leukemoid reaction and leukemia

Differentiation of leukemoid reaction and Leukemia.

1. LEUKEMOID REACTION AND LEUKEMIA-SLIDE DISCUSSION By- Dr. Priya Jaswani

2. Slide discussion of Leukemoid reaction and Chronic Myeloid Leukemia .

3. Chronic myeloid leukemia A 39 yr male patient came with c/o abdominal pain-2 week in duration vague dragging pain associated with fullness of abdomen no aggravating or relieving factors

4. h/o fatigue, fever ,increased sweating,early satiety + , h/o loss of appetite + No h/o loss of weight, no h/o bleeding tendency PAST h/o -> No h/o Tb/HTN/DM PERSONAL h/o -> consumes alcohol occasionally P/A –mild distention of abdomen+ moderate splenomegaly (+) mild hepatomegaly Sternal tenderness was present . No lymphadenopathy .

5. Peripheral smear findings Hemoglobin: 8.5 g/dl RBC series : Moderate anisopoikilocytosis . Predominantly normocytes are seen . Few macrocytes and tear drop cells seen . Polychromasia also seen .

6. WBC Series : Total Leucocyte count is 1.80 lakh cells / cumm . Differential count : Blasts:02% Promyelocyte : 03% Myelocyte :25 % Metamyelocyte : 17% Neutrophils (including band cells):39% Lymphocytes :01% Eosinophils;04% Monocytes :02% Basophils :07% Shift to left seen . Platelets :1.8 lakh / cumm No hemoparasite seen . Impression : Peripheral smear suggestive of Chronic Myeloid leukemia .

7. Marked Leukocytosis Predominantly neutrophils , metamyelocytes , myelocytes Myelocyte bulge. Less 3% are Myeloblast Eosinophilia & Basophilia

8. Absolute basophilia is seen . Hypogranular basophils were also seen .

9. Platelets showed variation in size . Few platelets lacked granulation.with targetoid appearance. Disturbed platelet function.

10. Bone marrow aspirate Cellularity :Markedly hypercellular (95 %) M:E ratio : 12:1 Erythroid series : Dimorphic .

11. Myeloid series : Blasts 02% , Promyelocyte 02% , Myelocytes 25% , Metamyelocytes 21% Neutrophils including band cells 29% . Eosinophils 06% Basophils 13 % lymphocyte 02% . Megakaryocytes : Slighty Increased in number Plasma cells :within normal limits.

12. Bone marrow aspirate Megakaryocytes are increased in number with focal clustering . Megakaryocytes are smaller and hypolobated : ‘Dwarf forms ’. Evidence of dysmegakaryopoiesis is seen.

13. Leukemoid reaction A 38 year old female was admitted in medical ward with the complain of Fever since one month . It was of moderate grade not associated with chills or rigor . She had cough along with expectoration since one month . Also she complained of increased frequency of micturition . Urine Culture :Positive for E.coli . P/A: No hepatomegaly , no splenomegaly

14. Peripheral smear Hb : 7.4 g/dl RBC series : Mild anisopoikilocytosis moderate hypochromia .Predominantly microcytic hypochromic cells seen.Few pencil cells , tear drop cells seen . .\

15. WBC Series : Total Leucocyte count is 56,000 cells / cumm . Differential count : Blasts:00 Promyelocyte : 01% Myelocyte :06% Metamyelocyte :19% Neutrophils (including band cells):56 % Lymphocytes :09% Eosinophils;03% Monocytes :04% Basophils :02% Shift to left seen . Platelets :1.8 lakh / cumm No hemoparasite seen .

16. Peripheral smear

17. Toxic granulation in Neutrophils .

18. Differentiation of leukemoid reaction and leukemia Leukocytosis , defined as an increase in white blood cell (WBC) count, is a common finding with a broad differential diagnosis, encompassing both benign and malignant entities. Classification and diagnosis of leukocytosis require confirmation of automated differential counts and examination of the peripheral blood smear.

19. Further if increased blasts are seen then it should prompt a workup for acute leukemia. For confirmation of reactive leucocytosis and chronic leukemias we require flow cytometric test, immunophenotyping and bone marrow examination with cytogenetic and molecular genetic tests.

20. CONTENTS 1.Brief introduction of Myeloid Leukemoid reaction Chronic Myeloid Leukemia Chronic Neutrophilic leukemia 2.Differentiation between above three on the basis of Peripheral smear, Bone marrow aspirate picture Bone marrow biopsy picture LAP score Cytogenetics Immunophenotyping 3.Brief discussion of Lymphoid leukemoid reaction and eosinophilic leukemoid reaction .

21. LEUKEMOID REACTION Leukemoid reaction — a secondary reversible significant increase in the number of leukocytes in response to a stimulus, accompanied by the appearance in the blood of immature forms of leukocytes. It is defined by a leukocyte count greater than 50,000 cells/ μL , caused by reactive causes outside the bone marrow

22. Rationale As reactive changes in blood are similar to hematological malignancies, it is important to differentiate them from leukemia. Careful history, good physical examination, and limited imaging studies may assist in revealing the underlying cause of leukemoid reaction .

23. MYELOID LEUKEMOID REACTION AND LEUKEMIA The diagnosis of Myeloid Leukemoid Reaction is based on the exclusion of chronic myelogenous leukemia (CML) and chronic neutrophilic leukemia (CNL).

24. Chronic Neutrophilic Leukemia is a rare, distinct myeloproliferative syndrome with a poor prognosis. The differential diagnosis between Leukemoid Reaction and Chronic Neutrophilic Leukemia may be difficult or even impossible because both conditions share identical morphological features, including a raised LAP score and the absence of the bcr / abl translocation .

25. Etiology and pathogenesis MYELOID TYPE LEUKEMOID REACTION : Leukemoid reactions of myeloid type develop in various infectious and noninfectious processes . ACUTE BACTERIAL INFECTIONS : Pneumonia, Pyogenic meningitis Cellulitis Infected burns Diphtheria

26. ACUTE STRESS STATES : Post surgery Post hemorrhage Myocardial Infarction MISCELLANEOUS : Steroid therapy Gout Rheumatoid arthritis

27. AGE LEUKEMOID REACTION CML CNL Any age Middle age (40-65 years) Elderly (54-85 years)

28. CLINICAL COURSE In leukemoid reaction the clinical course is related to cause . In CML clinical course is :Progressive . The progression of Ph+ CML that occurs when the condition is left untreated is described in three phases: Chronic Accelerated Blast

29. Clinical features LEUKEMOID REACTION CML CNL Features of underlying cause • Fatigue, lethargy, weight loss, sweats • Splenomegaly in >75 percent; may cause (L) hypochondrial pain, satiety and sensation of abdominal Fullness. • Gout, bruising/bleeding, and occasionally priapism • Signs include moderate to large splenomegaly (40% >10 cm), hepatomegaly (2%), Fatigue, lethargy, weight loss . Hepato-spenomegaly present.

30. Total leucocyte count Leukemoid Reaction CML CNL TLC is > 50,000 cells/ cumm . TLC ranges from 30,000 cells/ cumm to 10 lakh cells / cumm . TLC > 25,000 cells / cumm .

31. Peripheral smear LEUKEMOID REACTION CML CNL Leucocytes consist mostly of mature neutrophils . The differential count discloses a marked left shift, as evidenced by the presence of myelocytes and metamyeocytes . In addition PS discloses toxic granulation, Doëhle bodies, and cytoplasmic vacuoles in the neutrophils of patients with an LR attributed to an infection. In CML, there are more immature cells, absolute basophilia , and Eosinophils . Marked neutrophilia with fewer metamyelocytes and myelocytes (<5%). Immature granulocytes: promyelocytes , myelocytes , metamyelocytes are <10 % . Blasts <1% .

32. Band forms promyelocyte myelocyte metamyelocyte CML PERIPHERAL SMEAR CHRONIC PHASE

33. Bone marrow aspiration Leukemoid reactiom CML( Chronic phase ) CNL Increased cellularity with myeloid hyperplasia . But NO marrow fibrosis Markedly hypercellular . M:E ratio 15:1 to 32: 1. Myeloblast <5 %. Megakaryocytes show clustering and Dwarf forms. Pseudogaucher cells may be seen Hypercellular , majority are neutrophils , M;E ratio > 20:1 , Megakaryocytes are normal in number .

34. Bone marrow aspiration LEUKEMOID REACTION Increased cellularity with myeloid hyperplasia is the principle picture of an Leukemoid Reaction. No fibrosis is present.

35. Bone marrow aspiration cml Marrow is hypercellular with granulocytic predominance. Megakaryocytes are increased in number with abnormal morphology. Increase in reticulin fibrosis. Blasts less than 5%.

36. Pseudo- gaucher cells, sea-blue histiocytes Scattered amongst marrow cells are macrophages with linear striations or granular cytoplasm (Pseudo- Gaucher cells ) , some with sea blue colored granules resembling Sea-blue histiocytes .

37. BONE MARROW BIOPSY Two types of CML Granulocytic CML Granulocytic –megakaryocytic CML.

38. LEUCOCYTE alkaline phosphatase (LAP) score(40-100) Leukemoid reaction CML CNL Stimulated neutrophils of an LR have increased LAP scores LAP Score is markedly diminished to 0-20 and is characteristic finding . LAP Score is high .

39. Leukocyte alkaline phosphatase (LAP) score

40. vitamin B12-binding capacity . Leukemoid reaction CML CNL Normal Elevated Elevated

41. In CML there is increase in uric acid level lactate dehydrogenase . Increase in the level of angiogenic factors

42. Cytogenetics Entire chromosomal complement is evaluated to identify philadelphia chromosome and other abnormalities. Can be done on both peripheral blood and bone marrow . Cy togenetics cannot identify complex translocations.

43. The presence of the Philadelphia chromosome – shortened chromosome 22. t(9,22)( q34,q11)

44. Nearly 95 % patients demonstrate Ph chromosome . For CML patients who are cytogenetically Ph-chromosome–negative (Ph-) the following special techniques can be used to detect BCR-ABL Fusion: Fluorescence in situ hybridization (FISH) Reverse transcriptase polymerase chain reaction (RT-PCR) %

45. Molecular Probes : FISH ( Fluorescence In Situ Hybridization Normal in Leukemoid reaction Detect the BCR-ABL fusion gene on chromosome 22 Qualitative in CML.

46. Rt-pcr Detects different length products corresponding to chimeric BCR-ABL proteins of 190,210 and 230 kda . So helps in distinguishing CML from ALL and CNL.

47. Flow cytometry Immunophenotyping is necessary for assigning specific lineage to CML Blast crisis cells.

48. Leukemoid reaction CML CNL Peripheral blood Mature neutrophils , marked “left shift” Immature cells, basophils , and eosinophils Marked neutrophilia , no immature cells Bone marrow Myeloid hyperplasia, orderly maturation, normal morphology Basophilia , eosinophilia , monocytosis , slight increase in blasts and reticulin fibrosis. Similar morphology with LR, packed bone marrow, slight increase in reticulin . LAP score High Low High

49. LEUKEMOID REACTION CML CNL Cytogenetic analysis No cytogenetic abnormality . Bcr-abl fusion . T (9,22) q11 , q34. Ph + chromosome in 95 % patients . Cytogenetic abnormalities in 37% of cases Immunopheno - typing CD13 (+++), CD15 (+++), CD34 (−) HLA-DR (−) CD13 (+++), CD15 (+++), CD34(−) HLA-DR (+) CD13 (+++) CD15(+++), CD34 (−) HLA-DR (+) Serum G-CSF High Low Low

50. LEUKEMOID REACTION CML CNL Clonality studies Polyclonal Monoclonal Monoclonal

51. lymphocytic type : ACUTE INFECTIONS: Infectious mononucleosis, Chicken pox, Scarlet fever, Mumps Measles Rubella. CHRONIC INFECTIONS: Tuberculosis Brucellosis Syphilis

52. DIFFERNTIATING FEATURES . LYMPHOID LEUKEMOID REACTION . CLL / SLL AGE Any age. > 60 years of age . SYMPTOMS/SIGN Malaise , Fever , pharyngitis , etc . Asymptomatic . ONSET Acute . (Enlargement of lymph node / spleen) . Indolent (Enlargement of lymph nodes / spleen )

53. Lymphoid leukemoid reaction . CLL/SLL CBC Lymphocytosis . Lymphocytosis . PERIPHERAL SMEAR Atypical lymphocytes . Small lymphocytes .

54. Lymphoid leukemoid reaction CLL /SLL CLINICAL COURSE Self- limiting Progressive . Flow cytometry Normal . Abnormal .

55. Infectious mononucleosis and cll -Left: Atypical lymphocytes-> viruses irritate the lymphocytes caused them to become bigger and nucleus changes shape-> cytoplasm gives shape of "ballerina skirt cells"  -Right: Small lymphocytes-> Normal, small, rounded, slightly bigger than RBC, scant cytoplasm, round mature nuclei

56. Peripheral smear of a patient with viral infection showing activated lymphocytes— abundant deep basophilic cytoplasm

57. Leukemoid Eosinophilic reaction type   ALLERGIC STATES: Asthma Urticaria Hay fever Drug dermatitis MISCLLANEOUS : Tropical eosinophila Eosinophilic Pneumonia Eosinophilic granuloma . PARASITIC DISEASES: Roundworm infestation Hookworm infestation. Filariasis . Trichinosis .

58. Chronic eosinophilic leukemia  (CEL) is a myeloproliferative disorder characterized by clonal proliferation of eosinophilic precursors .

59. Persistent eosinophilia >1500/ cumm . Myeloblasts <20% in blood and bone marrow . There is multilobation,vacuolation and degranulation of eosinophils .

60. Leukemoid reaction monocytic type INFECTIONS: Tuberculosis Kala azar Malaria Trypanosomiasis Bacterial endocarditis Needs to be differentiated from : Chronic Myelo-monocytic Leukemia AML M4 and M5 Hodgkin’s disease