A Hematology Case Study

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ALL in a Days Work

• A Hematology Case Study
• about Leukemia
• by
• Sarah Wycoff

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Questions to Consider

• How do you accurately determine a leukemic blast
  cell from a lymphocyte?
• What cytochemical stains can be used to diagnose
  Acute Lymphoblastic Leukemia?

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Patient History

• 50-year-old female
• No prior medical problems
• Admitted to ER with chest pain, fatigue and
  shortness of breath

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CBC and Differential Results

• WBC 20.5 bil/L (4.3-10.9)
• Neutaphils 1.84 (7.0-7.2)
• Lymphocytes 4.10 (1.1-4.5)
• Monocytes 0.21 (0.0-0.8)
• Myelocytes 0.21 (0.0)
• Blast 14.14 (0.0)
• Reticylocytes 17 bil/L (25-85)

• RBC 3.16 tril/L (3.87-5.05)
• HgB 10.4 (12.1-15.0)
• MCV 91.8 fl (80-100)
• MCHC 35.9 (33-35)
• RDW 18.1 (11.5-15.0)
• Platelets 31 Bil/L (155-442)

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Peripheral Blood Smear

• Normal lymphocyte in the middle
• 4 blast cells in the corners

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Bone Marrow Aspirate

• Cellularity is increased at 95-100
  
• Normal hematopoietic marrow is replaced by an
  immature lymphoid infiltrate

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Normal Bone Marrow
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Cytochemial Stains- SBB(Sudan Black B)

• Positive control cell is the mature neutrophil
  (granulocytic cell line)
• Stain determines if blasts are granulocytic
• Patients blasts are negative

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Cytochemial Stains- MPO(Myeloperoxidase)

• Positive control cell is the mature neutrophil
  
• (granulocytic cell line)
• Stain determines if blasts are granulocytic
• Patients blasts are negative

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Cytochemical Stains- PAS(Periodic-Acid Shiff)

• Positive control cells are the lymphocytic cell
  line and neutrophils
• Stain will be positive in lymphocytic and
  erythrocytic blasts
• Patients blast are slightly positive

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Diagnosis Acute Lymphoblastic Leukemia (ALL)

• Regarded as a childhood disease (80 of cases
  occur between the ages of 2 to 10)
• ALL subtypes
• T-Cell - 20-25
• Precursor B-cell (L1 and L2) 70-75
• Mature B-cell (Burkitt L3) 5

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Clinical Manifestations of ALL

• Malaise, fatigue and pallor related to anemia
  (too few RBCs)
• Bruising, petechiae and epitaxis related to
  thrombocytopenia (too few PLTs)
• Weight loss, bone pain and sternal tenderness
  (due to proliferation of leukemic cells in bone
  marrow)

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Philadelphia Chromosome

• Commonly associated with CML (95 are Ph )
• 15 to 30 of adults with ALL are Philadelphia
  chromosome positive, making it the most common
  ALL associated chromosomal abnormality

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Treatment

• Chemotherapy with Cyclophosphamide, Mesnex,
  Viacritine, Doxorubican and Decadron
• Transferred to University of Michigan Medical
  Center to receive a bone marrow transplant

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Summary

• 50 year-old female admitted to ER
• Laboratory findings suggestive of adult ALL
• Diagnosis confirmed though cytochemisty and flow
  cytometry
• Transferred to University of Michigan to receive
  bone marrow transplant

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Answers to Questions to Consider

• Blasts have a higher nucleus to
• cytoplasm (NC) ratio and finer chromatin
  pattern than normal lymphocytes
• Cytochemical stains used to diagnosis Acute
  Lymphocytic Leukemia
• MPO negative
• SBB negative
• PAS positive

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Credits

• This case study was prepared by
• Sarah Wycoff, MT(ASCP)
• while she was a Medical Technology student in the
  
• 2004 Medical Technology Class at
• William Beaumont Hospital in Royal Oak, MI.