Transcription
Going to, can you hear me? Yes. Look, let's start with E. This is a 56-year-old man whose blood sample was recorded by a GP because of Lucy. He is otherwise well. And F, so this is the blood spin made by the lab. For you, you have a review. And this is power 10. Now I will move to 450. E, Finn, admit your friend in Waiting Lobby. All right. So those who joined, um, the last few seconds, this is a peripheral film of a 56-year-old patient. His blood sample was recorded by a GP because of liosis. The lab scientist have made the blood for you, and this is his blood. The patient is otherwise normal and healthy. I will go back to power to show you the power 10 view. This is power 10, translation. And this is the power 50 of the peripheral film. Now, is there any lab person first to comment on the blood and then refer to clinical pathologist or hematologist? Okay, I need someone to speak. Is there anyone from the lab side who can comment on this blood? Asal, you are first on the list. Yeah, hi. If you are appearing in part two exam, it would not keep calling. Yeah, yeah. Uh, actually, you asked for a lab person. I'm, I'm a clinical hematologist. There's no lab person, I guess. So, for example, I am the lab person. So I will report this blood film from the lab as, um, leukocytosis. Multiple blasts noted, likely acute leukemia. This is my lab report. For example, I have called you that there are multiple blasts in the blood. Right? Can you please come and review this blood for me? Now, you have come to the lab to see the blood. Yeah. And report for. Yeah. Uh, do I have the primary hemogram of this patient? This patient's hemoglobin is 130. The white cell count is 21, and platelet count is 200. AP. He is, he is clinically well, no symptomatic, no past medical history. This is the annual blood sample from a GP surgery here in UK. We have GP surgeries which do regular blood tests for people about 50, I think, annually. Right? And then they have found that the white cell count is. Yeah, I will report this film as, uh, RBC. I can see anisocytosis. There are the problem. The problem is in the white cell. Comment on the white cell first, please. Okay. So there is a lymphocytosis. Uh, the lymphocytes appear, uh, uh, appear mature with clumped chromatin, and, uh, very thin amount of cytoplasm. Um, and, uh, uh, I can see, I can see, yeah, I can see some nucleoli. Well, I will report this as a mature lymphocyte. Okay, mature lymphocytosis which appear clumped chromatin, mature. Um, a few cells show inconspicuous nucleoli, but the chromatin is clumped and, uh, uh, there are normal numbers of neutrophils. Other, uh, C, immature cells are not seen. U, the RBC shows anisocytosis and, uh, there are some, uh, spherocytes and, uh, uh, there are some spherocytes. Platelets, I think, are normal in number and morphology. Right? Is that it? Yeah. No, this is not the report. The report I will give as, uh, possibility of chronic lymphoproliferative disorder, and I will suggest immunophenotyping from the peripheral blood. Now, the report is complete. Because if you comment on the blood cells only, these comments will go back to the GP surgery which have sent these blood sample to you. And when he read the report, so he will call you that, okay, doctor, what is this? You have reported the blood film in the form of comments on the cell component. What is your impression? What is this? What should I do next? Or what should be done next? So, blood film report or aspirate report or tissue report include three components: comments on the cell line, then your impression, and then your next step. Suggest next step. What to do next? So you have mentioned this is likely a lymphoproliferative disorder, and you will do immunophenotype for this patient. The immunophenotype shows that CD2 is negative, CD4 is negative, CD7 is negative, 19 is positive, 20 is positive, 5 is positive, 10 is negative, 23 negative. 200 right. So this looks like a CD5 positive lymphoproliferative disorder, most likely mantle cell lymphoma. I will have to confirm this by running a bone marrow trephine biopsy and doing a Cyclin D1 and Cyclin D1 IHC on that. Okay. 11;14 translocation is positive. Yeah. So this confirms the diagnosis of mantle cell lymphoma. Okay. What is the option for this young man? Yeah. Uh, uh, this looks like an indolent form of mantle cell lymphoma. I will have to run the additional tests, Ki67 and TP53 mutation, and we will do a miP prognostic scoring. And, uh, I will also have to do a CT scan of the neck, thorax, abdomen, and pelvis. And, uh, depending upon the miP score, I will decide whether the patient has an aggressive disease or an indolent disease. And, uh, if the patient has an indolent disease, then he may not require any treatment if the other indications of treatments are not present. So, in this patient who is asymptomatically diagnosed, I will keep him on watchful waiting. Yes. Patient has no symptoms, he's well, just lymphocytosis. So we will do watchful waiting. Should I do a PET scan in this patient or a CT scan in this patient? Which one is preferred? CT scan is as good as PET-CT scan in mantle cell lymphoma. PET scan is preferred if there is any screening nodal involvement or there is any nodal involvement. And bone marrow biopsy will be done only if there is cytopenia. His full count is well within normal range and his hemoglobin was normal. I think at this stage, no need to do it. Only if you have cytopenia. But if I do not do a trephine, then how can I report Ki67 and Cyclin D1? Not required at the moment because the patient is asymptomatic. You are not planning any treatment for this patient. Okay. You can do FISH test on the blood. Yeah, I can do FISH for 11;14 and PCR on the blood. But if there is no cytopenia involved, no need for. If the Ki67 was high, this patient will be having lymphadenopathy and the constitutional symptoms as well. But he has no symptoms, he has no lymph nodes on examination. It means his Ki67 is well below 30% and TP53 mutated is an aggressive disease. This patient would have symptoms as well. Okay. So you always say on the report, this is most likely a proliferative disease. I need to do further tests to confirm my diagnosis. And those who are sitting for the F exam, they should write the report on the paper form because you have to write the report, not type the report. This gentleman is a 19-year-old child who presented to the emergency department with fever and few lymph nodes in the neck. The blood film shows hemoglobin 140, the white cell count 16, and platelet count is 350. The blood film to be seen by the lab scientist or hematologist. First, I will need a lab hematologist. Is there anyone from the lab? So this seems to be the, um, you are from the lymphocytosis. Yes, sir. This is, yes. Uh, it seems that there is lymphocytosis and thrombocytopenia. You have eagle eyes. If you can say this is thrombocytopenia from power 10. Actually, my eyesight is very weak. But anyhow, no, the platelets seem normal. Sorry. There's a call. Anyone else can jump in? There are marked RBC changes in this patient. Uh, there are a couple of target cells and, uh, anisochromia, and I can also see some hypochromic, hypochromic RBCs, markedly hypochromic RBCs. So looks like the patient is transfused. What is the baseline hemoglobin that you have reported? Hemoglobin with us was 140. 140. Okay. So anisocytosis and isochromia, target red blood cells, and, uh, WBCs and platelets seem unremarkable. What would be the cause of lymph nodes in the neck? Yeah, I can see now that there are some, uh, large lymphocytes, large lymphocytes with fair amount of cytoplasm. Looks like they're reactive lymphocytes. What is a reactive lymphocyte? A reactive lymphocyte is a lymphocyte with more fine chromatin, abundant cytoplasm, which can have granulation as well as vacuoles, usually secondary to some viral infections. Okay. So in the channel, have you seen the quiz number 14? Would like you to see the quiz number 14 in the morphology quizzes on the channel. Channel. And let's see what do you think about it. Okay, all right. The report, the blood. You are sitting in part, part exam, and this is a very common exam question. Make this victory. Right. This is power 100 now. Yeah. Report this blood. U, WBC, there is relative lymphocytosis. Uh, uh, the lymphocytes are larger with, uh, U, with abundant cytoplasm. Some of them are seen skirting the nearby RBCs. The granulocytes are normal in number, but they show left-sided maturation. Red blood cells, um, have anisocytosis. Some show target red blood cells. Platelets are normal in number and morphology. My impression is a reactive lymphocytosis secondary to viral infection. And did you comment on the red blood cell finding that you mentioned? There are red blood cell target red blood cells. That can be because of many reasons. Can be chronic liver disease or some cholesterol disorders, or that might be a, the patient can have some hemoglobinopathy underlying. You need to mention everything that you have seen in the blood film. Okay. Um, if this is a reactive lymphocytosis, that is fine. The diagnosis is correct. But if you have not mentioned the, uh, different target cells or stomatocytes, they will deduct marks from you because each finding will carry a mark. On their key. Right. And yes, this is a 19-year-old patient, and you will always see that in a 19-year-old patient, there will be two diagnoses in the exam: either it is ALL or it is infectious mononucleosis. This is not ALL. This is very different from ALL. But it is infectious mononucleosis reactive lymphocytosis. The lymphocytes are large with irregular nuclei and their cytoplasm is mostly basophilic and they scallop the red blood cell. You were saying cutting the red blood cell, but the actual term is scalloping. Okay. And yes, make this big for you. I'm sure you all will know about scalloping. But in case, so this cytoplasm is lining the red cell surface here. Or this, this is scalloping. You can see a monocyte here as well. You have mentioned that in your report. Maybe they would have written monocyte on their key, and if you have not mentioned to sign in the report, they will deduct one mark from you or 0.5 marks from you. So whenever you see a scenario of a young 19, 20, 21, 22-year-old child, adult patient comes with fever or sore throat or neck lymphadenopathy, think about infectious mononucleosis or ALL. The blood film will tell you what is actually inside. And the next question would be, what test you would like to do in this patient? I will do a monospot test and EBV serology, and also viral other viral serology as well, Hepatitis B and HIV. Okay. What is the treatment? The treatment is, uh, actually observation. Yeah. This case usually comes every now and then in the part two exam. So if you know about the WHO 2022 classification, you would be able to find out this case. Be finding of the third case. This is again a 56-year-old man with lymphadenopathy and the blood film shows leukocytosis, white cell count is 100. This is power 10. When we go to power 50. E. E. E. Yeah, some of the, some of the slides are old. So, um, you can see the bottom part of the slide become blurred. The issue. The old slide. I can report the film. Yes, go on. Uh, there is leukemic lymphocytosis. U, and the, the lymphocytes are, uh, heterogeneous in size. Some small lymphocytes with fairly clumped chromatin, and there are, uh, I think 50% of the lymphocytes are large with centrally placed nucleus and prominent nucleoli. And, uh, yeah, RBCs are unremarkable except some. It's unremarkable. And, uh, platelet counts appear reduced. Platelets appear reduced in number. My diagnosis is a lymphoproliferative disorder. I can see smudge cells also. I'm sorry. So my diagnosis is, uh, lymphoproliferative disorder, likely, uh, prolymphocytic leukemia, BPL. You don't know WHO 2022? Oh, yeah, yeah. So it is, uh, uh, it's splenic B-cell lymphoma with prominent nucleoli. You are sitting in exam. You are sitting in the exam. Yes. PA. This one. Okay. So your diagnosis is correct. This is, uh, SLPN, clinical leukemia with prominent nucleoli. The prolymphocytes are more than 60% in this patient. And according to WHO 2022, this is not BPL because BPL and here is a leukemia variant, they have been removed. They have been replaced by a single entity which is SLPN, clinical leukemia with prominent nucleoli. Amid, can I ask you one question? Yes. Yeah. If I'm not very confident about that diagnosis, can I write CLL, PLL also? You will say that this is most likely chronic lymphoproliferative disorder. This is a chronic lymphoproliferative disorder, most likely SLPN because there is no BPL now according to WHO 2022. But we need to confirm this. Like we will say most likely SLPN, but we need to confirm this on further testing because you do not make diagnosis on blood film. You give your only your likely impression. This is likely CLL, likely likely FL, but I need to do further tests to confirm. Right. Thank you. In practice, you would have seen many of time we say that, okay, this is, um, acute myeloid, but when you, the flow comes out, it is usually biphenotypic or it is ALL. It comes out as mantle cell lymphoma. So we have seen this multiple time. In, and so you can see these prominent nucleoli. These are prolymphocytes, not lymphocytes. And according to WHO 2022 category, this is SLPN. Sorry about the quality of the slide, but this is the only slide I have regarding SLPN. The fourth case is again a 56-year-old gentleman who presented to the emergency department with productive cough. Chest X-ray shows lymphocytic effusion. And the peripheral blood shows hemoglobin of 120, white cell count of 80, and platelet count of 188. This is the power 10 slide. Any lab person that won't comment on the peripheral first? We don't have anyone from the lab today. Very strange. All right. So, for example, I'm from the lab. I've seen this blood film and I think that this is CLL because there are quite a lot of mature lymphocytes, and I have referred this blood to the clinical hematology. So hopefully we have 192 people, they are all clinical. So kindly report this blood for me. Again, I can take it. Yes, go on. Anyone? Um, this patient, this lymphocytosis, the lymphocytes are, uh, small, appear mature, with, uh, uh, asymmetrical nucleus, very fine amount of basophilic cytoplasm, and prominent cytoplasmic blebs in most of them. The granulocytes, uh, are normal, and monocytes. So rest of the leukocytes appear normal. The, the RBCs are unremarkable. Platelets appear reduced in number by morphology. I want to give a diagnosis of T-PLL. Again, I have to do immunophenotyping from the blood for confirmation. So I am the first-year biomedical scientist, and I said that this is CLL, and you are saying this is T-PLL. So I would like to ask you, why this is not CLL and why you are saying this is T-PLL? What features make you think that this is T-PLL? CLL usually have very uniform morphology, uh, uh, and background smudge cells are also not seen. There is prominent cytoplasmic blebs which are present in most of the. Okay. So, so you say that this is likely T-PLL, and you want to do immunophenotype in this patient. So CD19 is negative, 20 is negative, 200 is negative, 43 is negative, 23 is negative. CD7 is positive, CD52 is positive, and CD5 is positive. Yeah, that confirms the diagnosis of T-PLL. I have to do a CD4 and CD8 as well. T-PLLs are usually both CD4 and CD8 positive. They are positive. Yeah. And what is the genotype? Cytogenetic involved? They usually have, I think, chromosome 14 abnormality, translocation 14;14 in version 14. Yeah. I think they are very fine. But these are whole Jolly bodies. I think you missed that. Oh, yeah. Then what is the treatment of choice if indicated? Most of the time, uh, this patients can be observed. I mentioned what is the treatment of choice if indicated. Okay. Campath is the first-line treatment. Alemtuzumab. We have to give supportive treatment for PJP and HP virus prophylaxis along with that and CMV monitoring. But Alemtuzumab is the first-line therapy. This patient, these patients carry CD52 positivity. If CD52 is positive, then you will give this patient if indicated. So the last case of the day. Dr. One question. AML M7 also has cytoplasmic blebs. So why we did not consider that if it is only on cytoplasmic blebs? Is it because of our rods? The AML M7 megakaryocytic leukemia presentation is quite different, and the megakaryocytes are bigger than these small mature lymphocytes. And then on immunophenotype, it was typical of T-leukemia, chronic leukemia. The AML would have told us this is 4;1 positive, 61 positive leukemic markers of the here as well. Can we keep them as like differential diagnosis? It should be your least lower most differential diagnosis because the acute myeloid blasts, they are quite big. Yes, they have blebs, but they are big, and patient presentation is different. It is acute leukemia. The patient would not be in a normal way. This patient has just started and the flow cytometry will differentiate. These cells are very, very small, just like the size of the RBC, and leukemia cells will not be in the size of megakaryocytic cells would not be in the size of RBC. And secondly, now the FAB classification has been removed from the WHO 2022 updates. So we use the cytogenetics most of the time. If you think this is acute leukemia, we say this, this is likely an acute leukemia. We need further testing to confirm. All right, right. Thank you. Acute megakaryocytic leukemia, leukemia, they are very rare, but they do appear some, but they are very rare. You will see one or two cases each year, not more. But the difference is in the size and patient presentation. So this is another case. This is again a 56-year-old man with leukocytosis, white cell count is 16, hemoglobin is 120, platelet count is 180. This is power 10. There is some leukocytosis. Now I'm going to 50. First, yeah, remember it's working. Any thought about that? Yeah, I can go for that. Yes, you can report the blood. Yeah. So there are, um, some leukocytosis with, uh, relative, um, lymphocytosis. There is a small, um, mature, um, lymphocyte with a minimal cytoplasm. MH, a granular, have got like compacted chromatin, with some have got a cleft. Mhm. No obvious nucleolus. Oh, um, yeah. Um, the red cells appears preserved. Yeah. Uh, no, no remarkable changes in the red cells. And the platelet counts, um, also like, yeah, um, seems adequate. So, my impression is, uh, likely, um, lymphoproliferative disorder, likely, uh, follicular lymphoma, but I will need to do further testing in terms of immunophenotyping for further confirmation. And, yeah, management. What do you think is the likely diagnosis? I think the likely diagnosis is follicular lymphoma. Okay. So why do you think this is follicular lymphoma? Is there any specific feature of these lymphocytes or anything? So it's just the cleft, really, in the nucleus, uh, in the nucleus, that I saw in, in couple of the cells. Nucleus. Yeah. So what test you would like to do next? Flow cytometry for the blood. Okay. Did flow cytometry? It shows that these cells are CD2 negative, CD4 negative, CD5 negative, CD7 negative, CD10 positive, 19 positive, 20 positive, 43 negative, 200 negative. And immunohistochemistry shows that they are BCL2 positive. Yeah. So it confirms my impression. Like it is going with the follicular. Oh, is there any mutation associated with that? Translocation, anything? Uh, yeah, they have got translocation 14;18. 14;18. Right. Can they transform into another lymphoma? Then, yeah, they can be transformed to high-grade lymphoma. Ly. Right. So when will you treat this patient? What are the indications of treatment for follicular? Okay. Um, so obviously I have to do the full assessment and staging for the patient. It's, um, I think, uh, if there was like, for example, like bulky disease in the imaging, or has got B symptoms, or if there was evidence of like progression of cytopenia. The blood counts now preserved, but if there was any progressive cytopenia, also could be an indication for treatment. Which criteria do you use for decision making? You mean for the assessment? MH. Yeah, it's Philip Call criteria. Oh, sorry. Yeah. Okay. The patient has progressive cytopenias, constitutional symptoms, bulky mass, or any lymph node which is causing threat to the critical musculature or nerve, like compression feature, then you decide to treat this patient. You did a PET scan. PET scan shows stage four disease and splenomegaly as well. Right. What are your first choices of treatment? Um, right. So, um, I think it could be either like, uh, based or based. He is fit. No previous background medical history. Sorry, he has no previous medical background history. He was completely fit before that. M. You say has got no significant medical history. Past medical history. MH. Okay. So, um, yeah, I think the R-CHOP is the standard of care, but like, in fit patients, you can try a bit intensive, but you can try. How many regimens are there based that you can offer to the patient? Not quite sure, not at the top of my head now. Sorry. R-CHOP and R-CVP. Okay. A bit intensive patient. I mean, which is not fit for intensive, we give them R-CVP. R-CHOP you usually avoid because if they progress in the future into DLBCL, then we will have some option. If he has used R-CHOP now, then we cannot give R-CHOP. After progressing to DLBCL, then R-CHOP is the usually choice of therapy. Molecular if indicated. Okay. So one question. I read somewhere that R-CHOP based regimen, we have to choose when the FLIPPI score is more than two. Is it only limited? Yes, yes. If the FLIPPI score is high and patient is fit, because Ritu-Zimab has a very serious reaction during the first exposure. Have you seen a patient? Any? You were warned? No, no. We give Ritu-Zimab to always in presence of an adopted, and they always react. They have to react. If they do not react, then we think that there is some problem with the chemotherapy. So all the Ritu-Zimab patients, they react to the chemotherapy in the form of flushing, cardiac, sorry, chest discomfort. And one of the patient had two fits last week when I give Ritu-Zimab. Or CLL, then we have to abandon the next week because there is a part one course. There will be no session on the Sunday, and you can see this coffee related stuff on the message in the message box. If you wish to donate, you can use this link to donate. And we will resume again on 16th because on next Sunday, we will be having a course at 9 a.m. on call. So on Sunday, 16th of March, we will be resuming our hematology session.