Anemias To Myeloma

Anaemias, polycythaemias. Robert Moore.

23/10/08

1

23/10/08

2

Anaemia: objectives • Know common classification systems for anaemia diseases. • Know the causes for small and pale red blood cells and laboratory tests for diagnosis and treatment. • Know the causes for normal but insufficient rbc and lab tests…… • Know the causes for rbc of increased size and lab tests…… 23/10/08

3

Anaemia, classification:

• By appearance – laboratory focus • By cause – clinical focus. 23/10/08

4

Appearance: microcytic, hypochromic (small and pale), the symptoms of anaemias:

• • • • • • • •

Pallor Fatigue Decreased exercise tolerance Dyspnoea Palpitations Oedema Irritability Poor feeding

23/10/08

5

Microcytic, hypochromic anaemia, causes: • • • • •

Iron deficiency Thalassaemias Pyridoxine (vitamin B6) deficiency Infections Lead poisoning

23/10/08

6

Microcytic hypochromic anaemia, causes: • Bleeding from the gut (hookworm in tropics, gastrointestinal cancer in the elderly) • Menstrual bleeding • Pregnancy • Malabsorption • Malnutrition • Urinary tract bleeding • Pulmonary haemosiderosis 23/10/08

7

Microcytic hypochromic anaemia, the lab tests:

• Serum Ferritin • Serum Iron • Serum TIBC or transferrin. • Bone marrow iron 23/10/08

8

Iron deficiency anaemia: management Find cause: gastrointestinal, gynaecological, haematuria, lungs (X ray), faeces – “occult” blood. 20% no cause found. 23/10/08

9

Iron deficiency anaemia, treatment: • • • • • • •

Oral iron FeSO4 200 mg 3 x /day Nausea Epigastric pain Diarrhoea or constipation 6 months of therapy Hb up by 20g/L each 3 weeks for success. Failure to respond then wrong diagnosis, non compliance, malabsorption, continued bleeding.

23/10/08

10

30 year old vegetarian is tired, microcytic, hypochromic • • • • •

Blood Haemoglobin 90 g/L (110-150) Erythrocytes 4.2 x 1012 /L(4.5-6.5) Haematocrit 0.3 (0.35-0.45) Serum iron 7 umol/L (10-30) Serum TIBC 69 umol/L (40-70)

23/10/08

11

Appearance: normocytic, normochromic, causes: • Blood loss • Haemolytic • Chronic disease – infections, uraemia, endocrine • Bone marrow infiltration • Aplastic or hypoplastic • Anaemia of pregnancy 23/10/08

12

23/10/08

13

Haemolytic anaemias: Haemolysis because of abnormal Hb: thalassaemia, sickle cell anaemia Haemolysis because of abnormal membrane: spherocytosis, elliptocytosis Haemolysis because of abnormal metabolism: G-6-PDH, PK Acquired: immune, iso-immune, non immune 23/10/08

14

Haemoglobin: • • • • •

Normal Hb HbA 97% (a2b2 chains) HbA2 (a2d2) HbF (a2g2) Gower 1, Gower 2, Portland

• Variant Hb, 800 known. 23/10/08

15

Haemoglobin variants, these may give haemolytic diseases: • S (sickle) (a2bs2) • C (a2bc2) • E (a2be2) • G Philadelphia (ag2b2) • O Arab (a2b02) • D Punjab (a23bd2) + 800 more 23/10/08

16

Clinical Indications for Hb testing: • Preanaesthetic screening for sickle cell haemoglobin, HbS. • Antenatal screening for genetic counseling and maternal management. HbS, C, D, E, F, Lepore, O Arab, thalassaemias. • Neonatal screening for HbS and betathalassaemia. 23/10/08

17

Beta-thalassaemia Minor: BBo, no symptoms. Major: BoBo • Severe anaemia at 3-6 months, Hb < 70 g/L. • Microcytic, hypochromic anaemia. • HbF could be 65-100%. • Iron overload • Abnormal growth. 23/10/08

18

23/10/08

19

Beta thalassaemia management • Blood transfusions • Iron chelation (desferrioxamine for 5-7 days a week) • Splenectomy • Genetic counselling • Bone marrow transplant

23/10/08

20

15 year chinese girl, hypochromic, reticulocytosis. b-Hb 86 g/L (110-150) Mean cell volume (MCV) 22 (26-33) rbc 4.4 x 1012 /L (3.8-5.6) Reticulocytes 5.5% (0.5-2.5) b-Hb electrophoresis: alpha/beta 0.6/1 (1/1) • What is diagnosis? 23/10/08

21

5 year-old child, italian parents. • • • • • • •

Frequent upper respiratory tract infections. Fever. Anaemia. Abdominal ascites. Enlarged spleen. Legs swollen. Thalassaemia.

23/10/08

22

23/10/08

23

Sickle cell anaemia • 6-9 months anaemia, jaundice, dactylitis and splenomegaly. • Painful crisis when sickling cells block blood vessels. • Diagnosis is by blood smear (film), electrophoresis, sickling test.

23/10/08

24

23/10/08

25

Sickle cell anaemia • Virus or folate lack causes crisis • Complications: genitourinary, skin, eyes, hepatobiliary. • Failure of spleen, cerebral infarct, glomerulosclerosis, osteonecrosis, retinopathy, lung disease.

23/10/08

26

Sickle cell trait, is it a problem? • Study of 2 million enlisted recruits in the US armed forces showed that recruits with sickle cell trait were 40 times more likely to die during strenuous exercise than others. • Physician and Sports Medicine 15 #12, 1987.

23/10/08

27

15 year old Afro -Canadian girl • • • • • • •

Pain in arms and legs Blood haemoglobin 80 g/L (115-165) Hct 0.097 (0.34-0.44) Erythrocytes 4 x 1012/L (4.5-5.9) Leukocytes 50 x 109/L (5-10) Serum iron 2.1 umol/L (9-30) Albumin 32 g/L (45-50)

23/10/08

28

Hereditary spherocytosis and elliptocytosis Spherocytosis: Autosomal dominant • Northern Europe 1%. • Defect in spectrin. • Variable severity. • Treatment by spleen removal. Elliptocytosis: very rare. • Cells are destroyed by spleen, splenomegaly, mild anaemia 23/10/08

29

Glucose-6-phosphate dehydrogenase deficiency • X chromosome • Black males 15% but also found in S Europe, middle east, SE Asia populations. • Newborn or when oxidative stress happens. • Sensitive to some analgesics, antimalarial drugs, Fava beans, infections. • Possible cause of infertility (National Post story). • Blood transfusions may be needed 23/10/08

30

Pyruvate kinase deficiency • Autosomal recessive • Erythrocytes cannot make sufficient ATP and become rigid • Increase in intracellular 2,3 diphosphoglycerate which helps to release oxygen from Haemoglobin and symptoms of anaemia are reduced. 23/10/08

31

20 year-old Amish woman has weakness • Abdominal pain, jaundice and splenomegaly. • Blood Hb is 109 g/L (110-165) • Haematocrit is 0.27 (0.37-0.47) • Reticulocytes 4.5% (0.5-2)

23/10/08

32

Acquired haemolytic anaemias – warm (IgG) Primary – • Idiopathic Secondary – • Lymphoproliferative • Neoplasia • Connective tissue disease. • Drugs • Infections 23/10/08

33

Acquired haemolytic anaemiascold (IgM) Primary – • Cold haemagglutination Secondary – • Lymphoproliferativ • Infections • Paroxysmal cold haemoglobinuria 23/10/08

34

Isoimmune haemolytic anaemia • Haemolytic blood transfusion reactions and haemolytic disease of the newborn • Mother is Rhesus negative (Rh-) and father is Rhesus positive (Rh+) • First pregnancy with Rh+ foetus is not harmed but mother makes antibodies against subsequent Rh+ foetuses • Mother’s antibodies cross the placenta and damage the foetus’s erythrocytes 23/10/08

35

Alvaro Domecq. Dead after 88 years. • • • • •

Sherry grandee Bullfighter 19 children 14 dead at birth 2 survived to adulthood • Globe and Mail 2005 october 23/10/08

36

Microangiopathic haemolytic anaemia, causes: • • • • • • • •

Haemolytic uraemic syndrome Thrombocytopenic purpura Carcinomatosis Vasculitis Severe infection Pre eclampsia Glomerulonephritis Malignant hypertension

23/10/08

37

Anaemia of chronic disease: • Rarely severe • Increased erythrocyte destruction, shortened life span • Could be excessive production of interleukin-1 by macrophages. An inflammatory disease

23/10/08

38

23/10/08

39

Anaemia of chronic disease, causes and treatment: Causes: • Malignancy • Rheumatoid arthritis • Some connective tissue diseases • Chronic infection • Extensive trauma Treat by blood transfusion or EPO 23/10/08

40

Aplastic anaemia – bone marrow failure • Pancytopenia – all cells reduced • Uncommon 2-5/1,000,000. Any age, both sexes • Clinical: anaemia frequent and severe infections

23/10/08

41

Aplastic anaemia: diagnosis • • • •

CBC Blood smear – precursor cells, blasts Bone marrow - increase in fat spaces >75% Tests for cause: liver, Virus, Fanconi’s in children

23/10/08

42

Aplastic anaemia: management • Removal of cause: drugs such as cytotoxic agents, phenylbutazone, indomethacin, penicillamine, carbamazepine, phenytoin, chloramphenicol, sulfonamides, gold salts • Supportive care: blood and platelet transfusion • Immunosuppression works in 50-70% • Bone marrow transplant 23/10/08

43

Sideroblastic/cystic anaemia: • Normoblasts with non Hb Fe • Defective haem • Hereditary sideroblastic anaemia: males, MCHC and reticulocytes decreased, iron increased, bone marrow loaded with iron. Defect: first step in protoporphyrin synthesis. • Acquired: idiopathic, secondary e.g. Pb, alcohol 23/10/08

44

Appearance: macrocytic/ megaloblastic anaemia, causes: vitamin B12 and folic acid deficiency • Small intestine disease • Liver diseases • Hypothyroidism • Pregnancy • Interference with DNA synthesis • Haemolytic anaemia with reticulocytes 23/10/08

45

23/10/08

46

Macrocytic (megaloblastic) anaemia • Deficiency of vitamin B12 or folate • Vit B12 - malabsorption • Folate - dietary lack but Vitamin B12 deficiency should be excluded or corrected before treatment with folate.

23/10/08

47

Macrocytic (megaloblastic) anaemia, clinical: • • • •

Loss of vibration sense Ataxia Hyperactive reflexes Weakness: spastic or flaccid

23/10/08

48

Macrocytic (Megaloblastic) anaemia • “Pernicious anaemia” – an autoimmune disease • IgG against gastric parietal cells give lack of “intrinsic factor” • Problem for women of north European descent. 23/10/08

49

Macrocytic (megaloblastic) anaemia – diagnosis: • Erythrocytes larger than normal, oval, a variety of sizes - poikilocytosis • Tongue is smooth, red and inflamed • Serum vitamin B12 < 100 ng/L • Serum folate < 3 ug/L or combination of lack of these vitamins • Schilling test –obsolete. 23/10/08

50

Macrocytic (megaloblastic) anaemia, treatment: • Vitamin B 12; IM injections for a time. Once cured 1 injection each 3 months for life. • Folate: orally 5 mg daily for several months. • Folate may be given in pregnancy to prevent spina bifida. • Folate has been added to flour. 23/10/08

51

Macrocytic anemia

• Cheaper to treat by dietary means than to test for it! In particular for folate lack.

23/10/08

52

Old man, tired, cold intolerant, feet numb, sore tongue, pale, icteric blood-Haemoglobin 64 g/L (135-170) Mean corpuscular volume MCV 131 fL (80-100) Leukocytes 3 x 10^9/L (4-11) Platelets 63 x 10^9/L(150-400) • What does he have and how can you diagnose it? Macrocytic anaemia, Blood smear, bone marrow, serum bilirubin, vitamin B12, folate, serum homocysteine. 23/10/08

53

Polycythaemia – symptoms: • Increased blood viscosity • Malaise • Fatigue • Headache • Congestive heart failure • Cyanosis 23/10/08

54

23/10/08

55

Polycythaemia – causes: Hypoxia

High altitude, hypoxic lung disease, cyanotic heart disease, smoking, abnormal Hb with decreased oxygen affinity Inappropriate Renal disease, hepatoma, cerebellar secretion of EPO haemangioblastoma, pheochromocytoma, fibroids. Other Neonatal polycythaemia, Hypertransfusion 23/10/08

56

Polycythaemia • Idiopathic erythrocytosis • Apparent polycythaemia: middle aged men. Obese, hypertensive, on diuretics, alcohol and tobacco. • Polycythaemia rubra vera: myeloproliferative disease, pruritis, itchiness, at risk for strokes, gout. Splenomegaly. Red faced. 23/10/08

57

Polycythaemia – diagnosis: Blood Hb males > 175 g/L females > 160 g/L • Kenyans > 200 g/L • Canadian marathon runners’ average Hb 145 g/L (1976)

23/10/08

58

IAAF/IOC wants to detect blood doping/boosting • By infusing your own packed erythrocytes. (Finns and Italians) • By injecting erythropoietin. (Woman winner of Ironman 2004 failed for this) • How can the laboratory be useful in each case? 23/10/08

59

Small and pale erythocytes: Anaemia Test. cause. Iron deficiency CBC, s ferritin, s iron, s total iron binding Beta CBC, Hb capacity Thalassaemia. electrophoresi Lead poisoning sCBC, film, u 23/10/08

or s lead

Treatment. Iron, absorption enhancers Transfusion chelation Chelation. 60

Normal but fewer erythrocytes: Cause. Blood loss Haemolysis Chronic illness Marrow invaded Aplastic marrow 23/10/08

Test. Reticulocytes Reticulocytes Disease markers Bone marrow cells Bone marrow cells

Treatment. Replace blood Tackle cause Tackle cause Chemotherapy, transplant Transplant

61

Big (macro): Cause. Nutritional.

Test. Treatment. Vitamin B12 and folate Replace vitamins

Haemolytic anaemias

Hb electrophoresis

Pernicious anaemia

23/10/08

Steroids, transplant Replace intrinsic factor.

62

Excesses: Polycythaemias.

Tests. CBC, viscosity, EPO.

Treatment Blood letting

Haemochromatosi CBC, Fe, total iron Blood letting s see unit 5 binding capacity, liver function tests, glucose.

23/10/08

63

Transfusion medicine Robert Moore.

23/10/08

64

ABO antigens Blood group

O

A

B

AB

Rbc antigen

none

A

B

A and B

Anti B

Anti A

0

42

8

3

Serum antibody Anti A+B Prevalence (UK)

23/10/08

47

65

Routine blood testing before transfusion • • • • • • • •

ABO group Rhesus group. At least D 85% of UK Erythrocyte antibody screen Hepatitis Bs antigen Antibodies to hepatitis C Antibody to HIV-1 Antibody to treponema palladium (syphilis) [USA, antibody to HTLV-1]

23/10/08

66

Transfusion testing • Erythrocytes for ABO and Rh – good for 98% compatibility. • Serum for A and B antibodies • Antibody screen: serum mixed with three sets of erythrocytes of known type to detect haemolytic non ABO antibodies • Cross matching: serum mixed with the erythrocytes from each donor. 23/10/08

67

Erythrocyte antigens + antibodies, sensitized or immune, usually IgG

• Rhesus cde/cde • Anti-D (anti-C, anti-c, anti-E less common) Rhesus negative • Anti-Kell 15% • Kell (K) 9%• Anti-Duffy • Duffy (Fya, Fyb) • Anti-Kidd 60% • Kidd (JKa, JKb) 75%

23/10/08

68

Adverse reactions Non immune

Immune

23/10/08

Acute Haemolytic, Septic, Aggregates, Lung infiltrate, Metabolic. Non haemolytic, Acute haemolytic,

Delayed Infections, Iron overload.

Graft versus host, Purpura, Platelet. 69

Transmission of microbial diseases in transfusions • Bacterial e.g. Yersinia • Protozoal e.g. malaria • Viral, plasma borne: Hepatitis A (very rare), B, C, HIV-1, HIV-2, parvovirus • Cell associated viruses: Cytomegalovirus, Epstein-Barr virus, HTLV-1, HTLV-II. • West Nile virus. •23/10/08 ? CJ disease, “mad cow” (BSE).

70

Probability of risk/unit of transfused blood, CRC: Cytomegalovirus (CMV) Hepatitis B Given wrong blood West Nile virus Bacterial contamination Hepatitis C Malaria HIV, AIDS 23/10/08

1:5,000 1:25,000 1:25,000 1:50,000 1:1,000,000 1:3,000,000 1:4,000,000 1:5,000,000 71

Patient reactions CRC: Fever Allergic, minor Allergic, major Volume overload Acute haemolytic Delayed haemolytic Acute lung injury Post transfusion purpura Graft against host 23/10/08

1:500 1:250 1:20,000 1:5,000 1:10,000 1:9,000 1:70,000 1:140,000 1:1,000,000 72

Blood component therapy • Erythrocyte concentrates • Washed erythrocytes • Leukocyte concentrates • Platelet concentrates • Fresh frozen plasma • Cryoprecipitate plasma • Albumin 5% • Albumin 25%. • Immunoglobulins •23/10/08 Coagulation factor concentrates

73

Erythrocyte transfusion, indications: • Haemorrhage, severe anaemia which is not corrected by other means or needs rapid correction • If repeated transfusion are likely then phenotype cells ABO and Rh which correspond as closely as possible to the minor cell antigens of the recipient to minimize sensitization 23/10/08

74

Blood substitutes • Fluorocarbons – Japan. • Treated haemoglobin. E.g. Haemosol from MDS (now sold to USA). • [Of great interest to French elite cyclist in the Tour de France 2003!]

23/10/08

75

Procedures to minimise blood transfusion: • Autologous (self) donation • EPO – (self) blood boosting then autologous transfusion. • Keyhole, laser surgery.

23/10/08

76

23/10/08

77

Leukocytes Robert Moore

23/10/08

78

Leukocytosis >10 billion/L 1. 2. 3. 4. 5. 6. 7. 8. 9.

Physiological –infancy, pregnancy Infection Haemorrhage Trauma Myeloproliferative disease Malignancy Myocardial infarction Drugs Chemicals

23/10/08

79

Leukocytes • • • • •

Neutrophils Eosinophils Basophils Monocytes Lymphocytes

23/10/08

80

Neutrophils • • • • • • • •

Half in blood, Half in reserve, Adhesion molecules on surface Most numerous Lifespan is 10 hours Enter tissues by Chemotaxis Phagocytosis Apoptosis (killing by oxidants and superoxides – the “respiratory burst”)

23/10/08

81

Neutrophils: increased • • • • • • • • •

Infections, Pregnancy Inflammatory disease Trauma Malignancy Acute haemorrhage Metabolic disease Myeloproliferative disease Drugs

23/10/08

82

Neutrophils decreased: under produced, worn out or pooled

1. Drugs 2. Autoimmune connective tissue disease 3. Infections 4. Idiopathic 23/10/08

83

Eosinophils • Chemotaxis • Growth factor IL-5 • Engulf large foreign bodies • Histamine involved Increased in • Allergies • Parasitic infections • Drugs • Connective tissue disorders •23/10/08 Hodgkin’s lymphoma

84

Basophils (Mast cells in tissues) • May not function in blood. • Release histamine following IgE on surface receptors Increased in: • Hypersensitivity • Myeloproliferative disease: CML • Inflammatory bowel disease • Hypothyroidism • Recovery after acute infections. 23/10/08

85

Monocytes (macrophages) • Phagocytic cells that last • Circulate for 20-40 hours then enter tissues, remain for days to months • Long cytoplasmic projections which interact with other cells • Present antigens to T-lymphocytes • Cytokine source e.g. IL-1 • In bone called osteocytes • In liver called Kuppfer cells 23/10/08

86

Monocytes Increased: • Infections • Inflammation • Malignancy Decreased: • corticosteroids

23/10/08

87

Leukaemias • • • • • • • •

10/100,000 population Men>women Genetic Radiation Chemotherapy Viral infections Smoking? Environment – power lines

23/10/08

88

23/10/08

89

Classification of haematological malignancies: Lymphoid

Acute ALL

Myeloid

AML

23/10/08

Chronic CLL HL NHL Multiple myeloma CML MDS myelodysplasia Myeloproliferative 90

Haematological malignancies: phenotype Clone of malignant cells • Apoptosis (death) - decreased • Proliferation - increased • Differentiation decreased. 23/10/08

91

Acute myeloid leukaemia (AML) • Malignant transformation of myeloid precursor cell into “blast” cells – 30% of bone marrow. • Incidence increased with age • Classification: FAB, 8 varieties • Clinically: some are very ill, some hardly ill. Acute onset < 3 months, anaemia, abnormal bruising, Disseminated intravascular coagulation DIC, skin, bone, gums with hypertrophy. 23/10/08

92

Acute myeloid leukaemia: diagnosis • • • • • • •

CBC-anaemia, thrombocytopenia, neutropenia Blood smear – Blast cells Bone marrow –Blast cells Cytochemistry – granules Auer rods Immunophenotype –CD33,CD13 etc Cytogenetics -karyotypes Molecular biology –11q23 etc

23/10/08

93

Acute myeloid leukaemia: management • Chemotherapy • Bone marrow transplant, if < 50 years • Supportive care • 80-90% of young have remission • Real cure rate is 30% 23/10/08

94

Acute lymphoblastic leukaemia (ALL) • • • • • •

Lymphoid precursor cell clone 80% are B lymphocytes 20% T lymphocytes Childhood illness 6 weeks to death Male>female

23/10/08

95

Acute lymphoblastic leukaemia:classification • FAB based on appearance: L1, L2, L3 • Immunophenotypes: Pro-B: CD19,TdT Common A : CD10,CD19,cytCD22,TdT Pre B-ALL: cyIg,CD19,cytCD22,TdT B-ALL: sMIg,CD19,CD20 T-ALL: CD7,cytCD3,TdT • Antigen measured Cell surface: sMIg • Morphological analysis: periodic acid Schiff (PAS) 23/10/08

96

Acute lymphoblastic leukaemia: clinical • • • • • • • • •

Anaemia. Infection Haemorrhage Anorexia Back pain Raised CNS pressure Hepatosplenomegaly Testes infiltration perhaps Sweating, fever, general malaise

23/10/08

97

ALL: management and prognosis • Supportive • Chemotherapy • Treatment by total body radiation or bone marrow transplant • In children, 2 years of treatment, 70% will survive for 5 years • In adults 20% will survive 23/10/08

98

Chronic myeloid leukaemia (CML) • • • • • •

Clone of a pluripotential stem cell Over production of neutrophils and precursors Chronic, accelerated, “Blast crisis” 1 in 100,000 All ages, peak 25-45 years of age Well during chronic phase but 80% go to AML and 20% to ALL. Median survival then is 4 years • Philadelphia chromosome (t9,22) in 95% 23/10/08

99

Chronic myeloid leukaemia: clinical • • • • • • •

Anaemia Anorexia Weight loss Night sweats Splenomegaly 90% Gout Hyperviscosity – priapism, headaches, visual disturbance

23/10/08

100

Chronic myeloid leukaemia: diagnosis • CBC – raised white cell count • Blood smear - basophils • Cytogenetics: Philadelphia chromosome 9,22(q34q11) • Low leukocyte ALP • High serum vitamin B12 • High serum uric acid • Bone marrow hypercellular with raised myeloid/erythroid ratio. 23/10/08

101

Chronic myeloid leukaemia: management • Chronic: cytotoxic drugs, hydroxyurea, alpha interferon, bone marrow transplants, tyrosine kinase inhibitor STI 571 under trial, Allopurinol to control gout. • Advanced: bone marrow transplant but results are poor 23/10/08

102

Chronic lymphatic leukaemia: • • • •

Clone of B lymphocyte Most frequent Disease of elderly, peak age 72 years. Commonest leukaemia in the West > 70 new cases/million/ year in the UK. Rare in Asia. • Male: female is 2:1 23/10/08

103

Chronic lymphatic leukaemia: clinical Mild: Stages A and B, slow and treatable. Rapid: Stage C, bone marrow fails. • Lymphadenopathy 60% • Hepatosplenomegaly 25% • Skin • Gastrointestinal • CNS • Lungs • Kidney • Bone 23/10/08 • Infections and some cancers

104

Chronic lymphatic leukaemia: diagnosis • CBC - lymphocytes 5-500 billion/L, Anaemia, thrombocytopenia • Blood smear – “smear” cells (sometimes “Hairy cell” leukaemia – rare) • Immunophenotype – B lymphocyte antigens CD19, CD22, CD5. Surface IgM weak, K or L • Serum immunoglobulins are depressed 23/10/08

105

Chronic lymphatic leukaemia: management • Chemotherapy: Chlorambucil for stage B, combination chemotherapy for stage C Purine analogues –Fludarabine for stage C • Radiotherapy • No cures • Chronic usually,10 years or more; does not go to acute but may flare up. 23/10/08

106

Acute leukaemias Acute myeloid leukaemia Older age Myeloid precursor Anaemia, leukaemia variable, coagulation Bone marrow: blast cells LD, urate increased Variable symptoms Cure 30% 23/10/08

Acute lymphoid leukaemia Childhood Lymphoid precursor Anaemia, lymphocytes, thrombocytopenia Philadelphia chromosome 1030% Child 70%, adult 20%

107

Chronic leukaemias Chronic myeloid leukaemia 25-40 years Neutrophils and precursor cells Anaemia, neutrophils, reticulocytes, thrombocytosis Philadelphia chromosomes 95% Urate increased Slow/advance to acute Few cures 23/10/08

Chronic lymphoid leukaemia Elderly B lymphocytes Lymphocytosis

Gamma globulin down Slow/ rapid No cure 108

Lymphocytes B lymphocytes –humoral immunity. Some live for years – memory. T lymphocytes – triggered by antigens from macrophages – cell medicated immunity. 70% in peripheral blood

23/10/08

109

23/10/08

110

Lymphocytes: increased • • • • • • •

Infections Lymphatic leukaemia CLL, ALL, NHL Physiological Thyrotoxicosis Hypopituitarism Some carcinomas myasthenia

23/10/08

111

Lymphocytes: decreased • • • • •

Inflammation Corticosteroids Immune deficiency Some cancers Connective tissue disease

23/10/08

112

lymphocytes T s te m

c e l ls

b u r s a e q u iv a le n t

T h ym us

B - ly m p h o c y te

T - ly m p h o c y te

p la s m a c y te

r e a c t iv e T - ly m p h o c y te

H U M O R A L IM M U N IT Y

C E L L M E D IA T E D IM M U N IT Y

23/10/08

113

Lymphocytes and leukocytes h e m a t o p o ie t ic s te m c e ll n o n ly m p h o id s t e m c e ll e r y t h r o c y te

23/10/08

m o n o c y te

g r a n u lo c y te

ly m p h o id s t e m c e ll th r o m b o c y te

T c e ll

B c e ll

p la s m a c y te

114

B-lymphocytes • Stimulate change to plasma cells • Make specific antibodies • First IgM • then IgG made

23/10/08

115

T-lymphocytes • • • •

75% of lymphocytes Selected in thymus 2/3 helper-T (CD4) Recognize antigen and self HLA on presenting cell • 1/3 cytotoxic (CD8) bind with antigen and HLA of target cell • Interleukin-2 is main T-cell growth factor. • Suppressor T cells regulate B cells 23/10/08

116

Immunophenotypic cell markers • • • • • • • • •

CD3 - mature T CD4 – helper T CD5 – T and B subset CD8 – suppressor T CD10 – precursor B (seen in ALL) CD14 – monocytes CD19 – B CD34 – stem cells CD56 – natural killer

23/10/08

117

Immune response • T cells - helper CD4 Suppressor CD8 Cytotoxic CD8 – can lyze antigen presenting cells APCs • B cells • APC – release IL-6, IL-7. • Plasma cells - immunoglobulins IgG, IgM, IgA, IgD and IgE. • Complement – plasma proteins and cell surface receptors. 23/10/08

118

Natural Killer cells • Subset of cytotoxic • Do not need HLA (CD56) • Kill by adhesion to the target cell or by antibody dependent cell mediated toxicity

23/10/08

119

23/10/08

120

Hodgkin’s lymphoma. Lymphoma I, HL • • • • • • •

Male 2:1 200 new case/year/million Peak incidence15-40 years ? After infection with EBV Early lymph cells and inflammation Over 50 years, due to environment Malignant cells are small part of tumour, rest is inflammation

23/10/08

121

Hodgkin’s lymphoma: clinical • • • • • • • • •

Enlarged nodes Splenomegaly Hepatomegaly Sweating Fever Weight loss Itching Fatigue Pain on drinking alcohol

23/10/08

122

Hodgkin’s lymphoma: diagnosis and staging • • • • •

Biopsy of lymph nodes CBC CT scan Lymphangiography Laparotomy

23/10/08

123

Hodgkin’s lymphoma • Management Early: radiotherapy Late: chemotherapy • Prognosis: Early 85% cure Late 70% cure • Secondary malignancy – leukaemia and NHL in 20% in 20 years, • Sterility. 23/10/08

124

Hodgkin’s L: laboratory work • • • •

Anaemia, normocytic, normochromic Leukocytosis, eosinophilia Leuko-erythroblastic blood film Erythrocyte sedimentation rate ESR increased • Serum lactate dehydrogenase LD increased.

23/10/08

125

20 year old man, microcytic anaemia, fever, night sweats. CBC: b-Hb 95 g/L (135-170) MCV 69 fL (80-96) RDW 26% (9-13) Platelets 250 billion/L (150-400) Leukocytes 60 billion/L (4-12) Bone marrow aspirates: polymorphic cell infiltrate, many Reed-Sternberg cells. Cervical lymph node biopsy: sclerosis, ReedSternberg cells. 23/10/08

126

Non-Hodgkin’s lymphoma (NHL). lymphoma II. • • • •

Common, 4th rank haematology cancer Increasing incidence Men: women 3:1, any age, median 50 years [ex-king Hussein and NHL players with NHL include Mario Lemieux, S. Koivu] • Causes: genetics, viral? 23/10/08

127

NHL: clinical • Nodal- painless lymphoadenopathy in cervical region • Extranodal- abdominal pain, anaemia, dysphagia, CNS disease, headaches, cranial nerve palsies, spinal cord compression, pancytopenia • Systemic – sweating, weight loss, hyperuricaemia, renal failure, hypercalcuria sometimes.

23/10/08

128

NHL: diagnosis and staging • • • • • •

Biopsy Immunotyping, B or T Chromosome studies CT or MRI Scanning Bone marrow aspirate Serum lactate dehydrogenase (LD)

23/10/08

129

NHL: laboratory work • Similar to HL : anaemia, leukocytosis, blast blood film, ESR, LD • Pancytopenia • Peripheral blood lymphocytosis • Paraprotein and hypogammaglobulinaemia

23/10/08

130

NHL: management • Low grade • High grade: CHOP 60% remit Bone Marrow Transplant Methotrexate • Cranial irradiation. • Cure rate 30-40%. 23/10/08

131

The REAL classification • B-cell neoplasms • T/NK-cell neoplasms

23/10/08

132

50 year old man, 6 months history aches, pains, tiredness. Thirst, , 2 months of night sweats, lost 18 kg in 9 months. Generalized lymphadenopathy. • Serum ALP 230 IU/L (<100) • Wbc 7 billion/L (4-11) • Hb 110 g/L (130-175) • Platelets 200 billion/L (150-400) • Urine protein 15 g/d (0) • Chest X ray, CT scan of abdomen, lymph node biopsy. 23/10/08

133

Infectious mononucleosis • Acute self limiting febrile illness of B lymphocytes • Caused by Epstein-Barr virus. • Young adults 15-21 years of age • ‘flu, pharyngitis, adenopathy, rash, petechiae, splenomegaly. • 2-4 weeks • No treatment. 23/10/08

134

“Mono” laboratory tests • • • • •

CBC: variable with atypical lymphocytes Rarely anaemia Rarely thrombocytopenia High titre of heterophile agglutinins Spot (Monospot) or slide tests widely used but clinical sensitivity is 80%.

23/10/08

135

Lymphomas: Hodgkin’s 20-30 years, virus? Lymphoid + inflammation Nodes, spleen, liver Pain on drinking alcohol Anaemia, leuko, eosinophilia ESR, LD increased Biopsy:Reed Sternberg cell Cure 70-80%,second cancer 23/10/08

Non Hodgkin’s (NHL) median 50 years, virus? May be CNS,spine,renal Nodes and beyond Abdominal pain Pancytopenia,lympho,hypgl oLD, urate, calcium increase Biopsy:B/T lymphocyte Cure 30-40%, 136

Myeloma

Malignant disorders of plasma cells 23/10/08

137

Myeloma • Clones of plasma cells in bone marrow • Fragments of immunoglobulins produced • Precipitate out in urine as Bence-Jones proteins. • [IL-6, IL-beta – lead to osteolysis, hypercalcaemia and renal failure] • 10-15% of haematological malignancies 23/10/08

138

Myeloma • • • • • • • • •

1% of population over 50 years, 50 cases/million. 3% if over 70 years Decreasing in incidence HIV patients have more of it than controls Herpes virus may be trigger Black:white 2:1 Men>women Median age at dx 71 years

23/10/08

139

Myeloma: clinical • • • • • •

Vertebral collapse 80% Bone pain, back and chest 67% Anaemia 90% Hypercalcaemia 45% Amyloidosis 45% Macroglossia, hepatosplenomegaly, carpal tunnel syndrome • Renal failure 45% • Weakness, fatigue, bleeding, bruising, infections. 23/10/08

140

Myeloma: diagnosis • • • •

Monoclonal protein in serum and/or urine Usually light chain If heavy chain in serum only 1-5% of myelomas do not put out a recognised protein • Typing: IgG, IgA, IgM or IgD Kappa or lambda chain Fc fragment 23/10/08

141

Myeloma:prognosis • IgG type - median survival 3 years 90% dead by 10 years • IgD type - median survival 2 years 80% dead by 5 years

23/10/08

142

Myeloma: paraprotein • • • • •

IgG IgA IgM IgD IgE

23/10/08

• • • • •

70% 20% Uncommon Rare Rare

143

Myeloma: bad news • • • • • • • •

b-Hb decreased s-calcium increased s-M or u-BJ protein much increased Multiple lytic lesions on X ray s-creatinine increased s-beta-2-microglobulin increased- prognosis s-albumin decreased s- cryoglobulins

23/10/08

144

Myeloma: treatment Delays death by up to 2 years Radiotherapy Bisphosphonates – strengthen bone Thalidomide Steroids Analgesics Renal dialysis 23/10/08

145

60 year old man. Low back pain, weight loss. In pain, pale. Proteinuria s-protein 100 g/L (60-80) s-EPG Monoclonal peak in gamma region. b-Hb 90 g/L (135-170) Platelets 60 billion/L (150-400) ESR 110 mm/h (0-20) 23/10/08

146

Related disorders • • • • •

MGUS – benign monoclonal gammopathy Primary amyloidosis Solitary plasmacytoma Waldenstrom’s macroglobulinaemia Plasma cell leukaemia

23/10/08

147

Mayo clinic 1149 patients Monoclonal gammopathy of undetermined 63% significance Myeloma 14% Amyloidosis

10%

Lymphoproliferative diseases

3%

23/10/08

148

Myelo/lymphocyte-problems summary: • AML – adults – blast cells • ALL- children, pre B lymph 80% • CML –young adult, Philadelphia chromosome 95%. • CLL – adult, B lymphocytes • Aplastic anaemia – pancytopenia • Hodgkin’s – nodes, bone marrow mostly inflammatory cells • NHL – extranodal more common • Myeloma – paraprotein by electrophoresis, plasma 23/10/08 149 cells

23/10/08

150