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o Questions 1 and 2: General question on anemia and tests used to detect (Slides 4 and 5).
Anemias also can be classified on the basis of red cell morphology, including the size,
color and shape of the red cells.
These features are judged subjectively by visual inspection of peripheral smears and also
are expressed quantitatively using the following indices: -
o Mean Cell Volume (MCV)
o Mean Cell Hemoglobin (MCH)
o Mean Cell Hemoglobin Concentration (MCHC)
o Red Cell Distribution Width (RDW)
Depending on the differential diagnosis, a number of other blood tests also may be
performed to evaluate anemia, including:
(1) iron indices
(2) plasma unconjugated bilirubin, haptoglobin, and lactate
dehydrogenase levels,
(3) serum and red cell folate and vitamin B12 concentrations
(4) hemoglobin electrophoresis
(5) Coombs test
o Question 3: What are the features shared by hemolytic anemias (Slides 8-10).
HEMOLYTIC ANEMIAS
Anemias caused by accelerated red cell destruction are termed hemolytic anemias.
Destruction can stem from either intrinsic (intracorpuscular) red cell defects, which are
usually inherited, or extrinsic (extracorpuscular) factors, which are usually acquired.
Features shared by all hemolytic anemias include:
(1) a decreased red cell life span
(2) a compensatory increase in erythropoiesis
(3) the retention of the products of degraded red cells (including iron) by the body.
Hemolytic anemias are associated with erythroid hyperplasia in the marrow and
increased numbers of reticulocytes in the peripheral blood.
Destruction of red cells can occur within the vascular compartment (intravascular
hemolysis) or within tissue macrophages (extravascular hemolysis).
Intravascular hemolysis can result from:
o mechanical forces (e.g., turbulence created by a defective heart valve)
o biochemical or physical agents that damage the red cell membrane
Leads to hemoglobinemia, hemoglobinuria, and hemosiderinuria.
The conversion of heme to bilirubin can result in unconjugated hyperbilirubinemia and
jaundice.
Massive intravascular hemolysis sometimes leads to acute tubular necrosis.
Extravascular hemolysis, the more common mode of red cell destruction, primarily takes
place within the spleen and liver, which contain large numbers of macrophages, the
principal cells responsible for the removal of damaged red cells from the circulation.
o Any reduction in red cell deformability makes passage through the splenic sinusoids
difficult and leads to splenic sequestration and phagocytosis.
Not associated with hemoglobinemia and hemoglobinuria, but often produces jaundice
and, if long-standing, leads to the formation of bilirubin-rich gallstones
In most forms of chronic extravascular hemolysis there is a reactive hyperplasia of
mononuclear phagocytes that results in splenomegaly.
4. Question 5 and 6: Specific categories (minor, major, etc.) and morphology of -thalassemia
(Slides 20-23).
b-Thalassemia
The mutations associated with -thalassemia fall into two categories:
1) 0, in which no -globin chains are produced
2) +, in which there is reduced (but detectable) -globin synthesis
Persons inheriting one abnormal allele have -thalassemia minor (also known as -
thalassemia trait), which is asymptomatic or mildly symptomatic.
Most people inheriting any two 0 and + alleles have -thalassemia major;
Occasionally, persons inheriting two + alleles have a milder disease termed -
thalassemia intermedia.
In contrast with -thalassemias, gene deletions rarely underlie -thalassemias
Chronic blood loss is the most important cause of iron deficiency anemia in the Western
world.
In the developing world, low intake and poor bioavailability due to predominantly
vegetarian diets are the most common causes of iron deficiency.
Increased demands not met by normal dietary intake occur worldwide during pregnancy
and infancy.
Malabsorption can occur with celiac disease or after gastrectomy
Regardless of the cause, iron deficiency develops insidiously. Iron stores are depleted
first, marked by a decline in serum ferritin followed by a decrease in serum iron and a
rise in the serum transferrin. Ultimately, the capacity to synthesize hemoglobin,
myoglobin, and other iron-containing proteins is diminished, leading to microcytic
anemia, impaired work and cognitive performance, and even reduced
immunocompetence.
6. Question 8: General question regarding megaloblastic anemias (Slides 37 and 38).
Megaloblastic Anemias
The morphologic hallmark of megaloblastic anemia is the presence of megaloblasts:
o larger than normal erythroid progenitors (normoblasts) that have delicate,
finely reticulated nuclear chromatin (indicative of nuclear immaturity) and
give rise to abnormally large red cells (macrocytes).
The two principal causes of megaloblastic anemia are folate deficiency and vitamin B12
deficiency.
Both vitamins are required for DNA synthesis and the effects of their deficiency on
hematopoiesis are essentially identical.
Underlying the cellular gigantism associated with megaloblastic anemia is a defect in
DNA synthesis that impairs nuclear maturation and cell division.
This maturational derangement contributes to the anemia in several ways:
1) Many megaloblasts are so defective in DNA synthesis that they undergo
apoptosis in the marrow (ineffective hematopoiesis).
2) Others mature into red cells but do so after fewer cell divisions, further diminishing the
output of red cells.
3) Granulocyte and platelet precursors are also affected (although not as severely) and
most patients present with pancytopenia (anemia, thrombocytopenia, and
granulocytopenia).
7. Question 9: Metabolism of folate (folate cycle) and folate deficiency (Slides 39-42).
The onset of the anemia of folate deficiency is insidious, being associated with
nonspecific symptoms such as weakness and easy fatigability.
The clinical picture may be complicated by the coexistent deficiency of other vitamins,
especially in alcoholics.
Unlike in vitamin B12 deficiency, neurologic abnormalities do not occur.
8. Question 10 and 11: Vitamin B12 absorption and consequences of deficiency (Slides 41 and
43-46).
The metabolic defects responsible for the anemia are intertwined with folate metabolism.
Vitamin B12 is required for recycling of tetrahydrofolate, the form of folate that is needed
for DNA synthesis. In keeping with this relationship, the anemia of vitamin B12
deficiency is reversed with administration of folate.
By contrast, folate administration does not prevent and may in fact worsen the neurologic
symptoms. The main neurologic lesions associated with vitamin B12 deficiency are
demyelination of the posterior and lateral columns of the spinal cord.
The severity of the neurologic manifestations is not related to the degree of anemia.
Indeed, the neurologic disease may occur in the absence of overt megaloblastic anemia.
Neutropenia
A reduction in the number of granulocytes in blood is known as neutropenia or, when
severe, agranulocytosis.
Neutropenic persons are susceptible to bacterial and fungal infections; in whom they can
be fatal.
The mechanisms underlying neutropenia can be divided into two broad categories:
1) Decreased granulocyte production.
o Clinically important reductions in granulopoiesis are most often causedby marrow
failure (as occurs in aplastic anemia), extensive replacement of the marrow by
tumor (such as in leukemias), or cancer chemotherapy.
2) Increased granulocyte destruction.
o This can be encountered with immune-mediated injury or in overwhelming
bacterial, fungal, or rickettsial infections.
10. Question 13: Know the different patterns of Chronic Nonspecific Lymphadenitis (Slide 58).
Reactive Lymphadenitis
Chronic Nonspecific Lymphadenitis
o Depending on the causative agent, can assume one of three patterns:
1) Follicular Hyperplasia This pattern occurs with infections or inflammatory
processes that activate B cells, which migrate into B cell follicles and create the
follicular (or germinal center) reaction. Causes of follicular hyperplasia include
rheumatoid arthritis, toxoplasmosis, and early HIV infection.
2) Paracortical Hyperplasia This pattern is caused by immune reactions involving the T
cell regions of the lymph node. Paracortical hyperplasia is encountered in viral
infections, after certain vaccinations, and in immune reactions induced by drugs
3) Sinus Histiocytosis This reactive pattern is characterized by distention and
prominence of the lymphatic sinusoids, owing to a marked hypertrophy of lining
endothelial cells and an infiltrate of macrophages (histiocytes). It often is encountered
in lymph nodes draining cancers.
11. Questions 14-17: Matching between specific types of lymphoid neoplasms and their
definitions. Specifically, I will have a defining feature of ALL (Slides 66 and 67), CLL (Slides
68-70), DLBCL (Slides 73 and 74), and Hodgkin lymphoma (Slides 78-81) that you will have to
match with the respective cancer. Will only match once (i.e. only one option/definition per
cancer to match). It would be a good idea to review the 5 background points listed for all
lymphoid neoplasms (Slides 62-65).
Note: I mentioned at the beginning of the review session that you only needed the
definitions on the summary slide for lymphoid neoplasms. However, since I agreed to
provide this study guide I will be taking the defining feature directly from the slides that
describe each cancer listed above. In other words, study the slides for each cancer that
you will be matching with their defining feature. This could be anything from the
defining mutation to the pathology they exhibit in a peripheral blood smear, etc.
Hodgkin Lymphoma
Hodgkin lymphoma encompasses a distinctive group of neoplasms that are characterized
by the presence of a tumor giant cell, the Reed-Sternberg cell.
Unlike most NHLs, Hodgkin lymphomas arise in a single lymph node or chain of lymph
nodes and typically spread in a stepwise fashion to anatomically contiguous nodes.
The Reed-Sternberg (RS) cell, a very large cell (15 to 45 m in diameter) with an
enormous multilobate nucleus, exceptionally prominent nucleoli and abundant cytoplasm
is the main morphological marker.
Particularly characteristic are cells with two mirror-image nuclei or nuclear lobes, each
containing a large (inclusion-like) acidophilic nucleolus surrounded by a clear zone,
features that impart an owl-eye appearance.
Hodgkin Lymphoma
Typical RS cells and variants have a characteristic
immunophenotype, as they express CD15 and CD30 and fail to
express CD45 (common leukocyte antigen), B cell
antigens, and T cell antigens.
Nodular sclerosis Hodgkin lymphoma is the
most common form. It is equally frequent in men
and in women and has a striking propensity to
involve the lower cervical, supraclavicular, and
mediastinal lymph nodes. Most patients are
adolescents or young adults, and the overall
prognosis is excellent.
Elegant molecular studies performed on single microdissected RS cells from any given
case possessed the same immunoglobulin gene rearrangements. In addition these studies
revealed that the rearranged immunoglobulin genes had undergone somatic
hypermutation. As a result, it is now agreed that Hodgkin lymphoma is a neoplasm
arising from germinal center B cells.
The characteristic non-neoplastic, inflammatory cell infiltrate is generated by a number of
cytokines, some secreted by RS cells. Conversely, the responding inflammatory cells,
rather than being innocent bystanders, produce additional factors such as CD30 ligand
that aid the growth and survival of RS cells and contribute further to the tissue reaction.
Note: Brentuximab vedotin and CD30
SLIDES (62-65):
Lymphoid Neoplasms
Historically, few areas of pathology evoked as much controversy and confusion as the
classification of lymphoid neoplasms, which is perhaps inevitable in view of the intrinsic
complexity of the immune system, from which they arise.
An international working group of pathologists, molecular biologists, and clinicians
working on behalf of the World Health Organization (WHO) has formulated a widely
accepted classification scheme that relies on a combination of morphologic, phenotypic,
genotypic, and clinical features.
Important principles to be considered:
1) B and T cell tumors often are composed of cells that are arrested at or derived from a
specific stage of their normal differentiation
As background, certain important principles need to be considered:
2) The most common lymphomas are derived from germinal center or post-germinal
center B cells. Mature T cells, which are genomically stable, give rise to lymphomas
infrequently.
3) All lymphoid neoplasms are derived from a single transformed cell and are therefore
clonal. Thus, analyses of antigen receptor genes and their protein products can be used to
differentiate clonal neoplasms from polyclonal, reactive processes.
4) Lymphoid neoplasms often disrupt normal immune function. Both
immunodeficiency and autoimmunity may be seen.
5) Although NHLs often manifest at a particular tissue site, sensitive molecular assays
usually show the tumor to be widely disseminated at diagnosis. As a result, with few
exceptions, only systemic therapies are curative.
Multiple Myeloma
Multiple myelomas (and related plasma cell tumors) secrete a single complete or partial
immunoglobulin.
Because these immunoglobulins can be detected in the serum, these disorders are also
referred to as monoclonal gammopathies, and the associated immunoglobulin is often
referred to as an M protein.
Although M proteins may be indicative of overt malignancy, they also are found often in
normal elderly personsa condition called monoclonal gammopathy of undetermined
significance (MGUS).
Collectively, these disorders account for approximately 15% of the deaths that are caused
by tumors of white blood cells. They are most common in middle-aged and elderly
persons.
Multiple myeloma usually manifests with multifocal destructive skeletal lesions, which
most commonly involve the vertebral column, ribs, skull, pelvis, femur, clavicle, and
scapula.
This destructive process in turn often leads to pathologic fractures, most frequently in
the vertebral column or femur.
The bone lesions usually appear as punched-out defects 1 to 4 cm in diameter
13. Question 19 and 20: Specific question on mutation events and/or peripheral blood smear
pathology in Acute Myeloid Leukemia and Chronic Myelogenous leukemia (Slides 84-87).
14. Question 21 and 22: Know the mechanisms that cause DIC and the two main consequences.
Understand what consumptive coagulopathy means (Slides 92-95).
DIC usually is triggered by either (1) the release of tissue factor or thromboplastic
substances into the circulation or (2) widespread endothelial cell damage.
(1) Thromboplastic substances can be released into the circulation from a variety of
sourcesfor example, the placenta in obstetric complications or certain types of cancer
cells. In gram-negative and gram-positive sepsis (important causes of DIC), endotoxins
or exotoxins stimulate the release of tissue factor from monocytes. Activated monocytes
also release IL-1 and TNF, both of which stimulate the expression of tissue factor on
endothelial cells and simultaneously decrease the expression of thrombomodulin.
DIC usually is triggered by either (1) the release of tissue factor or thromboplastic
substances into the circulation or (2) widespread endothelial cell damage.
(2) Severe endothelial cell injury can initiate DIC by causing the release of tissue factor
and by exposing subendothelial collagen and von Willebrand factor. Widespread
endothelial injury can be produced by the deposition of antigen-antibody complexes (e.g.,
in systemic lupus erythematosus), by temperature extremes (e.g., after heat stroke or burn
injury), or by infections (e.g., due to meningococci or rickettsiae).
DIC is most often associated with sepsis, obstetric complications, malignancy, and major
trauma
Whatever the pathogenic mechanism, DIC has two consequences. First, there is
widespread fibrin deposition within the microcirculation. Second, a bleeding
diathesis results from the depletion of platelets and clotting factors and the secondary
release of plasminogen activators.
15. Question 23: Specific question on one of the 3 causes of thrombocytopenia that I wanted you
to know Immune thrombocytopenic purpura, heparin-induced thrombocytopenia, or thrombotic
thrombocytopenic purpura (Slides 96-98).
THROMBOCYTOPENIA
Clinically important thrombocytopenia is confined to (1) disorders with reduced
production or (2) increased destruction of platelets.
When the cause is accelerated destruction of platelets, the bone marrow usually reveals a
compensatory increase in the number of megakaryocytes. Hence, bone marrow
examination can help to distinguish between these two major categories of
thrombocytopenia.
Note: thrombocytopenia is one of the most common hematologic manifestations of AIDS.
A count less than 150,000 platelets/mL generally is considered to constitute
thrombocytopenia.
Platelet counts 20,000 to 50,000 platelets/mL associated with increased risk of post-
traumatic bleeding, and spontaneous bleeding becomes evident when counts fall below
20,000 platelets/mL.
Most bleeding occurs from small, superficial blood vessels and produces petechiae or
large ecchymoses in the skin, the mucous membranes of the gastrointestinal and urinary
tracts, and other sites.
Larger hemorrhages into the central nervous system are a major hazard in those with
markedly depressed platelet counts.
16. Question 24 and 25: Specific questions on mechanism/consequences of vWF disease and
hemophilia A (Slides 99-103).
COAGULATION DISORDERS
Result from either congenital or acquired deficiencies of clotting factors.
Acquired deficiencies are most common and often involve several factors simultaneously
(e.g., vitamin K deficiency, hepatic parenchymal diseases, DIC).
Hereditary deficiencies of each of the coagulation factors have been identified. Only von
Willebrand disease, hemophilia A (a deficiency of factor VIII), and hemophilia B
(Christmas disease, a deficiency of factor IX) are sufficiently common to warrant further
consideration.
People with von Willebrand disease have compound defects in platelet function and
coagulation, but in most cases only the platelet defect produces clinical findings.
The classic and most common variant of von Willebrand disease (type I) is an autosomal
dominant disorder in which the quantity of circulating vWF is reduced.
Type II is divided into several subtypes characterized by the selective loss of high-
molecular-weight multimers of vWF.
Iron Metabolism
Iron is key component of many enzymes, including hemoglobin (Hgb) (largest amount
of iron in the body), myoglobin, cytochromes, catalase, etc.
STORAGE FORMS:
Coagulation
Clinical Assays:
1) Activated Partial Thromboplastin Time (APTT) Ca2+-chelated plasma (Na citrate)
is recalcified and incubated with negatively-charged PL & aluminum silicate (nr 26-33s).
2) Prothrombin Time (PT) recalcified plasma incubated with PL + TF, i.e.
thromboplastin (nr 12-14s).
Hematopoiesis
Hematopoiesis is the formation and development of red and white blood cells from stem
cells. Occurs in bone marrow.
Hematopoietic stem cells are pluripotent and thereby generate erythrocytes, granulocytes,
monocytes, mast cells, lymphocytes, and megakaryocytes.
Pluripotent stem cells differentiate along one of two pathways, giving rise to either a
lymphoid stem cell or a myeloid stem cell. These in turn differentiate into
progenitor cells.
Nonhematopoietic cells in the bone marrow, known as stromal cells, support the growth
and differentiation of hematopoietic cells.