Henry's Clinical diagnosis and management by McPherson and Pincus in 2016

Part 4: Hematology and transfusion medicine

hematopathology (510-734 = 224)

• 30. Basic examination of blood and bone marrow (510-539)

  • Hematology principles and procedures

    • Hemoglobin
    • Hematocrit (packed cell volume)
    • Erythrocyte indices
    • Manual blood cell counts
    • Instrument technology

  • Blood film examination

    • Examination of wet preparations
    • Making and staining blood films
    • Erythrocytes
    • Leukocytes on peripheral blood smear examination
    • Platelets on peripheral blood smear examination
    • Erythrocytes

• 31. Hematopoiesis (540-558)

• 32. Erythrocytic disorders (559-605)

  • 32.1 Anemias

    • General manifestations

    • Impaired production–Iron deficiency anemia

      • Iron metabolism

      • Iron deficiency anemia

        • Clinical features

        • Laboratory features

          • blood
          • marrow
          • serum iron
          • serum iron-binding capacity
          • percent saturation of TIBC
          • serum ferritin
          • erythrocyte porphyrins
          • serum transferrin receptors
          • serum transferrin receptors
          • serum transferrin receptor-to-serum ferritin ratio
          • reticulocyte hemoglobin content
          • hepcidin level
        • Differential diagnosis
        • Management
      • Iron-refractory iron deficiency anemia (IRIDA)

    • Impaired production–Megaloblastic anemia

      • Macrocytosis with normoblastic marrow

      • Megaloblastic anemia

        • blood
        • marrow
        • erythrokinetics
      • Cobalamin (Vitamin B12) metabolism

      • Cobalamin deficiency

        • Inadequate intake
        • Defective production of intrinsic factor

      • Pernicious anemia

        • clinical features
        • gastric findings
        • immune abnormalities
        • pernicious anemia in children
        • gastrectomy

        • defective absorption of cobalamin

          • malabsorption syndromes
          • lack of availability

        • diagnosis of cobalamin deficiency

          • therapeutic trial
          • serum cobalamin assay
          • methylmalonic acid and homocysteine assays
          • deoxyuridine suppression test
        • detecting the cause of cobalamin deficiency

      • Folic acid metabolism

        • The folate-cobalamin relationship

      • Folic acid deficiency

        • Inadequate intake of folate

          • Evolution of laboratory abnormalities
          • Nutritional folate defiency
          • Liver disease
        • Defective absorption of folate
        • Increased requirement for folate
        • Inadequate utilization of folate

        • Diagnosis of folate deficiency

          • Serum and red cell folate
          • Urinary formiminoglutamic acid (FIGLU)
          • Deoxyuridine suppression test
          • Plasma homocysteine assay
        • Acute megaloblastic anemia
      • Therapy for megaloblastic anemia

      • Other defects of nucleoprotein synthesis

        • congenital defects
        • synthetic inhibitors
        • refractory anemias

    • Impaired production–Other

      • Anemia of chronic disease
      • Anemia of renal insufficiency
      • Anemia of liver disease
      • Anemia in endocrine disease
      • Anemia associated with bone marrow infiltration (myelophthisic anemia)
      • Aplastic anemia

      • Pure red cell aplasia

        • Transitory arrest of erythropoiesis
        • Transient erythroblastopenia of childhood
        • Congenital red cell aplasia (Diamond-Blackfan anemia; Congenital hypoplastic anemia)
        • Acquired pure red cell aplasia
      • Sideroblastic anemia
      • Refractory anemia
      • Congenital dyserythropoietic anemias

    • Blood loss anemia

      • Acute posthemorrhagic anemia
      • Chronic posthemorrhagic anemia

    • Hemolysis–general

      • Erythrocyte survival studies

      • Hemoglobin destruction

        • Blood film
        • Bone marrow

    • Hemolysis–membrane disorders

      • Hereditary spherocytosis
      • Hereditary elliptocytosis

    • Hemolysis–hemoglobin disorders

      • Normal hemoglobins

        • Hb A (a2b2)
        • Hb F (a2g2)
        • Hb A2 (a2d2)
        • Embryonic hemoglobins
        • The globin gene clusters
        • Glycosylated hemoglobins
      • Laboratory investigation of hemoglobinopathies and thalassemias
      • Abnormal hemoglobin synthesis
      • Sickling disorders
      • Common alpha chain variants
      • Disorders of hemoglobin function

    • Thalassemias

      • Molecular defects

      • Beta-thalassemias

        • homozygous beta thalassemia (thalassemia major; Cooley’s anemia)
        • heterozygous beta-thalassemia (beta thalassemia trait; thalassemia minor; Cooley’s trait)
        • beta thalassemia trait with normal hemoglobin a2
        • delta-beta 0 thalassemia
        • delta-beta +: Lepore hemoglobins
      • Hereditary persistence of fetal hemoglobin

      • Alpha thalassemias

        • alpha thalassemia syndromes

          • hemoglobin Bart’s hydrops fetalis
          • hemoglobin H disease
          • alpha thalassemia trait: heterozygous alpha 0 thalassemia (* * / alpha alpha) or homozygous alpha + thalassemia (* alpha/ * alpha)
          • silent carrier alpha thalassemia (heterozygous alpha+ thalassemia) (alpha alpha/-alpha)
          • hemoglobin constant spring (alphaCS alpha/)
      • Screening and prenatal diagnosis of hemoglobin disorders

    • Hemolysis–metabolic disorders

      • Erythrocyte metabolism
      • Glucose-6-phosphate dehydrogenase deficiency
      • Pyruvate kinase (PK) deficiency
      • Other glycolytic enzyme deficiencies
      • Pyrimidine-5’-nucleotidase deficiency

    • Hemolysis–acquired; extrinsic

      • Chemical agents
      • Physical agents
      • Infectious agents
      • Immune hemolytic anemias

    • Laboratory investigations of anemia

      • Macrocytic anemia (increased MCV)

      • Microcytic and hypochromic anemias (decreased MCV and MCH)

        • iron deficiency anemias

          • low iron low TIBC

        • anemia of chronic disease

          • low iron normal TIBC

        • thalassemia

          • normal to elevated iron with hypochromic anemia and basophilic stippling
        • sideroblastic anemia

      • Normocytic and normochromic anemias (normal MCV)

        • optimal marrow response: reticulocyte production index greater than two

          • direct antiglobulin (Coombs) test
        • inadequate marrow response: reticulocyte production index less than two

  • 32.2 Polycythemia

    • Relative polycythemia
    • Absolute polycythemia
    • Measurement of erythrocyte and plasma volume

  • 32.3 Porphyrias

    • Physiology
    • Approach to the porphyrias
    • Clinical porphyrias and their biochemical basis
    • Analytic techniques

• 33. Leukocytic disorders (606-658)
  • 33.1 Leukocytes

  • 33.2 Nonneoplastic disorders

    • Granulocytic and monocytic disorders
    • Lymphocytic and plasmacytic disorders
    • Leukemoid reactions

  • 33.3 Neoplastic disorders primarily involving leukocytes

    • Overview of hematopoietic neoplasms

      • CML t(9;22)(q34;q11) BCR/ABL translocation targeted by imatinib / Gleevec
      • promyelocytic leukemia t(15;17)(q22;q12) PML/RARA abnormal retinoic acid receptor responds to all-trans retinoic acid

    • Chronic myeloproliferative disorders

      • Introduction

        • Includes clonal proliferations of pluripotent stem cells that can differentiate along granulocytic, erythroid, and megakaryocytic lines
        • The chronic course may terminate as acute leukemia, myelofibrosis, or coagulopathy

      • Chronic myelogenous leukemia

        • +/* BCR/ABL1

        • Clinical features

          • Young and middle aged; >50
          • Anemia, weight loss, splenomegaly, fever and night sweats

        • Laboratory features

          • Blood

            • increased leukocyte count (usually >5e9/L , possibly >30e9/L )
            • normocytic anemia

          • Marrow

            • markedly hypercellular due to granulocytic proliferation
            • failure to aspirate due to cellular density and increased reticulin
            • blue pigment laden macrophages

          • Neutrophil alkaline phosphatase

            • greatly reduced or absent in more than 90% of patients
            • this is in contrast to elevations seen in PV, IMF, and leukemoid reactions

          • Cytogenetic abnormalities

            • t(9;22)(q34;q11) in more than 95%

              • the BCR-ABL1 fusion results in a novel RNA transcript and associated growth factor with tyrosine kinase activity higher than that of the normal p145 protein encoded by the ABL1 gene

            • Major and minor breakpoint regions of BCR

              • M-BCR –> p210
              • mu region –> p230
              • m-BCR –> p190 –> usually associated with ALL

          • Other findings

            • Serum cobalamin and transcobalamin are usually increased as a result of increased transcobalamin I reflecting the size of the total blood granulocyte pool
            • Lysozyme (muramidase) is also increased

        • Course

          • Untreated patients or those who fail treatment progress to a more aggressive or accelerated phase characterized by features of progressive myeloproliferation
          • Blast phase is a progression to acute leukemia defined by >20% blasts in the blood or BM which is myeloid lineage in >70% of cases. In approximately 1/3 of cases ALL mostly of precursor B-lineage appears.
      • Chronic neutrophilic leukemia

      • Polycythemia vera

        • JAK2 V617F
      • Primary myelofibrosis
      • Essential thrombocythemia
      • MPN with eosinophilia and abnormalities of PDGFRA, PDGFRB, or FGFR1
      • Chronic eosinophilic leukemia
      • Mastocytosis
      • Myelodysplastic and myelodysplastic/myeloproliferative neoplasms
      • Myelodysplastic/myeloproliferative disease, unclassifiable
      • Myelodysplastic syndromes

    • Acute myeloid leukemia

      • Acute leukemia with recurrent genetic abnormalities

        • AML with balanced translocations/inversions

          • AML with t(8;21)(q22;q22) RUNX1-RUNX1T1
          • AML with inv(16)(p13q22) or t(16;16)(p13.1;q22), CBF beta/MYH11
          • Acute promyelocytic leukemia with t(15;17)(q22;q12) PML/RARA, and variants
          • AML with t(9;11)(p22;q23); MLLT3-MLL
          • AML with t(6;9)(p23;q34); DEK-NUP214
          • AML with inv(3)(q21q26.2) or t(3;3)(q21;q26.2); RPN1-EVI1
          • AML (megakaryoblastic) with t(1;22)(p13;q13); RBM15-MKL1

        • AML with gene mutations

          • AML with FLT3 mutation
          • AML with NPM1 mutation
          • AML with CEBPA mutation
      • Acute myeloid leukemia with myelodysplasia-related changes
      • Acute myeloid leukemia, NOS
      • Myeloid proliferations related to Down syndrome
      • Acute leukemias of ambiguous lineage

    • Precursor lymphoid neoplasms

      • B lymphoblastic leukemia/lymphoma
      • B lymphoblastic leukemia/lymphoma, NOS

    • Mature B cell neoplasms

      • Monoclonal B cell lymphocytosis

      • Chronic lymphocytic leukemia/Small lymphocytic lymphoma

        • M>F over 60 years
        • Fatigue, lymphadenopathy WBC > 5e3/uL, anemia, thrombocytopenia
      • B cell prolymphocytic leukemia
      • Splenic marginal zone lymphoma
      • Hairy cell leukemia
      • Splenic B cell lymphoma/leukemia, unclassifiable
      • Hairy cell leukemia variant
      • Lymphoplasmacytic lymphoma
      • Heavy chain diseases

      • Plasma cell neoplasms

        • MGUS
        • plasma cell myeloma
      • Monoclonal immunoglobulin deposition diseases
      • Extranodal marginal zone B cell lymphoma of mucosa-associated lymphoid tissue
      • Nodal marginal zone lymphoma
      • Follicular lymphoma
      • Mantle cell lymphoma
      • Diffuse large B cell lymphoma, NOS
      • Lymphomatoid granulomatosis
      • Primary mediastinal thymic large B cell lymphoma
      • Intravascular large B cell lymphoma
      • ALK-positive large B cell lymphoma
      • Plasmablastic lymphoma
      • Large B cell lymphoma arising in HHV8-associated multicentric Castleman’s disease
      • Primary effusion lymphoma
      • Burkitt lymphoma
      • B cell lymphoma unclassifiable with features intermediate between DLBCL and Burkitt lymphoma
      • B cell lymphoma unclassifiable with features intermediate between DLBCL and classical Hodgkin lymphoma

    • Mature T cell and natural killer cell neoplasms

      • T-prolymphocytic leukemia
      • Large granular lymphocyte leukemia
      • Chronic-lymphoproliferative disorders of NK cells
      • Aggressive NK cell leukemia
      • EBV-positive T cell lymphoproliferative disorders of childhood
      • Adult T cell leukemia-lymphoma
      • Extranodal NK/T cell lymphoma, Nasal type
      • Enteropathy-associated T cell lymphoma
      • Hepatosplenic T cell lymphoma
      • Subcutaneous panniculitis-like T cell lymphoma
      • Mycosis fungoides and Sezary syndrome
      • Primary cutaneous CD30-positive T cell lymphoproliferative disorder
      • Primary cutaneous gamma delta T cell lymphoma
      • Angioimmunoblastic T cell lymphoma
      • Peripheral T/NK cell lymphoma, unspecified
      • Anaplastic large cell lymphoma
      • Anaplastic large cell lymphoma ALK negative

    • Hodgkin lymphoma

      • Classical hodgkin lymphoma

        • nodular sclerosis
        • mixed cellularity
        • lymphocyte depletion
      • Nodular lymphocyte-predominant HL
      • Nodular lymphocyte-rich classical HL

    • Immunodeficiency-associated lymphoproliferative disorders

      • HIV-associated lymphomas
      • Posttransplant lymphoproliferative disorders

    • Histiocytic and dendritic cell neoplasms

      • Hemophagocytic syndromes, or hemophagocytic lymphohistiocytosis (HLH)
      • Langerhans cell histiocytosis
      • Interdigitating dendritic cell sarcoma/tumor
      • Follicular dendritic cell sarcoma/tumor
      • Dendritic cell sarcoma, not otherwise specified

• 34. The flow cytometric evaluation of hematopoietic neoplasia (659-679)

• 35. Immunohematology (680-734)

transfusion medicine

• 36. Transfusion medicine

• 37. Hemapheresis

• 38. Tissue banking and progenitor cells

Part 5: Hemostasis and Thrombosis

coagulation

• 39. Coagulation and fibrinolysis

• 40. Platelet disorders and von Willebrand disease

• 41. Laboratory approach to thrombotic risk

• 42. Antithrombotic therapy

Part 6: Immunology and immunopathoogy

43. Overview of the immune system and immunologic disorders

44. Immunoassays and immunochemistry

45. Laboratory evaluation of the cellular immune system

46. Laboratory evaluation of immunoglobulin function and humoral immunity

47. Mediators of inflammation: complement, cytokines, and adhesion molecules

48. Mediators of inflammation: cytokines and adhesion molecules

49. Human leukocyte antigen: the major histocompatibility complex of man

50. The major histocompatibility complex and disease

51. Immunodeficiency disorders

52. Clinical and laboratory evaluation of systemic rheumatic diseases

53. Vasculitis

54. Organ-specific autoimmune diseases

55. Allergic diseases

Part 8: Molecular pathology

65. Introduction to molecular pathology

66. Molecular diagnostics: basic principles and techniques

67. Polymerase chain reaction and other nucleic acid amplification technologies

68. Hybridization array technologies

69. Applications of cytogenetics in modern pathology progress indicators

• Definitions

• Cytogenetics

  • Chromosomes

    • Chromosome structure

    • Cell culture

      • specimens
      • cell culture technique
    • Staining

    • Karyotype analysis

      • computer-assisted imaging

    • Fluorescence in situ hybridization

      • technique
      • multicolor FISH
    • Microarray technology

  • Chromosome abnormalities

    • numerical abnormalities

      • euploidy
      • aneuploidy
    • structural chromosome abnormalities
    • nomenclature

• Clinical applications

  • Constitutional cytogenetics

    • prenatal
    • postnatal
    • childhood and adult
  • Cancer genetics

  • Cytogenetic disorders

    • Chromosomal Aneuploidy Syndromes

      • Autosomal Aneuploidies
      • Sex Chromosome Aneuploidies
    • Other Sex Chromosome Abnormalities
    • Structural Chromosome Anomalies
    • Microdeletion Syndromes and Contiguous Gene Syndromes

  • Other cytogenetic phenomena

    • Fragile X Syndrome

    • Breakage Syndromes

      • See list in table 69-6

• Summary

70. Establishing a molecular diagnostics laboratory

71. Molecular diagnosis of genetic diseases

72. Identity analysis: use of DNA analysis in parentage, forensic, and missing persons testing

73. Pharmacogenomics and personalized medicine

Part 9: Molecular pathology

74. Diagnosis and management of cancer using serologic and other body fluid markers

75. Oncoproteins and early tumor detection

76. Molecular diagnosis of hematopoietic neoplasms progress indicators

• Role of clinical molecular diagnostics in hematologic cancers

• Molecular diagnosis of leukemias

  • Gene fusion concept in leukemia and the basis for reverse-transcription polymerase chain reaction analysis

  • Acute myeloid leukemias

    • Acute Promyelocytic Leukemia: t(15;17) (q22;q21)/PML-RARA Abnormality
    • Core Binding Factor–Related Acute Myeloid Leukemias: t(8;21)(q22;q22)/RUNX1-RUNX1T1 and Inv(16)(p13q22) or t(16;16)(p13;q22)/CBFB-MYH11 Abnormalities

    • Acute Myeloid Leukemia with Other Translocations

      • AML with 11q23/MLL
      • AML with t(6;9)(p23;q34)/DEK-NUP214
      • AML with inv(3)(q21q26.2) or t(3;3)(q21;q26.2)/RPN1-EVI1
      • AML (Megakaryoblastic) with t(1;22)(p13;q13)/RBM15-MKL1
      • Acute Myeloid Leukemias with FLT3, NPM1, and CEBPA Gene Mutations
    • FLT3 Mutations in Acute Myeloid Leukemia
    • NPM1 Mutations in Acute Myeloid Leukemia
    • CEBPA Mutations in Acute Myeloid Leukemia

    • Other Gene Mutations in Acute Myeloid Leukemias

      • Mutations involving many other genes, including WT1 (see below), MLL, TET2, JAK2, IDH1/IDH2, EZH2, PLK1, NRAS, and KRAS, have been associated with prognostic or biologic importance in AML.

  • Acute lymphoblastic leukemia/lymphoma–B and T cell lineage

    • B Cell Lymphoblastic Leukemia/Lymphoma (Precursor B Cell Acute Lymphoblastic Leukemia, B-ALL)

    • Major Translocation Fusion Gene Abnormalities in B Cell ALL

      • t(9;22)(q34;q11.2)/1BCR-ABL1 is found in approximately 3% to 4% of childhood B-lineage ALL, but it occurs in 20% to 25% of adult B-ALL
    • Prenatal Origins of Childhood Leukemias
    • BCR-ABL1–Like B-Acute Lymphoblastic Leukemia
    • T Cell Lymphoblastic Leukemia/Lymphoma

  • Molecular diagnosis of myeloproliferative neoplasms

    • Chronic Myelogenous Leukemia with t(9;22) (q34;q11)/BCR-ABL1 Positive
    • Ph-Negative Myeloproliferative Neoplasms: Polycythemia Vera, Essential Thrombocythemia, and Primary Myelofibrosis—JAK2, MPL Gene, and CALR Mutations
    • Chronic Neutrophilic Leukemia and Atypical Chronic Myeloid Leukemia with CSF3R Gene Mutation
    • Mastocytosis and the KIT D816V Gene Mutation

• Neoplastic disorders associated with eosinophilia

• Molecular diagnosis of non-hodgkin lymphomas

  • Rationale for molecular genetic analysis in the lymphoid disorders

  • Antigen receptor gene rearrangements for clonality determination

    • Mechanism of Antigen Receptor Gene Rearrangements

    • Techniques to Detect Antigen Receptor Gene Rearrangements: Southern Blot Hybridization

      • Advantages and Shortcomings of Southern Blot Hybridization and Polymerase Chain Reaction for Lymphoid Clonality Assessment

  • Molecular detection and significance of common lymphoma-associated chromosomal translocations

    • t(14;18)/BCL2-IGH Abnormality in Follicular and Diffuse Large B Cell Lymphomas
    • t(11;14)/CCND1-IGH Abnormality in Mantle Cell Lymphoma
    • MALT1, BCL10, and FOXP1 Gene Abnormalities in Extranodal Marginal Zone B Cell Lymphomas
    • Chronic Lymphocytic Leukemia/Small Lymphocytic Lymphoma: Molecular and Cytogenetic Prognostic Markers
    • Diffuse Large B Cell Lymphomas: Role of BCL6 and MYC Gene Abnormalities and Classification Based on Gene Expression Profiling
    • MYC Gene Translocations in Burkitt Lymphomas and “High-Grade” B Cell Lymphomas, Unclassifiable
    • MYD88 Mutation in Non-Hodgkin B Cell Lymphoma
    • ALK Gene Abnormalities in Anaplastic Large Cell Lymphomas

    • TCL1A Gene Abnormalities in T Cell

      Prolymphocytic Leukemia

    • The Implication of Next Gene Sequencing (NGS) in Hematolymphoid Lesions

• Emerging technologies impacting molecular diagnosis and prognosis prediction in hematolymphoid neoplasia

77. Molecular genetic pathology of solid tumors

78. High-throughput genomic and proteomic technologies in the postgenomic era