Transcription
So it's 9:00 a.m. here in the UK. Now, that's okay. So this is the first case. This is a 60-year-old female who was admitted to the hospital three days ago because of fatigue and body ache. She has a background history of bilateral knee joint replacement and poly. The blood film shows, the blood picture shows hemoglobin of 89, white cell count of 13.1, and platelet count of 36. So the BMS has the left, left stop has prepared the blood film. If there is any lab stop, want to comment on this? This is power 10. Do you have any lab stop along? Attend me. All of you guys are clinicians. There is no lab stop here. So, for example, I am the lab stop and I have documented this blood as a lab stop that "Glycocytosis, say, trosy, anemia, impression of PL." And I have referred this blood cell to clinician for, uh, review and reporting. So you, as a clinician, came to the lab to see the blood film report, the blood film, and teach me as well. What is this and how did you identify?
So now the clinician, clinical hematologist or clinical pathologist, have entity. I will make it 15 for you. So the leukocytosis with prominent lymphocytosis, that is abnormal lymphocytosis. And the cells are moderate in size with the low NC ratio and pale basophilic cytoplasm, while the nucleus is round to oval and partially condensed chromatin. Okay, some have nucleoli as well. I can see one to two nucleoli as well. There's marked thrombocytopenia. However, the normal red cells are normal. Nor these have dominant in cytoplasm. There's a BMS. I did not understand what did you say. Can you repeat this? Could be, uh, prominent lymphoproliferative disorder. What are these? Which is present in front of you? These are looks like monocytosis with prominent granules in the cytoplasm. These are mature or immature? Raw cytoplasm. I think these are prominent. I can, I will not appreciate. Okay, there will be a delicately nuclear. Will you see? Okay, yeah. One, some are prominent. Some because of holding in that. Yeah. Uh, what is this? Yeah. If it is mature one, it should have holding or cleaving. This nucleus is complete without any cleaving. Blood cytoplasm with cuu. This is a monol. But not. Hello, you are there? Yes, yes. Look, I missed. Yeah. What were you saying? This is nucleoid here. And this one has very few folding. The cleaving inside the nuclear and few. This appears to be pro-monocyte. Not yes. Yeah, yeah. So you need to report this blood as well. Yeah. So, um, um, the pro-monocytes are very prominent. What was the, uh, history? May I? This patient is admitted with worsening fatigue and body ache. The blood, the blood count shows hemoglobin of 89, white cell count 13.1, and platelet count of 36. Okay. Um, are there any neutrophils? I can see there's no. Can I see some neutrophil component? I think they are. This is neutropenia. There's a blast as well, right? On the right. This is a neutrophil in the myeloid. I can see a myeloid blast as well. Yeah. So the acute, this is a acute leukemia. Acute myeloid leukemia with prominent monocyte component, prominent pro-monocytes and monoblast and RBC. Okay. Who is this speaking? Me. Re-re. This is not the way to report the blood film for part two exam. You need to report it for your short case and long case. My impression is anemia. Impression. What is the main body of the report? The blood contain what? Uh, say something about the blood film. What is there in the blood film? Okay, in the blood film, U, there's a prominent monocytes with pro-monocytes. Are not monocytes. These are monoblast, pro-monocyte. A prominent pro-monocyte with the blast as well. Myeloid blast that is medium in size and, with a basophilic cytoplasm. And, there's a, uh, prominent NRBC as well and low platelet. Cytopenia and red cells are normocytic, normochromic. Some are, uh, some are fragmented as well, but very few. And I can see a Howell-Jolly body on the background as well. So impression will be acute monocytic leukemia. According to WHO 2022, you do not say that this is a cute monocytic leukemia. This is acute leukemia. And then, yeah, I need, um, further investigation will be advised for bone marrow, define, and, cytogenetics. And the blood film contain leukocytosis. Majority of the cells are blasts with few myeloid blast or one blast in the bracket if you want to write. But majority of the cells are blood. Okay. The red cell shows aniso cytosis. Mainly shows you, uh, NRBC drop and Howell-Jolly body. There is general thrombocytopenia. No PL in the RBC. We have to mention macrocytosis or polychromasia as well because you can see this one. This is a macrocyte. You will not miss anything that you have seen in the blood film. And then the impression is acute leukemia. We need urgent flow for flow cytometry here. You can see this. We have missed this spherocyte as well. And then, B biopsy to confirm the diagnosis. B biopsy in the bracket, you will write cytogenetic, molecular, HTS, and NGS panel. Then you will report will be complete because the examiner who is checking, checking your part two paper, will be a population consultant. And he has a key whether this candidate has mentioned Howell-Jolly or not. No one mark. This candidate has mentioned, um, macrocytosis or polychromasia. No one more. Whatever you have written, even your diagnosis will be correct. Okay. You may tell me that this is by looking at the blood film from your experience, you say that this is in, in version 16 AML. But I don't care if your report is not in a way that the examiner wants. You will lose everything. All right. So this patient unfortunately died because of the cardiac event. And the cytogenetic was inversion 16. Isn't there prominent eosinophilia that we were worried as well? That why there was no eosinophilia? But the bone marrow refine had a lot of eosinophilic precursor, but they, they were not present on the blood film. Yeah. You are not required to say in version 16. This is version 16 or version 13. No, they will only ask you to report the blood film. What are your differential diagnosis? And what test you would like to do next? Like in acute leukemia, BSH 2022 has mentioned a panel to send to the, for the testing like FISH for inversion 16, 821, and K2A stereotyping, molecular for FLT3, ITD, FLT3, TD, and NPM1. And the NGS panel. These four things you need to send. And they may ask you, um, what treatment would you suggest for this patient? This patient has B joint replacement and no other comorbidity. So, and she is 60 year old. So if the performance status is better, comorbidity index is low as well, you can try intensive chemotherapy. So try to write down the report. You are an exam candidate. You may have a lot of experience in morphology, but if you cannot write the report for the exam purpose, you will suffer. So practice writing the report.
The second case is another 60-year-old patient presented to Oncology Department, to the Oncology outpatient, because of anemia. The patient's background is metastatic breast cancer for which she had received chemotherapy and radiotherapy five years ago. Yes. So this is power 10. Do we have any BMS or lab stuff? Yes. Yeah. What do you think as a lab stuff? Because the blood film will come to you first. Is it? Could you please say again the CBC? This patient is anemic, having hemoglobin of 80, white cell count of 8, and platelet count of 150 to 250. 250. She only has anemia, right? Yeah. Uh, okay. Um, I will start by. Why you want to start by white blood cell count when she has anemia? I always mention to you, start with the problem first. The patient has anemia. Start commenting on the. The previous case has a problem with white blood count to comment on white blood first. You are the staff, the lab staff, or lab hematologist. And this blood has come to you first. Or is it normocytic, normochromic cells? Some microcytes. I am a BMS student, first-year student. Okay. I don't know what is an anisocytosis. Can you tell me what is an anisocytosis? Clarify the difference between an aniso cytosis and anisocytosis. Is it different type of RBC? Okay. Is it different shape? Okay. So what size and shapes you have seen here? Size regarding size, micro size and normal size. What is this one? Drops. Fragmented cells. Occasional. This in the corner. I will fix it again. This one. This one. Completed RBC. You have to mention those in your comments, right? Go on. Segmented cells are very rare. I think you can, some hypochromic cells also. MH. I mentioned teardrop cells, polychromatic cells. May I shift to the white disease? Or there is something I say? Okay, go on. But there is some myeloid blast. Anyway, um, white disease. Occasional. Okay. Granulation. Myeloid side. Toxic granulation. MH. Myeloid side. Dysplastic reaction or picture? Which picture? Left shift with RBC. Okay. So you think that this is a leuko-plastic picture? I think. Okay. Right. Platelets are remarkable. Okay. All right. So I'm a first-year BMS. This blood fortunately came to me. And because there is a lot of fragment in this blood film, I called the clinical hematologist that we have a case of TTP. Now, so I need a clinical hematologist to report on this blood film. Prior to report the blood film? Yes. Anyone from the clinical hematology or pathology side? I think she has done a very good job. She have mentioned most of the things. But I will just like to summarize things. I will say, uh, um, um, red blood cells, aniso, poikilocytosis with a teardrop, nucleated red blood cells. We have fragments and, um, we could see spherocytes and microcytes as well. Uh, then as she have mentioned a leuko-arthroplastic picture with left shifted granulocytes. Neutrophils are well segmented and nucleated with some increased granulation. Band forms and metamyelocytes have been seen. I don't know if I have mentioned the teardrops as well. But platelet count, look, the platelet morphology looks unremarkable. Then I will conclude my report by saying, um, that it's, and I think there is some, I don't know, it's a rouleaux or agglutination. Yes, this is a rouleaux formation. A rouleaux formation. Yeah. So, um, it could be like an, um, a picture of hemolytic anemia. That test is negative. So you think this is hemolytic anemia? Yeah. Why would the hemolytic anemia contain dysplastic neutrophils and myeloid? Is it in the background of, um, MPN or something? There is something else happening. MPN? No, this patient's background is breast cancer for which she has received chemotherapy and radiotherapy five years ago. So the dysplasia can be because of that. Because so treatment-related. Okay. So what is your impression here? This is a very common exam question and very common in the oncology patient as well. So could that be like an, um, a treatment-related bone marrow fibrosis with associated hemolysis? It is treatment-related, but not hemolysis. So your BMS has has done a very good job that he has identified that it is a leuko-arthroplastic picture because we have dysplastic neutrophils, NRBC, we have band forms here as well. And this is a leuko-blastic picture. Okay. And what are the causes of leuko-blastic picture? A bone marrow stress. Yeah. Yes. For example, metastasis. Metastasis. And sepsis can sometimes also cause that. Yes. Infection. And when the patient has septicemia or having a DIC picture, you will see a lot of fragments. You will see a lot of NRBC, myeloid toxic granulation in a neutrophil. So you must be dealing with the oncology patient as well in terms of their blood. See their blood film, especially the one who has a metastasis. All of them will have a leuko-blastic picture, either from the bone infiltration or from the, um, infection. And, um, sometimes you will see treatment-related MDS picture in these patients as well. Myelofibrosis has a similar picture as well, but they have only target cells, few NRBC, and a few myeloid. Anything which which infiltrate the bone marrow or cause the fibrosis in the bone marrow or make the bone marrow under stress to leuko. This question can come in the exam in another way as well. Write down six features. And this, you have to mention this target cells, NRBC, teardrop, band forms, myeloid, normal RBC. Okay.
So this is another 40-year-old patient whose blood film is referred to you by whose bloods are referred to you by a GP. And he queried whether this patient has myeloproliferative neoplasm or not. This is power 10. [Music] Right. This is power 10 for a 40-year-old patient, a GP blood sample, and he is carrying myeloproliferative neoplasm in the patient. The blood film goes to lab scientist, BMS, or lab hematologist first. Anyone from the lab? Uh, um, so I can try. MH. For this is power 10 on 10. Power 10. This is looking like a dimorphic picture of red cells in the background. While WBC is quite normal, is not increased. H. So the red cells, these are, there is anisocytosis. Where is the problem? Where is the problem? Problem is in platelets. Platelet counts are. Why are you touching the right side again? Okay, sorry. So platelet counts are increased. These are, there is anisocytosis of platelets. These are of different size. And, RBCs are few. RBCs are microcytic, hypochromic, and few are normocytic. And you have target cells. And neutrophils are preserved. Granular clumps of platelets are also there. Okay. I'm looking for any lymphocyte. Yeah, yeah. So this is your lymphocytic, normochromic. If we compare the size of RBC with lymphocytes. But there are also a few microcytic hypochromic cells in the background with thrombocytosis. You are from the left side or you? I'm from the left side as well. Clinician. You want to report it as a clinical hematologist as well, or you want to refer it to your colleague? No, I can report. Oh, so report the blood film findings, impression, and suggestion. Okay. The peripheral peripheral film showed the dimorphic picture of the red cells with increased platelet count, thrombocytosis, and neutrophils and granular sites are preserved. And so the impression is thrombocytosis, which can be reactive or which can be clonal. So I will, uh, suggest to rule out the reactive causes of thrombocytosis by GP by doing a number of tests like rule out the iron deficiency anemia first. Because there is also a microcytic hypochromic picture. And any bleeding, infections, like CRP level. And, uh, if all reactive causes are ruled out, then further investigation for the clonal causes like MPN, JAK2 mutation, or essential thrombocythemia. Yeah. So you have commented on the, uh, cell component first, and then impression of thrombocytosis and suggested iron profile and infection profile in the patient because these are the two common causes of thrombocytosis in the UK and in the Western world. Right. And then you mentioned MPN profile. MPN profile include three for ET, JAK2, MPN, and, yeah, if this patient has JAK2 mutation as well, for example, or CALR mutation as well. Okay. And deficiency anemia. So you have deficiency anemia. But he has mutation. Would you treat this patient with any therapy or no? It depends upon that, if there is persistent thrombocytosis, and I have treated iron deficiency, but there is still thrombocytosis, and patient age is 40, right? Yes. And if there is a risk factor like I will, uh, certify the patient according to the risk factors like cardiovascular risk factors. Because patient is young. And but there is a mutation, it is a clonal cause. But if the based on risk factors, according to the guideline, if he is low risk, but having the risk factor for the thrombosis, then I will definitely treat the patient. This patient is young, as you mentioned, and an athlete. Sorry, no, she's an athlete. Okay. And she does not have an athlete. She does not have any mobility. He's completely fit. A patient is fit and young, then I will just watch the patient and also check the platelet count, target level. So the platelet count was 900. And after iron supplement, it is 700. Sorry, it is 600 now. Okay. Then I can give the, um, reassure the patient for lifestyle and to decrease the, um, risk factors by modifiable risk factors for the risk of thrombosis. And I can give the antiplatelet at this time because patient has no any history of thrombosis and, and no other comorbidities which likely to cause the thrombosis. So, but I will counsel the patient for the risk of thrombosis during any challenges like any type of surgery or any type of, if there is a history of thrombosis, family history of thrombosis, or if there is an ongoing risk factors for the thrombosis, then I will definitely start the treatment. So this is my management. Okay. You start antiplatelet in this patient and he got a DVT after a year. Then I will start the treatment. Like, what treatment you will start? You will give him paracetamol or something else? No, I, I will start the cytoreductive therapy like, um, hydroxyurea for the production of platelet count. They started the hydroxyurea. And he tell you that I'm pregnant. Okay. You exam. Yeah, yeah. Yes, she is a female. So, um, definitely there is, um, if she's pregnant, then I will go for another alternative option for the cytoreduction like interferon, because it is safe. Always mention reductive therapy in form of hydroxyurea if not pregnant. If pregnant, then you have entered. Okay. These are the daily life practice thing. But in the exam, if you do not mention, you lose the first.
Okay. This is a 35-year-old female who presented to us with, uh, high white, fatigue, and tiredness. The hemoglobin is 110, platelet count is, uh, 40. White cell count 16. This is the power, uh, sorry, Dr. AM. This is another case. Yes. The second last. Any lab stop, BMS, life scientist, MLP want to comment on the blood film? So if there is no lab stop, then the clinical hematologist can report this blood. Sorry, I could not hear you. Can I try? Yeah, uh, but sorry, I missed the, uh, the history you given. So this is a 35-year-old female presented to us with fatigue and tiredness. Hemoglobin is 110, white cell count is 16, and platelet count is 140. White 16, 16, okay. Only fatigue. Sorry. Fatigue only, right? Yes, yes. I will go to power 50. E off. So I start. Okay. Um, there are white to blast. Um, and I have to mention the percentage of to. If, if I can read, with the high N ratio, R of P, blast, a granular, complete your, complete your report. Yeah. Oh, white disease. So blood cells, and I have to mention the percentage. And I will describe it as C, high Inc ratio, fine chromatin, inconspicuous cytoplasm, not abundant. I mean, rim of cytoplasm, a granular. There are myeloid left shift also. U, some band forms are seen with the toxic granulation. RBCs, I see microcytic hypochromic cells with RBC also. What is, uh, acute leukemia for bone marrow examination, genetics, and flow cytometry. This patient has microcytic hypochromic anemia as well. Okay. So you did the flow cytometry and the flow cytometry shows CD34 negative, CD117 positive, 133 positive, CD15 positive, 19 negative, M positive, and CD2 negative. Can you please state the markers? CD34 negative, 117 positive, 133 positive, SADR positive, 19 negative, CD2 negative, and CD14 M positive. Yes. N is positive. 117 is positive. It is most likely myeloid, right? Yeah. 34 is negative. What does it suggest? Maybe fish mouth appearance of blast and NPM positive. I haven't mentioned NPM1 here, but this is a significant finding in these blocks. These your fish mouth or cup shape, whatever you want. Okay. Okay. So this is AML. And the cytogenetics shows that NPM1 is mutated. Do you know examples of CD34 negative? Yeah. These can be the abnormal pro-myelocytes. Acute promyelocytic leukemia. But this is not a new WHO. These are CD34 negative and monop plastic. Maybe these are CD34 negative and NPM1. And there are two more megakaryoblasts. Maybe CD34 negative KMT2A. And one more erythro erythroblast. BPC DN. BPC DN. Okay. Which has a typical flow cytometry of 1, 2, 3 positive, 4 positive, and 5, 6 positive. This is the last case. Be quick. Um, because I have to go somewhere. Sorry, Dr. AM. Can you again repeat the CD34 negative ones? Yes. There are four CD34 negative, um, malignancies. You can be asked this in the WHO as well, or it can be a MCQ question in part one. They are NPM1 mutated AML, KMT2A mutated AML, or they can be APML. These are from the myeloid malignancies. And the fourth one is BPC DN. This blastic plasma. Cytoplasmic blastic plasmacytoid dendritic neoplasm, which we are nowadays speaking with NT CD123. Theo first. Okay.
This is another blood film. The last blood of the day. And I want you to pick up the abnormalities in this blood. Anyone? Helocytosis. I will go to power. So we can see increased left shifted granular sites with band forms. Can see myeloid side. Start from RBC. What are the abnormalities you have seen? Then white cell count. What are the abnormalities you have seen? And then it. This blood. This blood film is not for reporting. You can have one of the 10 questions in part two which will say enumerate the abnormalities in a blood. Then you will give heading red cells, white cells. And then there is an anisocytosis in the red blood cells and isocytosis with the stomatocytes, hypochromasia, and polychromic cells. And we can see some teardrops as well. Plus, a few spherocytes and nucleated red blood cells. You mentioned NRBC, poikilocyte, stomatocyte. Yeah. Polychromic cells. And hypochromic cells. Yeah. Hypochromia. Right. Word sir. Yeah. So there is an increase granulocytes with the left shifting. So we can see band forms, metamyelocytes, and myelocytes. And I think some of the neutrophils are a bit, um, hypogranulated. And which one is a pro-myelocyte? Isn't this one? Myeloid is quite a big one. These are myeloid. This one. This one. I'm B. Can see B. The nucleated blood cell. So it is a leuko-blastic picture. Yes. True. That's more than met. Sir, is there any, sir, is there any, uh, promyelocyte in this field? That one look maybe toward the right. Yeah. It is this one. Look like a blast because there is a nucleus. This can be a pro-myelocyte or myeloid blast. They are normal. They are the same. This one is myeloid. This one is kidney shape or has a groove inside. This is a metamyelocyte. This one is myelocyte. A band form. Okay, sir. Thank you. And what about the platelets? Look reduced with no clumping and no like fragments. Oh. So what do you think is going on here? It's a true blastic picture with increase in and left shifting and nucleated red blood cells. So it could be and the teardrop could be myofibrosis. So teardrop will have myofibrosis. But what about this band form, metamyelocyte, myelocyte, and this center one? There is a promyelocyte. M. This could be again, it's an MPN. But and it can be like a CMML. CML. I would say CMML because yeah, because I don't think the number of blast is much increased. So say CML. It should be more than 20%. What is CMML? Myelomonocytic leukemia. Have you seen monocytes here? Monoblast here? A pro-monocyte? No, I haven't seen monocytes. TL is out of picture. Cor. This one is a reactive. What is it? Sorry. It was a reactive lymphocyte. Okay. This is a typical promyelocyte. A big one with the central nucleus. Okay. I'm the BMS. I say that this is CMML. You are the clinician. Do you agree with me or they want me that I'm wrong? Is there any basophil? Have you seen any up till now? Because I have a suspicious. Because I have seen only one basophil. You can ask me the history of the patient. This patient is admitted in ICU with bilateral receive. Is it more like a leukemoid reaction? Yes. We haven't seen any basophilia here. We have seen only one basophil in this whole blood. Okay. This is a leuko-blastic picture induced by sepsis. So they can ask you that, what is the differential diagnosis of this blood? You can. Why prominent or marked dysplasia? Even in red cells, there is cytoplasmic bridging in myeloid cells. These are hypogranular and hyposegmented. Yes, because the bone marrow is under stress. Bone bone marrow is vomiting everything that is present in it. That's why you are seeing all these progenitors here. Okay. Whenever bone marrow is stressed, you will see the whole myeloid series in the blood film. But, uh, we have seen the patients with toxic granulation in neutrophils in myeloid series. But I have never seen dysplasia like this. So if anyone is admitted with septicemia in ICU, look at the blood. You will see a similar picture or you will see Döhle bodies in their neutrophils. You have seen Döhle bodies? That video I had uploaded to my YouTube channel before. You can see that. Are these present here in this case? No, because the Döhle bodies are only present in the mature neutrophils, not in the progenitors. So we could not see it here. So the final diagnosis is septicemia, leuko-blastic picture with septic because of septic. What is this thing? Which one? This one. This one. This one. Yeah. Bar body. What is it? Significant. Uh, it is inactivated X chromosome in female. Doesn't in male or female? Oh, male. I think it is present in female. I don't exactly remember, but it is inactivated X chromosome. AC. All right. So, so what was that? Sorry, what was that? Is it was it bar body or anything else? It's a bar body in the neutrophil. Okay. And significant? No. Sign. It just says that this is a female. Okay. So next time we will see the crystals and some other. So have a nice Sunday and thank you, sir. Thank you. Thank you so much. Thank you very much.