ALL in a Days Work… A Hematology Case Study about Leukemia by Sarah Wycoff
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?
Patient History • 50-year-old female • No prior medical problems • Admitted to ER with chest pain, fatigue and shortness of breath
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) CBC and Differential Results
Peripheral Blood Smear • Normal lymphocyte in the middle • 4 blast cells in the corners
Bone Marrow Aspirate • Cellularity is increased at 95-100% • Normal hematopoietic marrow is replaced by an immature lymphoid infiltrate
Cytochemial Stains- SBB(Sudan Black B) • Positive control cell is the mature neutrophil (granulocytic cell line) • Stain determines if blasts are granulocytic • Patient’s blasts are negative
Cytochemial Stains- MPO(Myeloperoxidase) • Positive control cell is the mature neutrophil (granulocytic cell line) • Stain determines if blasts are granulocytic • Patient’s blasts are negative
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 • Patient’s blast are slightly positive
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%
Clinical Manifestations of ALL • Malaise, fatigue and pallor –related to anemia (too few RBC’s) • Bruising, petechiae and epitaxis – related to thrombocytopenia (too few PLT’s) • Weight loss, bone pain and sternal tenderness (due to proliferation of leukemic cells in bone marrow)
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
Treatment • Chemotherapy with Cyclophosphamide, Mesnex, Viacritine, Doxorubican and Decadron • Transferred to University of Michigan Medical Center to receive a bone marrow transplant
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
Answers to Questions to Consider • Blasts have a higher nucleus to cytoplasm (N:C) ratio and finer chromatin pattern than normal lymphocytes • Cytochemical stains used to diagnosis Acute Lymphocytic Leukemia: • MPO negative • SBB negative • PAS positive
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.