymes
gastritis
headache
Neuromuscular changes probably related to hypoxia
(gait problems are rare)
numbness
tingling
Confusion, disorientation, memory loss (elderly)
Pica
Evaluation
CBC analysis
Clinical manifestation analysis
Serum Iron profile
Plasma Iron (Fe)
Total Iron Binding Capacity (TIBC)
Transferrin carrier protein for iron
Ferritin storage form of iron
Free Erythrocyte Protoporphyrin (FEP) indicator of heme
synthesis within erythrocytes
Bone Marrow aspiration and analysis

Treatments
eliminate causes of blood loss
administer iron
offer dietary counseling
blood transfusion
monitor reticulocyte count for evidence of
responseto therapy

Iron Therapy
Oral Iron Preparations
Iron Salts
Ferrous Sulfate (DOC)
Ferrous Fumarate
Ferrous Gluconate
Carbonyl Iron
Parenteral Iron
Iron Dextran
Sodium-ferric Gluconate Complex ad Iron Sucrose
Ferrous Sulfate
Least expensive
Standard by which other therapies are
judged
Indications
Tx of Iron Deficiency Anemia
Prophylaxis
Adverse Effects
GI side effects
Staining of teeth (liquid forms
Ferrous Sulfate
Toxicity
Rare from therapeutic dosing
Mostly accidental or intentional overdosing
Adult fatality rare
Child mortality common
NVD, shock, then acidosis, gastric necrosis, hepatic
failure, pulmonary edema, vasomotor collapse
Early dx saves lives :Fe levels and gastric x-ray
Ferrous Sulfate
Drug Interactions
Antacids decrease iron absorption
Tetracyclines decrease absorption of both
Ascorbic acid increases absorption and side
effects
Formulations IR and SR
Dosage and administration
Elemental Iron is key
Relationship to meals
Carbonyl Irons
Pure elemental Iron
Parenteral Iron
Iron Dextran anaphylaxis precautions
Other
Sodium-Ferric Gluconate
Iron Sucrose

Microcytic Hypchromic Anemia
Sideroblastic Anemia
group of hereditary and acquired microcytic
hypochromic anemias characterized by
inefficient iron uptake resulting in
dysfunctional hemoglobin synthesis
Normocytic-Normochromic Anemia
Characterized by erythrocytes that are
relatively normal in size and hemoglobin
content, but insufficient in number
CBC characteristics
Anemia
Normocytic
Normochromic

Aplastic Anemia
Pathophysiology
Caused by bone marrow failure (hypoplasia or
aplasia)
Pancytopenia is common (RBC, WBC, &
platelet counts are all low)
Pure red cell aplasia (PRCA) is an associated
condition - only red cells are affected
Aplastic Anemia
Etiology
Acquired
Primary - Idiopathic
50% of all confirmed cases
80% of Aplastic anemia occuring over age 50
Secondary
Chemicals
Benzene
Chloramphenicol
Chemotherapy for cancer treatment
Ionizing radiation
Hereditary Fanconi anemia rare genetic anemia
Has been observed to be a precursor to leukemia for some persons
(preleukemic condition)
Aplastic Anemia
If WBCs are low expect infection
If platetets are low expect bleeding
Evaluation
CBC
Bone Marrow Biopsy analysis
Aplastic Anemia
Treatment
Treat underlying disorder
Prevent further exposure to causal agent
Blood transfusions

Post-Hemorrhagic Anemia
Pathophysiology
Caused by acute blood loss
Immediate effects are those of volume
depletion
Fluid Volume Deficit
Hypovolemic Shock
The stress response attempts to compensate for
the volume loss

Post Hemmorhagic Anemia
Sympathetic Nervous system (SNS) stimulation
If greater than 50% blood loss
Shock
Lactic Acidosis
Death
Classic Signs of anemia
If the blood loss becomes chronic loss of iron
recycling results in the development of iron deficiency
anemia with clinical manifestations as described
above

Evaluation
CBC analysis
Vital signs assessment &Physical examination
History driven
Look for bleeding if not obvious

Treatment
Stop the bleeding
Administer fluids
Blood transfusion

Hemolytic Anemia
Pathophysiology
Premature, accelerated destruction of RBCs
Erythropoiesis is normal and often accelerates
in an attempt to compensate for the increased
destruction
Elevated Bilirubin levels often occur as a
consequence of the increased destruction
Jaundice
Icterus (scleral icterus)
Hemolytic Anemia
Etiology
Acquired
Immune Mediated
Traumatic
Infectious
Toxic
Physical
Hypophosphatemic
Hemolytic Anemia
Etiology cont.
Hereditary
Structural Defects
Enzyme Deficiencies
Defects of Globin synthesis or structure
Sickle cell anemia
Thalassemia

Hemolytic Anemia
Classic Signs of Anemia
Jaundice
Splenomegaly
Evaluation
CBC analysis
Bone Marrow studies
Clinical Manifestation analysis
Other tests for immune status or Hgb examination etc.
depending on the cause of the hemolysis
Hemolytic Anemia
Treatment
Remove the cause
Treat the underlying disorder
Blood transfusions
Splenectomy if that is a site where hemolysis is
occurring
Corticosteroids to treat immune mediated
hemolysis
Administration of folate, iron, erythropoietin

Anemia of Chronic Disease (ACD)
Pathophysiology
Most common anemia in the hospitalized
patient
Three pathogenic mechanisms cause ACD
Decreased erythrocyte lifespan
Failure of mechanisms of compensatory
erythropoiesis
Disturbances of the iron cycle

Etiology
Chronic Infections
HIV
Hepatitis C
Chronic inflammatory diseases
RA
SLE
IBD
Malignancies
Usually normocytic-normochromic but may be
microcytic-hypochromic if iron cycle is
severely affected
Manifestations of Iron deficiency anemia if
microcytic-hypochromic

Evaluation
CBC analysis
Screening for malignancies if chronic infection
or inflammation is not present
Treatment
Treat the underlying disorder
Administer Erythropoietin
Blood transfusion

Hemoglobin Blood Products
Packed Red Blood Cells (PRBCs)
No plasma; easier to store
Less likelihood of fluid overload
Whole Blood
Contains clotting factors and proteins
Both
Used to replace blood losses
Contains hemoglobin
Can transmit viruses
Carry oxygen to cells
Contain citrates may affect calcium levels
PRBCs and Whole Blood
Poor shelf life, expensive (testing), availability varies
Must be typed and cross-matched (time consuming)
Many patients have developed antibodies against all blood
groups (patients with prior blood transfusions), and PRBCs
and whole blood must be "washed" to remove antigens
Can transmit viruses and other pathogens
Adverse (allergic) reactions common
RN must follow strict protocols when transfusing
Nursing students are not allowed to transfuse PRBCs and whole
blood !!!
Other Blood Products
Frosh Frozen Plasma (FFP)
Albumin
Platelets
Clotting Factors
Anemia
Anemia is a reduction in the number
of RBCs, the quantity of hemoglobin,
or the volume of RBCs
Because the main function of RBCs is
oxygenation, anemia results in varying
degrees of hypoxia
19/04/2011 397
Anemia
Prevalent conditions
Blood loss
Decreased production of erythrocytes
Increased destruction of erythrocytes

19/04/2011 398
Anemia (contd)
Clinical Manifestations:
1. Pallor.
2. Fatigue, weakness.
3. Dyspnea.
4. Palpitations, tachycardia.
5. Headache, dizziness, and restlessness.
6. Slowing of thought.
7. Paresthesia.
19/04/2011 399
Anemia (contd)
Nursing Management:
1. Direct general management toward addressing the cause
of anemia and replacing blood loss as needed to sustain
adequate oxygenation.
2. Promote optimal activity and protect from injury.
3. Reduce activities and stimuli that cause tachycardia and
increase cardiac output.
4. Provide nutritional needs.
5. Administer any prescribed nutritional supplements.
6. Patient and family education
19/04/2011 400
Nursing Actions for a Patient who is Anemic
or Suffered Blood Loss
Administer oxygen as prescribed
Administer blood products as prescribed
Administer erythropoietin as prescribed
Allow for rest between periods of
activity
Elevate the pts head on pillows during
episodes of shortness of breath
Provide extra blankets if the pt feels cool
Teach the pt/family about underlying
pathophysiology and how to manage the
symptoms of anemia
19/04/2011 401
Anemia Caused by Decreased Erythrocyte
Production
Thalassemia
Megablastic Anemia
19/04/2011 402
Iron-Deficiency Anemia
Etiology
1. Inadequate dietary intake
Found in 30% of the
worlds population
2. Malabsorption
Absorbed in duodenum
GI surgery
3. Blood loss
2 mls blood contain 1mg iron
GI, GU losses
4. Hemolysis

19/04/2011 403
Most common: pallor
Second most common: inflammation of the tongue
(glossistis)
Cheilitis=inflammation/fissures of lips
Sensitivity to cold
Weakness and fatigue
Diagnostic Studies
CBC
Iron studies Diagnostics:
Iron levels: Total iron-binding capacity (TIBC), Serum
Ferritin.
Endoscopy/Colonscopy
19/04/2011 404
Collaborative Care
Treatment of underlying disease/problem
Replacing iron
Diet
Drug Therapy
Iron replacement
Oral iron
Feosol, DexFerrum, etc
Absorbed best in acidic environemtn
GI effects
Parenteral iron
IM or IV
Less desirable than PO

19/04/2011 405
Nursing Management
Assess cardiovascular & respiratory status
Monitor vital signs
Recognizing s/s bleeding
Monitor stool, urine and emesis for occult blood
Diet teachingfoods rich in iron
Provide periods of rest
Supplemental iron
Discuss diagnostic studies
Emphasize compliance
Iron therapy for 2-3 months after the hemoglobin
levels return to normal
19/04/2011 406
Thalassemia
Etiology
Autosomal recessive genetic disorder of
inadequate production of normal hemoglobin
Found in Mediterranean ethnic groups
Asymptomatic major retardation life
threatening
Splenomegaly, hepatomegaly
19/04/2011 407
Thalassemia
Collaborative Care
No specific drug or diet are effective in
treating thalassemia
Thalassemia minor
Body adapts to Hgb
Thalassemia major
Blood transfusions with IV deferoxamine (used
to remove excess iron from the body)
19/04/2011 408
Megaloblastic Anemias
Characterized by large
RBCs which are fragile
and easily destroyed
Common forms of
megaloblastic anemia
1. Cobalamin deficiency
2. Folic acid deficiency

This picture shows large, dense,
oversized, red blood cells (RBCs)
that are seen in megaloblastic
anemia.
19/04/2011 409
Cobalamin (Vitamin B
12
)
Deficiency
Cobalamin Deficiency--formerly known as
pernicious anemia
Vitamin B
12
(cobalamin) is an important water-
soluble vitamin.
Intrinsic factor (IF) is required for cobalamin
absorption
Causes of cobalamin deficiency
Gastric mucosa not secreting IF
GI surgery loss of IF-secreting gastric mucosal cells
Long-term use of H
2
-histamine receptor blockers cause
atrophy or loss of gastric mucosa.
Nutritional deficiency
Hereditary defects of cobalamine utilization

19/04/2011 410
Cobalamin (Vitamin B
12
)
Deficiency
General symptoms of anemia
Sore tongue
Anorexia
Weakness
Parathesias of the feet and hands
Altered thought processes
Confusion dementia
19/04/2011 411
Cobalamin Deficiency
Diagnostic Studies
RBCs appear large
Abnormal shapes
Structure contributes to erythrocyte
destruction
Schilling Test: a medical investigation used
for patients with vitamin B12 deficiency.
The purpose of the test is to determine if the
patient has pernicious anemia.
19/04/2011 412
Collaborative Care
Parenteral administration of cobalamin
Dietary cobalamin does not correct the anemia
Still important to emphasize adequate dietary intake
Intranasal form of cyanocobalamin (Nascobal)
is available
High dose oral cobalamin and SL cobalamin can
use be used

19/04/2011 413
Nursing Management
Familial disposition
Early detection and treatment can lead to reversal of
symptoms
Potential for Injury r/t patients diminished
sensations to heat and pain
Compliance with medication regime
Ongoing evaluation of GI and neuro status
Evaluate patient for gastric carcinoma frequently

19/04/2011 414
Folic Acid Deficiency
Folic Acid Deficiency also causes
megablastic anemia (RBCs that are large
and fewer in number)
Folic Acid required for RBC formation and
maturation
Causes
Poor dietary intake
Malabsorption syndromes
Drugs that inhibit absorption
Alcohol abuse
Hemodialysis
19/04/2011 415
Folic Acid Deficiency
Clinical manifestations are similar to those of
cobalamin deficiency
Insidious onset: progress slowly
Absence of neurologic problems
Treated by folate replacement therapy
Encourage patient to eat foods with large amounts of
folic acid
Leafy green vegetables
Liver
Mushrooms
Oatmeal ( )
Peanut butter
Red beans 19/04/2011 416
Anemia of Chronic Disease
Underproduction of RBCs, shortening of RBC
survival
2
nd
most common cause of anemia (after iron
deficiency anemia
Generally develops after 1-2 months of sustained
disease
Causes
Impaired renal function
Chronic, inflammatory, infectious or malignant disease
Chronic liver disease
Folic acid deficiencies
Splenomegaly
Hepatitis
19/04/2011 417
Aplastic Anemia
Characterized by Pancytopenia
of all blood cell types
RBCs
White blood cells (WBCs)
Platelets
Hypocellular bone marrow
Etiology
Congenital
Chromosomal alterations
Acquired
Results from exposure to ionizing radiation, chemical agents,
viral and bacterial infections
19/04/2011 418
Aplastic Anemia
Etiology
Low incidence
Affecting 4 of every 1 million persons
Manageable with erythropoietin or blood transfusion
Can be a critical condition
Hemorrhage
Sepsis

19/04/2011 419
Aplastic Anemia
Gradual development
Symptoms caused by suppression of any or all bone
marrow elements
General manifestations of anemia
Fatigue
Dyspnea
Pale skin
Frequent or prolonged infections
Unexplained or easy bruising
Nosebleed and bleeding gums
Prolonged bleeding from cuts
Dizziness
headache

19/04/2011 420
Aplastic Anemia
Diagnosis
Blood tests
CBC
Bone marrow biopsy
19/04/2011 421
Aplastic Anemia
Treatment
Identifying cause
Blood transfusions
Antibiotics
Immunosuppressants (neoral, sandimmune)
Corticosteroids (Medrol, solu-medrol)
Bone marrow stimulants
Filgrastim (Neupogen)
Epoetin alfa (Epogen, Procrit)
Bone marrow transplantation

19/04/2011 422
Aplastic Anemia
Nursing Management
Preventing complications from infection and
hemorrhage
Prognosis is poor if untreated
75% fatal
19/04/2011 423
Anemia Caused By Blood Loss
Acute Blood Loss
Chronic Blood Loss
19/04/2011 424
Acute Blood Loss
Result of sudden hemorrhage
Trauma, surgery, vascular disruption
Collaborative Care
1.Replacing blood volume
2.Identifying source of hemorrhage
3.Stopping blood loss

19/04/2011 425
Chronic Blood Loss
Sources/Symptoms
Similar to iron deficiency anemia
GI bleeding, hemorrhoids, menstrual blood
loss
Diagnostic Studies
Identifying source
Stopping bleeding
Collaborative Care
Supplemental iron administration
19/04/2011 426
Anemia caused by Increased Erythrocyte
Destruction
Hemolytic Anemia
Sickle Cell disease (peds)
Acquired Hemolytic Anemia
Hemochromatosis
Polycythemia
19/04/2011 427
Hemolytic Anemia
Destruction or hemolysis of RBCs at a rate that exceeds
production
Third major cause of anemia
Intrinsic hemolytic anemia
Abnormal hemoglobin
Enzyme deficiencies
RBC membrane abnormalities
Extrinsic hemolytic anemia
Normal RBCs
Damaged by external factors
Liver
Spleen
Toxins
Mechanical injury (heart valves)

19/04/2011 428
Sequence of Events in Hemolysis

Fig. 30-1
19/04/2011 429
Acquired Hemolytic Anemia
Causes
Medications
Infections
Manifestations
S/S of anemia
Complications
Accumulation of hemoglobin molecules can
obstruct renal tubules Tubular necrosis
Treatment
Eliminating the causative agent
19/04/2011 430
Potential Nursing Dx for Patients with
Anemia
Activity Intolerance r/t weakness, malaise m/b
difficulty tolerating d activity
Imbalance nutrition: less than body requirements r/t
poor intake, anorexia, etc. m/b wt loss, + serum
albumin, + iron levels, vitamin deficiencies, below ideal
body wt.
Ineffective therapeutic regimen management r/t lack
of knowledge about nutrition/medications etc. m/b
ineffective lifestyle/diet/medication adjustments
Collaborative Problem: Hypoxemia r/t +hemoglobin
19/04/2011 431
Hemochromatosis
Iron overload disease
Over absorption and
storage of iron causing
damage especially to
liver, heart and
pancreas

19/04/2011 432
Polycythemia
Polycythemia is a condition in which
there is a net increase in the total number
of red blood cells
Overproduction of red blood cells may
be due to
a primary process in the bone marrow (a so-
called myeloproliferative syndrome)
or it may be a reaction to chronically low
oxygen levels or
malignancy
19/04/2011 433
Polycythemia
Complications
d viscosity of blood
hemorrhage and thrombosis
Treatment
Phlebotomy
Myelosupressive agents: A number of new
therapeutic agents such as, interferon alfa-2b (Intron A) therapy,
agents that target platelet number (e.g., anagrelide [Agrylin]), and
platelet function (e.g., aspirin).
19/04/2011 434
Thrombocytopenia
Disorder of decreased platelets
platelet count below 150,000
Causes
Low production of platelets
Increased breakdown of platelets

Symptoms
Bruising
Nosebleeds
Petechiae (pinpoint microhemorrhages)

19/04/2011 435
Thrombocytopenia
Types of Thrombocytopenia
Immune Thrombocytopenic Purpura
Abnormal destruction of circulating platelets
Autoimmune disorder
Destroyed in hosts spleen by macrophages
Thrombotic Thrombocytopenic Purpura
|d agglutination of platelets that from microthrombi

19/04/2011 436
Heparin-Induced Thrombocytopenia (HIT)
HIT
Associated with administration of heparin
Develops when the body develops an antibody, or allergy to heparin
Heparin (paradoxically) causes thrombosis
Immune mediated response that casues intense platelet activation and
relaese of procoaggulation particles.
Clinical features
Thrombocytopenia
Possible thrombosis after heparin therapy
Can be triggered by any type, route or amount of heparin
19/04/2011 437
Thrombocytopenia
Diagnostic Studies
Platelet count
Prothrombin Time (PT)
Activated Partial Thromboplastin Time (aPTT)
Hgb/Hct
Treatment
Based on cause
Corticosteroids
Plasmaphoresis
Splenectomy
Platelet transfusion

19/04/2011 438
Iron critical to bind oxygen
Lack of iron inhibits hemoglobin production in
bone marrow
Cells small and pale centered
Reduced oxygen-carrying capacity
Causes
Diet low in iron
Vitamin deficiency
NSAID or ASA therapy
GI disorders
Bleeding (internal or external)
Gastrectomy
Hemolytic Anemia
Premature red cell destruction
Hemolysis

Inherited disorder inside red cell
Abnormal rigidity of cell membrane

Acquired disorder
Mechanical forces disrupt RBCs
Autoimmune disorders
Microorganisms
AnemiaSigns and Symptoms
Fatigue and headaches

Sore mouth or tongue

Brittle nails

Severe - breathlessness and chest pain

Fever

Skin or mucous membrane bleeding
Anemia
Treatment to correct, modify, or diminish
process leading to:
Defective red cell production
Reduced red cell survival

Diagnosis
History
Laboratory tests
Leukemia
Several types of cancer

Disorganized proliferation of WBCs in bone
marrow

Impairs normal RBC production

Acute or chronic

LeukemiaSigns and Symptoms
Fatigue
Bone pain
Elevated temperature
Diaphoresis
Heat intolerance
Abdominal fullness
Bleeding

Bruising
Headache
Weight loss
Night sweats
Enlarged lymph nodes
Enlarged spleen, testes,
liver
Leukemia
Diagnosed by bone marrow biopsy

Treatment
Transfusion
Antibiotics
Anticancer drugs
Radiation
Lymphomas
Group of diseases

Slowly growing chronic disorders to rapidly
evolving, acute conditions

Hodgkins disease
Others called non-Hodgkins lymphomas
Hodgkins Disease
Malignant disorder of lymphoid tissue
Mainly in lymph nodes and spleen

Enlargement of lymph nodes
Cancer cells multiply
Displace healthy lymphocytes
Suppress immune system

Sign and symptoms

Diagnosis

Treatment
Hodgkins Disease
Swollen nodes in neck, armpits, groin

Fatigue

Chills

Night sweats

Itching, cough, weight loss

Shortness of breath, chest pain

Peak incidence in 20s
Hodgkins Disease
Confirmed by finding Reed-Sternberg cells

Treatment varies
Radiation
Chemotherapy

Curable cancer

Non-Hodgkins Lymphomas
Nature and activity of abnormal cells
Over 10 types of non-Hodgkins lymphoma
Vary in severity

Signs and symptoms
Lymph node swelling
Enlarged liver, spleen
Fever
Abdominal pain
Non-Hodgkins Lymphomas
Cause mostly unknown
Some linked to Epstein-Barr virus, HIV

Treatment
Radiation therapy
Anticancer drugs
Bone marrow transplantation
Polycythemia
Excess production of RBCs, WBCs, and
platelets

Response to hypoxia (secondary
polycythemia)

Unknown reasons (primary polycythemia)
Polycythemia Vera
Increased RBC production
Headache, dizziness
Blurred vision
Itching
Red hands/feet; red-purple complexion
Hypertension
Splenomegaly
Disseminated Intravascular Coagulopathy
(DIC)
Complication of severe injury, trauma, or disease
Abnormal clotting disorder

Disrupts balance between:
Procoagulants and inhibitors
Thrombus formation and lysis

Signs and symptoms

Management
DIC
Dyspnea, bleeding, hypotension

Two phases
Free thrombin in blood, fibrin deposits,
aggregation of platelets
Hemorrhage from depletion of clotting factors

Management
Correction of underlying disorder
Blood products
Hemophilia
Inherited bleeding disorder
Hemophilia A
Deficiency of factor VIII
Hemophilia B
Deficiency of factor IX

Bleeding may occur after minor injury or
during procedures
Tooth extraction
Hemophilia
Hemorrhage can occur anywhere
Joints, deep muscles, urinary tract, and
intracranial sites most common

Controlled by infusions of factor VIII

Most hemophiliacs seek emergency care for
complicated problems and trauma
Sickle Cell Disease
Sickle cell anemia

Debilitating recessive genetic illness

Affects persons of African descent
Less commonly Mediterranean origin)

Signs and symptoms

Pathophysiology

Management
Sickle Cell Disease
Signs and Symptoms
Weakness

Aching

Chest pain and dyspnea

Severe abdominal pain

Bony deformities

Jaundice

Fever

Joint pain

Sickle Cell versus
Normal Erythrocyte
Sickle Cell Crisis
Triggered by:
Dehydration
Stress
Infection
Trauma
Exposure to temperature extremes
Lack of oxygen
Strenuous physical activity
Sickle Cell Crisis
Management
Oxygen
IV therapy
Analgesia
Transport for additional care
Multiple Myeloma
Malignant neoplasm of bone marrow

Tumor destroys bone

Results in:
Pain
Fractures
Hypercalcemia
Skeletal deformities
Kidney problems
Multiple Myeloma
Diagnosed by:
X-ray
Blood studies
Biopsy

Treatment
Chemotherapy
Radiation

Assessment and Management
Many emergency presentations

Call to manage change in condition

Management
Oxygen
IV
Analgesia
Other symptomatic care
Transport to hospital, where patient receives primary care if
possible
Conclusion

The paramedics knowledge of hematologic
diseases enhances assessment skills and
provides an understanding of treatment
strategies needed for these patients.
Questions?
MONOCYTE
5-10 % Circulating
WBCs
When stimulated
become Macrophages
and dentritic cells in
the tissue
Clean up the debris
EOSINOPHIL
1-5% Circulating
WBCS
Involved in parasitic
infections
Involved with
mechanism associated
with allergy and
asthma
In case of w.w.w.
BASOPHIL
< 1% circulating
WBCS
Involved with allergic
and inflammatory
response
Release histamines
and cytokines
Hematological
Symptoms
Hematological Symptoms
Neutropeniadefined as ANC<1000/mm3
Anemia--RBC & Hgb
Thrombocytopenialow PLT <100,000
Leukopeniadecrease in WBC, below the
lower limit
Pancytopenia-an abnormal deficiency in all
blood cells, RBC, WBC, & PLT; usually
associated with bone marrow tumor or with
aplastic anemia)

Risk factors for febrile neutropenia
Previous Hx Chemo/Type of chemo/prior
radiation Tx
Age>65/ female gender
Poor nutritional status
Advanced cancer and bone marrow involvement
LDH, Hgb
Leukemia/lymphoma/lung cancer
Open wounds
DM
COPD

Prevention of Neutropenia
Growth stimulating factors activate
production of bone marrow cells. It can be
given prophylactically or therapeutically
BMT give GCSF on day+4 of stem cell
SCT
GCSF-/filgrastim 5mcg/kg
Pegfilgrastim--Neulasta 6mcg/kg

Neutropenic Precautions
Limit exposure of pts to infections
Hand washing spread
Avoid crowds
Avoid fresh fruits /vegetables/flowers
Avoid caring for animals esp. cleaning
excretes
Avoid gardening

Infections
Mechanical barriersskin, mucous
membranes
Chemical barriers-pH of tissues
Inflammatory and immune responses
Risks of Infections
High risk
Intermediate risk
Low risk
High Risk for infection
Allogeneic BMT
Acute Leukemia's
GVHD tx dose steroids
Neutropenic lasting >10 days
Break in skin/mucosal barrier
Prolonged ABX or steroid use
Poor nutrition
Invasive procedure
Poor personal hygiene
Intermediate Risks for infections
Autologous BMT
Lymphoma/MM/CLL
Neutropenic anticipated to last >7-10 days

Low Risk for infections
Standard Chemotherapy
Neutropenia <7 days
PT AND PTT
PT (PROTIME) Test the extrinsic pathway
PTT Tests the intrinsic pathway
COUMADIN (WARFARIN) Affects the
Vitamin K factors (II,VII,IX,X ) of which
factor VII is the most labile
Hemophilia is a factor VIII deficiency
INR: Method for standardizing Protimes. It
is a ration of tested results : control
COAGULATION PRODUCTS
Fresh Frozen Plasma
Cryoprecipitate: Factor VIII, Fibrinogen
Activated Products: Factor IX
Chemistry Tests
Liver Function Studies
Renal Function
ElectrolytesNa, K, Ca, Mg, Po4, Co2

LIVER FUNCTION
Hepatocelluar Enzymes:
AST (ASPARTATE AMINOTRANSFERASE)
ALT (ALANINE AMINOTRANSFERASE)

SGGT (very specific)
LDH (Lactate Dehydrogenase)
LIVER FUNCTION
ALKALINE PHOSPHATASE-AP not specific to liver
AP= LARGE COMPONENT IN BONE
BILIRUBIN -2 TYPES
DIRECT OR CONGUGATED AND INDIRECT OR
UNCONGUGATED.
AP / BILIRUBIN the first enzymes to
rise with liver GVHD
INDIRECT BILIRUBIN associated
with hemolysis

LDH
Nearly every type of cancer, as well as many other
diseases, can cause LDH levels to be , cannot be
used to dx a particular type of cancer.
LDH levels can be used to monitor treatment of
some cancers, including testicular cancer, Ewing's
sarcoma, non-Hodgkin's lymphoma, and some
types of leukemia
Elevated LDH levels can be caused by a number
of noncancerous conditions, including heart
failure, hypothyroidism, anemia, and lung or liver
disease.
RENAL
BUN (BLOOD UREA NITROGEN)
Elevated with:
Kidney dysfunction, Dehydration, excess protein
in blood such as TPN, High protein diet, GI bleeding
Creatinine: chemical waste is generated from
muscle metabolism. Creatinine is produced from
creatine, a molecule of major importance for
energy production in muscles. Creatinine is
transported through the bloodstream to the
kidneys. The kidneys filter out most of the
creatinine and dispose of it in the urine.
CREATININE CONT.
The ratio of BUN : creatinine determines renal
dysfunction VS pre-renal dysfunction such as
dehydration.

CALCULATED CREAT. CLEARANCE:
in ml/min---CRCL=(140-AGE) x ideal B.W./Scr. x 72 (x
0.85 for females)

ELECTROLYTES
SODIUM
POTASSIUM
CALCIUM
PHOSPHORUS
MAGNESIUM
CO2

SODIUM/POTASSIUM
SODIUM
/POTASSIUM
MEMBRANE PUMP
CALCIUM/PHOSPHORUS
DIRECT
INTERACTION
IF GIVEN
CONCOMBINETLY:
NaPO4 + CaCO3
=
CALCIUM
Calcium in plasma is bound to Albumin. If
Albumin is low, you get a falsely low serum
calcium.
2 ways to get a more accurate Calcium:
IONIZED CALCIUM
CORRECTED CALCIUM
CORRECTED Calcium:
[(4.0 serum alb) x 0.8 ] + s Ca = corrected
Ca

MAGNESIUM
Very important for Cardiac, Nervous and GI
systems.
Interacts with calcium and Potassium.
Difficult to get a Normal serum level of
Potassium if Mg is low.
CO2
Gives a rough idea of pH and buffer system
in blood
Infections typically have low venous CO2
Bone marrow Biopsy-aspirate
Used in Identi. metastatic Dz, esp
hematological malignancies
Assess iron stores
Assess megaloblastic maturation, in Vit
B12 and folate deficiencies or in MDS
Assess fat atrophy, aplasia or fibrosis
Other tests done in Hem/Onc
Fractionated bilirubinto differentiate
cause of hyperbilirumia
Stool guaiac--? bleeding
Coombes testdirect/indirect
Haptoglobin levelto detect hemolytic
anemia
Hgb electropheresis----
MICROBIOLOGY
BACTERIA
VIRUS
FUNGAL/YEAST
PROTOZOAN
BACTERIA
CATAGORIZED BY SHAPE AND
STAINING PROPERTIES
GRAMS STAIN
SHAPES ARE COCCI, RODS, AND
SPIROCHETES
BACTERIAL SHAPES
COCCI
RODS
SPIROCHETES
GRAMS STAIN
INTERACTS WITH THE BACTERIAL
MEMBRANE AND STAINS IT EITHER BLUE OR
RED
BLUE IS GM (+)
RED IS GM (-)

GRAM POSITIVE
COCCI: 1. STAPHALOCOCCUS
EITHER COAGULASE (-) OR (+)
COAG NEG=STAPH EPID.
COAG POS= STAPH AUREUS

2. STREP, ENTEROCOCCUS
RODS: BACILLUS, LISTERIA,
CORYNEBACTERIA DIPTHERIA
Staph aureus
GRAM NEGATIVE
COCCI: NEISSERIA, MORAXELLA,
ACINETOBACTER
RODS: E.COLI, PSEUDOMONAS,
SHIGELLA, SALMONELLA,
KLEBSIELLA, PROTEUS,
ENTEROBACTER, VIBRIO
Gram Negative rods
FUNGUS
MOLDS:
ASPERGILLUS ,
MUCOR,
YEAST AND
YEAST-LIKE:
CANDIDA,
TORULOPSIS,
HISTOPLASMOSIS,
CRYPTOCOCCUS,
BLASTO.
FUNGUS
VIRUS
CYTOMEGALOVIRUS
EPSTEIN-BAR
BK
ADENOVIRUS
INFLUENZA A & B
PARAINFLUENZA
RSV
PNEUMOCYSTIS CARINII
PREVIOUSLY
CONSIDERED A
PROTOZOAN BUT
NOW IN FUNGUS
CLASS
References
Demetri, G. (2001) Anemia and its functional consequences in
cancer pts, current challenges in management & prospects for
improving therapy. British Journal of Cancer,84,31-37
Dessypris, E, Erythropoiesis (1988). Lee G R, Foster J, Lukens J,
Wintrobe M M, eds.Wintrobes clinical hematolology. Pa:
Lippincott Williams & Williams 1998. 169-192.
Ludwig H, & Strasser K.(2001) Symptomatology of anemia. Seminars in
oncology, 28, 7-10
Means, R. (1999). The anemias of chronic disorders. Lee GR, Foerster J,
Lukens J, Paraskeras F, Greer J P, Rodgers GM, eds. WIntrobes
Clinical hematolgoy.10
th
ed, Pa. Lippincott Williams & Wilkin;1999:1011-
1021
National Comprehensive Cancer Network (2007). Cancer and treatment
related anemias, version 3.2007
Shortcut to DSC03990.lnk
The End
Hematology, also spelled
haematology ,is the branch of
internal medicine, physiology,
pathology, clinical laboratory work,
and pediatrics that is concerned
with the study of blood, the blood-
forming organs, and blood diseases.
Hematology includes the study of etiology,
diagnosis, treatment, prognosis, and prevention
of blood diseases. The laboratory work that goes
into the study of blood is frequently performed
by a medical technologist. Hematologists
physicians also very frequently do further study
in oncology - the medical treatment of cancer.

RBCs Disorders
Anemias
&Others
WBCs Disorders
Benign & Malignant
Hemostatic Disorders
ry 2 ry & 1
Transfusion
Medicine
Hematological
Disorders
Topics
OHematopoiesis
OComplete blood
count (CBC)
OAnemia
OPolycythemia
OLeukopenia
OLeukemia and
lymphoma
OMyeloma
OCoagulation
OTransfusion

Blood
Suspension of cells in a solute
of water, proteins, and
electrolytes
Average volume is 5 liters
O70mL per kg body weight
Plasma
OBlood from which the cellular
components (RBCs, WBCs,
platelets) have been removed by
centrifuge
Color is yellow
Contains coagulation proteins
(clotting factors)
Hematopoiesis
Development of blood cells and other formed elements
Sites vary throughout development
OFetal: yolk sac, liver, spleen
OPediatric: axial and appendicular skeleton
OAdult: axial skeleton (sternum and pelvis)
Stem cells
OPrimitive; self-replicate and differentiate to become
increasingly specialized progenitor cells which form mature
cells
Process regulated by growth factors (interleukins, erythropoietin,
thrombopoietin, G-CSF)
OEarly lineage division between progenitors for lymphoid and
myeloid cells

Hematopoiesis
Complete Blood Count
White blood cells (WBC)
Differential
Neutrophils, lymphocytes, monocytes, eosinophils,
basophils, bands
Must specify whether to include when ordering study
Red blood cells (RBC, Hgb, Hct)
Platelets (PLT)
Mean corpuscular volume (MCV)
Red cell distribution width (RDW)
Red Blood Cells
Transport oxygen via hemoglobin from
lungs to peripheral tissues and organs
Normal lifespan = 120 days
Reticulocytes
Immature red blood cells
Calculating proportion within circulation
assists in determining cause of anemia
Normal is 1-2%
Low suggests decreased production
(i.e. nutritional or marrow problem)
High suggests bleeding or premature
destruction of red blood cells (i.e.
hemolysis)

Red Blood Cells
ONormal
Anemia
Defined by measurement of hemoglobin
concentration
Normal 15 in males ; 14 in females
Patients are anemic when hgb is > 2 standard
deviations below normal
Determining reticulocyte count and MCV are first
steps in determining etiology
Almost 1/3 of the world population is anemic!

Anemia
Manifestations related to duration and severity
of anemia
May provide important clues as to etiology
Body has physiologic responses to chronic anemia
such that many patients are asymptomatic until hgb
< 8 g/dL
Fatigue, pallor, dyspnea, dizziness, dyspnea on
exertion, ischemic pain, cognitive abnormalities
Symptoms and signs of acute blood loss
(hemorrhage) are related to hypovolemia
Hypotension, tachycardia, palpitations, orthostasis,
syncope, shock
Anemia
Mechanisms
Blood loss / hemorrhage
Initial focus in ALL anemic patients
Gastrointestinal tract, menstruation
Hemolysis
Shortened RBC survival time not explained by bleeding
Details later
Decreased production (hypoproliferative)
Nutritional deficiency (iron, B12, and folate)
Systemic illness (CKD, cancer, rheumatologic disease,
etc.)
Bone marrow disorders
Microcytic Anemia
Microcytosis small cells (MCV <80)
Most common type of anemia encountered in
primary care
Differential diagnosis
OHemoglobinopathy (inherited)
OIron deficiency
OChronic disease (may also be normocytic)
OInflammation
OLead poisoning
Check iron studies for clarification
OBe familiar with interpretation (see next slide)
Microcytic Anemia
OMicrocytosis, Hypochromic
Microcytic Anemia
Dx Ferritin Serum Fe TIBC Saturation
Iron
deficiency
+ + q +
Chronic
disease
N or q + + N or q
RDW is often elevated in iron deficiency anemia ;
look for this along with low MCV on CBC report
Macrocytic Anemia
Macrocytosis large cells (MCV >100)
Differential diagnosis
OB12 deficiency
OPernicious anemia
OFolate deficiency
OETOH
OMedication
Check vitamin B12, RBC folate, fasting
homocysteine, and methylmalonic acid (MMA)
OHC and MMA are elevated in subclinical B12 and folate
deficiency

Hemolytic Anemia
History and physical findings
Review of PMH, FH, and medications
Jaundice is common
Occasional LUQ abdominal discomfort
(splenomegaly)
Lab findings
Elevated reticulocyte count
Reflects bone marrow compensating for peripheral RBC
destruction
Elevated LDH
Elevated total bilirubin (indirect/unconjugated)
Decreased haptoglobin
Abnormal cells on peripheral blood smear
examination
Hemolytic Anemia
Congenital
Membrane defects
Hereditary spherocytosis
Hereditary elliptocytosis
Enzyme defects
G6PD deficiency
Hemolytic Anemia
OCongenital, continued
Hemoglobin defects diagnosed by hemoglobin
electrophoresis
OThalassemias
OGroup of diseases characterized by globin chain (alpha and
beta) imbalance

Hemolytic Anemia
Congenital, continued
Sickle cell disease
RBCs become sickle-shaped hemolysis, vascular occlusion
Hgb S gene carried by 8% of African Americans
1:625 have disease
Genetic counseling available

Hemolytic Anemia
Acquired
Classified according to site of RBC destruction and whether mediated by
immune system
Intravascular
Extravascular
Autoimmune
Non-immune
Many causes be aware of these
Transfusion of incompatible blood (details later)
Autoimmune
Warm (IgG-mediated) ; most common
Cold (IgM-mediated)
Prosthetic valves
TTP/HUS
DIC
Cancer
Drugs

Polycythemia / Erythrocytosis
Abnormal elevation of hemoglobin
Rule out relative polcythemia caused by contraction of plasma volume, e.g.
dehydration
Primary
Polycythemia Vera
RBC production independent of EPO
EPO level is low / positive JAK-2 is diagnostic
Uncommon
May be associated with leukocytosis, thrombocytosis, splenomegaly
Hyperviscosity
Headache, vertigo, visual changes, mental confusion
Risk of transformation into acute leukemia
Refer to hematology
Secondary
RBC production in response to increased EPO production
EPO level is usually high
Very common
Usual etiology is chronic hypoxia (COPD, sleep apnea)
Phlebotomy (250-500 mL) to maintain hct 45-50% ; treat underlying problem!

White Blood Cells
Differential
Neutrophils 45-65%
Segs / Polys
Lymphocytes 15-40%
Monocytes 2-8%
Eosinophils 0-5%
Basophils 0-3%
Do you remember the physiologic role of each
type of WBC?
Benign WBCs Disorders
Leukopenia
Neutropenia is most common cause
Absolute neutrophil count (ANC) < 1.5 x 10
9
cells/L
Many causes
Benign racial neutropenia common
African Americans and Yemenite Jews may have ANC as low as 1.0
Viral infections
Epstein-Barr, Hepatitis B, HIV
Drugs *
Careful review of medications ; be suspicious of any medication recently
started in patient with acute onset neutropenia
See next slide
Splenomegaly
SLE (lupus), Rheumatoid Arthritis, etc.
Bone marrow disorders

Neutropenia
Common Medicinal Causes of Neutropenia
Cytotoxic agents
Antibiotics (Penicillins, Cephalosporins, Sulfonamides)
Anticonvulsants
NSAIDs
Antithyroid agents (Methimazole, PTU)
Phenothiazines
Allopurinol
Cimetidine
Diuretics (HCTZ, Spironolactone)
Leukocytosis
WBC count > 11,000
Determine which type of WBC is leading to the
leukocytosis
ONeutrophilia = most common
Infection
Connective tissue disorders
Medications (especially steroids, growth factors)
Cancer (CML and solid tumors)
Myeloproliferative disorders
Cigarette smoking
Stress (physiologic)
OPain, seizure, trauma
Idiopathic

Leukocytosis
Patients with acute bacterial infection often
present with neutrophilia and band formation ;
i.e. left shift
Bands = young neutrophils
Viral infections are usually associated with low
WBCs ; leukocytosis may suggest complications
Ex: bacterial pneumonia with underlying influenza
infection
Leukocytosis
Lymphocytosis
Viral infections
HBV, HCV, EBV, CMV
Tuberculosis
Pertussis
Drug Reaction
Stress (physiologic)
Trauma, MI, cardiac arrest, sickle crisis
Malignancy
ALL, CLL, lymphoma
Malignant WBCs Disorders
Types of Hematopoietic Malignancies
Leukemias
Acute leukemias
Acute myeloid leukemia
Chronic leukemias
Chronic myeloproliferative disorders
Chronic lymphoproliferative disorders
Lymphomas
Non-Hodgkin's lymphoma
Hodgkin's disease
Plasma cell disorders
Myeloma

Myeloid vs. Lymphoid
Myeloid malignancies
Acute myeloid leukemia
Chronic myeloproliferative disorders
Lymphoid malignancies
B-cell malignancies
Acute lymphoblastic leukemia, B-cell type
Non-Hodgkins lymphoma, B-cell types
Myeloma
T-cell malignancies
Acute lymphoblastic leukemia, T-cell type
Non-Hodgkins lymphoma, T-cell types
Hodgkins disease

Chronic Leukemia
Chronic myelogenous leukemia (CML)
Translocation between long arms of chromosomes 9
and 22 ; Philadelphia Chromosome ; bcr/abl
protein

Chronic Leukemia
Chronic lymphocytic leukemia (CLL)
Clonal malignancy of B-lymphocytes
Course is usually indolent ; affects older patients, average age at diagnosis is 70
years
Often found incidentally
Fatigue, lymphadenopathy common
Hepatosplenomegaly
Immunodeficiency is major clinical concern
Lymphocytes are defective ; do not make antibodies in response to antigens
Treatment
Observation
Indications for therapy include progressive fatigue, symptomatic lymphadenopathy, anemia,
or thrombocytopenia
Rituximab (Rituxan) and fludarabine +/- cyclophosphamide is initial approach
Gamma globulin (IVIG) used in patients with recurrent or severe bacterial infections
Allogeneic BMT is potentially curative but reserved for select patients
Prognosis improving ; survival is 10-15 years with early disease

Acute Leukemia
Acute Myelogenous Leukemia (AML)
OMost common in adults
OUsually no apparent cause
Exposure to radiation, benzene, and certain chemotherapy drugs (alkylators)
associated with leukemia
Underlying myelodysplastic syndrome (MDS) is risk factor
OSymptoms and signs
Related to replacement of marrow space by malignant WBCs
OPatients often very ill for period of just days or weeks
OSkeletal pain
OBleeding
OGingival hyperplasia
OInfection
OPancytopenia with circulating blasts is hallmark ; bone marrow biopsy required
Auer rods on peripheral smear are pathognomonic
Acute Leukemia
OAML, continued
Management
OImmediate referral to hematologist
Patients often hospitalized for therapy
Anthracycline (daunorubicin or idarubicin) plus
cytarabine results in CR in 80% of patients < 60
years
Additional high dose chemotherapy following CR leads to
cure rate of 35-40%
OAcute Lymphocytic Leukemia (ALL)
More often seen in children

Lymphoma
Hodgkins disease
Malignancy of B-lymphocytes
Reed-Sternberg cells
Various subtypes ; nodular sclerosing is most
common

Lymphoma
Non-Hodgkins Lymphoma (NHL)
Heterogeneous group of cancers affecting lymphocytes
Usually classified by histologic grade (low to high)
Follicular lymphoma
Small lymphocytic lymphoma
Diffuse large B-cell lymphoma
Burkitts lymphoma
Many others

Myeloma
Malignancy of plasma cells
Abnormal paraproteins are created leading to
systemic problems
IgG 60%
IgM 20%
Must be able to recognize in primary care setting
CRAB calcium, renal, anemia, bone
Primarily disease of elderly (median age 65 years)
Males > Females
Most common hematologic malignancy among
African Americans ; #2 among Caucasians

Myeloma
Osteolytic lesions
Hemostasis
Hemostatic Events
Tissue Injury
Vasoconstriction
Neural
Platelet-reinforced
Platelet Activation
Adhesion
Aggregation
Coagulation
Blood Clot
Thrombin generation
Fibrin polymerization
Fibrinolysis
Blood Clot Dissolution
Vascular Patency Restored

Secondar
y
Hemostas
is
Primary
Hemostasi
s
Categories of Hemostasis (page 572)
Primary
Vascular System
Endothelia
Sub endothelia/collagen
Platelets
Secondary
Coagulation System
Plasma Proteins
Cells: Platelets
Fibrinolytic System
Plasma proteins
Cells: Platelets, Endothelia

Graphic accessed at URL http://www.acta-ortho.gr/v55t4_4/Figure1.jpg 9/18/08.
Graphic accessed at URL http://www.kup.at/journals/abbildungen/gross/746.html 9/18/08.
Bleeding Disorders
Coagulation cascade
Causes of Bleeding(1)
Thrombocytopenia:
Primary:
ITP
Neonatal Isoimmune
TAR Syndrome
Wiskott-Aldrich Syn.
Secondary:
*Malignancy
*Aplastic Anemia
*DIC
*Sepsis
*HUS
*Hypersplenism
*Autoimmune(SLE)
Coagulopathy:
Primary:
vWF Deficiency
Hemophilia
Platelet dysfunction
Secondary:
DIC
Anticoagulants
Vit K deficiency
Hepatic Failure
Renal Failure
Maternal
Anticonvulsant

Vascular(Non-Hematologic)
Child Abuse
Vasculitis
Ulcer
Varices
Ehlers-Danlos Syndrome
Telangiectasia
Angiodysplasia

Characteristic Primary
hemostasis
Secondary hemostasis
Onset Spontaneous and
immediate
Delayed after trauma
Usual site Skin, mucous membranes Deep tissues /
hemarthrosis
Other sites Rare Retroperitoneum, CNS
Examples Thrombocytopenia,
platelet defects (vWD)
Factor deficiency or
inhibitor
Bleeding Disorders
Patterns of bleeding
OPrimary hemostasis platelet and vascular function
OSecondary hemostasis clotting factors

Bleeding Disorders
Petechiae in patient with acute ITP ; platelet
count = 10,000
Secondar
y
Hemostas
is
Primary
Hemostasi
s
Categories of Hemostasis (page 572)
Primary
Vascular System
Endothelia
Sub endothelia/collagen
Platelets
Secondary
Coagulation System
Plasma Proteins
Cells: Platelets
Fibrinolytic System
Plasma proteins
Cells: Platelets, Endothelia

Graphic accessed at URL http://www.acta-ortho.gr/v55t4_4/Figure1.jpg 9/18/08.
Graphic accessed at URL http://www.kup.at/journals/abbildungen/gross/746.html 9/18/08.
Thrombocytopenia:
Primary:
ITP
Neonatal Isoimmune
TAR Syndrome
Wiskott-Aldrich Syn.
Secondary:
*Malignancy
*Aplastic Anemia
*DIC
*Sepsis
*HUS
*Hypersplenism
*Autoimmune(SLE)
Coagulopathy:
Primary:
vWF Deficiency
Hemophilia
Platelet dysfunction
Secondary:
DIC
Anticoagulants
Vit K deficiency
Hepatic Failure
Renal Failure
Maternal
Anticonvulsant

Vascular(Non-Hematologic)
Child Abuse
Vasculitis
Ulcer
Varices
Ehlers-Danlos Syndrome
Telangiectasia
Angiodysplasia

Characteristic Primary
hemostasis
Secondary hemostasis
Onset Spontaneous and
immediate
Delayed after trauma
Usual site Skin, mucous membranes Deep tissues /
hemarthrosis
Other sites Rare Retroperitoneum, CNS
Examples Thrombocytopenia,
platelet defects (vWD)
Factor deficiency or
inhibitor
Bleeding Disorders
Patterns of bleeding
OPrimary hemostasis platelet and vascular function
OSecondary hemostasis clotting factors

Bleeding Disorders
Petechiae in patient with acute ITP ; platelet
count = 10,000
Thrombosis
Venous thromboembolism (VTE)
DVT and PE are very common in hospital setting
20% among general medical patients ; up to 80% of critical care patients
Be familiar with risk factors
Obesity
Oral contraceptives
Pregnancy
Tobacco abuse
Prolonged immobility
Surgery
Malignancy
Consider prophylaxis
Compression stockings and sequential compression devices
Lovenox 40 mg SQ once daily
Arixtra 2.5 mg SQ once daily
Unfractionated heparin 5000 units q 8-12 hours

Transfusion Medicine
History
19
th
century experimentation with animal and human blood transfusion
1900 ABO blood groups first described
1936 First US hospital blood bank established
Blood donation
Approximately 450 mL whole blood collected ; later processed into RBC,
plasma, and platelets
Apheresis removing whole blood, separating a portion, and returning the
rest to donor
Used for plasma and platelet donation
RBC storage period ranges 35-42 days depending on preservative
Up to 25% of transfused RBCs will be cleared from recipient circulation within 24
hours of delivery

Review of physiology
Anti-A and Anti-B are naturally occurring and develop in first months of life
in those lacking A or B antigens on RBC surface
Rh factor (D-antigen) absent in 15% of population
These patients may develop anti-D antibodies following pregnancy or transfusion
with Rh+ blood leading to severe reactions
Pretransfusion testing
ABO and Rh typing
Antibody screen (Coombs test)
If positive, further testing required to identify specific antibody ; donor unit is then
checked
Crossmatch
Donor RBC mixed with recipient serum and incubated to check for compatibility
Type O negative blood may be used in emergency
Limited supply ; only 15% of donors

When to transfuse
blood? Use clinical
judgment!
No single hgb/hct limit;
general indications
include:
Symptomatic anemia
Tachypnea, Tachycardia,
Cyanosis
Blood loss (>15% volume)
Chronic hypoproliferative
anemia (i.e. MDS)
Sickle cell crisis
Single unit of PRBC
increases hgb by 1.5 g/dL
or hct by 3-4%

Platelet transfusion
Platelet count < 10,000
Active bleeding in setting of significant
thrombocytopenia
Platelet count of 50,000 adequate for most surgical
procedures
Single apheresis unit will generally raise platelet
count by 30,000
Anticipate low yield with splenomegaly, DIC, sepsis
Immune factors may also cause patients to be refractory
Consider ordering HLA-matched platelets
Relative contraindications
ITP, TTP, and HIT

Plasma transfusion
Indications
Coagulation factor deficiency
Consider factor concentrates if available
Rapid reversal of warfarin effect
Hemorrhage in patients with liver disease
DIC (controversial)
Transfusion Reactions
Acute hemolytic reaction
Intravascular hemolysis (hemoglobinuria)
Fever, chills, pain, nausea, dyspnea, hypotension
May lead to ARF, DIC, and death
ABO incompatibility (human error) is most common cause
Proper labeling and patient identification is essential for prevention
STOP transfusion and notify blood bank immediately
Delayed hemolytic reaction
Occur days to weeks later
Caused by RBC antibodies not detected by pretransfusion testing
Febrile non-hemolytic reaction
Common in patients with multiple prior transfusions
Caused by cytokines or recipient antibodies to donor leukocytes
Allergic reaction
Associated with plasma ; may be related to residual plasma in PRBC specimen
Usually mild ; pruritis, flushing, urticaria
Occasional anaphylaxis

Transfusion reactions, continued
OHypotensive reaction
Caused by bradykinin generation
OPatients on ACE inhibitors at higher risk
Hypotension and tachycardia shortly after beginning transfusion ; BP returns to
baseline upon interruption
OUsually safe to resume at slower rate upon recovery
OBacterial contamination
Septic shock ; high mortality
Rare but unpredictable
OTransfusion-related acute lung injury (TRALI)
Occurs during or shortly after transfusion
Causes leakage of pulmonary capillaries presenting as pulmonary edema in absence of
heart disease
Resolves within 48-72 hours
Mortality rate is 10%

Pediatric Hematological Disorders
Whaley and Wong
Chapters 35, 36

Components of the Blood
Blood:
Plasma
water, albumin, electrolytes, clotting factors
Cellular Components
RBCs, WBCs, Platelets
All formed in the red bone marrow (after birth)
In utero- spleen, thymus, liver
lymphatic system regulates maturation
Erythrocytes
RBCs
carry hemoglobin which is attached to oxygen-
provides O2 to the tissues
life span 120 days
manufacture regulated by erythropoetin
Normal Hematocrit- 35-45%
Normal Hemoglobin- 12-16 grams

Problems of Erythrocyte Production
Anemia reduction of RBC volume or Hgb
concentration below normal
Classifications:
1. Etiology/Pathophysiology
causes of RBC/Hgb depletion
2. Morphology changes in RBC
size, shape, and color
Causes of Anemia
Nutritional deficiency iron, folate, B12
Increased destruction of RBCs sickle
cell anemia
Impaired or decreased rate of
production aplastic anemia
Excessive blood loss - hemophilia
Causes
- inadequate supply of iron
- impaired absorption
- blood loss
- excessive demands for iron reqd for
growth
- inability for form Hgb
Signs and Symptoms: due to tissue hypoxia
> lack of energy, easy fatigability, pallor
Diagnosis: CBC with diff, red cell indices
(MCV, MCH, MCHC), iron studies,
physical exam
Medical Treatment: supplement with
ferrous sulfate (dosages vary with age),
dietary counseling

Nursing Assessment and Interventions:
- educate parents about nutrition
- explain laboratory testing
- teach parents proper administration
of iron preparations, caution about
high toxicity of iron

Sickle Cell Anemia
Causes: genetic transmission, 2 parents with
the trait have 25% chance of having child
with SCD, found primarily in Blacks, occ
Hispanics
Hgb A is partly or completely replaced by
Hgb S
With dehydration,acidosis, hypoxia, and
temp elevations, Hgb S sickles
Sickle Cell Anemia
Pathophysiology:
- vaso-occlusion from sickled RBCs
- increased RBC destruction
- splenic congestion and enlargement
- hepatomegaly, liver failure
- renal ischemia, hematuria
- osteoporosis, lordosis, kyphosis
- cardiomegaly, heart failure, stroke

Sickle Cell Anemia
Signs/Symptoms:
Exercise intolerance
Anorexia
Jaundiced sclera
Gallstones
Chronic leg ulcers
Growth retardation
Sickle Cell Anemia
Diagnosis
- Sickledex
- Hgb electrophoresis
- Stained blood smear
Vaso-occlusive crisis
- mild to severe bone pain
- acute abdominal pain
- priapism
- arthralgia
Sickle Cell Anemia
Medical management
Supportive/symptomatic tx of crises
- bed rest
- hydration
- electrolyte replacement
- analgesics for pain
- blood replacement
- antibiotics
- oxygen therapy
Sickle Cell Anemia
Nursing care:
Minimize tissue deoxygenation
Promote hydration
Minimize crises
Pain management
Administering blood transfusions
Encourage screening and genetic counseling
Parent education
Thalassemia
Autosomal recessive disorder Greeks,
Italians, Syrians
Signs/symptoms microcytic anemia >
splenomegaly,jaundice,epistaxis, gout
Diagnosis Hgb electrophoresis
Medical Treatment transfusions, chelation
Hemophilia
Factor 8 or factor 9 deficiency
prolonged bleeding any where in the body!
Cause: X-linked recessive disorder, defects
in platelets and clotting factors
Diagnosis: history of bleeding episodes,
evidence of x-linked inheritence, labs
Medical Management: Factor VIII
concentrate, DDAVP (vasopressin)
Hemophilia
Nursing care:
Prevent bleeding
Recognize and control bleeding (RICE)
- Rest
- Ice
- Compression
- Elevation
Prevent crippling effects of bleeding
Client education

Idiopathic Thrombocytopenic Purpura
Causes: acquired hemorrhagic disorder of
unknown origin, probably an autoimmune
response to disease-related antigens
Diagnosis: platelet count < 20,000, abnl
bleeding time and clot retraction
Signs and Symptoms: petechiae, bruising,
bleeding from mucous membranes, prolonged
bleeding from abrasions
Medical management: supportive, steroids, Anti-D
antibody, splenectomy
Idiopathic Thrombocytic
Puerpera
Nursing Considerations:
Client/Parent teaching
No contact sports
No aspirin
Prevent infection
Blood Transfusions
Nursing Care
Take VS BEFORE administering blood
Check ID of recipient with donors blood type
Administer 50 mL or 1/5 volume SLOWLY STAY
WITH THE CHILD
Administer with NS on piggyback set-up
Use appropriate filter
Use within 30 mins infuse within 4 hrs
If reaction suspected: Stop the transfusion, maintain patent
IV line with NS, take VS, notify practitioner
Myeloid Cell Disorders
M2 Hematology/Oncology Sequence
John Levine, MD
Winter 2009
Myeloid Cell Disorders: Goals

Define members of the myeloid series
Understand:
white blood cell maturation
the white blood cell count and differential
philias and penias of the myeloid series
members and associated clinical settings
recruitment of WBC from the circulation.
Associate white blood cell defects with
function
596
Maturation of Myeloid Cells
GM-CSF
G-CSF
597
UMN Hematography Plus, Labeled by J. Levine
Mature Myeloid Cells
Neutrophil Eosinophil
Basophil Monocyte
598
Source Undetermined (All Images)
Assessment of Circulating WBC
The total white blood cell count (WBC) and
differential are measured in an automated counter
WBC reflects the circulating pool of myeloid and
lymphoid cells
WBC in each microliter (l;mm
3
) is reported
Relative proportion of each type of WBC is
indicated by a percentage
Absolute number is the percentage of each type of
WBC multiplied by the total WBC
599
White Blood Cell Counts: Normal Ranges
WBC PMN Band Lymph Mono Eos Baso
Birth
(0-1m)
6-30K 42-80% 2% 26-36% 3-8% 0-5% 0-2%
Child
(1m 12m)

6-18K 18-44% 3% 46-76% 3-8%

0-5% 0-2%
Child
(1y 16y)
5-14K 37-75% 3% 25-57% 3-8%

0-5% 0-2%
Adult 4-10K 36-75% 2% 20-50% 3-8%

0-5% 0-2%
600
J. Levine
White Blood Cell Counts: Disease States
WBC PMN Band Lymph Mono Eos Baso
Bacterial
Infection
16K 79% 8% 8% 3% 1% 1%
Steroid
Therapy
12K 79% 4% 14% 3% 0% 0%
Splenectomy 13K 50% 2% 40% 5% 2% 1%
Viral
Infection
3.5K 50% 2% 40% 5% 2% 1%
Chemo <3K 65% 0% 20% 12% 2% 1%
601
J. Levine
Neutrophil Maturation
25% 65%
8%
2%
Proliferation
Maturation
Intravascular
6-7 days 6-7 days
12 h
Tissues
12h
Bone Marrow
602
J. Levine
Neutrophil Maturation - Proliferative Phase
Myeloblast Promyelocyte Myelocyte
25 %
Proliferation
603
Source Undetermined (All Slides)
J. Levine
65 % of myeloid cells
Maturation 6-7 days
Neutrophil - Maturation Phase
Metamyelocyte Band Neutrophil
604
J. Levine
Source Undetermined (All Slides)
8% 2%
12 h
Tissues
12h
Intravascular
Approximately 10% of the developing neutrophils are in the
circulation, marginated or in the tissue.

Circulating
Marginating
Fate of the mature neutrophil
605
Disorders of Neutrophil Numbers
Definition
Neutropenia
Less than 1500/l
Neutrophila
Greater than 7700/l
Acquired
Or
Inherited
606
J. Levine
Definition of Neutrophilia - too many
Normal ANC is 1500-7700/l
Neutrophilia: abnormally high ANC
Shift to the left: d release of precursors
from the bone marrow
not necessarily associated with
neutrophilia
607
Neutrophilia
Chronic Stimulation
Excess cytokine stimulates
proliferative pool

Causes:
Infection
Down's Syndrome
Pregnancy/Eclampsia
Chemotherapy recovery
Myeloproliferative
disorders
Marrow metastases
Acute shift from
marginating to
circulating pool
measured WBC, not total
WBC
Causes:
Steroid treatment
Exercise
Epinephrine
Hypoxia
Seizures
Other stress
608
Example: exercise induced neutrophilia
609
Source Undetermined
Neutropenia: too few
Neutropenia
Definition: ANC < 1500/l
ANC 500-1000 increased risk of infection from
exposure
ANC < 500: increased risk of infection from
host organisms
African-Americans: lower normal
neutrophil counts (1000-1200)
610
Acquired Causes of Neutropenia
Decreased
Production
Increased
Destruction
Shift to
Marginating Pool
Bone marrow

Peripheral
circulation
Move from the
circulating pool to
attach along the
vessel wall
Medication:
Chemotherapy
Antibiotics, etc

Autoimmune
diseases
(Rheumatoid
arthritis, SLE, etc)
Severe infection
Endotoxin release
Hemodialysis
Cardiopulmonary
bypass
611
Increased Destruction
Anti-neutrophil
antibody
Neutrophil-Antibody
Complex
Uptake and
destruction of
neutrophil by the
RE system
612
J. Levine
Shift to Marginating Pool
Circulating
Marginating
Circulating
Marginating
Severe infection / Endotoxin release
Hemodialysis
Cardiopulmonary bypass
613
J. Levine
Evaluation of Neutropenia
If visit prompted by a fever and ANC is
low, treat promptly for infection
Suspect medication: major cause of
neutropenia
If no culprits, bone marrow exam for:
Malignancy
Infiltration by non-marrow cells
Arrest of cell growth
Myeloproliferative disorder
614
Cyclic Neutropenia
21 day cycle
autosomal dominant
fever, mouth ulcers
Treatment G-CSF
usually improves after
puberty
615
Source Undetermined
Congenital Neutropenia
Maturation arrest
frequent infections,
often serious
mouth sores
may lose teeth or
develop severe gum
infections
Increased risk of
leukemia
Tx: G-CSF, BMT
616
Source Undetermined
Role of Neutrophil
Responds to chemotactic factors released from damaged
tissue
Rolls and attaches to the endothelial cell wall
protein and carbohydrate interactions (selectins and their ligands).
Becomes activated by chemotactic factors
Tightly adheres through the integrin family of proteins.
Migrates across the endothelial cell wall.
Phagocytizes organisms so that they are contained within a
vesicle or phagosome.
Releases granule products and reduced oxygen species (e.g.
hydrogen peroxide and superoxide) to kill organisms
617
Function of the Circulating Neutrophil
Chemoattractant
Attachment/rolling
Activation
Adhesion
Migration
Phagocytosis
618
J. Levine
Disruption of Neutrophil
Function
Steps where defects in structural
components of neutrophils results in
impaired ability to fight infection
Recruitment from the circulation
Adhesion and subsequent migration
Defective production in active oxygen
metabolites
Deficiency in granules
619
Defect in Attachment/Rolling
Attachment/rolling
Sialyl Lewis
X
Selectins
Cell surface molecules expressing Sialyl Lewis X
interact with selectin proteins on the cell
surface of endothelial cells
LAD-2 Impaired expression of sialyl LewisX -
Neutrophils do not attach and are not recruited to the site of inflammation
Chemoattractant
620
J. Levine
Defect in Adhesion
Chemoattractant
Adhesion
Integrins on the surface of
neutrophils mediate tight adhesion
to the endothelial cell wall.
Cells then migrate.
Migration
Integrin
LAD-1 results from a defect in leukocyte integrins.
Decreased to absent expression on the cell surface.
Cells can not adhere and subsequently cannot migrate.
621
J. Levine
Clinical manifestations: LAD
622
Source Undetermined (Both Images)
Phagocytosis
Chemoattractant
Bacteria are engulfed and contained in a phagosome.
Contents of the granules are released.
Oxygen metabolites (superoxide and H
2
O
2
) kill bacteria
CGD: NADPH-Oxidase-defective
Cannot produce active oxygen species
Chediak-Higashi Syndrome: Defect in granule formation
623
J. Levine
Chediak-Higashi Syndrome
624
Source Undetermined
Chediak-Higashi Syndrome
Oculocutaneous
albinism
Photophobia
Sun sensitivity
Neuropathy
Infections, esp Staph
aureus

TX: BMT
625
W. B. Saunders
Adv Neonatal
Care
Chronic granulomatous disease (CGD)
626
Source Undetermined
Chronic granulomatous disease: CGD
Catalase positive organisms
Staph aureus
Serratia marcescens
Burkholderia cepacia
Fungal
Skin, lungs, bones, abscesses
Granuloma formation from chronic
infection

627
Myeloperoxidase deficiency
One of the more common disorders
1: 4000
Decreased production of hypochlorous acid
(HOCl)
Killing takes longer than normal
Clinically silent for most people
628
Diseases with Neutrophil Defects
Disease Step Molecular Defect
LAD-2 Rolling Sialyl Lewis X
Carbohydrate

LAD-1 Adhesion
Phagocytosis
Integrin
expression

Chediak-
Higashi
Syndrome

Migration
Degranulation

Vacuolar sorting
protein (large
granules interfere
with traversing
endothelial wall)

629
Diseases with Neutrophil Defects
630
Monocyte-Macrophages
Monocytes: circulating precursor of the
tissue macrophage.
Also known as the reticuloendothelial
system
Average count 300 cells /l
Range 0-800 cells/l

631
Proliferation
M
a
t
u
r
a
t
i
o
n

I
n
t
r
a
v
a
s
c
u
l
a
r

30-48 hours 24 hours 72 h
Bone Marrow
T
i
s
s
u
e
:

D
i
f
f
e
r
e
n
t
i
a
t
i
o
n

i
n
t
o

M
a
c
r
o
p
h
a
g
e
s

Monocyte Differentiation
632
Source Undetermined
Function of Monocytes and Macrophages
Antigen presentation of phagocytized particles to T Cells
Cytokines/
chemokines
633
J. Levine
Monocyte Function
Chemoattractant
Phagocytosis
Follow neutrophils to sites of inflammation within 12-24h
Number 1/30th that of neutrophils
Pts w/ CGD, CHS and LAD also have defects in monocyte fxn
634
J. Levine
Disturbances in Monocytes
Low counts
glucocorticoids
stress
Elevated counts
Malignancy
Granulomatous disease
Marrow recovery
Infections
malaria
TB
Rocky Mountain Spotted
fever
leishmaniasis
brucellosis
635
Eosinophils
Myelocyte
I
n
t
r
a
v
a
s
c
u
l
a
r

9 days
3-8
hours
T
i
s
s
u
e
s

Bone Marrow
Eosinophil
M
a
t
u
r
a
t
i
o
n

Proliferation
2.5
days
636
Source Undetermined (Both Slides)
Eosinophil Function
Bright red granules
IgE on cell surface (not on neutrophils)
Play a key role in killing parasites
Average absolute count 200/l
Non allergic individuals usually <400/l

637
Eosinophilia
Conditions:
Neoplasm (Hodgkins disease, lymphoma other tumors)
Allergies-drugs, environmental (grass, trees, dust)
Asthma
Collagen vascular diseases-vasculitis
Parasitic infection
Idiopathic hypereosinophilia: elevated eosinophil count
associated with organ dysfunction (GI, skin, CNS,
cardiovascular).
> 5000/l requires treatment with immunosuppressives
and antihistamines
638
Maturation of Basophils and Mast cells
I
n
t
r
a
v
a
s
c
u
l
a
r

T
i
s
s
u
e
s

Maturation
Proliferation
2.5
days
7 days
Basophil
Mast Cell
days
M
a
t
u
r
a
t
i
o
n

i
n

T
i
s
s
u
e
s

Proliferation
639
J. Levine
Basophil Function
Basophils and mast cells
Function remains obscure but may play a
role in host defense against certain
parasites

640
Disturbances in Basophil Count
Low count
hypersensitivity
glucocorticoids
High count
Allergies
infection
endocrinopathies
myeloproliferative
disorders
Systemic mastocytosis
symptoms due to excess
histamine release
641
Disorders of Blood Cells &
Blood Coagulation
CBC
WBC count
RBC count
WBC differential
Hemoglobin (HGB)
Hematocrit (HCT)
% of volume occupied
by RBCs
Red cell indices
Mean cell volume (MCV)
average size of RBC
Mean cell hemoglobin (MCH)
average amount of hemoglobin in
an average RBC
Mean cell hemoglobin
concentration (MCHC)
average concentration of
hemoglobin/unit of volume in an
average RBC

Major Determinants of Disease
Blood cells have a short life span & require continuous replacement
Most diseases of blood cells feature too many or too few cells because
of an imbalance in the production or loss of cells
Hemoglobin must be properly assembled & produced for effective O
2

transport
White blood cells are critical in the defense against infection
Diseases of lymphoid cells differ importantly from diseases of myeloid
cells
Malignancies of myeloid cells are associated with circulation of
malignant cells in the blood (leukemia)
Malignancies of lymphoid cells are associated with malignant cells in
the blood (leukemia) or masses in lymph nodes & other tissue
(lymphoma)
Most diseases that affect platelets cause a low platelet count
Anemia
Abnormally low hemoglobin
Caused by
decreased numbers of RBCs
decreased amount of hemoglobin
both
Sign of an underlying condition
Diagnose
CBC
Hemorrhage
Loss of O
2
carrying capacity
Loss of iron
Most common cause of iron deficiency anemia is
chronic blood loss
abnormal menstrual bleeding
intestinal bleeding
IRON DEFICIENCY ANEMIA IN A MAN OR
IN A POST-MENOPAUSAL WOMAN IS TO
BE CONSIDERED BLEEDING FROM GI
CANCER UNTIL PROVEN OTHERWISE
Hemolytic Anemia
Associated with
active, hypercellular bone marrow
high reticulocytes
increased LDH
low blood haptoglobin
increased bilirubin
Genetic & non-genetic causes
Hereditary Spherocytosis
Disorder of a
structural protein in
the cell membrane
Results in splenic
hemolysis
G6PD Deficiency
Lacking enzyme that
protects the RBC
from oxidation
Sickle Cell Anemia
Hemoglobin S
Sickling precipitated
by
low O
2
tension
infections
dehydration
acidosis
Thalassemias
Molecularly correct but not
enough produced
Several varieties
thalassemia major is most severe
most common type is a severe
microcytic hypochromic anemia
stimulates iron absorption
can lead to hemachromatosis
Non-Genetic Hemolytic Anemia
Immune hemolytic anemia
antibodies directed against
RBC antigens
Mechanical hemolytic
anemia
hemolyzed as they pass
through mechanical devices
such as artificial heart
valves
Associated with malaria
About 80% of iron is in hemoglobin with the rest stored as ferritin &
hemosiderin
Plasma ferritin levels vary directly with the amount of ferritin in bone
marrow
Transferrin transports iron
TIBC measures total transferrin
% saturation of TIBC is measuring how much iron is actually bound to the
transferrin
TIBC is high
Plasma iron is low
% saturation is low
Most common cause is chronic blood loss
menstrual abnormalities
GI bleeding
Macrocytic Anemia
aka megaloblastic anemia
Due to vitamin B
12
or folic acid deficiencies
needed for DNA synthesis
Hyperactive, hypercellular bone marrow
Most common cause is defective intestinal absorption
intrinsic factor
gastrectomy
surgical resection of ileum
inflammatory bowel disease
Pernicious anemia
autoimmune disease
associated with chronic atrophic gastritis
Aplastic Anemia
Failure to produce all blood cells
Idiopathic
Results in pallor & fatigue
Thrombocytopenia
Low WBC count
Hypocellular bone marrow
Myelophthisis
Bone marrow replaced by tumor or fibrosis
Fibrosis usually due to radiation but could
be a manifestation of a myeloproliferative
syndrome
Polycythemia
Too many RBCs
Relative
low plasma volume such
as in dehydration
stress polycythemia
Absolute
primary
polycythemia vera
secondary
due to
hypoxia from chronic lung
disease
high altitude
Leukopenia
Low WBC count
Caused by
hypersplenism
autoimmune disease
sepsis
bone marrow problem
Agranulocytosis
severe neutropenia
caused mostly by drugs
Leukocytosis
Too many WBCs
Can be reactive or malignant
Leukemias
Acute
immature cells
aggressive
short course
abrupt onset
symptoms include
anemia
infections
bleeding
bone pain
enlarged lymph nodes
Chronic
mature cells
less aggressive
longer course
insidious onset
symptoms include
fatigue
pallor
night sweats
infections
splenomegaly
hepatomegaly
Reactive Leukocytosis
Neutrophilia
leukemoid reaction if count > 50,000
Lymphocytosis
viral infections
Eosinophilia
allergic reactions or parasitic infections
Bands
when demand is great
shift to the left
Infectious Mononucleosis
Acute, self-limited
Atypical lymphocytes
Epstein-Barr virus
infects B cells
heterophile antibodies
Signs/symptoms
fever
sore throat
enlarged lymph nodes
Monospot test
Lymph Node Response
Infection
Malignancy
Immune reactions
Autoimmune disease
Lymphadenopathy
Enlarged nodes
tender = infectious
non-tender = malignant
Lymphadenitis
lymph node is infected
Reactive hyperplasia
acute
dental infections, sore throat,
genital infections
chronic
TB
Acute Lymphocytic Leukemia
ALL
Uncommon
mostly in children & young
adults
Immature B cells
Abrupt onset
Results in
bone pain
lymphadenopathy
hepatosplenomegaly

Chronic Lymphocytic Leukemia
CLL
B cells
About 1/3 of all
leukemias
Difficult to distinguish
from small cell
lymphocytic
lymphoma
Mostly in adults
Slow developing
Plasma Cell Dyscrasias
Activated B cells
Make too much of a particular antibody
On electrophoresis, appears as a dark band
called an M-spike
Light chains can pass through glomerulus &
into urine
Bence-Jones proteins
Multiple Myeloma
Malignant cells appear as nodular masses in
bone marrow
Multiple Myeloma
bone marrow
punched out lesions in skull & spine
Multiple Myeloma
bone marrow
punched out lesions in skull & spine
Hypogammaglobinemia
Susceptible to infections
Elderly most commonly affected
Lymphomas
Neoplasms of lymphocytes or lymphoblasts that grow
as nodular masses usually in lymph nodes
Hodgkin Lymphoma
EBV
Characteristic cell is Reed-Sternberg
(RS) cell
Most common neoplasm between 10-
30 yrs old
Usually have poor T cell immunity
Arises in a single lymph node or chain
of nodes & spreads in an orderly
manner
Rarely involves anything but lymph
nodes

Usually painless, non-
tender enlarged lymph
node in neck
Weight loss
Night sweats
Fever
Fatigue
Infection
Good survival but at risk
for other malignancies
Non-Hodgkin Lymphomas
B cells
Aggressive
Usually in advanced stage when diagnosed
1/3 arise in organs other than lymph nodes
Tend to spread widely
Follicular Lymphoma
About 50%
Less aggressive
Painless, enlarged lymph nodes
Diffuse Lymphomas
About 50%
No follicles
Usually over 60 except for childhood
lymphomas & those in AIDS
Appear quickly & grow rapidly
Lethal unless treated
Acute Myelocytic Leukemia
AML
Myeloblasts
Usually in middle age & older adults
Sudden onset
Marrow failure
anemia
infection
bleeding
bone pain
lymphadenopathy
hepatosplenomegaly
Chronic Myeloproliferative Disorders
2 features occur to some degree in each disorder
Myelofibrosis
bone marrow replaced by fibrous tissue
due to fibrogenic factors released by megakaryocytes
Extramedullary hematopoiesis
blood cell production outside of the marrow
Chronic Myelocytic Leukemia
CML
Granulocytes
Middle-aged adults usually
About 15% of adult leukemias
Slow onset but progressively
worsens
> 100,000 cells
May end in a blast crisis
Polycythemia Vera
Red cell precursors
Middle-aged adults
Appears slowly
HCT > 60%
High WBC count &
platelet count
May see giant platelets
Malignant Thrombocythemia
aka essential
thrombocythemia
Rare
500,000/ml or greater
Thrombosis &
hemorrhage
Survival is about 10-15
years
Myeloid Metaplasia with
Myelofibrosis
Marrow fibrosis predominates
Fibrogenic factors
Older adults
Extramedullary hematopoiesis
Increased basophils
Thrombosis & hemorrhage
May end in blast crisis
Major Determinants of Disease
Excessive bleeding is always associated with at least 1 of 3
factors
fragile blood vessels
low platelet count or defective platelet function
decreased coagulation factor activity
Bleeding related to platelet disorders usually occurs from
capillary-sized blood vessels
Bleeding related to coagulation factors usually occurs from
larger vessels
Most coagulation factors are proteins made by the liver, &
severe liver disease is often accompanied by excessive
bleeding
Intravascular clotting is always abnormal & secondary to
another disease
Hemorrhage
Usually due to vascular injury
If excessive, called hemorrhagic diathesis
Platelet problems or fragile small blood
vessels usually present as petechiae,
nosebleed, hematuria, or excessive menses
Coagulation factor deficiencies usually
bleed into deep tissues, joints, & body
spaces
Fragile Small Blood Vessels
Usually trauma
Seen in elderly
Autoimmune vasculitis
Scurvy

Thrombocytopenia
Characterized by petechiae in skin
or mucous membranes
130,000 400,000/ml is normal
No concern until < 100,000/ml
No excessive bleeding until <
50,000/ml
Spontaneous hemorrhage at
20,000/ml
Abnormal bleeding time
Causes include
primary bone marrow disorder
toxicity due to drugs
nutritional deficiencies
hypersplenism
Immune Thrombocytopenic Purpura
ITP
Common cause of low platelet count
Platelets destroyed by immune system
covered with antibodies & removed by spleen
Insidious onset
Usually presents as
easy bruising
epistaxis
bleeding gums
unusual bleeding after minor trauma
subungual or conjunctival petechiae
Classic Hemophilia
aka Hemophilia A
Factor VIII deficiency
X linked
Most common serious inherited coagulation
disorder
Normal bleeding time, PT, & platelet count
PTT is prolonged
von Willebrand Disease
Deficiency of von Willebrand factor (vWF)
made in endothelial cells & megakaryocytes
One of the most common inherited
coagulation disorders
Prolonged bleeding time
Normal platelet count
Platelets cannot adhere to endothelium well
Severe Christmas Disease
aka Hemophilia B
Factor IX deficiency
Named for 1
st
patient it was identified in
X linked
Disseminated Intravascular
Coagulation
DIC
Clotting inside vessels
May cause obstruction in
smaller vessels
Eventually begin to bleed
due to consumption of
coagulation factors
consumptive coagulopathy
Not a primary disease
Anemia, thrombosis, &
hemorrhage

Initiated by
obstetrical complications
toxemia
abruptio placentae
infections
gram-negative sepsis
malaria
neoplasms
tissue trauma
crush injuries
burns
others
snakebite
heat stroke

Venous Thrombosis
Usually due to local turbulence or endothelial
injury
Can be due to abnormalities of coagulation
proteins
lupus anticoagulant
anti-phospholipid antibody
interferes with blood coagulation tests suggesting a deficit
when there is not
suspect if PT or PTT is prolonged with no evidence of
bleeding disorder
factor V Leiden
abnormal form of factor V
autosomal recessive
HEMATOLOGY/
HEMATOPOIESIS
Introduction
HEMATOLOGY
Introduction
Study of blood & its components
Window of rest of body
BLOOD
Raison detre
Delivery of nutrients
Oxygen
Food
Vitamins
Removal of wastes
Carbon dioxide
Nitrogenous wastes
Cellular toxins
Repair of its conduit
Protection versus invading microorganisms
Multiple cellular & acellular elements
HEMATOLOGY
Divisions
Red Blood Cells/Oxygen & CO
2
transport
White Blood Cells/Protection versus
microorganisms
Coagulation/platelets/Maintenance of
vascular integrity
HEMATOLOGY
Hematopoiesis
In humans, occurs in bone marrow
exclusively
All cellular elements derived from
pluripotent stem cell (PPSC)
PPSC retains ability to both replicate
itself and differentiate
Types of differentiation determined by
the influence of various cytokines
HEMATOPOIESIS
Committed Stem
Cells
RED BLOOD CELLS
Introduction
Normal - Anucleate, highly flexible
biconcave discs, 80-100 femtoliters in
volume
Flexibility essential for passage through
capillaries
Major roles - Carriers of oxygen to &
carbon dioxide away from cells
ERYTHROPOIETIN
Cytokine - Produced in the kidney
Necessary for erythroid proliferation and
differentiation
Absence results in apoptosis
(programmed cell death) of erythroid
committed cells
Anemia of renal failure 2 to lack of
EPO
ERYTHROPOIETIN
Mechanism of Action
ERYTHROPOIETIN
Mechanism of Action
Binds specifically to Erythropoietin
Receptor
Transmembrane protein; cytokine
receptor superfamily
Binding leads to dimerization of receptor
Dimerization activates tyrosine kinase
activity
ERYTHROPOIETIN
Mechanism of Action
Multiple cytoplasmic & nuclear proteins
phosphorylated
Nuclear signal sent to activate
production of proteins leading to
proliferation and differentiation
ERYTHROPOIETIN
Regulation of Production
Erythropoietin
Response to Administration
0
10
20
30
40
50
Time
H
e
m
a
t
o
c
r
i
t
rhuEPO 150 u/kg 3x/wk
RBC Precursors
Pronormoblast
Basophilic normoblast
Polychromatophilic Normoblast
Orthrochromatophilic Normoblast
Reticulocyte
Mature Red Blood Cell
5-7 days from Pronormoblast to
Reticulocyte
RBC Assessment
Number - Generally done by automated
counters, using impedance measures
Size - Large, normal size, or small; all same
size versus variable sizes (anisocytosis).
Mean volume by automated counter
Shape - Normal biconcave disc, versus
spherocytes, versus oddly shaped cells
(poikilocytosis)
Color - Generally an artifact of size of cell
Red Blood Cells
Normal Values
RBC Parameters Normal Values
Hematocrit
Females 35-47%
Males 40-52%
Hemoglobin
Females 12.0-16.0 gm/dl
Males 13.5-17.5 gm/dl
MCV 80-100 fl
Reticulocyte Count 0.2-2.0%
RETICULOCYTE
Young red blood cell; still have small amounts
of RNA present in them
Tend to stain somewhat bluer than mature
RBCs on Wright stain (polychromatophilic)
Slightly larger than mature RBC
Undergo removal of RNA on passing through
spleen, in 1st day of life
Can be detected using supravital stain
Important marker of RBC production
RETICULOCYTE COUNT
Absolute Value
= Retic % x RBC Count
eg 0.01 x 5,000,000 = 50,000
Normal up to 100,000
More accurate way to assess bodys
response to anemia
ANEMIA
Causes
Blood loss
Decreased production of red blood cells
(Marrow failure)
Increased destruction of red blood cells
Hemolysis
Distinguished by reticulocyte count
Decreased in states of decreased production
Increased in destruction of red blood cells
RBC DESTRUCTION -
EXTRAVASCULAR
Markers
Heme metabolized to bilirubin in macrophage;
globin metabolized intracellularly
Unconjugated bilirubin excreted into plasma &
carried to liver
Bilirubin conjugated in liver &excreted into bile &
then into upper GI tract
Conjugated bilirubin passes to lower GI tract &
metabolized to urobilinogen, which is excreted
into stool & urine
RBC DESTRUCTION -
INTRAVASCULAR
Free Hemoglobin in circulation leads to
Binding of hemoglobin to haptoglobin,
yielding low plasma haptoglobin
Hemoglobin filtered by kidney &
reabsorbed by tubules, leading to
hemosiderinuria
Capacity of tubules to reabsorb protein
exceeded, yielding hemoglobinuria
INTRAVASCULAR
HEMOLYSIS
Serum Haptoglobin
Hemosiderinuria
Hemoglobinuria
HEMOLYTIC ANEMIA
Commonly used Tests
Test Result
Reticulocyte Count Increased
Unconjugated Bilirubin Increased
Lactate Dehydrogenase Increased
Haptoglobin Decreased
Urine Hemoglobin Present
Urine Hemosiderin Present
Problems with sensitivity & specificity
Introduction to Leukemia
Definition
Historic Perspective
Etiology and Risk Factors
Incidence
Classification
Comparison of Acute and Chronic
Leukemia
Leukemia

Definition
Leukemia is a malignant disease of hematopoietic
tissue characterized by the accumulation abnormal
white cells (neoplastic or leukemic) in the bone
marrow leading to bone marrow failure, a raised
circulating white cell count (leukocytosis) and
infiltrate organs (e.g liver, spleen, lymph nodes,
brain)
Leukemia

Historic Perspective

1945
The initial description of leukemia as a clinical
entity was made by Bennett in Scotland and in
Germany.

Leukemia
Etiology and Risk Factors

The etiology of leukemia is unknown.

Oncogenes mutation and tumor suppressor
gene alteration.

Host factors.
Environmental factors
Leukemia
Myeloid series Lymphoid series
Stem Cell
?
?
? ?
Oncogene mutation
Tumor suppressor gene
Chromosomal abnormality
Gene rearrangement
Host Factors
Congenital chromosomal
abnormalities
Increased frequency in patients with congenital
disorders that have tendency for chromosomal
abnormality.
Such as : Blooms syndrome, Fanconi anemia,
Downs and Klinefelters syndromes.
18-20 fold increase incidence of AL is seen in
children win DS.
Immunodeficiency
An unusually high incidence of lymphoid
leukemia and lymphoma has been described
in patients with hereditary immunodeficiency
states (ataxia-telangiectasia and sex-linked
agamaglobulinemia).
Usually related to T and B-lymphocyte gene
rearrangement.
Chronic bone marrow dysfunction
Patients with CBMD syndromes have an
increased risk of acute leukemic
transformation.
Examples include the myelodypalstic
syndromes, myeloproliferative disorders,
aplastic anemia and PNH
Environmental factors
Ionizing radiation
Leukemia is associated with exposure to
ionizing radiation such as nuclear weapons
in Hiroshima and Nagasaki.
Both acute and chronic forms of leukemia
including AML, ALL and CML were
associated.
Chemical drugs
A variety of chemicals and drugs have been
associated with the development of
leukemic transformation
Examples: Benzene, Chloramphenecol,
Phenylbutazone and Cytotoxic alkylating
chemotherapeutic agents.
Viruses
The human T-cell leukemia-lymphoma virus-I
(HTLV-I) has been implicated as a causative agent
of adult T-Cell leukemia-lymphoma.
Another related virus HTLV-II has been isolated
from patients with atypical hairy cell leukemia
(CLL)
The Epsteins Barr virus has been linked to
Burkitts lymphoma.
Incidence
In the USA 8-10 new cases per 100,000
individuals annually.
Approximately 28,600 new cases were
reported about 50% acute and 50% chronic
Leukemia strike more in adult than children
(10:1) and has slightly increase incidence in
males than females (1-2:1)
Classification of leukemia
Main classification
Chronic leukemia Acute leukemia
Lymphoid
Lymphoid
Myeloid
Myeloid
FAB
AML
M0
M1
M2
M3
M4
M5
M6
M7
CML
PV
ET
IMF
Introduction to leukemia
Acute leukemias
Leukemia is a malignant disease characterized
by unregulated proliferation of one cell type.
It may involve any of the cell lines or a stem cell
common to several cell lines.
Leukemias are classified into 2 major groups
Chronic in which the onset is insidious, the disease is
usually less aggressive, and the cells involved are usually
more mature cells
Acute in which the onset is usually rapid, the disease is very
aggressive, and the cells involved are usually poorly
differentiated with many blasts.
Both acute and chronic leukemias are further classified
according to the prominent cell line involved in the
expansion:
If the prominent cell line is of the myeloid series it is a
myelocytic leukemia (sometimes also called
granulocytic)
If the prominent cell line is of the lymphoid series it is a
lymphocytic leukemia
Therefore, there are four basic types of leukemia
Acute myelocytic leukemia AML- (includes
myeloblastic, promyelocytic, monocytic,
myelomonocytic, erythrocytic, and megakaryocytic)
Acute lymphocytic leukemia ALL- (includes T cell, B
cell, and Null cell)
Chronic myelocytic leukemia CML - (includes
myelocytic and myelomonocytic)
Chronic lymphocytic leukemia CLL - (includes
plasmocytic {multiple myeloma}, Hairy cell,
prolymphocytic, large granular cell lymphocytic,
Sezarys syndrome, and circulating lymphoma)
Etiology the exact cause is frequently not known,
but predisposing factors are known:
Host factors
Some individuals have an inherited increased
predisposition to develop leukemia
There is an increased incidence in those with an
inherited tendency for chromosome fragility or
abnormality or those with increased numbers of
chromosomes (such as Downs syndrome).
Many of these diseases are characterized by
chromosomal translocations.
There is an increased incidence in those with hereditary
immunodeficiencies.
There is an increased incidence in those with chronic
marrow dysfunction such as those with
myeloproliferative diseases, myelodysplastic
syndromes, aplastic anemia, or paroxsymal nocturnal
hemoglobinuria.
Environmental factors:
Exposure to ionizing radiation
Exposure to mutagenic chemicals and drugs
Viral infections
Incidence
Acute leukemias can occur in all age groups
ALL is more common in children
AML is more common in adults
Chronic leukemias are usually a disease of adults
CLL is extremely rare in children and unusual before
the age of 40
CML has a peak age of 30-50

Comparison of acute and chronic leukemias:
Acute Chronic
Age all ages usually adults
Clinical onset sudden insidious
Course (untreated) 6 mo. or less 2-6 years
Leukemic cells immature >30% blasts more mature cells
Anemia prominent mild
Thrombocytopenia prominent mild
WBC count variable increased
Lymphadenopathy mild present;often prominent
Splenomegaly mild present;often prominent
Acute leukemia
Is a result of:
Malignant transformation of a stem cell leading to
unregulated proliferation and
Arrest in maturation at the primitive blast stage. Remember
that a blast is the most immature cell that can be recognized
as committed to a particular cell line.
Clinical features
Leukemic proliferation, accumulation, and invasion of
normal tissues, including the liver, spleen, lymph nodes,
central nervous system, and skin, cause lesions ranging
from rashes to tumors.
A humoral mediator from the leukemic cells may inhibit
proliferation of normal cells.

Failure of the bone marrow and normal
hematopoiesis may result in pancytopenia with
death from hemorrhaging and infections.
Lab evaluation
The lab diagnosis is based on two things
Finding a significant increase in the number of
immature cells in the bone marrow including blasts,
promyelocytes, promonocytes (>30% blasts is
diagnostic)
Identification of the cell lineage of the leukemic cells
Peripheral blood:
Anemia (normochromic, normocytic)
Decreased platlets
Variable WBC count
The degree of peripheral blood involvement determines
classification:
Leukemic increased WBCs due to blasts
Subleukemic blasts without increased WBCs
Aleukemic decreased WBCs with no blasts
Classification of the immature cells involved may be
done by:
Morphology an experienced morphologist can look at the
size of the blast, the amount of cytoplasm, the nuclear
chromatin pattern, the presence of nucleoli and the presence
of auer rods (are a pink staining, splinter shaped inclusion
due to a rod shaped alignment of primary granules found
only in myeloproliferative processes) to identify the blast
type:
AML the myeloblast is a large blast with a moderate
amount of cytoplasm, fine lacey chromatin, and
prominent nucleoli. 10-40% of myeloblasts contain
auer rods.

Myeloblasts with auer rods
ALL in contrast to the myeloblast, the lymphoblast is
a small blast with scant cytoplasm, dense chromatin,
indistinct nucleoli, and no auer rods
Cytochemistry help to classify the lineage of a
leukemic cell (myeloid versus lymphoid)
Myeloperoxidase is found in the primary granules of
granulocytic cells starting at the late blast stage.
Monocytes may be weakly positive.
Sudan black
Sudan black stains phospholipids, neutral fats and
sterols found in primary and secondary granules of
granulocytic cells and to a lesser extent in monocytic
lysosomes. Rare positives occur in lymphoid cells
Nonspecific Esterase
Nonspecific esterase is used to identify monocytic
cells which are diffusely positive. T lymphocytes may
have focal staining
Acid phosphatase
Acid phosphatase may be found in myeloblasts and
lymphoblasts. T lymphocytes have a high level of acid
phosphatase and this can be used to help make a
diagnosis of acute T-lymphocytic leukemia.
Leukocyte Alkaline phosphatase
Leukocyte alkaline phosphatase is located in the
secondary granules of segmented neutrophils, bands
and metamyelocytes. The LAP score is determined by
counting 100 mature neutrophils and bands. Each cell is
graded from 0 to 5. The total LAP score is calculated
by adding up the scores for each cell.
Leukocyte alkaline phosphatase
Immunologic markers (immunophenotyping) these are
used mainly for lymphocytes, i.e., for determining B cell or
T cell lineage. These tests rely on antibodies made against
specific surface markers.
They constitute what we would call the primary
antibody and in an indirect assay they are allowed to
react with the cells and unbound antibody is then
washed away.
Fluorescently labeled antibody (secondary antibody)
against the primary antibody is added and allowed to
react and then unbound secondary antibody is washed
away.
The cells are then sent through a flow cytometer that
will determine the number of cells that have a
fluorescent tag and which are thus positive for the
presence of the surface marker to which the primary
antibody was made.
In a direct assay, the primary antibody is fluorescently
labeled.
Direct versus indirect labeling of
antigens
B or T Cell
marker
B or T cell
specific Ab
B or T cell
specific Ab
B or T Cell marker
Flow cytometer
Terminal deoyxtidyl transferase
This is a unique DNA polymerase present
in stem cells and in precursor B and T
lymphoid cells.
High levels are found in 90% of
lymphoblastic leukemias.
It can also be detected using appropriate
antibodies and flow cytometry.
Cytogenetics cytogenetics studies can now be used for
diagnosis and for prognosis of hematologic malignancies.
Many leukemias (and lymphomas) are characterized by
specific chromosomal abnormalities, including specific
translocations and aneuploidy. The specific type of
malignancy can be identified based on the specific
abnormality or translocation. These may be identified
by
Looking at the karyotypes of the chromsomes from the
abnormal cells
DNA based tests these tests are very useful for
following the course of the disease
RT-PCR
Southern blotting
A normal karyotype is usually associated with a better
prognosis.

Chromosomal translocation
Chromosome karyotyping
Acute leukemias
They may be classified on the basis of the cytological
features of the lymphoblasts into;
L1 - This is the most common form found in children and it
has the best prognosis.
The cell size is small with fine or clumped homogenous
nuclear chromatin and absent or indistinct nucleoli.
The nuclear shape is regular, occasionally clefting or
indented.
The cytoplasm is scant, with slight to moderate
basophilia and variable vacuoles.
L2 This is the most frequent ALL found in adults.
The cell size is large and heterogenous with variable
nuclear chromatin and prominent nucleoli.
The nucleus is irregular, clefting and indented.
The cytoplasm is variable and often moderate to
abundant with variable basophilia and variable vacuoles.

ALL-L1
ALL-L2
Acute leukemias
L3 This is the rarest form of ALL.
The cell size is large, with fine, homogenous nuclear
chromatin containing prominent nucleoli.
The nucleus is regular oval to round.
The cytoplasm is moderately abundant and is deeply
basophilic and vacuolated.
ALL-L3
Acute leukemias
ALL may also be classified on the basis of
immunologic markers into:
Early pre-B ALL
Pre-B ALL
B ALL
T ALL
Null or unclassified ALL (U ALL) - lack B or T
markers and may be the committed lymphoid
stem cell)
B cell maturation
T cell maturation
Acute leukemias
Incidence ALL is primarily a disease of
young children (2-5 years), but it can also
occur in adults
Clinical findings pancytopenia with
resulting fatigue, pallor, fever, weight loss,
irritability, anorexia, infection, bleeding, and
bone pain.
L1 occurs in children, L2 in adults, and L3 is
called Burkitts leukemia
Acute leukemias
Prognosis age, WBC count, and cell type are the
most important prognostic indicators
Patients younger then 1 and greater than 13 have a poor
prognosis
If the WBC count is < 10 x 10
9
/L at presentation, the
prognosis is good; If the WBC count is > 20 x 10
9
/L at
presentation the prognosis is poor
T cell ALL (more common in males) has a poorer prognosis
than any of the B cell ALLs which have a cure rate of 70%
Acute leukemias
Acute leukemias with mixed lineage
occasionally there are acute leukemias that are
biphenotypic and display phenotypes for two
different lineages
B lymphoid/myeloid
T lymphoid/myeloid
B/T lymphoid
Myeloid/Natural killer
A rare trilineage leukemia has also been seen (was
B/T lymphoid/myeloid!)

Acute leukemias
Acute myeloid leukemia (also called acute
granulocytic leukemia) classification depends
upon
Bone marrow blast morphology
Degree of cell maturation
Cytochemical stains
Immunophenotyping
AML is divided into 7 different classifications:
M1 myeloblastic without maturation
The bone marrow shows > 90% blasts and < 10%
promyelocytes
The disease occurs in older adults
AML M1
Note the myeloblasts and the auer rod:
Acute leukemias
M2 myeloblastic with maturation
The bone marrow shows 30-89% blasts and > 10%
promyelocytes;
This is characterized by an 8,21 chromosomal
translocation
This occurs in older adults
M3 hypergranular promyelocytic
This form of AML has a bone marrow with >30%
blasts
Is more virulent than other forms
Occurs with a medium age of 39
The WBC count is decreased
Treatment causes a release of the granules and may
send the patient into disseminated intravascular
coagulation and subsequent bleeding
It is characterized by a 15,17 chromosomal
translocation
AML M2
Note myeloblasts and hypogranulated
PMNs:
AML M3
Note hypergranular promyelocytes:
Acute leukemias
M3m hypogranular promyelocytic
The bone marrow has > 30% blasts
The WBC count is increased.
Like the M3 type, treatment causes a release of the
granules and may send the patient into disseminated
intravascular coagulation and subsequent bleeding and
It is characterized by a 15,17 translocation
M4 acute myelomonoblastic leukemia
Both myeloblasts and monoblasts are seen in the bone
marrow and peripheral blood
Infiltration of extramedullary sites is more common
than with the pure granulocytic variants
AML M3M
Note hypogranular promyelocytes:
AML M4
Note monoblasts and promonocytes:
Acute leukemias
M5 acute monoblastic leukemia
>80% of the nonerythroid cells in the bone marrow are monocytic
There is extensive infiltration of the gums, CNS, lymph nodes and
extramedullary sites
This form is further divided into
M5A - Poorly differentiated (>80% monoblasts)
M5B - Well differentiated (<80% monoblasts)
M6 erythroleukemia
This is rare and is characterized by a bone marrow having a
predominance of erythroblasts
It has 3 sequentially morphologically defined phases;
Preponderance of abnormal erythroblasts
Erythroleukemia there is an increase in both
erythroblasts and myeloblasts
Myeloblastic leukemia M1, M2, or M4
Anemia is common
AML M5A
Note monoblasts:
AML-M5B
Note monoblasts, promonocytes, and
monocytes:
AML M6
Note M1 type monoblasts
Acute leukemias
M7 - Acute megkaryoblastic leukemia
This is a rare disorder characterized by extensive
proliferation of megakaryoblasts, atypical
megakaryocytes and thrombocytopenia
Treatment of leukemias
There are 2 goals:
Eradicate the leukemic cell mass
Give supportive care
Except for ALL in children, cures are not common
but complete remission (absence of any leukemia
related signs and symptoms and return of bone
marrow and peripheral blood values to within normal
values) is

Acute leukemias
There are four general types of therapy
Chemotherapy usually a combination of drugs
is used
Radiotherapy
Immunotherapy stimulate the patients own
immune system to mount a response against the
malignant cells
Monoclonal antibodies examples include
Rituxin

Therapeutic Options
Primary Goal of Therapy for CML:
a Complete Cytogenetic Response
Elimination of the Ph chromosome
Cytogenetic/molecular response

Other therapeutic goals
Hematologic response
Disappearance of splenomegaly
Normal physical examination
Therapeutic Options for CML
Allogeneic stem cell transplantation
(SCT)
IFN-obased treatments
Chemotherapy with hydroxyurea,
busulfan
Imatinib mesylate (formerly STI571)
Allogeneic SCT, the Only Known Cure, Is Associated
With High Morbidity and Mortality Rates in CML
National Marrow Donor Program (NMDP) overview slide presentation.
Available at http://www.marrow.org/NMDP/SLIDESET/sld031.htm#slide. Accessed June 17, 2002.
Survival by Disease Stage, June 2001,
based on transplants 1987 Feb 2001.
P=.0001
0 1 2 3 4
5
100
90
70
60
50
40
30
20
10
0
80
100
90
70
60
50
40
30
20
10
0
80
Years After Transplant
S
u
r
v
i
v
a
l

(
%
)

S
u
r
v
i
v
a
l

(
%
)

Blast Phase (n=159)
Accelerated and 2
nd
CP (n=744)
First Chronic Phase (n=1903)
Mechanism of Action of STI571
Goldman JM. Lancet. 2000;355:10311032.
Bcr-Abl
ATP
Substrate
STI571
Y = Tyrosine
P = Phosphate
Bcr-Abl
Substrate
P
P
P
P
Imatinib Mesylate Inhibits the Growth of
Bcr-AblPositive Cells

Gambacorti-Passerini C et al. Blood Cells Mol Dis.
1997;23:380-394.
*Bcr-Ablnegative cell
lines.
Bcr-Ablpositive cell
lines.
Imatinib Mesylate Concentration (M)
U937*
KG1*
SU DHL1*
KCL22

K562

KU812

%

C
o
n
t
r
o
l

C
P
M

Imatinib Mesylate
Clinical Trials
IRIS Study Design: Imatinib Mesylate
Versus IFN-o + ara-C
S
Imatinib Mesylate
IFN-
o
+ ara-C
R Crossover
IF:
-
Loss of MCR or CHR
-
Increasing WBC count
-
Intolerance of treatment
-
Failure to achieve MCR at 12 months*
-
Failure to achieve CHR at 12 months*
-
Request to discontinue IFN-o*
Progression
-
Increasing WBC count
-
Loss of MCR or CHR
-
Accelerated phase or blast crisis
-
Death
S = screening.
R = randomization.
*Independent Data Monitoring Board Recommended Protocol Amendments
1106 patients enrolled from June 2000 to January 2001
Major Cytogenetic Responses With
Imatinib Mesylate Were Rapid
Imatinib mesylate
IFN-o + ara-C
Months Since Randomization
%

R
e
s
p
o
n
d
i
n
g

83%
20%
0
10
20
30
40
50
60
70
80
90
100
0 3 6 9 12 15 18 21
Complete Hematologic Responses
Were Rapid With Imatinib Mesylate
96%
67%
0
10
20
30
40
50
60
70
80
90
100
0 3 6 9 12 15 18 21
%

R
e
s
p
o
n
d
i
n
g

Months Since Randomization
Imatinib mesylate
IFN-o + ara-C
Resistance to Imatinib Mesylate Occurs
Predominantly During Advanced Phase CML
Advanced stage cancers are
characterized by multiple
genetic changes
Patients in advance phase
often relapse with the
development of
chemotherapy resistance
Some patients in blast crisis
CML initially respond to
imatinib mesylate but then
tend to relapse
Chronic Phase Blast Crisis Relapse
Ph+
Ph+ blasts Ph-negative
Ph+ imatinib mesylate-
resistant blasts
H
e
m
a
t
o
p
o
i
e
t
i
c

d
i
f
f
e
r
e
n
t
i
a
t
i
o
n

B
o
n
e

m
a
r
r
o
w

t
o

p
e
r
i
p
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e
r
a
l

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l
o
o
d

Courtesy of Charles L. Sawyers, MD, UCLA.
CML
Bcr-abl is necessary and sufficient for the development and
maintenance of the CML phenotype

Secondary genetic and epigenetic events may contribute to
the progression of CML

The bench has provided the opportunity fo the
development of targeted therapies for CML via inhibition
of bcr-abl
M3*
M4
M5
M6
M0, M1, M2
58%
7%
M0, M1, M2
M7
M6
M5
M4
M3*
52%
9%
Adults Adults Children Children
Frequency of Acute Myeloid Leukemia Subtypes Frequency of Acute Myeloid Leukemia Subtypes
Prognostic Factors
Prognostic factors: for CR, relapse risk
From multivariate models
Prior hematologic disorder/chemotherapy
Age >60 years
Increased number of deaths from toxicity
Adverse cytogenetics, prior MDS
Tendency to undertreat
WBC

MDS = myelodysplastic syndrome.
Cytogenetics and Prognosis
Risk
Group
Includes %pts Relapse
@5 yrs
Surv.
@5yrs
Good t(8;21)
inv16
t(15;17)
25% 34% 72%
Std Other 65% 51% 43%
Poor -5/5q-, -7
3q
Complex
10% 75% 17%
Cytogenetics and Treatment
Outcome
5 yr
Survival
Chemo. Allo. Auto.
Good 70% 72% 77%
Std 45% 66% 57%
Poor 19% 38% 29%

Allo = Allogenic; Auto = autologous.
Asp
Mut
Asp
Extracellular domain
T
M

T
M

T
M

ITD
Intracellular domain
Flt3 mutations in AML
Clinical development of Flt-3 inhibitors
PKC412 (Novartis Pharmaceuticals)

CT53518 (Millennium Pharmaceuticals)

CEP-701 (Cephalon Inc)

SU11248 (Sugen/Pharmacia)
Leukemia Genome Project
Definable set of mutations contributes
to pathogenesis of AML
Single hematopoietic progenitor
Defining these mutations at the DNA level
essential for development of new therapies
Defining germline mutations involved
in susceptibility
How to look for mutations and
therapeutic targets in AML
The overall hypothesis
A definable set of genetic mutations
contributes to the pathogenesis of AML
These mutations must be defined at the
level of DNA
Leukemogenic pathways and outcomes may
be determined by these mutations

How do we find the key mutations?
Targeted assessment of genes likely to be
involved in AML
Comprehensive analysis to detect
unsuspected contributors
Use of mice and selected human models to
define new candidates that were not
suspected

The Critical Role of Mice
A tool to identify candidate genes for AML
pathogenesis
A tool to verify the biologic significance of
mutations
A preclinical platform to evaluate new
therapies
Verifying the biology of potential
mutations in mice
Retroviral transductions of GFP-tagged
cDNAs into hematopoietic stem and
progenitor cells
Lineage and development-specific
transgenesis
Loss of function via knockouts
Regulated, targeted mutations via knockins
Roles of cooperating mutations
M3*
M4
M5
M6
M0, M1, M2
58%
7%
M0, M1, M2
M7
M6
M5
M4
M3*
52%
9%
Adults Adults Children Children
Frequency of Acute Myeloid Leukemia Subtypes Frequency of Acute Myeloid Leukemia Subtypes
Genetic Changes Contributing to
AML Pathogenesis
Susceptibility

Germline
FPD (Runx1)
SCN (ELA2)
DNA repair (FA)
others
I nitiation

Somatic
PML-RARo
AML-ETO
CBFB-MYH11
MLL fusions
others
Progression

Somatic
a FLT3
a KIT
a RAS
others
Relapse/Resistance

Somatic
PML-RARo
Efflux Transporters
others

What infrastructure will be
required to define these
mutations?
Draft sequences of the relevant genomes
A Genome Sequencing Center
WUMS GSC

-One of the largest academic
sequencing centers in the world

-3 million reads/month

-Vast capability for generating,
storing, analyzing, annotating,
and exporting sequence data

-Custom Array Facility

-Extensive Informatics support

AML Patients
Stem Cell Transplant/
Leukemia Service

-300 Transplants/year

-100 New AMLs/year

-Uniform Treatment

-Clinical Database

-7 faculty attendings
(inc. 4 PPG members)
AML patient samples (tumor and
germline)
SCC Tumor Bank/
GAML Bank

-Skin for germline

-BM/PB for tumor
banking

-DNA/RNA preps

-QC

-Affy-based array
facility

An NCI designated Cancer
Center
-Siteman Cancer Center

-NCI Designated 2001

-Hematopoietic Devel-
opment and Malignancy
Program

-Bioinformatics Core
-Biostatistics Core
-Tissue Bank Core
-Array Core
-ES Cell Core

Mouse Modeling Facilities and
Expertise

-39,000 barrier cages
at WUMS

-5 PPG investigators
experienced with
murine AML models
(2,500 cages)
Stem Cell Transplant/
Leukemia Program
Mouse Models of AML
Siteman Cancer Center
& Cores
Genome Sequencing
Center
Genomics of AML
Diagnostics & Therapeutics
for AML patients
Treatment of AML using
Hypomethylating Agents
John F. DiPersio, MD, PhD
Division of Oncology
Siteman Cancer Center
Washington University School of Medicine
Hypermethylation in AML
p15 methylation increases with MDS disease
evolution toward AML*
78% patients have methylation at time of
transformation

Additional methylated genes: ER, MYOD1,
PTX2, GPR37, MDR1, ID4, and SDC4
&

Methylation may be associated with disease
progression or development of chemo-resistance
&

* Quesnel et al, Blood 1998; 91: 2985; Uchida et al, Blood 1997; 90: 1403
&
Blum W et al., Clinical Advances in Hematology & Oncology . 2005;3:855-882
Confirmatory Phase III AZA Trial Study Design
354 patients

RAEB/RAEB-T INT-2 or High

AZA: 75mg/m
2
/sc qd x 7 q 28 days x 6 cycles max.

Conventional care:
- best supportive care
- low dose Ara-C: 20 mg/m
2
sc qd x 14 d q 28-42d
- standard 7 + 3 anti-leukemic chemotherapy
Vidaza Significantly Extends Overall
Survival
Vidaza median OS = 24.4 months
Conventional care regimens (CCR) median OS =
15 months (p = .001)
Vidaza 2 yr survival = 58.8% vs. CCR = 22%
Median # of Vidaza treatment cycles = 9

1:1 randomization Vidaza vs. CCR
Decitabine Phase 3
Study Design (D-0007)
Open-label, 1:1 randomized, multicenter study in US and
CA
Schedule: 3-hour infusion of 15 mg/m
2
q 8 hrs x 3 days
Eligible
Patients
(n = 170)
Decitabine + Supportive Care*
(n = 89)
R
A
N
D
O
M
I
Z
E
D
Supportive Care*

(n = 81)
Stratification
IPSS 0.5;
All FAB subgroups
Prior chemotherapy
Study center
*Antibiotics, growth factors, and/or transfusions.
Kantarjian , et al. Cancer. 2006;106:1794-1803.
Primary Endpoints:
Response Rate (CR+PR)
Time to AML or death
Secondary Endpoints:
Duration of Response,
Cytogenetic Response,
Transfusion Requirement,
QOL, Survival, Toxicity
AML Survival in Patients over
Age 55
Rowe, Hematology, 2001
ECOG Trials since 1973
Chemotherapy-Based Trials
in Older Adults with AML*
Remarkably similar induction rate, toxic death rate, and poor overall survival
across studies:

Med age CR Toxic death Survival
CALGB 8923 69 52% 25% 9.6 mo
SWOG 9031 68 45% 16% 8.5 mo
HOVON AML 9 68 42% 18% 9.5 mo
CALGB 9720 70 46% 20% 10 mo
ECOG 3351 68 42% 17% 7.5 mo
SWOG 9333 68 43% 18% 9 mo
Stone et al. N Engl J Med. 1995;332(25):1671-1677; Godwin et al. Blood. 1998;91(10):3607-3615; Lowenberg et al. J Clin Oncol.
1998;16(3):872-881; Baer et al. Blood. 2002;99(1):252-257; Anderson et al. Blood. 2002;100(12):3869-3876; Rowe et al. Blood.
2004;104(2):558-560.
* Deemed chemotherapy candidates, all age > 55.
Decitabine in AML
Clinical Monotherapy Studies
Decitabine Phase III
Response in Patients with AML
Subgroup analysis
*IWG AML Response Criteria.
One patient was a CRi (morphologic complete remission with

incomplete blood count recovery). Cheson et al. J Clin Oncol. 2003;21:4642-49;
Kantarjian HM, et al. Cancer. 2006;106:1794-1803; Data on File, MGI PHARMA.
2 (22)
3 (33)
5 (56)
Decitabine
n = 9 (%)
0 (0)
0 (0)

0 (0)
Supportive
Care
n = 3 (%)
Partial
Response
Complete
Response

Overall
Response*
Low dose Decitabine in AML
Relapsed/Refractory Patients
Phase 1 Study: Decitabine doses of 5-20 mg/m
2
x 5 days for 2 weeks
Results: 14% (5/37) CR and 8% (3/37) PR
Median duration of response = 8 weeks
Three patients remained disease-free at last follow-up, including 1
patient with relapsed AML after allogeneic transplantation
Adverse events included elevations in liver function tests, fever,
infection and myelosuppression
Issa JP et al., Blood. 2004;103:1635-1640.
Phase II Decitabine AML Study
Preliminary Results (IWG Criteria)
53 Patients Treated; 32 Evaluable Patients
11/32 (34%) Overall Response
5 CR, 6 CRi
Median time to response was 3 cycles
Two patients with leukemia cutis experienced complete resolution of
skin lesions
Most common adverse events: myelosuppression, fatigue and nausea

Cashen, A, et al. Blood. 2006;108:561a-562a.Abstract 1984.
Patient AML diagnosis
cytogenetic
risk ECOG best response
time to
response (#
cycles)
total #
cycles
1 de novo poor 0 PD 3
2 MDS poor 1 CR 3 relapsed 10
3 secondary intermediate nd PD 2
4 de novo poor 1 SD 4
5 MDS poor 1 1
6 0
7 0
8 MDS intermediate 0 SD 7
9 MDS intermediate 1 CRi 2 5
10 MDS intermediate 0 PD 11
11 de novo poor 1 expired 0
12 MDS intermediate 1 expired 2
13 CMML intermediate 1 CRi 3 relapsed 6
14 de novo intermediate 2 expired 2
15 MDS intermediate 0 CRi 4 relapsed 8
16 secondary poor nd expired 1
17 MDS intermediate 0 SD 6
18 MDS poor 2 CR 3 19
19 MDS intermediate 0 CR 2 6
20 de novo intermediate 0 SD 4
21 de novo intermediate 0 CR 5 19
23 de novo intermediate nd expired 1
24 0
26 de novo intermediate 0 CRi 6 12
28 de novo poor 1 expired 1
29 de novo poor 0 CRi 5 relapsed 8
30 0
31 de novo intermediate 0 CR 4 13
33 de novo intermediate 2 CRi 4 relapsed 8
34 de novo intermediate 2 PD 7
35 de novo intermediate 0 PD 3
Patient Characteristics
No. of patients evaluable for response or death 32
Age, median (range) 72 (62-88)
AML diagnosis, n (%)
De novo 19 (59)
Transformed from MDS 11 (34)
Secondary 2 (6)
Cytogenetic risk, n (%)
Poor 11 (34)
Intermediate 21 (66)
ECOG score, n (%)
0 13 (45)
1 12 (41)
2 4 (14)
Patient Demographics
CR CRi Total Response Rate (>SD)
Overall response (n=32) 5 6 34% (11/32)
AML diagnosis
De novo (n=19) 2 3 26% (5/19)
Prior MDS (n=11) 3 3 55% (6/11)
Secondary (n=2) 0 0 0
Cytogenetic risk
Poor (n=11) 2 1 27% (3/11)
Intermediate (n=21) 3 5 38% (8/21)
Response Rates
Kinetics of Response
Median time to CR or CRi was 4 cycles
(range, 2-12)
Median number of cycles received was 5
(range 1-19)
Six patients (19%) died during the first 2
cycles
Non-Hematologic Toxicities
Hematologic Toxicities
Our Study Design
N=53 patients >60 yr with AML
DAC 20 mg/m2 IV qd x 5 d
Proteomics
RNA profiling
Germline DNA
Methylation
Limited resequencing
AML DNA
Methylation
Limited resequencing
AML DNA
Methylation

Germline DNA
Methylation

Proteomics
RNA profiling
Two cycles and assess response
Chemotherapy-Based Trials
in Older Adults with AML*
Remarkably similar induction rate, toxic death rate, and poor overall survival
across studies:

Med age CR Toxic death Survival
CALGB 8923 69 52% 25% 9.6 mo
SWOG 9031 68 45% 16% 8.5 mo
HOVON AML 9 68 42% 18% 9.5 mo
CALGB 9720 70 46% 20% 10 mo
ECOG 3351 68 42% 17% 7.5 mo
SWOG 9333 68 43% 18% 9 mo
Stone et al. N Engl J Med. 1995;332(25):1671-1677; Godwin et al. Blood. 1998;91(10):3607-3615; Lowenberg et al. J Clin Oncol.
1998;16(3):872-881; Baer et al. Blood. 2002;99(1):252-257; Anderson et al. Blood. 2002;100(12):3869-3876; Rowe et al. Blood.
2004;104(2):558-560.
* Deemed chemotherapy candidates, all age > 55.
TRM for treatment of elderly
AML
Standard 7 +3induction: 43% 23% 9.0 mo

Decitabine (Cashen et al): 34% 19% ?

Azacitidine (Sudan et al): 45% 15% ?

Regimen Rem% TRM OS
Conclusions
The role of hyomethylating agents for the treatment of AML
remains to be determined

Toxicities appear to be acceptable but TRM may not be
significantly different than standard 7+3.

? Increased RR in AML evolving from MDS vs. de novo AML

Understanding the genomics, and epigenetics of AML and MDS
may improve future therapies

Combination therapies should be developed
especially for the elderly AML patients similar
to MDS

Should a randomized study ever be done in AML >60 comparing
hypomethylating therapy to 7+3 (?>60 yr <70 yr)

Acknowledgements
Washington Univ/Division of Oncology: Tim Ley

WUGSC: Rick Wilson

Center for Cancer Genomics (Siteman Cancer Center)

Orion Biosciences: Nate Lakey

WUSM BMT/Leukemic Team

Amanda Cashen

LEUKEMIA
DR. AYESHA JUNAID
MBBS,MCPS,FCPS.
Professor of Pathology
Consultant Haematology
Incharge Blood Transfusion Services-SIH
Leukemia
OBJECTIVES

What is leukemia?
What is the Pathogenesis of Leukeima?
How do we classify leukemia?
(WHO 2008 classification)
Leukemia
OBJECTIVES

What is their clinical presentation?
How do we diagnose leukemia in
laboratory?
What are the basic principles of
management?

Leukemia vs Leukemoid Reaction

Leucocytosis
Neutrophilia,Eosinophilia,Lymphocyt
es
Leucopenia
Leukemoid Reaction
Leukemia
Leukemia

Myeloid cells
Mitotic pool (blast to myelocytes)
Maturation pool (ends with the
mature neutrophil)
Storage pool (Mature neutrophils
residing in the bone marrow)

LEUKEMIA

Leukemia is a disease resulting from
the neoplastic proliferation of
hemopoeitic or lymphoid cells
LEUKEMIA
It results from the mutation in a
single stem cell
The progeny of which form a clone of
leukemic cells
LEUKEMIA

Genetic events contributing to malignant
transformation include

Inappropriate expression of oncogenes
Loss of function of TSG
LEUKEMIA CLASSIFICATION
LINEAGE & DEGREE OF MATURATION

MORPHOLOGY
CYTOCHEMICAL
CYTOGENETICS
IMMUNOPHENOTYPICAL
IMMUNOHISTOCHEMISTRY
MOLECULAR GENETICS

LEUKEMIA CLASSIFICATION
WHO 2008
Evidence based classification for daily
therapeutic decisions.

Provides a flexible framework for
integration of new data
LEUKEMIA
Acute leukemia
Chronic leukemia

Acute Myeloid Leukemia
Acute Lymphoid Leukemia
Chronic Myeloid Leukemia
Chronic Lymphoid Leukemia
ACUTE LEUKEMIA

Heterogeneous group of clonal disorders
arising from
Pluripotent stem cells
Clinical course
Response to therapy
ACUTE LEUKEMIA

Acute leukemia accounts for
approximately 10% of all human
cancers
Is the leading cause of cancer deaths
in adults younger than 35 years of
age

BONE
MARROW
TREPHINE
HIGH AND
LOW POWER
CYTOCHEMISTRY
It identifies diagnostically useful enzymes or other
cytoplasmic substances of hemopoietic cells

Particularly useful for identification of immature cells
in leukemia

SUDAN BLACK B
PERIODIC ACID SCHIFF(PAS)
ACID PHOSPHATASE

Leukemia

AML/ALL MORPHOLOGY
Differentiation on morphological grounds
alone is not possible

Morphological features favoring lymphoid
derivation include

Blasts including relatively condensed
chromatin
Absence of conspicuous nucleoli
Presence of scanty agranular cytoplasm
CYTOCHEMISTRY
CYTOCHEMISTRY
PAS
ACUTE LEUKEMIA
AML ALL
ACUTE LEUKEMIA
CLINICAL FEATURES
ONSET
Abrupt, acute
Insidious, slowly progressive
Bone marrow malfunction
Anemia, infection & bleeding

ACUTE LYMPHOBLASTIC
LEUKEMIA
CLINICAL FEATURES
Bone pain & tenderness
Lymphadenopathy
Splenomegaly
Hepatomegally
CNS manifestations
Testicular involvement
Skin

LEUKEMIA
LABORATORY EVALUATION

Anemia
Leukocytosis/leukopenia/normal TLC
Thrombocytopenia
Bone marrow examination
Aspirate & biopsy
LEUKEMIA
Chronic Myeloid Leukemia and other
Myeloproliferative Neoplasms (MPNs)
Dale Bixby, M.D., Ph.D
Clinical Assistant Professor
Assistant Program Director
Division of Hematology and Oncology
Department of Internal Medicine
University of Michigan

Winter 2010
Definitions
Myeloproliferative Neoplasms (MPNs): are a group of clonal
myeloid neoplasms in which a genetic alteration occurs in a
hematopoietic progenitor cell leading to its proliferation
resulting in an increase in the peripheral blood white blood cells
(WBCs), red blood cells (RBCs), platelets, or a combination of
these cells.
Hematopoietic Progenitors and MPNs
Genetic
Mutation
National Cancer Institute
More Definitions

The type of disorder is often based on the predominant cell line that is affected, but
because blood counts are often abnormal in more than one cell line, diagnoses
based upon blood counts alone may be inaccurate.

Four Main MPNs: Additional MPNs:
1. Chronic Myelogenous Leukemia (CML) 1. Systemic Mastocytosis
2. Polycythemia Vera (PV) 2. Hypereosinophilic Syndrome
3. Essential Thrombocytosis (ET) 3. Chronic Myelomonocytic Leukemia
4. Primary Myelofibrosis (PMF) 4. Chronic Neutrophilic Leukemia
5. Chronic Eosinophilic Leukemia

MPN overview
In CML, the predominant feature is a leukocytosis with a left shift. A mild anemia, normal
to elevated platelet count, and a peripheral blood basophilia is often seen.

In PV, the predominant features are elevated red blood cell indicies (RBC count,
hemoglobin, and hematocrit). Patients often also have a mild leukocytosis and
thrombocytosis.

In ET, the predominant feature is an elevated platelet count. Patients also often have a mild
leukocytosis and polycythemia.

In PMF, the predominant feature is evidence of extramedullary hematopoiesis in the form of
hepatomegaly, splenomegaly, and lymphadenopathy. Patients often have a mild anemia,
but their WBC and platelet counts can be quite variable. Leukoerythroblastosis (tear
drops, nucleated RBCs and early myeloid progenitors (including blasts) are often seen in
the peripheral blood.

Clonal Genetic Abnormalities Define Many MPNs

Figure showing
classification
and molecular
pathogenesis of
the MPD
removed

Original source: Levine et al. Role of JAK2 in the pathogenesis and therapy of
myeloproliferative disorders. Nature Reviews Cancer 2007;7:673-683
See online at: http://img.medscape.com/fullsize/migrated/563/885/nrc563885.fig1.gif
Chronic Myeloid Leukemia (CML)
Epidemiology of CML
Approximately 5,050 cases in the U.S. in 2009 (11% of all leukemias) with an
incidence that increases significantly with age (median age ~ 55)

Risk Factors include:
prior high dose radiation exposure (WW II / Chernobyl / etc)
exposure to certain organic solvents (benzene)
age
gender (male > female)

A very small percentage (< 0.1%) of individuals can express Bcr-Abl but not
develop CML (wrong cell of origin, multiple genetic mutations leading to non-
viability, immune surveillance)

CML Pathophysiology
the Philadelphia Chromosome
Source Undetermined Source Undetermined
Bcr-Abl and CML
Source Undetermined
Source Undetermined
Multiple Breakpoints in Bcr-Abl
Sources Undetermined
Pathophysiologic Result
of the Expression of Bcr-Abl
Bcr-Abl expression alone is necessary and sufficient for the development of CML
Stephen B. Marley and Myrtle Y. Gordon. Chronic myeloid
leukaemia: stem cell derived but progenitor cell driven Clinical
Science (2005) 109, (13*25)
Clinical Presentation
Asymptomatic (~ 30%)

Fatigue, weight loss, fever

Abdominal fullness, pain and/or early satiety due to splenomegaly (~ 50-
90%)

Easy bruising and purpura

Leukostasis
Pulmonary symptoms
Neurologic symptoms

CML Peripheral Blood and BM Findings
Peripheral smear can only give a presumptive
diagnosis of CML [you need to confirm the t(9;22)]:
1) leukocytosis with a left shift
2) normocytic anemia
3) thrombocytosis in 50% of pts
4) absolute eosinophilia with a normal % of Eos.
5) absolute and relative increase in basophils
6) LAP score is low (not frequently employed)
Source Undetermined
Diagnosing Chronic Myeloid Leukemia
Diagnostic Considerations in
Karyotyping in CML

1) Allows for the diagnosis of CML
2) Requires a bone marrow aspirate for
optimal metaphases
3) Allows for evaluation of clonal evolution as
well as additional chromosomal abnormalities
in the non-Ph
+
clones
4) Occasional cryptic and complex karyotypes
can result in the missed identification of the
t(9;22)
Demonstrating the presence of the t(9;22) or its gene product is
absolutely essential in diagnosing a patient with CML
Source Undetermined
Fluorescence in-situ hybridization
(FISH) in CML:
2) Does not require a bone marrow aspirate for
optimal results
3) Allows for the identification of potential
duplications of the Ph chromosome
4) Allows for the identification of the loss of the
der (9) chromsome
5) Allows for the identification of cryptic
translocations involving Bcr-Abl

Bcr- Ch 22
Abl Ch 9
Bcr-Abl Fusion
Source Undetermined
FISH in CML
Red Bcr probe
Green Abl Probe
Yellow fusion of Bcr and Abl
Ch 9 Ch 22
Bcr- Ch 22
Abl Ch 9
Bcr-Abl Fusion
Source Undetermined
Source Undetermined
Bcr-Abl
Bcr
Abl
cDNA
Quantitative RT-PCR
for Bcr-Abl in CML
2) Does not require a bone marrow aspirate for
optimal results
3) Can quantify the amount of disease
4) Allows for the identification of cryptic
translocations involving Bcr-Abl
5) Many primers sets only detect the p190 and/or
the p210 translocation and may miss the p230
or alternative translocations

Source Undetermined
Quantitative RT-PCR for Bcr-Abl in CML
0 3 6 9 12 15 18 21 24 27 30
33 36
PCR Cycle Number
Amount of
Fluorescenc
e
High Concentration
Moderate
Concentration
Low Concentration
C
T
(~13.5)
C
T
(~28)
D. Bixby
Disease Diagnosis and
Monitoring in CML
Test Target Tissue Sensitivity (%)* Use
Cytogenetics Ph chromosome BM 1-10 O Confirm diagnosis of CML
O Evaluate karyotypic
O abnormalities other than Ph
O chromosome (ie, clonal
O evolution)
FISH Juxtaposition of
bcr and abl
PB/BM 0.5-5 O Confirm diagnosis of CML
O Routine monitoring of
O cytogenetic response in
O clinically stable patients
O Routine measurement of
O MRD
RT-PCR bcr-abl mRNA PB/BM 0.0001-0.001 O Routine measurement of
O MRD
O Determine the breakpoints of
O the fusion genes
*Number of leukemic cells detectable per 100 cells.
BM = bone marrow; FISH = fluorescence in situ hybridization; PB = peripheral blood;
MRD = minimal residual disease; RT-PCR = reverse transcriptase polymerase chain reaction.

Wang et al. Genes Chromosomes Cancer. 2001;32:97
Chronic Myeloid Leukemia -
Diagnostic Criteria for the 3 Phases of the Disease
D. Bixby
Therapeutic Options in
History of CP-CML Therapies
Interferon +/- AraC
Hydrea, or radiation therapy
or Busulphan
intensive chemotherapy
early Interferon trials
Quintas-Cardama et al. Mayo Clin Proc 2006; 81(7):973-988
Imatinib (Gleevec, Novartis)
a small molecule tyrosine kinase inhibitor
X
Source Undetermined
Frontline Therapy in Chronic Phase - Chronic
Myeloid Leukemia

Hochhaus A, Druker B, Larson R, et al. Blood (ASH Annual
Meeting Abstracts), Nov 2007; 110: 25.
Hochhaus A, OBrien S, Guilhot F, et al., Leukemia (2009) 23,
10541061.
Treatment Milestones for CML
Definitions of Responses to Treatments
Hematologic Response
Complete Hematologic response
1) Normal PB counts (WBC < 10 and plt < 450)
2) Normal WBC differential
3) No Dz symptoms
4) Normalization of the size of the liver and spleen
Cytogenetic Responses: Ph
+
Metaphases
1) complete: 0%
2) partial: 1% - 35%
3) minor: 36% - 65%
4) minimal: 66% - 95%
5) none: 96% - 100%
Molecular Responses: ratio of Bcr-Abl/Abl
Major Molecular Response
3-log
10
reduction from initial diagnosis sample
(i.e. 25 0.025)
Amount of Dz
1X10
12

1X10
11
1X10
10
1X10
8-9

D. Bixby
Imatinib has Revolutionized
the Treatment of CML
IRIS Trial
1

1. Newly diagnosed CML patients were randomized to receive either Imatinib 400 mg daily or Interferon- at approximately 5X10
6
U/day
as well as Ara-C 20 mg/m
2
d1-10 q 8 days. Graph shows outcomes of 553 pts randomized to Imatinib.
96%
98%
85%
69%
92%
87%
Druker et al. N Engl J Med 2006; 355(23): 2408-2417.
2009 ELN Recommendations
for Response Assessment for Treatment
Baccarani M, Cortes J, Pane F, et al., J Clin Oncol. 2009 Dec 10;27(35):6041-51.
Mechanisms of Imatinib Resistance

Resistance Mechanisms
1) Bcr-Abl Kinase mutations
> 50 known mutations within Abl sequence which
inhibits Imatinib from binding
mutations identified in 30-80% of individuals with
resistant disease
2) Bcr-Abl duplication
duplication of the Bcr-Abl sequence has been
identified in cell lines with Im resistance
3) Pgp over-expression
export pump of many chemotherapeuticsleading to
lower intracellular Im concentration
4) hOct-1 under-expression
import pump for Im which may lead to lower
intracellular levels of IM
5) Src-Family kinase (SFK) expression
activation may circumnavigate the Bcr-Abl
addiction of the transformed cell
Primary resistance
failure to achieve preset hematologic and/or
cytogenetic milestones

IRIS data indicates a rate of ~ 15%
by failing to a achieve a PCyR at 12 months
and 24% by failing to achieve a CCyr
by 18 months of therapy.

rates higher in accelerated and blast phase
disease

Secondary resistance
loss of a previously achieved hematologic
or cytogenetic milestone

rates may be 10-15% on Imatinib, but
become rarer as time on therapy progresses

rates higher in accelerated and blast phase
disease
Bcr-
Abl
imatinib
Mut. Bcr-Abl
imatinib
Mut. Bcr-Abl
dasatinib
D. Bixby
Redaelli S, Piazza R, Rostagno R, et al. Activity of bosutinib, dasatinib, and nilotinib against 18 imatinib-
resistant BCR/ABL mutants. J Clin Oncol. 2009;27(3):469-471, PMID: 19075254.
Imatinib Poorly Control Advanced Phase Disease
Kamb et al. The value of early detection, the right drug and the right patient population. Nature Reviews Drug Discovery 2007; 6: 115-120.
Treatment Options for Resistant Disease
1) Dose Escalation of imatinib

2) Second Generation TKIs

3) Bone Marrow Transplant

4) Clinical Trial Participation
Dose Escalation of imatinib
START-R Trial
1

Patients resistant to 400mg-600 mg of imaitnib were treated with either 70 mg BID of dasatinib or
800 mg of imaitnib
primary endpoint of the trial was the rate of MCyR at 12 weeks and this was equal
(D=36%; IM=29%; p=.40)
At a minimum follow-up of 2 years, dasatinib demonstrated higher rates of:
complete hematologic response (93% vs 82%; P = .034)
major cytogenetic response (MCyR) (53% vs 33%; P = .017)
complete cytogenetic response (44% vs 18%; P = .0025)

The depth of the previous response to imatinib may be associated with the proportion
of patients responding to dose escalation. Patients having achieved a prior major
cytogenetic response (MCyR) with imatinib reported a greater than 50% chance of re
achieving that response with high-dose imaitnib, yet only 7% of patients who did not
achieve any cytogenetic response on standard dose imatinib were able to achieve a
MCyR.
Kantarjian H, Pasquini R, Levy V, et al. Dasatinib or high-dose imatinib for chronic-phase chronic myeloid leukemia resistant to imatinib at a dose of 400 to 600 milligrams
daily: two-year follow-up of a randomized phase 2 study (START-R). Cancer. 2009.
Second Generation
Tyrosine Kinase Inhibitors (TKIs)
The FDA has approved 2 additional oral TKIs for the treatment of
imatinib relapsed/refractory or imatinib intolerant CML

dasatinib (Sprycel BMS)

oral multi-kinase inhibitor
~ 325 times more potent than IM
active against the open and closed
confirmation of Bcr-Abl
active against many of the identified
kinase domain (KD) mutations
active against the SFKs
may not be a substraight for Pgp or
hOct-1
nilotinib (Tasigna
Novartis)

oral multi-kinase inhibitor
~ 30 times more potent than
IM
active against only the
closed
confirmation of Bcr-Abl
active against many of the
KD
mutations
not active against the SKFs
may not be a substraight for
hOct-1

Bone Marrow Transplantation
Allogeneic bone marrow transplant remains the only known curative option in CML

Associated with an increased morbidity and mortality (TRM -10%-30%)

Therefore, not typically applied for upfront therapy for CML
considered only in cases of matched-related Txp for extremely young pts (pediatrics)

However, often considered in those with relapsed/refractory disease to TKI based therapies
efficacy of the transplant dependent upon the phase of the disease at the time of the
transplant: CP>AP>BP

Clinical Trial Options in CML
D. Bixby
Polycythemia Vera (PV)
Polycythemia
A hematocrit greater than 48%() or 52 % () constitutes polycythemia

Likewise, a hemoglobin of >16.5 g/dL () or >18.5 g/dL () raises the suspicion for polycythemia

Absolute polycythemia is characterized by an increase in red blood cell (RBC) mass
Five common causes include: 1) primary polycythemia, 2) hypoxia, 3) carboxyhemoglobinemia,
4) cushings syndrome or corticosteroids, and 5) erythropoietin-secreting tumors

Relative polycythemia is characterized by a decrease in plasma volume.
Two common causes:
Dehydration (e.g., from vomiting, diarrhea, excessive sweating, or diuretics) can deplete plasma
volume, leading to a relative polycythemia.
Stress erythrocytosis (Gaisbcks polycythemia) actually results from contraction of the plasma
volume and is therefore a misnomer. This benign disorder is seen most often in hypertensive,
obese men.

Red Blood Cell Mass Assay:
used to distinguish an absolute versus a relative polycythemia
does not subclassify absolute polycythemias
Clinical Presentation of Primary PV
Symptoms:
non-specific complaints: headache, weakness, dizziness, and excessive sweating
pruritus, especially following a warm bath or shower
erythromelalgia, or burning pain in the feet or hands accompanied by erythema, pallor, or
cyanosis
symptoms related to either an arterial or venous thrombosis (CVA, MI, DVT,
Budd Chiari syndrome or other portal venous thrombosis)

Signs:
facial plethora (ruddy cyanosis)
splenomegaly
hepatomegaly
gouty arthritis and tophi

Diagnostic Criteria for Primary PV
2008 WHO Diagnostic Criteria for Primary Polycythemia Vera
Major Criteria
Elevated RBC mass
>36 cc/kg in men
>32 cc/kg in women
Oxygen saturation >92%
Splenomegaly
Minor Criteria
Plt count > 400,000
WBC > 12,000
Elevated LAP score (>100)
Serum vitamin B12 >900 pg/mL or serum
unbound B12 binding capacity >2,200 pg/mL
All 3 major criteria OR the first 2 major and any 2 minor criteria
Polycythemia Vera Study Group (PVSG) Criteria for PV
Major Criteria
1) Hgb > 18.5g/dl () or 16.5g/dl ()
or
Hgb or Hct > 99%
or
Hgb > 17g/dl () or 15 g/dl () and
a documented increase of 2 g/dl
or
RBC mass > 25% of mean normal

2) Presence of a JAK2 V617F or similar
mutation

Minor Criteria
1) Bone marrow trilineage expansion
2) Subnormal EPO level
3) Endogenous erytyhroid colony growth
two major or first major and two minor criteria

Tefferi et al. Leukemia (2008) 22, 1422

JAK2 Mutations Seen in Three Different MPNs

Figure showing
classification
and molecular
pathogenesis of
the MPD
removed

Original source: Levine et al. Role of JAK2 in the pathogenesis and therapy of
myeloproliferative disorders. Nature Reviews Cancer 2007;7:673-683
See online at: http://img.medscape.com/fullsize/migrated/563/885/nrc563885.fig1.gif
JAK2 Mutations and MPNs
Receptor Tyrosine Kinase - maps to chromosome 9p

Valine to phenylalanine substitution at amino acid 617 (V617F) in pseudokinase
domain of JAK2 allows for the constitutive activation of the receptor

Somatic acquired mutation

High incidence in PCV (~95%)
Not present in every patient with PCV

Lower incidence in ET (~50%) and PMF (~50%)
JAK2 Mediated Signaling
Nature Reviews | Cancer
Outcomes and Treatment of PV
Survival outcomes in PV are affected by:
1) hyperviscosity and associated ischemic sequela
2) thromboses independent of hyperviscosity
3) transformation to myelofibrosis or acute myeloid leukemia (~3%-10%)
Therapeutic Options in PV:
1) Low Risk: phlebotomy (to an Hct of <45 in and <42 in ) + low dose aspirin
(81 mg daily) decreases risk of thrombosis
2) High Risk: phlebotomy + ASA + hydroxyurea

High Risk for Thrombosis:
age over 70
prior thrombosis
platelet count >1,500,000/l
presence of cardiovascular risk factors

JAK2 Inhibitors in MPNs
A number of inhibitors of the JAK2 kinase have been developed and inhibit the proliferation
and survival of JAK2 V617F transformed cell lines in-vitro

Clinical studies (Phase I and Phase II) have been initiated and demonstrate some
symptomatic improvement as well as improvement in splenomegaly in a number of
patients, but unlike CML, the percentage of JAK2
+
progenitor cells have not been
significantly altered. However, a large number of trials continue at this time.

Leads to speculation that JAK2 may not be sufficient for the development of MPNs and there
may be an earlier genetic mutation that is driving the phenotype.

Essential Thrombocythemia (ET)
Thrombocytosis
Etiology of Thrombocytosis
Primary - if the thrombocytosis is caused by a myeloproliferative neoplasm, the
platelets are frequently abnormal and the patient may be prone to both bleeding
and clotting events.
Secondary - if thrombocytosis is secondary to another disorder (reactive), even
patients with extremely high platelet counts (e.g., > 1,000,000 cells/l) are
usually asymptomatic.

Differential Diagnosis of secondary thrombocytosis:
1. Malignancies
2. Infections and inflammatory disorders (e.g., Crohns disease)
3. Post surgical status
4. Connective tissue disorders
5. Iron deficiency anemia
6. Splenectomy
7. Recovery of the bone marrow from a stress (chemotherapy or alcohol)
8. Essential Thrombocythemia

Definition: thrombocytosis is defined as a platelet count > 450,000 cells/L
Clinical Presentation of
Essential Thrombocythemia (ET)
Asymptomatic (~ 30-50%)

Vasomotor symptoms including headache, syncope, atypical chest pain, acral
paresthesia, livedo reticularis, and erythromelalgia

Thrombosis and hemorrhage occur to various degrees in 5%-25% of patients

Early satiety and abdominal bloating due to splenomegaly

JAK 2
+
(V617F) in approximately 50% of patients
Diagnostic Criteria for ET
Diagnosis of essential thrombocythemia requires meeting all four major criteria

Teferri et al. Leukemia (2008) 22, 1422

2008 WHO Diagnostic Criteria for Essential Thrombocytosis

1. Platelet count > 450,000
2. Megakaryocytic proliferation with large, mature morphology and
with little granulocytic or erythroid expansion
3. Not meeting WHO criteria for CML, PV, PMF, MDS or other
myeloid neoplasm
4. Demonstration of the JAK2V617F or other clonal marker or lack
of evidence of a secondary (reactive thrombocytosis)
Outcomes in ET
Most patients with ET enjoy a normal life expectancy

Like PV, the major risks are secondary to thrombosis and disease transformation:
15-year cumulative risks:
thrombosis - 17% risk
clonal evolution into either myelofibrosis (4%) or AML (2%)

High risk for thrombosis:
age 60
prior thrombosis
long-term exposure to a plt count of > 1,000,000

Treatment of ET
Low Risk:
Age <60 years
No previous history of thrombosis
Platelet count <1 million/l
aspirin (81 mg daily) if vasomotor Sx or other medical need for ASA
if otherwise low risk and plt >1.5 X 10
6
, screen for an acquired
von Willebrand disease before instituting ASA

High Risk:
Age 60 years
A previous history of thrombosis
hydroxyurea + aspirin (81 mg daily)
if plt >1.5 X 10
6
, screen for an acquired von Willebrand disease
before instituting ASA
anagrelide is an option, but when c/w hydroxyurea, it was assn with
an increased risk of arterial thrombosis, venous thrombosis, serious
hemorrhage, or death from vascular causes

Primary Myelofibrosis (PMF)
Primary Myelofibrosis
(Chronic Idiopathic Myelofibrosis)
Signs and Symptoms:
asymptomatic (15% - 30%)
severe fatigue
splenomegaly
hepatomegaly
fever and night sweats
signs or symptoms of anemia or thrombocytopenia
foci of extramedullary hematopoiesis may occur in almost any organ
bone or joint involvement

CBC Findings:
anemia (hgb<10 in 50% of pts); anisocytosis, poikilocytosis, teardrop-
shaped red blood cells (dacrocytes), and nucleated red blood cells
leukoerythroblastosis (increased presence of immature myeloid cells and
nucleated erythrocytes in the circulating blood.
WBC and Plt counts are variable (ranging from low to high) with
increased circulating CD34
+
precursor cells
BM Biopsy shows increased fibrosis (reticulin fibers or mature collagen)
JAK2
+
(V617F) in approximately 50% of cases
Diagnostic Criteria for PMF
Diagnosis of primary myelofibrosis (PMF) requires meeting all three major criteria and two minor criteria

Teferri et al. Leukemia (2008) 22, 1422

2008 WHO Diagnostic Criteria for Primary Myelofibrosis
Major:
1. Megakaryocytic proliferation and atypia with either reticulin
or collagen fibrosis
or
If no fibrosis, mekakaryocytic expansion must be assn. w/
increased BM cellularity
2. Does not meet WHO criteria for CML, PV, MDS, or other
myeloid neoplasm
3. Demonstration of the JAK2 V617F mutation or other cloanl
marker
or
no other evidence of a reactive marrow fibrosis
Minor:
1. Leukoerythroblastosis (immature RBCs and WBCs in the PB)
2. Increased LDH
3. Anemia
4. splenomegaly
DDx of Myelofibrosis
Myeloid Neoplasms
PMF
CML
ET
PV
MDS
Acute myelofibrosis (potentially assn. w/ FAB M7 AML)
AML
Mast Cell Disease
Lymphoid Neoplasms
lymphoma
Hairy Cell Leukemia
Multiple Myeloma
Non-Hematologic Disorders
Metastatic cancer
Connective tissue diseases
Rickets
Infections
Renal Osteodystrophy
Source Undetermined
Outcomes in PMF
As fibrosis progresses, cytopenias worsen leading to a transfusion dependency
symptoms related to extrmedullary hematopoiesis increase (worsening
splenomegaly and B symptoms) also are frequently identified

Rarely do patients transform to Acute Leukemia (~ 4%)
clonal evolution was common in these patients
some evidence that in all MPNs, cases of JAK2
(-)
Acute Leukemia
arise out of a JAK
+
MPN, causing speculation that there are additional
genetic changes that either initiate and/or propagate these diseases

Despite the lack of transformation to leukemia, three-year survival rate is
approximately 52%
Risk Assessment in PMF
Mayo Scoring System
(pts age < 60)
Score
Median
Survival
0 173 mo
1 61 mo
2 26 mo
Risk Factors: Hemoglobin <10 g/dL
White blood cell count <4000/l or >30,000/ l
Absolute monocyte count >1000 L
Platelet count <100,000/ L

Transplant Scoring System
(pts age < 55)
Score Median
Survival
0 or 1 15 yrs
2 3 yrs
Risk factors: Hemoglobin <10 g/dL
B symptoms present (eg, fever, NS, weight loss)
Circulating blasts >1 percent

Elliott et al. Leuk Res. 2007;31(11):1503-9.
Dupriez et al. Blood 1996 Aug 1;88(3):1013-8.
Treatment of PMF
Risk stratification is critical in deciding on therapeutic options
(see previous scoring systems)

Low Risk without symptoms expectant management

Low Risk with symptoms hydroxyurea
androgenic and corticosteroids
splenectomy if adequate BM hematopoiesis
splenic irradiation
thalidomide or lenalidomide
High Risk and age < 55(?) consider a reduced intensity allogeneic BMT

One Genetic Abnormality and Three Diseases Possible
Role of Allele Burden
Larsen et al. Eur J Hemeatology 2007; 79: 508-515
Review Question # 1
42 yo woman with no past medical Hx presented to her PCP for an annual health
maintenance examination. Physical exam was normal. A CBC was drawn and
revealed a WBC of 14.2 (normal differential), Hbg of 13.5 and a plt count of 752,000.

Her diagnosis is:
A) Polycythemia Vera (PV)
B) Essential Thrombocythema (ET)
C) Chronic Myeloid Leukemia (CML)
D) Reactive Thrombocytosis
E) Not sure need more data

Review Question #1 (cont)
Iron studies are normal and there was no evidence of inflammation on history or examination. There
was no history of recurrent infections or connective tissue diseases. Further blood testing
demonstrated no evidence of the JAK2 V617F mutation by gene sequencing.

Her diagnosis is:

Additional testing of her peripheral blood demonstrated a negative RT-PCR for the Bcr-Abl p210 and
p190 gene products but the peripheral blood FISH for the Bcr-Abl translocation was positive in
72% of cells. Repeat testing confirmed both of these findings.

Her diagnosis is:

Source Undetermined
Review Question #2
A 34 yo woman presents for her annual HME and a CBC reveals a WBC count of 11.2, hgb of 17.1
and a platelet count of 390,000. Peripheral blood was sent to evaluate for the JAK2 mutation
and was negative. What is the most appropriate next step in the evaluation of the patient?

A) Bone marrow biopsy to evaluate for a myeloproliferative neoplasm
B) Repeat CBC in 3 months
C) Repeat JAK2 testing to ensure laboratory accuracy
D) Red cell mass assay to determine a primary versus a seconday erythrocytosis
E) Referral to hematology
Review Question#2 (cont)
The patient underwent a red cell mass assay that demonstrated a true erythrocytosis (increased
red cell mass). Upon further questioning, she states that she was previously treated
with phlebotomy for the elevated Hgb and felt horrible for 3-4 weeks. She also
indicates that her brother has a similar condition as did her mother and her mothers
sister, but no one has been able to find a cause. What is the most appropriate next step
in the management of this patient.

A) Repeat phlebotomy, but take only 250 cc/session
B) Initiate treatment with low dose aspirin (81 mg/day) and hydroxyurea
C) Repeat phlebotomy, but take only 250 cc/session and also treat with low dose aspirin
(81 mg/day)
D) Evaluate for an inherited cause of polycythemia

Hemoglobin (Hb) Ypsilanti is a rare, high-oxygen-affinity
hemoglobin first described in 1967 and named for the Michigan
city in which the index family resided.
1-3

Like other high-oxygen-affinity hemoglobins, of which there are
now substantially more than 100 described, Hb Ypsilanti manifests
as a true erythrocytosis.

Phlebotomy in individuals with an appropriate erythrocytosis (high
affinity Hgb, CO poisoning, living at altitude, sleep apnea) will
increase symptoms because the erythrocytosis is an appropriate
correction for the primary disorder.
1. Rucknagel DL, Glynn KP, Smith JR. Hemoglobin Ypsilanti, characterized by increased oxygen affinity, abnormal polymerization, and erythremia [abstract]. Clin Res.
1967;15:270.
2. Glynn KP, Penner JA, Smith JR, et al. Familial erythrocytosis: a description of three families, one with hemoglobin Ypsilanti. Ann Intern Med. 1968;69:769-776.
3. Mais DD, Boxer LA, Gulbranson RD, Keren DF. Hemoglobin Ypsilanti: a high-oxygen-affinity hemoglobin demonstrated by two automated high-pressure liquid chromatography
systems. Am J Clin Pathol. 2007 Nov;128(5):850-3.
CHRONIC MYELOID
LEUKAEMIA
Dr Rosline Hassan
Department of Haematology
School of Medical Sciences
Universiti Sains Malaysia
Leukaemias
What are Leukemias
Neoplasm of white blood cell and its precursor
Clonal proliferations and accumulation of cells
in marrow
Classify as
Acute leukaemias
Chronic leukaemias

Types of Leukaemia
Acute : No
maturation
beyond blast
Chronic :
Maturation
beyond blast
Lymphocytic (B
or T lineage)
ALL CLL
Myeloid
granulocytes
Erythroids
Monocytes
Platelets
AML CML
Introduction- CML
Clonal malignant myeloproliferative disorder
characterized by increased proliferation of the
granulocytic cell line without the loss of their
capacity to differentiate
Results in increases in myeloid cells, erythroid
cells and platelets in peripheral blood and marked
myeloid hyperplasia in the bone marrow
Originate in a single abnormal haemopoietic stem
cell
Introduction- CML
Incidence :1 per 100,000 (UK)
Accounts for 7-15% of all leukaemia in
adults
Median age : 53 years
All age groups, including children, can be
affected
Introduction- CML
Etiology
Not clear
Little evidence of genetic factors linked to the
disease
Increased incidence
Survivors of the atomic disasters at Nagasaki &
Hiroshima
Post radiation therapy
Leukaemogenesis
Leukaemogenesis
Philadelphia
chromosome is an
acquired cytogenetic
anomaly that is
characterizes in all
leukaemic cells in CML
90-95% of CML pts
have Ph chromosome
Reciprocal translocation
of chromosome 22 and
chromosome 9

Leukaemogenesis
BCR (breakpoint cluster region) gene on
chromosome 22 fused to the ABL (Ableson
leukemia virus) gene on chromosome 9
Ph chromosome is found on myeloid,
monocytic, erythroid, megakaryocytic, B-
cells and sometimes T-cell proof that CML
derived from pluripotent stem cell

Leukaemogenesis
Molecular consequence of the
t(9;22) is the fusion protein
BCRABL, which has
increased in tyrosine kinase
activity
BCR-ABL protein transform
hematopoietic cells so that
their growth and survival
become independent of
cytokines
It protects hematopoietic cells
from programmed cell death
(apoptosis)
Clinical Features
Disease is biphasic,
sometimes triphasic
40% asymptomatic
Chronic phase
Splenomegaly often
massive
Symptoms related to
hypermetabolism
Weight loss
Anorexia
Lassitude
Night sweats
Clinical Features
Clinical features cont
Features of anaemia
Pallor, dyspnoea, tachycardia
Abnormal platelet function
Bruising, epistaxis, menorrhagia
Hyperleukocytosis
thrombosis
Increased purine breakdown : gout
Visual disturbances
Priapism
Lab features
Peripheral blood film
Anaemia
Leukocytosis (usu >25 x 10
9
/L, freq> 100 x
10
9
/L
WBC differential shows granulocytes in all
stages of maturation
Basophilia
thrombocytosis
Lab features
Bone marrow
Hypercellular (reduced fat
spaces)
Myeloid:erythroid ratio
10:1 to 30:1 (N : 2:1)
Myelocyte predominant
cell, blasts less 10%
Megakaryocytes increased
& dysplastic
Increase reticulin fibrosis
in 30-40%
Lab features
Other lab features :
NAP reduced
Serum B12 and transcobalamin increased
Serum uric acid increased
Lactate dehydrogenase increased
Cytogenetic : Philadelphia chromosome
Laboratory- summary
Lab investigation to confirm diagnosis
Full blood picture
Neutrophil alkaline phosphatase
Bone marrow cytogenetic
Phases
Accelerated phase
Median duration is 3.5 5 yrs before evolving to more
aggressive phases
Clinical features
Increasing splenomegaly refractory to chemo
Increasing chemotherapy requirement
Lab features
Blasts>15% in blood
Blast & promyelocyte > 30% in blood
Basophil 20% in blood
Thrombocytopenia
Cytogenetic: clonal evolution

Phases
Blastic phase
Resembles acute leukaemia
Diagnosis requires > 30% blast in marrow
2/3 transform to myeloid blastic phase and 1/3
to lymphoid blastic phase
Survival : 9 mos vs 3 mos (lym vs myeloid)
General Management
Discussion with family
The disease & diagnosis
Prognosis
Choices of treatment
Cytotoxic drug vs bone marrow transplant
Side effect
CML - principles of treatment
Relieve symptoms of hyperleukocytosis,
splenomegaly and thrombocytosis
Hydration
Chemotherapy (bulsuphan, Hydoxyurea)
Control and prolong chronic phase (non-curative)
alpha interferon+chemotherapy
imatinib mesylate
chemotherapy (hydroxyurea)
CML - principles of treatment
Treatment cont
Eradicate malignant clone (curative)
allogeneic transplantation
alpha interferon ?
imatinib mesylate/STI 571 ?(Thyrosine kinase
inhibitor)

Chemotherapy
Busulphan
Alkylating agent
Preferred in older pts (not candidate for
transplant)
Side effect :
prolonged myelosuppression
Pulmonary fibrosis
Skin pigmentation
infertility
Chemotherapy
Hydoxyures
Fewer side effect
Acts by inhibiting the enzyme ribonucleotide reductase
Haematological remissions obtain in 80% for both
drugs
However disease progression not altered and
persistence of Ph chromosome containing clone

Chemotherapy
Recombinant human - Interferon
Prolong chronic phase and increase survival
Haematogical and cytogenetic remission
Side effect
Flu like symptoms
Fever and chills
Anorexia
Depression

CML - prognosis
Median survival 3.5 yrs (range 2-8 yrs)
Interferon + chemotherapy :6 years
Transplant : 5+ years
imatinib mesylate ?

Thank you
(ALL)
Clonal proliferation and accumulation of
blast cells in blood, bone marrow and other
organs
Disorder originates in single B or T
lymphocyte progenitor
Heterogenous disease with different
biological subtypes
Incidence in adults : 20% of acute leukemias
Etiology - unknown

Acute leukemias - clinical features
1. Bleeding
2. Fever/infection
3. Bone/joint pain
4. Hepatomegaly
5. Splenomegaly
6. Lymphadenopathy
7. CNS involvement

Acute leukemias - laboratory
findings (1)
1. Blood examination
- anemia,
- thrombocytopenia,
- variable leukocyte count, usually increased,
- blood morphology: presence of blast cells
2. Bone marrow morphology
- presence of blast cells,
- suppression of normal hematopoiesis
Acute leukemias - Laboratory findings
(2)
3. Cytochemical stains
4. Immunophenotyping
5. Cytogenetics
6. Molecular studies
Morphologic subtypes of acute
lymphoblastic leukemias (FAB
classification)
Subtype Morphology
Occurrence (%)
L1 Small round blasts
75
clumped chromatin
L2 Pleomorphic larger blasts
20
clefted nuclei, fine chromatin
L3 Large blasts, nucleoli,
5
vacuolated cytoplasm
Acute lymphoblastic leukemias
- reactivity with special stains
Subtype Peroxidase or Non-specific Periodic
Sudan black esterase acid-Schiff
L1 - - +++
L2 - - +++
L3 - - +++

Immunologic classification of
acute lymphoblastic leukemias
B- lineage (80%) Markers
Pro-B CD19(+),Tdt(+),CD10(-),CyIg(-),
Common CD19(+),Tdt(+),CD10(+),CyIg(-),
Pre-B CD19(+),Tdt(+),CD10(+),CyIg(+),SmIg(-)
Mature-B CD19(+),Tdt(+),CD10(),CyIg(),SmIg(+)
T-lineage (20%)
Pre-T CD7(+), CD2(-), Tdt(+),
Mature-T CD7(+), CD2(+), Tdt(+),
Chromosomal/molecular
abnormalities with prognostic
significance in ALL
Better prognosis
- normal koryotype
- hyperdiploidy
Poor prognosis
- t (8; 14)
- t (4; 11)
Very poor prognosis
- t (9; 22); BCR/ABL (+)

Risk classification in ALL
1. Standard risk
2. High risk
3. Very high risk
High-risk ALL
1. Pre - T
2. Pro - B
3. Age > 35 years,
4. WBC > 30 G/L in B-ALL
> 100 G/L in T-ALL
5. No remission after 4 weeks of
induction
therapy
Very high-risk ALL
Chromosome Philadelphia -
positive or BCR/ABL (+)
Treatment strategy in ALL
In ALL the choice of
treatment-strategy depends on:
1. Risk qualification
2. Immunophenotype of leukemic cells
- T lineage,
- early B lineage,
- mature B lineage,
3.Age and biological condition
4. Goal of treatment
Remission induction therapy in
ALL
1. Antineoplastic treatment
a/Drugs: prednisone, vincristine, asparginase,
cyclophosphamide
duanorubicin/adriablastin/epirubicin,
cytosine arabinoside,
b/Treatment duration: 4-8 weeks
c/ No of courses: 1- 2
2. CNS prophylaxis
3. Supportive care
4. Treatment of complications
Post-remission therapy in standard-
risk ALL
1. Chemotherapy
a/. Maintenance therapy: 6-
mercaptopurine,
methotrexate - for 2-3 years.
b/. Intensification treatment periodically
repeated: daunorubicin/adriablastin,
prednisone, vincristine,
cyclophosphamide.
2. CNS prophylaxis
Post-remission therapy in high-risk
ALL
1. Intensification treatment: amsacrine,
mitoxantrone, idarubicine, high dose
cytosine arabinoside, high dose
methotrexate, high dose
cyclophosphamide.
2. Hematopoietic stem cell transplantation
- high-dose therapy
- reduced intencity conditioning

Post-remission therapy in very
high
-risk ALL
- High-dose therapy ( reduced-intencity
?) +
allogeneic stem cell transplantation
Treatment results in ALL

Adults
Complete remission (CR)
80-85%
Leukemia-free survival (LFS)
30-40%

Children
Complete remission (CR)
95-99%
Leukemia-free survival (LFS)
70-80%

AutoHSCT in ALL

Treatment related mortality (TRM) 2-8%
CR1
LFS 42% (15-65%)
RI ( relapse incidence) 51%
CR2
LFS 24% (20-25%)
RI 60%
AlloHSCT in ALL
Sibling donor
CR1 >CR2
relapsed/refractory
LFS 51% (21-80) 34% (13-42) 20% (12-
33)
RI 26% (9-50) 47% (40-69) 71% (59-
76)
TRM 29% (12-42)

Matched unrelated donor

LFS 39% (38-42)
RI 22% (19-23)
TRM 48%
Lymphoma
David Lee MD, FRCPC
Lymphomas: The Basics
Brad Kahl, MD
Assistant Professor of Medicine
Director, UW Lymphoma Service
Lymphomas: NHL vs Hodgkins
EPIDEMIOLOGY
Biology
Classification
Approach to the Patient
Hodgkins Disease
Epidemiology
14% of malignant lymphomas
0.5% of all malignancies
approximately 8000 new cases/yr in US
approximately 1500 deaths/yr
over past 30 years
age adjusted incidence rates declined appreciably
mortality rates declined substantially

Hodgkins Disease
Epidemiology
men > women
whites > blacks > Asians
no clear risk factors, several implicated
EBV (pathogen or passenger)
HIV
woodworking, farming
rare familial aggregations

NHL: Epidemiology
Most common hematologic malignancy
60,000 new cases annually
6th leading cause of cancer death
incidence rising
overall incidence up by 73% since 1973
epidemic
2nd most rapidly rising malignancy

NHL: Epidemiology
Why the increase?
Increase noted mostly in farming states
MN #1, WI #7 NHL incidence
possible role of herbicides, insecticides, etc.
Other environmental factors?

NHL: Epidemiology
Other risk factors
immunodeficiency states
AIDS, post-transplant, genetic
autoimmune diseases
Sjogrens
Sprue
infections
H. pylori, EBV, HHV-8
Epidemiology
SEER 5 year survival data
NHL Hodgkins
1974-76: 47.2 71.1%
1977-79: 48.1 73.0%
1980-82: 51.1 74.3%
1983-90 52.0 78.9%

Hodgkins Disease
Epidemiology
BIOLOGY
Classification
Hodgkins Disease
Background
first described in 1832 by Dr. Thomas Hodgkin
characterized by the presence of Reed-
Sternberg cells
multinucleated giant cells
described by Sternberg in 1898 and Reed in 1902
classified as an infectious disease until 1950s
Reed-Sternberg Cell
Hodgkin Biology
RS is a crippled germinal center B cell
does not have normal B cell surface antigens
micromanipulation of single RS followed by PCR
demonstrates clonally rearranged, but non functional
immunoglobulin genes
somatic mutations result in stop codon (no sIg)
no apoptotic death malignant transformation
unclear how this occurs; ? EBV
unclear how cells end up with RS phenotype
Hodgkins Disease
Epidemiology
Biology
CLASSIFICATION
APPROACH TO THE PATIENT
Hodgkin Lymphoma Classification
Classic Hodgkins Disease
nodular sclerosis
mixed cellularity
lymphocyte depleted (very rare)
classical lymphocyte rich
HRS cells CD30 and CD15 positive
nodular lymphocyte predominant
HRS cells (L&H cells) have B cell markers
CD 20 and surface Immunoglobulin
Classic Hodgkin Lymphoma
Nodular Sclerosing
Hodgkin Lymphoma
Hodgkins Disease
approach dictated mainly by where the disease
is located rather (results of staging) than the
exact histologic subtype
NHL
approach is dictated mainly by the histologic
subtype rather than the results of staging
Hodgkins Disease
staging evaluation
H & P
CBC, diff, plts
ESR, LDH, albumin, LFTs, Cr
CT scans chest/abd/pelvis
bone marrow evaluation
**PET or gallium scan**
**lymphangiogram or laparotomy**
Ann Arbor Staging System
Stage I: single lymph node region (I) or single
extralymphatic organ or site (I
E
)
Stage II: > 2 lymph node regions on same side of
diaphragm (II) or with limited, contiguous
extra lymphatic tissue involvement (II
E
)
Stage III: both sides of diaphragm involved, may include
spleen (III
S
) or local tissue involvement (III
E
)
Stage IV: multiple/disseminated foci involved with > 1
extralymphatic organs (i.e. bone marrow)
(A) or (B) designates absence/presence of B
symptoms
Ann Arbor Staging System for Hodgkin's
Disease and Non-Hodgkin's Lymphoma
Stage I Stage II Stage III Stage IV
Reprinted with permission. Adapted fromSkarin.
Dana-Farber Cancer I nstitute Atlas of
Diagnostic Oncology. 1991.
Modified Ann Arbor Staging
E designation for extranodal disease
B symptoms
recurrent drenching night sweats during previous month
unexplained, persistent, or recurrent fever with temps above 38
C during the previous month
unexplained weight loss of more than 10% of the body weight
during the previous 6 months
Criteria for bulk
10 cm nodal mass
mediastinal mass > 1/3 thorax diameter

Hodgkin Lymphoma
Treatment
approach depends upon stage, prognostic factors,
and co-morbidities
Stage I-II
consider XRT, chemotherapy, or combined therapy
Bulky stage I-II
combined modality therapy
Stage III-IV
ABVD x 6-8 cycles gold standard
Hodgkin Lymphoma
Adverse prognostic features for stage I & II (EORTC data)
more than 3 nodal sites
bulky adenopathy
ESR > 50
B symptoms
invasion into critical organs
male
age > 40
MC or LD subtype
should probably not receive XRT alone if any of the above
present (excessive relapse rate)

Hodgkin Lymphoma
Independent adverse prognostic factors
advanced stage (III-IV)
male sex
age > 45
albumin < 4 gm/dl
HgB < 10.5 mg/dl
stage IV disease
WBC count > 15,000/mm
3

lymphocyte count < 600/mm
3
(Hasenclever et al, NEJM 339,1506-1514;1998)

Hodgkins Disease
Role for Stem Cell Transplantation
clinical trials show benefit for patients who
receive high dose chemotherapy followed by
SCT for patients who have relapsed after initial
therapy or for patients are primary refractory

Hodgkins Disease
Results of Treatment
stage 5 year overall survival
I 90%
II 90%
III 80%
IV 65%

Hodgkin Lymphoma
Late Complications
depends upon treatment modality utilized
XRT vs. MOPP vs. ABVD vs. CMT
issues depends upon the age of patient
relative risks higher in younger patients
absolute risks higher in older patients
major focus of current clinical trials to to maintain high
cure rate while minimizing late complication
shorter courses of chemotherapy with lower radiation doses in
smaller fields
elimination of radiotherapy

Hodgkins: future directions
Limited stage and good prognosis advanced stage
cure rate high
current goal is to minimize late complications
trials looking at CMT with less chemotherapy and less
radiation
Advanced stage
cure rate around 50-70%
trial comparing ABVD to Stanford V
Clinical Trials
NHL
Epidemiology
BIOLOGY
Classification
Lymphoma Biology
Indolent vs. Aggressive NHL
key principle in understanding biology, and approach to
the patient
Indolent = incurable
Aggressive = curable
WHY?
Chromosomal Abnormalities in NHL
frequent chromosomal translocations into Ig gene loci
t(8;14), t(2;8), t(8;22) Burkitts
t(14;18) follicular NHL

Lymphoma Biology
Aggressive NHL
short natural history (patients die within months
if untreated)
disease of rapid cellular proliferation
Indolent NHL
long natural history (patients can live for many
years untreated)
disease of slow cellular accumulation

NHL
Epidemiology
Biology
CLASSIFICATION
NHL: Classification
Historically- a mess
1940s Gail and Mallory
1950s Rappaport
1970s Lukes-Collins
1970s Kiel
1982 Working
1994 REAL
1999 WHO
NHL: Classification
Key Points
cell size: small cell vs. large cell
nodal architecture: follicular vs. diffuse

Principle
More aggressive: diffuse, large cell
More indolent: follicular, small cell
NHL: Classification
Terminology (refers to natural history)
low grade = indolent
intermediate grade = aggressive
high grade = aggressive

Principle
indolent: slow growing, incurable
aggressive: rapidly growing, curable
NHL
Epidemiology
Biology
Classification
APPROACH TO THE PATIENT
NHL: Approach to the Patient
Approach dictated mainly by histology
reliable hematopathology crucial

Approach also influenced by:
stage
prognostic factors
co-morbidities
Staging evaluation
History and PE
Routine blood work
CBC, diff, plts, electrolytes, BUN, Cr, LFTs, uric
acid, LDH, B2M
CT scans chest/abd/pelvis
Bone marrow evaluation
Other studies as indicated (lumbar puncture,
gallium, etc)
Indolent NHL: typical scenario
patient presents with painless adenopathy
otherwise asymptomatic
follicular small cell histology
average age 59
usually stage III-IV at diagnosis
Indolent NHL: guiding treatment principle
early treatment does not prolong overall survival
When to treat?
constitutional symptoms
compromise of a vital organ by compression or
infiltration, particularly the bone marrow
bulky adenopathy
rapid progression
evidence of transformation

Indolent NHL: typical scenario
watchful waiting: 2-4 years
first remission length: 3-4 years
second remission: 2-3 years
third remission: 1-2 years
each subsequent remission shorter than prior
median survival 8-12 years for FLSC
Indolent NHL: treatment options
watchful waiting
radiation to involved fields
single agent chemotherapy
chlorambucil + prednisone, fludarabine
combination chemotherapy
CVP, CF, FND, CHOP
chemotherapy + interferon
chemotherapy + monoclonal antibodies
monoclonal antibodies
radiolabeled monoclonal antibodies
stem cell transplantation
Aggressive NHL: typical scenario
patients notes B symptoms of several weeks
duration
work-up reveals pathologic adenopathy
histology: diffuse large cell lymphoma
about 50% patients stage I-II, 50% stage III-IV
average age 64
IPI score
Aggressive NHL: treatment approach
Stage I-II: combined modality therapy
CHOP chemotherapy x 3 + IF radiotherapy
cure rate around 70%
Stage III-IV (also bulky stage II)
(R)CHOP chemotherapy x 6-8 cycles
cure rate around 40%
(R)CHOP is the standard

International Prognostic Index
Risk Factors (0-5)
age > 60
two or more extranodal sites
performance status > 2
elevated LDH
stage III-IV
Age adjusted IPI (0-3)
CR and OS stratified by IPI
# RFs CR 5 yr OS
0,1 87% 73%
2 67% 51%
3 55% 43%
4,5 44% 26%
Is CHOP the best we can do?
R-CHOP may be better
National Trials opening looking at alternative
strategies in poor prognosis DLCL
age adjusted IPI > 2
CHOP vs. CHOP + SCT
Risk stratification is the current trend in NHL
Sorting out role for stem cell transplantation
Sorting out role for innovative combinations
Role for Autologous Stem Cell Transplantation
Aggressive NHL
clear benefit when used for aggressive NHL in
first relapse in appropriately selected patients
1/3 of these patients can be cured by SCT
Indolent NHL
no indication that patients are cured
no indication that OS is prolonged
NHL: future directions
Indolent
monoclonal antibodies (Rituximab)
radiolabeled monoclonal antibodies
chemotherapy combined with antibodies
antibodies combined with immunomodulators
Aggressive
risk stratification
CHOP vs. CHOP plus SCT
chemotherapy plus antibodies
Clinical Trials
Summary
NHL incidence increasing, Hodgkins decreasing
Hodgkins cure rate quite high
approach is dictated mainly by disease stage
NHL cure rate mediocre
approach is dictated mainly by histologic subtype
indolent vs. aggressive
indolent: watchful waiting perfectly acceptable for
asymptomatic patients
aggressive: require aggressive treatment ASAP to achieve cure
Lymphoma Clinic
Multidisciplinary
radiotherapy-Dr. Scott Tannehill
hematopathology-Dr. Catherine Leith
Emphasis on clinical trials
formal testing of promising new therapies
Every Wednesday
Clinic phone #: 608-263-7022

Overview
Concepts, classification, biology
Epidemiology
Clinical presentation
Diagnosis
Staging
Three important types of lymphoma

Conceptualizing lymphoma
neoplasms of lymphoid origin, typically
causing lymphadenopathy
leukemia vs lymphoma
lymphomas as clonal expansions of cells at
certain developmental stages
ALL MM CLL Lymphomas
Hematopoietic
stem cell
Neutrophils
Eosinophils
Basophils
Monocytes
Platelets
Red cells
Myeloid
progenitor
Myeloproliferative disorders AML
Lymphoid
progenitor T-lymphocytes
Plasma
cells
B-lymphocytes
nave
B-cell development
stem
cell
lymphoid
progenitor
progenitor-B
pre-B
immature
B-cell
memory
B-cell
plasma cell
DLBCL,
FL, HL
ALL
CLL
MM
germinal
center
B-cell
mature
naive
B-cell
Clinically useful
classification
Diseases that have distinct
clinical features
natural history
prognosis
treatment
Biologically rational
classification
Diseases that have distinct
morphology
immunophenotype
genetic features
clinical features
Classification
Lymphoma classification
(2001 WHO)
B-cell neoplasms
precursor
mature
T-cell & NK-cell neoplasms
precursor
mature
Hodgkin lymphoma
Non-
Hodgkin
Lymphomas
A practical way to think of lymphoma
Category Survival of
untreated
patients
Curability

To treat or
not to treat

Non-
Hodgkin
lymphoma
Indolent

Years

Generally not
curable

Generally
defer Rx if
asymptomatic

Aggressive

Months

Curable in
some

Treat

Very
aggressive

Weeks

Curable in
some

Treat

Hodgkin
lymphoma

All types

Variable
months to
years

Curable in
most

Treat

Mechanisms of
lymphomagenesis
Genetic alterations
Infection
Antigen stimulation
Immunosuppression
Epidemiology of lymphomas
5
th
most frequently diagnosed cancer in both
sexes
males > females
incidence
NHL increasing
Hodgkin lymphoma stable
Incidence of lymphomas in comparison with
other cancers in Canada
Year
1985 1990 1995 2000
a
g
e

a
d
j
u
s
t
e
d

i
n
c
i
d
e
n
c
e
/
1
0
0
,
0
0
0
/
y
r
0
10
20
30
40
50
60
70
Hodgkin
lymphoma
NHL
breast
colorectal
lung
Age distribution of new NHL cases in
Canada
Age (years)
0
-
1
1
-
4
5
-
9
1
0
-
1
4
1
5
-
1
9
2
0
-
2
4
2
5
-
2
9
3
0
-
3
4
3
5
-
3
9
4
0
-
4
4
4
5
-
4
9
5
0
-
5
4
5
5
-
5
9
6
0
-
6
4
6
5
-
6
9
7
0
-
7
4
7
5
-
7
9
8
0
-
8
4
8
5
+
I
n
c
i
d
e
n
c
e
/
1
0
0
,
0
0
0
/
a
n
n
u
m
0
20
40
60
80
100
Age distribution of new Hodgkin
lymphoma cases in Canada
Age (years)
0
-
1
1
-
4
5
-
9
1
0
-
1
4
1
5
-
1
9
2
0
-
2
4
2
5
-
2
9
3
0
-
3
4
3
5
-
3
9
4
0
-
4
4
4
5
-
4
9
5
0
-
5
4
5
5
-
5
9
6
0
-
6
4
6
5
-
6
9
7
0
-
7
4
7
5
-
7
9
8
0
-
8
4
8
5
+
i
n
c
i
d
e
n
c
e
/
1
0
0
,
0
0
0
/
a
n
n
u
m
0
1
2
3
4
5
6
Risk factors for NHL
immunosuppression or immunodeficiency
connective tissue disease
family history of lymphoma
infectious agents
ionizing radiation
Variable
severity: asymptomatic to extremely ill
time course: evolution over weeks, months, or years
Systemic manifestations
fever, night sweats, weight loss, anorexia, pruritis
Local manifestations
lymphadenopathy, splenomegaly most common
any tissue potentially can be infiltrated
Other complications of
lymphoma
bone marrow failure (infiltration)
CNS infiltration
immune hemolysis or thrombocytopenia
compression of structures (eg spinal cord,
ureters)
pleural/pericardial effusions, ascites

Diagnosis requires an adequate
biopsy
Diagnosis should be biopsy-proven before
treatment is initiated
Need enough tissue to assess cells and
architecture
open bx vs core needle bx vs FNA

Stage I Stage II Stage III Stage IV
Staging of lymphoma
A: absence of B symptoms
B: fever, night sweats, weight loss
Three common lymphomas
Follicular lymphoma
Hodgkin lymphoma
Relative frequencies of different
lymphomas
Hodgkin
lymphoma
NHL
Diffuse large B-cell
Follicular
Other NHL
Non-Hodgkin Lymphomas
~85% of NHL are B-lineage
Follicular lymphoma
most common type of indolent lymphoma
usually widespread at presentation
often asymptomatic
not curable (some exceptions)
associated with BCL-2 gene rearrangement
[t(14;18)]
cell of origin: germinal center B-cell
defer treatment if asymptomatic (watch-
and-wait)
several chemotherapy options if
symptomatic
median survival: years
despite indolent label, morbidity and
mortality can be considerable
transformation to aggressive lymphoma can
occur
most common type of aggressive
lymphoma
usually symptomatic
extranodal involvement is common
cell of origin: germinal center B-cell
treatment should be offered
curable in ~ 40%
Hodgkin lymphoma
Thomas Hodgkin
(1798-1866)
Classical Hodgkin Lymphoma
Hodgkin lymphoma
cell of origin: germinal centre B-cell
Reed-Sternberg cells (or RS variants) in the
affected tissues
most cells in affected lymph node are
polyclonal reactive lymphoid cells, not
neoplastic cells
Reed-Sternberg cell
RS cell and variants
popcorn cell lacunar cell classic RS cell
(mixed cellularity) (nodular sclerosis)
(lymphocyte
predominance)
A possible model of pathogenesis
germinal
centre
B cell
transforming
event(s)
loss of apoptosis
RS cell
inflammatory
response
EBV?
cytokines
Hodgkin lymphoma
Histologic subtypes
Classical Hodgkin lymphoma
nodular sclerosis (most common subtype)
mixed cellularity
lymphocyte-rich
lymphocyte depleted
Epidemiology
less frequent than non-Hodgkin lymphoma
overall M>F
peak incidence in 3rd decade

Associated (etiological?) factors
EBV infection
smaller family size
higher socio-economic status
caucasian > non-caucasian
possible genetic predisposition
other: HIV? occupation? herbicides?

Clinical manifestations:
lymphadenopathy
contiguous spread
extranodal sites relatively uncommon
except in advanced disease
B symptoms
Stage Treatment Failure-
free
survival
Overall 5
year
survival
I,II ABVD x 4
& radiation
70-80% 80-90%
III,IV ABVD x 6 60-70% 70-80%
Long term complications of
treatment
infertility
MOPP > ABVD; males > females
sperm banking should be discussed
premature menopause
secondary malignancy
skin, AML, lung, MDS, NHL, thyroid, breast...
cardiac disease
Overview
Concepts, classification, biology
Epidemiology
Clinical presentation
Diagnosis
Staging
Three important types of lymphoma

Non-Hodgkins Lymphoma

Luis Fayad, MD
Assistant Professor
Clinical Medical Director Lymphoma/Myeloma Department
Non-Hodgkins Lymphoma
Non-Hodgkins lymphomas (NHL) are a heterogeneous
group of malignant lymphomas. There are many different
subtypes, every few years the classification is updated.
Today, morphology, immunophenotype, molecular,
cytogenetics, and other techniques are used for diagnosis.
Treatment generally depends on the aggressiveness of the
disease (indolent, aggressive, or very aggressive)
Current ICD-9-CM diagnosis code range 200.0_ 200.8_
and 202.0_ 202.9_
Behavior
Indolent these lymphomas grow slowly. The majority of
NHLs are considered indolent. Indolent lymphomas are
generally considered incurable with chemotherapy and/or
radiation therapy.
Aggressive these lymphomas have a rapid growth
pattern. This is the second most common form of NHL
and are curable with chemotherapy.
Very Aggressive these lymphomas grow very rapidly.
They account for a small proportion of NHLs and can be
treated with chemotherapy. Unless treated rapidly, these
lymphomas can be life threatening.
WHO/REAL Classification of Lymphoid Neoplasms
B-Cell Neoplasms
Precursor B-cell neoplasm
Precursor B-lymphoblastic leukemia/lymphoma
(precursor B-acute lymphoblastic leukemia)
Mature (peripheral) B-neoplasms
B-cell chronic lymphocytic leukemia / small lymphocytic
lymphoma
B-cell prolymphocytic leukemia
Lymphoplasmacytic lymphoma

Splenic marginal zone B-cell lymphoma
(+ villous lymphocytes)*
Hairy cell leukemia
Plasma cell myeloma/plasmacytoma
Extranodal marginal zone B-cell lymphoma of MALT type
Nodal marginal zone B-cell lymphoma
(+ monocytoid B cells)*
Follicular lymphoma
Mantle cell lymphoma
Mediastinal large B-cell lymphoma
Primary effusion lymphoma

Burkitts lymphoma/Burkitt cell leukemia

T and NK-Cell Neoplasms
Precursor T-cell neoplasm
Precursor T-lymphoblastic leukemia/lymphoma
(precursor T-acute lymphoblastic leukemia

Formerly known as lymphoplasmacytoid lymphoma or immunocytoma
II
Entities formally grouped under the heading large granular
lymphocyte
leukemia of T- and NK-cell types
* Provisional entities in the REAL classification

Mature (peripheral) T neoplasms
T-cell chronic lymphocytic leukemia / small
lymphocytic lymphoma
T-cell prolymphocytic leukemia
T-cell granular lymphocytic leukemia
II

Aggressive NK leukemia
Adult T-cell lymphoma/leukemia (HTLV-1+)
Extranodal NK/T-cell lymphoma, nasal type
#

Enteropathy-like T-cell lymphoma**
Hepatosplenic T-cell lymphoma*
Subcutaneous panniculitis-like T-cell lymphoma*
Mycosis fungoides/Szary syndrome
Anaplastic large cell lymphoma, T/null cell,
primary cutaneous type
Peripheral T-cell lymphoma, not otherwise characterized
Angioimmunoblastic T-cell lymphoma
Anaplastic large cell lymphoma, T/null cell,
primary systemic type
Hodgkins Lymphoma (Hodgkins Disease)
Nodular lymphocyte predominance Hodgkins lymphoma
Classic Hodgkins lymphoma
Nodular sclerosis Hodgkins lymphoma (grades 1 and 2)
Lymphocyte-rich classic Hodgkins lymphoma
Mixed cellularity Hodgkins lymphoma

Lymphocyte depletion Hodgkins lymphoma

Not described in REAL classification

Includes the so-called Burkitt-like lymphomas
** Formerly known as intestinal T-cell lymphoma
#
Formerly know as angiocentric lymphoma
Indolent (35%)
Diffuse large
B-cell (31%)
Armitage et al. J Clin Oncol. 1998;16:27802795.
Mantle cell (6%)
Peripheral T-cell (6%)
Other subtypes with a
frequency s2% (9%)
Frequency of NHL Subtypes in Adults
Composite
lymphomas (13%)
Marginal Zone Lymphoma
Indolent
Currently codes to 202.8_
Accounts for ~10% of all lymphomas
Subcategories
MALT (XRT?)
Nodal
Extra Nodal
Splenic
Mantle Cell Lymphoma
Aggressive
Accounts for ~ 6% of all lymphomas
Considered incurable with traditional RX
Stem cell transplant is offered often as
front-line consolidation treatment in
younger patients
Primary CNS Lymphoma
Aggressive
Accounts for ~ 1-2% of all lymphomas
Different chemotherapy treatments
Often requires radiation to the brain:
Brain dysfunction in younger patients
Dementia in older patients

Anaplastic Large Cell
Lymphoma (ALCL)
Aggressive
Two groups:
ALCL ALK-1+ better prognosis, more common in
younger patients and children
ALCL ALK-1-negative : as bad as any other T-cell
lymphoma
Peripheral T-cell Lymphoma
Aggressive
Worse prognosis, often associated with
extranodal presentation
Often requiring salvage treatment and
transplant
Large Cell Lymphoma
Very Aggressive
Other Recommendations
Changes to terminology
Changes in disease process
Questions?
Non Hodgkin's Lymphoma
Questions?
What is Hodgkin's?

What is a Lymphoma?

What does Non-Hodgkin's mean?
Lymphomas and leukemias

A Leukemia is a tumor that produces abnormal white blood
cells in the blood stream. A lymphoma is a tumor of the lymph
nodes that causes them to expand, invade other organs and
cause the abnormal growth of lymphoid tissue elsewhere.

Leukemias are tumors of the bone marrow, while lymphomas
are tumors of the lymphoid organs and lymphatics
Classification of NHL
Hodgkin's vs. Non Hodgkin's
through microscopy, if the tumor presents with Reed-Sternberg
cells, then the disease is classified as Hodgkin's Lymphoma. All
other forms are classified as non-Hodgkin's.
The original classification known as the "Working Formula"
addressed the NHL into 16 different groups, classified by
aggressiveness. There is little correlation between the stages, and
thus, the REAL (Revised European-American Lymphoma) and
WHO classifications are currently more adapted into medical
language.
These classifications organize the lymphomas into over 43
distinguishable diseases.
They still classifiy Hodgkin's lymphoma, but do not specifically
identify NHL. People still use the term, although due to it's broad
spectrum, provides little clinical relevance.
Hodgkin's Lymphoma
WHO Classification Overview
Classifications are based on the morphological presentation as opposed to the
aggressiveness.

B cell Neoplasms
Precursor B cell Neoplasms
Mature B cell Neoplasms (most common)
o Follicular B cell lymphoma
o Diffuse Large B cell Lymphoma
B cell proliferations unclassified
T cell and NK cell Neoplasms
Precursor T and NK cell neoplasms
Mature T and NK cell Neoplasms
T and NK proliferations unclassified

Hodgkin's Lymphoma

Histiocytic Neoplasms

Dendritic cell Neoplasms
Lymphoma classification
B cell Lymphomas

90% of cases are Mature B cell Lymphomas, < 1% are
precursor B cell lymphoma
Follicular B cell Lymphoma
Mantle Cell Lymphoma
Marginal Zone Lymphoma
Interfollicular Lymphomas
Burkitt Lymphoma
Diffuse Large B cell Lymphoma
Primary Effusion Lymphoma


B cell Developement
Lymphoma Classification continued
T cell Lymphomas

< 12% of cases are T cell and NK cell Lymphomas, although
uncommon, they are one of the most aggressive lymphomas.

Peripheral T cell Lymphoma, unspecified
Anaplastic Large Cell Lymphoma
Angioimmunoblastic T cell Lymphoma
Primary Cutaneous T cell Lymphoma
Lymphoma Classification continued
Rare Lymphomas

Histiocytic tumors
Similar to Anaplastic Large cell Lymphoma, within the
dermis or gastrointestinal tract. Express a "histiocytic"
phenotype, but has no specific markers, thus the diagnosis is
that of exclusion.

Dendritic Cell Tumors
Neoplasms related to accessory cells (DC). Extremely
rare, and present a significant diagnostic
challenge. Symptoms are unpredictable, showing forms of
indolence to lethality.
Risk Factors For
NHL
Systemic Lupus
Rheumatoid arthritis
Celiac Disease
AIDS
Organ Transplant recipients
Congenital Immunodeficiency disorders
Chromosomal abnormalities, specifically with chromosomes
2, 8, 14, and 22 (seen in ~ 60% of cases)

Typical Patient Signs and Symptoms
Over the age of 55
Severe night sweats (often times drenching the bed sheets)
Itchiness, generally all over
Fever
Weight Loss
Loss of appetite
Weakness and Fatigue, along with typical signs of anemia
Breathlessness, primarily due to swelling of the face and/or
neck
Physical Exam

Waxing and waning
lymphadenopathy often present
for long periods prior to diagnosis

**This disease progresses slowly


Nodal enlargement commonly
found in the neck and the
abdomen.

Masses can be found outside the
lymphatic system: the
gastrointestinal tract, testes,
thyroid, skin, breast, bone or
brain

40% cases present with
extranodal extramedullary
disease.

**This is an aggressive disease

Labs

Normal CBC (may show
with signs of anemia)
Peripheral smear normal
Lymph node biopsy

Normal CBC (may show with
signs of anemia)
Peripheral smear normal
Flow cytometry-
Immunophenotype generally
includes pan-B-cell antigens
such as CD19, CD20, CD22
and CD79a
Excisional tissue biopsy
Both biopsies require the distinction between:
benign vs. malignant
lymphoma vs. nonlymphoid malignancies
T cell vs. B cell lymphoma
HL vs. NHL
subtyping of HL and NHL
Prognosis
Variable
Depends upon:
the amount of dissemination,
the staging of the disease
and the type of lymphoma

when first diagnosed the disease has spread throughout the
body in 70-90% of patients

although most patients develop progressive disease over 2-6
years, survival rate is 75% over 5-years

Treatments
Traditional Treatments:
consists of radiation and/or chemotherapy
and occasional splenectomy

o remission rates presently 70-90% at 5-years with that
treatment
Treatments
Naturopathic Treatments:
o Nutrition

o Hydrotherapy

o Botanicals

o Supplements

o Manipulation

o Homeopathy
Treatments
Nutrition
o Non-Hodgkin's lymphoma:
1. decrease intake of fats severely
2. vitamin C rich foods
3. apples, celery, collards, guava, kohlrabi

o Recommendation for all cancers
seaweed, mushrooms (Shiitake), figs, beets, papaya,
mung beans, licorice, sea cucumbers, carrot, garlic,
walnut, mulberries, asparagus, pumpkin, burdock,
dandelion greens, taro roots, pearl barley, grains, fresh
fruit and vegetables
Treatments
Hydrotherapy
1. fever treatment

2. constitutional hydrotherapy

3. castor oil packs: over abdominal area and spleen, add
phytolacca oil, 2x/week, 1 hour

4. Epsom salt baths: 2x/week, 20-30 min. end with cold
friction, dry and stay warm
Treatments
Botanicals (General cancer/neoplasm):
1.Arctium lappa: alterative for the lymphatic system
2.Berberis aquifolium: dyscrasiae due to cancerous
cachexia
3.Calendula officinalis: for lymphatic system
4.Echinacea spp.: increases interferon production, purifies
blood
5. Galium aparine: specific for enlarged lymph nodes
6.Gentiana lutea: bitter; promotes appetite, improves
digestion in chronic debility
7.Iris versicolor (toxic): soft glandular swellings
8.Rumex crispus: to prevent early stages of cancer
9.Taraxacum officinale: loss of appetite, weak digestion
10. Trifolium pratense: alterative; purifies blood, cancerous
diathesis; with daily use; patient are slower in developing
carcinoma after excision
Treatments
Supplements
o 1. beta carotene (150,000 IU QD)
o 2. vitamin C (to bowel tolerance)
o 3. vitamin E (400 IU TID)
o 4. selenium (200mcg TID)
Treatments
Manipulation
o check and align T5, T10-12
Treatments
Homeopathy
1. Apis: on neck with hectic fever; edema of skin and mucus
membranes
2. Arsenicum album: great exhaustion; burning pains;
lymphoma on neck with hectic fever, with holes as in a sieve
3. Arsenicum iodatum: weakness, night sweats
4. Belladonna: sore throat, swollen face, dry cough
5. Graphites: with fever
6. Phosphorus: with fever, suddenness of symptoms, with
nervous debility; emaciation
7. Pulsatilla: with digestive problems
8. Rhus toxicodendron: restlessness and soreness
Multiple Myeloma
By Dr.Sujith S.
Introduction
Malignant proliferation of plasma cells
derived from single clone.

Osteoclasts Activating Factor

Plasma cell
A variety of chromosomal alterations - most
common translocations are
t(11;14)(q13;q32) and t(4;14)(p16;q32),

Mutations in p53 and Rb-1 have also been
described.

Myeloma increases in incidence with age.
The median age at diagnosis is 68 years; it
is uncommon under age 40.
The yearly incidence is around 4 per
100,000 .
Males are more commonly affected than
females
Blacks have twice the incidence of whites
Clinical Features
Bone pain (70%)

Mechanism of lytic lesion in the bone

Site of involvement
Back & Ribs,Pain precipitated by movement

Clinical features(cont.d)
Complications
Pathological fracture-persistent pain at the local site

Spinal Cord Compression due to collapse of the vertebrae
Increase susceptibility to bacterial
infections.
The most common infections are
pneumonias and pyelonephritis
Organisms in the lungs- Streptococcus
pneumoniae, Staphylococcus aureus, and
Klebsiella pneumoniae.
Organisms in the urinary tract- Escherichia
coli and other gram-negative

Contributory causes
Renal failure occurs in nearly 25% of
myeloma patients,
Hypercalcemia
Glomerular deposits of amyloid,
hyperuricemia, recurrent infections, frequent
use of nonsteroidal anti-inflammatory agents
for pain control, use of iodinated contrast dye
for imaging, bisphosphonate use, myeloma
cells infiltrates
Tubular damage associated with the excretion
of light chains
Clinical Features(cont.d)
The earliest manifestation of this tubular
damage is the adult Fanconi syndrome (a
type 2 proximal renal tubular acidosis),

Glomerular function is usually normal

Proteinuria is uncommon

Decreased anion gap because the M
component is cationic
Hyponatremia (pseudohyponatremia)
susceptible to acute renal failure if they
become dehydrated
Anemia - 80% .

It is usually normocytic and normochromic

Some have megaloblastic anemia due to either
folate or vitamin B
12
deficiency.

Granulocytopenia and thrombocytopenia are very
rare.

Clotting abnormalities may be seen
failure of antibody-coated platelets to function properly
interaction of the M component with clotting factors I,
II, V, VII, or VIII.

Deep venous thrombosis is also observed
Raynaud's phenomenon and impaired
circulation may result if the M component
forms cryoglobulins

Hyperviscosity
Depends on the physical properties of the M
component (most common with IgM, IgG,
and IgA paraproteins).

Paraprotein concentrations of ~40 g/L (4
g/dL) for IgM, 50 g/L (5 g/dL) for IgG3,
and 70 g/L (7 g/dL) for IgA.

Symptoms: headache, fatigue, visual
disturbances, and retinopathy

Hypercalcemia - lethargy, weakness,
depression, and confusion.
Bony damage and collapse - cord
compression, radicular pain, and loss of
bowel and bladder control.
Infiltration of peripheral nerves by amyloid-
cause of carpal tunnel syndrome sensory
,motor mono and polyneuropathies.
Sensory neuropathy is also a side effect of
thalidomide and bortezomib therapy
Variants of Myeloma
Solitary bone plasmacytomas may recur in
other bony sites or evolve into myeloma.
Extramedullary plasmacytomas
submucosal lymphoid tissue of
nasopharynx or paranasal sinus without
marrow plasmacytosis
rarely recur or progress

Both highly responsive to local radiation
theray
Diagnostic features
Plasmacytosis in marrow
Monoclonal protein in serum or urine
Lytic disease of bone

Asymptomatic Multiple Myeloma
M protein in serum>30g/L
Bone marrow clonal plasma cells > 10%
No myeloma-related organ or tissue
impairment (no end organ damage,
including bone lesions) or symptoms

Symptomatic Multiple Myeloma
M protein in serum and/or urine
Bone marrow (clonal) plasma cells or
plasmacytoma
Myeloma-related organ or tissue
impairment (end organ damage, including
bone lesions
Nonsecretory Myeloma
No M protein in serum and/or urine with
immunofixation
Bone marrow clonal plasmacytosis 10%
impairment (end organ damage, including
bone lesions)

Solitary Plasmacytoma of Bone
No M protein in serum and/or urine

Single area of bone destruction due to
clonal plasma cells
Bone marrow not consistent with multiple
myeloma
Normal skeletal survey (and MRI of spine
and pelvis if done)
No related organ or tissue impairment (no
end organ damage other than solitary bone
lesion
impairment (ROTI)
Calcium levels increased
renal insufficiency
anemia
bone lesions
symptomatic hyperviscosity,
amyloidosis,
recurrent bacterial infections (>2 episodes in
12 months)
Investigations
CBC with differential may reveal anemia
ESR is elevated.
Rare patients (~2%) may have plasma cell
leukemia with >2000 plasma cells/L.
Serum calcium, urea nitrogen, creatinine,
and uric acid levels may be elevated.
Protein electrophoresis and measurement of
serum immunoglobulins and free light
chains.
Cont.d
A 24-h urine specimen is necessary to
quantitate protein excretion
Serum alkaline phosphatase is usually
normal
It is also important to quantitate serum
Beta
2
-microglobulin.
Serum soluble IL-6 receptor levels and C-
reactive protein may reflect physiologic IL-
6 levels in the patient
Serum M Component
IgG in 53% of patients, IgA in 25%, and
IgD in 1%
20% of patients will have only light chains
in serum and urine.
Bence Jones protein is falsely negative in
~50% of patients with light chain myeloma.

Serum M Component
Fewer than 1% of patients have no
identifiable M component- have light chain
myeloma
About two-thirds of patients with serum M
components -urinary light chains.
Criteria for Diagnosis of Multile
Myeloma
Durie Salmon Diagnostic Criteria
Major Criteria
I-Plasmacytoma on tissue biopsy.
II-Bone marrow plasmacytosis(>30%
plasma cells)
III-Monoclonal immunoglobulin spike
IgG>3.5g/dl or IgA>2g/dl
kappa/lamda chain excretion>1g/dayin
24 hr UPEP

Minor Criteria
a)Bone marrow plasmacytosis(10-30%plasma cells).
b)Lesser magnitude of Ig spike
c)Lytic lesions
d)Normal IgM:<50mg/dl
Normal IgA<100mg/dl or
Normal IgG<600 mg/dl
I plus b, c, or d
II plus b, c, or d
III plus a, c, or d
a plus b plus c
a plus b plus d

Durie-Salmon staging

Staging system is based on the
hemoglobin, calcium, M component, and degree of skeletal
involvement
low (stage I), intermediate (stage II), or high (stage III),
stages are further subdivided on the basis of renal function
[A if serum creatinine <2 mg/dL, B if >2 mg/dl].
stage IA have a median survival of >5 years and those in
stage IIIB about 15 months.
This staging system has been found not to predict
prognosis after treatment with high-dose therapy or the
novel targeted therapies that have emerged.
Stage I

Estimated Tumor Burden < 0.6 (x 10
12

cells/m
2)

Hemoglobin >100 g/L (>10 g/dL)
Serum calcium <3 mmol/L (<12 mg/dL)
Normal bone x-ray or solitary lesion
Low M-component production
IgG level <50 g/L (<5 g/dL)
IgA level <30 g/L (<3 g/dL)
Urine light chain <4 g/24 h
Stage III

Hemoglobin <85 g/L (<8.5 g/dL)
Serum calcium >3 mmol/L (>12 mg/dL)
Advanced lytic bone lesions
High M-component production
IgG level >70 g/L (>7 g/dL)
IgA level >50 g/L (>5 g/dL)
Urine light chains >12 g/24 h
International Staging System

Beta
2
M < 3.5, alb 3.5
Beta
2
M < 3.5, alb < 3.5 or Beta
2
M = 3.55.5
Beta
2
M > 5.5
Disorder Associated with Monoclonal
Protein

Neoplastic cell proliferation
multiple myeloma
solitary plasmacytoma
Waldenstrom macroglobulinemia
heavy chain disease
primary amyloidosis
Undetermined significance
monoclonal gammopathy of undetermined
significance (MGUS)
Disorder Associated with Monoclonal
Protein

Transient M protein
viral infection
post-valve replacement
Malignacy
bowel cancer, breast cancer
Immune dysregulation
AIDS, old age
Chronic inflamation

Monoclonal gammopathy of
undetermined significance ( MGUS)

M protein presence, stable
levels of M protein: IgG < 3.5g IgA < 2g
LC<1g/day
normal immunoglobulins - normal levels
marrow plasmacytosis < 10%
complete blood count - normal
no lytic bone lesions
no signs of disease

Monoclonal gammopathy of
undetermined significance ( MGUS)

M protein
3% of people > 70 years
15% of people > 90 years
MGUS is diagnosed in 67% of patients with
an M protein
10% of patients with MGUS develop
multiple myeloma
Treatment

Patients with symptomatic and/or progressive
myeloma require therapeutic intervention.
symptomatic supportive care to prevent serious
morbidity from the complications of the
disease.
Therapy can significantly prolong survival and
improve the quality of life for myeloma
patients.

Treatment - Transplant

Alkylating agents such as melphalan should be
avoided since they damage stem cells, leading
to decreased ability to collect stem cells for
autologous transplant.
High-dose pulsed glucocorticoids have been
used either alone or VAD combination for 3
weeks for initial cytoreduction.
Treatment - Transplant

Initial therapy is continued until maximal
cytoreduction.
Agents bortezomib, a proteasome inhibitor,
and lenalidomide, an immunomodulatory
derivative of thalidomide, have similarly been
combined with dexamethasone and obtained
high response rates without compromising
collection of stem cells for transplantation
Treatment - Chemotherapy Only

Intermittent pulses of an alkylating agent, L-
phenylalanine mustard (L-PAM, melphalan)
and prednisone administered for 47 days
every 46 weeks.

The usual doses of melphalan/prednisone (MP)
are melphalan, 8 mg/m
2
per day, and
prednisone, 2560 mg/m
2
per day for 4 days.
Treatment - Chemotherapy Only

In patients >65 years, combining thalidomide
with MP (MPT) obtains higher response rates
and overall survival than MP alone
MPT is the standard therapy for patients who
are not transplant candidates

High-dose melphalan therapy (HDT) with
hematopoietic stem cell support have shown
that HDT can achieve high overall response
rates and prolonged progression-free and
overall survival;
Only few patients are cured.
Complete responses are rare (<5%) with
standard-dose chemotherapy, HDT achieves
2540% complete responses.
Refractory Myeloma

lenalidomide and/or bortezomib.
These agents target not only the tumor cell but
also the tumor cellbone marrow interaction
These agents in combination with
dexamethasone can achieve up to 60% partial
responses and 1015% complete responses in
patients with relapsed disease

Thalidomide, if not used as initial therapy, can
achieve responses in refractory cases.
High-dose melphalan and stem cell transplant,
if not used earlier, can be used

Supportive Treatment
Supportive care directed at the anticipated
complications of the disease may be as
important as primary antitumor therapy.
Hypercalcemia
Dehydration
ARF
Hyperviscosity
UTI
Recurrent serious infection-Prophylactic
IV globulin
Supportive Treatment

Patients developing neurologic symptoms in
the lower extremities, severe localized back
pain, or problems with bowel and bladder
control may need emergency MRI and
radiation therapy for palliation.
Most bone lesions respond to analgesics and
chemotherapy
The anemia associated with myeloma may
respond to erythropoietin along with
hematinics (iron, folate, cobalamin).
Prognosis

The median overall survival of patients with
myeloma is 56 years,
Subsets of patients surviving over 10 years.
The major causes of death are
progressive myeloma,
renal failure, sepsis, or
therapy-related acute leukemia or myelodysplasia.
intercurrent age related illnesses: myocardial
infarction, chronic lung disease, diabetes, or stroke

Myelodysplastic syndromes
Achievements in understanding and treatment
Clonal hematopoietic stem cell disorder characterized by
ineffective hematopoiesis and peripheral cytopenias
Although a substantial proportion of MDS cases evolve to
acute myeloid leukemia (AML), the natural history of these
syndromes ranges from more indolent forms of the disease
spanning years to those with a rapid evolution to AML
the leukemic disorder in which neoplastic clone that has
been established may or may not fully progress to acute
leukemia

Refractory anemia (RA): cytopenia of one PB lineage;
normo- or hypercellular marrow with dysplasias; < 1% PB
blasts and <5% BM blasts
Refractory anemia with ringed sideroblasts (RARS):
cytopenia, dysplasia and the same % blasts involvement in
BM and PB as RA. Ringed sideroblasts account for > 15%
of nucleated cells in marrow.
Refractory anemia with excess of blasts (REAEB):
Cytopenia or two or more PB lineages; dysplasia involving
all 3 lineages; < 5% PB blasts and 5-20% BM blasts
Refractory anemia with excess blasts in transformation:
(REAEB-t): hematologic features identical to RAEB. >5%
blasts in PB or 21-30% blasts in BM, or the presence of
Auer rods in the blasts
Chronic myelomonocytic leukemia (CMML):monocytosis
in PB>10
9
/L; < 5% blast in PB and up to 20% BM balsts

FAB classification system
Myelodysplastic syndromes:
Refractory anemia (RA)
With ringed sideroblasts (RARS)
Without ringed sideroblasts
Refractory cytopenia (MDS) with multilineage dysplasia
(RCMD)
Refractory anemia with excess blasts (RAEB)
5q
-
syndrome
Myelodysplastic syndrome, unclassifiable
Myelodysplastic/Myeloprolipherative diseases
Chronic myelomonocytic leukemia (CMML)
Atypic chronic myelogenous leukemia (aCML)

WHO classification system
Marrow blast percentage:
< 5 0
5-10 0.5
11-20 1.5
21-30 2.0
Cytogentic fetures
Good prognosis 0
(Y, 5q
-
, 20q
-
)
Intermediate prognosis 0.5
(+8, miscellaneous singleabnormality, double abnormalities)

Poor prognosis 1.0
(abnor. 7, complex- >3 abnor.)
Cytopenias
None or one type 0
2 or 3 type 0.5

IPSS risk-based classification system
Overall score: Median survival:
low
0 5.7 years
Intermediate
1 (0.5 or 1) 3.5 years
2 (1.5 or 2) 1.2 years
High
> 2.5 0.4 years

Overall IPSS score and survival
Known molecular abnormalities in
MDS
Gene Type of anomaly Incidence
(%)
RAS
(N or K)
Point mutation
(codon 12, 13 or 61)
10-30%
P53

Point mutation or
deletion of other allele
5
FMS
(encodes M-CSF
receptor)
Point mutation
(codon 969 or rarely 301)
5-10
Diagnosis of MDS
Aplastic anaemia and some disease
accompanied by marrow dysplasia,
including wit. B
12
and/or folate deficiency,
exposure to haevy metals, recent cytotoxic
therapy and ongoing inflamation (including
HIV and chronic liver disease/alcohol use)
should be ruled out
MDS clinical findings
These are non-specific, and are usually the
consequences of cytopenias, including:
- symptoms of anaemia
- infections due to neutropenia, but also to the
frequently associated defect in neutrophil function
- bleeding due to thrombocytopenia (may also occur
in moderately thrombocytopenic patients or even
in patients with normal platelets count, because of
thrombocytopathy)
Myelodysplastic features in MDS

MDS Bone marrow and/or
peripheral blood findings

Dyserythropoiesis
Bone marrow:
multinuclearity, nuclear
fragments, megaloblastoid
changes, cytoplasmic
abnormalities, ringed
sideroblasts
Peripheral blood:
Poikilocytosis,
anisocytosis, nucleated red
blood cells
Myelodysplastic features in MDS

MDS Bone marrow and/or
peripheral blood findings

Dysgranulopoiesis
Nuclear abnormalities
including: hypolobulation,
ring-shaped nuclei,
hypogranulation
Dysmegakariopoiesis Micromegakariocytes
Large mononuclear forms
Multiple small nuclei
Bone marrow biopsy
Blood examination and bone marrow
aspirate are sufficient for a diagnosis of
MDS
It is obviously important in cases of difficult
diagnosis , and it could brink additional
prognostic information in some cases
- normal or increased cellularity is seen in 85-
90% od cases
- abnormal localization of immature
precusors (ALIP)
- Fibrosis (significant in 15-20% of cases)

Dysplasia, apoptosis and
cytokines in MDS
Despite increased proliferation of the marrow,
there is an increased rate of prgrammed cell
deathkinetically the apoptosis prevails over the
increased proliferation, causing the peripheral
cytopenia
Cytokines derived from unselected marrow
mononuclear cells are belived to be extrinsic
factors predisposing to apoptosis (TNF
o
- inhibit
normal and MDS colony growth; INF
, IL1, TGF|
- have also be implicated in causing apoptosis)
Evidence for an immune
mediated suppression of the
marrow in MDS
T cells inhibit MDS CFU-E
CD8
+
cells inhibit CFU-GM
Immunosuppressive agents improve cytopenia in
MDS and eliminate autosuppressive T cells
T cells are activated in MDS
T cell are show a skewed T cell receptor V-|
repertoire
HLA-DR 15 over representation in MDS and
aplastic anemia
Chronic Neutrophilic Leukemia
and Leukemoid Reaction
Andrea Honeycutt
AM Report
Regulation of hematopoiesis

PMN development

Chronic Neutrophilic Leukemia:
Incidence
The disease is rare, with approximately 150
reported cases to date.
Median age at diagnosis is approximately
67 years
The disease is equally prevalent in both
sexes.
Fatigue is the most common presenting
symptom.
Other reported symptoms include weight
loss, easy bruising, bone pain, and night
sweats.
Most patients have palpable splenomegaly
at diagnosis.
Most patients are mildly anemic at
presentation.
The platelet count is often normal.
However, later in the clinical course,
thrombocytopenia accompanies progressive
splenomegaly.
Diagnosis
The differential diagnosis of CNL includes
reactive leukocytosis, plasma cell
proliferative disorders, AML, CML, MPD,
and MDD.
Reactive leukocytosis might accompany
chronic infections and inflammatory or
malignant conditions.
Diagnosis
Neutrophilia seen in association with
plasma cell proliferative disorders
represents a reactive phenomenon.
Prognosis
The disease course is heterogeneous and includes a
clinically indolent chronic phase followed over a
variable period by an accelerated or blast phase.
Disease acceleration is heralded by progressive
treatment-refractory neutrophilia, marked
splenomegaly, anemia, thrombocytopenia, and the
appearance of immature myeloid progenitor cells in
the peripheral blood.
Prognosis
Median survival is approximately 2 years.
Causes of death include blast transformation
(always myeloid), progressive disease
without blast transformation, bleeding, and
infection.

Treatment
Treatment reports of CNL have included
splenic irradiation, splenectomy,
cytoreductive agents including
hydroxyurea, busulfan, 6-thioguanine, low-
dose cytarabine, cladribine, AML-like
induction chemotherapy, and allogeneic
stem cell transplantation (ASCT).

Treatment
Hydroxyurea as first-line therapy and
expect response in 75% of patients.
Responses often last for a median of 12
months.
Second-line treatment, interferon alfa based
on reports of successful use in a small
number of patients.
Treatment
Splenectomy is generally not recommend
because of the potential for exacerbating
leukocytosis.
Acute myeloid leukemialike induction
chemotherapy is ineffective in CNL
ASCT is a potentially curative treatment
modality for transplant-eligible recipients
who are still in chronic phase.
Leukemoid Reaction: Definition
A leukemoid reaction (LR) is a hematological
disorder, defined by a leukocyte count greater than
50,000 cells/mcL with reactive causes outside the
bone marrow
LR is characterized by a significant increase in
mature neutrophils in the peripheral blood and a
differential count showing marked left shift.
The diagnosis of LR is based on the exclusion of
chronic myelogenous leukemia (CML) and
chronic neutrophilic leukemia (CNL).
Leukemoid Reaction Major Causes:
Infections
Clostridium difficile colitis
Severe shigellosis
Disseminated tuberculosis
Serious bacterial infections

Work up of LR should include cultures of blood,
sputum, and bone marrow for common bacteria
and mycobacteria. Stool cultures should not be
overlooked.
Infections
C. difficile colitis with an LR appears to be
associated with a much higher mortality rate
(approx 50%).
Drugs/Toxins
Corticosteroids
Minocycline
Recombinant hematopoietic growth factors
Ethylene glycol

Malignancy
Carcinomas (lung, oropharyngeal,
gastrointestinal, genitourinary)
Hodgkin's lymphoma
Melanoma
Sarcoma

Malignancy
Leukemoid reactions can present
simultaneously with malignancy, late in the
course of the disease, or precede the
diagnosis by as many as 4 years.
In a study of 227 patients with carcinoma of
the lung, 33 patients (14.5%) were
diagnosed with tumor-related leukocytosis
and 6 patients (2.6%) with LR.

Malignancy

The mechanism of the generation of an LR in
association with a neoplasm has not been fully
elucidated.
It is likely that various cytokines produced
irregularly by the tumor cells, including
granulocyte colony-stimulating factor (G-CSF),
granulocyte-macrophage colony-stimulating factor
(GMCSF), and interleukin 6 (IL-6), may underlie
the pathogenesis of LR in such conditions.
Leukemoid Reaction versus CNL
versus CML
CML:
immature cells, basophilia or monocytosis
decreased leukocyte alkaline phosphatase (LAP) score
bcr/abl translocation.
The differential diagnosis between LR and CNL
may be difficult or even impossible because both
conditions share:
identical morphological features
increased LAP score
absence of the bcr/abl translocation.
versus CML: The Smear
In CML, there are more immature cells,
basophils, and eosinophils.
In LR, consist mostly of mature neutrophils.
The differential count discloses a marked
left shift, presence of myelocytes and
metamyelocytes.
In CNL, there is marked neutrophilia with
no immature cells
versus CML: The Bone Marrow
In CML, basophilia, eosinophilia, monocytosis, or
even a minimum percentage of blasts are
characteristic.
Increased cellularity with myeloid hyperplasia is
seen in both LR and CNL.
In LR there is marked proliferation and orderly
maturation of all normal myeloid elements with
normal morphology, without fibrosis.
versus CML: The Bone Marrow
Similar morphological features are present
in CNL and LR, but a packed bone marrow
biopsy, together with a slight increase in
reticulin fibrosis, may help differentiate it
from a reactive process.

versus CML: Cytogenetics
The presence of Philadelphia 1 chromosome
in the karyotype or the detection of t(9;22)
translocation (creating the bcr/abl
oncogene) by molecular techniques is the
hallmark for CML and excludes CNL/LR.

versus CML: LAP score
LAP is an enzyme present in the cytoplasmic
microsomes of neutrophils, bands,
metamyelocytes, and myelocytes, but not in
lymphocytes or monocytes.
Immature neutrophils, such as those observed in
CML, have decreased LAP scores.
Stimulated neutrophils of an LR have high LAP
scores.

versus CML: LAP score
Leukocyte alkaline phosphatase (LAP)
score is high in infection/inflammation,
polycythemia vera and CNL.
LAP score is low in CML.
versus CML: Cytokine Levels
Although G-CSF, GM-CSF, and IL-6 are not
included in diagnostic criteria for CNL,
measurement of enzyme-linked immunosorbent
assay (ELISA) have been used to elucidate
cytokine-producing tumor and the development of
an LR.
Generally CML and CNL patients have
significantly low G-CSF levels, suggesting that
neoplastic granulopoiesis can exert a suppressor
effect on G-CSF synthesis.
Chronic Myeloid Leukemia and other
Myeloproliferative Neoplasms (MPNs)
Dale Bixby, M.D., Ph.D
Clinical Assistant Professor
Assistant Program Director
Division of Hematology and Oncology
Department of Internal Medicine
University of Michigan

Winter 2010
Definitions
Myeloproliferative Neoplasms (MPNs): are a group of clonal
myeloid neoplasms in which a genetic alteration occurs in a
hematopoietic progenitor cell leading to its proliferation
resulting in an increase in the peripheral blood white blood cells
(WBCs), red blood cells (RBCs), platelets, or a combination of
these cells.
Hematopoietic Progenitors and MPNs
Genetic
Mutation
National Cancer Institute
More Definitions

The type of disorder is often based on the predominant cell line that is affected, but
because blood counts are often abnormal in more than one cell line, diagnoses
based upon blood counts alone may be inaccurate.

Four Main MPNs: Additional MPNs:
1. Chronic Myelogenous Leukemia (CML) 1. Systemic Mastocytosis
2. Polycythemia Vera (PV) 2. Hypereosinophilic Syndrome
3. Essential Thrombocytosis (ET) 3. Chronic Myelomonocytic Leukemia
4. Primary Myelofibrosis (PMF) 4. Chronic Neutrophilic Leukemia
5. Chronic Eosinophilic Leukemia

Evaluation of Thrombocytopenia
By
Dr. Stephen Szabo

Copyright 2005 American Society of Hematology. Copyright restrictions may apply.
Maslak, P. ASH Image Bank 2005;2005:101353
Figure 1. The granular appearance of the platelets helps to distinguish them from artifact in
the peripheral smear
Brief history of the platelet
Studies by Osler, Hayam, and Bizzozero identified
small particles in the blood, these were believed to
be either bacteria or red cell fragments
James Homer Wright Wright Stain identified
platelets as a distinct hematopoetic component
arising from megakaryocytes
William Duke in 1910 described 3 patients with
low platelet counts that had hemorrhagic disease
Duke created a venous shunt from a normal donor
to a thrombocytopenic recipient and showed that
the platelet count could rise and the bleeding
would cease
Practical Importance of Assessing
Thrombocytopenia
1/3 of all Hematology Consults in a General
Hospital are for thrombocytopenia
5 to 10% of all hospital patients are
thrombocytopenic in the ICU the number
increases to 35%
Thrombocytopenic patients in the hospital
suffer a twofold greater mortality rate than
those who are not

Platelet Kinetics
Normal circulating platelet count
150 to 450 K in Northern Europeans
90 to 300 K in people of Mediterranean descent
1/3 of platelets are sequestered in the spleen
Half life of a platelet is 9 to 10 days
Platelet production is the function of the
multinucleated megakaryocyte
15 to 45 K platelets are produced daily to
maintain steady state

Figure 1. Platelets can be seen as individual structures forming on the periphery of this
megakaryocyte
Figure 1. Clusters or chains of platelets are shed from the megakaryocyte and carried off into
the bloodstream
Thrombopoietin (TPO)
TPO is the primary regulatory protein in the
production of platelets
TPO gene is on chromosome 3
TPO is expressed in the liver, kidneys, and smooth
muscle cells
Has a plasma half life of 30 hours
The receptor for TPO is c-MPL which is present
on the megakaryocytes and platelest
TPO rises with platelet fall and declines as the
megakaryocyte and platelet mass increase
Stratifying levels of thrombocytopenia
The primary reason for evaluating
thrombocytopenia is to assess the risk of bleeding
and assess the presence of underlying disorders
(TTP, HIT etc.)
< 20 K increased risk of bleeding
20K to 50 K rarely have increase risk of
spontaneous bleeding but increase risk of
bleeding from procedures
50K to 100K no increased risk of spontaneous
bleeding and can undergo most procedures
Relation of bleeding risk and platelet
count
Bleeding time increases in a linear fashion below a
platelet count of 100 K
In leukemic children major forms of hemorrhage
occurred at platelet counts <10 K
Slichter et al tagged RBC and found fecal blood
loss
10 K 5 cc/day
5 to 10 K 10 cc/day
< 5 K 50 cc/day

Organization of Thrombocytopenia
Decrease
Production
Marrow Damage
Aplasia
Drugs
Malignancy
Congenital Defects
Ineffective
Production
B12, Folic Acid
Def

Increase
Destruction
Non Immune
DIC
TTP
HELLP
Immune
ITP
HIT
SLE, AIDS
TTP
Maslak, P. et al. ASH Image Bank 2002;2002:100523
Figure 3. EDTA may produce this effect causing a spurious decrease in the platelet count
Reasons to Suspect a Congenital Platelet
Disorder
Persistence of neonatal thrombocytopenia
or onset of bleeding symptoms in childhood
Family history of thrombocytopenia or
mucocutaneous bleeding
Platelet count unresponsive to typical
treatments for ITP
Congenital Causes of Thrombocytopenia
Low MPV Normal MPV Large
MPV____
WAS X linked FPD/AML Bernard
Soulier
TAR Platelet type
vWD
AT/RS MYH9
CAT Grey Platelets
11q- disorder GATA1

Treatment of Bleeding generally involves the use of platelets
if possible as well as the use of DDAVP and rFVIIa
Figure 1. Giant platelets are larger than red cells
Types of Autoimmune thrombocytopenia
Neonatal Thrombocytopenia
Isoimmune, Associated with Maternal ITP, Drug-Related
Drug Induced
Quinidine, Quinine, Sulfa, Gold Salts, Abx (Vanco etc),
Heparin
Lymphoma
Thyroiditis, SLE, Colitis, Sarcoidosis
Infections
HIV, Rubella, viral Hepatitis, CMV, Lyme disease
Postransfusion Purpura
ITP
Immune Mediated Thrombocytopenia
Purpura
ITP is defined as isolated thrombocytopenia with no
clinically apparent associated conditions or other causes of
thrombocytopenia
ITP is a high prevalence disease 16 to 27 per million per
year
Incidence increases with age
Female predominance under the age of 60 but not over the
age of 60
It can have an abrupt onset or insidious onset. It is
generally abrupt in onset with children
Pathogenesis of ITP
Increased platelet destruction caused by
antiplatelet antibodies
Lack of compensatory response by
megakaryocytes due to suppressive effect of
antiplatelet antibodies
Pathogenesis was proved by Harrington
when he infused himself with plasma from a
women with ITP
Evaluation of ITP
Features consistent with the diagnosis of ITP
Thrombocytopenia with normal or slightly large
platelets
Normal RBC morphology and number (may have
associated iron def or thallasemia etc.)
Normal white cell number and morphology
Splenomegaly rare
Features not consistent with the diagnosis of ITP
Giant platelets
RBC abnormalities ie schisotocytes
Leukocytosis or Leukopenia
Laboratory evaluation of ITP

Not Much !!!!!!!
Platelet associated immunoglobulin reflect
plasma concentration and alpha granule
concentration
Bone Marrow not very helpful as initial test
May be helpful in patient over 50 years and
concerned about MDS
If patient has failed initial treatment and diagnosis is
in question
TSH and HIV test helpful, Peripheral Smear
helpful
Management of ITP
Most patients with ITP do not have
clinically significant bleeding
Risk of intracranial bleed 0.1 to 1% (This is an
overestimate)
Wet Purpura ie epistaxis, gingival bleeding is a
risk factor for major bleeding
In asymptomatic patients with platelets
counts greater then 20 K observation is
reasonable
Acute Pharmacologic Management of
ITP
Steroids
Prednisone 1mg/kg/day with taper over 2 to 3
months
Decadron 40 mg/day x 4 days
Solumedrol 1 gram/day x 2 days
Antibodies
IVIG 1 gram/day x 2 days
Anti-D 50 mcg/kg IV x1

Chronic Management of ITP
Splenectomy
Immunize with Pneumovax, Hib,
Meningococcal
Chronic Anti-D therapy
Does not put the disease in remission
Rituximab
AMG 531, Eltrombopag c-MPL agnonists
Observation
Management of ITP in pregnancy
Gestational Thrombocytopenia
Platelet count >70K, occurs late in gestation,
not associated with fetal thrombocytopenia,
resolves after pregnancy
ITP in pregnancy
Treat if symptoms intermittent IVIG,
Prednisone, anti-D
Epidural anesthesia appears safe if platelet
count > 50K
Monitoring for neonatal thrombocytopenia
TTP Thrombotic Thrombocytopenia
Purpura
TTP is characterized my microangiopathic
hemolytic anemia and profound
intravascular platelet clumping
The disease was first reported in 1923 by
Dr. Eli Moschowitz at Beth Israel in NYC
16 year old girl who presented with anemia,
petechia ultimate coma and death
Terminal arterioles and capillaries were
occluded by hyaline thrombi mostly composed
of platelets
Lazarchick, J. ASH Image Bank 2001;2001:100174
Figure 1. Peripheral smear showing microangiopathic hemolytic features with numerous RBC
fragments (helmet cells/schistocytes)
Lazarchick, J. ASH Image Bank 2001;2001:100174
Figure 2. Peripheral smear showing RBC fragmentation consistent with a microangiopathic
hemolytic process
Clinical and Lab Manifestations of TTP
Severe thrombocytopenia and hemolytic anemia
with one or several fragmented red cells in high
power oil >1% total number of RBC
Neurologic Manifestations, abdominal pain
Fever and Renal Abnormalities occur in the
minority of patients
Thrombocytopenia range from <30 K to 75 to 100
K
Elevated LDH
Initially coagulation studies are normal

Type of TTP
Familial chronic relapsing
Acquired idiopathic
Drug related
Ticlopidine, Clopidogrel
Thrombotic Angiopathies that resemble
TTP
Mitomycin, cyclosporine, tacrolimus, quinine
Chemotherapy, gemcitabine, TBI
BM and Solid organ transplant
Moake J. N Engl J Med 2002;347:589-600
Proposed Relation among the Absence of ADAMTS 13 Activity in Vivo, Excessive Adhesion and
Aggregation of Platelets, and Thrombotic Thrombocytopenic Purpura
Differential Diagnosis of TTP
Hemolytic-uremic syndrome
DIC
Evans Syndrome
Malignant Hypertension
Malfunctioning prosthetic cardiac valves
Severe vasulitis
Pregnancy
Preeclampsia/eclampsia
HELLP

Treatment of TTP
Infusion of FFP 30 cc/kg/day until ready for
plasma exchange
Daily plasma exchange with either FFP or
cryopoor FFP (45 to 55 cc/kg/day)
Steroids (Prednisone 1 mg/kg/day)
Red Blood Cells if needed
Platelets only if absolutely necessary
Heparin Induced Thrombocytopenia
Described in 1958 by Rodger Weismann
and Richard Tobin after extracting platelet
fibrin thrombi that formed after 1 to 2 week
course of heparin
HIT is the presence of a multimolecular
complex between platelet factor 4, and
heparin
HIT is associated with thrombosis despite
profound thrombocytopenia

Clinical Features of HIT
Timing
Onset between days 5 and 10 after heparin
initiation
Rapid onset if previously exposed to heparin
Thrombocytopenia nadir between 15 K to
150 K
>50% develop a new thrombosis both
venous and arterial
Absence of petechia
Diagnosis of HIT
Clinical Suspicion (ie greater then 50%
drop in platelets in the setting of heparin
use)
Laboratory Studies
Platelet Activation Studies (Complicated and
physiologic)
PF4/Polyanion Studies (Less time consuming
but not necessarily physiologic)
Even without evidence of thrombosis
patient should get lower extremity dopplers
Treatment of HIT
Removal of all Heparin products
Begin direct thrombin inhibitor (DTI)
(Argatroban or Refludan)
Treat with DTI until platelet count
normalizes then may begin anticoaguation
with coumadin
Fondaparinux (Arixtra) is a reasonable
agent to use for DVT prophylaxis in patient
with history of HIT
Practical Aspects for the management of
thrombocytopenia
What is an adequate platelet count for procedures?
Routine Dentistry >10K
Dental Extraction >30K
Regional Dental Block >30K
Minor Surgery >50K
Major Surgery>80K
Epidural is okay at platelet count 50K for patient with
ITP
The target platelet count for a bleeding patient is
generally >40K
Prophylactic platelet transfusions for platelets <
10K
Essential Thrombocythemia
Jennifer Pagliei
July 31, 2006
Essential Thrombocythemia
Also called essential thrombocytosis or primary
thrombocytosis.
First described over 70 years ago.
A subgroup of the chronic myeloproliferative
disorders (CMPDs).
The most common myeloproliferative disorder.
The only CMPD that is a diagnosis of exclusion.
It is heterogeneous both clinically and
biologically.

Pathogenesis
Neither thrombopoietin (TPO), the key hormone in the
regulation of megakaryocyte differentiation and
proliferation, nor its receptor, c-Mpl, has been implicated
in the pathogenesis of ET.
Mutations involving the c-Mpl gene have not been
identified in ET.
Serum TPO levels are inappropriately normal or elevated.
A clonal defect in platelet and megakaryocyte expression of c-Mpl
receptors causes impaired binding of TPO and thus increased bone
marrow production of TPO.
Also seen in reactive thrombocytosis.
Epidemiology
Incidence rate of 2.5 new cases/100,000
people per year.
In the US, approximately 6,000 people are
diagnosed with ET each year.
A female preponderance exists with a
female to male ratio of approximately 2:1.
The median age at diagnosis is 60 years.
Up to 20% of patients are younger than 40
years old.
Up to 50% of patients may be totally
asymptomatic at presentation.
The remaining 50% of patients may have
vasomotor symptoms, thrombotic events,
or hemorrhagic complications.
Vasomotor symptoms include:
Headache
Lightheadedness
Syncope
Atypical chest pain
Acral paresthesia
Livedo reticularis
Erythromelalgia
Burning pain of the hands or feet associated with erythema and
warmth
Transient visual disturbances
Amaurosis fugax
Scintillating scotomata
Ocular Migraine

Vasomotor Symptoms
Usually controlled by treatment with low or
standard doses of aspirin (40 to 325
mg/day).
Some patients may be resistant to
antiplatelet therapy and require
cytoreductive therapy.
Thrombosis
A common complication of ET.
Incidence rates in ET vary between 9 and 22%.
Thrombotic events include:
Stroke
Transient ischemic attacks
Retinal artery or venous occlusions
Coronary artery ischemia
Pulmonary embolism
Hepatic or portal vein thrombosis
Deep vein thrombosis
Digital ischemia
Thrombosis
Risk factors include:
History of prior thrombosis
Age over 60 years
Prolonged exposure to substantial degrees of
thrombocytosis
The role of cardiovascular risk factors is
disputed, however, smoking, hypertension,
and obesity have been implicated in some
studies.
Hemorrhage
A less frequent complication of ET.
Incidence rates in ET vary between 3 and 9%.
Usually involves spontaneous bleeding at
superficial sites such as the skin or mucous
membranes of the GI, respiratory, or GU tracts.
The risk is significantly associated with:
Extreme thrombocytosis
Platelet counts >1 million/microlL, >1.5 million/microL, and
>2 million/microL.
Aspirin in doses greater than 325 mg/day.
Following treatment with NSAIDs.
Hemorrhage
In some patients with platelet counts >1
million/microL, acquired von Willebrand disease
may develop due to a reduction in higher
molecular weight multimers of von Willebrand
factor.
Increased bleeding may occur in such patients,
especially when treated with aspirin.
Cytoreduction usually corrects both the clinical
and laboratory abnormalities.
Risk Stratification
Low risk - <2% risk of thrombosis over 4 years
Age <60 years
No previous history of thrombosis
Platelet count <1,500,000/microL
No cardiovascular risk factors
High risk
Age >60 years
A previous history of thrombosis
Intermediate risk
Patients who do not qualify for either the low or high
risk groups
Disease Transformation
ET may transform into:
Polychthemia vera (PV)
Agnogenic Myeloid Metaplasia (AMM)
Acute myeloid leukemia (AML)
Myelofibrosis with myeloid metaplasia
(MMM)
It is not clear whether specific therapy for
ET, including hydroxyurea or anagrelide,
modifies the risk of fibrotic transformation.
Pregnancy
Results in spontaneous abortions
approximately 45% of the time, primarily
occurring in the first trimester.
The occurrence of abortions cannot be
predicted from the disease course, platelet
count, or specific therapy.
Aspirin is associated with a decreased
incidence of miscarriage.
Physical Exam
Palpable splenomegaly
Present in 25 to 48% of patients at diagnosis.
Usually only modest in degree.
Hepatomegaly and lymphadenopathy are
uncommon.
Differential Diagnosis
Includes:
Reactive thrombocytosis
Familial essential thrombocythemia
Chronic myelogenous leukemia (CML)
Polychthemia vera (PV)
Agnogenic Myeloid Metaplasia (AMM)
Diagnosis
ET is a diagnosis of exclusion.
May be diagnosed in patients with persistent
thrombocytosis only in the absence of a known
cause of reactive or clonal thrombocytosis.
There are no laboratory findings that are
pathognomonic for ET.
Peripheral blood smear and bone marrow biopsy
may show clusters of giant platelets,
megakaryocyte clusters, and/or mild reticulin
fibrosis.
Peripheral Smear and Bone Marrow
Biopsy
Diagnosis
Confirm thrombocytosis by repeating CBC.
Examine the peripheral blood smear to exclude spurious
thrombocytosis.
Perform a complete history and physical exam.
Attempt to determine the duration of thrombocytosis.
Obtain a serum ferritin concentration, ESR, CRP, and
plasma fibrinogen level to evaluate for reactive
thrombocytosis.
Consider testing for the JAK2 mutation.
Perform a bone marrow biopsy with reticulin staining and
cytogenetic studies to distinguish among the CMPDs.

Diagnosis
JAK2 mutation:
Present in approximately 50% of ET patients.
Differentiates patients with myeloproliferative
disease-associated thrombocytosis from those
with reactive thrombocytosis.
However, it does not allow differentiation
among ET, PV, and AMM.
Presence of the mutation does not appear to
carry significant treatment or prognosis relevant
information.
Diagnostic Criteria
The Polycythemia Vera Study Group (PVSG)
criteria include:
A consistently elevated platelet count >600,000/
microL.
Megakaryocytic hyperplasia on bone marrow aspiration
and biopsy.
Absence of the Philadelphia chromosome on routine
cytogenetic study.
Molecular studies of the BCR/ABL gene rearrangement are
now recommended to exclude cytogenetically masked cases of
CML.
Diagnostic Criteria
Absence of infection, inflammation, and other
causes of reactive thrombocytosis.
Absence of peripheral blood, bone marrow, and
karyotypic evidence for a myelodysplastic
disorder or AMM.
Normal iron stores, as evidenced by normal
serum ferritin and normal red cell mean
corpuscular volume.
Diagnostic Criteria
The PSVG criteria are the gold standard
for the diagnosis of ET.
The World Health Organization (WHO)
criteria are similar and include:
A sustained platelet count >600,000/microL.
Bone marrow biopsy showing proliferation of
enlarged, mature megakaryocytes.
No evidence of PV, CML, chronic idiopathic
myelofibrosis, myelodysplastic syndrome, or
reactive thrombocytosis.

Treatment
Some patients with ET may have a significantly
decreased life expectancy although many have
normal life expectancy without associated disease-
related complications.
The most frequent symptoms are vasomotor and
are easily managed with low dose aspirin (40 to
325 mg/day).
Thrombotic events in low-risk patients are
infrequent and therefore cytoreductive therapy is
not indicated.
Treatment
Cytoreductive therapy is indicated in high-risk
patients to prevent thrombosis.
The decision to use drug therapy in intermediate
risk patients should be made on an individual and
may be considered in patients with extreme
thrombocytosis (platelets >1.5 million/microL).
Bleeding complications are less frequent than
thrombosis and may be prevented by the
avoidance of doses of aspirin greater than 325
mg/day and avoidance of NSAIDs.
Therapeutic Agents
Hydroxyurea:
Inhibits DNA synthesis by inhibiting the enzyme
ribonucleotide reductase, producing a megaloblastic
blood picture.
Initial dose of 15 mg/kg per day po in divided doses.
Dose is adjusted to keep platelets between 100,000 and
400,000/microL.
Rapid onset of action, usually within 3-5 days.
Teratogenic and should not be used in pregnancy,
breast-feeding, or women with childbearing potential.
Hydroxyurea
Side effects are usually minimal and may include:
Oral ulcers
Hyperppigmentation
Skin rash
Nail changes
Leg ulcers
Nausea
Diarrhea
Alopecia
Fever
Abnormal liver function tests
Anemia
Neutropenia

Therapeutic Agents
Anagrelide:
An oral imidazoquinazoline derivative that
inhibits platelet aggregation via platelet anti-
cyclic AMP phosphodiesterase activity.
Lowers platelets via interference with
megakaryocyte proliferation and maturation,
resulting in platelet underproduction.
Initial dose is 0.5 mg po tid or qid.
Dose is adjusted according to platelet count
response and symptomatology.

Anagrelide
Side effects are mainly related to direct
vasodilatory and inotropic effects and
include:
Headache
Palpitations/tachycardia
Fluid retention
Diarrhea
Congestive heart failure
Hydroxyurea versus Anagrelide
Anagrelide plus aspirin has been shown to
carry a higher risk of arterial thrombosis,
venous thrombosis, serious hemorrhage,
and death from vascular causes, in addition
to a significantly higher rate of
transformation into myelofibrosis at five
years than hydroxyurea plus aspirin.
Thus, hydroxyurea plus aspirin is
recommended as first line therapy in ET.
Therapeutic Agents
Alpha Interferon
High cost and toxicity issues.
Reserved for use in high-risk women of childbearing
age, pregnant women, and patients failing treatment
with hydroxyurea.
Platelet apheresis
Reduces the platelet count only in the short-term.
Restricted to acute cerebrovascular complications,
digital ischemia, and rare life-threatening situations.
Pipobroman
An alkylating agent.
Not available in the US, but used widely in Europe.
Therapeutic Agents
Low dose aspirin
40 to 325 mg/day.
Prevents recurrent vascular events in high-risk groups
as well as thrombosis.
Effective in treating vasomotor symptoms.
Radiophosphorus
Radioactive phosphorus 32P oral or IV
IV is used only for patients with a life expectancy
estimated to be less than 10 years.
Summary
ET is a member of the family of chronic
myeloproliferative disorders.
ET is suspected in a patient with:
A chronically elevated platelet count.
Clinical thrombotic or hemorrhagic symptoms.
A mild degree of splenomegaly.
ET is a diagnosis of exclusion, therefore:
Causes of reactive thrombocytosis must be ruled out.
Other CMPDs or myelodysplasia must be ruled out.
References
Harrison, Claire. Essential thrombocythemia:
challenges and evidence-based management,
British Journal of Haematology, 2005.
Schaffer, Andrew. Thrombocytosis, NEJM,
March 18, 2004.
Tefferi, Ayalew. Approach to the patient with
thrombocytosis. UpToDate, 2006.
Tefferi, Ayalew. Diagnosis and clinical
manifestations of essential thrombocythemia,
UpToDate, 2006.
Tefferi, Ayalwe. Prognosis and treatment of
essential thrombocythemia, UpToDate, 2006.

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One patient was a CRi (morphologic complete remission with

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