Hematologic Malignancies 2

Front 1

Defining criteria for acute leukemia?

Back 1

Rapidly proliferatingbone marrow or peripheral cells that resemble the undifferentiated progenitors (“blasts”) at a level of about 20%. The real number is arbitrary but the presence of blasts is the main diagnostic indicator.

Front 2

Why does blast morphology have little clinical utility in determining acute leukemia?

Back 2

Historically, pathologistshave had a century-long romance with the notion that oncogenesis recapitulates ontogeny - I.e. thatyou can say something clinically useful about a tumor if you determine whatnormal cell type it represents based on its shape and size on a peripheral smear. But this method is not accurate.

Front 3

How is immunophenotyping done (2 methods) and how would you rate its clinical utility?

Back 3

1- flow cytometry 2-immunohistochemistry

(Both methods determine surface markers of cells and further subtyping can include FISH or genetic sequencing)

It is a great method but many hematologic malignancies break the rules and display mixed immunophenotypes. So, it is part of the diagnostic workup but it is not the defining test.

Front 4

What kind of cells display CD34 as a surface marker?

Back 4

Myeloid and Lymphoid blasts

Front 5

What kind of cells display TdT as a surface marker?

Back 5

B and T cell lymphoid blasts

Front 6

Lineage marker specific for myeloid cells?

Back 6

CD33

Front 7

Lineage marker specific for B cells?

Back 7

CD19 and CD20

Front 8

Lineage marker specific for T cells?

Back 8

CD3 and CD5

Front 9

What kind of cells display CD10 as a surface marker?

Back 9

Immature B cells, between blast and mature stages

Front 10

What kind of cells display CD33 as a surface marker?

Back 10

Myeloid blasts

Front 11

Advantages of genotyping for identifying acute leukemias?

Back 11

Indicative of the oncogenesis mechanism, so not only is there an increased predictive value of leukemia subtypes, but also it can help determine the value of specific therapies.

Front 12

Name the major translocated genes and the subtype of leukemia they are associated with:
t(15;17)(q22;q12)

Back 12

PML-RARA is an AML subtype

Front 13

Name the major translocated genes and the subtype of leukemia they are associated with:

t(8;21)(q22;q22)

Back 13

RUNX1-RUNXT1 is an AML subtype

Front 14

Name the major translocated genes and the subtype of leukemia they are associated with:
t(12;21)(p13;q22)

Back 14

TEL-AML1 is an ALL subtype

Front 15

Describe the genotype and the subtype of leukemia they are associated with:
inv(16)(p13.1;q22)

Back 15

CBFB-MYH11 is an AML subtype

Front 16

Name the three subtypes of AML for which we can use cytogenetic findings (regardless of blast count) to make the diagnosis of AML.

Back 16

-t(8;21)(q22;q22);RUNX1-RUNX1T1

-inv(16)(p13.1;q22);CBFB-MYH11

-t(15;17)(q22;q12); PML-RARA

Front 17

Explain the genetic mechanism underlying acute promyelocytic leukemia (APL) and its effect.

Back 17

AMLwith t(15;17) (previously called AML-M3, or acute promyelocytic leukemia, or APL) results from thefusion of a transcription factor (vitamin A receptor, or RARA) to a somewhat mysteriousprotein (PML). The fusion protein (PML-RARA) blocks transcription of genes involved in thedifferentiation of myeloid precursors into neutrophils, thereby inhibiting granulocyte differentiation.

Front 18

What is ATRA and what is its significance in AML?

Back 18

Vitamin E (“alltrans retinoic acid") enantiomer used intravenously to treat APL by inducingdifferentiationof the blasts to granulocytes and yielding CLINICAL REMISSION.

Front 19

Immunophenotype of AML with t(15:17)?

Back 19

-Weak/absentCD34, HLA-DR -CD13+, CD33+

Front 20

Morphology on smear of AML with t(15:17)?

Back 20

-Bigblasts, cleaved “bat wing” nuclei, -Many cytoplasmic granules

-Auer rods in stacks

Front 21

Clinical presentation of AML with t(15:17)? Prognosis?

Back 21

-Severethrombocytopenia

-leukocytosis or leukopenia

-seen at any age group

-If you catch it early and make the diagnosis, it responds well to treatment.

Front 22

Roughly what percentage of AML cases tend to be PML-RARA?

Back 22

5-8%

Front 23

Roughly what percentage of AML cases tend to be Runx1-Runx1T1?

Back 23

5%

Front 24

Explain the pathological mechanism and effect of AML with t(8;21)(q22;a22);Runx1-Runx1T1.

Back 24

Fusionprotein of two transcription factors results in a dominant negative repressor ofmyeloid maturation.

Front 25

What is the normal function of Runx1 in the cell?

Back 25

Runx1is part of a heterodimerictranscription factor called Core bindingfactor (CBF).

Front 26

Clinical presentation of AML with t(8;21)(q22;a22); Runx1-Runx1T1? Morphology? Immunophenotype? Prognosis?

Back 26

-Youngerpatients/kids

-Somematuration to myelocytes

-Occasional crystallization of granule contents (“Auer rods”)

-CD34+, HLA-DR+

-CD13+, CD33weak

-Goodresponse to chemo

Front 27

Explain the pathological mechanism and effect of AML withinv(16)(p13.1;q22)or t(16;16)(p13.1;q22); CBFβ-MYH11.

Back 27

Fusionprotein of transcription factor CBFβ (theothercomponent of the CBF heterodimer) with MYH1 results in a dominantnegative repressor of myeloid maturation.

Front 28

Clinical presentation of AML with inv(16)(p13.1;q22)or t(16;16)(p13.1;q22); CBFβ-MYH11? Morphology? Immunophenotype? Prognosis?

Back 28

-Younger patients/kids

-Mixed granulocyte-monocyte features (“Myelomonocytic”)

-Increased eosinophils in blood and marrow

-CD34+, CD117+ (blasts)

-CD13+, CD33+(granulocytes) -CD14+, CD11b+(monocytes)

-Better than most if “risk adapted” therapy is used(highlights clinical utility of genotyping)

Front 29

Roughly what percentage of AML cases tend to be caused by inv(16)(p13.1;q22)or t(16;16)(p13.1;q22); CBFβ-MYH11?

Back 29

5-8%

Front 30

Which leukemias are grouped together asthe“core binding factor” leukemias?

Back 30

AMLwith t(8;21)(q22;a22); Runx1-Runx1T1 and AMLwith inv(16)(p13.1;q22)or t(16;16)(p13.1;q22); CBFβ-MYH11

Front 31

What is the most important treatment consideration for AML with normal cytogenetics?

Back 31

You need to do molecular studies in order to determine prognosis

Front 32

Roughly what percentage of AML cases tend to have normal cytogenetics?

Back 32

40-50%

Front 33

What morphological and clinical features can you expect for AML with normal cytogenetics?

Back 33

None. Because theycan trend toward any morphologic type and can present in any age group, immunophenotype varies, and the defining consideration will be molecular studies.

Front 34

Prognosis for AMLcases with three or more cytogenetic findings (complex karyotype)?

Back 34

Poor, especially because TP53 deletion is common.

Front 35

Roughly what percentage of AML cases tend to have three or more cytogenetic findings (complex karyotype)?

Back 35

5-10%

Front 36

Clinical presentation of ALL? General morphology? Prognosis?

Back 36

-Clinically: It is primarily a pediatric disease; 75% of cases occur in kids, and over 80% of acute leukemias in kids are ALL.

-Morphologically: the blasts in this condition are just large, monotonous cells with big nuclei, prominentnucleoli, little cytoplasm, and no cytoplasmic granules, and the lineage of cellswith this appearance has to be determined by immunophenotyping (usually flow cytometry).

-Prognosis: depends on genetic studies (FISH or sequencing) after immunophenotype.

Front 37

What is the difference between AML and ALL and how is it determined?

Back 37

Immunophenotyping isused to distinguish between blasts of myeloid lineage (acute myeloblastic leukemia, AML) and those oflymphocyte lineage (acute lymphoblastic leukemia, ALL) using blast markers, lineage markers, and maturation markers.

Front 38

Genetic B cell abnormalities in ALL and their expected prognosis?

Back 38

-t(9;22)(q34;q11.2); BCR-ABL1 (bad prognosis) -t(v;11q23); MLL rearranged (badprognosis) -t(12;21)(p13;q22); TEL-AML1 (ETV6-RUNX1) (goodprognosis)
-Hyperdiploid(>50 chromosomes) (goodprognosis)

Front 39

Clinical presentation of ALLwith t(12;21)(p13;q22); TEL-AML1(ETV6-RUNX1)? Morphology? Immunophenotype? Prognosis?

Back 39

-ClinicalPresentation: Kids.

-Morphology: Big agranular blasts

-Immunophenotype: TdT+,CD34+, CD10+,CD20-

-Prognosis: Good! 90% cure rate

Front 40

Roughly what percentage of ALL are caused by t(12;21)(p13;q22); TEL-AML1(ETV6-RUNX1)?

Back 40

25% of pediatric B-ALL.

Front 41

Explain the pathological mechanism and effect of ALLwith t(12;21)(p13;q22); TEL-AML1(ETV6-RUNX1).

Back 41

Fusionprotein that acts as a dominant negative transcription factor with multipleeffects on gene expression; in generalthese block maturation you’d expect to find in a clone of cellsstuck at an early stage in B-cell or T-cell differentiation.

Front 42

Clinical presentation of ALLwith t(9;22)(q34;q11.2); BCR-ABL1? Morphology? Immunophenotype? Prognosis?

Back 42

-ClinicalPresentation: Older adults (25% of ALL cases); kids <1 (2-4% of pediatric ALL)

-Morphology: Big agranular blasts

Immunophenotype:CD10+,CD19+,TdT+

Prognosis: Poor

Front 43

Explain the pathological mechanisms and effect of ALLwith t(9;22)(q34;q11.2); BCR-ABL1.

Back 43

-Fusionprotein of part of a serine-threonine kinase (BCR) to a tyrosine kinase (ABL1). (Usually “p190”, a different size than the “p210” seen in CML): Proliferation activator

IKZF1 transcription factor mutated in 84%of cases: Differentiationinhibitor

Front 44

Explain the pathological mechanisms and effect of ALLwitht(v;11q23);MLL rearranged.

Back 44

-Promiscuous translocation of MLL resulting in fusion of a transcription regulator(histone methyl transferase) to any of several partners: Inhibits differentiation (Also found in AML)

-FLT3 mutations in 20% of cases: enhanced proliferation.

Front 45

Clinical presentation of ALLwith t(v;11q23);MLL rearranged? Morphology? Immunophenotype? Prognosis?

Back 45

-ClinicalPresentation: most common leukemia in kids <1years of age
-Morphology: Big agranular blasts
-Immunophenotype: CD10-, CD19+, TdT+
-Prognosis: Poor

Front 46

-Explain the genetic mechanisms that cause T-ALL.

-Clinical presentation of T-ALL? Morphology? Immunophenotype? Prognosis?

Back 46

-Mosthave a translocation of an oncogene to a T-cell receptor promoter

ClinicalPresentation: Kids. 25% of pediatric ALL. Oftenwith thymic mass or lymph node, spleen involvement.

Morphology: Big agranular blasts

Immunophenotype: TdT+,CD3+, CD5+; can express myeloid or B-cell antigens aswell

Prognosis: “High risk”

Front 47

What is the most common genetic motif causing lymphoid malignancies (ALL)?

Back 47

Oncogenetranslocation to an Ig orTCR promoter.

Front 48

How to differentiate between B and T cell ALL? Common features of the two?

Back 48

-T-cellALL’s lack expression of the B-cell markers we’ve covered (CD20, CD10), andB-cell ALL’s lack CD3 and CD5 expression.

-Bothtypes express TdT

Front 49

What is "risk stratification" in T-ALL?

Back 49

In kids, application of a more intense chemotherapy regimen for these “high risk”patients results in a survival rate comparable to that of kids with B-ALL.

Front 50

Three basic types of myeloproliferative disease?

Back 50

Myeloid,erythroid, and megakaryocyte derived types

Front 51

What kind of malignancies are represented by chronically proliferating clones that differentiate as circulating blood cells?

Back 51

Myeloproliferative disorders

Front 52

Differential features of chronic myelogenous leukemia (CML)?

Back 52

-High WBC
-All stages of granulocyte maturation end up in blood

Front 53

Differential features of Chronicmyelomonocyticleukemia (CMML)?

Back 53

-High WBC
-Monocytes, promonocytes, and weird hybrids between monocytes and granulocytes
-Shows both myelodysplastic and myeloproliferative features

Front 54

Which twotypes of myeloproliferative neoplasm present with anelevated eosinophil count?

Back 54

ChroniceosinophilicLeukemia(CEL) orPDGFRneoplasm

Front 55

Difference between chroniceosinophilicLeukemia(CEL) orPDGFRneoplasm?

Back 55

Thetwo types respond differently to different therapies.

Front 56

What is the only myeloproliferative disease associated with a presentation of only increased mast cells?

Back 56

Mastocytosis

Front 57

What are two myeloproliferative diseases often present withthrombosis or elevated platelet count?

Back 57

Essentialthrombocythaemia or Primarymyelofibrosis

Front 58

What myeloproliferative disease often presents with elevated RBC count?

Back 58

Polycythemia vera

Front 59

When should you suspect a myeloproliferative disease is present instead of a reactive infection?

Back 59

Ahigh WBC count with no toxic granulation BUT there is a "myeloid bulge" with more myelocytes than metamyelocytes instead of a left shift (bands>metamyelocytes>myelocytes) on the manual count of the peripheral smear.

Front 60

Main technique of diagnosing CML today? Previously?

Back 60

Today, even low suspicion should prompt use of peripheral blood in an RT-PCRassay for the BCR-Abl1 fusion protein, but a bone marrow biopsy is still required to make sure patient cells are not progressing to an accelerated or blast phase.

Before, bonemarrow biopsies and routine cytogenetic studies (T(9;22)(q34;q11.2)) showed hypercellurity with many myeloid precursors, little dysplasia, and no increase in blasts.

Front 61

How treatable is CML? Why?

Back 61

Very. >95% complete hematologicresponse (WBC count is normalized)and 70-90% complete cytogenetic response (absence of translocation) because CML serves as a model of translational genetics research. Identification of the Philadelphia chromosome led to developing a specific inhibitor of the mutated kinase (Imatinib).

Front 62

Most sensitive gauge of treatment efficacy in CML?

Back 62

Absence of fusion transcript via RT-PCR confirms a complete molecular response.

Front 63

Why should a bone marrow biopsy still be done if CML is confirmed by molecular diagnostics (RT-PCR)?

Back 63

CMLpatients can progress to an accelerated phase, with increased blasts in themarrow, or to a “blast phase” that is essentially the same as an acuteleukemia (usually myeloid, sometimes lymphoid). At diagnosis, and occasionally duringtreatment, you need to make sure they’re not progressing.

Front 64

Describe the genetic pathogenesisof polycythemia vera.

Back 64

An activatingmutation (Jak2V617F) in Jak2 kinase of peripheral leukocytes or in the EPO receptor (Mpl) mimics the presence of erythropoietin (EPO) in a clone ofcommitted erythroid progenitors resulting in constitutive production and increased levels of RBCs which can cause stroke/MI/elevated BP/etc.

Front 65

Describe the diagnosis of polycythemia vera.

Back 65

Increased RBC count followed by molecular testing for JAK2V617F.

EPO is NOT elevated (if it is, then consider lung disease)

Front 66

Morphology and prognosis of polycythemia vera?

Back 66

-Hypercellular marrow, erythroid hyperplasia, increased megakaryocytes

->10 yrsurvival is common but it can progress to myelofibrosis,MDS, or acute leukemia

Front 67

Describe the genetic pathogenesisof essential thrombocythemia.

Back 67

Same mutation as polycythemia vera is commonly associated (Jak2V617F mutation) in peripheral leukocytes but mutations of calreticulin are also (less) common

Front 68

Which causes increased platelets more often: iron deficiency or essential thrombocythemia?

Back 68

Iron deficiency

Front 69

Onesignificant difference between the morphologies of essential thrombocythemia and P. vera?

Back 69

The megakaryocytesin ET look “bizarre” and huge.

Front 70

Prognosis of essential thrombocythemia?

Back 70

>10 yrsurvival is common but it can progress to myelofibrosis,MDS, or acute leukemia

Front 71

Critical diagnostic finding for primarymyelofibrosis? Is it the same for early and late stages?

Back 71

Reviewof the peripheral smear isusually the critical diagnostic step because it will show leukoerythroblastic findings which make you do a bone marrow biopsy where you find increased megs and fibrosis.

Late stages show thrombocytosisand/or leuko-erythroblastic changes (worse survial times).

Front 72

Stain used to find fibrosis on bone marrow biopsy?

Back 72

Reticulin stain

Front 73

Most common site for systemic involvement of mastocytosis? How does this dz present and what is a commonly forgotten lab test that points to this differential?

Back 73

-Bone marrow proliferation of non blast cells

-Presentasbenign cutaneous lesions in kids

-Serum tryptase is often elevated

Front 74

Bone marrow findings in mastocytosis?

Back 74

-Blandlooking cells, round or spindle shaped

Front 75

Genetic findings in mastocytosis?

Back 75

-EithercKIT mutants OR PDGFRA activation (FIP1translocation)

Front 76

How do you diagnose mastocytosis?

Back 76

Immunostain of bone marrow showing non blast cells and an immunophenotype for tryptase, CD117 (C-KIT, the SCF receptor!),and usually CD25

Front 77

What diagnostic test is indicated wheneosinophiliais thought to be myeloproliferative rather than reactive? Why?

Back 77

Molecular testing for increasedactivity of a tyrosine kinase, whether in the form of a fusion protein or dueto a point mutation, is getting to be a common motif in MPN’s

Front 78

How are myelodysplasias usually diagnosed?

Back 78

Bone marrow morphology in unexplained cytopenias (poorly function though nonspecific clones), but cytogenetic findings can also help.

Front 79

Clinical presentation and significance of myelodysplasias?

Back 79

MDSusually presents in elderly patients with low risk as an unexplained cytopenia, and in some cases our therapies willharm rather than help. But for othersthe condition carries higher risks, and for some of those there are effectivetherapies available.

Front 80

5 major adult forms of myelodysplasias from best to worst prognosis?

Back 80

-Refractory cytopenia with unilineage dyplasia-Refractory anemia with ring sideroblasts-Myelodysplastic syndrome with isolated del(5q)-Refractory cytopenia with multilineage dysplasia-Refractory anemia with excessblasts

Front 81

What are the major features worth knowing in refractorycytopenia with unilineal dysplasia?

Back 81

Diagnosis depends on the unexplained cytopenia presenting with nonspecific morphology of weirdlooking precursors, binucleation or irregular nuclei, fibrosis, high or low cellularity, or megaloblastoid features. Cytogenetic findings are usually nonspecific as well. Good prognosis.

Front 82

Diagnosis of refractoryanemia with ring sideroblasts is dependent on what?

Back 82

Clearly iron (blue) ring-sideroblasts with dyspoietic features after finding the cytopenia, usually in an elderly patient. Good prognosis

Front 83

Features needed to diagnose MDS with isolated del(5q)? Prognosis?

Back 83

-Anemia,often severe; usually elderly patients(>65 yrs),more often women

-Mononuclear megakaryocytes

-Good median survival; treatable with lenalidomide; BUT, 10% progress to AML

Front 84

Features needed to diagnose refractorycytopenia with multilineage dysplasia? Prognosis?

Back 84

-Anemia, often severe; usually elderly patients (>65 yrs),more often women

-Granulocytes(if affected) don’t granulate normally; nuclei don’t lobulate normally

-Mediansurvival 30 months and 10% progress to AMLin 2 years because there is no specific treatment currently

Front 85

Features needed to diagnose refractory anemia with excess blasts? Prognosis?

Back 85

-5% -9% morphologic blasts (RAEB-1)

-10% - 19% morphologic blasts (RAEB-2)

-Blasts and dyspoietic maturation seen with relevant immunophenotyping (CD34+, and/or CD117+)

-RAEB-1: 25% progress to AML.

-RAEB-2: 33% do so.