Hematopoietic and

Lymph Node Pathology

Istr. Övgü İşbilen
Cyprus International University
Faculty of Pharmacy
Hematopoietic and Lymph Node Pathology
Normal Development
Differentiation of Hematopoietic Cells
Bone Marrow
Bone Marrow
Bone Marrow, RBC Precursors
RBC Expelling the Nucleus
Myeloid Maturation
Anemias
Not a disease in itself
Just a symptom, like a fever
Must Understand why.
Fix underlying cause
Unpredicted outcomes
Anemia
Acute
Trauma
 Blood loss, either internal or external
 Reticulocytes 10-15% in a week

Chronic
Time to adapt
GI bleeds, colon ca
Increased demands of pregnancy
Anemia Workup
History, History & More History
 Age, sex, medications, duration….
Physical
 Nailbeds, mucus membranes…..
Lab
 CBC
 RBC size, shape, HgB, RDW, MCV, MCHC
 Reticulocyte count
 Chemistries
 Iron, B-12, Folate
 Bone marrow
 Fancy stuff
Erythrocytes
Size
 Anisocytosis (an/iso/cytosis)
Shape
 Poikilocytosis (poikilo/cytosis)
 Fragmented cells
Hemoglobin content of cells and whole blood
 HBG and HCT
 MCH & MCHC
Mean volume of the RBCs (MCV)
 Uniformity (RDW)
Cytoplasmic inclusions
 Congenital problems
 Sickle cell among others
Anemias by Etiology

Blood loss
Acute, no time to accommodate
 Trauma
 Massively bleeding ulcer or esophageal varices
Chronic, slow with some adaptation
 GYN loss
 Ulcer
 Colon cancer

RBCs are ‘normocytic’

Retic count better go up
History and Physical
Anemias by Etiology

Congenital
Hemoglobin
Sickle cell
Enzyme
G6PD
Membrane
Spherocytosis
Sickle Cell Disease
 Homozygous vs. heterozygous
 Chronic anemia
 Acute crisis
 Microvascular occlusion
 Infections
 Relative malaria resistance for AS
Hemolytic Anemias
Premature destruction
or removal of RBCs
Genetic
Sickle S
Spherocytosis
Acquired
Antibody mediated
Intravascular
Antibody mediated
Free hemoglobin
Extravascular
Problems of RBC Production

Genetic related
Nutritional deficits
Iron
B12
 Dietary or problems of absorption?
 Chronic gastritis

Folic acid
Chronic renal failure (no erythropoietin)
Aplasia of RBC line in bone marrow
Nutrient Deficit
Inadequate dietary source?
Absorption?
Utilization?
Thalassemia

Genetic
Collection of problems of production of one of the
hemoglobin chains.
Beta and Alpha chains
Thalassemia
Microcytic
 Small RBCs
Target cells
Mismatched
production of β
and α chains
Hemoglobin
globs in RBC
Reduced RBC
survival
Thalassemia
B12 Deficiency

Dietary
Pernicious Anemia
 Absorption
 Binding factor missing
 Chronic gastritis
Macrocytic anemia
 Large cells
 Delayed nuclear maturation
Neurological signs
 Myelin production
Macrocytes and Megaloblasts

Macrocyte
 Large RBC
Megaloblast
 Large BM precursor
Folic acid can have similar
look
CNS with B12 only
 Be careful correcting B12
deficiency with folic acid.
 Anemia corrects, but
neurological problems
progress.
Folic Acid and B12
Microcytic Anemia

 Small RBCs
 Iron deficiency
 Thalassemia
 Iron Deficiency

 Dietary?
 Rarely in US
 How much anyway?
 Blood loss
 Chronic
 GYN
 Colon cancer
 RBCs are
 Microcytic
 Hypochromic
 Lack iron for hemoglobin
production
Anemia of Chronic Disease

Problem is of excessive drive to store iron.

Chronic inflammation
 Arthritis
 TB
 Even cancer
Most of incoming iron is sent to storage
 Part of the normal response to inflammation.
In time anemia develops because of
 Reduced iron for utilization
 Not dietary lack or
 Failed absorption
Aplastic Anemia

Something kills
precursor in BM.
 Virus
 Radiation
 Chemotherapy
Over Production of RBCs
Believe it or not, it’s not a good thing.
Response to increased need
High altitude living
Lung disease
 Emphysema
Over production of erythropoietin.
Renal disease
Tumors
Uncontrolled production at bone marrow level
Hemolytic Disease of Newborn
Pregnant mother is Rh-, fetus is Rh+
If mom should have antibodies to the Rh factor, they
will cross the placenta.
Destruction of baby’s RBCs
Previous maternal exposure
Miscarriage
Previous delivery
Wrong transfusion
Treatment: Mom gets Rhogam
WBC Disorders
WBC Disorders
Quantity
Do we have enough WBCs
Quality
If the number looks right, are the cells working?
Higher than expected number (leukocytosis)
Cell type
Reactive or
Neoplastic
 Benign
 Malignant

Leukopenia
Leukopenia

Low WBC count

Under 3,000 per mm3
Causes
Production problem
 Sick BM
 Replacement of BM space

Peripheral destruction
 Autoimmune destruction
Sequestration of cells
 Large spleen
 Rheumatoid arthritis
Leukocytosis

High WBC count in peripheral blood

>10,000 per mm3
Cell type?
Healthy Cells?
Reaction to need
Pneumonia
Incr granulocytes; bacterial infection, necrosis
Incr monocytes; TB, brucella, rickettsia
Incr lymphocytes; virus, tumor response
Incr eosinophil; allergic, parasite
Distinguish Malignant Proliferation

History and physical

Maturity of cells
Visual inspection of blood smear
Flow cytometry
Nuclear maturity
 Nucleoli
Cellular inclusions
Chromosomal studies
Bone marrow
Leukemia

Malignant proliferation of WBCs and/or precursors.

Classification
 Cell line
 Granulocytes or Lymphocytes
 Cell population:
 Chronic, mature, slower developing
 Acute, immature cells, rapidly developing
The big three features: All three cell lines affected
 RBC
 WBC
 Platelets
Causes
 Chromosomal breaks, but why?
 Viruses, chemical exposure, radiation…..
Leukemia

Organs involved
 BM
 Blood
 Nodes
 Liver and Spleen
 Brain……
Common presenting symptoms
 Recurrent serious infections
 Pneumonia
 Bleeding tendency
 Anemia
 Fever with no obvious cause
 Bone pain
Lymphocyte Maturation
Lymphoid Malignancies

‘Solid’ vs. ‘Liquid’

Leukemia
 Bone marrow predominately
Lymphoma
 Lymph nodes
Cell type and level of maturation
Cell size
CD typing
Where did it come from in the follicle?
 Acute Lymphobalstic Leukemia

Children
 Less common, but does
occur in adults
Precursor B leukemia
 CD19, TdT +
 Ig locus t(12:21)
 Marked BM replacement
Precursor T leukemia
 CD1 and TdT +
 Chromosomal breaks
 Adolescent males
 Mediastinal mass
 +/- spleen and liver
Acute Myelogenous Leukemia
 Acute Myelogenous Leukemia

Myeloid line
 Many subtypes
 Level of maturation determines
what malignant cells look like.
Adults
Aure rods ->
Adults
Rarely pure monocytic
Symptoms
 Infections
 Mouth ulcers
 Gingival hypertrophy (mono)
Chronic Lymphocytic Leukemia

Mature lymphocytes
High WBC count
B-Cells
Adult and older
Indolent course
Tissues
 BM
 Nodes
 Liver and Spleen
May accelerate
 Blast crisis
 Richter’s syndrome
Chronic Lymphocytic Leukemia
Chronic Myelocytic Leukemia

Middle age and older

High WBC count
Stem cell is malignant
All phases present
Low LAP (cells don’t work)
Ph’ Chromosome
 t(9:22)
Organs
 BM
 Spleen
Blast crisis
Soft tissue met
 Chloroma
Ph’ Chromosome
Splenomegally in Chronic Granulocytic Leukemia
Myelofibrosis Etc

Myelofibrosis
Scarring process
Reticulum fibers
Loss of marrow space
Extramedullary hematopoiesis
Metastatic cancer
Preleukemia

RBC abnormalities easiest to spot.

All cell lines have abnormal maturation.
Chromosomal abnormalities
Some end in leukemia
Most end with myelofibrosis
Bleeding Disorders
Takes three things working for hemostasis
Platelets
Clotting proteins
Vessels
The question is always
Quantity
Quality
Platelet Related Bleeding

Platelet problems
Petichae
Bruises (purpura)
Quantity
120,000-400,000
Production
Destruction
Quality
Aspirin
Renal failure
Clotting Factor Related Bleeding

Hematoma
Deep muscle
Joint bleeds
Bleeding gums
Poor wound healing
Quantity
Can you make it
Genetics
Liver disease
Quality
Hemophilia A & B

Hemophilia A
 X-linked recessive
 Boys express
 Factor VIII enzymatic
Hemophilia B
 Christmas Disease
 Factor IX
 Also X-linked recessive
 Not as severe as VIII
 Von Willebrand’s
Von Willebrand disease (VWD) is a genetic
disorder caused by missing or defective von
Willebrand factor (VWF), a clotting protein.
VWF binds factor VIII, a key clotting protein,
and platelets in blood vessel walls, which help
form a platelet plug during the clotting
process.
Factor VIII, ‘structural’
Platelet binding
 Collagen of damaged vessel
 Platelet – platelet binding
Clinically, bleeding looks more like platelet
abnormality.
Autosomal dominant
Multiple types
 Type I
 Most common
 Reduced quantity of vWF
 Type II
 Problem with multimeric form of vWF
Generic Platelet Problems

Quantity (thrombocytopenia)
Lack of bone marrow production
Autoimmune destruction (ITP)
Heparin induced thrombocytopenia
Lack of stabilizing factor (TTP)
Quality
Aspirin induced platelet dysfunction
Idiopathic thrombocytopenic purpura (ITP) is
a disorderthat can lead to easy or excessive bruising and
bleeding. The bleeding results from unusually low levels of
platelets — the cells that help blood clot. Idiopathic
thrombocytopenic purpura, which is also called immune
thrombocytopenia, affects children and adults
Thrombotic thrombocytopenic purpura (TTP) is a rare
blood disorder. In TTP, blood clots form in small blood
vessels throughout the body. The clots can limit or block the
flow of oxygen-rich blood to the body's organs, such as the
brain, kidneys, and heart. As a result, serious health problems
can develop.
Disseminated Intravascular Coagulation
 Runaway train
 OB disaster
 Sepsis and endothelial cell injury
 Massive muscle injury
Hypercoagulation
Thick blood
Increased clotting
proteins
Decreased braking
forces
Endothelial injury
Genetics
Factor V Leiden
Diseases of Lymph Nodes
Basic Node
Basic Node
Lymph Node Disorders
Reactive vs. Neoplastic
History & Physical Exam
Histological pattern
Nodal architecture recognizable?
 Effaced?
Diagnostic inflammatory changes
Reactive Conditions

Non-neoplastic reaction to
Infections, necrosis, tumors
Histological pattern
Follicular
Sinusoidal
Specific patterns
 Abscess
 Granuloma
Neoplastic Diseases
Classification is very important
 Treatment options
 Predicting outcome
Histological pattern
 Hodgkin Lymphoma vs. Non-Hodgkin Lymphoma
 Cell type (where did it come from in the node?)
 Degree of differentiation (grade)
 Diffuse or Follicular
Stage (extent of spread)
 Know the difference between stage and grade
Systemic symptoms (so-called B symptoms)
 Fever
 Night sweats
 Weight loss
Basic Node
Non-Hodgkin Lymphoma, SLL
Small cell lymphocytic lymphoma
Tissue phase of CLL
Diffuse replacement of nodal architecture
Long-lived B-cells (CD19, CD20)
Surface immunoglobulins
Non-Hodgkin Lymphoma, Follicular Pattern
Nodal architecture is effaced
Nodular or follicular pattern
‘Centrocytic’ cells (from germinal centers)
B-cell markers
Surface immunoglobulins
 Burkitt’s Lymphoma

Two types
American
Retroperitoneal
African
Jaw
cancer of the lymphatic
system, caused by the
Epstein–Barr virus,‘Starry
sky’ appearance
B-cell
African Burkitt’s
Hodgkin’s Disease

Distinguished from NHL by

Hodgkin's lymphoma — formerly
known as Hodgkin's disease — is a
cancer of the lymphatic system, which
is part of your immune system. It may
affect people of any age, but is most
common in people between 20 and 40
years old and those over 55.
Reed-Sternberg cell ->
 In its proper background
 This is the malignant cell
 The others are reactive
Bimodal age distribution
Distinctive patterns
 Nodular sclerosis
 Lacunar cells ->
 Mixed-cellularity
 Lymphocyte predominate
Hodgkin’s Disease
Hodgkin’s Staging
Stage I
Single node or single extranodal site (I-e)
Stage II
Two or more nodal regions on the same side of the
diaphragm
Stage III
Both sides of the diaphragm
+/- Splenic involvement (III-s)
+/- Extranodal (III-e)
Stage IV
Multiple disseminated foci
 Multiple Myeloma
Plasma cell malignancy
Term refers to holes in the bone
because of nest of plasma cells ->
The replace marrow space.
The cells make an intact, or
fragment, of immunoglobulin.
Real problems with infections
 No inflammatory cells
Bleeding
 Protein coats platelets
Renal failure
 protein clogs tubules
 Multiple Myeloma

Protein electrophoresis
Large amount of abnormal
protein in blood.
Immunoglobulin
Patient sample
 Huge gamma band
 All of it is kappa light chain