Atlas of Clinical Hematology - part 7 ppt

IV Fig. 110 e – f e Higher-power view of d f ANAE reaction in the same smear 256 Chapter IV · Blood and Bone Marrow IV Fig. 111 a – e. Recurrence of AML with deficient granulocyte maturation a Bone marrow at onset of the recurrence shows increased blasts b Mature granulocytes are still relatively abundant but are accompanied by markedly dysplastic, polypoid forms c, d Peroxidase reaction differentiates granulocytes that are still normal from the predominantly dysplastic granulo- cytes, which are peroxidase-negative 257 5 · Bone Marrow IV Fig. 111 e CE reaction shows the same pattern as peroxidase 258 Chapter IV · Blood and Bone Marrow IV Rare Acute Myeloid Leukemias (Figs. 112 – 114) Fig. 112 a – h. Acute eosinophilic leukemia a Blasts with reddish to purple granules and some large vacuoles that contain coarse inclusions b Some of the granules are dark purple and highly variable in appearance c Large vacuoles containing orange- colored granules d, e Peroxidase reaction. Two neutro- philic precursors are seen at top and center. All other cells contain variable granules, some quite large an d some with central pallor. These granules cor- respond to eosinophilic granules in pre- cursors 259 5 · Bone Marrow IV Fig. 112 e – h f, g CE reaction. The granules ( red) are CE-positive and correspond in size and shape to those with peroxidase activity g h The cells were identified as immature eosinophils by the positive Adam reac- tion of the granules (here grayish-blue) and by staining with luxol fast blue and the peroxidase modification for eosino- phils. A specific chromosome aberration could not be identified in this patient, and molecular genetic analysis did not detect inversion 16 (CBFb/MYH11) 260 Chapter IV · Blood and Bone Marrow IV Fig. 112 i, j Two additional cases of eosinophilic leukemia with a higher degree of maturation but also with atypical eosinophilic granulocytes containing very fine granules. Both patients were men, 20 and 63 years of age i Clumped purple granules and pleo- morphic nuclei in the cells of the 20-year- old man. As in the case above, the granules gave a positive Adam reaction. Cytogenetic analysis identified a t(10;11)(q11;p13 – 14) translocation. The Wilms tumor gene (wt1) was expressed, in contrast to hypereosinophilic syndrome j The 63-year-old man had immature cells, also with Adam-positive granules. Some of the granules were CE- and peroxidase-positive. No chromosome abnormalities were found. The greater than 30 % proportion of blasts clearly identifies the disease as an acute leuke- mia 261 5 · Bone Marrow IV Acute basophilic leukemia (Fig. 113 a – e) These cases require differentiation from a basophilic phase of CML and from tissue mast cells leukemia Fig. 113 a – d. a, b Acute basophilic leukemia with a large proportion of blasts. Some cells contain abundant basophilic granules, and scattered inclusions like Auer rods are seen. Pappenheim stain (a), toluidine blue stain (b) c Higher degree of maturation in a different patient d Toluidine blue stain 262 Chapter IV · Blood and Bone Marrow IV Fig. 113 e e Distinct, in part large granules in a different patient 263 5 · Bone Marrow IV Hypoplastic AML (Fig. 114 a –d) Sample evaluation is feasible in these cases only if sufficient bone marrow fragments can be aspirated and mounted as smears. Otherwise the case should be evaluated by core biopsy and histologic examination. It can be very difficult to distinguish this variant of AML from aplastic anemias. Even his- tologic examination of the bone mar- row can be misleading unless blasts are positively identified. The diagnosis re- lies on demonstrating a frequently cir- cumscribed collection of blasts. Spora- dic cases of acute lymphocytic leukemia may also start with an aplastic preli- minary stage, and frequent follow-ups are necessary to establish a clear di- agnosis Fig. 114 a – d. a Hypocellular bone marrow with increased fat cells b Higher-power view of a more cellular site shows myeloblasts and erythroblasts (left and bottom) c Hypocellular bone marrow in a different patient d Myeloblasts and isolated lymphocytes in an isolated hypercellular area of the same sample 264 Chapter IV · Blood and Bone Marrow IV 5.10.2 Acute Lymphoblastic Leukemia (ALL) (Fig. 115 a – d) Fig. 115 a – d. a Small blasts. These may closely resemble lymphocytes but are distin- guished by their finer chrom atin struc- ture and the occasional presence of nu- cleoli b Different case showing blasts of varying sizes, some with pleomorphic nuclei. Panels a and b illustrate B-lineage ALL c Peroxidase reaction. All lymphoblasts are negative and are interspersed with residual cells of granulocytopoiesis, whose proportion is more clearly demonstrated by the peroxidase reaction d Terminal deoxynucleotidyl transferase (TDT), detected by the immun operoxi- dase reaction in the nuclei. TDT is not specific for lymphoblasts but is useful for differentiating forms of ALL from mature- cell lymphatic neoplasias and large-cell lymphomas. Today this reaction is usually performed in a fluorescence-activated cell sorter 265 5 · Bone Marrow [...]... to Burkitt lymphoma and mature B-ALL (B IV) a b IV 274 Chapter IV · Blood and Bone Marrow T-lineage ALL (Fig 121 a – e) Usually the B-cell and T-cell forms of ALL are morphologically indistinguishable The pronounced irregularity of the nuclear contour (“convoluted nucleus”) and high rate of mitoses are more consistent with T-ALL Fig 121 a – c IV a Pappenheim stain in T-ALL b The focal or paranuclear... blasts of moderate size with intensely basophilic cytoplasm and sharply defined (fat-containing) vacuoles IV a – c Various examples of this subtype of ALL b c d Bone marrow smear in which infiltration is confined to the upper part of the field 271 5 · Bone Marrow Fig 119 a – h ALL with cytoplasmic granules One morphologic subtype of ALL violates the dogma that cytoplasmic granules are suggestive of AML... pattern shown here is typical of T-lineage ALL c Acid phosphatase reaction using a different technique (Sigma) 275 5 · Bone Marrow Fig 121 d, e d A case of T-ALL with consistently round nuclei e Another case with some irregular nuclear contours IV 276 Chapter IV · Blood and Bone Marrow Fig 122 a – d T-lineage ALL a Vacuolation of the cytoplasm may also be observed in T-ALL IV b Acid phosphatase reaction... Detection of CD3 in the same case d Basophilic cytoplasm and vacuoles in a different case 277 5 · Bone Marrow Other Morphologic Variants of ALL (Fig 123 a – h) Fig 123 a – d a “Hand-mirror” form with a handle-like extension of the cytoplasm This morphologic subtype of ALL has no special significance but is shown to avoid confusion with monoblasts b Different case with fine granules and a hand-mirror... configuration of the cytoplasm c Detection of CD19 in smears from the same patient d Detection of CD10 in a smear from the same patient Findings are consistent with c-ALL IV 278 Chapter IV · Blood and Bone Marrow Fig 123 e – g e Very rarely, pseudo-Gaucher cells are also found in ALL This case involves a T-ALL IV f Acid phosphatase reaction in the same case shows strong activity in the cytoplasm of a pseudo-Gaucher... Blood and Bone Marrow B-lineage ALL (Fig 116 a – g) Fig 116 a – d a The pan-B marker CD19 is very useful for the immunocytochemical detection of B-cell lineage 100 % of the blasts in this sample are positive (red) IV b Contrast with the T-lineage marker CD3: the blasts are negative, and interspersed mature T lymphocytes are positive (same case as a) c Different case with lymphoblasts of varying size d Same... the granules described above (Courtesy of Prof Dr Muller-Her¨ melink, Wurzburg) ¨ h 273 5 · Bone Marrow Fig 120 a, b Chromosome abnormalities in ALL The (9;22) translocation in ALL indicates a particularly unfavorable prognosis This finding corresponds cytogenetically to that described in CML In terms of molecular genetics, the minor breakpoint cluster region (m-bcr) is predominantly affected in ALL... Immunological Characterization of Leukemias has proposed a point system to assist in classification which has been taken over by WHO [see Bene, MC et al (1995) Proposals for the immunological classification of acute leukemias European Group for the Immunological Characterization of Leukemias (EGIL) Leukemia 9: 178 3 – 178 6] These types of leukemia most commonly occur in early T-ALL with myeloid markers They... involvement of granulocytopoiesis 281 5 · Bone Marrow Fig 125 a – f Originally diagnosed as AML, this case was identified by immunocytochemical analysis as bilinear AL with concomitant involvement of the T-ALL and myeloid lines a Peripheral blood reveals a blast with a round nucleus and mature granulocytes with Auer rods b Higher-power view of a granulocyte with multiple Auer rods c Low-power view of bone... cytoplasmic granules are suggestive of AML This case is a B-lineage type of ALL with cytoplasmic granules that are peroxidase-negative and behave as lysosomes a Blasts above the center of the field contain coarse purple granules Several finer granules are visible below b PAS reaction The abnormal granules stain pink, contrasting with the burgundy-red staining of the other glycogen granules c ANAE reaction The . B-ALL (B IV) a b 273 5 · Bone Marrow IV T-lineage ALL (Fig. 121 a –e) Usually the B-cell and T-cell forms of ALL are morphologically indistinguishable. The pronounced irregularity of the nu- clear. (Courtesy of Prof. Dr. Mu¨ ller-Her- melink, Wu¨rzburg) h 272 Chapter IV · Blood and Bone Marrow IV Fig. 120 a, b. Chromosome abnormal- ities in ALL. The (9;22) translocation in ALL indicates a particularly. granules are suggestive of AML. This case is a B-lineage type of ALL with cytoplasmic granules that are peroxi- dase-negative and behave as lyso- somes a Blasts above the center of the field contain